**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, review of facility documentation, and interviews for one of two sampled residents (Resident #68) reviewed for dignity, the facility failed to ensure that the resident's rights were honored during a meal. The findings include: Resident # 68 was admitted to the facility on [DATE] with diagnoses which included metabolic encephalopathy, hypothermia, and congestive heart failure. The care card dated 3/16/24 identified Resident #68 was independent with feeding. The care plan dated 3/18/23 identified Resident #68 was newly admitted to the facility. Interventions included involving the resident in decision making regarding care. The admission MDS assessment dated [DATE] identified Resident # 68 had intact cognition, was occasionally incontinent of bowel, frequently incontinent of bladder, required partial assistance with toileting and bathing, and was independent with eating. Interview and observation on 3/24/24 at 8:25 AM identified Resident #68's breakfast meal tray set up at his/her bedside table by NA #2. Following the tray delivery and set up, NA #2 was observed applying a large clothing protector to Resident #68's chest area and then securing the protector in place at the back of Resident #68's neck area. During this observation, NA #2 did not speak to Resident #68 prior to applying the clothing protector. NA #2 was then observed exiting Resident #68's room. Immediately following this observation, Resident #68 identified that this was the first time a clothing protector had been applied to him/her during a meal. Resident #68 identified that he/she would have liked to have been asked and given the option to choose to use a clothing protector by NA #2. Interview with NA #2 on 3/24/24 at 8:50 AM identified she could not remember if Resident #68 had ever asked for a clothing protector, but that she should have asked Resident #68 if he/she wanted to wear the clothing protector before applying it. Interview with the DNS on 3/26/24 at 11:25 AM identified Resident #68 should have been asked if he/she needed a clothing protector by NA #2. The DNS identified Resident #68 had the right to decide if he/she wanted a clothing protector while eating. The facility policy on resident rights directed that all residents of the facility had the right to be treated with consideration, respect, and full recognition of their dignity and individuality. The policy further directed that residents of the facility had the right to make choices about aspects of their lives that were significant to them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, review of facility documentation and interviews for 1 sampled resident (Resident #75) reviewed for edema, the facility failed to ensure APRN or physician were notified that weights were not obtained per physician order. The findings include: Resident #75 was admitted on [DATE] and readmitted to the facility on [DATE] with diagnoses which included edema, congestive heart failure, and dementia. A physician's order dated 9/22/23 directed to complete a daily weight in the morning. Notify the provider for a weight gain greater than 2 lbs. in 1 day and 5 lbs. in a week. The care plan dated 9/22/23 identified congestive heart failure. Interventions directed to complete a daily weight in the morning. Notify the provider for a weight gain greater than 2 lbs. in 1 day and 5 lbs. in a week and give medications per physician order. The admission MDS assessment dated [DATE] identified Resident #75 had moderately impaired cognition, was frequently incontinent of bowel and bladder and required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. A physician's order dated 10/13/23 directed to complete a daily weight in the morning. Notify the provider for a weight gain greater than 2 lbs. in 1 day and 5 lbs. in a week. A physician's order dated 10/16/23 directed to administer Furosemide( a diuretic medication ) 40 mg 2 times a day for CHF (chronic heart failure). Review of the TAR (treatment administration records) for the months of November 2023 though March 24, 2024 identified the following : 11/1/23-11/30/23 identified 6 missed opportunities out of 30 for daily weights. 12/1/23-12/31/23 identified 10 missed opportunities out of 31 for daily weights. 1/1/24-1/31/24 identified 10 missed opportunities out of 31 for daily weights. 2/1/24- 2/29/24 identified 15 missed opportunities out of 29 for daily weights 3/1/24- 3/31/24 identified 12 missed opportunities out of 24 for daily weights. Review of the TAR indicated Resident #75 had refused on 7 occasions dated 3/4, 3/13, 3/14, 3/20, 3/21, 3/22, 3/24/24. Review of the progress notes dated November 1, 2023-March 24, 2024 did not reflect any refusals and/or explanation of why the weights were not documented . Additionally,the clinical record did not reflect that the APRN or physician were notified of the weights not obtained or refused. Interview with the DNS on 3/25/24 at 10:45 AM indicated the charge nurse was responsible for making sure the nursing assistants obtain the daily weights for Resident #75. The DNS indicated the expectation was if a resident refuses the daily weight the nurse must educate the resident and then try again. The DNS indicated if the resident still refuses the nurse must write a progress note explaining why the weight was not obtained and why the resident refused. Additionally, the DNS indicated if the weight is not obtained or refused the APRN or physician must be notified and documented in the progress notes. After clinical record review, the DNS indicated that the progress notes did not reflect that the APRN or physician had been notified of the missing weights or the refusals of weights in the last 5 months. Review of the facility Weight Management Policy identified to ensure all residents weights are routinely checked, to assess any variations, and implement appropriate interventions for significant weight loss or gain. Although requested the policy for notification of a change in condition it was not provided. Review of the facility Change of Condition Policy identified the facility shall notify the resident, his/her physician, and residnet representative of changes in the residents medical condition. The nurse will notify the physician if there was a refusal of treatment or medications. The nurse will record in the residnet's medical record information relative to changes in the residents medical condition or status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility documentation, and interviews, for one sampled resident( Resident #69) reviewed for an allegation of staff to resident abuse, the facility failed to implement policies to protect the resident's from abuse. The finding includes: Resident #69 was admitted [DATE] with diagnosis which included unspecified dementia with psychotic disturbances, emphysema/COPD, and depression. Facility documentation dated 8/22/22 identified Resident #69 believed NA #1 was making a joke about the resident being moved off of the unit by singing the song Celebration. Resident #69 notified his/her spouse of the situation, stated NA #1 was rude, sang Celebration and was delighted about the move. The spouse was visibly upset and expressed concerns to management regarding the treatment. NA #1 was sent home immediately pending investigation. Interview and review of the incident with NA #1 on 03/25/24 at 11:10AM identified her recall of the incident was Resident #69 was either being discharged or moved to another floor. She identified Resident #69 had a history of being mean toward her and was combative with staff. Resident #69's spouse would often yell at staff at times, and Resident #69 was also noted to be accusatory and required an assist of 2 NAs due to behaviors. NA #1 denied singing or disrespecting Resident #69 however stated she was impolite to the spouse and walked away as the spouse was conversing with her. NA #1 stated she could have kept her job had she apologized to Resident #69's spouse however she refused to apologize and at this point was remorseful about that decision. Interview and review of the incident on 03/25/24 at 03:05 PM with then interim DNS RN #9 identified she was unable to substantiate the allegation of abuse as all of the staff supported NA #1 and there no resident heard the dialogue exchange. Review of the facility incident report identified substantiated and when asked did the abuse occur with the resident, the spouse or both, RN #9 identified it was with the spouse and could not substantiate abuse with the resident. RN #9 further stated NA #1 was placed on final warning and called back to the facility to advise her that she would be placed on final warning, however NA #1 encountered the spouse in the parking lot and told the spouse that she was untouchable and proceeded to insult the family member. RN #9 indicated she spoke to her Administrator and in the absence of HR Generalist they terminated NA#1's employment Review of NA #1 personnel file failed to identify the documentation of the incident, the final warning of 8/11/22, or a background check. Although NA #1 completed the application for fingerprinting, her personnel file failed to identify a returned fingerprint verification. Interview with HR Director on 3/25/24 at 1:20 PM identified NA #1 was hired 4/22. The HR Director was unable to locate any preliminary screening associated with NA #1's employment application. Interview with the DNS on 3/25/24 at 3:25PM identified neither he nor the Administrator were employed by the facility in 2022. It would be his expectation that employees are screened, and background checks are done prior to an offer for hire and that personnel files are complete. Although attempted a call to the Administrator of the facility in 2022 was not returned. Although requested a policy for hiring and screening was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, review of facility documentation, and interviews for 1 of 2 residents (Resident #75) reviewed for respiratory care, the facility failed to ensure a comprehensive care plan was developed related to the use of respiratory equipment. The findings include: Resident #75 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary edema, dementia, and obstructive sleep apnea. The admission MDS assessment dated [DATE] identified Resident #75 had moderately impaired cognition, was frequently incontinent of bowel and bladder and required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. Additionally, the MDS assessment did not indicate the use of a C-pap. The baseline care plan dated 10/4/23 did not identify the use of a C-pap. The comprehensive care plan dated 10/10/23 did not identify diagnosis of sleep apnea or the use of the CPAP. The physician's orders dated 1/20/24 (120 days after admission) directed the use the CPAP with medium full face mask oxygen flow rate at 2 liters per minute. On every night, off every morning and as needed when napping. Cleanse CPAP tubing with 1/2 water, 1/2 white vinegar (place tubing into a basin) remove the tubing from the basin and allow tubing to be air dry every Sunday on 11:00 PM-7:00 AM shift. (scheduled while resident is using the CPAP). Observation on 3/24/24 at 7:00 AM Resident #75 was lying in bed wearing a CPAP mask with tubing connected to a machine on a rolling cart on the left side of the bed. Interview with the DNS on 3/25/24 at 10:23 AM indicated the MDS coordinator was responsible to include the use of the CPAP in the baseline care plan and the comprehensive care plan since admission. The DNS indicated the MDS coordinator( RN #8 )works remotely and completes the MDS assessments based on physician orders. The DNS indicated that he would have expected a care plan since admission regarding the CPAP. Interview with MDS coordinator (LPN #3), on 3/25/24 at 11:10 AM indicated she was responsible or MDS coordinator RN #8 to include the use of the CPAP on the care plan. LPN #3 indicates that they do the care plan based off the admission physician's orders. LPN #3 indicated that the CPAP was not in the initial admission orders, so it got missed. After surveyor inquiry, the comprehensive care plan dated 3/25/24 included alteration in respiratory status and resident uses a C-pap. Interventions included cleaning the c-pap mask daily per policy, fill humidifier with sterile water per physician order, change the mask and tubing per physician order. Review of the facility Care Plan Policy identified the facility will have an interdisciplinary care plan to achieve and maintain optimal status for each resident. The resident care plan will include the residents needs, realistic goals, and the care and services needed to meet these goals. The MDS coordinator is responsible for ascertaining that all MDS triggered items have been addressed.

Based on review of the clinical record, review of facility documentation, and interviews for 1 of 2 residents (Resident #161) reviewed for discharge, the facility failed to ensure the final summary of the resident's stay included the resident's skin integrity, including consultation by the wound physician, and the facility failed to ensure the respiratory equipment was delivered to the resident's home prior to discharge. The findings include: Resident #161 was admitted to the facility in December 2023 with diagnoses which included acute respiratory failure with hypoxia, diabetes, and atrial fibrillation. The physician's order dated 12/27/23 directed to administer oxygen at 2 Liters via nasal cannula continuously every shift The nursing evaluation dated 12/27/23 at 10:51 PM identified Resident #161 was admitted with bruising to top of scalp, bruising to upper middle back, bruising to right elbow, bruising to left hip area, skin tear to left elbow and the use of Oxygen at 1.5 Liters. The care plan dated 12/27/23 identified Resident #161 has altered respiratory status related to acute hypoxic respiratory failure. Intervention included to administer oxygen via nasal cannula as ordered. The care plan dated 12/27/23 identified Resident #161 has a community acquired pressure ulcer stage II to the thoracic spine. Intervention included to administer treatment as ordered and to apply an air mattress. The wound progress note dated 12/28/23 identified Resident #161 was seen for initial evaluation and treatment for right upper extremity skin tear measuring 5.6 cm x 3.8 cm x 0.1 cm with small serosanguinous. Pressure ulcer to thoracic spine stage II measuring 3 cm x 1.6 cm x 0.2 cm with small serosanguinous. Diagnoses laceration to right upper arm and pressure ulcer stage II thoracic spine. Treatment recommendations: Right upper extremity skin tear apply bacitracin and xeroform, cover with dry clean dressing, change every day, and as needed. Thoracic spine pressure ulcer apply bacitracin, cover with foam dressing, change every day and as needed. The wound progress note dated 1/15/24 identified Resident #161 was seen for follow up evaluation and treatment regarding a right upper extremity skin tear, a pressure ulcer to thoracic spine, and a malignancy to the left ear. Resident #161 was also seen for Moisture Associated Skin Damage (MASD) to the sacrum. The case was discussed with the resident representative at bedside in detail. The nurse's note dated 1/20/24 at 11:55 AM identified Resident #161 was discharged home at 10:54 AM with all active medications and discharge instructions. All medications were reviewed with Resident #161 and resident representatives at bedside. The social service note dated 1/20/24 at 12:18 PM identified Resident #161 was discharged back to the assisted living facility with visiting nurses. Resident #161 was provided medications and a copy of the discharge paperwork. Review of the Transfer/Discharge Report and the interagency referral ( W-10) dated 1/20/24 included a list of the resident's current active medications and did not include the use of oxygen at 2 Liters via nasal cannula. Further, the Transfer/Discharge Report failed to identify that Resident #161 had a right upper extremity skin tear, a thoracic spine pressure ulcer, a malignancy to the left ear, and a MASD to sacrum. The Discharge instruction forms dated 1/20/24 with resident representative signature failed to identify that Resident #161 had a right upper extremity skin tear, a thoracic spine pressure ulcer, a malignancy to the left ear, and a MASD to sacrum. Further, the Discharge instruction form failed to identify oxygen at 2 Liters via nasal cannula. Interview with the SW #1 on 3/26/24 at 8:29 AM identified she was responsible for Resident #161 discharge. SW #1 indicated she had emailed the physician's order to the oxygen company on 1/18/24 and they were supposed to deliver the oxygen to Resident #161 home. SW #1 indicated she was not aware that the oxygen was not delivered. SW #1 indicated she was not aware that the oxygen company did not call the resident representative. SW #1 indicated she was responsible for making sure the oxygen was delivered to Resident #161 home prior to discharge. SW #1 indicated she acknowledged that this was not a safe discharge. SW #1 indicated she had submitted a physician's order to another oxygen company on 1/20/24 at 12:15 PM and that oxygen company did not accept the order until 1/22/24. SW #1 indicated she was not aware that the discharge paperwork failed to identify that Resident #161 had a right upper extremity skin tear, a thoracic spine pressure ulcer, a malignancy to the left ear, and a MASD to sacrum. Further, the Discharge instruction form failed to identify oxygen at 2 Liters via nasal cannula. Interview with the DNS on 3/26/24 at 11:00 AM identified SW #1 is responsible for discharging residents and ordering equipment. The DNS indicated he was not aware of the discharge paperwork failed to identify that Resident #161 had a right upper extremity skin tear, a thoracic spine pressure ulcer, a malignancy to the left ear, and a MASD to sacrum. Further, the Discharge instruction form failed to identify oxygen at 2 Liters via nasal cannula. Interview with Person #3 on 4/2/24 at 12:22 PM identified Resident #161 was discharged from the facility to the assisted living facility without oxygen on 1/20/24 in the early afternoon. Person #3 indicated that he/she had notified the resident representative that Resident #161 will need oxygen prior to admission and if there was no oxygen Resident #161 would have to go back to the nursing home or the hospital. Person #3 indicated Resident #161 needed oxygen before going to bed because the resident's oxygen desaturates with sleep. Person #3 indicated he/she called the nursing home regarding the oxygen order and the person stated they did not know anything about an oxygen order. Person #3 indicated she finally spoke to the discharge person at the nursing home and told her this was not a safe discharge as the resident was discharged without an oxygen being in place. Person #3 indicated she called an oxygen company emergency number and inquired about oxygen for Resident #161 to be delivered before 8:00 PM on 1/20/24. Person #3 indicated an oxygen company responded and had delivered the oxygen around 8:00 PM. Person #3 indicated Resident #161 representative was very upset about the discharge procedure from the nursing home. Person #3 indicated she did not receive a phone call from the nursing home, she was the one that called the nursing home regarding the oxygen equipment not being delivered to the assisted living facility prior to Resident #161 discharge. Review of the facility discharge policy identified resident being discharged from the facility shall have a planned discharge when possible. Residents should only be discharged upon written order of the attending physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident # 84 was admitted to the facility on [DATE] with diagnoses that included dementia with agitation, post traumatic stress disorder (PTSD), and anxiety. The physician's orders dated 3/13/24 directed that Resident #84 required Quetiapine (an antipsychotic medication) 25 mg twice daily for anxiety and Trazadone (a psychotropic medication) 25 mg at bedtime for insomnia. The admission MDS assessment dated [DATE] identified Resident # 84 had severely impaired cognition, was always incontinent of bowel and bladder and required with moderate assistance with dressing, transfers, and set up for meals. The March 2024 care plan identified Resident #84 was at risk for depression due to history of PTSD. Interventions included to monitor, document and re/port any risk for harm to self, harm to others, and signs/symptoms of depression including hopelessness and negative statements. A physician's order dated 3/17/24 at 8:04 PM directed Resident #84 be placed on 1:1 monitoring until seen by psychiatry due to suicidal ideation's. The nurse's note dated 3/17/24 at 10:14 PM identified Resident #84 had reported he/she wanted to harm his/herself at 6:41 PM. The note further identified Resident #84 was placed on 1:1 monitoring until cleared by the on call psychiatric APRN. The note also identified that 1:1 monitoring was discontinued following clearance by psychiatry. The nurse's note by RN #4 dated 3/18/24 at 11:54 AM identified that Resident #84 had reported he/she wanted to harm his/herself. The note further identified Resident #84 was placed on 1:1 monitoring until seen by psychiatry and that Resident #84's significant other was at the bedside visiting. The nurse's note further identified that Resident #84's significant other was instructed to notify RN #4 prior to leaving the facility to resume 1:1 monitoring. Review of the facility visitor log for 3/18/24 identified Resident #84's significant other was at the facility from 11:40 AM to 6:35 PM. Review of the clinical record failed to identify any additional documentation related to behaviors including 1:1 monitoring for Resident #84 on 3/18/24 and 3/19/24. Review of the clinical record also identified LPN #7 cared for Resident #84 on 3/18/24 3 PM-11 PM shift and LPN #6 cared for Resident #84 on 3/18/24 11 PM-7 AM shift. A nurse's note dated 3/19/24 at 12:04 PM identified Resident # 84 was seen by PhD #1 (psychologist) and was cleared of suicidal ideation and was off 1:1 monitoring. Interview with RN #4 on 3/26/24 at 10:05 AM identified that Resident #84 was placed on 1:1 monitoring sometime during her shift on 3/18/24 but she could not remember what time Resident #84 verbalized suicidal ideation or when 1:1 monitoring was initiated. RN #4 further identified that once Resident #84's significant other arrived to the facility, no 1:1 monitoring observations were completed by facility staff, and that she instructed Resident #84's significant other to notify someone when he/she was leaving so that 1:1 monitoring could be resumed by the facility and that Resident #84's significant other was still at the facility when she left. RN #4 identified that the facility policy was for a shift note to be documented, and that she did not document any other notes on 3/18/24 related to Resident #84's behaviors or 1:1 monitoring. Interview with LPN #6 on 3/26/24 at 10:24 AM identified that she did not provide any 1:1 monitoring for Resident #84 on 3/18/24. LPN #6 identified she received report from LPN #7 and was notified that Resident #84 had verbalized suicidal thoughts on 3/18/24 during the 7 AM-3 PM shift and had been placed on 1:1 monitoring, but that the monitoring had been discontinued prior to change of shift at 3 PM. LPN #6 identified Resident #84 was not on any type of behavior monitoring and did not have any orders related to 1:1 or behavior monitoring in place when she took over care. Interview with APRN #3 (psychiatric APRN) on 3/26/24 at 10:55 AM identified that Resident #84 should have had 1:1 monitoring by the facility staff and that that staff should have remained with Resident #84 until cleared by psychiatry. APRN #3 further identified that while Resident #84 would be able to have visitors during the monitoring, it was the responsibility of the facility staff and not Resident #84's visitors to provide 1:1 monitoring for suicidal ideation. Interview with the DNS on 3/26/24 at 11:30 AM identified Resident #84 should have had continuous 1:1 monitoring for suicidal ideation on 3/18/24 until cleared by the psychiatric provider. The DNS identified that the 1:1 monitoring did not necessarily need to be completed by nursing staff of the facility, and that any staff member with training in behavior monitoring and 1:1 observation could be assigned, it was not appropriate rely on Resident # 84 to perform any behavior monitoring as visitors to residents of the facility are not facility staff members. The DNS also identified that 1:1 monitoring would include keeping the resident within eye sight, but this would be based on a case by case basis. The DNS also identified that the facility did not have any policy related to specifics of that 1:1 monitoring should include, and that the facility only documented progress notes related to 1:1 monitoring periodically in the clinical record. Although attempted, an interview with LPN #7 was not obtained. Although attempted, an interview with PhD #1 was not obtained. The facility policy on resident suicide threats identified that residents who have threats of suicide should remain on 1:1 until deemed safe, and that staff would monitor the resident's mood and behavior accordingly. The facility policy on psychoactive medication use directed any residents receiving antipsychotic medications with a diagnosis of dementia and agitated/psychotic behaviors should have specific behaviors quantatively documented, including number of episodes and occurrences. Based on review of the clinical record, review of facility documentation, and interviews for 1 of 1 resident (Resident #47) reviewed for accidents, the facility failed to ensure the neurological assessment was completed per policy after an unwitnessed fall with injury and, and for 1 of 3 residents (Resident #84) reviewed for behaviors, the facility failed to ensure behavior observation and monitoring was provided for a resident that required 1:1 constant supervision. The findings include: 1. Resident #47 was admitted to the facility with a diagnosis which included dementia, diabetes, and difficulty in walking. The care plan dated 8/31/23 identified multiple falls. Interventions included dycem to wheelchair, offer toileting after lunch and before end of 7:00 AM to 3:00 PM, and encourage participation in activities. Resident #47 was non ambulatory and uses a mechanical lift for transfers. The quarterly MDS assessment dated [DATE] identified Resident #47 had moderately impaired cognition and required extensive assistance with dressing, toileting, and personal hygiene. Additionally, that Resident #47 had no falls prior to admission and no falls since prior assessment. Review of the accident and incident report dated 11/20/23 at 5:15 PM indicated Resident #47 had an unwitnessed fall at his/her bedside. The resident was awake, alert, and forgetful. Resident #47 was last seen in bed with heel booties on prior to the fall and fell onto his/her face resulting in a laceration to the bridge of the nose and copious amounts of frank red blood. Assessment identified the bridge of the nose identified it was red, painful and swollen. Resident #47 remained on the floor until EMS arrived. The nurse's note dated 11/21/2023 at 1:49AM identified Resident #47 returned to facility at 1:40 AM from the emergency room via ambulance stretcher. Resident #47 is alert and oriented to self. Confused at baseline. Resident #47 has an abrasion, edema and hematoma noted to nose. Diagnosis with nasal fracture related to fall and a urinary tract infection. New order for antibiotic for 5 days. On call APRN notified and follow up with house APRN in the morning. Neurological checks and range of motion as tolerated. Safety measures maintained and continue to monitor. Summary of accident and incident report dated 11/22/23 indicated that Resident #47 had sustained a nasal fracture from the unwitnessed fall. Resident returned from the emergency room on [DATE] with a diagnosis of nasal fracture, atrial fibrillation, and urinary tract infection. Intervention to offer toileting and for Resident #47 to get out of bed around dinner time. Resident #47 was started on antibiotics for the urinary tract infection. A review of the clinical record failed to provide evidence of neurological assessments following the fall on 11/20/23. Interview with DNS on 03/25/24 at 7:00 AM indicated that his expectation was that any resident that had an unwitnessed fall would have neurological assessments including vital signs completed per facility policy. The DNS indicated if the resident goes to the emergency room and returns, he expects the neurological assessments to continue when the resident returns. The DNS indicated that Resident #47 went to the hospital but when he/she returned the nurses should have restarted the neurological assessments that include the vital signs. Review of the facility Fall Prevention Program Policy identified that if a resident has an unwitnessed fall or suffers a head injury, a neurological assessment is to be completed and neurological signs are to be documents according to the following time line: every 15 minutes for the first 2 hours, every 30 minutes for the next 2 hours, every hour for the next 4 hours, every 4 hours for the next 16 hours, and every shift for the next 48 hours. If any point there is a change in the neurological signs, the healthcare provider will be notified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility documentation, facility policy and interview for 1 resident ( Resident #12) reviewed for bowel protocols, the facility failed to follow its policy to assist a resident in maintaining bowel function. The findings include: Resident # 12 was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease with dyskinesia, dysphagia, and unspecified convulsions. The annual MDS assesssment dated 2/18/24 identified Resident # 12 had moderately impaired cognition, was wheelchair dependent and incontinent of both bowel and bladder. The care plan dated 2/27/24 identified a focus on constipation with interventions that included follow facility protocol for bowel management. A physician's order dated 3/1/24 directed to administer Milk of Magnesia (laxative) 30 ml every 24 hours as needed for constipation and give Miralax 17 grams (laxative) by mouth daily as needed for no bowel movement in 3 shifts (mix with 120 ml of water, tea, juice or coffee), and Bisacodyl suppository 10mg (laxative), use if Miralax is not effective. The nurse's note dated 3/13/24 at 10:06AM identified that Resident #12 had no bowel movement in 5 days, an assessment was done, identifying abdomen soft and not tender, denies abdominal pain, APRN notified and new orders for Miralax 17 gm and Senna -S 2 tablets .daily at bedtime, responsible party notified of change. An interview and clinical record review with the DNS on 3/25/24 at 2:25PM was unable to provide documentation that Resident #12 bowels were monitored per facility policy and the Resident #12's care plan. The DNS identified the interventions should have begun on the fourth day without a bowel movement. The facility policy for bowel regime states when a resident has had no bowel movement on day number 4; the 3-11 charge nurse will administer milk of magnesia. If constipation continues, the 11-7 nurse will give the resident a suppository at 6:00AM am following the milk of magnesia dose. If constipation continues on day #5 the 7-3 charge nurse will administer a fleet enema. All of the as needed charting is to be documented in the medication administration record for the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, review of facility documentation, and interviews for one of three residents (Resident #19) reviewed for choices, the facility failed to ensure that a resident's prescribed diet was followed per the physician's order. The findings include: Resident # 19 was admitted to the facility on [DATE] with diagnoses which included acute metabolic acidosis, chronic kidney disease, and ileostomy. The physician's orders dated 3/10/24 identified Resident #19 required a renal diet and Lokelma (a medication used to treat high potassium levels) 10 gram packet by mouth twice daily. The care plan dated 3/12/24 identified Resident #19 was at risk for nutritional problems due to multiple chronic diseases and the need for a therapeutic diet. Interventions included to provide and serve a renal diet as ordered. The admission MDS assessment dated [DATE] identified Resident # 19 had intact cognition, was continent of bladder and bowel with ileostomy, and required a therapeutic diet. Review of the clinical record identified Resident #19 had an elevated potassium level of 5.9 (normal range per lab result 3.5-5.1) on 3/24/24 at 1:40 AM. A nurse's note dated 3/24/24 at 3:28 AM identified stat lab result had been received and reported to APRN with new orders for 0.9% sodium chloride IV to run at 60 ml/hr for a total of 1 liter and to administer Kayexalate (a medication used to treat high potassium) 15 gm/60 ml once by mouth and repeat lab on 3/25/24. Review of the clinical record identified Resident #19 had a potassium level of 5.1 (normal range per lab result 3.3-5.1) on 3/25/24 at 12:27 PM. Observation and interview with Resident #19 on 3/25/24 at 12:40 PM identified issues with Resident #19's meal tray. Resident #19 identified he/she had issues with high potassium levels and was supposed to be served meals with low potassium foods. Resident #19 identified that the facility had repeatedly provided high potassium food items, including items with tomatoes, tomato sauce, and potatoes almost daily. Resident #19 also identified his/her lunch tray, which was observed to have a full serving size (approximately one cup) of mashed potatoes. Resident #19 identified he/she was aware that he/she must avoid high potassium foods and did not understand why his/her meal trays kept including these items. Interview with the Dietary Director on 3/25/24 at 3:00 PM identified he had been made aware by Resident #19 that his/her lunch tray did include potatoes. The Dietary Director identified that Resident #19 should not have received any high potassium food items with a renal diet order. The Dietary Director identified he would re-educate his staff regarding therapeutic diet orders. Interview with the Dietician and Regional Dietician on 3/26/24 at 8:30 AM identified that they were aware of Resident #19's renal diet order and elevated potassium levels. The Regional Dietician identified that the renal diet provided by the facility would restrict high potassium and high phosphorus food items, but would try to be as liberalized as possible. The Regional Dietician identified that the facility utilized instant potatoes instead of fresh potatoes when mashed, and that instant potatoes did have a lower potassium level, however she was unable to identify how that would impact a resident on a renal diet with high potassium levels. The Dietician identified that while she was aware Resident #19 had elevated potassium levels, she was not aware Resident #19 had required additional medication or IV fluids as there had not been any nutritional consults placed. The Dietician identified that going forward, Resident #19's meals would include double portions of protein and vegetable with low potassium foods and no starches. Interview with APRN #2 on 3/26/24 at 9:56 AM identified Resident #19 had orders for a renal diet and that would include avoiding any food items high in potassium. APRN #2 identified Resident #19 should not have potatoes of any kind as part of his/her diet since they are high in potassium and could increase Resident #19's already elevated potassium levels. Interview with the DNS on 3/26/24 at 10:54 AM identified he had been notified of the issue with Resident #19's renal diet order and meal trays by the Dietary Director and that going forward the dietary staff were to be re-educated on what foods residents should avoid on a renal diet, and that Resident #19 should not receive any high potassium food items. The facility policy on nutritional management directed that all residents would have their nutritional needs assessed and receive diets as prescribed by the physician. The facility policy on guidelines for a renal diet directed individuals with compromised kidney function may have trouble clearing minerals including potassium, phosphorus, and calcium. The policy further identified foods that should be avoided on renal diet included potatoes and tomatoes.

**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 2 residents (Resident #5, #75) reviewed for respiratory care, the facility failed to ensure respiratory equipment was cleaned, changed, and stored per policy and manufacturer's recommendations (for 189 days). The findings include: 1. Resident # 5 was admitted to the facility on [DATE] with diagnoses which included COPD, centrilobular emphysema, and diabetes type 2. The admission MDS assessment dated [DATE] identified Resident # 5 had intact cognition, utilized a walker and wheelchair for mobility, and was on oxygen therapy. The care plan dated 12/22/23 identified a focus on emphysema/COPD with interventions that included oxygen settings via nasal cannula as ordered. A physician's order dated 3/10/24 directed to apply oxygen at 2-3 liters per minute via nasal cannula to keep oxygen saturation level greater than 88% ever shift for COPD, oxygen dependent. Observations on 03/24/24 08:32 AM identified no date on tubing for oxygen nasal cannula which was on the floor, no date on nasal cannula attached to a portable oxygen canister affixed to the back of the wheel chair which was in use by Resident #5, or date on a nebulizer mask which was on the bedside table. LPN #1 identified that the dating of tubing for the O2 canister, temporary/portable oxygen tank and nebulizer tubing is dated and bagged is done on the Sunday 11-7 shift. LPN#1 was not able to explain why dating of the tubing was not completed. Interview with DNS on 3/25/24 at 2:25 PM noted that the oxygen tubing should be changed and dated on the 11 PM-7AM shift on Sunday night. 2. Resident #75 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary edema, dementia, and obstructive sleep apnea. The admission MDS dated assessment dated [DATE] identified Resident #75 had moderately impaired cognition, was frequently incontinent of bowel and bladder and required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. Additionally, did not indicate the use of a CPAP. The physician's orders dated 1/20/24 (120 days after admission) directed the use the CPAP with medium full face mask oxygen flow rate at 2 liters per minute. On every night, off every morning and as needed when napping. Cleanse CPAP tubing with 1/2 water, 1/2 white vinegar (place tubing into a basin) remove the tubing from the basin and allow tubing to be air dry every Sunday on 11:00 PM-7:00 AM shift. (scheduled while resident is using the C-pap). Observation on 3/24/24 at 7:00 AM Resident #75 was lying in bed wearing a CPAP mask with tubing connected to a machine on a rolling cart on the left side of the bed. Observation on 3/24/24 at 7:30 AM CPAP mask was draped over the machine on a cart without the benefit of a bag and was not labeled or dated. Observation and interview with LPN #2 on 3/24/24 at 7:40 AM indicated the CPAP tubing and mask were not labeled and dated. LPN #2 indicated that the tubing should be labeled and dated each week after being cleaned. LPN #2 indicated that the CPAP full face mask probably should be in a bag when not in use. LPN #2 indicated that the tubing and mask are cleaned once a week with vinegar and water scheduled for Sundays during the 11:00 PM- 7:00 AM shift. LPN #2 indicated that he would get a bag for the full-face mask of the CPAP. LPN #2 indicated he was not aware if any of the tubing or mask get cleaned daily or how often. Interview with the DNS on 3/25/24 at 8:09 AM indicated that the C-PAP full-face mask should be bagged at the bedside when not in use. The DNS indicated he would have to check the policy for changing the mask and tubing. The DNS indicated he knows that they must be changed but not sure how often. The DNS indicated that he would get the policy and the manufacture book for that CPAP. Interview with the DNS on 3/25/24 at 9:05 AM indicated that he did not think the CPAP had a filter or a humidifier chamber. The DNS indicated that he was not sure how often if at all the full-face mask and tubing needed to be changed or cleaned. The DNS indicated that he would have to check his policy. After clinical record review, the DNS indicated there was an order to clean the tubing once a week. The DNS indicated that the filter, mask, and tubing had not been changed since admission. Observation and interview with the DNS on 3/24/24 at 9:10 AM indicated that the mask and tubing were not dated when last changed. The DNS after being shown where the filter was removed the white filter that has a layer of dust on it. After reviewing the clinical record and policy, the DNS indicated that Resident #75 had an order for the CPAP with the settings and to wash tubing weekly. The DNS indicated that Resident #75 was missing the physician orders for cleaning the tubing and the full-face mask must be cleaned daily with warm water and soap, must clean humidifier chamber every morning, disinfect humidifier chamber once a week, masks need to be disinfected weekly, change the tubing every 2 weeks, headgear for the mask should be hand washed once a month or sooner, and white disposable filter needs to be changed once a month. The DNS indicated he will need to add in the physician's orders for the care and cleaning of the CPAP per the facility policy. After surveyor inquiry, a physician's order dated 3/25/24 (189 days later), directed to change the white filter in the C-pap monthly, headgear and mask to be hand washed once monthly at bedtime, disinfect nasal and full-face mask weekly, disinfect chamber once a week in the morning, fill humidifier with sterile water to the fill line prior to the start of therapy at bedtime, nasal and full-face mask and clean humidifier chamber clean every day with warm water and soap daily and let air dry, and cleanse the humidifier chamber every morning with soap and water and let air dry then place in covering plastic bag, Review of the facility C-PAP and Bi-pap Policy identified all residents who have physician orders for a C-PAP will have equipment provided to them through designated Respiratory program or may bring in their own personal equipment. If using disposable tubing change them every 2 weeks. If using the disposable tubing clean tubing every day with warm soap and water. Full face masks need to be cleaned daily with warm water and soap. Masks also needed to be disinfected once a week. The headgear for the masks needs to be hand washed at least once a month cleaned or sooner. The ultra white disposable filter needs to be changed once a month. The humidifier chamber needs to be cleaned every morning with warm water and soap and let air dry. Fill with sterile or distilled water to the fill line prior to therapy daily and disinfect chamber once a week. Additionally, the manufacturer recommendations identified to change the full-face mask and air tubing every 3 months and the mask headgear and humidifier tubing every 6 months.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, review of facility documentation, and interviews for 1 sampled (Resident #88) reviewed for catheters, the facility failed to ensure there the nursing staff were competent to care for specialized medical equipment. The findings include: Resident #88 was admitted to the facility with diagnoses which included dementia, chronic cholecystitis, and hydronephrosis with renal and ureteral calculus obstruction. The quarterly MDS assessment dated [DATE] identified Resident #88 had severely impaired cognition and has a indwelling Foley catheter for urine and a colostomy for bowels. Resident #88 requires total assistance for dressing, toileting, showering, and personal hygiene. A physician's order dated 2/19/24 directed to apply bacitracin to JP( Jackson Pratt drain is a surgical suction drain that draws fluid from a wound following surgery) drain site in right lower quadrant and cover with a dry clean dressing daily and as needed. Document on wound bed, odor, drainage, surrounding skin, and wound outcome. With any symptoms or signs of infection contact the physician. A physician's order dated 2/26/24 directed to empty JP drain to right lower quadrant of abdomen every shift and document output. Monitor for signs and symptoms of infection every shift and make sure to squeeze bulb before capping to continue the suction every shift per policy. The care plan dated 3/14/24 identified Resident #88 has a Jackson Pratt (JP) drain related to cholecystitis. Interventions included observing JP drain output as ordered and JP drain care as ordered, observe for signs and symptoms of infection at the insertion site and update provider. A physician's order dated 3/21/24 directed to apply bacitracin to JP site 2 times a day for redness for 10 days. Observation on 3/24/24 at 10:50 AM Resident #88 was lying on his/her back flat in bed with head of bed slightly elevated. Noted on the right side of bed a clear tube stretching from Resident #88 to the floor with the bulb touching the floor. Observation and interview with LPN #4 on 3/24/24 at 10:55 AM indicated that Resident #88 had his/her gall bladder removed and has a JP drain. LPN #4 indicated that the JP drain should be lying on the bed next to the resident's leg unsecured. LPN #4 indicated that the bulb from the JP drain absolutely should not be touching the floor. LPN #4 picked the JP drain bulb and tubing up off the floor and laid it on the bed next to Resident #88's upper thigh under the sheets without the benefit of disinfecting the bulb prior to placing against resident's skin. LPN #4 indicated that she would go and educate the nursing assistants about the JP drain and placement for infection control reasons. LPN #3 did not disinfect the drainage bulb prior to placing on bed against resident's skin, did not secure the collection bulb, and did not check the placement of the tubing at the insertion site of Resident #88's abdomen. Observation of LPN #5 on 3/26/24 at 6:43 AM she used hand sanitizer and put gloves on, flipped the cap open off top of bulb, emptied the bulb into a clear drinking 8-ounce cup then transferred the liquid into small medication cup. LPN #5 indicated it measured 25 cc. LPN #5 noted the dressing at the insertion site of the JP drain into the abdomen was not labeled or dated. LPN #5 indicated that all dressings require at the time it was changed the nurse's initials and the date it was changed. LPN #5 indicated she has not received any education on the JP drain for at least the last 2 years and if there is any education it is just a read and sign this. Observation and interview with NA #5 on 3/26/24 at 6:58 AM who was assisting NA #4 with care, indicated she does not know what that tube and drainage device is called but she thinks it has something to do with urine like the Foley so knows by common sense the resident should not lay on it and it lays next to the resident. NA #5 indicated she has not been educated about it but uses her common sense. Interview with NA #4 on 3/26/24 at 7:00 AM indicated that Resident #88 had that tube for urine. NA #4 indicated that she was educated during certified nursing school about that JP tube. NA #4 indicated that the facility did not educate her on how to care for the JP drain. Interview NA # 7 on 03/26/24 at 8:24 AM indicated that the drain goes somewhere into Resident #88's stomach. NA #7 indicated that she drains the device into a urinal and in then informs the charge nurse how much was drained. NA #7 indicated after she drains it that she squeezes the device prior to closing it. NA #7 indicated that she drains the liquid into a urinal and if less than 100 ml see with estimate how much. NA #7 indicated she does not use an alcohol pad to open or close the device to empty it. NA #7 indicates in the last year or two she has not had any education on that tube. NA #7 indicated the charge nurse LPN #2 had shown her how to empty it but there was no additional education, and it was done verbally only by LPN #2. Interview with RN #7 on 3/26/24 at 8:34 AM indicated if the nursing assistants see a problem with a dressing, she will go look at it. RN #7 indicated that if round bulb has fluid she will empty because she has to document how many cc's. RN #7 indicated the nursing assistants when she works do not empty it. RN #7 indicated that when the dressing is changed around the JP drain insertion site the nurse must assess the area and must describe if there was any swelling or redness. RN #7 indicated the nurse must put on the new dressing including labeling it with the date, sign it with their initials and put the shift on it. Interview with the DNS on 3/26/24 at 8:43 AM indicated the charge nurses are responsible to change the dressing and empty the drain. The DNS indicated that the nurse must empty the collection bulb using the bedpan or a urinal and then measure it. The DNS indicated he didn't know if the facility had anything to measure something as small as 20 ml's. The DNS indicated maybe the charge nurse could use a medication measurement with 3-4 med cups. The DNS indicated that the charge nurses should empty the JP drain so the nurse could assess the liquid. The DNS indicated that nursing staff education should be done if it was something new for the staff to learn about then the staff development nurse should provide education. The DNS indicated that JP drains were taught in nursing school and are part of nurse's scope of practice. Interview with Staff Development and Wound Nurse (RN #2) on 3/26/24 at 9:21 AM indicated that education for the JP drain was done on hire for general orientation but after review of his general orientation check list it was not part of general orientation. RN #2 indicated that there was not any education or competencies done with the nurse's or nursing assistants in 2022, 2023, or 2024 regarding how to care for a resident with a JP drain, how to empty a JP drain, or dressing changes. RN #2 indicated he would only do competencies and education if we are aware of a need with a nurse. RN #2 indicated that he had just focused on the mandatory training requirements but this year he will look at adding in something about lines and drains for 2024. RN #2 indicated after review of the licensed staff general orientation for new hires that there was not a check off related to lines, drains, or JP drains. RN #2 indicated he would be responsible to do the nursing staff competencies. Although requested a policy on competent nursing staff it was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation and facility policy, for one of six residents ( Resident #12 ) reviewed for unnecessary medications, the pharmacy failed to identify a non-crushable medication as a do not crush. The findings include: Resident # 12 was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease with dyskinesia, dysphagia, and unspecified convulsions. The annual MDS dated [DATE] identified Resident #12 had moderately impaired cognition, was wheelchair dependent and incontinent of both bowel and bladder. The care plan dated 2/27/24 identified long term use of antipsychotics related to schizoaffective disorder and the presence of drug induced tremors. Interventions included to monitor, document and report as needed adverse reactions to psychotropic medications, tardive dyskinesia, or drug induced movement disorders such as shuffling gait, rigid muscles, or shaking. A physician's order dated 3/1/24 directed to provide the following medications: Aspirin 81mg EC (enteric coated) Austedo 6 mg (film coated) ( a medication used for tardive dyskinesia) Janumet 50-1000mg (film coated) ( a medication used for diabetes ) The medication was originally ordered 4/14/22 Review of the Medication administration records from April 2022 through 4/1/2024 identified the medication was administered 720 times crushed. According to Sanoski, Vallerand (2024) Davis's Drug Guide for Nurses 18th edition identified Austedo 6 mg can be used to reduce the severity of tardive dyskinesia and the medication should not be crushed and both the immediate release as well as the extended release must be swallowed whole. Interview with LPN #1 on 3/25/24 at 9:35AM identified Resident #12 takes their medications crushed in applesauce, and is unable to swallow medications whole. Interview and clinical record review with APRN #1 on 3/25/24 at 3:25PM identified the change was made as recommended by the pharmacy on 4/14/22. She identified she was not aware the medication was a do not crush at the time the decision was made. She further identified it is the responsibility of the APRN, physician, pharmacy, as well as nursing to identify if a medication can be crushed for a resident prior to administration, and failed to provide an explanation as to why a do not crush indicator was not included on the medication from the pharmacy nor acknowledged by the facility. Interview and clinical record review with Person #4 (pharmacist) on 3/26/24 at 7:55AM identified the medication Austedo is a do not crush, and failed to provide information as to why the medication was not identified by the pharmacy as a do not crush. He failed to provide information on the efficacy or toxicity of administering Austedo as crushed medication. Interview and clinical record with Person #5 (pharmacist supervisor) on 3/26/24 at 9:25AM identified the medication is a do not crush and will research the toxicity and efficacy and call. She further identified that medications can be coated to create a more pleasant taste for ingesting, or medications can be comprised of several clustered pellets which would impact efficacy and or toxicity if crushed. Although attempted, an interview with the medical director was not obtained. The policy for medication administration identified personnel administering drugs shall refer to the Physician's Desk Reference (PDR) or other reference material when unfamiliar with the pharmacology of the drug, its potential toxic contraindications, antidotes, etc., as well as the specific indications and uses of each drug. The PDR for Austedo identified that the medication should be taken with food, swallowed whole and do not chew, crush or break the tablets. (PDR by ConnectiveRx, March 2024, Drug Summary (pdr.net))

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation and facility policy for one resident (Resident #12) reviewed for blood sugar monitoring, the facility failed to monitor blood sugars according to professional standards of care. The findings include: Resident # 12 was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease with dyskinesia, dysphagia, and diabetes type 2. The annual MDS assessment dated [DATE] identified Resident #12 had moderately impaired cognition, was wheelchair dependent and incontinent of both bowel and bladder. The care plan dated 2/27/24 identified a diagnosis of diabetes which is controlled with diet and oral meds with interventions that included oral medication as ordered, and monitor labs as ordered. The clinical record identified labs drawn on 10/20/23 identified glucose level of 51 mg/dl (normal range 74-100mg/dl) resulting in no new orders. The clinical record identified the last blood sugar documented was on 11/28/23 with a reading of 87 mg/dl with a physician's order to discontinue as blood sugar levels were within normal range of 82-133. Subsequent lab was drawn on 1/23/24 resulting in a glucose level of 41 mg (normal range 74-100mg/dl) which was defined as a critical lab resulting in a follow up call to the facility advising of the low glucose level. An HgA1C of 5.3 was also noted (normal range 4.8-5.6). The 1/23/24 labs were signed by APRN #2 as reviewed and entry into Resident #12's chart. Interview and clinical record review with APRN #2 on 3/26/24 at 9:50AM identified Resident #12's diabetes was managed. She stated the HgA1C was 5.3 on 1/23/24. An additional review of the labs identified the glucose reading of 41 mg. dl on 1/23/24 which was a critical lab resulting in immediate notification to the facility of the glucose level. APRN #2 indicated the critical lab of 1/23/24 was concerning even though the HgA1C was 5.3. APRN #2 further identified the blood sugar should have been monitored as a result of the critical glucose level of 41 mg/dl. Interview and clinical record review with the DNS on 3/26/24 at 12:40PM identified APRN #2 had reviewed the labs of 1/23/24, documented the results, and no new orders were issued. He indicated it is his expectation that diabetes is appropriately managed for residents. The DNS further identified it is his expectation that the critical glucose level of 41 mg/dl obtained on 1/23/24 warranted additional monitoring. Although attempted, an interview with the Medical Director was not successful. The policy for diabetes protocol identified that the physician will follow up on any acute episodes associated with a significant change in blood sugars or deterioration of previous glucose control and document resident status as subsequent visits until the acute situation is resolved. The physician will order appropriate lab tests (for example, periodic finger sticks or A1C) and adjust treatments based on these results and other parameters such as glycosuria, weight gain or loss, hypoglycemic episodes, etc.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, review of facility documentation, and interviews for one of five residents (Resident #84) reviewed for unnecessary medications, the facility failed to ensure targeted behaviors were identified and monitored for a resident receiving psychotropic medications. The findings include: Resident # 84 was admitted to the facility on [DATE] with diagnoses which included dementia with agitation, post traumatic stress disorder (PTSD), and anxiety. The physician's orders dated 3/13/24 directed to administer Quetiapine (an antipsychotic medication) 25 mg twice daily for dementia with agitation; Lexapro 20 mg (an antidepressant medication) for depression, and Trazadone (an antidepressant medication) 25mg at bedtime for insomnia. Review of the clinical record failed to identify any orders or documentation related to targeted behavior monitoring for Resident #84 following admission to the facility on 3/13/24. The care plan dated 3/14/24 identified Resident #84 was at risk for depression due to history of PTSD. Interventions included monitor, document, and report any risk for harm to self, harm to others, and signs/symptoms of depression including hopelessness and negative statements. A physician's order dated 3/15/24 directed to administer Trazadone 25 mg every 8 hours as needed for restlessness, anxiety and agitation for 14 days. A physician's order dated 3/16/24 directed Resident #84 required behavior monitoring every shift for 48 hours, beginning 3 PM-11 PM shift on 3/16/24. The admission MDS assessment dated [DATE] identified Resident # 84 had severely impaired cognition, was always incontinent of bowel and bladder and required with moderate assistance with dressing, transfers, and set up for meals. The MDS also identified Resident #84 had been taking antipsychotic medication on a routine basis. A physician's order dated 3/17/24 directed to administer Mirtazapine (an antidepressant medication) 15 mg at bedtime. Review of the clinical record identified Resident #84 verbalized suicidal ideation's to facility staff on 3/17/24 and 3/18/24. A physician's order dated 3/22/24 (9 days after admission) directed Resident #84 required behavior monitoring every shift for antipsychotic medication use related to behaviors that included uncontrolled agitation, physical aggression, and danger to self and others. Interview with APRN #3 (psychiatric APRN) on 3/26/24 at 10:55 AM identified she completed the initial assessment on Resident #84 following admission to the facility and had also seen him/her several times since admission. APRN #3 identified that Resident #84 should have had targeted behavior monitoring ordered upon admission to the facility based on antipsychotic medication use and that it was an oversight on her part. Interview with the DNS on 3/26/24 at 11:30 AM identified Resident #84 should have had behavior monitoring ordered upon admission the facility, and that while it was missed initially, there were orders for monitoring in place beginning 3/22/24. The facility policy on psychoactive medication use directed that residents receiving these medications would be monitored for medication effectiveness, adverse reactions, and side effects and that specific behaviors would be quantitatively documented. The policy further directed any residents receiving antipsychotic medications with a diagnosis of dementia and agitated/psychotic behaviors must have their targeted behaviors identified and monitored.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident # 91 was admitted to the facility on [DATE] with diagnoses which included bladder cancer, asthma, and hyperlipidemia. The quarterly MDS assessment dated [DATE] identified Resident # 91 had intact cognition, was continent of bowel, occasionally incontinent of bladder and required moderate assistance with transfers, dressing, and set up only for meals. The care plan dated 3/7/24 identified Resident #91 was at risk for Covid 19 infection. Interventions included to follow facility protocol for Covid 19 precautions. Review of the clinical record identified Resident #91 tested positive for Covid 19 infection on 3/14/24. A physician's order dated 3/14/24 directed Resident #91 was placed on contact/droplet precautions for Covid 19. As part of the entrance to the facility on 3/24/24, the facility staff identified to the survey team that the facility had no active Covid 19 outbreaks. A daily nursing roster report dated 3/24/24 identified Resident #91 as Covid 19 positive. Interview with the DNS on 3/24/24 at 7:20 AM identified that he was unsure if Resident #91 was Covid + or had been cleared and would have to look into the matter. Observation on 3/24/24 at 7:30 AM identified Resident #91's room door with a sign that identified the following: Quarantine-Droplet/Contact Precautions. Everyone must-including visitors, doctors, and staff-must clean hands when entering and exiting; gown, don an N-95 respiratory, eye protection, and gloves, and keep door closed. During this observation, no PPE storage cart or equipment was observed outside or around Resident #91's room. Observation on 3/24/24 at 8:38 AM identified that Resident #91's room door no longer had any signage related to contact/droplet precautions. A line list provided by the facility on 3/24/24 at 11:03 AM identified Resident #91 had active Covid 19 infection on contact/droplet precautions through 3/24/24. Observation on 3/24/24 at 12:23 PM identified a PPE cart located outside Resident #91's room. A sign mounted to the cart identified the following: Quarantine-Droplet/Contact Precautions. Everyone must-including visitors, doctors, and staff-must clean hands when entering and exiting; gown, don an N-95 respiratory, eye protection, and gloves, and keep door closed. During this observation, Resident #91's door was observed to be completely open to the unit hallway. Interview with RN #3 (IP nurse) on 3/24/24 at 12:28 PM identified that Resident #91 was still considered to have active Covid 19 and would not be removed from precautions until 3/25/24. RN #3 identified that there was confusion with the DNS, ADNS and clinical staff regarding when Resident #91 was supposed to have Covid 19 precautions removed but that Resident #91 was still considered Covid 19 positive and in an active outbreak upon the survey team's entrance to the facility. Observation on 3/25/24 at 11:00 AM identified that all precaution signage and PPE equipment had been removed from Resident #91's doorway. Interview with RN #3 and LPN #9 (Regional IP Nurse) on 3/25/24 at 11:34 AM identified that there was confusion among the clinical staff and administration regarding when day 10 of Resident #91's outbreak was. LPN #9 identified that the ADNS had been notified by the clinical staff on Resident #91's unit that he/she was off precautions effective 3/24/24, and it was the ADNS who removed all the signage and PPE equipment from Resident #91's room. RN #3 identified that going forward she would be the one to remove precaution signage and PPE carts from resident areas to eliminate confusion for residents on transmission-based precautions. Interview with the ADNS on 3/25/24 at 11:55 AM identified that she removed the PPE cart in front of Resident #91's room on 3/24/24 shortly after 6:30 AM but did not remove the precautions sign from Resident #91's door after being notified by the RN supervisor that Resident #91 was no longer on precautions for Covid. Review of the clinical record identified the physician's order dated 3/14/24 for contact/droplet precautions for Covid 19 was discontinued on 3/26/24 at 7:39 AM. Interview with the DNS on 3/26/24 at 10:54 AM identified that he was not 100% clear on whether Resident #91 was considered Covid 19 positive on 3/24/24 and that RN #3 was new to the IP role. The DNS identified it was a bad day and that the facility was usually very detailed with tracking residents who required transmission-based precautions. The facility policy on Covid 19 infection prevention directed residents with a positive Covid 19 test would be cohorted and placed on precautions per CMS guidelines as able and that a line list of residents with respiratory symptoms would be maintained. The policy further directed that full PPE should be worn per CDC guidelines for care of any resident with known or suspected Covid 19. The facility policy on droplet and contact precautions directed that droplet precautions were used to care for specific residents with documented or suspected infections from highly transmissible or epidemiologically significant pathogens. The policy directed PPE should be utilized including face mask, goggles/face shield and gloves. 3. Resident # 311 was admitted to the facility on [DATE] with diagnoses that included osteoarthritis, chronic obstructive pulmonary disease and hypertension. The baseline care plan dated 3/20/24 identified Resident #311 was at risk for altered cardiovascular status due to hypertension. Interventions included to monitor vital signs as ordered. A physician's order dated 3/20/24 directed to obtain vital signs every day shift for 5 days. 4. Resident #312 was admitted to the facility on [DATE] with diagnoses that included post surgical care, diverticulitis and peritoneal abscess. The baseline care plan dated 3/21/24 identified Resident #312 was at risk for altered gastrointestinal status due to diverticulitis. Interventions included to monitor vital signs as ordered. A physician's order dated 3/21/24 directed to obtain vital signs every day shift for 5 days. Observation on 3/24/24 at 7:45 am identified NA #3 entering the room of Resident #311 and #312, who resided in the same room. NA #3 was observed obtaining vital signs including blood pressure, oxygen saturation via pulse oximeter, and oral temperature from Resident #311. Prior to placing the pulse oximeter on Resident #311's right index finger, Resident #311 was observed rubbing his/her face and nose with his/her right hand. NA #1 then applied the same equipment to Resident #312 without sanitizing or wiping down the equipment. Interview with NA #3 on 3/24/24 at 7:50 AM identified that she only wiped down the vital sign monitoring equipment between residents based on if a resident was on any type precautions and did not routinely clean the equipment between residents who were not on any precautions. Interview with RN #3 and LPN #9 (Regional IP Nurse) on 3/25/24 at 11:34 AM identified that all medical equipment shared between resident should be sanitized after use on each resident. LPN #9 identified she was in the process of providing additional education to NA #3 regarding infection prevention including wiping down equipment between use on residents. Interview with the DNS on 3/26/24 at 10:54 AM identified that all medical equipment that is used between multiple residents should be cleaned prior to use on each resident. The facility policy on cleaning durable medical equipment directed the purpose of the policy was to prevent the spread of infection and provide care with clean equipment. The policy further directed that after reusable medical equipment enters a resident's room or was used, the equipment should be cleaned at minimum with alcohol or germicidal/bleach wipes. Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 1 resident (Resident #88) reviewed for catheters, the facility failed to ensure there the medial equipment was maintained in a sanitary manner and for one sampled resident (Resident #91) reviewed for transmission-based precautions, the facility failed to ensure transmission based precautions were maintained for a resident with a infection; and for 2 sampled residents reviewed for infection control (Resident #311 and Resident #312), the facility failed to ensure shared medical equipment was sanitized between use on residents. The findings include: Resident #88 was admitted to the facility with diagnoses which included dementia, chronic cholecystitis, and hydronephrosis with renal and ureteral calculous obstruction. The quarterly MDS assessment dated [DATE] identified Resident #88 had severely impaired cognition and has a indwelling Foley catheter for urine and a colostomy for bowels. Resident #88 requires total assistance for dressing, toileting, showering, and personal hygiene. A physician's order dated 2/19/24 directed to apply bacitracin to JP drain site in right lower quadrant and cover with a dry clean dressing daily and as needed. Document on wound bed, odor, drainage, surrounding skin, and wound outcome. With any symptoms or signs of infection contact the physician. The consultant report dated 2/20/24 identified Resident #88 had a laparascopic cholecystectomy with a JP drain. The drain was left in place and continue to monitor the output. Add Doxycycline(antibiotic) for 10 days because of redness at the drain site. Follow up will consulting physician in 2 weeks. A physician's order dated 2/26/24 directed to empty JP drain to right lower quadrant of abdomen every shift and document output. Monitor for signs and symptoms of infection every shift and make sure to squeeze bulb before capping to continue the suction every shift per policy. The consultant report dated 3/4/24 identified Resident #88 has a JP drain in place with serous drainage. Continue to monitor output. Will see Resident #88 in 2 weeks and will remove drain once drainage is about 20 ml per 24 hours for 3 days. The care plan dated 3/14/24 identified Resident #88 has a Jackson Pratt (JP) drain related to cholecystitis. Interventions included observing JP drain output as ordered and JP drain care as ordered, observe for signs and symptoms of infection at the insertion site and update provider. A physician's order dated 3/21/24 directed to apply bacitracin to JP site 2 times a day for redness for 10 days. 1. Observation on 3/24/24 at 10:50 AM Resident #88 was lying on his/her back flat in bed with head of bed slightly elevated. Noted on the right side of bed a clear tube stretching from Resident #88 right side under the sheets to the floor with the collection bulb touching the floor. Observation and interview with LPN #4 on 3/24/24 at 10:55 AM indicated that Resident #88 had his/her gall bladder removed and has a JP drain. LPN #4 indicated that the JP drain should be lying on the bed next to the resident's leg unsecured. LPN #4 indicated that the bulb from the JP drain should not be touching the floor. LPN #4 picked the JP drain bulb and tubing up off the floor and laid it on the bed next to Resident #88's upper thigh under the sheets without the benefit of disinfecting the bulb prior to placing against resident's skin. LPN #4 indicated that she would go and educate the nursing assistants about the JP drain and placement for infection control reasons. LPN #3 did not disinfect the drainage bulb prior to placing on the resident's bed under the sheets against resident's skin and did not check the placement of the tubing at the insertion site of Resident #88's abdomen. Interview with the DNS on 3/26/24 at 8:43 AM indicated the JP drain had to be positioned with the resident and it should not be touching the floor because infection control issues. The DNS indicated the tubing from the abdomen to the collection bulb should be attached with a clip to the resident or the side rail but definitely not touching the floor. The DNS indicated if the tubing or drainage bulb touches the floor his expectation was that the charge nurse would use the disinfectant wipes on it to thoroughly clean the collection bulb before securing it to the resident or the bed or place the collection bulb into a bag like a Foley bag. Interview with Staff Development and Wound Nurse (RN #2) on 3/26/24 at 9:21 AM indicated if the JP collection bulb was on the floor the nurse should clean the collection bulb and tubing with alcohol and secure it back in bed with resident. RN #2 indicated that it was an infection control issue if the collection bulb connected to the resident's open wound had touched the dirty floor. RN #2 indicated the collection bulb should be secured with either tape on the side of the resident abdomen or clip it to resident's shirt or his/her person or could tape the tubes to the resident's abdomen on the side. 2. Observation of LPN #5 on 3/26/24 at 6:43 AM she used hand sanitizer and put gloves on, flipped cap open off top of the collection bulb, emptied the bulb into a clear drinking 8-ounce cup of off the medication cart and then transferred the liquid into a small medication cup. LPN #5 indicated it measured 25 cc. LPN #5 emptied the cup into the toilet. LPN #5 removed gloves and used hand sanitizer. LPN #5 noted the dressing at the insertion site of the JP drain into the abdomen was not labeled or dated. LPN #5 indicated that all dressings require at the time it was changed the nurse's initials and the date it was changed. LPN #5 indicated she has not received any education on the JP drain for at least the last 2 years and if there is any education it is just a read and sign this. Interview with the DNS on 3/26/24 at 8:43 AM indicated Resident #88 the charge nurses are responsible to empty the collection bulb to the JP by using the bedpan or a urinal and then measure it. The DNS indicated he didn't know if the facility had anything to measure something as small as 20 ml's. The DNS indicated maybe the charge nurse could use a medication cup and if needed to use 3-4 medication cups. The DNS indicated that the charge nurses should empty the JP drain so the nurse could assess the liquid. Interview with Staff Development and Wound Nurse (RN #2) on 3/26/24 at 9:21 AM indicated only the nurses are allowed to empty the JP drains and measure the output with a disposable sterile cup and discard in the biohazard or a pill cup it is the nurse's discretion. RN #2 indicated the nurses were responsible to follow the policy for emptying the JP drain. Review of the facility policy Jackson Pratt Drain (JP) identified it is the policy of the facility to monitor the JP drainage every shift. The purpose was to ensure safe, effective drainage of serosanguinous fluid from a wound site. Empty the contents once per shift if drainage has accumulated. If excessive drainage, empty the contents more often per the physician's orders. The procedure for emptying wash hands thoroughly with soap and water and put on non-sterile gloves. Release the vacuum by removing the spout plug on the collection chamber. Empty the contents into a graduated cylinder, note the amount, appearance, and odor of the drainage. Use an alcohol swab or sponge to clean the unit's spout and plug. To establish the vacuum that creates the suction power, fully compress the vacuum unit. With one hand holding the unit compress to maintain the vacuum and replace the spout plug with your other hand. The system must be airtight to work properly. Secure the vacuum unit to the residents clothing, fasten it below the wound level to promote drainage. Observe the sutures that secure the drain the residents' skin, look for signs of pulling or tearing and for swelling or infection or surrounding skin. Cleanse the sutures per the physician's order. Flush the drainage contents down the toilet. Review of the facility Infection Control Policy identified standard precautions should be followed when dealing with bodily fluids. Apply disinfection to the area following normal disinfection procedures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, review of facility documentation, and interviews for 1 of 5 residents (Resident #74) reviewed for immunization status, the facility failed to provide the pneumococcal immunization. The findings include: Resident #74 was admitted to the facility on [DATE] with diagnoses which included hypertension and diabetes mellitus. Review of Resident #74's immunization record identified he/she received PCV (Prevnar) 13 on 9/26/13. The quarterly MDS assessment dated [DATE] identified Resident #74 had severely impaired cognition and was not up to date with the Pneumococcal vaccination. The quarterly MDS assessment failed to indicate a reason that the Pneumococcal vaccine was not received. Interview and clinical record review with the Infection Control Nurse (RN #3) on 3/25/24 at 11:52 AM failed to identify Resident #74 had received a Pneumococcal vaccination since 2013. RN #3 indicated that she had begun working as the Infection Control Nurse in November of 2023 and was unsure if Resident #74 was eligible to receive or had received a Pneumococcal vaccine while a resident at the facility. RN #3 indicated that she would further investigate Resident #74's vaccine eligibility and status. A physician's order dated 3/25/24 directed to administer Pneumococcal 20-Valent Conjugate vaccine, 0.5 ml intramuscularly one time. Interview with RN #3 and Regional Nurse (LPN #9) on 3/26/24 at 9:44 AM identified that Resident #74 should have been offered the Pneumococcal vaccine this year, but he/she had been missed by the previous Infection Control Nurse. LPN #9 further identified that on 3/25/24 Resident #74's responsible party consented to the administration of the Pneumococcal vaccination, and Resident #74 received the vaccine. Interview with the DNS on 3/26/24 at 1:00 PM identified that it was his expectation that all applicable vaccines are offered to residents on admission to the facility and whenever they are eligible to receive a vaccine. The DNS indicated that he would also expect the Infection Control Nurse to audit residents' clinical records for vaccine eligibility. The Pneumonia Vaccine Schedule directs that it is the policy of the facility to vaccinate residents for the different strains of pneumonia as recommended by the CDC. The CDC Pneumococcal vaccination guidance directs adults who received an earlier pneumococcal conjugate vaccine (PCV13 or PCV7) should talk with a vaccine provider to learn about available options to complete their pneumococcal vaccine series. Adults 65 years or older have the option to get PCV 20 if they have already received PCV 13, at any age.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of facility documentation, and interviews, the facility failed to ensure opened refrigerator items were dated and discarded, per the facility policy, spoiled food products were discarded, frozen food items were covered, and beverage items were stored in a sanitary manner. The findings include: 1. During an initial tour of the facility kitchen on 3/24/24 at 7:10 AM with the Dietary Director, the following were identified: a. Observation of the reach-in refrigerator identified 4 opened Lactaid cartons without the benefit of an open date label and 1 carton of tomato juice, with an open date of 3/9/24. Interview during the tour with the Dietary Director identified that all opened containers should be labeled with an open date to ensure there is no guessing when the containers were opened or when they should be discarded. The Dietary Director indicated that it is the responsibility of the person who opened the container to create an open date label. The Dietary Director further indicated that the kitchen staff are expected to utilize the Date Marking Quick Reference Guide to determine when food items should be used or discarded by, and based on the reference guide the open carton of tomato juice should have been used or discarded after 7 days (3/16/24). b. Observation of the walk-in refrigerator identified a box of iceberg lettuce with a delivery date of 3/12/24 containing 6 heads of lettuce that had spoiled and further observation of the dry storage identified an undated bag of round buns that had blue-black discoloration on the bottom slices. The Dietary Director disposed of the iceberg lettuce and buns. Interview the Dietary Director identified that the box of iceberg lettuce was a recent delivery, and it should not be spoiled; it is his expectation that fresh produce and perishable food items be inspected upon delivery and daily. The Dietary Directory indicated that it is the cook's responsibility to ensure the food is fresh and to notify him of any perishable food items that were delivered spoiled. The Dietary Director further indicated that all bags of bread should be delivered from the vendor with an expiration date stamped on the bag or printed on the clip. The Dietary Director identified that he would call the vendor to notify them that some bread bags were delivered without an expiration date, and he will ensure the kitchen staff date any undated bags of bread upon delivery. c. Observation of the pantry identified an opened, unsealed bag of rice and further observation of the walk-in freezer identified the following un-wrapped items: chicken tenders, beef patties, pie shells, breaded [NAME], tortellini, and hash browns. Interview with the Dietary Director identified that it is his expectation that all food items stored in the refrigerator, freezer, and pantry must be wrapped up after opening. The Dietary Director further identified that if food is not properly sealed it will be exposed to the surrounding environment and it will not taste fresh. d. Observation of 1 of 6 refreshment carts set with fresh juices, coffee, creamers, water, and cups for breakfast service identified the bottom shelf containing the following used or soiled items: a cup partially filled with juice, 2 towels, and a coffee cup containing old coffee and a spoon. Interview with the Dietary Director identified that there should be no dirty items on the service carts, the carts are only for new drinks and snacks; there are designated carts specifically for dirty items. The Dietary Director directed the dietary aide to clean, sanitize, and restock the cart. The Date Marking Woodlake [NAME] policy ensures the proper rotation of ready-to-eat foods and potentially hazardous foods to prevent or reduce foodborne illness and directs that foods will be date marked with the name of the product, the date of the production or opening. Refer to Quick Reference List for discard date. A designated employee(s) will be assigned to monitor products within department refrigerators/freezers within their responsibility. Processes will be monitored by the food service director. The Dry Food Storage policy directs opened boxes of food shall be re-wrapped, dated, and used as soon as possible. The Cold Food Storage directs all prepared foods in the refrigerator shall be kept covered, labeled, and dated. The Sanitation Policy directs that the sanitation of the facility complies with all state, local, and federal guidelines. Kitchen surfaces and equipment will be maintained in a manner to promote clean and sanitary conditions for food preparation and service.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #2) reviewed for abuse, the facility failed to ensure the resident was free from mistreatment. The findings include: Resident #2's diagnoses included myotonic muscular dystrophy, acute kidney failure, diabetes mellitus, and recurrent depressive disorders. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 was alert and oriented, and required extensive assistance of two (2) with bed mobility, transfers, dressing, toilet use, and personal hygiene. The Resident Care Plan (RCP) dated 4/20/2023 identified Resident #2 had an ADL self-care deficit related to myotonic dystrophy. Interventions directed to provide assistance of two (2) people with bed mobility, and provide incontinent care. Review of the Grievance Log dated 5/7/2023 (no time recorded) identified Resident #2 alleged a complaint against NA #1. Follow-up response indicated NA #1 was removed from the care of Resident #2, immediately suspended, then terminated due to poor customer service report. Review of facility social services email written by SW #1 to department heads dated 5/7/2023 at 10:02 AM identified NA #1 provided Resident #2 with incontinent care, NA #1 made derogatory remarks about Resident #2 and used foul language in front of Resident #2, which Resident #2 heard. Resident #2 alleged NA #1 told him/her you should not be s------ yourself and was upset with Resident #2 for being incontinent. The email further indicated NA #1 requested Resident #2 to roll over in the bed and NA #1 became more irritated because Resident #2 did not roll over quick enough. The email indicated Resident #2 reported that NA #1 made him/her anxious. Further, after NA #1 left the room, Resident #2 heard NA #1 use foul language in the hallway when speaking about the care provided to Resident #2. Interview with Resident #2 on 7/31/202323 at 2:15 PM identified the incident occurred during the 11 PM to 7 AM shift. Resident #2 indicated when NA #1 provided incontinent care, NA #1 made multiple statements including you need to change your diet, you shouldn't be s------ yourself, and I shouldn't have to clean up after you. Resident #2 requested NA #1 to immediately leave and she did. Resident #2 indicated he/she could hear NA #1 speaking with another person in the hallway about him/her. Although attempted, interview with NA #1 was unable to obtained. Review of the written statement by NA #1 dated 5/7/2023 identified NA #1 was assigned to care for Resident #2 and indicated he provided care to Resident #2 during the 3 to 11 PM shift, and during the 11 PM to 7 AM shift. The statement failed to identify any inappropriate comments were made by NA #1 to Resident #2 or within hearing distance of Resident #2. Interview with the DON on 7/31/2023 at 3:00 PM identified although the facility investigation determined NA #1 used inappropriate (foul) language within the hearing distance of Resident #2, the language was not used in the presence of Resident #2. The DON indicated although Resident #2 was alert and oriented, the facility did not substantiate abuse occurred, and NA #1's employment was subsequently terminated for poor customer service. Review of the Abuse Policy directed in part, verbal abuse is defined as any use of oral, written, or gestured language that includes disparaging and derogatory terms to residents regardless of their age, ability to comprehend or disability. Mental abuse is defined as, but is not limited to, humiliation, harassment, threats of punishment, or withholding or treatment or services. Mental abuse may occur through either verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #2) reviewed for abuse, the facility failed ensure the State Agency was notified of an allegation of abuse in a timely manner. The findings include: Resident #2's diagnoses included myotonic muscular dystrophy, acute kidney failure, diabetes mellitus, and recurrent depressive disorders. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 was alert and oriented, and required extensive assistance of two (2) person with bed mobility, transfers, dressing, toilet use, and personal hygiene. The Resident Care Plan (RCP) dated 4/20/2023 identified Resident #2 has an ADL self-care deficit related to myotonic dystrophy. Interventions directed to provide assistance. Review of the Grievance Log dated 5/7/2023 (no time recorded) identified Resident #2 alleged a complaint against NA #1. Follow-up response indicated NA #1 was removed from the care of Resident #2, immediately suspended, then terminated due to poor customer service report. Review of facility social services email written by SW #1 to department heads dated 5/7/2023 at 10:02 AM identified NA #1 provided Resident #2 with incontinent care, NA #1 made derogatory remarks about Resident #2 and used foul language in front of Resident #2, which Resident #2 heard. Resident #2 alleged NA #1 told him/her you should not be s------ yourself and was upset with Resident #2 for being incontinent. The email further indicated NA #1 requested Resident #2 to roll over in the bed and NA #1 became more irritated because Resident #2 did not roll over quick enough. The email indicated Resident #2 reported that NA #1 made him/her anxious. Further, after NA #1 left the room, Resident #2 heard NA #1 use foul language in the hallway when speaking about the care provided to Resident #2. Review of the Department of Public Health's FLIS Reportable Event Tracking System failed to identify the facility notified the State Agency of the allegation of mistreatment made on 5/7/2023 (no notification as of 7/31/2023). Interview with the DON on 7/31/2023 at 3:00 PM identified although the facility was aware of the allegation of mistreatment on 5/7/2023, the DON was unable to explain why the State Agency was not notified of the allegation timely. The DON further indicated that the results of the facility investigation identified NA #1 provided poor customer service and since the facility did not substantiate the allegation of abuse, the facility did not report the allegation after the investigation was completed. Review of the CT Public Health Code directed in part, a Class B event is a complaint of patient abuse. The Code further directed, a Class B event requires immediate notice by telephone to the Department, confirmed by a written report within seventy-two (72) hours of the event. Review of the Abuse Policy directed in part, to report allegations involving abuse (physical, verbal, sexual, mental) not later than two (2) hours after the allegation is made.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation review, facility policy review, and interviews for two sampled residents (Resident #104 and #223) reviewed for advance directives, the facility failed to ensure the advance directives were completed timely. The findings include: a. Resident #104 was admitted to the facility during 8/2021 with diagnoses that included dementia with behavioral disturbance. The admission MDS dated [DATE] identified Resident #104 had severely impaired cognition and required total dependence with personal hygiene and one physical assist. The Resident Care Plan (RCP) dated [DATE] identified Resident #104 had impaired cognition. Interventions directed communicate with the resident/family regarding resident's needs. Review of the clinical record identified Resident #104 had a Power of Attorney (POA) for health care decisions. Additional review of the physician's orders from 8/18 through [DATE] failed to identify an order to direct the resident's code status (advanced directives/advance care planning). Additional clinical record review identified the Advance Care Planning (ACP) form dated [DATE] identified the form was checked to indicated Resident #104 was Do Not Resuscitate (DNR). The line description included I do NOT want CPR (chest compressions) nor do I want intubation (breathing tube). Further review of the form identified it was not signed by the resident, the POA or Resident #104's physician. Review of the nurse's notes and social service notes from 8/18 through [DATE] failed to reflect documentation addressing Resident #104 advance care planning code status, and the RCP failed to reflect advance directives. Review of the electronic medical record (EMR) and hard copy chart failed to identify the advanced care plan form and physician order was addressed. Interview with the DNS on [DATE] at 2:08 PM identified he was not aware that Resident #104 did not have an advanced care planning form completed and did not have a physician's order regarding advanced directives. The DNS indicated it is the responsibility of the admission nurse and the floor nurse to address the advanced directives with the resident or the responsible party. The DNS indicated it is the responsibility of the nurse to have the physician review the advanced directives and to obtain a physician's order that reflects the resident's choice for advanced directives in the medical record. DNS indicated Resident #104's advance directives should have been addressed. b. Resident #223 was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance. and atrial fibrillation. Clinical record review identified Resident #223 was responsible for him/herself. The Resident Care Plan (RCP) dated [DATE] identified Resident #223 desired to be a Full Code. Interventions included to review the code status quarterly, re-admission or as needed. The admission MDS assessment dated [DATE] identified Resident #223 was severely cognitively impaired. Review of the physician's orders from 9/16 through [DATE] failed to identify an order for Resident #223's advance care planning code status. Review of the nurse's notes from 9/16 through [DATE] failed to identify documentation addressed Resident #223's advance care planning code status. Review of the electronic medical record and hard copy chart failed to identify the advanced care plan form and physician order was addressed. Review of the Advance Care Planning (ACP) form dated [DATE] identified line #2 was checked to direct Do Not Resuscitate (DNR) I do NOT want CPR (chest compressions) nor do I want intubation (breathing tube). Further, Line #3 was checked to direct I do NOT want to be transferred to the hospital, and line #4 was marked yes, I will/_____ will NOT accept IV antibiotic therapy. Additional review of the form identified the form was not signed by Resident #223, the emergency contact or the attending physician. Interview with the DNS on [DATE] at 2:08 PM identified he was not aware that Resident #223 did not have an advanced care planning form completed and did not have a physician's order directing advanced directives. The DNS indicated it was the responsibility of the admission nurse and the floor nurse to address the advanced directive with the resident or the responsible party. The DNS indicated it is the responsibility of the nurse to have the physician review the advanced directives and obtain a physician order that reflects the advanced directive in the medical record. Review of the undated Advanced Directive Policy, directed in part, all residents will be asked upon admission if they have Advance Directives. A copy of the Advance Directives will be placed into the resident's chart. All residents will be asked to make a decision on resuscitation in the event of a severe medical situation. The DNR option form will be utilized. Facility did not provide a policy regarding completion of the Advance Care Planning form for surveyor review.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation review, facility policy review, and staff interviews for one sampled resident (Resident # 42) reviewed for personal property, the facility failed to ensure reported missing items were included on the facility missing item form, and the facility failed to ensure the missing item form resolution was identified. The findings included: Resident #42 was admitted to the facility with diagnoses that included Alzheimer's and vascular Dementia with behavioral disturbance. The quarterly Minimum Data Set assessment (MDS) dated [DATE] identified severe cognitive impairment and did not walk. Review of the missing item form completed by Social Worker #1, dated 4/13/2021 at 2 PM identified a Resident #42's responsible party (Person #1) reported a painting was missing. Additionally, the report identified Person #1 noted the painting missing on 3/11/2021 and it was last seen prior to COVID-19 pandemic. The report indicated all departments were notified, and multiple room searches were conducted throughout the facility. Additional review of the report identified that although the Missing Item Form identified that staff searched for the missing painting, the form did not identify if the missing item was found or not found, and the resolution of the missing item was blank. Interview with Person #1 on 10/6/2021 at 12:29 PM identified Resident #42's room was changed when he/she had COVID-19. Upon Resident #42's return to his/her prior room, Person #1 identified a missing jewelry box and two small sculptures were missing. He/she indicated the items had sentimental value from Resident #42's previous life and reported to facility staff that the items were missing. Interview and facility documentation review with Social Worker #1 (SW #1) on 10/07/2021 at 8:05 AM identified that during April 2021, Person #1 reported Resident #42's painting was missing as well as a small statue and a jewelry box. SW #1 indicated that although all the items were reported missing on the same day, she did not add the jewelry box and small statue to the missing items report because she forgot. SW #1 indicated the items could have been lost when Resident #42's room was changed. She indicated that she should have included all the missing items on the form, and she should have completed the form to identify if the items were found or not found, and included a resolution on the form. Interview with the Administrator identified all grievances/missing items should be reported to the Administrator and DNS. Additionally, all grievances/missing items should be reviewed by the Administrator and the DNS. She indicated that she should have been notified. Review of the facility Missing Items policy (dated 11/12/19) directed in part, that staff who are aware of a missing item must report it to their immediate supervisor. Any staff member who become aware of a missing item will complete a missing item form and will send a copy of the form to the social service office. The nursing department will begin the follow process. The original form will be forwarded to the manager for follow up and Administration will be notified about the missing item.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation review, and interviews for two of three residents (Resident #47 and #72) reviewed for hospitalization, the facility failed to notify the Office of the State Long-Term Care Ombudsman timely when the resident was transferred to the hospital. The findings include: a. Resident #47 had diagnoses that included emphysema and transient cerebral ischemic attack. The admission MDS dated [DATE] identified Resident #47 had severely impaired cognition and required total dependence with personal hygiene. Clinical record review identified that on 7/14/2021, Resident #47 was discharged from the facility and admitted to the hospital and was readmitted to the facility on [DATE]. The social service note dated 7/20/2021 at 9:24 AM identified Resident #47 was readmitted to the facility on [DATE] from the hospital with a diagnoses of a urinary tract infection, and social services will provide support as needed. A nurse's note dated 8/5/2021 at 7:46 PM identified Resident #47 was transferred to the hospital at 5:30 PM per APRN orders due to new findings of cerebral infarct, new onset of leg weakness and spinal compression. Clinical record review identified Resident #47 was discharged from the facility and admitted to the hospital on [DATE]. The social service note dated 8/9/2021 at 1:46 PM identified after Resident #47's hospital transfer, a Notice of Emergency transfer and bed hold policy was sent to Resident #47 and his/her responsible party. Additional review of the clinical record and facility documentation failed to identify the facility notified the office of the State Long-Term Care Ombudsman of when the resident was transferred to the hospital multiple times and provide a copy of the notice to the long-term care ombudsman after Resident #47's hospital transfers on 7/14 and 8/5/2021. b. Resident #72's diagnoses included transient cerebral ischemic attack, atherosclerotic heart disease, chronic atrial fibrillation. The quarterly MDS dated [DATE] identified Resident #72 had severely impaired cognition and required extensive assistance with personal hygiene and two physical assistance. The APRN note dated 9/25/2021 at 4:47 PM identified Resident #72 had a sudden onset of unresponsiveness, was non-verbal, and had right side weakness that progressed to bilateral upper extremities weakness. APRN directed to transfer Resident #72 to the hospital. A nurse's note dated 9/25/2021 at 5:42 PM identified Resident #72 was transferred to the hospital. A nurse's note dated 9/26/2021 at 3:16 PM identified the hospital called and Resident #72 was admitted to the hospital (discharged from the facility). Additional clinical record review and facility documentation review failed to identify the Office of the State Long-Term Care Ombudsman was notified of Resident #72's discharge. Interview with the Ombudsman on 10/7/2021 at 4:18 PM identified she has not received notification of resident transfers or discharges from the facility since 4/27/2021. Interview with the DNS on 10/12/2021 at 8:30 AM identified the DNS was unable to provide documentation that the Ombudsman was notified of the resident discharges on 7/14 and 8/5/2021 and 9/25/2021. He indicated that he was not aware that the Ombudsman was not notified when Resident #47 was transferred to the hospital. Further, he indicated that he was not aware the Ombudsman was not notified of any resident transfers or discharges since 4/27/2021 and indicated that the Ombudsman should be notified. Interview with the Administrator on 10/12/2021 at 9:38 AM identified she was unable to provide documentation that the Ombudsman was notified of the resident discharges. She indicated that she was not aware that the Ombudsman was not notified when Resident #47 and #72 were transferred to the hospital. Further, she indicated that she was not aware the Ombudsman was not notified of any resident transfers or discharges since 4/27/2021 and indicated that the Ombudsman should be notified. Although requested, a facility policy was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, and interviews for three of six residents (Residents #5, 6, and 7), reviewed for resident assessments, the facility failed to transmit the residents Minimum Data Set (MDS) assessments in a timely manner. The findings include: a. Resident #5 was admitted to the facility on [DATE] with diagnoses that included sprain of left foot and depressive disorder. Resident #5's admission MDS had an Assessment Reference Date (ARD) of 5/12/2021. The MDS, section Z0500B was signed as completed on 6/6/2021; the MDS was signed completed 26 days after the ARD (13 days after the required 14-day completion). b. Resident #6's diagnoses included Alzheimer's disease and dementia with behavioral disturbance. Resident #6's quarterly MDS had an assessment reference date (ARD) of 3/4/2021. The MDS, section Z0500B was signed as completed on 4/11/2021; the MDS was signed completed 39 days after the ARD (19 days after the required 14-day completion). Additional review of Resident #6's clinical record identified a significant change MDS with the ARD 5/14/20/21. The MDS section Z0500B was signed as completed on 5/30/2021, four days after the required 14-day completion date due. c. Resident #7's diagnoses included dementia with behavioral disturbance and chronic kidney disease stage 3. Resident #7's quarterly MDS had an assessment reference date (ARD) of 3/4/2021. The MDS section Z0500B was signed as completed on 4/11/2021, twenty-six days after the required 14-day completion date due. Additional review of Resident #7's clinical record identified a quarterly MDS with the ARD 5/27/2021. The MDS section Z0500B was signed as completed on 6/20/2021, twelve days after the required 14-day completion date due. Interview, clinical record review and facility documentation review with LPN #5 on 10/7/2021 at 7:24 AM identified that she completes the MDS assessments and an RN off-site (RN #12) reviews and signs the MDS as complete. LPN #5 was unable to explain why the MDS assessments were signed late by RN #12 to identify the MDS assessments were complete. LPN #5 indicated that the expectation is that the MDS should be completed timely. Interview, clinical record review and facility documentation review with the DNS on 10/12/2021 at 8:28 AM identified his expectation was that the MDS assessments should be completed and transmitted timely in accordance with CMS guidance. The DNS indicated he was not aware that the MDS assessments not completed timely. Interview with the Administrator on 10/12/2021 at 9:10 AM identified she was not aware the MDS assessments not completed timely, and that the expectation was that the MDS assessments would be completed in accordance with CMS guidelines. RN #12 was unavailable for interview during survey. Review of the, undated, facility Minimum Data Set (MDS) Policy directed in part, the MDS on a new admission will be completed within 14 days. Further the MDS coordinator is responsible for the timely completion of the MDS. Review of the CMS RAI Manual, MDS 3.0, Chapter 5, directed in part, for all non-comprehensive assessments, the MDS Completion Date (Z0500B) must be no later than 14 days from the Assessment Reference Date (ARD). The Manual further directed, the MDS Completion Date (Item Z0500B) No Later Than the ARD plus 14 days for the Annual (comprehensive) and the Quarterly (non-comprehensive), and the 14th calendar day after determination that significant change in resident ' s status occurred.

**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 six residents (Resident #4) reviewed for resident assessments, the facility failed to ensure the Minimum Data Set (MDS) assessment was transmitted timely, and the facility failed to ensure a discharge assessment was completed timely. The findings include: Resident #4's diagnoses included diabetes and chronic atrial fibrillation. Clinical record review identified Resident #4 was admitted to the facility on [DATE]. The admission MDS assessment had an Assessment Reference Date (ARD) of 5/8/2021. The MDS section Z0500B was signed as completed on 5/17/2021 (day 10 after the ARD), and the MDS was due to be transmitted by day 14 after the MDS completion date (due by 5/30/2021). Facility documentation review identified the MDS was transmitted on 6/9/21; the MDS was transmitted eleven (11) days late (11 days after the date of 5/30/2021 due to transmit). Additional clinical record review and facility documentation review identified that Resident #4 was admitted to the facility on [DATE], with the admission MDS ARD 5/8/2021. Review identified the next MDS completed was an entry MDS dated [DATE]. Additional review failed to identify a discharge MDS was completed to reflect a discharge prior to the entry MDS dated [DATE]. Interview, clinical record review and facility documentation review with LPN #5 on 10/7/2021 at 7:24 AM identified that she completes the MDS assessments and an RN off-site (RN #12) reviews and signs the MDS as complete. LPN #5 was unable to explain why the admission MDS assessment dated [DATE] was transmitted late and why the discharge MDS assessment was not completed. She indicated that the admission MDS assessment should have been transmitted timely and the discharge MDS assessment should have been completed when Resident #4 was discharged . Interview, clinical record review and facility documentation review with the DNS on 10/12/2021 at 8:28 AM identified his expectation was that the MDS assessments should be completed and transmitted timely in accordance with CMS guidance. The DNS indicated he was not aware that the MDS assessments not transmitted timely, and he was not aware that the discharge MDS assessment was not completed. Interview with the Administrator on 10/12/2021 at 9:10 AM identified she was not aware the admission MDS assessment was not transmitted timely and she was not aware the discharge MDS assessment was not completed. She indicated that the expectation was that the MDS assessments would be completed in accordance with CMS guidelines and transmitted timely. A review of the facility Minimum Data Set (MDS) policy identified it is the policy of this facility to complete the MDS on a new admission within 14 days and review it quarterly thereafter. The MDS coordinator is responsible for the timely completion of the MDS and for completing the physical/medical sections of the MDS. Review of the CMS RAI Manual, Submission and Correction of the MDS Assessments directed in part, the MDS is required to be transmitted within 14 days after a facility completes a resident's assessment, a facility must electronically transmit encoded, accurate, and complete MDS data to the CMS System. Further, the Manual directed a discharge MDS assessment was required when a resident is discharged to a private residence, when a resident is admitted to a hospital or other care setting, or when a resident has a hospital observation stay greater than 24 hours regardless of whether the hospital admits the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, facilty documentation review and facility policy review for one of four Residents (Resident #38) reviewed for activities of daily living, the facility failed to ensure showers were provided according to resident preference. The findings included: Resident #38 was admitted with diagnoses that included atrial fibrillation and a history of falls. The quarterly minimum data set assessment (MDS) dated [DATE] identified impaired cognition and Resident #38 required assistance of one person with personal hygiene. The Resident Care Plan (RCP) dated 8/24/2021 identified a problem with activities of daily living secondary to a shoulder fracture and osteoarthritis. Interventions directed assist of person for dressing and bathing and to assist Resident #38 with showers every Monday on the day shift. The physician orders dated 8/24/2021 directed to conduct a weekly skin audit on shower day every Monday. The Nurse Aide Patient Care Card directed to give Resident #38 a shower every Monday on the day shift. The nursing progress notes dated 9/21/2021 identified the Administrator met with Resident #38 and regarding Resident #38 did not receive a shower as scheduled on 9/20/2021 wthi the plan for Resident #38 to receive a shower on 9/21/2021 during the evening shift. Further review of the clinical record identified the Treatment Administration Record (TAR) record dated 10/11/2021 indicated the weekly shower scheduled on 10/11/2021 was not provided. Interview with LPN #6 on 10/12/2021 at 11:17 AM identified Resident #38 did not receive a shower on 10/11/2021 and was provided with a sponge bath instead. She indicated that they did not have the usual number of NAs working and the shower was not given. Interview with the DNS on 10/12/2021 at 11:39 AM identified the shower should have been provided on 9/21 and on 10/12/2021 as scheduled, or if staff were unable to provide the shower on the scheduled day it should be rescheduled. Review of the facility policy entitled Bath and Showers directed in part, to give the resident a shower when it is required by the weekly shower schedule or as indicated by the plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility policy review, and staff interviews for one of five residents reviewed for pressure ulcers, the facility failed to ensure a consultant physician recommendation for a resident with a pressure ulcer was acted upon timely. The findings included: Resident #95 was admitted to the facility with diagnoses that included Alzheimer's disease, Type 2 diabetes, and HTN. The quarterly Minimum Data Set Assessment (MDS) dated [DATE] identified Resident #95 had severe cognitive impairment, was dependent on two (2) staff for bed mobility and transfers, was at risk for pressure ulcer development and had one stage III pressure ulcer. The Resident Care Plan (RCP) dated 9/4/2021 identified Resident #95 had a potential/actual impairment to skin integrity. Interventions directed to monitor skin daily with care, administer treatments as ordered and report improvements and declines to the physician. Review of the clinical record identified Resident #95 was followed by a wound physician for his/her pressure ulcer. The wound consultant recommendation notes dated 9/7/2021 identified a problem of stage 2 pressure ulcer of the left heel with 3 adjacent areas that were mildly improving, pulses were not palpable and significant Peripheral Vascular Disease (PVD) may be delaying wound healing. Treatment recommendations and physician ' s order directed to obtain an Ankle Brachial Index Test (ABI) and Pulse Volume Recording (PVR) to detect blockages and evaluate blood flow in the legs to determine the degree of peripheral arterial disease. Further, if revascularization procedure to restore the blood flow was an option, it may speed up the wound healing and the plan was discussed with facility staff. Review of the wound consultant note dated 9/14/2021 identified they physician repeated the recommendation and order for the ABI study. The nurse's note dated 9/14/2021 at 2:35 PM identified Resident #95 was seen by the wound doctor with new recommendations for an ABI study. Resident #95 required a referral for the vascular study, and the physician and family were updated. Additional review of wound consultant physician notes identified the recommendation and order for the ABI study was repeated on 9/21, 9/28 and 10/5/2021. Additional clinical record review failed to identify the wound consultant recommendations for an ABI and PVR were acted upon. Interview with LPN #6 on 10/12/2021 at 11:17 AM identified she was not aware of the recommendation for the ABI and PVR study and did not know why it was not scheduled. Review of the clinical record and Interview with the DNS on 10/12/2021 at 11:39 PM identified he did not know the ABI/PVR study was recommended by MD #1. He indicated that the ABI and PVR tests were never scheduled, and he did not know why it was not addressed. The DNS further indicated that the process for consultant recommendations included the nurse would read the consult, transcribe the orders into the computer and notify the scheduler to book the appointment and that the appointments should have been scheduled. Interview with MD #1 (wound physician), on 10/12/2021 at 11:46 PM identified the left heel ulcer was slowly improving and he had ordered the ABI and PVR study to determine if Resident #95 had peripheral arterial disease that may qualify for surgery to restore the blood flow to his left foot to help the wound heal. Additionally, he would have expected the procedures to be completed within 2 weeks as they are simple noninvasive procedures. He indicated that he did not know why the appointment was not scheduled and he wanted them completed. Interview with The Scheduler on 10/12/2021 at 2 PM identified that she was never notified an ABI and PVR test was required for Resident #95, and she did not schedule the tests. She indicated that each unit had an appointment book and when a recommendation for an appointment was made, the charge nurse would complete the form to request the appointment and she would check the book twice daily. Once the appointment was scheduled, the scheduler would keep a master copy and return the original to the appointment book on the unit and this process was not followed. She further indicated that if the wound physician made the recommendation, the appointment should have been scheduled. Review of the facility undated Consultations Policy directed in part, that an order shall be obtained from the residents attending physician for all consultant services. The Policy further directed to notify the resident and responsible party, and to book the appointment and transportation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, facility documentation review, and staff interviews for one of two residents (Resident # 95) reviewed for position and mobility, the facility failed to ensure a splint was applied in accordance with physician ' s orders. The findings included: Resident #95 was admitted to the facility with diagnoses that included Alzheimer's disease, Type 2 diabetes, and HTN. The quarterly Minimum Data Set Assessment (MDS) dated [DATE] identified Resident #95 had severe cognitive impairment and had limited range of motion of his/her bilateral upper and lower extremities and did not wear orthotics. The Resident Care Plan (RCP) dated 9/4/2021 identified Resident #95 had a problem of left hand and digit extension contractures, bilateral elbow contractures, and bilateral ankle contractures. Interventions directed to apply orthotics as ordered and monitor contractures for worsening and conduct PT or OT screen as needed for changes. The physician orders dated 7/25/2021 directed to apply a left hand grip orthotic 6-8 hours during the 7 AM to 3 PM shift. The Therapy Splint Form dated 7/28/2021 directed the use of a left-hand grip splint to apply in the morning and wear 6 to 8 hours daily and to store the device in a closet between use. Observation on 10/07/21 at 11:22 AM identified Resident #95 lying in bed and was not wearing the left-hand grip splint. The facility splint/brace audit tool dated 10/7/2021 identified the left-hand grip splint was missing and OT would address. Interview and observation with NA #11 on 10/07/21 at 11:24 AM identified she was the primary NA assigned to Resident #95 four (4) days a week. She indicated that Resident #95 was not wearing the splint because it had been missing for months. Additionally, NA #11 identified she did not recall that she had informed anyone of the missing splint. Further, NA #11 identified the splint was required for a hand contracture and was to be put on Resident #95 during care and left on for the day shift, and she has not done this. Interview, clinical record review, and observation with LPN #6 on 10/07/2021 at 11:30 AM identified that she was the regular charge nurse on the unit. She indicated that NA #11 should have applied Resident #95 ' s hand splint during morning care and the splint was ordered to be worn for six (6) to eight (8) hours a day during the day shift. Further, she indicated that she did not know Resident #95 was not wearing the splint or that the splint was missing. Interview with the DNS on 10 /07/2021 11:45 AM identified the splint should have been applied during morning care and he was not aware the splint was missing. Further, he indicated that he would expect staff to report if the splint was missing. Interview and clinical record review with The Director of Rehab on 10/07/2021 at 11:54 AM identified Resident #95 required the hand splint to prevent worsening of contractures and should wear the splint six (6) to eight (8) hours a day during the day shift. She indicated that she was not aware Resident #95 had not been wearing the hand splint or that it was missing. Additionally, the Director of Rehab identified OTR #1 had just completed a quarterly screen on 10/7/2021 and they identified the splint was not in use because it was missing. The Director of Rehab indicated that she would expect to be notified when a splint is missing, and she was not notified that Resident #95 ' s splint was missing. Further, the Director of Rehab indicated that Resident #95 would be evaluated by occupational therapy to assess the status of contracture and order a new splint. Although requested, no facility policy was provided for surveyor review regarding splint use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation review, and interviews for one of five residents (Resident #104) reviewed for unnecessary meds, the facility failed to ensure an the pharmacist recommendation was acted upon timely. The findings include: Resident #104 was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance. A physician's order dated 8/18/21 directed to administer Quetiapine Fumarate (Seroquel), an antipsychotic medication, 12.5 milligrams (mg) tablet by mouth every 12 hours as needed for agitation related to dementia with behavioral disturbance. The admission MDS dated [DATE] identified Resident #104 had severely impaired cognition and required total dependence with personal hygiene and received an antipsychotic medication seven out of the last seven days. The care plan dated 8/26/2021 identified Resident #104 used psychotropic medications. Interventions directed to administer psychotropic medications as ordered by physician. Review of the pharmacy monthly regimen review dated 9/21/2021 identified that Resident #104 was receiving an as needed (prn) antipsychotic medication, Seroquel (Quetiapine) 12.5mg every twelve (12) hours as needed. The pharmacy review further identified that PRN antipsychotic medication orders are only valid for 14 days, and after every 14-day period, the resident must be re-evaluated, and a new order written for another 14 days if indicated. The pharmacist recommended to re-evaluate the need for the PRN Seroquel and to limit the order to 14 days. Clinical record review failed to identify the pharmacist recommendations were acted upon. Review of the physician's monthly orders dated 8/18/21 through 10/12/21 (1 month and 3 weeks), identified the order for Quetiapine Fumarate 12.5 mg tablet by mouth every 12 hours as needed (prn) was in place with no evidence or documentation of a 14 day stop date. Interview with the DNS on 10/12/21 at 9:00 AM identified that the licensed staff should acted upon the pharmacist recommendation regarding the Seroquel use, and they should have notified the APRN psychiatrist to evaluate and antipsychotic medication and renew the order. Although requested, a facility policy was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based review of the clinical record and interviews for one of five residents (Resident #104) reviewed for unnecessary meds, the facility failed to ensure an as needed (prn) antipsychotic medication was limited to 14 days. The findings include: Resident #104 was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance. A physician's order dated 8/18/21 directed to administer Quetiapine Fumarate (Seroquel), an antipsychotic medication, 12.5 milligrams (mg) tablet by mouth every 12 hours as needed for agitation related to dementia with behavioral disturbance. The admission MDS dated [DATE] identified Resident #104 had severely impaired cognition and required total dependence with personal hygiene and received an antipsychotic medication seven out of the last seven days. The care plan dated 8/26/2021 identified Resident #104 used psychotropic medications. Interventions directed to administer psychotropic medications as ordered by physician. Review of the physician's monthly orders dated 8/18/21 through 10/12/21, 1 month and 3 weeks, identified the order for Quetiapine Fumarate 12.5 mg tablet by mouth every 12 hours as needed (prn) was in place with no evidence or documentation of a 14 day stop date. Interview with the DNS on 10/12/21 at 9:00 AM identified that the licensed staff should acted upon the pharmacist recommendation regarding the Seroquel use, and they should have notified the APRN psychiatrist to evaluate and antipsychotic medication and renew the order. Although requested, a facility policy was not provided.

Based on observation, review of facility documentation, facility policy review, and interview, the facility failed to maintain an accurate record of the temperatures for the dishwasher, the freezer and the refrigerator. The findings include: a. Building Fire Safety Inspection (BFSI) tour of the kitchen on 10/6/2021 at approximately 10:30 AM with the Maintenance Director identified the October 2021 dishwashing machine temperature record log had been completed for the dates of 10/1/21 through 10/6/21 for breakfast and dinner. The log failed to reflect that the dishwasher temperatures were recorded for the noon meal on 10/4 and 10/5/2021. b. Review of the freezer and refrigerator temperature form for the month of August 2021 identified the freezer and refrigerator temperature form failed to reflect documentations for 8/27, 8/28, and 8/29/2021. Further, the facility was unable to provide the September 2021 freezer and refrigerator temperature form for review; the form was not available. Interview with the Food Service Director (FSD) on 10/6/2021 at 12:40 PM identified she was not aware of the dishwasher machine temperature missing temperatures. FSD indicated she does not know who filled out the log. The FSD indicated she was unable to find the freezer and refrigerator temperature form for the month of September 2021. The FSD indicated the missing temperatures for the dishwasher, the freezer and the refrigerator should have been recorded, and a form should have been completed for September 2021. Interview with the Administrator on 10/12/2021 at 9:15 AM identified she was not aware of the missing temperatures. She indicated the missing temperatures for the dishwasher, the freezer and the refrigerator should have been recorded, and a form should have been completed for September 2021. Review of the facility dishwasher machine policy dated 7/1/2021 directed in part, all dining services employees shall follow appropriate dishwashing procedures. Staff must maintain log of wash and rinse temperatures three times daily. Dish machine should be run through a few cycles to ensure that appropriate temperatures exist before commencement of dishwashing. The policy further directed the Food Service Director will monitor documentation and accuracy of temperature logs and procedures. Review of the refrigerators and freezers policy dated 7/1/2021 directed in part, the facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. Monthly tracking sheets for all refrigerators and freezers will be posted to record temperatures. Food service supervisor or designated employees will check and record refrigerator and freezer temperatures at least twice daily to include opening and closing times of kitchen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, facility documentation review, facility policy review, and interviews for one resident (Resident # 70) reviewed for respiratory care, the facility failed to ensure oxygen tubing were changed timely in accordance with the physician's order, and for facility infection control review, the facility failed to ensure meal trays removed from resident rooms were not placed on top of the clean linen cart. The findings include: a. Resident #70's diagnoses included COPD, chronic respiratory failure and emphysema. Resident Care Plan (RCP) dated 7/2/21 identified Resident #70 had an altered respiratory status/difficulty breathing related to asthma, COPD and oxygen use. Interventions directed to administer oxygen as ordered. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified that R #70 was alert and oriented and used oxygen. The Physician's order dated 8/2/2021 directed to administer oxygen at two (2) liters a minute (l/m) via a nasal canula, and to change the oxygen tubing every week on Wednesday on the 11-7 shift. Observation on 10/04/2021 at 11:55 AM identified Resident #70 was receiving oxygen via a nasal canula at 2 l/m and the cannula tubing was dated 9/22/2021 (13 days prior to the observation). Observation and interview with LPN #4 on 10/5/2021 at 11:35 AM identified Resident #70 was receiving oxygen via a nasal canula at 2 l/m and the cannula tubing was dated 9/22/2021 (14 days prior to the observation). LPN #4 indicated the oxygen tubing should be changed weekly by the nurse on the 11 PM to 7 AM shift. Observation and interview with the Administrator and LPN #4 on 10/6/2021 at 11:45 AM identified Resident #70 was receiving oxygen via a nasal canula at 2 l/m and the cannula tubing was dated 9/22/2021 (15 days prior to the observation). Interview identified that the oxygen tubing should have been changed weekly. Further, LPN #4 indicated that she did not change the tubing on 10/5/2021 after surveyor inquiry because she thought that the nurse on the 11 PM to 7 AM shift would change it. She indicated that she should have changed the tubing. Subsequent to surveyor inquiry, the oxygen tubing was changed. Although requested, a facility policy regarding changing oxygen tubing was not provided. b. Observation and interview with LPN #2 on 10/4/2021 at 12:53 PM identified NA #1 was carrying a tray with dirty dishes including a food plate cover, cups and silverware. NA #1 was observed to place the tray with the dirty/used items on top of a clean linen cart currently in use by NA # 4. LPN #2 identified the tray should not be placed on top of the clean linen cart. Subsequent to surveyor inquiry, LPN #2 removed the tray with dirty dishes/utensils from the top of the clean linen cart. Interview with NA #4 on 10/4/2021 at 12:55 PM identified that she had removed the tray with dirty dishes from a resident room and she should not have placed the tray on top of the clean linen cart. Interview with the DNS on 10/5/2021 at 12:09 PM identified the tray with dirty dishes should not have been placed on the clean linen cart. Although requested, a policy for disposal of dirty dishes after meals was not provided.

Based on facility documentation review and interviews for facility Resident Council review, the facility failed to ensure staff acted upon resident council concerns timely. The findings include: A resident council meeting was conducted on 10/5/2021 at 9:00 AM with nine (9) representatives of the resident council in attendance. Residents attending identified grievances were voiced during resident council meetings regarding call-bell response time on all shifts, staff not introducing themselves when providing resident care, staff loud in the halls during shift change, snacks not provided, and staff not walking residents on the weekends. Residents further indicated that they had consistently reported the above issues to the nursing staff, the issues had not been addressed, and no changes had occurred. Review of the Resident Council minutes from 9/21/2020 to 6/15/2021 identified that Resident Council members voiced grievances regarding long call-bell response time on 9/21 and 10/19/2020, and on 1/18 and 6/15/2021 (4 times). Further review identified grievances were voiced regarding staff and agency staff not introducing themselves to residents receiving care on 5/18, and 6/15/21 (2 times) and on 6/15/2021 staff using cell phones when administering medications and providing resident care. Minutes dated 9/21 and 10/19/20, and 1/18, 5/18, and 6/15/2021 (5 times) recorded resident grievances regarding NA's were loud and noisy in the halls discussing their assignments, and snacks were not offered. Additional minutes dated 9/21, 10/19/2020 and 3/16/2021 (3 times) identified residents voiced grievances regarding staff not walking residents on weekends. Review of the Resident Food Committee meeting from 9/21/2020 to 6/15/2021 identified that on 5/18 and 6/15/2021 (2 times) residents reported grievances regarding not receiving snacks. Additional review of the resident council minutes identified that although resident grievances were recorded and documented as reported, the minutes failed to identify that the resident's grievances were acted upon and included a response back to the Council. Interview and facility documentation review with the DNS on 10/5/2021 at 11:00 AM identified he was not aware of the issues. The DNS indicated the expectation of the facility was that all staff members answer call lights timely and staff should introduce themselves to residents. He further indicated that staff should not be using cell phones on the units, staff should not be loud in the halls, snacks are available on the units and should be offered/provided to residents as indicated, and residents should be walked by staff on the weekends as indicated for the resident. The DNS was unable to provide documentation that the grievances voiced by residents were addressed by the facility and indicated they should have been addressed. Subsequent to surveyor inquiry, the DNS indicated he will address the resident grievances. Interview with the Administrator on 10/12/2021 at 9:10 AM identified she was not aware of the issues identify during resident council meeting. Although requested, a facility policy was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, facility documentation review, facility policy review, and interviews for dietary review, the facility failed to ensure food temperatures were maintained at accepted temperatures. The findings include: During an interview with Resident #56 on 10/4/2021 11:04 AM, Resident #56 indicated that hot foods are served cold. Interview with Resident #43 on 10/4/2021 at 3 PM identified the food is cold. Observation of point of service dining (steam table) of the first floor on 10/06/2021 at 12:40 PM identified a steam cart in the hallway outside of the dining room was plugged into the wall. Dietary Aide (DA) #1 and DA #2 were portioning food onto uninsulated plates with covers and placing them on a uninsulated rolling cart. NA #4 and NA #7 were delivering food to residents directly from the steam cart and while the NA #4 and NA #7 were delivering food, DA #1 and DA #2 prepared additional plates with food and left the plates (with food) on either the side of the steam cart or on the rolling cart, without the benefit of an insulated plate holder or insulated plate cover. When the uninsulated rolling cart was full, NA #4 rolled the cart down the hall and delivered the plates of food to residents. Interview with NA #7 on 10/6/2021at 12:45 PM identified she and NA #4 were the only 2 staff available to serve meals to residents in their rooms because the other nurse aides were assisting in the dining room. Interview with [NAME] #1 on 10/6/2021 at 12:57 PM identified the steam table is delivered to the unit daily at approximately 12 PM and plugged into the wall outside the dining room. Cold foods including tuna salad and chicken salad were stored inside an insulated box on the steam cart without the benefit of any ice (items were not in an ice bath). Pasta salad with an oil dressing was stored in a metal container and sat on the side of the steam cart without the benefit of an ice bath. [NAME] #1 indicated that the steam table remains in place when serving residents that are in their rooms. He further indicated that he did not know why the plates with food were not placed on insulated bottoms and covers, or why the plates with food were left on an uninsulated cart. Further observations failed to identify a thermometer or temperature log on the steam table. DA #1 indicated he was not aware he was required to have a thermometer on the steam cart. DA #1 called [NAME] #1 to bring a thermometer to the steam cart. Subsequent to surveyor inquiry, DA #1 plated a meal and immediately checked the food temperature of various foods on the steam cart as follows: chicken with gravy were 125.6 degrees Fahrenheit (F); Mushrooms 120 F; sautéed onion was 131.7 F; oil-based pasta salad with oil dressing 51 F; chicken salad 64.4 F and tuna salad 63.3 F. Interview with DA #1 at the time of the observation identified that hot foods should be held and served above 135 F and [NAME] #1 identified the cold foods should be at 36 to 40 F. [NAME] #1 indicated that the chicken with gravy, mushrooms, onions were not stored at the appropriate hot temperatures (should have been 135 F) and the pasta, chicken salad and tuna salad were not held at the appropriate cold temperatures (they should have been 36 to 40 F). [NAME] #1 further identified that staff did not store the cold foods on ice because they take the food from the walk-in refrigerator and it is placed directly into the thermo box on the steam cart which keeps food either hot or cold. Interview with DA #2 on 10/06/2021 at 1:06 PM identified there should be a thermometer on the steam table and he did not know why there was not. Additionally, the cold food such as the tuna and chicken salad were pulled from the refrigerator directly before coming to the unit (a little over an hour ago) and placed in the insulated box on the cart which can keep items either hot or cold. Interview with the FSD Food Service Director on 10/6/2021 at 1:30 PM identified cold food should be served on ice in the steam cart. Further, the food from the steam cart should be plated and delivered directly to the resident. She further indicated that the plates with food should not be left on a cart or wheeled down the hall. The facility Food Storage Policy dated 7/1/2021 directed in part, cold foods would be stored at temperatures of 40 Degrees Fahrenheit or below and hot foods will leave the kitchen or steam table at 140 degrees or above. Review of the facility undated policy entitled Point of Service Dining directed in part, that the preheated steam table will be plugged in to an appropriate outlet at a central location on the unit to maintain proper food temperatures. If cold items are to be served, necessary steam table wells will remain turned off and the wells will be filled to an appropriate level with ice. All products requiring refrigeration will remain on an ice bath to maintain temperature. Additionally, the [NAME] or Server will check and log facility food temperatures prior to serving residents and will replace or change any food pans as needed. Further, the nursing staff will coordinate the timing of the plates and for those residents needing assistance with the Cook/Server so that food temperatures are maintained, and plates are not sitting out and waiting for attention.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility documentation review, facility policy review and staff interviews for one sampled residents (Resident #56) for facility review of dining, the facility failed to ensure snacks were offered, and for facility review of meals, the facility failed to ensure substantial evening snacks were offered when the breakfast meal was more than 14 hours after the evening meal. The findings included: a. Resident #56 had diagnoses that included iron deficiency anemia and vitamin deficiency. The quarterly MDS assessment dated [DATE] identified Resident #56 was alert and oriented, was able to eat independently, and had no weight loss/gain. The Resident Care plan dated 8/9/2021 identified a problem of high nutrition risk related to depression and insidious weight loss and anemia. Interventions directed to provide nourishments, snacks and fluids. The physician's orders dated 8/2/2021 identified to offer a snack at 8 PM (resident likes peanut butter and jelly sandwich on wheat) in the evening. Interview with Resident #56 on 10/5/2021 at 9:44 AM identified she does not received an evening snack. Review of the Treatment Administration Record (TAR) dated 9/1 through 9/30/2021 identified the evening snack was administered on 9/4, 9/8, 9/10, 9/13 and 9/14/2021; administered 5 days out of 30 days in the month of September (missing 25 days). Review of a weekly snack checklist identified Resident #56 should receive a peanut butter and jelly and wheat bread every evening. Interview with the FSD on 10/6/2021 at 9:10 AM identified that although the kitchen should be preparing recommended snacks and delivering them to the unit, they have not been doing that and Resident #56; Resident #56 was not receiving the bedtime snack as recommended by the dietician. The FSD indicated the Dietary Aide should stock the unit refrigerator and unit kitchen with cereal bars, chips, cookies, yogurt and pudding but has not been making or sending designated afternoon or bedtime snacks to the units. Interview with the Dietician on 10/6/2021 at 9:30 AM identified dietary staff should prepare and deliver snacks to the units to ensure snacks were available for residents. She further indicated that snacks were not being delivered to the units and she did not know why. She identified on 10/5/2021 Resident #56 had informed her that he/she was not receiving bedtime snacks and she had directed dietary staff to deliver the snacks for bedtime. Further, all residents should be offered a snack without having to ask and snacks must be provided at bedtime to accommodate the time lapse between the supper and breakfast meals. Interview with the Administrator on 10/6/2021 at 10:22 AM identified she was not aware the kitchen was not providing the designated substantial evening snacks and was not aware all residents were not offered snacks. She indicated that all residents should be offered a snack. Interview with LPN# #2 on 10/6/2021 at 3:08 PM identified a bedtime snack is not received from the kitchen for Resident #56. Although requested a snack policy the facility did not provide. b. Review of the facility scheduled mealtimes identified the mealtimes were as follows. On the rehab Unit meals were served at: breakfast 8:15 AM, lunch 11:45 AM and supper 4:45 PM (15 ½ hours between the supper meal and the breakfast meal). On the Main Floor Unit meals were served at: breakfast 8:15 PM, lunch 12 noon, supper 5 PM (15 ¼ hours between the supper meal and the breakfast meal). On the Second Floor Unit meals were served at: breakfast 8:15 AM, lunch 12:30 PM and supper 5:30 PM (14 ¾ hours between the supper and breakfast meal). Interview with the FSD on 10/6/2021 at 9:10 AM identified that kitchen staff should be preparing recommended snacks and delivering them to the unit, but they have not been preparing or delivering resident snacks; residents were not receiving a substantial bedtime snack. She indicated that although a Dietary Aide stocks the unit refrigerators and supplies the unit kitchens with cereal bars, chips, cookies, yogurt and pudding, they do not provide a substantial snack for residents for bedtime snacks. Interview with the Dietician on 10/6/2021 at 9:30 AM identified all residents should be offered a snack and snacks must be provided at bedtime to ensure the time lapse between the supper and breakfast meal was not greater than 14 hours. Interview with the Administrator on 10/6/2021 at 10:22 AM identified she was not aware the kitchen was not providing designated substantial evening snacks and indicated substantial snacks should be provided. Interview with NA #3 on 10/13/3021 at 12:10 PM identified the kitchen does not provide substantial snacks for residents at bedtime. Interview with NA #9 on 10/6/2021 at 3 PM identified the kitchen does not provide substantial snacks for residents at bedtime. Interview with NA # 8 om 10/6/2021 at 3:05 PM identified the kitchen does not provide substantial snacks for residents at bedtime. Interview with LPN# #2 on 10/6/2021 at 3:08 PM identified the kitchen does not provide substantial snacks for residents at bedtime. Interview with NA #10 on 10/6/2021 at 3:10P M identified the kitchen does not provide substantial snacks for residents at bedtime. Review of the facility policy entitled Mealtimes and Frequency directed in part, that meals will be served in a timely manner, and will be no more than 14 hours between the evening meal and breakfast the following day unless a substantial evening snack is provided at bedtime.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, facility documentation review, facility policy review, and staff interviews for facility review of dining, the facility failed to ensure sufficient dining staff to ensure meals were provided within the scheduled times, and the facility failed to steam table food temperatures were maintained and served at holding temperatures, and for one sampled resident (Resident #115) reviewed for unnecessary medications, the facility failed to ensure residents who require insulin injections with meals receive their meals timely. The findings included: Review of facility documentation identified the scheduled meal times were: Rehab unit - 8:15 AM, 11:45 AM and 4:45 PM; Main floor - 8:15 AM, 12 noon and 5 PM; and the Second floor - 8:15 AM, 12:30 PM and 5:30 PM. a. Resident # 56's diagnoses included spinal stenosis, depression and HTN. The quarterly MDS dated [DATE] identified intact cognition and could eat independently. Resident #56's room was located on the Main floor. Interview with Resident #56 on 10/4/2021 at 11:04 AM identified that lunch came at 1:30 PM on 10/3/2021 (a Sunday) and the evening meal was served at 7:00 PM. Resident #56 indicated that he/she was told there was no staff in the kitchen and a NA had to go get the food truck. Review of the dietary staff time punches for Sunday 10/3/2021 identified [NAME] #1 worked from 5:27 AM to 2:44 PM, DA #1 worked 11:16 AM to 7:38 PM and DA #4 worked 10:27 AM to 7:34 PM, providing no scheduled [NAME] for the evening meal and two (2) DAs for the day. Interview with the Food Service Director (FSD) on 10/6/2021 at 9:10 AM identified on 10/3/2021 the meals were late due to short staffing in the kitchen. She indicated that although the unusual dietary staffing pattern was four (4) to five (5) dietary staff during the day shift, on 10/3/2021 there were three (3) dietary staff that worked during the day shift. The FSD indicated the dietary department was understaffed because of staff call outs. Additionally, the FSD indicated that on 10/3/2021 he was notified that the kitchen was short staffed due to a staff member's absence (no call/no show) and DA #1 was late to work. The FSD indicated that on 10/3/2021 she came in around 11AM to provide additional dietary staffing. Interview with NA #3 on 10/6/2021 at 12:10 PM identified the steam cart was delivered to the Main floor unit at approximately 9:30AM (1 ¼ hours late). She indicated that she was informed there was no dietary staff to serve the food from the steam table, so she went behind the steam table to scoop the food onto plates for the residents. She indicated that she had never received training for serving the meals from the steam cart. She plated the food and gave the plates to other NAs to serve the meal to residents. Additionally, NA #3 indicated that the noon meal was late because of dietary staffing. She indicated that she did not know if the nursing supervisor was aware of the staffing issue in the dietary department. Interview with the Administrator on 10/6/2021 at 10:22 AM identified she was notified of the dietary staffing issues on 10/3/2021 between 10:30 AM and 11 AM. She indicated that she was not aware of number of staff that called out, and or issues with the meals served late to the residents. Further, the Administrator identified several dietary positions were open and the facility was using agency staff while attempting to fill the open positions. She indicated that resident meals should have been provided timely, and served by dietary staff. During an interview with [NAME] #1 on 10/12/2021 at 10:30 AM, [NAME] #1 indicated that on 10/3/2021 there were only two (2) dietary staff until 11 AM. He indicated that the residents received breakfast late because of a lack of staff in the kitchen. He notified the nursing supervisor of the dietary call outs, and indicated that on the Second floor and Rehab floors the food was served from the steam table by dietary staff, and NA #3 served the food on the first floor. [NAME] #1 indicated that there should have been one dietary staff to serve the meals for each floor during breakfast and two dietary staff for all other meals. Interview with the FSD on 10/12/021 at 10:40 AM identified the kitchen had six (6) open positions, used agency staff for coverage and was in the process of hiring and interviewing staff. Additionally, although there should have been four (4) to five (5) dietary staff in the morning on 10/3/2021 and there were only two (2) dietary staff. Review of the facility undated policy entitled Mealtimes and Frequency directed in part, that meals will be served in a timely manner. 1. Resident #115's diagnoses included insulin dependent diabetes mellitus. The quarterly MDS dated [DATE] identified Resident #115 was alert and oriented and received insulin injections seven out of the last seven days. The Resident Care Plan (RCP) dated 9/17/2021 identified Resident #115 had type 2 diabetes. Interventions directed to administer insulin as ordered. Physician's order dated 8/2/2021 directed to administer Novolog Insulin two (2) units subcutaneously with meals; hold if does not eat. Review of the Medication Administration Record for October 2021 identified the Novolog Insulin two (2) units was scheduled to be administered at 8:30 AM, 11:30 AM, and 5:30 PM, and was signed as administered. Interview with Resident #115 on 11/2/2021 at 9:45 AM identified he/she receives insulin injections late due to receiving meals late. Interview with the FSD on 10/12/021 at 10:40 AM identified that meals should be served in accordance with the scheduled mealtimes. Interview and facility documentaiton review with the Administrator on 11/2/2021 at 9:20 AM identified meals should be delivered timely to facilitate medication administration. No policy was provided for surveyor review. b. Observations of the Main floor on 10/5/2021 at 9:26 AM identified the steam cart was delivered at 9:20 AM and NA #3 was observed passing breakfast meal trays to residents. Observations of the Main floor on 10/6/2021 at 9:13 AM identified the breakfast meal was delivered to residents on the first floor. Observations of the Main floor on 10/7/2021 at 9:47 AM identified the steam cart arrive to the first floor to start serving breakfast to the residents. Interview with the FSD on 10/12/021 at 10:40 AM identified the kitchen had six (6) open positions, used agency staff for coverage and was in the process of hiring and interviewing staff. Additionally, although there should have been four (4) to five (5) dietary staff in the morning on 10/3/2021 and there were only two (2) dietary staff. Further the FSD indicated that meals should be served in accordance with the scheduled meal times. Review of facility undated Mealtimes Policy directed in part, to serve breakfast served at 8:15 AM on the Main floor. Review of the facility undated policy entitled Mealtimes and Frequency directed in part, that meals will be served in a timely manner. c. Interview with Resident #56 on 10/04/2021 at 11:04 AM identified that foods that should be hot are cold. Interview with Resident #43 on 10/4/2021 at 3 PM identified the food is served cold (not at the appropriate temperature). Observation of point of service dining (steam tables) on First floor (Main floor) on 10/06/2021 at 12:40 PM identified a steam cart plugged into the wall in the hallway outside of the dining room. DA #1 and DA #2 were observed portioning food onto uninsulated plates with covers and placing them on a rolling uninsulated cart. NA #4 and NA #7 were the only NAs delivering food to residents directly from the steam cart and other NAs were delivering food from the rolling uninsulated cart. While NAs were delivering resident's meals, DA #1 and DA #2 continued to fill additional plates and left the plates on the side of the steam cart or on the rolling cart without the benefit of an insulted plate holder. When the cart was full NA #4 rolled the cart down the hall and delivered the plates of food from the uninsulated cart. Interview with NA #7 on 10/6/2021 at 12:45 PM identified she and NA #4 were the only NAs passing food to residents in their rooms because other NAs were assisting residents in the dining room. Interview with [NAME] #1 on 10/6/2021 at 12:57 PM identified the steam table arrived on the unit around 12 PM and was parked outside the dining room (parked outside the dining for all meals). [NAME] #1 identified the steam table remained stationary to serve all residents in the dining room and in their rooms because it took too long to move it down the hall. He indicated that plates with food were put on the uninsulated rolling cart and were not placed on plate warmers or inside insulated plates and insulated lids. Observation on 10/6/2021 at 1:06 PM, after the last resident had been served identified tuna and chicken salad in portion cups stored inside an insulated box on the steam cart on a metal tray without the benefit of ice for cooling, and the steam cart was plugged in. The pasta salad was stored in a metal container and sat on the side of the steam cart without the benefit of an ice. Additionally, there was no thermometer or temperature log on the steam table. DA #1 indicated he was not aware he was required to have a thermometer on the steam cart. DA #1 called [NAME] #2 to bring a thermometer to the steam cart. Subsequent to surveyor inquiry, DA #1 checked the food temperatures as follows: chicken and gravy were 125.6 degrees Fahrenheit (F), Mushrooms 120 F, and the sautéed onions were 131.7. F. Additionally, the oil-based pasta salad was 51 F, the chicken salad was 64.4 F and the tuna salad was 63.3 F. Interview with DA #1 at the time of the observation identified the hot foods should be held and served above 135 F and [NAME] #2 identified the cold foods should have been held and stored between 36 and 40 F, and he did not know why the foods were outside the accepted temperature range. Additionally, [NAME] #2 indicated that staff did not store the cold foods on ice because they take the food from the walk-in refrigerator and it is placed directly into the thermo box on the steam cart which keeps food either hot or cold. Interview with DA #2 on 10/06/2021 at 1:06 PM identified there should be a thermometer on the steam table and he did not know why there was not. Additionally, the cold food such as the tuna and chicken salad were pulled from the refrigerator directly before coming to the unit a little over an hour ago and they were placed inside the insulated box on the cart which can keep items either hot or cold. Interview with the Food Service Director (FSD) on 10/6/2021 at 1:30 PM identified she was not familiar with point of service dining (steam tables). Additionally, the FSD identified that she thought cold food should be served at 41-45 F and hot food at 160 F but was not sure and would check the policy. Further, the FSD indicated cold food should be served on ice in the steam cart and was not sure if the insulated box on the steam cart kept food hot or cold. Further, the food from the steam cart should be plated and delivered directly to the resident. The facility policy entitled Food Storage dated 7/1/2021 directed in part, cold foods would be stored at temperatures of 40 Degrees Fahrenheit or below and hot foods will leave the kitchen or steam table at 140 degrees or above. Review of the facility policy undated and entitled Point of Service Dining directed in part that the preheated steam table will be plugged in to an appropriate outlet at a central location on the unit to maintain proper food temperatures. If cold items are to be served, necessary steam table wells will remain turned off and the wells will be filled to an appropriate level with ice. All products requiring refrigeration will remain on an ice bath to maintain temperature. Additionally, the [NAME] or Server will check and log facility food temperatures prior to serving residents and will replace or change any food pans as needed. Further, the nursing staff will coordinate the timing of the plates and for those residents needing assistance with the Cook/Server so that food temperatures are maintained, and plates are not sitting out and waiting for attention.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, a review of the clinical record, staff interviews, a review of facility documentation, and a review of the facility policy, for one sampled resident reviewed for activities of daily living (Resident # 32), the facility failed to follow a functional maintenance plan in accordance with the resident's plan of care. The findings include: Resident #32 was re-admitted to the facility on [DATE] with diagnoses that included unspecified dementia, acute respiratory failure with hypoxia, functional dyspnea and orthostatic hypotension. The quarterly Minimum Data Set (MDS) dated [DATE] identified intact cognition, extensive assistance for transfers and locomotion on unit with the assistance of one staff member. The care plan dated 7/8/19 identified assistance with ADL's, and mobility. Interventions directed to follow the ambulation program with a rollator and oxygen therapy. The nurse's note dated 7/18/19 through 12/12/19 did not reflect ambulation documentation. The physical therapy plan of care dated 7/18/2019 identified Resident #32 had been on a walking program two times a day for 50 feet with a wheeled walker and a wheelchair follow with the assistance of one person. Resident #32 reported he/she had not been walking and the Nurse Aide (NA) documentation confirms he/she had not been walking. Resident #32 indicted he/she did not have a wheeled walker in his/her room as it was borrowed for another resident. NA #2 stated that they do not have enough time in the day to ambulate Resident #32. Physical therapy changed the ambulation program to 50-150 feet 2 times a day with assistance of one and a wheelchair follow. The resident care card revised on 7/19/2019 identified ambulation with the assistance of one with a rolling walker and oxygen, walk twice daily 50-150 feet with a wheelchair to follow, and rollator, staff to manage the oxygen tubing. The ambulation record dated July 2019 identified the residents goal for ambulation was twice a day with the rollator and oxygen 50-100 feet, and wheel chair (w/c) to follow. The document was signed off seven out of sixty two occasions. The ambulation record dated August 2019 identified the residents goal for ambulation was twice a day with the rollator and oxygen 50-100 feet, and a w/c to follow. The document was signed two out of sixty two occasions. The ambulation record dated September 2019 identified the residents goal for ambulation was twice a day with the rollator and oxygen 50-100 feet, and a w/c to follow. The document was signed off four out of sixty two occasions. The ambulation record dated October 2019 identified the residents goal for ambulation was twice a day with the rollator and oxygen 50-100 feet, and a w/c to follow. The document was signed off three out of sixty two occasions. The ambulation record dated November 2019 identified the residents goal for ambulation was twice a day with the rollator and oxygen 50-100 feet, and a w/c to follow. The document was signed off five out sixty two occasions. The ambulation record dated December 2019 was missing from the nurse aide binder and confirmed by the Director of Nursing Service (DNS) that it was missing and not filled out. An interview with NA #2 on 12/11/19 at 12:24 PM identified he/she does not routinely care for Resident #32 and was aware of his/her ambulation schedule and due to lack of help on the unit, NA #2 was not able to ambulate the resident per the plan of care. NA#2 further identified administration was aware. An interview with PT#1 on 12/11/19 at 12:45 PM indicated when a resident was discharged with a functional plan of care, the Physical Therapist would write the ambulation request on a green sheet which then gets transferred over to the care card. PT#1 was not aware that Resident #32 had not been ambulating per the plan of care, and that his/her expectation was that if there were concerns, the charge nurse or supervisor should have brought it to their attention. PT #1 further stated that ambulation should be documented on the ambulation record. A further interview on 12/12/19 at 9:02 AM identified that had therapy been notified Resident #32 was not ambulating per the plan of care, therapy would have conducted a re-evaluation sooner. Subsequent to the surveyor inquiry, PT #1 stated a re-evaluation was conducted. The physical therapy plan of care dated 12/11/19 identified therapy was necessary for evaluation secondary to the residents report that he/she had not been ambulating per the plan of care established in July 2019. Physical therapy changed the frequency of the ambulation program to three times per week as the resident had been able to maintain functional levels while not ambulating seven times a week with nursing staff. Interview with the Director of Nursing (DNS) on 12/12/19 at 09:59 AM identified his/her expectation was that documentation would be completed at the end of each shift by the NA, and if documentation was not completed it was the charge nurse's responsibility to follow up with the NA and find out why. The DNS indicated that she/he was not aware Resident #32's ambulation record was not completed, and she would put a plan in place to correct the error. The facility policy for Activities of daily living (ADL) directed in part that instructions are to be updated by the nursing staff to reflect any changes in the resident's status or changes in the nursing care plan that affects the performance of ADL's. Any discrepancies found while providing care would be reported to the charge nurse for evaluation and changed in the NA resident profile.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a clinical record review, a review of facility documentation and interviews for one of three sampled residents reviewed for pressure injuries (Resident #31), the facility failed to ensure that measures were in place to prevent the development of a pressure ulcer. The findings include: Resident #31 was admitted to the facility on [DATE] with diagnoses that included osteoarthritis, muscle weakness, dementia without behavioral disturbance, restless legs syndrome, hypertension, idiopathic gout, reduced mobility and peripheral vascular disease. A significant change MDS assessment dated [DATE] identified severe cognitive impairment, absence of behavioral symptoms, extensive assistance of two with bed mobility and transfers, non-ambulatory, no range of motion limitations, wheelchair for mobility, and was at risk of developing pressure ulcers/injuries. A Braden scale assessment (used for predicting pressure sore risk) dated 09/12/19 identified Resident #31 had a score of 16 (A total score of 15-18 indicates mild risk). According to the Braden assessment it noted that if a resident was a mild risk then the facility should consider at least one intervention in each category depending on the score. According to the Braden assessment the resident scored a 3 for mobility and the guidelines note that for a mobility score of 3, one of the following interventions should be considered; avoid repositioning on red areas, physical therapy and/or occupational therapy screen, float heels, turn and reposition every two hours, elbow and/or heel protectors, obtain wheelchair cushion, and assess placement of the cushion every shift. A review of the treatment record for the month of October failed to identify interventions in place related to floating the resident's heels or turning and repositioning in the bed. A review of weekly wound tracking sheets identified on 10/30/19, Resident #31 was noted to have a left heel deep tissue pressure injury that measured 0.4 centimeter (cm) in length by 0.4 cm in width by 0.1 cm in depth and was acquired in the facility. The area was noted to be dark purple and not painful. Review of physician's orders identified an order with an origination date of 10/30/19 that directed to off load heels when in bed and to apply skin prep to left heel twice per day. Review of the treatment record for the month of October/2019 identified the interventions of skin prep and to offload the heels were put into place on 10/30/19. Further review of the weekly wound tracking dated 11/22/19 identified a left heel deep tissue pressure injury that measured 3.0 cm in length by 3.0 cm in width and was noted to be 80% of eschar and 20% of white tissue. The treatment was noted to be skin prep with the off-loading of the heels. A weekly wound tracking sheet dated 11/27/19 identified that the left heel wound measured 3.5 cm in length by 4.0 cm in width. A treatment order dated 11/27/19 directed to apply skin prep followed by opsite to the left posterior heel weekly on Tuesdays along with off-loading boot. It noted that therapy was notified to evaluate wheelchair foot pedals. A weekly wound tracking sheet dated 12/02/19 identified the left heel pressure injury measured 3.5 cm by 4.0 cm with the depth noted as unable to determine. The appearance of the wound was dark purple with heavy serosanguineous drainage. The treatment order dated 12/02/19 directed to clean the pressure injury to the left posterior heel with normal saline, skin prep to periwound, apply calcium alginate AG to wound bed only followed by an abdominal pad and secure with rolled gauze, and to change every other day and as needed. The off-loading boot was to be worn on the left foot at all times. A weekly wound tracking sheet dated 12/08/19 identified the left posterior heel pressure injury measured 3.5 cm by 4.0 cm with an inability to determine depth. It was noted to have moderate drainage. Weekly wound tracking dated 12/10/19 identified the left posterior heel pressure injury developed into an unstageable wound that measured 3.0 cm by 4.0 cm and unable to determine depth. The wound was described as containing slough with moderate serosanguineous drainage. The noted from the wound nurse identified the treatment was changed to Santyl (topical debriding agent). A physician's order dated 12/10/19 directed to clean the left posterior heel with normal saline, skin prep to periwound, apply nickel thick Santyl to wound bed followed by an abdominal pad and secure with rolled gauze, change daily and as needed. An observation of Resident #31's dressing change with the wound nurse on 12/12/19 at 11:05 AM identified the resident was in bed with the off-loading boot on. The wound nurse proceeded to remove the old dressing which was noted to have a moderate amount of serosanguineous drainage. The area appeared to be about the size of a 50 cent piece and contained greenish, whitish colored slough. An interview with the wound nurse on 12/11/19 at 3:00 PM identified although the deep tissue pressure injury was first noted on 10/30/19, she/he was not aware Resident #31 had a pressure injury until 11/27/19 when she was consulted. She noted that was the reason why she did not perform an assessment of the resident until 11/27/19 and notes that the tracking was missing up until that date due to her being unaware. The wound nurse indicated that one of the forms was dated 11/22/19 but she/he identified that date should have reflected 11/27/19. She/he further noted that once she was made aware and performed her/his assessment, she/he notified dietary and physical therapy because she was concerned about the way the resident's foot lay on the metal part of the foot rest and felt that this could have contributed to the development of the pressure injury. The wound nurse further identified that she/he is a certified wound nurse and that she/he had developed the intervention guidelines noted on the back of the Braden assessment. When reviewed she/he noted that the resident did not have any of the suggested interventions in place for a resident with a mobility score of 3 on the Braden assessment. She/he further identified that she would have expected for the resident to have at least one of the interventions in place and for a person who needed so much assistance with bed mobility, she/he would expect the heels to be floated. She also noted that had she been made aware sooner, she would have put the heel lift boot in place earlier and she would have completed the physical therapy consult when the area was found. A review of the facility's skin integrity policy dated 03/22/19 directed in part that when abnormal findings are identified the physician and skin care team/wound nurse were to be notified. It further identified the wound nurse was responsible for assisting nursing with appropriate interventions as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, a review of the clinical record, a review of facility documentation, staff interviews and a review of the facility policy for two of four residents reviewed for accidents (Resident # 10, #87), the facility failed to provide an environment that was free from accident hazards and, the facility failed to ensure that appropriate supervision and safety measures were in place to prevent an injury during a transfer. The findings include: a. Resident # 10 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia without behavioral disturbance and Alzheimer's disease. The annual MDS dated [DATE] identified severe cognitive impairment and required extensive assistance with eating. A physician's order dated 11/22/19 directed to offer Resident #10 finger foods, to supervise the resident and provide him/ her with verbal cues when eating. The care plan dated 12/9/19 identified Resident #10 required assistance with activities of daily living. Interventions included setting up and supervising the resident with meals, offering verbal cues and providing finger foods when possible. Observations on 12/11/19 at 6:06 PM during dining identified Resident #10 sitting in a wheelchair with a tray of food in front of his/her wheel chair. The resident's was seated outside the dining area beside the mobile food cart across from the nursing station. Three nurses were observed by the nursing desk. Resident #10 was observed with a 5 inch long by 1 inch wide silver utility like knife blade pointing up toward the palm of his/ her cupped hand. Resident #10 was observed making a sawing like motion with his/her hand, fingers pointed down, above a ¼ of a bun on the plate on the tray table. A person was seated to the right of Resident #10 with his/ her eyes closed. The surveyor noticed unit manager, RN #2 concern related to Resident #10 on 12/10/19 at 6:06 PM. Observation and interview on 12/11/19 at 6:07 PM with RN #2 identified she was able to obtain the silver knife from the resident and handed it to the person seated in the chair beside the resident. The person sitting beside the resident identified the knife was a military knife he/she carried in his/her pocket and had utilized to cut the sandwich for Resident #10. The person beside the resident identified it was not his/ her intent for the resident to have the knife. RN #2 identified the person sitting beside the resident was the spouse. RN #2 identified she was surprised to see the opened knife in the resident's hand. RN #2 identified it was dangerous for the resident to have the knife as the resident had a diagnosis of dementia. RN #2 identified Resident #10 required supervision with dining and was encouraged to have finger foods so she would expect the nurses aide serving the food to the resident to ensure it was cut up appropriately. Additionally, RN #2 identified Resident #10 was in a common area because he/she required supervision with eating as he/she had dementia. RN #2 identified she would have expected staff in the vicinity to observe the resident with the knife and take it away as it was a large sharp knife, not a butter knife, in the resident's palm. During the interview with RN #2, she returned to Resident #10 and was observed taking the knife away from the resident returning it to the resident's spouse. Interview with RN #2 identified that the resident had the knife again and this was problematic. Interview with NA #1 on 9/11/19 at 6:25 PM identified she was assigned to care for Resident #10 and had provided the resident with his/ her dinner. NA #1 identified the resident's spouse was with him/her and NA #1 had seen the spouse's knife on the table beside the resident. NA #1 identified the spouse carried the knife all the time and used it to cut up Resident #10's meal. NA #1 identified that although she saw the knife on Resident #10's tray table, she did not share this with any other staff. NA #1 identified upon reflection, because Resident #10 had a diagnosis of dementia, it was not safe for the resident to have sharp knife on the table where he/she could reach it. Interview with Administrator, DNS, and ADNS on 12/11/19 at 6:33 PM identified that it was not safe for Resident #10, who had a diagnosis of dementia to have the knife obtained from his/ her spouse. The Administrator, DNS, ADNS would have expected NA #1 to notify the charge nurse or supervisor that the resident's spouse brought a knife to the facility and notified the charge nurse or supervisor of the knife on the resident's tray table. Resident #10's spouse had been educated that he/she was not allowed to bring the knife to the facility again. The Administrator, DNS and ADNS would ensure that staff was educated to remove anything that may pose a safety risk to a resident or visitor explaining it is a safety issue. The object was turned over to the supervisor immediately. Additionally, the Administrator, DNS and ADNS identified Resident #10's spouse had been educated that the knife was a safety concern. The spouse would no longer be allowed within the facility with a knife for safety concerns and he/she agreed to be reminded by the receptionist to check his/ her pockets to ensure the knife was not brought into the facility by mistake. Furthermore, the Administrator and DNS identified that NA #2 would be provided additional education in conjunction with Human Resources as it was unacceptable for her to have been aware of the knife and not intervened nor shared concern with the staff for the resident's safety. Review of a Reportable Event Form dated 12/11/19 identified Resident #10 had a diagnosis of dementia. The form identified that Resident #10's spouse brought in a pocket knife that was used to cut up food. The spouse left the knife on the tray table and the resident was able to grab the knife. The Witness Statement signed by NA #1 on 12/11/19 at 6:55 PM identified that she saw the Resident #10's spouse brought in a knife. NA #1 identified that she saw the knife closed on the table in front of the spouse. NA #1 continued to serve food because the knife was in front of the spouse and NA #1 didn't consider it was a threat to the resident. A Reportable event investigation (to be completed by charge nurse) dated 12/11/19 identified Resident #10's spouse carries a pocket knife which was used to cut the resident's food. The knife was within the resident's reach and the spouse dozed off. The resident took the knife and was holding it loosely with both hands with blade falling up and her fingers pointed down. The resident handed the knife to RN #2 and did not sustain harm or injury. Precipitating factors included poor judgement of spouse. The knife was removed, a meeting was held with spouse and the spouse was informed knives not allowed to be brought into facility from home. Educational documentation with staff signatures dated 12/12/19 identified staff education was initiated directing staff to remove anything that poses a safety risk to any resident, for example a sharp knife, pocket knife, letter opener, box cutter, etc. The employee should immediately remove the object from the resident or visitor explaining that it is a safety issue. They must then notify and turn the object over to the supervisor immediately. Review of the Resident's [NAME] of rights identified that residents have the right to a safe environment. b. Resident #87's diagnoses include congestive heart failure, Type 2 diabetes mellitus, hypertension, atrial fibrillation, chronic kidney disease (stage 3), macular degeneration, unsteadiness on feet and lymphedema. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified intact cognition, no behavioral symptoms, required extensive assistance of two for bed mobility and transfers. The assessment further identified that the resident did not ambulate, was not steady and only able to stabilize with staff assistance when transferring between bed, chair or wheelchair. The assessment also noted that the resident utilized a wheelchair for mobility. Review of the resident's care plan dated 06/05/19 identified the resident required assistance with activities of daily living, with interventions that included the assistance of one for stand pivot transfers. The care plan further identified that the resident utilized a power wheelchair. A physical therapy progress and Discharge summary dated [DATE] identified the resident, family and nursing staff were educated in the use of the power wheelchair. Review of a reportable event form dated 08/03/19 identified at 7:20 PM, Resident #87's right medial lower leg was hit against the electric wheelchair. The reportable event form further identified the resident had a 2.5 centimeter (cm) by 1.0 cm by 0.5 cm laceration with a large amount of bloody drainage and deep tissue exposure. The form also noted that he physician was notified and the resident was sent to the hospital emergency department. Facility documentation identified that Nurse Aide (NA) #8 indicated during a transfer from the bed to the wheelchair, either the resident's hand or the nurse aide's hand hit the control panel on the resident's electric wheelchair causing the wheelchair to move forward and hit the resident's right leg causing a laceration. Facility documentation further identified that action taken to prevent further skin injuries was to ensure electric wheelchair was turned to the off position prior to transferring. A nurse's note dated 08/3/19 at 11:00 PM identified that Resident #87 returned to the facility from the emergency room at 10:45 PM and the resident had received five sutures to the lacerated site. An interview with the Director of Nurses (DNS) on 12/12/19 at 10:30 AM identified physical therapy was responsible for in-servicing the staff on wheelchair functioning. The DNS further noted NA #8 was a per diem nurse aide and that it would have been the responsibility of the charge nurse to update NA #8 of the functioning of Resident #87's electric wheelchair. An interview on 12/12/19 with NA#8 identified that he/she was aware the wheelchair control should have been turned off and that he/she thought it was turned off but it was not, and during the transfer the resident's hand hit the controls and the wheelchair lurched forward and hit the resident's leg. Review of facility documentation identified a corrective action notification form dated 10/15/19 identified NA #8 had failed to turn off a motorized wheelchair during a resident transfer and the resident had sustained an injury when the wheelchair lurched forward. It further identified NA #8 was educated about the need to ensure that any electric wheelchairs are locked prior to transfer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on 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 #2) reviewed for respiratory care, the facility failed to obtain a physician's order for the use of a continuous positive airway pressure machine and failed to ensure respiratory equipment was maintained in a safe and sanitary manner. The findings include: Resident #2 was admitted to the facility on [DATE] with diagnoses that included periprosthetic fracture around the internal prosthetic right hip joint, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side and obstructive sleep apnea. Review of the patient belongings checklist/item inventory for Resident #2 dated 11/23/19 identified personal items included a continuous positive airway pressure machine. (CPAP -The machine that forces air into the nasal passages at pressures high enough to overcome obstructions in the airway and stimulate normal breathing.) The care plan dated 11/25/19 identified Resident #2 required assistance with activities of daily living. Interventions included providing assistance with bed mobility, transfers, bathing, dressing, eating and personal hygiene. The admission history and physical dated 11/25/19 identified Resident #2's past medical history included obstructive sleep apnea and he was on a continuous positive pressure airway pressure machine. The admission MDS dated [DATE] identified intact cognition, extensive assistance with bed mobility, transfers, dressing, personal hygiene and eating. Review of facility documentation for respiratory assessments for November 2019 failed to identify CPAP use. Review of 11/23/19 through 12/11/19 treatment administration record failed to identify cleansing of Resident #2's CPAP machine. Interview and observations with Resident #2 on 12/09/19 at 2:54 PM identified Resident #2 historically had his/ her CPAP machine's water humidification reservoir, tubing and nasal pads cleaned or rinsed daily, however since his/ her most recent admission to the facility, no one had cleaned or offered to assist with cleaning of the CPAP. Observation of CPAP nasal pillow on resident's bedside table, not in a bag. Interview and record review with RN #1 on 12/12/19 at 8:08 AM identified she regularly cared for Resident #2 and the resident utilized a CPAP. RN #1 identified cleansing of the CPAP would be documented in the Treatment Administration Record. (TAR) Review of the TAR from 11/23/19 to 12/12/19 failed to reflect documentation of the CPAP cleaning. RN #1 identified although the resident was using the CPAP there was not an order for the CPAP. She identified the admitting nurse would have been responsible initially for obtaining the physician order. The order for the CPAP would have triggered orders for cleaning of the CPAP. RN #1 identified all nurses would be responsible for ensuring the CPAP was cleaned. RN #1 identified cleaning of the CPAP was important for preventing infection. Additionally, RN #1 identified that the nasal pillows or a CPAP mask would be stored in a clean bag to ensure cleanliness. Interview and record review with RN #3, nurse manager on 12/12/19 at 9:19 AM identified there was no order for Resident #2's CPAP. Additionally, review of the TAR failed to reflect Resident #2's CPAP was cleaned. RN #3 identified nursing was responsible for ensuring that there was an order for the CPAP and for cleaning of the machine and tubing. She identified that the nasal pads or mask of a CPAP should be stored in a clean plastic bag to prevent contamination. RN #3 identified cleaning the CPAP and storing the nasal pillows in a clean bag not directly on a table top would be important to prevent infection. Review of Facility Policy for CPAP identified that nasal and full face masks are to be cleaned daily using warm water and a mild soap. It is to be air dried before being used. Units with humidifiers are to have the chambers cleaned every morning using warm water and a mild soap. The chamber is to dry before being filled with sterile or distilled water each night before use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility documentation and staff interviews, the facility failed to ensure that nursing staff who insert intravenous lines, possessed the competencies and skill sets necessary to provide nursing care in a safe and competent manner. The findings include: Resident #58 was admitted to the facility on [DATE]. A physicians order dated 12/9/19 identified intermittent medication infused by an intravenous (IV) needle. Nurse's note dated 12/9/19 at 4:30 PM identified a peripheral IV (PIV) was placed to the Resident #58's left forearm, #22 gauge with 2 attempts. PIV was placed without incident. Interview with the ADNS on 12/11/19 at 9:15 AM identified the IV therapy log noted a peripheral IV was inserted on 12/9/19 for Resident #58. Interview and clinical documentation review with RN #4 on 12/10/19 at 1:30 PM, failed to provide documentation that RN #5 completed an IV therapy course. RN #4 identified that s/he was not in possession of it and does not know where it may be. S/he further stated that it was her responsibility to maintain the competencies and had not offered the continuing education for IV insertion training. Interview with the Assistant Director of Nursing (ADNS) on 12/11/19 at 9:15 AM identified the IV therapy log noted a peripheral IV inserted on 12/9/19 for Resident #58 by RN #5. Interview with the DNS on 12/11/19 at 9:36 AM noted that s/he was unable to obtain the documentation of completion of training for RN# 5 and the continuing education training for the last 5 years that RN #5 had worked at the facility. Interview with RN # 5 on 12/11/19 09:49 AM identified that s/he routinely inserts IV's in the facility, and had completed a form on hire to the facility but was unable to find the document and the continuing education since. RN #5 further identified that she had last inserted an IV on 12/9/19 without complications. The facility policy for IV insertion identified that peripheral IV catheters would be inserted by those licensed nurses who had successfully completed an IV therapy class and clinical practicum.

Based on observation, a review of the facility documentation, staff interviews and a review of the facility policy, the facility failed to ensure food was stored, prepared, and served in a safe and sanitary manner. The findings included: a. Observations of the kitchen with the Facility Director of Dietary on 12/9/19 at 9:35 AM identified the following: 3 dented 7 pound cans of real fresh chocolate pudding cans in dry storage for resident consumption. 1 opened box with a non-sealed open plastic bag containing skillet omelets in the walk in refrigerator. 1 Slice of cake on a plate wrapped in plastic without a label or date visible in the walk in refrigerator. 1 opened cardboard box containing an opened bag of uncooked hamburger patties in the walk in freezer. 1 open unsealed box missing egg rolls in the freezer. 1 cardboard box labeled Sysco imperial berry with 13 containers of pureed mixed berry labeled as packed on 9/24/18 with ice crystals visible on inside of clear plastic topping, 8 containers of peach pureed dated as packed 2/5/18, 4 containers of broccoli pureed with label not readable as when packed and 3 containers of pineapple pureed dated 3/13/18 dated as packaged on 3/13/18. Interview with Facility Director of Dietary on 12/9/19 at 9:35 AM during tour of kitchen identified the pudding was in dry storage for resident consumption. She identified dietary staff was responsible for ensuring dented cans of pudding were stored separately from food for resident consumption so as to prevent potential food borne illness. She removed the cans from the dry storage area for resident use. Facility Director of Dietary identified that the omelets, egg rolls, and hamburger should have been stored in sealed containers as they had been opened. Facility Director of Dietary identified dietary staff was responsible to ensure food items were labeled, dated and sealed when opened to ensure the food integrity was maintained and to prevent food borne illnesses. The Facility Director of Dietary identified that the un-labeled slice of cake was likely for a resident birthday and should have been labeled and dated so as to know how long the item was safe to consume. Facility Director of Dietary identified the cardboard box containing the pureed mixed berry, peach, broccoli and pineapple were outdated and should not have been stored in the refrigerator. She identified the dietary staff was responsible to ensure the expired items were not stored in areas with food for resident consumption. b. Observations of the kitchen with Facility Director of Dietary on 12/9/19 at 9:50 AM identified the following: Brown sticky coating covering inside of the top oven doors and brown splatter stains and debris on the inside of oven base. Black charred debris coating ridges of grill top and on sides of grill between grill and gas stove. Black coating on stainless steel backing of ridged grill. Yellow and brown matter stuck to the top of the gas stove top grates and black staining on the stainless steel back. Black build up and debris observed on the stainless steel topped gas warming area to the right of the gas stove top. Scattered brown and black crumb like debris and dark brown stains on the floor between stove, grill and oven areas and on black mats in front of the cooking area. Ceiling air vents above food preparation areas with brown rust colored stains and gray debris clinging to vents. Black staining on ceiling around vent. 1 light over the food preparation area with cob web like debris hanging above food prep table. Interview with Facility Director of Dietary on 12/9/19 at 9:55 AM identified the oven doors, grill, gas stove, warming area, floor around oven and stoves and grills, ceiling and ceiling air vents, and light fixture was dirty and in need of cleaning. She identified the kitchen staff was responsible for cleaning the entire kitchen and staff had designated duties outlined in their job descriptions. Facility Director of Dietary identified that although staff had cleaning duties, there was not documentation required when tasks were completed. The Facility Director of Dietary identified she was responsible for ensuring the staff completed cleaning but had been distracted with a broken dishwasher and refrigerator and did not know when the stove, oven, gas grills warming area or floor in front of the cooking equipment had last been cleaned. Facility Director of Dietary identified the kitchen ceiling and lights were not on the kitchen staff cleaning lists and no other department was scheduled to clean any area of the kitchen. Furthermore, she identified the cleanliness of the kitchen was important to prevent food borne illness and for safety. Interview with [NAME] #1 on 12/9/19 at 10:00 AM identified he had worked at the facility for more than 20 year. He identified it was important to have clean cooking equipment to prevent food borne illness and for safety. He identified the gas stove was not clean and had no comment about who was responsible to clean the equipment, when the equipment was to be cleaned or if when he cleaned the equipment last. c. Observation of kitchen Facility Director of Dietary on 12/9/19 at 10:10 AM testing the sanitizer in 2 of 4 sanitizer buckets utilized in the kitchen to sanitize food contact surfaces in the kitchen food preparation areas identified the test strips measured less than 200 part per million (PPM). (The manufacturer directs the product concentration be 200 to 400 PPM to render it effective.) Interview with Facility Director of Dietary on 12/9/19 at 10:10 AM identified that the testing strips indicated the sanitizer was not effective because it was not the right concentration. She identified the sanitizer buckets had to be changed every two hours to maintain the correct concentration and that all dietary staff was responsible for changing the sanitizer solution every two hours. Facility Director of Dietary identified the solution in the two buckets had not been changed since [NAME] #1 filled them at the start of his shift (more than 3 hours earlier). She dumped the existing sanitizer and directed staff to refill the buckets and test the solution to ensure its effectiveness. Facility Director of Dietary identified that upon reflection, there was no system in place for making sure the sanitizer was replaced as needed and she planned to reeducate the staff as it was necessary to have effective sanitizer to prevent food borne illness. Interview with Dietary Aide #1 on 12/9/19 at 10:20 AM identified he had been working since 6:30 AM and did not fill the sanitizer near the prep area he was working that tested below 200 PPM. He identified that the bucket was filled when he was at work and no one directed him to change it. Furthermore, he identified it would be important for the sanitizer to be the correct concentration for it to sanitize the food preparation surfaces effectively. Interview and brief tour of the kitchen with RD #1 on 12/9/19 at 10:40 AM identified that food should be stored in sealed containers, expired food should be discarded and food in dented cans should not be used and not be stored in areas with food for resident consumption to prevent food borne illness. Additionally, RD #1 identified that the oven, grill, gas stove, floor in cooking area, ceiling vents, ceiling and light fixture over the food preparation area were dirty and in need of cleaning. She identified it was important to keep the kitchen clean to prevent food borne illness. Additionally, RD #1 identified that sanitizer used to clean food preparation areas needed to be the right concentration for it to be effective. d. Observation of food pass on the rehabilitation unit with Facility Director of Dietary on 12/09/19 at 11:54 AM identified Dietary Aide #2 had one and a half inch long facial hair on his chin and was plating food from the mobile food cart for resident consumption without a beard restraint. Interview with Dietary Aide #2 on 12/9/19 at 11:55 AM identified he had never been asked to wear a beard restraint. Interview with Facility Director of Dietary on 12/9/19 at 11:56 AM identified that she would expect Dietary Aide #2 to use a beard restraint to protect food from contamination. Facility Director of Dietary noted that Dietary Aide had recently grown a beard and she had not noted it until surveyor inquiry. She identified she would be responsible for ensuring dietary staff was compliant with wearing hair nets and beard restraints. Interview with Corporate Director of Dietary on 12/10/19 at 10:48 AM identified that he spoke with the Facility Director of Dietary about the issues identified during tour with surveyor on 12/9/19. He identified that open food items should be labeled and stored in sealed containers, outdated food items should be discarded. Corporate Director of Dietary identified that the oven, stove, grill, floor in the cooking area, ceiling vents and light above the food preparation area were in need of cleaning. He identified he had directed Facility Director of Dietary to develop a cleaning log to document and hold accountable staff for the cleaning tasks. He noted that the kitchen staff was responsible for the cleaning, however, it would be possible for the Environmental Services Department to assist if a request was made. He identified that additional dietary hours had been authorized to assist with cleaning of the oven, stove, grill, and floor areas in front of the cooking area. Additionally, Environmental services was requested to assist with cleaning of the ceiling and ceiling vents over the food preparation areas. Corporate Director of Dietary identified the lights over the food preparation area needed to be added to the cleaning list. He identified, subsequent to surveyor tour of the kitchen, he provided the Facility Director of Dietary with direction related to creation of an updated policy to ensure the sanitizer was changed every 2 hours as directed by the manufacturer so it would be effective. He identified that he, the DNS and administrator went on bi-weekly rounds in the kitchen, but he did not have documentation related to the rounding. The Director of Dietary noted that his focus most recently has been on fixing a refrigerator and dishwasher so he may not have noticed the condition of the oven, stove, grill, floor in the cooking area, ceiling vents and light above the food preparation area. He identified it was important for the kitchen to be clean to prevent food borne illnesses and staff with a beard would be expected to don a beard restraint. Corporate Director of Dietary Services identified the Facility Director of Dietary Services was responsible for ensuring the dietary staff stored food according to facility policy, cleaned kitchen and equipment to keep it clean and sanitary, utilized sanitizer according to policy, and wore appropriate beard restraints/ hair restraints. Interview with the DNS on 12/11/19 at 7:00 PM identified that although she was part of environmental rounds, she did not enter the kitchen and could not provide insight into the cleanliness of it. Interview with Administrator on 12/11/19 at 7:05 PM identified that although she was part of environmental rounds, she did not take notes nor be able to share information about the kitchen. Subsequent interview with Facility Director of Dietary on 12/12/19 at 9:20 AM identified that she planned to review with food supply and storage policy with the staff during a formal staff meeting and to hold the staff accountable for signing off on the cleaning log for tasks they are responsible for. She planned to do bi-weekly audits of the kitchen for cleanliness. Furthermore, Facility Director of Dietary identified she was revising the sanitizing policy to include delegating staff specific duties related to changing the sanitizing solution every two hours. The Facility Director of Dietary identified the staff will be required to sign off on changing the sanitizer in the buckets every two hours for accountability. She identified she had verbally educated the staff related to the new sanitizing policy and planned to present the policy change in a staff meeting on 12/12/19. Review of facility policy related to food supply and storage identified open food packages are to be covered, labeled and dated. Expired or past expired food items are to be discarded. Frozen foods should be wrapped tightly to prevent cross contamination. Food items that are damaged (such as dented cans) are to be stored in a designated area to be returned to the supplier. Review of facility policy on sanitizing food contact surfaces identified the sanitizer must have a concentration of 200 to 400 PPM and a minimum temperature of 75 degrees Fahrenheit to be effective. Sanitizer buckets are to be replaced every 2 hours or more frequently if visibly dirty. Review of facility policy on dress code identified associates working with food must have facial hair effectively restrained. Although requested on 12/9/19, 12/10/19 and 12/12/19 copies of the environmental round documentation from the Corporate Director of Rehabilitation was not provided.