**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, interviews, and review of facility documentation and policies for one (1) of three (3) residents reviewed for fluid status, the facility failed to complete dehydration evaluations in accordance with facility policy and failed to notify the provider with the results of a dehydration evaluation timely. The findings included: Resident #1 had diagnoses that included adjustment disorder with depressed mood, peripheral vascular disease, and unspecified congestive heart failure. Review of the Nursing admission assessment dated [DATE] identified Resident #1 had a very poor food intake pattern, Resident #1 never ate a complete meal, rarely ate more than one-third of any food offered, ate two (2) servings or less of protein (meat or dairy products) per day, and took fluids poorly. Review of the Comprehensive Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Mental Interview for Mental Status (BIMS) of five (5) indicative of severely impaired cognition. The MDS further identified Resident #1 required moderate assistance with oral and personal hygiene and set-up assistance with eating. Review of Resident #1's Care Plan dated 12/26/24 identified the Resident #1 was exhibiting signs and symptoms of Corona Virus and had the potential for nutritional decline related to poor appetite interventions directed to encourage fluids up to fluid restriction, if applicable, to prevent dehydration, and to record intake and output as ordered. Review of the Resident #1's Nutritional assessment dated [DATE] identified Resident #1 had an estimated daily fluid need of 1445 milliliters to 1740 milliliters. Review of Resident #1's Fluid Intake Chart dated 12/30/24 through 1/12/25 identified the following: -A fluid intake of 580 milliliters on 12/30/24. -A fluid intake of 720 milliliters on 12/31/24. -A fluid intake of 650 milliliters on 1/1/25. -A fluid intake of 960 milliliters on 1/2/25. -A fluid intake of 980 milliliters on 1/3/25. -A fluid intake of 1080 milliliters on 1/4/25. -A fluid intake of 960 milliliters on 1/5/25. -A fluid intake of 1020 milliliters on 1/6/25. -A fluid intake of 860 milliliters on 1/7/25. -A fluid intake of 760 milliliters on 1/8/25. -A fluid intake of 480 milliliters on 1/9/25. -A fluid intake of 380 milliliters on 1/10/25. -A fluid intake of 600 milliliters on 1/11/25. -A fluid intake of 640 milliliters on 1/12/25. Intake for the 14 days were all below the residents minimum daily fluid needs of 1445 milliliters. a) Review of Resident #1's Dehydration Evaluations identified evaluations were completed on 12/31/24, 1/3/25, 1/6/25, and 1/11/25 which indicated dark urine, decreased skin turgor, dry tongue, and dry mucous membranes. The evaluations identified that the practioner was notified on 12/31/24, 1/3/25, and 1/6/25. Interview with the Director of Nursing Services (DNS) on 3/5/25 at 3:10 PM identified that a Dehydration Evaluation should be completed when a resident's fluid intake was below his/her fluid goal for three (3) consecutive days and that Resident #1 should have had a Dehydration Evaluation. The DNS further identified that although the dehydration assessments were completed in accordance with facility policy on 12/31/24, 1/3/25, and 1/6/25, a Dehydration Assessment should have been completed on 1/9/25 instead of 1/11/25 (2 days late) as his/her fluid intake did not meet the established parameters on 1/6/25, 1/7/25, and 1/8/25. b. Review of the 1/11/25 Dehydration Evaluation identified Resident #1 had dark urine, decreased skin turgor, dry tongue and mucous membranes, and that APRN #1 was notified of the findings. Review of LPN #2's SBAR (Situation, Background, Assessment, Recommendation) dated 1/13/25 at 7:53 PM identified Resident #1 with increased lethargy, had mental status changes, was not eating or drinking, and that the family requested the resident be sent to the emergency room. Review of the hospital paperwork dated 1/13/25 identified that the resident was dehydrated and required Intravenous (IV) fluid resuscitation. Interview with LPN #1 (who performed the 1/11/25 Dehydration Evaluation) on 3/6/25 at 2:55 PM identified she did not call the provider on January 11, 2025 she placed the Dehydration Evaluation into the Advanced Practice Registered Nurse (APRN) binder for review, however, the physician/APRN should have been called regarding Resident #1's 1/11/25 Dehydration Evaluation results and decreased fluid intake because January 11, 2025 was a Saturday and it was not guaranteed that a provider would be at the facility on that day. Interview with APRN #1 on 3/5/25 at 3:00 PM identified that he/she was not made aware of the 1/11/25 Dehydration Evaluation findings until 1/13/25 (Monday) when he/she was at the facility and would expect to have been called on 1/11/25 (Saturday) if the resident was at risk for dehydration. Interview with the DNS on 3/5/25 at 3:10 PM identified it was acceptable practice to place Dehydration Evaluations in the APRN binder during the week (Monday through Friday) as the physician/ APRN were in the facility on a regular basis, however if the evaluation was completed over the week-end (1/11/25 was a Saturday),and the assessment identified signs of dehydration the physician/APRN should have be called regarding findings/concerns on 1/11/25. The DNS further identified at risk residents should be seen within 24 hours of their Dehydration Evaluation if signs of dehydration are identified. The facility did not have a Dehydration Evaluation policy to provide. Review of the Hydration Protocol directed new patients would have a daily fluid goal of 1500 milliliters unless otherwise ordered by the physician. Review of the Intake/Output policy directed to ensure adequate hydration and prevent dehydration to the extent possible based on each resident's individualized care needs and choices. Review of the Hydration Protocol directed all residents will receive sufficient fluids to maintain proper hydration and health.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the clinical record, review of facility policy/procedures and interviews for one of two sampled residents (Resident #252) reviewed for respiratory care, the facility failed to ensure a physician order was in place for a resident who required oxygen therapy. The findings included: Resident #252 was admitted to the facility on [DATE] with diagnoses included dementia, without behavioral disturbance, psychotic disturbance, mood disturbance anxiety, and dyspnea. The hospital Discharge summary dated [DATE] identified Resident #252 was administered oxygen via nasal cannula at 2 lpm (liters per minute) while in the hospital. The nursing admission assessment dated [DATE] at 11:05 AM identified Resident #252 was admitted to the facility with diminished lung sounds, exhibited shortness of breath (SOB) with exertion, utilized oxygen, and had diagnoses of asthma, and chronic obstructive pulmonary disease (COPD) The baseline care plan dated 1/29/25 identified Resident #252 received respiratory treatment with interventions that included oxygen and O2 sats as ordered, suction as ordered, head of bed elevated to comfort level, lung sounds as ordered, watch for increased cough, congestion, wheeze, edema, and shortness of breath. Th physician's orders dated 1/29/25 directed to change and label the oxygen (O2) set up every Saturday on the night shift. The nurse's note dated 1/29/25 at 12:25 PM identified Resident #252's O2 saturation was 95% on 5 liters of oxygen. The nurse's note dated 1/30/25 at 3:05 PM identified Resident #252's O2 saturation was 97% on 5 liters of oxygen. The occupational therapy evaluation and plan of treatment dated 1/30/25 identified the short-term goal for care to improve standing tolerance by 2 minutes with no shortness of breath on 2 liters of O2. Review of the clinical record identified nursing notes dated 1/31/25, 2/1/2, 2/2/25 and 2/6/25 that identified Resident #252 had oxygen in place. Observation on 2/6/25 at 11:33 AM identified Resident #252 had oxygen in place via nasal canula and the oxygen level was set at 0.5 liters per minute. Observation on 2/8/25 at 7:37 AM identified Resident #252 sleeping in bed with nasal canula in place and oxygen set and flowing at 2 liters per minute. Interview on 2/8/25 at 8:01 AM with RN#3 identified that residents receiving oxygen therapy should have a physician's order in place directing the use of oxygen and the level the oxygen should be set at. Review of the clinical record with RN #3 failed to identify an oxygen order for Resident #252. Interview on 2/8/25 at 10:00 AM with the DNS, Administrator, RN#4, and RN#8, identified there should be a doctor's order in place directing the use of oxygen. Additionally, the DNS identified there was not a policy related to the monitoring of a resident that utilizes continuous oxygen therapy. Interview with RN #2 on 2/8/25 at 2:33 PM identified that she completed the admission paperwork for Resident #252 and noted orders for oxygen were not noted on the W10, so they were not included on the admission orders for the facility. An unsuccessful attempt was made to interview MD #1 on 2/8/25 at 2:41 PM regarding the lack of oxygen therapy orders for Resident #252. The nasal cannula oxygen administration policy identified that the procedure for oxygen administration contained verification of the physician's order and review of the patient chart to familiarize yourself with the patient history and directed use of a humidifier bottle if flow is greater than 4 LPM. Additionally, the policy directed to record the start of oxygen in the patient's chart.

Based on observations, review of facility policy/procedures and interviews, the facility failed to ensure the medication administration cart was appropriately secured during the medication administration pass while not within the line of sight of the nurse. The findings include: Observations of medication administration on 2/6/25 at 9:31 AM identified LPN #2 was able to access the medications without using a key to unlock the medication cart. She used her fingers to pull the lock out and was able to open the drawers containing the medications. LPN #2 prepared Resident #45's medications and then pushed the lock in on the cart and entered the resident's room and pulled the privacy curtain. The medication cart was not within LPN #2's line of sight. LPN #2 returned to the cart and was able to pull the locking mechanism out and without using a key, was able to access medications. At 9:52 AM, LPN #2 prepared medications for Resident #250, LPN#2 pushed the locking mechanism on the med cart, entered the room, and pulled the privacy curtain closed. The medication cart was not within LPN #2's line of sight. Interview on 2/6/25 at 10:00 AM with LPN#2 identified that if the cart was in the resident's doorway and the nurse was in the room, the cart did not have to be secured with the key. Interview on 2/7/25 at 10:14 AM with the DNS identified that the medication cart must be locked when the nurse walks away from it. The DNS indicated that if the cart was visible, and the nurse was close by, then it may be okay to not use the key. Additionally, the DNS identified that the locks will be checked because they should not be able to be opened when in the locked position without a key. Facility policy on medication storage and administration identified that medication administration carts are locked when not visible to the nurse or qualified staff, and that the nurse or qualified staff should stay with resident until medications have been taken.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, review of facility policy, review of facility documentation, and interviews for two of five sampled residents (Resident #4 and Resident #5), reviewed for immunizations, the facility failed to ensure that the pneumococcal vaccine was administered as requested by the resident upon admission. The findings include: 1. Resident #4 was admitted to the facility in September of 2024 with diagnoses that included dementia, type 2 diabetes mellitus, anemia, and atrial fibrillation. The admission MDS assessment dated [DATE] identified Resident #4 had moderately impaired cognition. Review of the Pneumococcal Vaccine Consent form identified Resident #4 responsible party gave the facility permission to administer the pneumococcal based on the guidance provided on current pneumococcal vaccine schedule per the Centers for Disease Control and Prevention (CDC) in collaboration with the provider oversight on 10/9/24. Review of Resident #4 clinical records on 2/6/25 failed to identify that he/she received the vaccination or documentation that the resident refused the vaccine. Interview with the Regional Director of Nursing Services (RN #4) and the Infection Preventionist (IP) Nurse (RN #5) on 2/7/25 at 9:14 AM identified she was responsible for ensuring the resident was administered the pneumococcal vaccine as requested, however she was trying to administer the COVID-19, influenza vaccine, dealing with outbreaks and monitoring vaccine reaction. IP identified COVID-19 outbreak was in September of 2024 and December of 2024, and gastrointestinal outbreak in January of 2024. The IP further indicated the vaccine should be administered when requested but had to check historical immunization prior to administration, however the vaccine was not administered to the resident at the time when it was requested. 2. Resident #5 was admitted to the facility in January of 2024 with diagnoses that included dementia, chronic obstructive pulmonary disease, and pulmonary fibrosis. The admission MDS assessment dated [DATE] identified Resident #5 had moderately impaired cognition. Review of the Pneumococcal Consent Form (PCV 23), (PVC 20) and (PVC 15) identified Resident #5's responsible party gave the facility permission to administer the pneumococcal on 1/30/24. Review of another Pneumococcal Vaccine Consent form identified Resident #4 responsible party gave the facility permission again to administer the pneumococcal based on the guidance provided on current pneumococcal vaccine schedule per the Centers for Disease Control and Prevention (CDC) in collaboration with the provider oversight on 10/8/24. Review of Resident #5 clinical records on 2/6/25 for January and February of 2024 and October of 2024 all failed to identify that he/she was administered the vaccination. Interview with Person #2 on 2/8/24 at 10:57 AM identified he/she had given the facility permission to administer the pneumococcal vaccine to Resident #5 in quite a while now and had assumed it was automatic administered after the consent is signed, but it seem as it was not administered as the facility called him/her on 2/7/25 stating Resident #5 was not feeling well hence they were unable to administer the pneumococcal vaccine on 2/7/25. Interview with the Regional Director of Nursing Services (RN #4) and the Infection Preventionist (IP) Nurse (RN #5) on 2/7/25 at 9:14 AM identified she was responsible for ensuring the resident had received the pneumococcal vaccine as required, however indicated she was not the IP at the time when the Resident #5's pneumococcal consent was first signed in January of 2024. Interview with the RN #4 and RN #5 on 2/7/25 at 10:42 AM identified that on admission residents are assessed and offered the pneumococcal vaccination. RN #5 identified the process for administering vaccine to the resident, a consent is received from the resident/the resident responsible party to administer the vaccine, then a physician's order is obtained, and the vaccine is administered by the IP nurse or the nurse on the unit. Both RN #4 and RN #5 identified that the pneumococcal vaccine should have been administered when requested by the resident/resident representative and currently in the process to ensure all residents are updated with their pneumococcal vaccination. They further identified that Resident #4 and Resident #5 are eligible for PCV 20 and will be receiving the vaccine. Review of the Pneumococcal policy identified residents, or their responsible party will be offered the pneumococcal vaccine according to their specific eligibility that aligns with the current Center for Disease Control (CDC) Adult immunization schedule upon admission. The facility should obtain historical pneumococcal vaccination history and collaborate with the MD to determines appropriate vaccine needs. The policy further identified the facility would document date and location of injection site, refusal and re-offer and historical pneumococcal vaccine administration in the medical record if given in the community.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility documentation, review of facility policy/procedures and interviews, the facility failed to establish a system of records of receipt and disposition of all controlled medications in sufficient detail to enable an accurate reconciliation and failed to have a system in place to keep an accurate accounting of controlled medications. The findings include: Observation on [DATE] at 11:35 AM identified the DNS office contained a binder that held the yellow Controlled Substance Disposition Records (CSDR), the CSDR sheets were organized alphabetically. Additionally, some of the yellow CSDR sheets were from 2023 and had not yet been reconciled with the white CSDR nor were the medications identified as having been destructed. The book did not contain audit sheets for 2024 and the last signed off narcotic audit was [DATE] Interview on [DATE] at 11:45 AM with the DNS and RN#8 identified that the DNS is responsible for narcotic reconciliation in the facility and completed an audit on [DATE]. The DNS indicated that she doesn't use the audit sign off sheets to log the audits and signs the yellow Controlled Substance Disposition Record (CSDR) sheet to identify when an audit of that medication was completed. The DNS indicated the audits should be completed twice a month, but she sometimes runs out of time. The DNS was not able to demonstrate that narcotics were reconciled regularly or in some cases, at all. The DNS noted that sometimes when a resident is discharged , they are discharged with the medication, and she does not know what happens to the white CSDR that was with the medication in the med cart. The DNS further identified that the white sheets may go with the chart to the records department. When asked how the medications were reconciled without having the white CSDR sheets match up against the yellow CSDR sheets, the DNS did not answer but indicated that she was trying to implement a better system. Interview on [DATE] at 11:55 AM with RN#4 and RN#8 identified that narcotic audits should be completed two times per month and that the audit signature sheets are provided to keep track of the audits. Interview on [DATE] at 12:13 PM with RN#3 identified that the white CSDR sheets are turned into the DNS if the resident is discharged with the remaining medication after it is zeroed out. RN#3 indicated that the DNS takes the unused narcotics from the unit carts if a resident dies and/or if the medication is discontinued or changed, or the resident leaves without it. Observation and interview on [DATE] at 12:33 PM with the DNS identified she attempted to reconcile 10 CSDR sheets and the audit identified that only two of the ten controlled medications remained in the medication cart. The DNS indicated she was going to check the destruction bin and the records department. She identified that the nurses sometimes discharge residents and place the white copies of the CSDRs into the chart and the records department takes them. The DNS identified she would like to receive the white copies, but nursing doesn't give them to her. Interview on [DATE] at 1:09 PM with the DNS identified that she found the white CSDR sheets, and they were in the records department from discharged residents, two of the residents were deceased residents and the white CSDRs and medications were in the DNS office. The facility policy for medication administration identified narcotics and controlled substances must be double-locked and counted per facility protocol and that medication reconciliation should be done upon resident admission, transfer and discharge.

Based on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for grievances, the facility failed to initiate a grievance concern for a missing item. The findings include: Resident #1 had diagnoses that included dementia, anxiety, agitation, and depression. A progress note dated 1/10/2023 at 12:07 P.M. written by the Administrator identified she was notified of Resident #1's misplaced wedding ring. The Administrator identified a concern form would be initiated, she spoke with Resident #1's family member regarding Resident #1's misplaced wedding ring and will initiate a search. A progress note dated 1/11/2023 at 8:25 P.M. written by the Administrator identified she followed up with Resident #1's family member in person today regarding Resident #1's misplaced ring and a search was still in progress. Review of the facility's Grievance Log from 1/1/2023 to 12/31/2023 failed to provide documentation to reflect a grievance concern form was completed on 1/10/2023 for Resident #1's missing wedding ring. Interview and clinical record review with Administrator on 7/3/2024 at 1:35 P.M. she was unable to provide documentation to reflect that on 1/10/2023 when Resident #1's wedding ring was misplaced that a grievance concern form was completed nor documentation to identify the outcome of the grievance. The Administrator identified the social worker is responsible for completing a grievance concern form when a resident reports a missing item and once the investigation is completed the summary is documented on the concern form to indicate the findings. The Administrator identified on 1/10/2023 the facility was without a social worker and that a grievance concern form was not completed when Resident #1's wedding ring was reported to be misplaced. The Administrator indicated that Resident #1's wedding ring was found to be in possession by h/her family member, however, she was unable to provide documentation to reflect Resident #1's misplaced wedding ring was found. Upon surveyor inquiry the Administrator provided this surveyor with a progress note dated 7/3/2024 at 10:24 A.M. (the day of the survey) that indicated she had discussed with the former therapeutic recreation director who confirmed Resident #1's ring was with h/her family member and that the former infection preventionist had confirmed that Resident #1's family member had the ring. Review of facility grievance policy, in part, identified it is the right of a resident and/or responsible party to have a prompt and reasonable resolution of a complaint or concern. Each concern form will contain the concern, the resolution, and the person responsible for resolving the concern. The grievance policy directs a complaint or concern should be put in writing using the concern form, the concern form shall be completed as soon as possible, and the resident/responsible party shall be informed of the resolution.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation review, and interviews for one of three residents (Resident #2) reviewed for medication errors, the facility failed to ensure medication was administered in accordance with physician orders and failed to ensure the resident received the correct dose of a cancer treatment medication. The findings include: Resident #2's diagnoses included malignant neoplasm of the prostate and malignant neoplasm of the bone. A physician order dated 10/3/2022 directed to administer Abiraterone Acetate (used to treat cancer) 250 milligrams (mg), four (4) tablets once a day for a total dose of 1000 mg for prostate cancer. The admission Minimum Data Set assessment dated [DATE] identified Resident #2 had moderately impaired cognition, had a diagnosis of cancer, benign prostatic hyperplasia (BPH) and obstructive uropathy. The facility medication error report dated 11/2/2022 identified after counting the Abiraterone Acetate for planned discharge, the facility staff identified a discrepancy in the number of tablets, and indicted the correct dose of the medication was not administered. The facility incident report dated 11/4/2022 identified Resident #2 was alert and oriented and included statements from LPN #1 and LPN #2 (11:00 PM to 7:00 AM charge nurses) that indicated both LPN #1 and LPN #2 stated they gave the Abiraterone Acetate medication as ordered, 4 tablets once a day. The incident report further identified upon discharging Resident #2, when staff counted the medication tablets, it was identified staff failed to administer 51 tablets. Facility investigation identified Resident #2 was administered 29 tablets, and Resident #2 should have received 80 tablets (51 tablets were not administered in accordance with physician orders). Facility investigation did not identify the dates of the errors. The investigation further identified Resident #2 was seen by his/her oncologist on 11/3/2022 and the physician identified no immediate side effects were present (the error was not significant), and Resident #2 was to continue on the Abiraterone Acetate with no change in the dosage ordered. Interview and documentation review with the Administrator on 5/24/2024 at 1:44 PM identified Resident #2's Abiraterone Acetate was brought into the facility by the resident's family member. The Administrator identified it was her recollection the family member counted the tablets upon discharge and the DNS did a recount of the tablets, which identified the discrepancy in the number of tablets that should have been administered. The Administrator identified an additional recount was completed which confirmed the medication error. The Administrator identified it was facility policy to always ensure the right route, right resident, right dose, right time, and right documentation was followed, and that for Resident #2, facility staff did not follow the facility policy and the medication error occurred. The Administrator stated the medication should have been administered as ordered by the physician and was unable to explain why it was not given as ordered. Although requested, a policy regarding medication administration was not provided for surveyor review.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 sampled resident reviewed for misappropriation (Resident #15), the facility failed to implement the written policies and procedures for abuse to thoroughly investigate an allegation of misappropriation. The findings include: Resident #15 was admitted with diagnoses that included multiple sclerosis, bladder cancer and depression. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #15 was cognitively intact requiring limited assistance with 1 staff member for bed mobility, transfer, and personal hygiene. The social services note dated 9/21/22 at 12:35 PM identified a concern report form was filled out regarding NA care. The report noted the social worker, DNS and Administrator will follow up. A facility Reportable Event form dated 8/4/22 identified that Resident # 15 reported that s/he had given $20.00 to NA #8 to purchase personal items at the store and that NA #8 never bought the items. The event was reported to the state health department as a staff to resident abuse without injury. Interview and review of the Reportable Event file with the administrator on 10/3/22 at 10:00 AM failed to identify investigative documents other than a statement from Occupational Therapist (OT #1) who reported that NA #8 did not purchase the items for Resident #15 and a statement from Social Worker (SW) #2 who interviewed Resident #15 after OT#1 's report. The administrator confirmed that there were no other investigative documents in 8/4/22 investigation file of Resident #15 ' s concern regarding missing money and that she did not investigate Resident #15 ' s allegation as she was just transitioning into the role of Administrator and that SW #2 had completed the investigation. Interview with the Director of Nursing Services (DNS) on 10/3/22 at 10:30 AM identified that she was not involved in the investigation or follow up for Resident #15's allegation of the missing money as the Administrator handled the investigation at this time secondary to her just starting the DNS position. Interview with OT #1 on 10/4/22 at 9:00 AM identified NA #8 asked in the presence of Resident #15 for $20.00 to purchase some personal items for the Resident #15. Resident #15 had left some money in the therapy office and NA #8 was provided the $20.00 from Resident #15 's money. A few weeks after, OT#1 asked Resident #15 if NA #8 had purchased and provided the items to Resident #15 and Resident #15 responded no. OT #1 stated she notified the administrator when Resident #15 stated that she had not received any of the items from NA#8 on 8/4/22. Interview with the Administrator on 10/4/22 on 9:30 AM identified that she would consider the 8/4/22 investigation file of Resident #15 ' s concern regarding missing money as not complete and indicated that SW#2 had completed the investigation. Interview with SW#2 on 10/4/22 at 12:37 PM identified she had followed up with Resident #15 after being informed by OT #1 that NA #8 had been given money to buy Resident #15 some personal care items and that NA#8 had never provided them to the resident. She continued by stating that Resident #15 denied she ever gave NA #8 money. She continued to state that it was a psychosocial visit as a follow up to an allegation of abuse as per the facility process. SW # 2 stated that she did not investigate the issue as the Administrator was handling investigation; her role as the social worker was to gather information and determine how the resident was reacting to the event and to provide support to the resident as needed. She stated she did not conduct any other interviews regarding Resident #15 and the missing money. She also stated that Resident #15 was calm, showing no distress and had some forgetfulness. SW # 2 stated that she provided the information from her interaction with Resident #15 to the Administrator who needed the information for her investigation. Attempts to contact NA #8 were unsuccessful. The facility policy Abuse/Resident defines misappropriation of resident property as a form of abuse and as such directs in part that in the investigation by the Administrator/DNS/Designees such include interviewing all witnesses, including the person accused of the abuse, interview all other parties who may have knowledge useful to the investigation, obtain dated and signed statements from all involved including the accused.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for sampled resident reviewed for misappropriation (Resident #15), the facility failed to implement the written policies and procedures for abuse to thoroughly investigate an allegation of misappropriation to prevent further abuse. The findings include : Resident #15 was admitted with diagnoses that included multiple sclerosis, bladder cancer and depression. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #15 was cognitively intact requiring limited assistance with 1 staff member for bed mobility, transfer, and personal hygiene. The social services note dated 9/21/22 at 12:35 PM identified a concern report form was filled out regarding NA care. The report noted the social worker, DNS and Administrator will follow up. A facility Reportable Event form dated 8/4/22 identified that Resident # 15 reported that s/he had given $20.00 to NA #8 to purchase personal items at the store and that NA #8 never bought the items. The event was reported to the state health department as a staff to resident abuse without injury. Interview and review of the Reportable Event file with the administrator on 10/3/22 at 10:00 AM failed to identify investigative documents other than a statement from Occupational Therapist (OT #1) who reported that NA #8 did not purchase the items for Resident #15 and a statement from Social Worker (SW) #2 who interviewed Resident #15 after OT#1 's report. The administrator confirmed that there were no other investigative documents in 8/4/22 investigation file of Resident #15 ' s concern regarding missing money and that she did not investigate Resident #15 ' s allegation as she was just transitioning into the role of Administrator and that SW #2 had completed the investigation. Interview with the Director of Nursing Services (DNS) on 10/3/22 at 10:30 AM identified that she was not involved in the investigation or follow up for Resident #15's allegation of the missing money as the Administrator handled the investigation at this time secondary to her just starting the DNS position. Interview with OT #1 on 10/4/22 at 9:00 AM identified NA #8 asked in the presence of Resident #15 for $20.00 to purchase some personal items for the Resident #15. Resident #15 had left some money in the therapy office and NA #8 was provided the $20.00 from Resident #15 ' s money. A few weeks after, OT#1 asked Resident #15 if NA #8 had purchased and provided the items to Resident #15 and Resident #15 responded no. OT #1 stated she notified the administrator when Resident #15 stated that she had not received any of the items from NA#8 on 8/4/22. Interview with the Administrator on 10/4/22 on 9:30 AM identified that she would consider the 8/4/22 investigation file of Resident #15 ' s concern regarding missing money as not complete and indicated that SW#2 had completed the investigation. Interview with SW#2 on 10/4/22 at 12:37 PM identified she had followed up with Resident #15 after being informed by OT #1 that NA #8 had been given money to buy Resident #15 some personal care items and that NA#8 had never provided them to the resident. She continued by stating that Resident #15 denied she ever gave NA #8 money. She continued to state that it was a psychosocial visit as a follow up to an allegation of abuse as per the facility process. SW # 2 stated that she did not investigate the issue as the Administrator was handling investigation; her role as the social worker was to gather information and determine how the resident was reacting to the event and to provide support to the resident as needed. She stated she did not conduct any other interviews regarding Resident #15 and the missing money. She also stated that Resident #15 was calm, showing no distress and had some forgetfulness. SW # 2 stated that she provided the information from her interaction with Resident #15 to the Administrator who needed the information for her investigation. Attempts to contact NA #8 were unsuccessful. The facility policy Abuse/Resident defines misappropriation of resident property as a form of abuse and as such directs in part that in the investigation by the Administrator/DNS/Designees such include interviewing all witnesses, including the person accused of the abuse, interview all other parties who may have knowledge useful to the investigation, obtain dated and signed statements from all involved including the accused and to review the employment record and history of the individual.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of facility documentation, review of policy and staff interview for one sampled resident (Resident # 20) reviewed for falls, the facility failed to revise the care plan timely to provide further falls and for. The findings include: Resident #20 was admitted with diagnoses that included personal history of cerebral infarction, muscle weakness with difficulty walking and dementia. The quarterly MDS assessment dated [DATE] identified Resident #20 had severe cognitive impairment, required extensive two person assist with bed mobility, transfers, ambulated with assist of a walker, and had a history of previous falls. The care plan dated 5/13/22 identified Resident #20 required assist with Activities of Daily Living (ADL). Intervention includes to provide the assistance of two with a rolling walker. The care plan also identified the resident was at risk for falls and had a history of falls. Interventions included: the provision of a flat call bell on the left side of the bed, have a recliner next to the bed for comfort and when getting up for breakfast and to place in the resident in a recliner chair instead of wheelchair. a) Nursing progress note dated 6/5/22 identified Resident #20 experienced an unwitnessed fall where s/he was found on the floor next to the bed on right side with his/her head stuck at the nightstand. The responsible party declined an emergency room transfer. Neurological checks were in place and a fall risk assessment was completed. The Reportable Event dated 6/5/22 identified Resident #20 experienced on 6/5/22 an unwitnessed fall where s/he was found on the floor next to the bed on right side with his/her head stuck at the nightstand. Resident #20 stated s/he was going to work. Resident #20 was assessed and noted to have sustained two lumps on top on the head and was determined to have been in bed prior to the fall. The Advanced Practice Registered Nurse (APRN) and family were notified, and an ice pack were applied to the head. A review of the care plan following the fall did not include any revision for prevention of future falls following the 6/5/22 unwitnessed fall. b) Nursing progress note dated 6/19/22 identified Resident #20 had an unwitnessed fall where s/he was found on the floor next to bed. An RN assessment was completed and determined no injury was identified at the time of the fall. Neurological checks were initiated. The Reportable Event dated 6/19/22 identified Resident #20 was found next to the bed on the floor mat lying sideways with the head up against the bottom of the bed. The APRN and responsible party were notified, and neurological checks were initiated. A review of the care plan following the fall did not include a revision for prevention of future falls following the 6/19/22 unwitnessed fall. An interview on 10/03/22 at 2:48 PM with the DNS identified the care plan was not revised following the falls on 6/5/22 and 6/19/22 to prevent future falls and indicated the care plan should have been revised after the falls. Although a policy for reviewing and revising the care plan was requested, none was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation, facility policy, and interviews for 1 resident (Resident # 20) reviewed for medication administration, the facility failed to ensure medications were administered according to professional standards and within facility policy. The findings include: Resident #20 was admitted with diagnoses that included personal history of cerebral infarction, muscle weakness with difficulty walking and dementia. The quarterly MDS assessment dated [DATE] identified Resident #20 had severe cognitive impairment and required assist with personal care. The care plan dated 5/13/22 identified Resident #20 was confused and forgetful due to dementia and required assist with ADL. Interventions included to allow time to respond when speaking, offer gentle reminders and if confused directed to restate in simpler terms. The nursing progress note dated 7/19/2022 at 11:56AM identified during morning medication pass, GPN (Graduate Practical Nurse identified as LPN #4) accidentally gave the resident's roommates medication to Resident # 20 which consisted of the administration of Metformin (hypoglycemic)1000 Milligram (MG) and levetiracetam (Anti-seizure) 125 mg. The APRN was notified and ordered the resident's blood sugars (BS) to be monitored before meals and at 2:00 AM. If the resident's BS remained stable, there was no need to continue monitoring. Resident # 20's vital signs were stable. The responsible party was notified and continue monitoring was in place. The Medication Error Report dated 7/19/22 identified at 8:15AM, Lamictal (Anti-seizure) 125 mg, metformin 1000mg was administered to Resident #20 in error. The reason for the error was secondary to a new nurse was orienting and gave the medications intended for the resident's roommate to Resident #20. The precepting nurse (LPN #5) was at the bedside, but her back was turned away from the resident at the time of the incident. The APRN and responsible party were notified. No adverse effects were noted. Precautions were put in place to prevent future errors and to ensure while orienting staff, eyes are on the nurse at all times and all rights of medication administration are followed. The report was signed by the DNS, Administrator, Medical Director, and LPN #4 but did not include the signature of LPN #5 who did not provide adequate supervision at the time of the incident. An interview on 9/29/22 at 9:55AM with LPN #4 identified she began working at the facility mid July 2022 as a graduate Licensed Practical Nurse waiting to take the license examination. LPN #4 indicated she was assigned to complete the medication pass on 7/19/22 under the supervision of LPN #5. LPN #4 started off administering the medications while supervised. LPN #5 then instructed LPN #4 to give the medications while she popped them to remain in compliance with time. LPN #4 indicated LPN #5 would pour the medications for the person in the first bed and then the second bed as they went along. LPN #4 stated when they got to Resident #20, she gave the medications as the resident was in the first bed. LPN #5 was preparing medications for another resident so did not notice until the medications were administered. LPN #5 stopped immediately and went to notify the DNS. LPN #4 indicated she was never asked what had occurred or provided a statement. Instead, the DNS provided LPN #4 with the Medication Error Report for her to sign, which she did. An interview on 9/29/22 at 9:34 AM with the DNS identified LPN #5 was orienting a new nurse during the medication pass on 7/19/22. According to the DNS, LPN #5 was checking the medications in the medication administration record and cleaning up. LPN #5 turned around and the incorrect medications had already been given to Resident #20. Although, the DNS indicated she spoke to LPN #4 and LPN #5 separately and they both corroborated the story, she was unable to provide the investigation including statements from each nurse. The DNS further stated the interactions were verbal. The facility policy for General Dose Preparation and Medication Administration direct that each time a medication is administered, staff should ensure that it is the correct medication, the correct dose, the correct route, the correct rate, for the correct resident as set forth by the facility's medication administration schedule. Attempts to reach LPN #5 were unsuccessful.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #20) reviewed for falls, the failed to ensure neurological testing was completed for a resident who sustained an unwitnessed fall and for one resident (Resident #30) reviewed for skin condition(s), the facility failed to ensure consistent weekly wound monitoring for a resident with non-pressure related wounds and failed to follow recommendations from a specialty service or hospital for a resident with a non-pressure related wound and for 1 sample resident (Resident # 41) reviewed for death, the facility failed to ensure that there was a written physician's order of RN May Pronounce Death when a resident death was anticipated. The findings included: 1. Resident #20 was admitted with diagnoses that included personal history of cerebral infarction, muscle weakness with difficulty walking and dementia. A quarterly MDS assessment dated [DATE] identified Resident #20 had severe cognitive impairment, required extensive two person assist with bed mobility, transfers, ambulated with assist of a walker, and had a history of previous falls. The care plan dated [DATE] identified Resident #20 required assist with ADL that included assist of two with a rolling walker. The care plan also identified Resident # 20 was at risk for falls and had a history of falls with interventions that included the provision of a flat call bell on the left side of the bed, have a recliner next to the bed for comfort and when getting up for breakfast, place in recliner chair instead of wheelchair. The nursing progress note dated [DATE] at 12:49 AM identified Resident #20 was observed on the floor next to his/her bed alert and verbal. There was no visible injury. Mentation was at baseline. Resident #20 stated s/he was going home. The APRN and responsible party were notified. Resident #20 was reminded this was his/her home constantly throughout the night. A Reportable Event dated [DATE] identified Resident #20 had an unwitnessed fall where s/he was observed on the floor next to the bed. Resident #20 was unable to recall the incident due to impaired cognition. The APRN and family were notified. A body audit and RN assessment was completed which determined there were no obvious signs of injury. The nursing progress notes, or facility documentation dated [DATE] through [DATE] did not include neurological assessments for Resident #20 following the unwitnessed fall. An interview on [DATE] at 2:48 PM with the DNS identified neurological assessments were not completed as part of the clinical record for Resident #20 and should have been conducted. The facility policy for Falls: Minimizing Risk of Injury directed a resident who experiences an unwitnessed fall and unable to verbalize if they hit their head due to cognitive status or or experienced any type of head injury will have neurological checks instituted. 2. Resident #30 was admitted with diagnoses that included type II diabetes mellitus, hemiplegia and hemiparesis following other cerebrovascular disease affecting left non-dominant side. A quarterly minimum data set (MDS) assessment dated [DATE] identified Resident #30 was without cognitive impairment, required extensive 2 person assist with bed mobility and personal care, total assist with transfers, was at risk for the development of pressure ulcers and did not have any unhealed pressure ulcers, The care plan dated [DATE] identified Resident #30 was at risk for skin breakdown due to decreased mobility, incontinence, and poor circulation. Interventions included consultation with wound care specialist as ordered/needed, follow all recommendations of treatments weekly and maintain offloading devices. a. Weekly Skin Audit dated [DATE] noted a 7.5 cm fluid filled blister and 16 cm reddened area to the abdomen. The APRN Progress note dated [DATE] noted Resident #30 with an abdominal wound Initial wound encounter measurements are 7 cm length x 3 cm width x 0.1 cm depth, with an area of 21 sq cm and a volume of 2.1 cubic cm. No tunneling had been noted. No sinus tract had been noted. No undermining has been noted. There was no drainage noted. The patient reported a wound pain of level 5/10. Wound bed has 26-50% slough, 26-50% pink granulation, no eschar, and no epithelialization present. The periwound skin texture and moisture was normal. The peri-wound skin color and temperature were also normal. Peri-wound skin did not exhibit signs or symptoms of infection. Treatment orders were placed. The Wound Specialist note dated [DATE] noted Resident #30 had wounds that included an abdominal wound since [DATE] due to a seat belt and a wound to the left leg first noted on [DATE]. There were no corresponding measurements or characteristics. Both areas with noted as improving. Review of the facility wound tracking, nursing progress notes, medical progress notes and wound notes dated [DATE] through [DATE] did not include weekly measurements or identifying characteristics for the abdominal wound and left leg wound and any subsequent newly identified non- pressure injuries on the following dates: [DATE], [DATE], [DATE], [DATE] through [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. An interview on [DATE] at 10:48 AM with LPN #3 identified she was responsible for monitoring facility wounds under the supervision of the DNS. LPN #3 identified Resident #30 was originally followed by wound care specialists within the facility and then began seeing wound care specialists out in the community. LPN #3 indicated she was not tracking the wounds for Resident #30 as wound evaluations were conducted with each visit. LPN #3 indicated she did not complete wound tracking during timeframe's when Resident #30 was not seen by wound specialty and had often thought about if she should have been. An interview on [DATE] at 2:25PM with the DNS identified that although she was responsible for overseeing LPN #3 ' s duties regarding wound monitoring, she had not been overseeing LPN #3 ' s wound tracking for Resident #30. The DNS indicated wound tracking should be completed according to policy. An interview on [DATE] at 12:43 PM with the Medical Director identified although the development of Resident #30 ' s wounds were unavoidable due to underlying medical conditions and immobility; she would expect wound monitoring be completed in accordance with facility policy. The facility policy for Wound and Skin Protocols direct once a wound had been identified, all skin areas are to have weekly documentation using the skin/wound tracking record until healed. The documentation is to include the site, size in length, width and depth, appearance, any undermining, surrounding skin and drainage. Although a request was made for all wound consultations, it is undetermined if all were provided. Subsequent to surveyor inquiry, LPN #3 initiated weekly wound tracking. b. Wound Care Specialist consult dated [DATE] had recommendations that included Resident #30 be showered 1-2 times weekly due to a rash and wounds. Resident Care Card indicated Resident #30 was to be bathed once weekly. A review of the shower log dated [DATE]- [DATE] identified showers were provided twice weekly two weeks out of 10, once weekly 4 weeks out of 10 and, no shower was provided 4 weeks out of 10. An interview on [DATE] at 10:57 AM with Resident #30 identified the wound specialist requests requested showers twice weekly but was lucky if s/he receive one due to staff shortages. Resident #30 indicated she had a conversation with the Administrator who, according to Resident #30 would need to take what was provided. An interview on [DATE] at 9:23AM with the Administrator identified residents were provided one shower weekly. A resident may request additional showers which would be provided if time allowed. The Administrator indicated there had been no previous conversation with Resident #30 regarding showers but would speak to him/her subsequent to surveyor inquiry. An interview on [DATE] at 11:49AM with APRN #1 identified she had been providing specialty wound services for Resident #30 beginning [DATE]. APRN #1 indicated Resident #30 had expressed s/he needed to be bathed. APRN #1 stated she made the request that Resident #30 be bathed twice weekly. An interview on [DATE] at 10:44 AM with the DNS indicated showers were provided at least once weekly. More often if determined to be medically necessary. The DNS indicated she could not say why the recommendations from wound specialty were not followed and that it was her expectation that recommendations from specialty services be followed. c. Hospital Discharge summary dated [DATE] noted Resident #30 was admitted [DATE] for hypoxia with right middle lobe pneumonia. A wound consultation and wound debridement took place during the hospital course. Discharge recommendations included for wounds to the arms, abdomen, legs and right lateral thigh/ hip, cleanse with saline. Spray peri-wound with barrier spray, apply medihoney followed by a foam dressing. Medihoney hydrogel to wounds without slough. Additionally, recommendations were made for a heel device. Place wedge on lateral side f boot to offload the pressure from the calf and ankle wounds. The admission orders did not include the hospital recommendations. An interview on [DATE] at 10:44 AM with the DNS identified she would expect recommendations from specialty services be followed. An interview on [DATE] at 4:15PM the Medical Director identified if the facility did not have the exact product but instead used something comparable, orders could be modified. Otherwise, the Medical Director indicated she would expect staff to follow specialty/hospital recommendations. Although a policy for responding to recommendations by specialty services was requested, none was provided. 3. Resident #41 diagnoses included dementia without behavioral disturbance, type 2 diabetes mellitus, hypertension, and failure to thrive. Review of the physician's order dated [DATE] directed to administered Do Not Resuscitate (DNR), Do Not Intubate (DNI), Do Not hospitalized (DNH), no Intravenous (IV), or artificial means of nutrition per advance directive. The physician's order did not indicate that the RN May Pronounce Death. The quarterly MDS assessment dated [DATE] identified Resident #41 had intact cognition and required extensive to total assist of 2 person with toileting, dressing, transfer, and non-ambulatory. Review of certified copy of death record identified RN #1 sign and pronounce the death of Resident #41 on [DATE] at 3:20 AM. Interview with RN #1 on [DATE] at 9:30 AM identified that only the RN may pronounce a resident death. He also indicated that a physician would order the RN may pronounce death in the physician's order. RN #1 further indicated he could not provide a physician's order for the RN may pronounce a resident death. Although he called the on-call physician to notify the physician of the resident's death, he was not sure if he could obtain a RN may pronounce death via a verbal order. RN # 1 further indicated that he found a provider written progress note that indicated Resident #41 was a RN may pronounce death and wrote a physician's order RN may pronounce death. He then used the date of [DATE] when the progress note was written. Interview with Director of Nursing (DON) on [DATE] at 10:00 AM identified that the RN was responsible when pronouncing a resident death. She also indicated that the physician's order would indicate the RN may pronounce death. Inquiry to Resident #41 death on [DATE], she indicated that the physician's order written on [DATE] should include the RN may pronounce death. She also indicated that the nursing staff should clarify with a physician when the physician's order RN may pronounce death was missing. She further stated that RN #1 cannot based the physician's order from the provider progress note. The facility failed to have a written physician's order of RN May Pronounce Death when death was anticipated. A review of facility nursing policy title Death of Resident Pronouncement by a Registered Nurse identified notes in part the facility enables the RN to pronounce the resident's death. The procedure would require a written physician's order RN may pronounce death and a progress note explaining that death was anticipated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Base clinical record reviews, facility policy review and interviews for 1 sample resident (Resident # 241) reviewed for hydration, the facility failed to monitor and record Intake and Output (I&O) according to the facility policy and for 1 sample resident (Resident # 9) reviewed for edema, the facility failed to monitor the resident weight according to the physician order. The findings included: 1. Resident #241 diagnoses included acute ischemic heart disease, anxiety, depression, hypertension and type 2 diabetes mellitus and dehydration. The admission MDS assessment dated [DATE] identified Resident #241 had intact cognition and required extensive assistance of 1 to 2 person with toileting, dressing, transfer, and non-ambulatory The physician's order dated 9/13/22 directed to push fluid every shift for 7 days. Review of Electronic Medication Administration Record (e-MAR) from 9/13/22 through 9/19/22 identified nursing staff was signing off the administered push fluid every shift without recording the actual fluid intake. The physician's order dated 9/27/22 directed to administered sodium chloride solution 0.45% at 50 ML/HR intravenously related to elevated Blood Urea Nitrogen (BUN - a test for kidney function) for 2 liters. Observation on 9/28/22 at 10:30 AM identified Resident #241 had sodium chloride solution 0.45% infusing at 50 ML/HR at the right forearm while lying on the bed. The Resident Care Plan (RCP) dated 9/28/22 identified Resident #241 received intravenous hydration secondary to elevated BUN. Interventions included: directed to administered intravenous fluid as ordered, check laboratory as ordered, check vital sign as needed and provide care to the intravenous insertion site as per facility protocol. Interview with DNS on 10/3/22 at 11:00 AM identified the nursing staff was responsible for accurately recording the I&O and the nurse would evaluate the I&O. She also indicated that she would expect her nursing staff to update the physician when the resident was not taking enough fluid. The DNS further indicated that all newly admitted resident would have an I&O for 72 hours to establish the resident fluid baseline or when there was a physician's order. Subsequent to Inquiry the DNS directed the nursing staff to start monitoring and record the I&O for the physician to evaluate the resident's actual fluid intake. The facility failed to monitor and record the resident I&O accurately. The facility was unable to provide the I&O documentation on admission and when it was ordered by the physician. A review of facility nursing policy title Intake/Output notes in part all residents will be place on I&O on admission for 72 hours or and if there is a physician's order. All nursing personnel will be responsible for recording the I&O in the clinical record. The nurse is responsible for completing the subtotal I&O at the end of each shift and will total all three shifts at the end of 24 hours period. 2. Resident #9 diagnoses included heart failure, type 2 diabetes mellitus, atrial fibrillation, and Chronic Obstructive Pulmonary Disease (COPD). The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #9 had severely impaired cognition and required extensive assist of 1 to 2 person with toileting, dressing, transfer, hygiene, and non-ambulatory. The physician's order dated 9/12/22 directed to obtain weight three times weekly on Monday, Wednesday, and Friday morning on day shift. Review of weight record from 9/12/22 to 10/3/22 identified Resident #9 had no weight documentation for 5 times out of 9's opportunities. Review of Electronic Medication Administration Record (e-MAR) from 9/12/22 through 10/3/22 failed to identified Resident #9 had refused the weight. The Resident Care Plan (RCP) dated 9/16/22 identified Resident #9 with heart failure. Intervention included: to monitor vital sign and weight as ordered by the physician, monitor to report increase cough, congestion, crackles, shortness of breath and to monitor for increasing edema and to report to the physician. Interview with LPN #2 on 10/3/22 at 2:30 PM identified nursing staff would be responsible obtaining a resident weight. She also identified that the weight would be documented in the resident's computerized clinical record or at times in the paper record weight form. Clinical record review with LPN # 2 identified Resident #9 had a physician's order for Monday, Wednesday, and Friday for weight monitoring secondary to the heart failure. She also indicated Resident #9 was confused and had behavior of refusing care; However, the administration record would indicate whether he/she refuse the weight. Interview with the DNS on 10/4/22 at 10:30AM identified the license nurse would be responsible for ensuring the resident's weight was taken and recorded when order by the physician. The DNS further indicated her expectation is that the nursing staff follow the physician's order. She also indicated Resident #9 had a tendency of refusing care; however, she would expect her license staff would document the refusal of the weight in the clinical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 sampled resident (Resident#26) reviewed for specialized treatment, the facility failed to ensure the resident's communication form to the specialized center was complete and the facility failed to ensure the licensed staff consistently reviewed the communication form after the resident received specialized services and the facility failed to ensure consistent monitoring and documentation of Intake and Output for a resident on fluid restriction who received specialized treatment and the facility failed to ensure a medication receive during specialized treatment was secure in the medication storage room or medication cart and the facility failed to obtain a physician's order for a resident receiving specialized treatment. The findings included: 1. Resident #26 was admitted to the facility on [DATE]. The resident's diagnoses included end stage renal disease, dependence on specialized treatment, type 2 diabetes mellitus, heart failure, and cerebral infarction. The quarterly MDS assessment dated [DATE] identified Resident #26 had intact cognition and required extensive assistance with personal hygiene and received specialized services. The care plan dated 9/13/22 identified Resident #26 has a history of renal disease. Resident #26 goes to specialized treatment center three times a week. Resident #26 is at risk for bleeding, infection, and septic shock. Resident #26 has an AV fistula through which he/she receive specialized treatments. Interventions included any questions regarding my care contact the specialized treatment center. Encourage me to go to specialized treatment but honor my wishes if I refuse. Fluid restriction as per MD orders. Encourage compliance. Intake & Output as ordered and per policy. Document in medical record. a. Review of Resident #26 specialized treatment communication sheets in a binder dated 6/1/22 through 9/21/22 identified for June 2022 there were (7 specialized communication sheets in the binder out 13 specialized appointments) where staff failed to complete a specialized treatment communication sheets with each appointment and that was sent with Resident #26 on his/her specialized treatment days to the center. In July 2022 there was (1 specialized treatment communication sheet in the binder out 13 specialized treatment appointments) staff failed to complete the communication sheets with each appointment and send with Resident #26 on his/her specialized treatment days to the center. In August 2022 there was (2 specialized communication sheets in the binder out 14 specialized treatment appointments) staff failed to complete a specialized treatment communication sheet with each appointment and send with Resident #26 on the specialized treatment days to the center. In September 2022 there was (1 specialized treatment communication sheet) in the binder out 13 specialized appointments) staff failed to complete a specialized treatment communication sheet with each appointment and send with Resident #26 on his/her specialized treatment days to the center. Observation on 10/4/22 at 9:10 AM with the DNS identified Resident #26 communication book, and a medication blister pack for Midodrine HCL 10 MG tablet with 3 pills remained in the blister pack was in the specialized treatment bag in the back of the wheelchair in the resident's room. Resident #26 and roommate were in the room in bed. Interview with the DNS on 10/4/22 at 9:15 AM identified she was not aware of the specialized treatment communication binder was in the specialized treatment bag on the back of Resident #26 wheelchair. The DNS indicated it is the responsibility of all the nurses to remove the specialized treatment communication binder when the resident return from the center and review for any new report or new orders. The DNS indicated she was not aware that the specialized treatment communication sheet was not sent with each specialized appointment. The DNS indicated she would in-service all nurses on the facility practice and policy for specialized treatment. Interview with MD #1 on 10/4/22 at 1:43 PM identified she was not aware that the specialized treatment communication sheet was not sent with each specialized treatment appointments. MD #1 indicated it is the expectation of the facility that all license nurses complete specialized treatment communication sheet before each appointment and send with the resident to the center. Interview with LPN #7 on 10/5/22 at 9:15 AM identified she has been employed by the facility for approximately 4 weeks. LPN #7 indicated she worked on 10/3/22 on the 7:00 AM - 3:00 PM shift and she was not aware that the specialized treatment communication sheet was not already filled out before she placed the communication binder in the bag. LPN #7 indicated it is the nurse's responsibility to complete the specialized treatment communication sheet and place the sheet in the communication binder on each specialized treatment days. Interview with Person #1 on 10/6/22 at 1:14 PM identified she was aware the facility does not send specialized treatment communication sheets consistently with Resident #26 on specialized treatment days. Person #1 indicated she has spoken to the nurses at the facility many times to send a specialized treatment communication sheet on treatment days with Resident #26. Person #1 indicated there are times that the specialized treatment center needs to communicate with the facility and when there is no specialized treatment communication sheet in the binder, the center will use a blank white sheet of paper to document a report or new orders. Person #1 indicated she is aware that using the blank white sheet of paper to document is not legal. Review of the facility Specialized Treatment policy identified the facility and specialized treatment center will communicate information with one another via W-10 or a communication tool for every pre/post specialized treatment. Any issues such as concerns, laboratory blood work, medications, diet, weights, vital signs, etc. that affect the plan of care are to be communicated. A completed W-10 and/or communication sheet, current medication list and any other pertinent information such as concerns, laboratory, diet, weights, vital signs, etc. are sent with patient/resident for each specialized treatment. Patient's/resident's information/communication is reviewed by the licensed staff as soon as possible upon return to the facility from specialized treatment center. The facility failed to ensure outgoing communication forms were completed for a resident who receives specialized services, and the facility failed to ensure the licensed staff review the communication form after a resident received specialized services. b. A physician's order dated 2/23/22 directed Fluid Restriction of 1250 ML/24 Hours. The Resident Care Card with a date of 6/1/22 revision identified open purpura left arm. Additionally, identified Fluid Restriction 1000 ML. Additionally, the care card failed to identify current physician's orders to reflect documentation of the breakdown of the amount of fluid Resident # 26 could consume from nursing and dietary in a 24-hour period. Review of Resident #26 dietary form identified Fluid Restriction of 1000 cc. The current physician's orders dated September and October 2022 failed to reflect current physician's order of the resident's fluid restriction. The physician's orders dated September and October 2022 failed to reflect documentation of the breakdown of the amount of fluid Resident # 26 could consume from nursing and dietary in a 24-hour period. A review of Resident #26's Intake and Output record dated 6/1/22 through 10/3/22 identified for June 2022 there were (73 out of 90 occasions) where staff failed to document the resident's intake. In July 2022 there were (93 out 93 occasions) where staff failed to document the resident's intake. In August 2022 there were (76 out of 93 occasions) where staff failed to document the resident's intake. In September 2022 there were (39 out 90 occasions) where staff failed to document the resident's intake. On October 1, 2022, through October 3, 2022, there were (6 out of 9 occasions) where staff failed to document the resident's intake. Interview with MD #1 on 10/4/22 at 1:43 PM identified she was not aware the facility was not following the physician's order and the specialized treatment center order for fluid restriction. MD #1 indicated her expectation would be that the nurses' follow the physician's order. Interview with the DNS on 10/4/22 at 2:33 PM identified she was not aware of Resident #26 intake and output forms were not being filled out completely by each shift and missing days. The DNS indicated she was not aware that the fluid restriction physician's order was not being followed. The DNS further indicated she was not aware that the kitchen staff did not have the right fluid restriction order. The DNS also indicated she would in-service the nursing staff on ensuring the forms are completed and physician's orders are followed. Interview with LPN #7 on 10/5/22 at 9:15 AM identified she was not aware Resident #26 was on Intake and Output. LPN #7 indicated she was not aware Resident #26 was not meeting the fluid restriction per physician's order. LPN #7 indicated there is a book for intake and output for the nurse aides to fill out each shift. Although attempted during the survey to obtain an interview with the dietician the attempt was unsuccessful. Review of the facility specialized treatment policy directs in part to maintain fluid restrictions as ordered by the physician. Monitor I & O and notify physician and specialized treatment center if patient/resident is non-compliant with fluid restrictions. The facility failed to ensure consistent monitoring and documentation of Intake and Output for a resident on fluid restriction who received specialized services. c. A physician's order dated 8/7/22 directed for Midodrine HCL tablet 10mg give 3 tablets by mouth every Monday, Wednesday, and Friday for low blood pressure during specialized treatment. To be administered by the specialized treatment center staff, not to be given at facility. Resident to take with her/him to the specialized treatment center. Observation on 10/4/22 at 9:10 AM with the DNS identified Resident #26 communication book, and a medication blister pack for Midodrine HCL 10 MG tablet with 3 pills remained in the blister pack was in the specialized treatment center bag given to Resident # 26 on the back of the wheelchair in the resident's room. Resident #26 and his/her roommate were in the room in bed. Interview with the DNS on 10/4/22 at 9:15 AM identified she was not aware of the issues of the communication book and a medication blister pack was left in the specialized treatment bag in the back of the wheelchair. The DNS indicated it is the responsibility of the nurse on the unit to remove the medication blister pack from the bag and place it in the medication storage room where it would be secured and locked when Resident #26 returns from the specialized treatment center. The DNS indicated the medication blister pack should not have remained in Resident #26 room. The DNS indicated she would in-service the licensed staff to ensure all medication are secured and locked. Interview with MD #1 on 10/4/21 at 1:43 PM identified she was not aware of the issues. MD #1 indicated the nurse on duty when the resident return from the specialized treatment should have removed the medication from the bag and place it in the medication storage room where it would be secured and locked. Although attempted an interview with the licensed staff for 10/3/22 on the 3:00 PM - 11:00 PM shift the attempt was unsuccessful. Review of the facility storage and expiration dating of mediations, biological policy revision date 7/21/22 identified the facility should ensure that all medications and biological's, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. The facility failed to ensure a medication receive during specialized treatment was secure in the medication storage room or medication cart. d. Review of the physician's order for the month of 8/1/22 through 8/31/22 failed to reflect documentation for an order regarding specialized treatment three times a week, and the name of the specialized treatment center. The month of 9/1/22 through 9/30/22 failed to reflect documentation for an order regarding specialized treatment three times a week, and the name of the center. The month of 10/1/22 failed to reflect documentation for an order regarding specialized treatment three times a week, and the name of the dialysis center. Interview with the DNS on 11/1/22 at 1:36 PM identified she was not aware of the issues until now. The DNS indicated there should have been an order for the specialized treatment. The DNS indicated she will address the issue immediately and in-service the nurses. The facility failed to obtain a physician's order for a resident receiving specialized treatment.

Based on review of facility documentation, facility policy and interview, the facility failed to ensure mandatory annual training for all staff was completed for 2 Nurse Aides (NA #2 and NA #3). The findings include: Review of NA #2's employee file on 10/3/22 and 10/4/22 identified that NA #2 had not completed the mandatory annual competency training required for a NA. Review of NA #3 employee file on 10/3/22 and 10/4/22 identified NA #3 had not completed the mandatory annual competency training required for a NA. Interview with the DNS on 10/4/22 at 12:35 PM identified she was responsible of ensuring all staffs attended and completed their mandatory annual training. She also indicated that she started the annual mandatory training model for all the staffs this year rather than using a rolling monthly education for all the staffs. The DNS further indicated NA #2 and NA #3 were per diem nurse aides who are required to attend and complete the mandatory annual training including that same as the regular staff. The facility failed to ensure that all staff members completed the annual mandatory training. A review of facility nursing policy title Education identified that all staff must have yearly education training.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and interview for two of five residents reviewed for Unnecessary Medication for (Resident # 20), the facility failed to consistently monitor the resident's blood pressure according to facility policy and procedure and for (Resident # 241), the facility failed to address the pharmacy recommendation in a timely manner in accordance to facility practice. The findings included: 1. Resident # 20's diagnoses included dementia with behavior disturbances, Transient Ischemic Attack (TIA), Acute Kidney Failure, hypertension, arteriosclerotic heart disease, hyperlipidemia, and major depression. An annual MDS assessment dated [DATE] identified the resident was severely cognitively impaired and required extensive assistance with most ADL. A pharmacy report dated April 2022 noted Metoprolol for hypertension and directed to please monitor blood pressure at least weekly as directed by prescriber per facility policy and procedure. The quarterly MDS 5/3/22 and a significant change MDS assessment dated [DATE] identified the resident was severely cognitively impaired, had memory problems and required extensive assistance with personal hygiene. A review of the Pharmacy Report from 5/2022 through 9/1/2022 directed weekly blood pressure monitoring. However, review of the clinical record and vital signs records dated 5/2022 through 9/1/2022 failed to reflect that Resident # 20's blood pressure had been monitored weekly by the licensed per plan of care. Interview and review of Resident # 20's clinical record and vital signs record on 10/4/22 at 11:42 AM with the DNS identified she could not provide the missing weekly blood pressure monitoring from 5/2022 through 9/1/2022 per plan of care. 2. Resident #241 diagnoses included acute ischemic heart disease, anxiety, depression, hypertension, and type 2 diabetes mellitus. A review of the clinical record identified the resident was admitted to the facility on [DATE]. The resident was discharged on 8/23/22 and readmitted on [DATE]. The Resident Care Plan (RCP) dated 8/26/22 identified Resident #241 at risk for alteration of behavior related to increase anxiety and required medication. Interventions included: directed staff to attempt to keep routine schedule, be aware of changes in mood or behavior, psychiatric evaluation or follow-up as needed, and medications as ordered. The pharmacy recommendation dated 8/19/22 noted to consider gradual dose reduction of Seroquel (anti-psychotic) medication, to consider Abnormal Involuntary Movement Scale (AIMS) test related to use of anti-psychotic medication, to consider monitoring for orthostatic blood pressure related to use of anti-psychotic medication and monitor laboratory blood work (CBC and BMP) every 2 weeks related to use of heparin injection (anti-coagulant). Further of the clinical record identified the physician did not address the pharmacy recommendations until on 8/30/22 which was 11 days later. Interview with DNS on 9/29/22 at 12:00 PM identified that pharmacy recommendations are sent to the supervisor and the DNS office for review. She also indicated she would expect the nursing supervisor to address the pharmacy recommendation with the physician within 48 hours. Inquiry to Resident #241 pharmacy recommendation, the physician should address the pharmacy recommendation within 48 hours and not on the 11 days later. The facility failed to ensure that the physician address pharmacy recommendation timely. A policy was requested but the facility was unable to provide at the time of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 2 of 5 residents (Resident # 6 and Resident #29) reviewed for Pneumococcal immunization, the facility failed to develop a method to track and / or monitor immunization status, screen for eligibility and provide for Pneumococcal vaccination as ordered. The findings include: 1. Resident #6 was admitted to the facility with diagnoses that included dementia, epilepsy, and depression. An admission MDS assessment dated [DATE] identified Resident # 6 had mildly impaired cognition and required limited assistance with 2 staff for bed mobility and limited assistance with 1 staff for personal hygiene. A Pneumococcal conjugate consent form was signed by Resident #6 ' s responsible party on 4/20/22 authorizing Resident #6 to receive the pneumococcal conjugate (PCV 13) vaccine. A physician's order dated 4/21/22 directs to provide Resident #6 pnuemovax 0.5 ml in on admission if not received. Interview and review of Resident #6's record with LPN # 3 (Infection Preventionist) on 10/3/22 at 10:00 AM identified that Resident #6 did not receive the 4/21/22 ordered pneumovax vaccination. She did identify Resident #6 was a resident of the facility since admission with a hospital stay from 6/11/22 to 6/15/22 and the resident had not received the physician ordered pneumococcal (pneumovax) vaccine as ordered on 4/21/22. LPN # 6 continued by stating that she was contacting Resident #6 's physician or APRN to get a new order for the pneumococcal vaccine as she was not comfortable executing the 4/21/22 order as she considered it to be too old at this time. 2. Resident #29 was admitted to the facility with diagnoses that included dementia, stoke, and chronic kidney disease. An admission MDS assessment dated [DATE] identified Resident #29 was severely cognitively impaired requiring limited assistance with 1 staff member for bed mobility, transfer, and personal hygiene. Interview and review of Resident #29's clinical record with LPN # 3 (Infection Preventionist) on 10/3/22 at 10:10 AM identified that Resident #29's medical record lacked documentation Resident # 29 was screened for pneumovax vaccination at the time of admission. LPN #3 continued by stating that she is new to the facility and had not started a tracking mechanism for vaccination for residents. She stated that she had been unaware that it was her responsibility to assure that the residents received the required vaccinations. She identified that the process was the nurse that admitted the resident would review the vaccination packets with the resident or their responsible party on admission and get the necessary approvals if vaccinations were required. The physician orders would in place, either by a standard admission order set or by the nurse staff member who reviewed the vaccination information on admission. The nurse was then responsible to execute the order. She continued by stating that she could also administer the ordered vaccine but had no process in place for her to be aware that a resident wasn ' t ' screened or provided an ordered vaccination. Interview with the DNS on 10/4/22 at 10 AM identified that it is the nurse who admits the resident to the facility, reviews the admission packet with the resident and/or responsible party that includes the screening the resident for vaccination eligibility, providing the appropriate education and consents as for vaccination as needed. There is an admission order set and based on the resident 's vaccination eligibility, the same nurse should trigger the appropriate vaccination order. She continued by stating that the Infection Preventionist has the responsibility to oversee the vaccination program and that she would expect the Infection Preventionist to have a tracking process to assure proper oversight. The facility policy, Pneumococcal Vaccine 23 dated 8/4/21 directs that pneumococcal vaccine will be offered to residents upon admission and the Infection Control Nurse will obtain history of previous vaccinations to determine need for the vaccine. The policy continued to direct that the resident and/or responsible party will be provided education and a consent form related to the vaccine. A physician's order will be obtained, and licensed nursing staff will administer the vaccine. Subsequent to the surveyor 's observation, LPN #3 began to track vaccination status of all residents to determine screening and vaccination status and to address any gaps in the process as identified by the facility policy Pneumococcal Vaccine 23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of facility documentation and interviews, the facility failed to ensure the environment was maintained in a clean, sanitary, and homelike manner. The findings included: Review of the infection control surveillance and safety rounds dated 8/22 completed by LPN #3 (who collected data) identified all areas has been met. Recommendations of Infection Control Nurse identified the facility needed painting. Observations during tour on 9/28/22 from 10:30 AM through 11:30 AM and again on 10/4/22 at 8:38 AM with the Administrator, DNS, and the Maintenance/Housekeeping/Laundry Director identified the following: a. Damaged, chipped, marred bedroom walls, bathroom walls, hallways walls, and/or bathroom doors in rooms on the [NAME] Court unit #204, 207, 210, and 211. The Migeon Lane unit #101, 103, 105, hallway, 110, 114, 116, and rehabilitation department. b. Damaged and cracked floor tiles in bedroom in rooms on the [NAME] Court unit 200, nurse's station, hallway, and in 206. The Migeon Lane unit 108. c. Damaged and peeling cove base in bedroom or bathroom in rooms on the [NAME] Court unit 206, hallway, 207, 210, and 211. The Migeon Lane unit 105, 108, and 114. d. Damaged, broken, and rusty radiator covers in bathroom in room on the Migeon Lane unit 108. e. Damaged, broken, and rusty radiator covers in bedroom in rooms on the [NAME] Court unit 204. The Migeon Lane unit 103, and 104. f. Damaged, dirty, stains on floor mats in room on the [NAME] Court unit 200. g. Stains, dirt, debris, discoloration, and wax build up on the floor and crevices in rooms on the [NAME] Court unit 200, 201, 203, 204, 206, 207, 210, and 211. The Migeon Lane unit 108, 110,115, 116, and rehabilitation department. h. Damaged and running water in sink from the faucet in bathroom in room on the Migeon Lane unit 117. i. Damaged and torn armrest on 1 chair at the nurse's station on the [NAME] Court unit. j. Damaged and stains on privacy curtain in bedroom in room on the [NAME] Court unit 206. k. Damaged and stains on ceiling tile in bedroom in room on the [NAME] Court unit 200. l. Damaged and broken nightstand in bedroom in room on the [NAME] Court unit 200. Interview with the Maintenance/Housekeeping/Laundry Director on 10/4/22 at 8:51 AM identified he was aware of the issues identified above with the environment. The Maintenance/Housekeeping/Laundry Director indicated its just him and an assistance who works approximately 30 hours. He indicated the maintenance department has been without an assistance for quite some time. The Maintenance/Housekeeping/Laundry Director indicated that staff are responsible for notifying the maintenance department with issues or problems that require repair. The Maintenance/Housekeeping/Laundry Director also indicated that staff are responsible for filling out the Maintenance Log located at the nurse's station on every unit with issues or problems that require repair. He further indicated the facility has one housekeeper assigned to each unit. Interview with the Administrator on 10/4/22 at 8:56 AM identified she was aware of the issues with the environment. The Administrator indicated there are 2 staff members in the maintenance department. The Administrator indicated the expectation of the facility is that all residents have a right to a clean, comfortable, and homelike environment. The Administrator indicated housekeeping and maintenance services are necessary to maintain a sanitary, orderly, and comfortable environment. Interview with the Director of Nursing Services (DNS) on 10/4/22 at 9:00 AM identified she was not aware of some of the issues identified. The DNS indicated she will have an in-service with the nursing staff regarding documenting repair issues in the maintenance log and to notify the Housekeeping/Laundry Director with the cleanliness of the resident rooms. Interview with Licensed Practical Nurse (LPN #3) on 10/4/22 at 9:31 AM identified she was not aware of some of the issues identified above. LPN #3 identified she has been employed by the facility for 5 months (4/15/22). LPN #3 indicated environmental rounds data is collected quarterly. LPN #3 indicated she has done one environmental round and it was done last month. LPN #3 indicated the only issues she had identified is that the facility needs to be painted. Review of the maintenance supervisor job description identified plans, organizes, and directs maintenance and repairs of the physical plant, equipment, and all essential building systems. Ensures the facility is safe and secure while fostering TQM and striving to attain the facility's mission statement. Ensures the compliance with facility policies regarding cleanliness, infection control, safety, security, hazardous communication program and fire and disaster plans. Review of the housekeeping supervisor job description identified plans, organizes, and directs the provision of housekeeping services. Ensures the facility is safe and secure while fostering TQM and striving to attain the facility's mission statement. Review of the housekeeping assistance job description identified under direct supervision provides quality housekeeping services, and a clean, orderly, and safe environment for all facility residents and staff. As define in job routines or department instructions, cleans the facility on a schedule basis to meet high standards of cleanliness, infection control, safety, and hazardous communication program. Reports to supervisor any needed repairs. Review of the infection control surveillance and safety rounds directs to observe for facility compliance with infection control policies and procedures. Surveillance rounds are to be conducted on a quarterly basis by the infection control nurse or his/her designee.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident # 30) reviewed for pressure ulcers, the facility failed to ensure consistent conduct weekly wound monitoring for a resident with a pressure ulcer. The findings include: Resident #30 was admitted with diagnoses that included type II diabetes mellitus, hemiplegia and hemiparesis following other cerebrovascular disease affecting left non-dominant side. A quarterly minimum data set (MDS) assessment dated [DATE] identified Resident #30 was without cognitive impairment, required extensive 2 person assist with bed mobility and personal care, total assist with transfers, was at risk for the development of pressure ulcers and did not have any unhealed pressure ulcers, The care plan dated 9/2/21 identified Resident #30 was at risk for skin breakdown due to decreased mobility, incontinence, and poor circulation. Interventions included consultation with wound care specialist as ordered/needed, follow all recommendations of treatments weekly and maintain offloading devices. Weekly Skin Audit dated 9/2/21 noted a 7.5 cm fluid filled blister and 16 cm reddened area to the abdomen. The Nursing progress noted dated 10/7/21 at 11:39 AM noted Resident #30 had a new pressure injury to the left outer ankle related leg brace. Cleansed with NS, BF applied for protection at this time. There was no documented assessment that included measurements or characteristics of the wound. The Nursing progress note dated 10/7/2021 at 1:22PM noted Resident #30 was seen by a wound physician for ongoing treatment and evaluation for other skin conditions unrelated to the newly identified pressure injury with no new corresponding orders. Review of the facility wound tracking, nursing progress notes, medical progress notes and wound notes dated 9/8/21 through 9/30/22 did not include weekly measurements or identifying characteristics for the abdominal wound and left leg wound and any subsequent newly identified pressure injuries on the following dates: 9/22/21, 9/29/21, 10/6/21, 10/15/21 through 11/30/21, 12/15/21, 2/14/22, 2/21/22, 2/28/22, 3/7/22, 3/14/22, 3/28/22, 5/23/22, 5/30/22, 6/7/22, 6/14/22, 6/21/22, 7/14/22, 7/19/22, 8/8/22, 8/31/22 and 9/7/22. An interview on 9/29/22 at 10:48 AM with LPN #3 identified she was responsible for monitoring facility wounds under the supervision of the DNS. LPN #3 identified Resident #30 was originally followed by wound care specialists within the facility and then began seeing wound care specialists out in the community. LPN #3 indicated she was not tracking the wounds for Resident #30 as wound evaluations were conducted with each visit. LPN #3 indicated she did not complete wound tracking during timeframe when Resident #30 was not seen by wound specialty and had often thought about if she should have been. An interview on 10/03/22 at 2:25PM with the DNS identified that although she was responsible for overseeing LPN #3's duties regarding wound monitoring, she had not been overseeing LPN #3 ' s wound tracking for Resident #30. The DNS indicated wound tracking should be completed according to policy. An interview on 10/04/22 at 12:43 PM with the Medical Director identified although the development of Resident #30 ' s wounds were unavoidable due to underlying medical conditions and immobility; she would expect wound monitoring be completed in accordance with facility policy. The facility policy for Wound and Skin Protocols direct once a wound had been identified, all skin areas are to have weekly documentation using the skin/wound tracking record until healed. The documentation is to include the site, size in length, width and depth, appearance, any undermining, surrounding skin and drainage. Although a request was made for all wound consultations, it is undetermined if all were provided. Subsequent to surveyor inquiry, LPN #3 initiated weekly wound tracking.

Based on observation, review of facility documentation, facility assessment, and interviews, the facility failed to ensure that staffing levels were adequate for (44) residents on 2 units in accordance with the plan of care. The findings include: a. A review of the daily staffing breakdown schedule from 6/1/22 through 10/4/22 identified insufficient staff on all shifts. Further review of the staffing identified the facility had been scheduling the Temp Student Nurse Aides and the Hospitality Aides on the daily staffing schedule. The facility has been utilizing the Student Nurse Aides and the Hospitality Aides as a Certified Nurse Aide and counting the Hospitality Aides and Temp Student Nurse Aides as part of the staffing count on all shifts. A review of the staffing allocation sheet dated 10/3/22 identified the day shift had one (1) Registered Nurse, two (2) Licensed Practical Nurse, four (4) Nurse Aides. The allocation sheet failed to reflect documentation that one of the Nurse Aide was Temp Student Nurse Aide, and only three Nurse Aides was scheduled. A review of the census report on 10/3/22 identified the facility capacity was 56 beds and the census was 44 residents in the facility. Review of the census report dated 10/4/22 identified the skilled nursing unit (consist of 2 units) had a census of 44 residents. b. A review of the daily staffing breakdown schedule dated 10/3/22 for the 7:00 AM - 3:00 PM shift identified the skilled units (consist of 2 units), the census was 44 and there was (0) Registered Nurse, two (2) Licensed Practical Nurse, four (4) Nurse Aides. The daily staff breakdown schedule failed to identified documentation that the Temp Student Nurse Aide was included in the count. Observation on 10/3/22 at 12:30 PM identified on the Forest Court unit one (1) Licensed Practical Nurse, one (1) Nurse Aides for 20 residents, and one (1) Temp Student Nurse Aide. Review of the resident list for the Forest Court unit on 10/3/22 identified the census was 20 residents on the unit. Interview with the DNS on 10/3/22 at 12:43 PM identified she has been employed by the facility approximately 1 year. The DNS indicated she was aware of the insufficient staffing. The DNS indicated the facility has not had an RN supervisor for the 7:00 AM - 3:00 PM shift. The DNS indicated she has been working as the 7:00 AM - 3:00 PM RN supervisor or has a charge nurse on the floor during the day. The DNS indicated she had discussed with the Administrator regarding hiring an RN supervisor for the 7:00 AM - 3:00 PM shift. The DNS indicated the facility has just hired an RN supervisor for the 7:00 AM - 3:00 PM shift with a start date of 10/3/22. Interview with the Administrator on 10/3/22 at 12:46 PM identified she is aware of the insufficient staffing in the facility. The Administrator indicated the facility has hired a few Licensed Practical Nurse (LPN) for the units, and an RN for the supervisor position on the 7:00 AM - 3:00 PM shift with a start date of 10/3/22. The Administrator indicated the RN is on orientation today. The Administrator indicated the DNS started in that position in 4/22. The Administrator also indicated prior to being the DNS, the DNS worked 16 hours in the Staff Development position, and 16 hours as the RN supervisor on the day shift. The Administrator indicated the facility had hired an RN supervisor early summer, but the employee did not work out. Interview with NA #5 on 10/3/22 at 1:17 PM identified she has been employed by the facility for 3 years. NA #5 indicated she is the only Nurse Aide on the unit (Forest Court) with a Temp Student NA. NA #5 indicated the Temp Student NA did not get a whole assignment. NA #5 indicated the Temp Student NA provided care to a few residents on the unit. Interview with Temp Student NA #1 on 10/3/22 at 1:22 PM identified she has been employed by the facility for approximately 4 months on the 7:00 AM - 3:00 PM shift. Temp Student NA indicated she has just finished her classes on 9/21/22 she is waiting for a test date to take her NA board test to become a Certified Nurse Aide. Temp Student NA #1 indicated she was assigned to the Forest Court unit and provide direct care to 5 residents. Temp Student NA #1 indicated she has been working on the floor as a NA. Interview with LPN #7 on 10/3/22 at 1:30 PM identified she was not aware that she was working with one NA and one Temp Student NA. LPN #7 indicated she reviewed the daily schedule this morning and it indicated that the Forest Court unit had 2 Nurse Aides. LPN #7 indicated she was not aware that one of the NA was a Temp Student NA. Interview with the Scheduler on 10/3/22 at 2:35 PM identified she has been employed by the facility since March 2022. The Scheduler indicated the Administrator notifies her with the title of the new staffs. The Scheduler indicated she has been scheduling the Temp Student Nurse Aide on the daily schedule on each shift and they are counted in the Certified Nurse Aide staffing count. The Scheduler indicated she has been scheduling the Hospitality Aides on the daily schedule on the 7:00 AM - 3:00 PM shift, and the 3:00 PM - 11:00 PM shifts as part of the Certified Nurse Aide count. The Scheduler indicated she has been scheduling the Hospitality Aides on the daily schedule as Temp Student Nurse Aides. The Scheduler indicated the Recreation Director also works as a Certified Nurse Aide on the 7:00 AM - 3:00 PM shift during the week at times and during the weekend when staffing is short. The Scheduler also indicated she notify the Administrator and the DNS throughout the week about the schedule when short of nurse aides. A review of the staffing allocation sheet dated 10/4/22 identified the day shift had one (1) Registered Nurse, two (2) Licensed Practical Nurse, four (4) Nurse Aides, with one (1) Student Nurse Aide. The allocation sheet failed to reflect documentation that the Student Nurse Aide was a Hospitality Aide, and only three Nurse Aides was scheduled. A review of the daily staffing breakdown schedule dated 10/4/22 for the 7:00 AM - 3:00 PM shift identified the skilled units (consist of 2 units), the census was 44 and there was (0) Registered Nurse, two (2) Licensed Practical Nurse, three (3) Nurse Aides, and one (1) Student Nurse Aide. The staff breakdown schedule failed to identified documentation that the Student Nurse Aide was a Hospitality Aide. A review of the census report on 10/4/22 identified the facility capacity was 56 beds and the census was 44 residents in the facility. Review of the census report dated 10/4/22 identified the skilled nursing unit (consist of 2 units) had a census of 44 residents. Observation on 10/4/22 at 10:30 AM identified on the Migeon Lane unit one (1) Licensed Practical Nurse, one (1) Nurse Aides for 24 residents, and one (1) Hospitality Aide. Review of the resident list for the Migeon Lane unit on 10/4/22 identified the census was 24 residents on the unit. Interview with NA #4 on 10/4/22 at 11:50 AM identified she has been employed by the facility for 15 years. NA #4 indicated she is the only Nurse Aide on the 7:00 AM - 3:00 PM shift on the Migeon Lane unit. NA #4 indicated it is impossible to give showers when she is the only nurse aide on the unit. NA #4 indicated there is a Student NA on the unit and she cannot provide direct care to the residents, she can only answer call lights, pass out hydration, make beds, pass out and pick up meal trays. (The Student Nurse Aide is a Hospitality Aide). Interview with LPN #2 on 10/4/22 at 12:03 PM identified she was aware that there was only one nurse aide on the Migeon Lane unit today on the 7:00 AM - 3:00 PM shift. LPN #2 indicated she is aware that it is difficult for the nurse aide to give showers to the resident on the 7:00 AM - 3:00 PM shift when there is only one nurse aide. LPN #2 indicated the nurse aides do the best that they can. LPN #2 indicated she does her best to help by answering call lights, and toilet residents to help the nurse aide. Interview with the Scheduler on 10/4/22 at 12:15 PM identified she had scheduled four Nurse Aides for the 7:00 AM - 3:00 PM shift today. The Scheduler indicated she was directed to count the Student NA has a nurse aide on the schedule. The Scheduler indicated the Student NA on the schedule is a Hospitality Aide leaving the Migeon Lane unit with one Nurse Aide. Interview with the Administrator on 10/4/22 at 12:16 PM identified she is aware of the insufficient staffing issue at the facility. The Administrator indicated the facility has been recruiting Nurse Aide every Tuesday and Thursday. The Administrator indicated the facility has 2 applicants at the moment. The Administrator indicated there has been a shortage of Nurse Aides on the 7:00 AM - 3:00 PM shift since July 2022, the 3:00 PM - 11:00 PM shift has been an issue since I have been here as an Administrator, and the 11:00 PM - 7:00 AM shift has been an issue on and off has well. The Administrator indicated staffing is a challenge. The Administrator indicated the facility has been utilizing the Temp Student Nurse Aides and Hospitality Aides in the staff count. The Administrator indicated she was notified that the facility can utilize the Temp Student Nurse Aides has Nurse Aides in the staff count on the floor. The Administrator indicated the facility follows the public health code for staffing. Interview with the DNS on 10/4/22 at 12:30 PM identified she is aware of the insufficient staffing today on the 7:00 AM - 3:00 PM on the Migeon Lane unit. The DNS indicated she had tried to call all the staff to work, and no one was able to come in. The DNS indicated she is aware of the insufficient staffing on all shifts. The DNS indicated the facility has been doing the best that they can to hire Nurse Aides. Review of the hospitality aide duties policy identified reports to staff nurse/nurse supervisor, and clinical coordinator. Hospitality Aides are here to support the staff with various tasks that would normally take scheduled nurse's aide away from patient care. Hospitality Aides cannot perform direct patient care. Tasks/Duties: Answer call lights, make beds, clean - wipe down bedside tables, etc., empty barrels/take out trash, assist with transportation to/from dining room, health drive, recreation, hairdresser, fill oxygen tanks, dirty laundry, pass snacks, pass out meal trays, and pick up meal trays. Review of the facility assessment identified 56 licensed beds, and average daily census 44-48 residents. Staffing plan identified Direct care staff. Days: 4 - 6 aides and 2 License Nurses. Evening: 3 - 4 aides and 2 License Nurses. Nights: 2 aides and 2 License Nurses. This staff pattern goes up to 56 residents and can be altered with census. Staffing assignments are reviewed regularly in relation to resident needs and adjusted as needed, staff assignments are based on the resident acuity rather than numbers. Assignments are created to equal regarding resident care needs.

Based on review of facility documentation, facility assessment, and interviews, the facility failed to ensure nursing staff possess the competencies and skill sets necessary to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental, and psychosocial well-being. The findings include: A review of the daily staffing breakdown schedule from 6/1/22 through 10/4/22 identified insufficient staff on all shifts. The facility had been scheduling the Temp Student Nurse Aides and the Hospitality Aides on the daily staffing schedule. The facility has been utilizing the Hospitality Aides as a Certified Nurse Aide and counting the Hospitality Aides as part of the staffing count on all shifts. Review of the daily staffing breakdown schedule from 6/1/22 through 9/30/22 identified on numerous days and shifts the Temp Student Nurse Aide and the Hospitality Aide had been left alone on the unit for one to four hours alone on the units. Review of the daily staffing breakdown schedule from 6/1/22 through 9/30/22 identified on numerous days and shifts the Temp Student Nurse Aide and the Hospitality Aide had been left alone on the unit for 8 hours alone as the nurse aide on the unit. Interview with the Scheduler on 10/3/22 at 2:35 PM identified she has been employed by the facility since March 2022. The Scheduler indicated the Administrator notifies her with the title of the new staffs. The Scheduler indicated she has been scheduling the Hospitality Aides on the daily schedule on the 7:00 AM - 3:00 PM shift, and the 3:00 PM - 11:00 PM shifts as part of the Certified Nurse Aide count. The Scheduler indicated she has been scheduling the Hospitality Aides on the daily schedule as Temp Student Nurse Aides. The Scheduler indicated the Recreation Director also works as a Certified Nurse Aide on the 7:00 AM - 3:00 PM shift during the week at times and during the weekend when staffing is short. The Scheduler also indicated she notify the Administrator and the DNS throughout the week about the schedule when short of nurse aides. Interview with the Administrator on 10/4/22 at 12:16 PM identified she was aware of the insufficient staffing issue at the facility. The Administrator indicated the facility has been recruiting Nurse Aides every Tuesday and Thursday. The Administrator indicated the facility has 2 applicants at the moment. The Administrator indicated there has been a shortage of Nurse Aides on the 7:00 AM - 3:00 PM shift since July 2022, the 3:00 PM - 11:00 PM shift has been an issue since I have been here as an Administrator, and the 11:00 PM - 7:00 AM shift has been an issue on and off has well. The Administrator indicated staffing is a challenge. The Administrator indicated the facility has been utilizing the Temp Student Nurse Aides and Hospitality Aides in the staff count. The Administrator indicated she was notified that the facility can utilize the Temp Student Nurse Aides as Nurse Aides in the staff count on the floor. The Administrator indicated the facility follows the public health code for staffing. Interview with the DNS on 10/4/22 at 12:30 PM identified she was aware of the insufficient staffing today on the 7:00 AM - 3:00 PM on the Migeon Lane unit. The DNS indicated she had tried to call all the staff to work, and no one was able to come in. The DNS indicated she was also aware of the insufficient staffing on all shifts. The DNS indicated the facility has been doing the best that they can to hire Nurse Aides. Review of the hospitality aide duties policy identified reports to staff nurse/nurse supervisor, and clinical coordinator. Hospitality Aides are here to support the staff with various tasks that would normally take scheduled nurse's aide away from patient care. Hospitality Aides cannot perform direct patient care. Tasks/Duties: Answer call lights, make beds, clean - wipe down bedside tables, etc., empty barrels/take out trash, assist with transportation to/from dining room, health drive, recreation, hairdresser, fill oxygen tanks, dirty laundry, pass snacks, pass out meal trays, and pick up meal trays. Review of the facility assessment identified 56 licensed beds, and average daily census 44-48 residents. Staffing plan identified Direct care staff. Days: 4 - 6 aides and 2 License Nurses. Evening: 3 - 4 aides and 2 License Nurses. Nights: 2 aides and 2 License Nurses. This staff pattern goes up to 56 residents and can be altered with census. Staffing assignments are reviewed regularly in relation to resident needs and adjusted as needed, staff assignments are based on the resident acuity rather than numbers. Assignments are created to equal regarding resident care needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility policy, and interviews for 1 of 2 medication storage room, the facility failed to maintain the medication storage room in a clean manner and for 1 of 2 narcotic refrigerator, the facility failed to ensure the narcotic refrigerator freezer was free from build-up ice, and for 1 of 2 medications carts, the facility failed to maintain the medication cart in a clean and sanitary manner, and the facility failed to secure a medication following a specialized services appointment. The findings included: 1. Observation of the medication storage room on [NAME] Court unit on 9/29/22 at 10:38 AM with the DNS identified the window curtains with multiple brown stains, and dirt. 2. Observation of the medication storage room on [NAME] Court unit on 9/29/22 at 10:38 AM with the DNS identified the narcotic refrigerator freezer with accumulation of build-up ice. Interview with the DNS on 9/29/22 at 10:38 AM identified she was not aware of the above issues. The DNS indicated the licensed nurse is responsible for to notifying the housekeeping department of the need to change the window curtain when it has a stain or dirty and when the narcotic refrigerator freezer needs to be clean. The DNS indicated education and in-service will be given to the nursing staff. Medication refrigerators will be cleaned on a regular basis by housekeeping personal under the direct supervision of the licensed nurse to ensure cleanliness. The nursing staff on all shifts and all units are directly responsible for maintaining proper cleanliness of all medication storage areas and mobile medication carts. Medication carts and refrigerators will be cleaned regularly. All spills will be cleaned immediately. 3. Observation of the medication cart on [NAME] Court on 9/29/22 at 10:40 AM with the DNS identified an accumulation of loose medication pills and blister pack back covers at the bottom of first drawer and/or stains and spilled liquids at the bottom of second drawer of the medication cart. Interview with the DNS on 9/29/22 at 10:40 AM identified she was not aware of the loose medication pills and blister pack back covers and/or stains and spilled liquids at the bottom of drawer. The DNS indicated it is the responsibility of all the nurses to keep the medication cart clean at all times. The DNS further indicated education and in-service will be given to the nursing staff. Interview with LPN #1 on 9/29/22 at 10:50 AM identified it is the responsibility of all nurses to keep medication carts clean at all times. 4. Resident #26 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease, type 2 diabetes mellitus, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #26 had intact cognition and required extensive assistance with personal hygiene. The physician's order dated for the month of 10/1/22 directed to administer Midodrine HCL 10 MG tablet give 3 tablets by mouth every Monday, Wednesday, Friday for low blood pressure during specialized treatment. To be administered by the specialized treatment staff. Not to be given at skilled nursing facility. Resident # 26 to take medication with her to specialized treatment center. A nurse's note dated 10/3/22 at 2:54 PM identified Resident #26 went to the specialized treatment center via car chair at 11:45 AM. The specialized treatment center book packed, and sweater offered. Resident #26 to return later in the day. The nurse's note failed to reflect documentation that Resident #26 had left the facility with the blister pack of the medication Midodrine HCL 10mg. The nurse's note dated 10/3/22 failed to reflect documentation Resident #26 had returned to the facility from the specialized treatment center at a specific time with the medication Midodrine HCL 10mg blister pack. And that the medication Midodrine HCL 10mg blister pack was removed and placed in the medication storage room in a locked area. Observation on 10/4/22 at 9:10 AM with the DNS identified Resident #26 communication book, and a medication blister pack for Midodrine HCL 10 MG tablet with 3 pills remained in the blister pack was in the specialized treatment bag in the back of the wheelchair in the resident's room. Resident #26 and roommate were in the room in bed. Interview with the DNS on 10/4/22 at 9:15 AM identified she was not aware of the issues. The DNS indicated it is the responsibility of the nurse on the unit to remove the medication blister pack from the specialized treatment center bag and place it in the medication storage room where it can be secured and locked after returning from the specialized treatment center. The DNS indicated the medication blister pack should not have remained in Resident #26's room. The DNS indicated she will in-service the licensed staff. Although attempted an interview with the licensed staff for 10/3/22 on the 3:00 PM - 11:00 PM shift was attempted the attempt was unsuccessful. Interview with LPN #7 on 10/5/22 at 9:04 AM identified she has been employed by the facility for approximately 4 weeks. LPN #7 indicated she worked on 10/3/22 on the 7:00 AM - 3:00 PM shift. LPN #7 indicated she was not aware that she was supposed to place medication in specialized treatment bag and document that the medication was sent with Resident #26 to center in the nurse's note. LPN #7 indicated the 3:00 PM - 11:00 PM shift nurse should have removed the medication from the specialized treatment bag and place it in the medication storage room. The facility failed to secure a medication following a specialized treatment appointment. Review of the facility storage of medication policy identified it is the policy of this facility to provide for storage of all drugs and biological under proper conditions of security, segregation, and environmental control at all times. Only licensed nursing personnel shall have access to any areas in which drugs and biologicals are stored. Review of the facility storage of medication policy identified it is the policy of this facility to provide for storage of all drugs and biological under proper conditions of security, segregation, and environmental control at all times. Medications are stored primarily in a locked mobile medication cart which is accessible only to licensed nursing personnel. Review of the facility's pharmacy services, and procedures manual identified facility should ensure that external use medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors.

Based on observations of the kitchen, review facility documentation, facility policy, and interviews, the facility failed to ensure a clean and sanitary kitchen. The findings included: An observation on 9/28/22 at 9:50AM of the kitchen identified the following: 1. A large amount of brown congealed buildup along the back of the sink, stoves, and all counter against the wall where the floor meets the wall. 2. Multiple smears and smudges on door of the stove with large amount of brown buildup on the front and sides of the stove and a moderate amount of brown buildup on the sides of the handle on the stove. 3. The Convection oven with a large amount of brown congealed buildup on the control knobs, along the sides and behind the stove on the floor. 4. A large amount of brown congealed buildup on the steam table face and around control knobs. 5. Ice holder with a small amount of blackened buildup at the bottom of the holder and small amount of caked gray buildup on the top closure. 6. The face of the ice machine was observed with a large amount of scaled white buildup along the front and sides. 7. The grease trap surface and surrounding floor space was noted with an excessive amount of yellow and black buildup after being emptied. 8. A large amount of grey matter buildup was noted on the top of each wall sanitizer. Review of the daily cleaning list dated 9/1/22 through 9/27/22 identified the above surface areas were to be cleaned and sanitized daily were checked off as having been completed. An interview on 9/28/22 at 12:51PM with the Food Service Director (FSD) identified she started working for the facility in December 2021. The FSD indicated there used to be a cleaning company to come in and complete deep cleaning before she started working at the facility. The FSD also indicated she was unsure why the deep cleaning company stopped coming. The FSD indicated she had noticed the kitchen was not as clean as it should be and was doing the best she could to keep up with sweeping and mopping daily but that it was difficult keeping up with daily tasks. The FSD also indicated she had not had a discussion with the Administrator to express her concerns or needed support. The facility policy for General Cleanliness of the Dietary Department directs employees are responsible for cleaning up after each task. Any equipment is cleaned and sanitized after use. Employees are responsible for a thorough cleaning prior to the end of the shift at the close of each day including but not limited to cleaning and sanitizing all work surfaces, sweeping, mopping kitchen and dish room floor, proper storage of all dishware and over all cleanliness of the department. Subsequent to surveyor inquiry, cleaning of surface areas was being addressed including surface area of the grease trap.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, facility policy review and interviews for infection control, the facility failed to follow infection control guideline regarding discarding soiled gloves and failed to ensure isolation gowns were readily available for adherence to proper Personal Protective Equipment (PPE) use. The finding included: 1. Observation on [DATE] at 10:50 AM identified Hospitality Aide (HA) #1 exited room [ROOM NUMBER] with gloves on. Hospitality Aide (HA) #1 walked down the hallway with 1 plastic bag of soiled and dirty linen (touched bedroom doorknob with glove hand). HA #1 observed surveyor watching her then she removed glove off one hand. Interview with HA #1 on [DATE] at 10:55 AM identified she has been employed by the facility for 6 months. HA #1 indicated she forgot to take her gloves off before coming out of the room. HA #1 indicated she is aware she is not supposed to come out of a room and touched the doorknob with gloved hands. Interview with the DNS on [DATE] at 10:16 AM identified she was not aware staff were wearing soiled gloves in the hallway and touching doorknobs. The DNS indicated HA #1 did not follow infection control practices and indicated HA #1 should not have touched the room doorknob and walk in the hallway wearing dirty gloves. The DNS further indicated HA #1 should have removed one glove prior to touching the doorknob. The DNS indicated the nursing staff and the hospitality staff will be in-service. Review of the facility hospitality aide duties identified hospitality aides are here to support the staff with various tasks that would normally take schedule NA's away from patient care. Hospitality Aides cannot perform direct patient care. Hospitality Aide Task/Duties: Answer call lights, make beds, remove dirty laundry, empty barrels/take out trash, and pass snacks. 2. Interview with the Director of Maintenance on [DATE] at 1:00 PM identified that he had just inspected the emergency stores of personal protective equipment (PPE) and identified that the isolation gowns were expired as of [DATE]. The Director of Maintenance further indicated that he would be reaching out to their corporate office to obtain more isolation gowns. Observation and interview on [DATE] at 1:30 PM with LPN #3 (Infection Preventionist) identified that there were 8 boxes with 50 gowns in each box in their main medical supply room for the facility with a stamp on the side of each box that indicated the gowns expired 2 years after their production date of [DATE]. LPN #3 noted that they were also expired and after looking through the remaining items in the supply, identified that there were no other available isolation gowns in the facility. She continued by stating that she had no residents on isolation at this time. After the surveyor's observation, the Director of Maintenance obtained new isolation gowns from their corporate supply and disposed of the expired isolation gowns. The facility policy, Infection Prevention and Control Recommendations for COVID-19 in part directs that transmission-based precautions are designed for residents that are documented or suspected to be infected with highly transmissible microorganisms (infectious diseases) for which additional precautions beyond standard are needed to interrupt transmission in the facility. The policy continued by directing a gown is worn whenever anticipating that clothing will have direct contact with the resident or potentially contaminated environmental surfaces or equipment near the resident. The facility assessment reviewed on [DATE] identified that the facility serves Residents with infectious diseases such as ehrlichiosis (virus), methicillin resistant staph aureus (MRSA, a bacteria), Vancomycin resistant enterococci (VRE, a bacteria), Clostridia difficile (bacteria) and COVID-19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy and procedures and interviews for one of three residents reviewed for skin integrity (Resident #15), the facility failed to develop skin interventions on the Baseline Resident Care Plan. The findings included: Resident #15 was admitted to the facility on [DATE] with diagnoses that included, altered mental status, non-healing comminuted intra-articular fracture of the left distal femur, left ischial wound and osteomyelitis. A hospital discharge summary and the inter-agency patient referral form (W-10) dated 9/6/19 identified Resident #15 was status post Stage 2 pressure ulcers to the left ischial tuberosity and coccyx. The W-10 further directed pressure ulcer prevention interventions per protocol, low air loss bed or mattress, frequent repositioning every 2 hours, waffle cushion when out of bed to chair, limit sitting times to 1-2 hour intervals, and frequent weight shifts for the coccyx and left ischium, continue wound care to the left coccyx and left ischium (which is currently closed) with a gentle cleanse of normal saline and apply foam dressing every three days. An admission nursing assessment dated [DATE] identified Resident #15 was alert/orient with confusion and having a skin assessment which noted Resident #15 had an indentation to the left gluteal fold, right hand and upper left arm ecchymosis and hammer toes to the bilateral feet. A Braden Scale (tool for measuring pressure ulcer risk) dated 9/7/19 identified Resident #15 was at a moderate risk for developing pressure ulcers. The Baseline Resident Care Plan dated 9/8/19 identified skin concerns that included bilateral lower extremities and utilizing an immobilizer at all times (but failed to reflect Resident #15's hospital W-10 recommendations). No interventions or approaches were further identified. A wound tracking report dated 9/18/19, noted the Resident #15 with a questionable old healing deep tissue injury (DTI) to the left buttocks measuring, 3.0 centimeter (cm) x 1.5 cm x 0.1 cm. On 12/12/19 at 10:01 AM, an interview and review of Resident #15's Baseline Resident Care Plan, physician orders and Treatment Administration Record with the DNS failed to reflect W-10 preventive skin instructions were in place or developed in the Baseline Resident Care Plan at the time of resident's admission to the facility on 9/6/19. According to the facility's wound and skin care protocols identified in part, the care plan including the admission/readmission care plan will address preventive and treatment of impaired skin integrity and pressure ulcer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy and interviews for one of three sampled residents reviewed for skin integrity (Resident #15), the facility failed to implement preventative skin recommendations and failed to complete a weekly body audit. The findings included: Resident #15 was admitted to the facility on [DATE] with diagnoses that included, altered mental status, non-healing comminuted intra-articular fracture of the left distal femur, left ischial wound and osteomyelitis. A hospital discharge summary and the Inter-Agency Patient Referral form (W-10) dated 9/6/19 identified Resident #15 was status post Stage 2 pressure ulcers to the left ischial tuberosity and coccyx. The W-10 further directed pressure ulcer prevention interventions per protocol, low air loss bed or mattress, frequent repositioning every 2 hours, waffle cushion when out of bed to chair, limit sitting times to 1-2 hour intervals, and frequent weight shifts for the coccyx and left ischium, continue wound care to the left coccyx and left ischium (which is currently closed) with a gentle cleanse of normal saline and apply foam dressing every three days. An admission nursing assessment dated [DATE] identified Resident #15 was alert/orient with confusion and having a skin assessment which noted Resident #15 had an indentation to the left gluteal fold, right hand and upper left arm ecchymosis and hammer toes to the bilateral feet. A Braden Scale (tool for measuring pressure ulcer risk) dated 9/7/19 identified Resident #15 was at a moderate risk for developing pressure ulcers. A weekly body audit at the time of admission on [DATE] identified Resident #15 as having no skin issues or concerns, but failed to reflect the weekly body audit was completed on 9/13/19. The Baseline Resident Care Plan dated 9/8/19 identified skin concerns that included utilizing an immobilizer at all times to bilateral lower extremities but failed to reflect Resident #15's hospital W-10 discharge instructions or other approaches for pressure ulcer prevention. On 12/12/19 at 10:01 AM an interview and review of Resident #15's Baseline Resident Care Plan, physician orders and Treatment Administration Record with the DNS failed to reflect preventive measures were in place or developed in the Baseline Resident Care Plan with interventions according to the hospital discharge summary and the W-10 at the time of resident's admission to the facility on 9/6/19. Upon further review of the clinical record with the DNS, a wound tracking report dated 9/18/19, noted the Resident #15 with a questionable old healing deep tissue injury (DTI) to the left buttocks measuring, 3.0 centimeter (cm) x 1.5 cm x 0.1 cm. Subsequent to the wound tracking report of the left buttocks DTI, physician orders dated 9/18/19 directed a treatment of normal saline, followed by Triad paste, then apply AGB dressing daily for 7 days, then re-evaluate (wound). The weekly body audit was resumed on 9/20/19, two weeks after the resident's admission and two days after the resident was identified as having a questionable healing DTI to the left buttocks area on 9/18/19. The maintenance log identified a low air mattress for Resident #15 was requested on 9/19/19 and was delivered on 9/21/19 (despite W-10 recommendations for a low air loss mattress on 9/6/19). The Resident Care Plan was updated on 9/20/19 which identified the resident at risk for alterations in skin integrity as the focus with approaches that included instructions directed by the discharge summary and W-10 noted at the time of the resident's admission on [DATE]. 12/12/19 at 10:10 AM an interview with the DNS indicated a body audit is done at the time of admission and re-admission and then weekly on the resident's shower day. The resident was to have had a weekly body audit performed on 9/13/19 one week following the resident's admission. According to the facility's wound and skin care protocols identified in part, the care plan including the admission/readmission care plan will address preventive and treatment of impaired skin integrity and pressure ulcer. Resident #15 was admitted to the facility on [DATE] from the hospital, status post Stage 2 pressure ulcers to the left ischeal tuberosity and coccyx. Hospital W-10 discharge instructions were not instituted or responded to by the physician and a weekly body audit was not completed when due on 9/13/1. A weekly body audit was then completed on 9/18/19 when a wound tracking form identified a questionable healing DTI to the left buttocks. There was no documentation or monitoring of a healing DTI from admission [DATE]) through 9/18/19 when a weekly body audit identified a healing DTI to the left buttocks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and review of facility policy, for one of one resident observed for wound care (Resident #23), the facility failed to follow infection control practices during a wound treatment and for one of fifteen bathrooms observed, the facility failed to ensure personal care items were stored in a safe and sanitary manner. The findings include: 1. Resident #23's diagnoses included peripheral vascular disease, hypertension and cognitive deficit. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #23 had a short and long term memory problem, required extensive assistance of two for bed mobility, extensive assistance of one for dressing, eating, toilet use, and required total assistance of one for personal hygiene. The Resident Care Plan dated 8/7/19 identified Resident #23 had an alteration in skin integrity/multiple areas to the right foot related to cognitive impairment, immobility, incontinence, and a nutritional deficit. Interventions included to turn and position every two hours, perform incontinent care every two hours or as needed, and perform pressure ulcer wound care as per facility policy. Physician orders dated 12/5/19 directed to cleanse the right great toe with Normal Saline and apply Calcium Alginate with Silver Cover with ABG dressing, to be changed every other day and as needed. On 12/11/19 at 9:26 AM an observation of Resident #23's wound care with Advanced Practice Registered Nurse (APRN) #1 and Registered Nurse (RN) #2 identified RN #2 removed Resident #23's old dressing from a right medial great toe wound, performed hand hygiene, cleansed the one area of intact skin and one open area with normal saline, cut a foam-like dressing and attempted to place the dressing on the open wound without first doffing gloves and performing hand hygiene. RN #2 was requested to stop and perform hand hygiene after handling the open area and prior to applying the clean dressing. Upon completion of wound care, RN #2 gathered wound care supplies from the bedside tray table (while wearing the gloves used to apply the wound dressing) including a box of gloves, place items in a plastic bag with the exception of the box of gloves and remove additional soiled items from the waste basket in Resident #23's room which was also placed into the plastic bag. RN #2 was observed to have doffed her gloves while holding the box of gloves in the crux of her arm, then place box on a wall unit in Resident #23's room for future use of others entering in the room, before he/she performed hand hygiene. An interview on 12/11/19 at 9:26 AM with RN #2 identified while he/she was aware to perform hand hygiene between clean and dirty tasks, he/she failed to do so in this instance as it was an oversight and he/she was nervous. The facility policy for Hand Hygiene directs all staff to wash hands as a means of preventing the spread of infection. Hand hygiene should be performed after handling contaminated items or equipment and after contact with broken skin. 2. Observation with Registered Nurse (RN) #1 of the shared bathroom of room [ROOM NUMBER]/116 on 12/9/19 at 10:05 AM identified two tubes of toothpaste (one without a cap), one toothbrush, one tube of Triad paste, one tube of DermaCerin, one bottle of mouthwash and one medication cup one third full of a white powder stored on a shelf; an emesis basin containing two tubes of toothpaste, two toothbrushes and a haibrush was noted on the back of the sink; on the floor below the sink was a basin with a urine catch container in it; none of these items were labelled with a resident's name. Interview with RN #1 at that time identified the items should not have been stored there, should not be unlabeled, and the nursing staff were responsible to label the items with the resident's name. RN #1 identified that he/she would dispose of all these items. Interview with the DNS on 12/12/19 at 10:56 AM identified that the personal care items should have been labeled and stored in the resident's nightstand. Additionally, the DNS identified there is no policy regarding this, it is an expectation of nursing staff. The facility policy for Care of Brush and Combs identified brush or comb would be stored in the resident's nightstand.