**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews facility failed to determine whether the self-administration of medications was clinically appropriate for one resident (Resident #10) out of seven residents sampled; as evidenced by observation of medication in resident's drawer and no self-administration assessment completed. There were 36 residents residing in the facility at the time of survey. The findings included: On 4/29/2024 at 9:04 AM Resident #10 asked surveyor to retrieve lozenges from drawer. Upon opening Resident#10's top drawer, one white bottle labeled supplements and two boxes labeled lozenges were observed inside. (see photo evidence). On 4/29/2024 at 9:05 AM, the surveyor approached Staff B, Licensed practical Nurse (LPN) and asked if Resident #10 was approved to self-medicate or keep medications in room. Staff B, LPN stated [Resident #10] has not been evaluated to self-administer medication. The surveyor informed Staff B, LPN that medications were observed in the top drawer in Resident #10's room. Staff B, LPN and surveyor entered Resident #10's room; Staff B, LPN retrieved one white bottle and attempted to retrieve the boxes of lozenges however Resident #10 grabbed the Lozenges and refused to let go. Staff B, LPN explained to Resident #10 that an order from the physician for these medications was required and Resident #10 did not release the boxes of lozenges. On 4/29/2024 at 9:19 AM Staff C, LPN stated: I will notify the Unit Manger about this situation. On 4/30/2024 at 12:00 PM Staff C, LPN stated: an assessment was done for self-administration for [Resident #10] and the physician is now aware and has approved of the lozenges to be kept in [Resident #10's] top drawer and that drawer is locked, and the key kept by [Resident #10]. On 4/30/2024 at 12:06 PM. Surveyor entered Resident #10's room with Staff C, LPN, and the top drawer next to resident was locked. Record review of demographic sheet for Resident #10 revealed an admission date of 4/3/2024 with diagnosis that included Gastro-esophageal reflux disease without esophagitis. Record review of admission Minimum Data Set (MDS) dated [DATE] Section C for cognitive status revealed a Brief Mental Status Score of score 14 out of a scale of 0-15 indicated no cognitive impairment. Section GG for functional status revealed Resident #10 required set up/clean up assistance for eating/oral hygiene. Record review of Care Plan start date 4/3/2024 and revision date 4/16/2024 revealed Resident #10 Self Care deficit with interventions that included: Encourage the resident to complete task(s) she is safely capable of and provide with assistance as needed. Record review revealed an assessment dated [DATE] for Self-Administration of medication. Record review of physician orders revealed an order dated 4/29/2024 for [brand] Dry Mouth Lozenge Administer one lozenge by mouth every one hour as needed for Dry Mouth and resident to self-administer. Record review of Progress Note 4/29/2024 revealed resident noted with home medications in room and refusing to surrender medication to the nurse despite many attempts made. Supplements and dry mouth Lozenges currently in room. [Resident #10] stated she would like to self-administer dry mouth Lozenges and does not want to continue with supplements while she is here in the facility. [Resident #10] was able to provide a return demonstration on how to properly store the dry mouth Lozenges in the drawer, how to self-administer, how to lock and unlock drawer. Physician made aware and orders obtain for dry mouth Lozenges every hour as needed for dry mouth and ok for [Resident #10] to self-administer. On 5/02/2024 at 8:05 AM The Director of Nursing stated: Upon admission we educate the resident and family that medications are not to be kept in the rooms, we complete a check of the room to determine if any medications are in the room, and we ask the resident and the family if any medication was brought into facility so we can retrieve the medication and keep it in the medication room or ADON (Assistant Director of Nursing) office and label it with the name of the resident so it can be returned to resident upon discharge. For any resident who wants to keep medications at bedside, the Unit Manager completes a self-administration assessment for that resident and then we notify the doctor to get an order for self-administration. The next step is to get a lock for the drawer to keep the medication in the room, print a paper MAR (Medication Administration Record) for the resident to notate the administration and the Unit Manger monitors the MAR to see when medication was taken. Record review of the facility's Policy and Procedure for Medications-Bedside Storage and Self-Administration effective date May 2007 revision date 2017 Philosophy Resident Care Policies are intended to describe the Company commitment to a customer -centered approach to care provided throughout the continuum of clinical services. Purpose The policy establishes guidelines for the storage and documentation of medication kept at a resident's bedside and for self-administration of medication in Skilled Nursing (SN). Process Prescription and non-prescription over the counter (OTC) medications, except narcotic analgesics and other Class II drugs, may be stored at the bedside in a secure, locked drawer when ordered by a healthcare provider with prescriptive authority, and after the assessment and approval by the interdisciplinary team of the resident's ability to self-administer medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to provide assistive devices to prevent accidents for one resident (Resident #185) out of seven residents sampled as evidenced by observations of Resident#185 in bed and the floor mats folded up, against the wall. There were 36 residents residing in the facility at the time of the survey. The findings included: On 4/29/2024 at 9:25 AM an observation was made of Resident#185 in bed with eyes closed, one floor mat in place on the right of the bed and the other floor mat was noted folded up against the wall. (photo evidence) On 5/01/2024 at 8:42 AM an observation was made of Resident #185. The resident was awake and in bed, the two floor mats were folded up against the wall. (photo evidence) Record review of demographic sheet of Resident #185 revealed an admission date of 4/24/2024 with diagnosis that included history of falling and other abnormalities of gait. Record review revealed an admission Minimum Data Set (MDS) dated [DATE] was in process. Record review of Care Plan dated 4/25/2024 revealed Resident #185 at risk for fall due to debility from recent Cerebrovascular Accident, history of falls, impaired mobility, new surroundings with interventions that included keep bed in lower position, equipment and devices as ordered, Record review of physician orders revealed an order dated 4/24/2024 for floor mats at bedside twice a day 7:00 AM to 7:00PM and 7:00 PM to 7:00AM. On 5/01/2024 at 8:42 AM Staff B, Licensed Practical Nurse (LPN) was notified by surveyor that floor mats were folded and against the wall while the Resident#185 was in bed. Staff B, LPN entered Resident #185's room with surveyor and placed mats onto floor on both sides of bed. On 5/01/2024 at 8:42 AM Staff B, LPN stated: [Resident#185] has an order for floor mats twice a day. I did rounds at 7:00 AM and [Resident#185] was in bed and both floor mats were on the floor on each side of the bed. On 5/01/2024 at 9:06 AM The Assistant Director of Nursing (ADON) approached surveyor and stated: I removed the floor mats because I was readjusting the resident to prepare for breakfast and to prevent dizziness. once I left the room, I did not replace the mats because I was in and out of the room. When a resident has an order for floor mats, all staff are to follow the order. This resident has a current order for floor mats twice a day and the floor mats should have been in place this morning when I was not in the room. On 5/02/2024 at 8:14 AM The Director of Nursing (DON) stated: We use floor mats to prevent injury during a fall for residents who are at risk of falling. Also Stated there is always a physician order for floor mats. Further stated all staff are required to follow physician orders and they sign every shift for that specific order. Stated the only time the floor mats can be removed when staff are providing care or if the resident is not in bed. Record review of Policy and Procedure entitled, Fall Prevention Protocol revised October 2017 Purpose This protocol describes mechanisms for assessing residents at risk for falls and providing interventions to reduce the likelihood of falls. 13. The SN interdisciplinary team, the resident and the resident's family/responsible agent may consider using the following fall prevention devices, which include but are not limited to: concave mattress, low bed, mattress/pads on floor.

Based on observation, interview and record review, it was determined that the facility failed to ensure the hydration cart, ice cooler and ice scoop was handled in a manner to prevent contamination. The findings included: During an observation on the nursing unit on 4/30/2024 at 11:15 AM, a person was observed to walk over to the Hydration cart, that was located across from the nursing station. The person picked up the ice scoop from its holder, opened the ice cooler, put ice in a plastic glass and filled the glass with water from the water container. Then the person was observed to walk into a resident's room. The person was not observed to sanitize her hands before or after obtaining the ice and water and was not wearing gloves. On 4/30/2024 at 11:25 AM, the Assistant Director of Nursing (ADON) was observed in the hallway. The surveyor interviewed the ADON about the observation and gave a description of the person. The ADON reported, it was Resident #185's spouse. The person was then observed walking out of Resident #185's room. The ADON reported, they have spoken to her about this, and the residents wife gets upset when they speak to her. The ADON reported, the resident has water at the bedside, but the resident's spouse still gets water for him. The surveyor explained to the ADON that the person was not observed to use hand sanitizer before using the scoop and cooler. The ADON reported, she did not see her go into the cooler. (Photo of the hydration cart was obtained). The ADON reported, the cooler, scoop, and the hydration cart are changed daily and cleaned in the kitchen, then another hydration cart is put out daily. On 4/30/24 at 1:23 PM, Resident #185's spouse was observed at the ice cooler and hydration cart with a glass, obtained water and returned to Resident #185's room. The person was not observed to use hand sanitizer prior to obtaining ice and water. Record review of the facility's policy and procedure for the category of Resident Care and titled Infection Control Program and Committee revised June 2020 documents, in the section for Process - The Infection Control Team Program and Committee is responsible for investigation, reporting, control and prevention of infections, reviewing occupational exposures to blood, body fluid or other potentially infectious materials and for monitoring staff performance to ensure that infection control policies, protocols and procedures are implemented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, facility failed to send an accurate Nursing Home Transfer and Discharge Notice to The Office of the State Long term care Ombudsman for one resident (Resident #184) out of seven residents sampled, as evidenced by a fax confirmation of The Nursing Home Transfer and Discharge Notice with a discharge date of 12/01/2023 was sent to The Office of the State Long term care Ombudsman and a nursing note dated 12/04/2024 documented that Resident#184 was discharged to home. The findings Included: Record review of demographic sheet for Resident#184 revealed an admission date of 10/19/2023 and discharge date of 12/4/2024 with diagnosis that included Displaced oblique fracture of shaft and right femur. Record review of discharge return not anticipated Minimum Data Set (MDS) Section A documented the resident was discharged to home and section C for cognitive status revealed a Brief Interview for Mental status score of 14 out of a scale of 0-15, indicated no cognitive impairment. Section Q for Participation in assessment and goal setting revealed active discharge planning in progress for the resident to return to the community. Review of the resident's Care Plan revealed a start date of 10/20/23 and revised date of 11/7/2023 for resident expects to return to community and discharge to community determined to be feasible. The interventions included provide written instructions for care/resources to use in case of emergency, provide education, and explain relevance of treatment regimen. Record review of physician orders revealed a discharge to home order dated 11/29/2023 for 12/1/2023. Record review of The Nursing Home Transfer and Discharge Notice signed by the resident's son on 11/28/2023 and discharge date of 12/1/23. Record review of a fax confirmation sheet revealed The Nursing Home Transfer and Discharge Notice was sent to the office of The State Long Term Care Ombudsman on 12/11/2023. Review of the Social Services notes indicated on 11/07/2023, Resident #184's son was notified about the upcoming discharge date of 11/22/2023 and on 11/17/2023 Resident #184's son stated, she will be ready to go home by that time. Further record review of the Social Services notes revealed on 11/27/2023 the Social Worker (SW) spoke to the son about an updated discharge date of 12/1/2023, and that it can be appealed .Continued review of the social services notes revealed on 12/1/2023 the facility's Administrator confirmed Resident #184's son made a second appeal and the resident had an additional 72 hours to reside in facility. Review of nursing notes revealed on 12/04/2023 Resident #184 was discharged to home and left the facility with son. On 05/01/2024 at 11:56 AM, the Social Services Manager stated: The determination of discharging a resident is made during the care plan meetings with the resident, family, and Interdisciplinary Team (IDT) after evaluating the status of the resident and once a date is set, I notify the resident or family about the discharge date , their right to appeal if they disagree and coordinate home health services and durable medical equipment needed for discharge. This discharge was facility initiated due to the resident reaching maximum potential in therapy. [Resident #184] initial discharge date was 11/22/2023 and son the was notified on 11/7/2023 and he disagreed with the discharge date , and it was changed to 12/1/2023 and son was notified on 11/17/2023 of the change and he agreed. [Resident #184's] son was notified on 11/27/2023 of the right to file an appeal the discharge date if he disagrees and on 11/29/2023 I informed [Resident#184's] son that if his appeal was denied the discharge date would remain on 12/1/23. On 12/1/2023 the Administrator confirmed there was a second appeal pending for [Resident #184] and [Resident#184] had an additional 72 hours to remain in the facility, and that appeal was denied. Resident #184 was discharged to home on [DATE] accompanied by son. The Nursing Home Notice of Transfer or Discharge was faxed to The Ombudsman on 12/11/23 and has a discharge date of 12/1/2023 even though the resident was discharged on 12/4/2023 because that was the initial discharge date . There is no other Transfer Letter to the Ombudsman for this resident.

Based on record review and interview the facility failed to ensure the arbitration agreements presented to residents upon admission informed residents or their representatives of the nature and implications of any proposed binding arbitration agreement, to inform their decision on whether or not to enter into such agreements. There were 36 residents residing in the facility at the time of the survey. The findings included: Record review for Arbitration agreements on facility letterhead documented the following: 1) The facility offers arbitration agreements; 2) The facility asks residents to enter into an arbitration agreement and provides new admissions with the arbitration agreement during the admission process, 3) No residents residing in the facility have signed the arbitration agreements and 4) The Outreach Manager and Admissions Assistant are responsible for the binding arbitration agreements. Review of the Arbitration Clause (Arbitration Agreement) received on 4/29/2024 revealed that the form did not document the binding arbitration agreement allowing the resident or anyone else to communicate with federal, state, or local officials such as federal and state surveyors, other federal or state health department employees and representative of the Office of the State Long Term Care Ombudsman. On 5/01/2024 at 10:24 AM, interview and record review with the Outreach Manager and Admissions Assistant of the Arbitration Clause. The Arbitration Clause revealed that the form did not document the binding arbitration agreement allowing the resident or anyone else to communicate with federal, state, or local officials such as federal and state surveyors, other federal or state health department employees and representative of the Office of the State Long Term Care Ombudsman. He stated, I have been here a year, and no one has signed the Arbitration Agreement. A subsequent interview with the Outreach Manager on 05/01/2024 at 11:11 AM, he presented a new Dispute Resolution Agreement (Arbitration Agreement), which was not given when requested upon entrance to the facility. He stated, I just got this from the Administrator, and we were using the wrong one. This one contains all of the information you requested. On 5/01/2024 at 12:47 PM, interview and record review with the Administrator confirmed that the Dispute Resolution Agreement form did not document the binding arbitration agreement allowing the resident or anyone else to communicate with federal, state, or local officials such as federal and state surveyors, other federal or state health department employees and representative of the Office of the State Long Term Care Ombudsman. Requested Arbitration policy and procedure from the Administrator and she revealed that the facility does not have one.

Based on observation, record review and interviews facility failed to use appropriate infection control practices for one Resident #187 out of seven sampled residents, as evidenced by staff using sanitizing wipes to clean blood pressure machine after taking vitals for a resident on isolation precaution. The findings included: On 4/30/2024 at 7:55 AM, Staff C, Licensed Practical Nurse (LPN) approached room of Resident#187, stopped donned gown and gloves then entered room with blood pressure machine, cleaned blood pressure machine with a wipe. On 4/30/2024 at 8:01 AM, Staff C, LPN exited Resident #187's room with blood pressure machine. On 4/30/2024 at 8:01 AM, Staff C, LPN was asked by surveyor what was used to clean blood pressure machine. Staff C, LPN stated: the resident has her own blood pressure cuff, and I cleaned the blood pressure machine with sanitizing wipes. Staff C, LPN showed surveyor a bottle of wipes with a purple top, labeled Germicidal Sani wipes. The surveyor asked Staff C, LPN to point out where it is indicated on the bottle that it is approved to disinfect surfaces for Clostridium difficile (C-diff.). C-diff was not listed on the bottle. Record review of demographic sheet for Resident #187 revealed an admission date of 1/17/2024 with diagnosis that included Enterocolitis due to Clostridium difficile (C-diff.) Record review of MDS 3/21/2024 Interim Payment assessment revealed Section C for cognitive status revealed a Brief Mental Status Score of 7 on a scale of 0-15 indicated moderate cognitive impairment. Section O for Special Treatments, Procedures, and Programs revealed Resident #187 was on Isolation or quarantine for active infectious disease (does not include standard body/fluid precautions). Record review of Care Plan start date 4/10/2024 revealed Resident #187 required isolation due to C diff. Interventions included dispose of all products in room per facility infection control protocol, place all protective equipment and garments outside of resident room and all care and services are to be brought to the resident's room. Record review of physician orders revealed an antibiotic order dated 4/20/2024 for Vancomycin 125 mg capsule by mouth twice a day 14 days for C-diff. On 4/30/2024 at 8:09 AM Staff A, Registered Nurse (RN) Unit Manager stated: blood pressure machine should be cleaned with bleach wipes after usage with a resident on isolation with a diagnosis of C-Diff. On 4/30/2024 at 10:53 AM Staff C, LPN stated: I know the procedure I used was wrong. The correct procedure when disinfecting the blood pressure machine when used with a resident under isolation precaution for C-diff is to use the bleach wipes located on the caddy outside the room. On 5/02/2024 at 8:18 AM The Director of Nursing (DON) stated: The protocol for cleaning the blood pressure machine after use with a resident under isolation precaution for C-diff is to stop at the door and don appropriate PPE (Personal protective equipment) and then bring machine into room, use the dedicated blood pressure cuff for that resident, remove cuff and clean the cuff, and use bleach wipes to clean the blood pressure machine. Staff can take the bleach wipes into room inside a plastic bag or remove bleach wipes out the container from the station in front of the door. Record review of the facility's Policy and Procedure for Equipment cleaning effective date May 2007 Revision Date October 2017 Philosophy Operations Policies are intended to describe the services of and standards for the major functional support areas of the business units and Company service lines. Purpose This policy describes the process for cleaning equipment used in the care of residents in Skilled Nursing (SN). Process Medical equipment used in the care of the resident is cleaned with community approved disinfectant before it is stored or used for another resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to coordinate care with Hospice for 1 of 1 sampled resident for hospice care (Resident #9). There were 3 residents residing in the facility receiving hospice services at the time of the survey. The findings included: Review of clinical records revealed, Resident #9 was admitted to the facility on [DATE], and readmitted on [DATE]. A comprehensive assessment dated [DATE] documented the resident had severe cognitive impairment, and required total two-person assist with activities of daily living. The assessment further documented the resident received hospice services. Resident #9 was care planned for hospice services on 03/28/22. An intervention dated 01/20/23 included: Hospice Nurse and Hospice CNA (Certified Nurse Assistant) to visit weekly/ as needed. Coordinate care and services via communication among staff. Record review revealed an order dated 03/26/22 for Resident #9 to be admitted under Hospice. An interview was conducted with the hospice nurse on 01/26/23 at 11:00 AM. The hospice nurse stated she comes once a week to evaluate Resident #9. The hospice nurse stated she communicates with the resident's nurse for any changes and updates. The hospice nurse provided documentation of such visits kept in a hospice binder at the facility's nursing station. The hospice nurse further stated Resident #9 received hospice CNA services 3 times a week. The hospice nurse stated the CNA does not leave any documentation at the facility, but does electronic charting through the hospice system. The hospice nurse stated the CNA used to make their own schedules, and just show up. Now the CNA has a set schedule, and was scheduled to visit Resident #9 on Monday, Tuesday, and Wednesday. The facility's Unit Manager (UM) overheard the above conversation and stated she did not see the hospice CNA yesterday (Wednesday). The UM presented a sign in sheet for hospice at the nursing station The sign in sheet last documented a visit from hospice on 01/07/23. When asked if there was any other place someone would have to sign in, the UM stated they would sign in at the front gate/garage prior to entering the facility. The surveyor requested documentation for hospice visits for Resident #9. An interview was conducted with Staff E, a CNA, on 01/26/23 at 11:30 AM. Staff E stated she did not know if Resident #9 was on hospice services. Staff E, CNA stated they alternate assignments, and she was a float (works where she is needed). An interview was conducted with Staff F, a CNA, on 01/26/23 at 11:35 AM. Staff F stated she works with Resident #9 frequently. The resident requires 2 persons assist. Staff F stated she usually gets assistance from restorative for care. Staff F stated she knows the resident receives hospice services, but the new CNA has not had any communication. Staff F stated they do not wait for the hospice CNA, because they don't know when they are coming. Staff F reported that hospice drops off supplies for Resident #9 on Fridays. An interview was conducted with the hospice CNA via telephone on 01/26/23 at 11:40 AM. The hospice CNA reported that she saw Resident #9 on a regular basis, and asks the CNA if they need any help. She last saw the resident on Monday and Tuesday (01/23/23 and 01/24/23). The hospice CNA stated she was not aware of a sign in sheet at the facility, as she just started working with the resident a little over a month ago. The CNA stated she spoke to the CNA on Monday, but does not remember the CNA's name. The hospice CNA stated she did not speak with anyone on Tuesday. The hospice CNA stated she did not come to the facility on Wednesday (01/25/23). She usually drops off supplies on Friday. A copy of the hospice CNA's notes was provided by the hospice nurse. The hospice CNA has notes dated 01/23/23, 01/24/23, and 01/25/23 that documented care provided by the hospice nurse for Resident #9. A review of the sign in document from the front gate/garage prior to entering the facility revealed the hospice nurse signed into the facility grounds on 01/23/23 and 01/24/23.