**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for 1 of 1 sampled resident reviewed for tube feeding, Resident #43. The findings included: Review of the facility's policy, titled, Tube Feeding and Medication Administration, with a revised date of 06/2018, included in part the following: Check for placement of the nasogastric, Dobhoff, gastric or PEG tube before every feeding or administration of medication to be sure it hasn't slipped out of the resident's stomach. Note: Never give tube feeding until proper positioning of the tube is determined. For a nasogastric, Dobhoff, gastric or PEG tube check the tube for patency and position: Aspirate and measure residual gastric contents. Return aspirant to stomach. Inject 5-10 milliliters of air through the tube while you auscultate with a stethoscope. Listen for a swooshing sound to confirm proper tube positioning. Record review for Resident #43 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Parkinsonism, Alzheimer's Disease, and Gastrostomy Status. The Minimum Data Set (MDS) assessment dated [DATE] documented in Section C a Brief Interview of Mental Status (BIMS) score of 0 indicating severe cognitive impairment. Review of the physician's orders for Resident #43 revealed in part the following: An order dated 06/07/24 for Enteral Feed Order every shift. Check tube placement before initiation of formula, medication administration, and flushing tube or at least every 8 hours. An order dated 06/13/24 for Enteral Feed Order one time a day related to Gastrostomy Status flush before and after connecting / disconnecting enteral feeding at 2:00 PM and 10:00 AM via peg tube 150n cc of water two times a day. An order dated 06/07/24 for Enteral Feed Order every night shift. Complete tube site care every day. An order dated 06/07/24 for Enteral Feed Order every hour for nutrition and prevent clogged tubing flush hourly with 30 cc for 20 hours while feed running 2pm to 10 am. An order dated 06/07/24 for Enteral Feed Order every shift Continuous Feed: Check residual every 4-6 hours, prior to irrigation and PRN (Confirm with physician regarding withholding feedings). An order dated 06/07/24 for Enteral Feed Order every shift Observe for signs of dehydration, nausea, vomiting, distention, diarrhea, reflux, constipation, and breath sounds every shift. An order dated 06/07/24 for Enteral Feed Order every shift Elevate height of bed 30 to 45 degrees at all times during feeding and for at least 30 minutes after stopped. An order dated 07/03/24 for Enteral Feed Order every shift for enteral nutrition Jevity 1.5 via peg tube at 70cc/hour x 20 hours off at 10:00 AM and on at 2:00 PM. An order dated 03/07/25 for Enhanced Barrier Precautions. Review of the care plans for Resident #43 dated 06/07/24 with a focus on the resident required tube feeding to provide nutrition and hydration due to dysphagia, revealed: 'The resident is at risk for weight loss and dehydration due to enteral tube status and was recently hospitalized s/p [status post] seizures and pneumonia. Other conditions that could impact the resident's nutritional status include diagnoses of Parkinson's Disease, Gout, Dementia, and Constipation. The goals were for the resident to have no significant weight change in the next 30 and 180 days, will have no s/s dehydration, will have no s/s of aspiration or choking and will have no N/V/C/D [nausea / vomiting / constipation / diarrhea] related to peg tube feeding by the next review date. The interventions included in part the following: Provide resident with enteral feeding as ordered by my Medical Doctor (MD). Provide flushes as ordered by my MD. Family has preference for Jevity products.' On 04/29/25 at 2:18 PM, an observation was made of Staff A, Licensed Practical Nurse (LPN), who entered the room of Resident #43 to connect tube feeding to the resident. Staff A connected the tube feeding to the resident's PEG tube and turned on the tube feeding without checking placement of the PEG tube or checking the PEG tube for patency. An interview was conducted on 04/29/25 at 2:25 PM with Staff A who was asked about checking for placement, patency and residual of the PEG tube prior to connecting the tube feeding, Staff A stated she checked all of that between 12:00 PM and 1:00 PM when she administered medications to the resident.

Based on observations, interviews, and record review, the facility failed to ensure all nursing staff professional standard of quality for 1 of 24 nurses employed by the facility observed during 1 of 4 medication administration observations, to ensure the correct process was followed. The findings included: Review of the facility's policy titled, Orientation for Professional Staff, dated 08/2021, included the following: To strive to assure that all nurses 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 wellbeing. Procedure: 1. The Orientation Checklist for Professional Staff is completed by the Director of Nursing (DON), who will provide orientation to the new employee. Review of the facility's policy, titled, Medication Administration & Management, dated 10/2019, included the following: To strive to ensure safe and efficient administration of medications to residents in [facility name]. Procedure: 3. Dose Preparation: All authorized community staff should adhere the following guidelines: f. Verify that the medication name and dose are correct. 4. Prior to Medication Administration: All authorized community staff should adhere to the following guidelines: a. Verify the correct drug, correct dose, correct rate, correct time and current resident prior to each medication administration. b. Confirm that the Medication Administration Record (MAR) reflects the most recent medication order. On 04/30/25 at 5:54 PM in the 200s unit hallway, the surveyor approached Staff D, Registered Nurse (RN), who was at a medication cart and actively crushing medications. She was asked if she had any other medication administration to do, she stated yes. Staff D poured the crushed medications into the medication cup and realized she did not have apple sauce on the medication cart. She stated she would get the apple sauce and then she stored the cup of crushed medications in the top drawer of the medication cart and locked the cart. She went down the hallway, around the corner where the nurses' station was located. An observation of the medication cart revealed only a pill crusher machine and a pitcher of water on top of the cart (no computer, notepad or cooler was observed). Staff D returned at 5:56 PM with a cooler (containing apple sauce and Boost supplement drinks) and a laptop computer. She sat them on top of the medication cart and attempted to log into the laptop but was not able to. She stated that she would be right back because she must log out of the other computer and at 5:57 PM left again, went down the hallway and around the corner where the nurses' station was located. She returned at 6:04 PM and was able to log into the laptop computer and began dispensing medications for a resident for the medication administration observation. An interview was conducted with Staff D following the medication administration observation who stated she has worked at the facility for a month. The surveyor inquired about the medications that she previously had crushed and stored in the top drawer of the medication cart. She stated that she would discard them because the resident is not in his room. Staff D was asked how she knew which medications to dispense if she did not have the laptop computer on the medication cart. She then stated that she is always scheduled to this hallway, she knows her residents well and she had pulled up the resident's MAR in the other computer (which was located by the nurses' station). Staff D was asked if this is per facility's standards, she stated that this laptop computer gives her problems, and she does not like using it. She also stated management is aware, but the laptop still does not work well. During the medication administration, the surveyor observed the laptop was able to display the MAR for the resident. On 04/30/25 at 6:50 PM, the surveyor discussed the medication administration observation conducted with Staff D with the Director of Nursing (DON). She was upset and stated that they have recently reviewed medication administration and Staff D is a new nurse. She stated there will be lots of education and training scheduled. On 05/01/25 at 1:25 PM, an interview was conducted with the Administrator. She stated Staff D recently became an RN. The NHA stated she was a Licensed Practical Nurse (LPN) prior. The Administrator stated the staff developer, who was also the Assisting Director of Nursing (ADON), was responsible for Staff D to complete the Orientation Checklist for Professional Staff. She acknowledged the ADON was terminated last Friday 04/25/25 due to inconsistency in her work. The Administrator was beside herself when she was told about the medication administration observation that was conducted with Staff D. She stated that it appeared that Staff D was not prepared to work, and it is not acceptable. A side-by-side review of Staff D's Orientation Checklist for Professional Staff was conducted with the Administrator. Review of the medication administration section of the checklist dated 04/12/25 revealed Staff D required education on preparing and organizing everything needed before starting Medication Administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and observation, the facility failed to maintain a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation, to determine that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled for 1 of 5 sampled residents reviewed for controlled medications, Resident #4. The findings included: Review of the facility's policy titled, Medication, Controlled Substances, with a revised date of 04/2024, included in part the following: To strive to ensure that strict management of controlled substances is maintained as evidence by special handling, storage , disposal and record keeping. When a resident receives a narcotic, the licensed nurse signs off each dose of the controlled medication given by documenting the following on the narcotic sheet and the electronic medication administration record [eMAR]. Record review for Resident #4 revealed a most recent readmission to the facility on [DATE] with diagnoses that included in part the following: Displaced Supracondylar Fracture Without Intracondylar Extension of Lower End of Right Femur Subsequent Encounter for Closed Fracture with Routine Healing, Fall on Same Level From Slipping Tripping and Stumbling Without Subsequent Striking Against Object Subsequent Encounter, Pain in Left Knee, and Periprosthetic Fracture Around Internal Prosthetic Left Knee Joint Subsequent Encounter. The Minimum Data Set, dated [DATE] documented in Section C a Brief Interview of Mental Status score of 14 indicating a cognitive response. Review of the physician's orders for Resident #4 revealed an order dated 02/24/25 for Tramadol HCl Oral Tablet 50 MG (Tramadol HCl) Give 1 tablet by mouth every 6 hours as needed for pain was discontinued 04/11/25. Review of the physician's orders for Resident #4 revealed an order dated 03/26/25 for Tramadol HCl Oral Tablet 50 MG (Tramadol HCl) Give 1 tablet by mouth every 8 hours as needed for moderate (pain). Review of Controlled Medication Utilization Record for Resident #4 for Tramadol 50mg tablet give 1 tablet by mouth every 8 hours as needed for pain documented in part the following: On 04/10/25 at 1:30 AM, 1 tablet was removed. On 04/25/25 at 7:00 AM, 1 tablet was removed. Review of the Medication Administration Record for Resident #4 for the month of April 2025 revealed no documentation of Tramadol having been administered on 04/10/25 at 1:30 AM or on 04/25/25 at 7:00 AM. An interview was conducted on 05/01/25 at 11:00 AM with Staff C, Registered Nurse (RN), who stated she has worked at the facility for 5 years. When asked about the process of removing and administering controlled medications, she stated they remove the medication, mark it on the Control Sheet, and sign it off on the MAR once it is given to the resident. An interview was conducted on 05/01/25 at 11:15 AM with Staff A, Licensed Practical Nurse (LPN), who stated she has worked at the facility for 3 years. When asked about the process for removing and administering controlled medications, she stated they remove the medication, mark it on the Control Sheet, and sign it off on the MAR once it is given to the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to monitor behaviors as per physician's orders for 2 of 5 sampled residents reviewed for unnecessary medications, Resident #7 and Resident #23. The findings included: Review of the facility's policy, titled, Psychotropic Medications, dated 03/2025, included the following: 3. The community supports the goal of determining the underlying cause of behavioral symptoms so that appropriate treatment of the environment, medical, and/or behavioral interventions, as well as psychotropic medications, (if clinically necessary), can be used to meet the needs of the individual resident. Procedure: 1. The physician or nurse practitioner, as allowed per state requirements, will document and substantiate reasons for use of the medication in the progress notes. The notes are to include: c. Identification of targeted symptoms/behaviors. 8. Documentation, in the care plan and nursing notes, should reflect the monitoring of the resident for the desired responses of medication use, in addition to the non-pharmacological interventions attempted. 9. Presence or absence of adverse behavior and side effects from medication use, if present, will be documented on the pharmacy provided behavior monitoring form, administration record, or in the progress notes. 1. Record review revealed Resident #7 was admitted to the facility on [DATE] with diagnoses to include Parkinson's Disease, Vascular Dementia and Major Depressive Disorder. Section C of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. The physician order summary report showed an order for Sertraline HCl (a psychotropic medication) at 50 milligrams, to give 1 tablet by mouth in the morning for Depression dated 12/20/24. Continued review of the order summary report revealed an order for behaviors: monitor the following: feeling sad, tearful, emptiness or hopelessness, angry outbursts, irritability or frustration, loss of interest or pleasure in most or normal activities such as hobbies, sports or reading, sleep disturbances, including insomnia or sleeping too much. Indicate with (Y) if signs/symptoms noted, then write progress note. Indicate with (N) if no signs/symptoms note every shift with a start date 04/01/25. In addition, if a behavior was observed, there was a physician's order to enter the following intervention codes: (1)=Redirect (2)=One on one (3)=Ambulate (4)=Activity (5)=Return to room (6)= Toileted (7)=Give food (8)=Give fluids (9)=Change position (10)=Encourage to rest (11)=Backrub (12)=Refer to nurse's notes (13)=Assess for pain. outcome codes: (+)=Improved (-)=Worsened (0)=Unchanged (N)=See progress notes, every shift start date 04/01/25. Record review of the April 2025 Medication Administration Record (MAR) revealed Resident #7 was monitored for behavior and interventions. However, on 04/02/25 during the day and night shift and on 04/28/25 night shift, it had documented behaviors were observed (marked in the MAR with a Y), but there were no intervention codes documented on those days or in nursing progress notes. Review of the nursing progress notes dated 04/02/25 documented: was a behavior observed? Yes, however, no other documentation for which of the behaviors was observed, or the intervention that was implemented. On 04/03/25, the nursing progress note documented a behavior observed (not documented in the MAR), however no additional documentation was found regarding which behavior was observed and what interventions were implemented. Further review of the progress notes, on 04/17/25 documented behavior was observed (not documented in the MAR), and no follow up documentation for interventions. 2. Record review revealed Resident #23 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease, Depression and Dementia. Section C of the MDS dated [DATE] revealed Resident #23 had a BIMS of 00, indicating severe cognitive impairment. The physiciian order summary report showed an order for Mirtazapine (a psychotropic medication) at 7.5 milligrams, to give 1 tablet by mouth at bedtime for Depression dated 07/17/24. Continued review of the order summary report revealed an order for behaviors: monitor the following: feeling sad, tearful, emptiness or hopelessness, angry outbursts, irritability or frustration, loss of interest or pleasure in most or normal activities such as hobbies, sports or reading, sleep disturbances, including insomnia or sleeping too much. Indicate with (Y) if signs/symptoms noted, then write progress note. Indicate with (N) if no signs/symptoms note every shift with a start date 04/01/25. Further review revealed if a behavior was observed to enter the following intervention codes: (1)=Redirect (2)=One on one (3)=Ambulate (4)=Activity (5)=Return to room (6)= Toileted (7)=Give food (8)=Give fluids (9)=Change position (10)=Encourage to rest (11)=Backrub (12)=Refer to nurse's notes (13)=Assess for pain. outcome codes: (+)=Improved (-)=Worsened (0)=Unchanged (N)=See progress notes, every shift start date 04/01/25. The care plan that was initiated on 08/06/24 showed Resident #23 demonstrated behavior(s) such as restlessness, agitation, trying to get up the wheelchair without assistance and not easily to be redirected. Some of the interventions were shown to monitor the behavior episodes and attempt to determine underlying causes; consider location, time of day, people involved, and situations; and document my behavior and potential causes. Record review of the April 2025 MAR revealed Resident #23 was monitored for behavior however, the documentation was check marks instead of Yes or No to indicate if signs/symptoms were noted as per the physician's orders. Further review revealed intervention codes were documented on 04/12, 04/13, 04/21, 04/26 and 04/27/25 during the day shift. Review of the nursing progress notes for those dates revealed no documentation on the resident's behavior or the interventions that were put in place. An interview was conducted on 04/30/25 at 10:59 AM with Staff A, Licensed Practical Nurse (LPN), who stated she has worked at the facility since January 2025. She stated residents on psychotropic medication are monitored for behaviors daily. She also stated that any change in behavior is documented in the progress notes and will include what happened, the interventions that were implemented, then the provider is contacted, and monitoring of the resident will continue. An interview was conducted on 04/30/25 at 11:11 AM with Staff C, Registered Nurse (RN), who stated she has worked at the facility for 4 years. She stated they used to document the behaviors on paper, however, now they document in the computer which include the behavior, interventions and the side effects of the psychotropic medications. Staff C stated the physician's orders provides instructions on what to document and use codes for the interventions and then add it to the progress notes. An interview was conducted on 04/30/25 at 3:00 PM with the Director Of Nursing (DON) who stated that the behaviors are monitored and documented in the progress notes. During the interview, a side-by-side review of Resident #7 and Resident #23's April MAR was conducted, the DON acknowledged that the documentation did not follow the physician's orders for monitoring of behaviors for both residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review, the facility failed to secure 1 of 3 medication carts, failed to secure 1 of 2 treatment carts, and failed to secure and properly dispose of medications (meds) during 1 of 4 medication administration observations. The findings included: Review of the facility's policy, titled, Storage and Expiration Dating of Medications and Biologicals, with a revised date of 08/01/24, included in part, the following: Facility should ensure medications and biologicals are stored in an orderly manner in cabinets, drawers, carts, refrigerators / freezers of sufficient size to prevent crowding. Facility should ensure all 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. Facility should ensure the medications and biologicals for each resident are stored in the containers in which they were originally received. Facility should ensure no transfers between containers are performed by non-pharmacy personnel. 1. Upon entrance to the facility on [DATE] at 8:40 AM, an observation was made of an unlocked and unsecured treatment cart (later identified as the Pineapple treatment cart) located next to the East Reception Desk. On 04/28/25 from 10:15 AM to 10:30 AM, an observation was made of the Pineapple treatment cart located next to the East Reception Desk, and it was unlocked and unattended. A side-by-side observation on 04/28/25 at 10:30 AM with Staff A, Licensed Practical Nurse (LPN), was conducted who acknowledged the Pineapple treatment cart next to the East Reception Desk was left unlocked an unattended. Inside the treatment cart were several (no less than 15) prescription medications (including ointments, creams and powders) for various residents. The nurse immediately locked the cart. An interview was conducted on 04/28/25 at 10:30 AM with Staff A who stated she has worked at the facility since January 2025. When asked if med carts and treatment carts are left unlocked when unattended, she said, 'no, everything is supposed to be locked at all times'. 2. During an observation conducted on 04/30/25 at 12:07 PM while doing an environmental tour of the facility with the Administrator and the Maintenance Tech, there was an unsecured and unattended med cart on the Oasis hallway. The Administrator immediately called for the nurse. An interview was conducted on 04/30/25 at 12:10 PM with Staff A, LPN, who stated she had accidentally left the med cart unlocked when she answered a call light and entered a resident's room. 3. A medication administration (Med Pass) observation was conducted on 04/30/25 at 6:05 PM with Staff D, Registered Nurse (RN), for Resident #23. Observation revealed Staff D poured the following medications: Magnesium Oxide 400 mg one tablet for Supplement Pravastatin Sodium 40 mg one tablet for Hyperlipidemia Polyethylene Glycol 3350 Powder to give 17 Grams for Bowel management PreserVision AREDS 2 (Multiple Vitamins w/ Minerals) 1 capsule for Supplement. During the observation, Staff D realized she had dispensed the medications and had not sanitized her hands throughout the Med Pass, however, she had no hand sanitizer bottle on top of her cart. She then walked away from the medication cart across the hallway (about 8 feet away with her back to the cart) to the wall sanitizer dispenser leaving the dispensed medications on top of the medication cart unattended. Staff D then returned to the cart and poured water into the cup with the Polyethylene powder, stirred it with a spoon, then threw the spoon in the garbage while touching the garbage lid. She again realized she needed to use the hand sanitizer and again walked across the hallway to the wall hand sanitizer dispenser, leaving the dispensed medications unattended on top of the cart. After the medication administration observation for Resident #23, Staff D was interviewed about leaving the medications unattended on top of the cart. She stated that she just went to use the hand sanitizer dispenser, and it did not take too long. She was asked about the medications that she had crushed (prior to starting the Med Pass for Resident #23) and are now stored in the top drawer of the medication cart. She stated that she would discard them because the resident was not in his room. Staff D opened the top drawer, removed the small cup with the crushed medications and discarded them in the garbage container attached to the medication cart. She was asked if that was per facility's policy to discard the medications in the garbage and she stated, I should have thrown them down the toilet. The surveyor asked Staff D to open the bottom drawer of the cart and pointed to a bottle, she picked up the bottle which was labeled Drug Disposal. Staff D acknowledged the medications are to be disposed of in the Drug Disposal bottle.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to perform hand hygiene during 1 of 4 medication (med) administration observations and failed to wear appropriate Personal Protective Equipment (PPE) during tube feeding connection for 1 of 1 sampled residents reviewed for tube feed (Resident #43). The findings included: Review of the facility's policy titled, Guidelines for Isolation Precautions with a revised date of 03/2023 included in part the following: Under section Enhanced Barrier Precautions (EBP) 1. EBP are used as an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs). 2. This precaution expands on the use of PPE and refers to the use of gown and gloves during high-contact resident care activities (unless otherwise indicated as part of Standard Precautions) that provide opportunities for transfer of MDROs to staff hands and clothing. 3. EBP will be applied (when Contact Precautions do not otherwise apply) to residents with any of the following: a. Wounds or indwelling medical devices, regardless of MDRO colonization status. 5. Implementation - High-contact resident care activities that require gown and glove use for EBP include: g. Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator. Review of the facility's policy, titled, Hand Washing and Hand Hygiene with a revised date of 03/2020, included in part, the following: To strive to prevent infections through adequate hand washing and hand hygiene techniques. If hands are not visibly soiled, an alcohol-based hand rub may be used for routinely decontaminating hands. Always decontaminate hands: After removing gloves. Other aspects of hand hygiene a) The use of gloves does not eliminate the need for hand hygiene. 1. Record review for Resident #43 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Parkinsonism, Alzheimer's Disease, and Gastrostomy Status. The Minimum Data Set (MDS) assessmnet dated 03/28/25 documented in Section C a Brief Interview of Mental Status score of 0 indicating severe cognitive impairment. Review of the physician's orders for Resident #43 revealed in part the following: An order dated 06/07/24 for Enteral Feed Order every shift Check tube placement before initiation of formula, medication administration, and flushing tube or at least every 8 hours. An order dated 06/13/24 for Enteral Feed Order one time a day related to Gastrostomy Status flush before and after connecting/ disconnecting enteral feeding at 2:00 PM and 10:00 AM via peg tube 150n cc of water two times a day. An order dated 06/07/24 for Enteral Feed Order every night shift. Complete tube site care every day. An order dated 06/07/24 for Enteral Feed Order every hour for nutrition and prevent clogged tubing flush hourly with 30 cc for 20 hours while feed running 2pm to 10 am An order dated 06/07/24 for Enteral Feed Order every shift Continuous Feed: Check residual every 4-6 hours, prior to irrigation and PRN (Confirm with physician regarding withholding feedings). An order dated 06/07/24 for Enteral Feed Order every shift Observe for signs of dehydration, nausea, vomiting, distention, diarrhea, reflux, constipation, and breath sounds every shift. An order dated 06/07/24 for An order dated 06/07/24 for Enteral Feed Order every shift Elevate height of bed 30 to 45 degrees at all times during feeding and for at least 30 minutes after stopped. An order dated 07/03/24 for Enteral Feed Order every shift for enteral nutrition Jevity 1.5 via peg tube at 70cc/hour x 20 hours off at 10:00 AM and on at 2:00 PM An order dated 03/07/25 for Enhanced Barrier Precautions. Review of the care plan for Resident #43 dated 06/07/24 with a focus on the resident required tube feeding to provide nutrition and hydration due to dysphagia. The resident is at risk for weight loss and dehydration due to enteral tube status and was recently hospitalized s/p seizures and pneumonia. Other conditions that could impact the resident's nutritional status include diagnoses of Parkinson's Disease, Gout, Dementia, and Constipation. The goals were for the resident to have no significant weight change in the next 30 and 180 days, will have no s/s dehydration, will have no s/s of aspiration or choking and will have no N/V/C/D (nausea/vomiting/constipation/diarrhea) related to peg tube feeding by the next review date. The interventions included in part the following: Provide resident with enteral feeding as ordered by my Medical Doctor (MD). Provide flushes as ordered by my MD. Family has preference for Jevity products. On 04/29/25 at 2:18 PM, an observation was made of Staff A, Licensed Practical Nurse (LPN), who entered the room of Resident #43 to connect tube feeding to the resident. Staff A did not wear a gown, but only wore gloves. Staff A connected the tube feeding to the resident's PEG tube and turned on the tube feeding. During an interview conducted on 04/29/25 at 2:25 PM with Staff A who was asked if Resident #43 was on Enhanced Barrier Precautions, she said yes because he has a PEG tube. When asked what Personal Protective Equipment needed to be worn, she said gown and gloves. When asked why she did not wear a gown when connecting the tube feeding, she said because she was only connecting the tube feeding. 2. During a medication administration (Med Pass) observation conducted on 04/30/25 at 6:05 PM with Staff D, Registered Nurse (RN), stated she has worked at the facility for a month. She dispensed the medications into a small medication cup and stated that the resident gets her medications crushed with apple sauce. Staff D then donned clean gloves, without performing hand hygiene, and poured the medication tablets into a pouch (except for a medication capsule) and crushed the medications and poured them into another cup. She threw away the pouch and removed the gloves, without performing hand hygiene, donned clean gloves and grabbed the medication capsule and stated that she squeezes the medication because the resident cannot swallow the capsule. After 15 seconds of squeezing the capsule, Staff D was able to pop the capsule and liquid got on her gloves and some in the medication cup. She then removed her gloves and discarded them and the shell of the capsule in the garbage. Without performing hand hygiene, she continued to prepare the medications. An interview was conducted with Staff D following the medication administration observation. She stated she realized she should perform hand hygiene more often during the Med Pass observation. During an interview conducted on 04/30/25 at 6:50 PM with the Director of Nursing (DON), the surveyor discussed the medication administration observation. She was upset and stated that they have recently reviewed medication administration and hand washing. The DON acknowledged that there will be lots of education and training scheduled.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure bathrooms are adequately equipped to allow residents / staff / visitors to call for staff assistance through a communication system for 4 of 73 bathrooms in the facility. The findings included: Review of the facility's policy titled, Call Light, Responding with a revised date of 10/2022, included in part the following: The call bell system will be checked routinely by maintenance for proper functioning. On 04/28/25 at 10:36 AM, an observation was made of the emergency pull cord wrapped around grab bar in bathroom next to Oasis Kitchen and was unable to be activated by pulling on the cord. On 04/28/25 at 10:55 AM, an observation was made of the emergency pull cord wrapped around grab bar in bathroom in room [ROOM NUMBER] and was unable to be activated by pulling on the cord. On 04/28/25 at 10:59 AM, an observation was made of the emergency pull cord wrapped around grab bar in bathroom in room [ROOM NUMBER] and was unable to be activated by pulling on the cord. On 04/28/25 at 11:02 AM, an observation was made of the emergency pull cord wrapped around grab bar in bathroom next to Social Worker office and was unable to be activated by pulling on the cord. On 04/29/25 at 8:45 AM, a second observation was made of the emergency pull cord wrapped around grab bar in bathroom next to Social Worker office and was unable to be activated by pulling on the cord. On 04/29/25 at 10:30 AM, a second observation was made of the emergency pull cord wrapped around grab bar in bathroom next to Oasis Kitchen and was unable to be activated by pulling on the cord. On 04/30/25 at 9:10 AM, a second observation was made of the emergency pull cord wrapped around grab bar in bathroom in room [ROOM NUMBER] and was unable to be activated by pulling on the cord. On 04/30/25 at 9:40 AM a second observation was made of the emergency pull cord wrapped around grab bar in bathroom in room [ROOM NUMBER] and was unable to be activated by pulling on the cord. On 04/30/25 at 9:42 AM, a third observation was made of the emergency pull cord wrapped around grab bar in bathroom next to Oasis Kitchen and was unable to be activated by pulling on the cord. During a tour of the facility conducted on 04/30/25 at 12:00 PM with the Maintenance Tech and the Administrator, they acknowledged the emergency pull cords were wrapped around the grab bare in the bathroom next to the Oasis Kitchen and in rooms [ROOM NUMBERS]. The bathroom next to the Social Worker office was locked and we were unable to enter at time of this tour. An interview was conducted on 04/30/25 at 12:20 PM with Maintenance Tech who stated they will make sure they do rounds to consistently look for the emergency pull cords to ensure they are no emergency pull cords wrapped around the grab bars.

Based on observations, interviews, and policy review, the facility failed to follow standards of professional practice for food safety, as evidenced by raw chicken and Mighty Shakes were stored in the refrigerator past the recommended time frames for food safety. This had the potential to affect 42 of 44 residents on oral diets. The findings included: Review of the facility's policy included a Food Storage Chart by HACCP, last revised in October 2014. It said that raw meat can be stored in the refrigerator for 4 days (including the day of delivery). Review of the United States Food and Drug Administration's (USFDA) Refrigerator and Freezer Storage chart dated March 2018, stated that uncooked chicken can be stored in the refrigerator for 1-2 days. According to the USFDA, these short but safe time limits will help keep refrigerated food, 40' F, from spoiling or becoming dangerous. The chart also stated that product dates were not a guide for the safe use of a product. Photographic Evidence Obtained. Review of the product guide for Mighty shakes revealed that after Mighty shakes were thawed, the shelf life was 14 days when refrigerated. Photographic Evidence Obtained. During the initial observation of the kitchen on 04/28/25, at 9:00 AM, the surveyor was accompanied by the Director of Culinary Services (DCS) & Staff B. The following observations and interviews were occurred: a. A forty-pound box of boneless, skinless, chicken breast was observed in the walk-in refrigerator (Refrigerator #1). The lid of the box had a small white rectangular sticker with the date 04/22/25 on it. When the DCS was asked what the date on the sticker meant, she said the date April 22 was the date that the chicken was received at this facility. When the DCS was asked when the chicken was pulled out of the freezer, she said it was not put in the freezer after it arrived. She explained that after delivery, it was placed directly into the refrigerator. When the DCS was asked how long raw chicken was safe to use when stored in the refrigerator, the DCS said it was good to use for about one week. The DCS said the chicken had Cryovac packaging, (a low oxygen form of wrapping, that extends the shelf life of food). There was a large white rectangular sticker on the lower half of the box of raw chicken that came from the vendor / food distributor. It had the packed date, 04/16/25, printed in a large font. The packed date represented the date that the chicken was packed into the plastic bag before it was boxed for shipping from the distributor. There was no use by date on the box of raw chicken. On the date of the initial survey, the box of raw chicken breasts was stored in the refrigerator for 6 days. Photographic Evidence Obtained. b. In refrigerator #1, a box of Mighty shakes, dated 04/14/24, was observed on the shelf. The directions Keep Frozen were printed on the top edge of each 4-ounce carton. When asked what the date 04/14/24 represented, the DCS said that's the date we received the item from the vendor. When asked when this item was pulled out from the freezer, Staff B said it was pulled out about 1 month ago. There was no use by date on the box of Mighty shakes. The surveyor informed the DCS and Staff B that Mighty shakes were safe to use for 14 days after they were removed from the freezer. The DCS said she was unaware of this and agreed to follow-up with the vendor of the Mighty Shakes for information related to the storage of the shakes in the refrigerator. During an interview with the DCS on 04/28/25 at 3:08 PM, the DCS said she received a printout from the distributor that said that the chicken had a shelf life of 16 days. The surveyor took a photo of the email printout that showed 16 in the box next to the word shelf, there was no mention of refrigeration or freezing on the printout. In addition, the DCS said she called the vendor of the Mighty Shakes. She said that the facility's sales representative confirmed that the Mighty shakes must be used within 14 days after they were removed from the freezer. During a follow-up tour of the main kitchen on 04/30/25 at 11:20 AM, the DCS and the surveyor entered Refrigerator #1 to revisit the boxes of uncooked chicken breasts. The DCS commented, we now have use by days written on these boxes. She showed the surveyor the use by label was dated 05/01/25 to indicate the raw chicken was to be used within 16 days of the packed date. On 04/30/25, the raw chicken was in the facility's refrigerator for 9 days. The surveyor observed that the plastic wrap was a loose plastic bag around the chicken. The surveyor reminded the DCS that on 04/28/25 the DCS said the chicken had Cryovac packaging. The surveyor pointed to items in the refrigerator that appeared to be wrapped with a Cryovac (low oxygen) method. The wrap for some meat in the refrigerator appeared to have a tight plastic covering that was sealed with a low oxygen packaging method. The surveyor clarified with the DCS that the box of boneless, skinless, chicken breasts was not packaged with a low oxygen process. The DCS acknowledged this. The packaging specifications were provided to the surveyor. There was no indication that low oxygen packaging was used. The surveyor informed the DCS that the USFDA's Refrigerator and Freezer storage chart for food safety recommended raw chicken in the refrigerator for 1-2 days. The DCS said she just followed recommendations from the distributor based on that individual product.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and records review, the facility failed to ensure that 1 of 12 sampled residents, Resident #5, was treated with dignity during food service, as evidenced by serving meals to the resident in an environment with a pervasive obnoxious odor in the room; and failed to follow its policy related to food service for the residents. The findings included: Review of the policies and procedures, for Meal Serving, dated 9/2000 and revised on 3/2016; 7/2016; 5/2028, and 9/2022, outlined that staff will: 1. Assist residents to the bathroom before mealtime, as needed 2. Assist the resident with handwashing or sanitation prior to the meal. 3. Accompany residents to the dining room, if a resident is in a wheelchair, transfer the resident out of the wheelchair and into a dining room chair. Resident # 5 was admitted to the facility on [DATE], with admitting diagnoses that included: Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, And Anxiety; Major Depressive Disorder, Recurrent, Mild; Senile Degeneration of Brain, Not Elsewhere Classified; Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, And Anxiety. Other Specified Problems Related to Psychosocial Circumstances, Generalized Anxiety Disorder. Review of the Minimum Data Set (MDS) assessemtn and the Brief Interview for Mental Status (BIMS) dated 11/22/23 showed a score of 2 of 15, indicating the resident had severe cognitive deficits. Section GG of the MDS documented the resident required: Partial to moderate assistance for toileting, for showers, substantial to maximal assistance; for eating, set up is required. Personal Hygiene, partial to Maximal assistance required. The resident ambulated independently and transferred independently. Review of the Care Plan outlined the following: At times, (Resident #5) may resist care such as taking showers. She prefers to bathe herself despite staff's offers to assist. Review of the nursing progress notes dated 11/21/23 documented that Resident #5: remains alert, and oriented with cognitive decline. Her long and short-term memory is impaired. She usually makes herself understood and sometimes understands others. She repeatedly asks the same questions over and over. She is fixated on when her meal will arrive. She is followed by MD/psychiatrist for medication management. She continues to frequently refuse showers. Placement remains appropriate for long term due to need for 24 hrs. care/supervision. [Staff] Will visit for socialization, reality orientation, redirection, encouragement and emotional support as needed. Review of an Activity progress note dated 11/18/23 documented: Resident #5 is alert with confusion and forgetfulness. She is very hard of hearing; staff are encouraged to speak in her right ear. She has adequate vision with her glasses. She prefers to stay in her room and will only come out to see when her meals are coming to her room. She is on one-to-one visits 2-3 times a week for sensory and mental stimulation. On 01/22/24 at 10:57 AM, it was observed that Resident #5 had her food tray placed across her bed right in front of the resident. Resident #5 was lying in a semi-erect position in her bed, and the room had an overwhelming and unsanitary ammonia-like odor. Resident # 5 could not be interviewed due to apparent cognitive deficits. On 01/22/24 at 12:46 PM, during lunch the same abhorrent odor described above was still present, and lunch was served. An interview with Employee A, Certified Nursing Assistant (CNA), on 01/22/24 at 12:48 PM, revealed the resident's room was not free of unpleasant odor, before she served lunch to Resident #5. On 01/23/24 at 10:33 AM, Resident #5 was observed in bed sleeping. The breakfast tray was on the bedside table which was placed transversal to the bed. The room odor was not as it was the day before but was noticeably 'masked'. The procedures in place were to ensure residents eat in a sanitary manner. The environment where Resident #5's meals were served dining meals had an unpleasant and nauseating ammonia-like odor. On 01/25/24 at 9:44 AM, Resident #5 was observed in her room in bed. There was no food tray on her bedside table. The urine-like odor in the room was nauseating. The surveyor could not stay to speak with the resident due to the overwhelming odor of urine. An interview was conducted with Employee B, CNA on 01/25/24 at 9:56 AM, who stated she started her shift at 7:00 AM. Employee B said she has been working at this facility for a long time. Employee B stated that Resident #5 always complains about being hungry, so they make sure to serve her first. She stated even when Resident #5 finishes eating, Resident #5 always complains to have her food tray. Staff B continued to state Resident #5 is hard of hearing, has mental illness, and even though Resident #5 refuses care, she knows, as a CNA, that it is not her acting, but it is the illness. Staff B stated they try to redirect the resident and postpone care for later. A follow-up interview was conducted with CNA, Employe A, on 01/25/24 at 10:05 AM, who revealed she had seven residents assigned to her to care for among whom was Resident #5. Employee A said that she provided early care to Resident #5 on that day before 7:00 AM, she had removed the dirty linens in the room, made the bed, washed the resident and had put new garments on her. At this time, they entered Resident #5's bedroom, and Employee A was asked to give her impression about the odor in the room. Employee A said that the room always smells bad. Employee A said that it was the carpet that smelled so bad, the carpet is dirty, and soiled with urine and feces. On 01/25/24 at 10:29 AM, an interview was conducted with the Minimum Data Set (MDS) Coordinator who clarified that Resident #5 exhibited abnormal behavior which consisted in Resident #5 urinating and defecating on the floor. She stated they had addressed that concern in Resident #5's care plan. The coordinator also confirmed that when they clean the room, it is okay for a few days then the odor comes back. On 01/25/24 at 10:29 AM, the Director of Environmental Services stated they cleaned the room yesterday or on 01/24/24, because they noticed that it smelled bad. She said that the odor dissipated after the room was cleaned, and they usually clean up the rooms as necessary. She said, they have a monthly cleaning schedule for deep cleaning. She said that this week was the only time she became aware of a reoccurring odor in the room. The Director of Environmental Services said that she was not aware that Resident #5 had exhibited any abnormal toileting behaviors. The Environmental Service Director said that she has been working at this facility for nearly five years. On 01/25/24 at 10:44 AM, the Director of Nursing (DON) stated she has been working at this facility for 4 months. She said that she attends the care plan meetings, and Resident #5 stays in her room most of the time, ambulates with her walker; and is hard of hearing. The DON said that she did not know that Resident #5 had toileting-related behaviors. She said that before they do anything for the Resident, they must tell her what they are going to do for her before doing it, so she can comply. The DON said that Resident #5 has a regular CNA who is very familiar with her. The DON said that there was once a concern with odor in Resident #5's room. She notified housekeeping and they immediately took care of that, it has been three months. The DON further stated there was a plan to change the carpets in the rooms. She learned from the CNA that the resident tends to refuse care. She said they have an Advanced Psychiatric Nurse Practitioner (ARNP) who has been providing mental care to the resident. The DON said that she was informed this week that the room smelled bad. She saw housekeeping cleaning up the room. The DON stated Resident #5 tends to urinate on the bathroom floor due to incontinence. She said that there is a plan in place to remove the carpet in her room. An interview was conducted with the Administrator and the Executive Director of the facility on 01/25/24 at 11:12 AM. The Administrator acknowledged Resident #5 has toileting behaviors. She said that they have been discussing removing the carpets in the rooms in the area where Resident #5 resides. The Administrator stated she did not recall when the meeting was held, but a Company came and took measurements and has started replacing the carpets in some rooms. She said that they had a meeting to discuss Resident #5's behavior on 01/08/23, the Psychiatric nurse came in and saw the Resident on 01/11/24. The Administrator said the resident's behaviors entailed defecating and urinating on the floor, and that this behavior is not new. On 01/25/24 at 11:25 AM, the Executive Director provided their plan to replace the carpets that has been ongoing for nearly two years. She said that they have been meeting with the flooring company since April 2023, have recently started replacing the carpets in the hallways, will be changing the carpets in the rooms next and that Resident #5's room would be among the first ones.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews, the facility failed to follow the physician orders for 1 of 5 sampled residents reviewed for Unnecessary Medications, as evidenced by not holding a medication when the resident's systolic blood pressure was below 120 as per physician order, Resident #15. The findings included: Review of the facility's policy, titled, Medication Administration and Management, with no revision date, documented, .to ensure safe and efficient administration of medications to residents .verify the correct drug, correct dose . Review of Resident #15's clinical record documented an admission on [DATE] and no readmissions, with diagnoses that included: Essential Hypertension, Cerebrovascular Disease, Hypertensive Heart, Stage 4 Chronic Kidney Disease, Type 2 Diabetes Mellitus, and Vascular Dementia with Behavioral Disturbance. Review of Resident #15's Minimum Data Set (MDS) significant change assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 0, indicating the resident had severe cognition impairment. Resident #15's care plan, titled, I have an altered cardiovascular status related to hyperlipidemia, hypertension, initiated on 09/02/19, was reviewed. Review of Resident #15's physician order dated 09/02/22 documented, Carvedilol Tablet 12.5 mg (milligrams), give 1 tablet by mouth two times a day for Hypertension related to ESSENTIAL (PRIMARY) HYPERTENSION. Hold for systolic BP (blood pressure) less than 120. Review of Resident #15's November 2023 Medication Administration Record (MAR) documented Carvedilol Tablet 12.5 mg give 1 tablet by mouth two times a day for Hypertension, Hold for systolic BP less than 120. Further review revealed Resident #15's had a systolic blood pressure less than 120 and Carvedilol tablet was not held, as per physician order on the following dates: 11/16/23 morning (112/68). 11/21/23 morning (118/68). 11/24/23 evening (112/60). 11/25/23 evening (110/70). 11/28/23 evening (118/70). Review of Resident #15's December 2023 MAR documented, Carvedilol Tablet 12.5 mg, give 1 tablet by mouth two times a day for Hypertension, Hold for systolic BP less than 120. Further review revealed that Resident #15's had a systolic blood pressure less than 120 and Carvedilol tablet was not held, as per physician order on the following dates: 12/12/23 evening (118/60). 12/14/23 morning (105/57). 12/14/23 evening (119/65). 12/16/23 morning (115/65). 12/16/23 evening (118/77). 12/22/23 evening (114/66). 12/29/23 evening (119/64). 12/31/23 evening (118/68). Review of Resident #15's January 2024 MAR documented, Carvedilol Tablet 12.5 mg, give 1 tablet by mouth two times a day for Hypertension, Hold for systolic BP less than 120. Further review revealed that Resident #15's had a systolic blood pressure less than 120 and Carvedilol tablet was not held as per physician order on the following dates: 01/01/24 morning (114/69). 01/02/24 evening (118/72). 01/12/24 evening (114/62). 01/20/24 evening (118/70). On 01/22/24 at 10:20 AM, observation revealed Resident #15 sitting in a wheelchair and attempting to wheel himself out of his room. An attempt was made to interview the resident and he stated, get out of here. On 01/24/24 at 11:36 AM, an interview was conducted and a side-by-side review of Resident #15's January 2024 MAR with Staff G, Registered Nurse (RN). Staff G was asked what a checkmark written on the resident's MAR meant. Staff G stated they get a green check on the e-MAR when a medication was administered. On 01/24/24 at 11:47 AM, an interview was conducted with Staff D, Licensed Practical Nurse (LPN), who stated that if a resident's medication had blood pressure parameters, and the blood pressure was less than what the parameters stated, she would document code #5 meaning the medication was held due to blood pressure less than what the physician orders said. On 01/25/24 at 2:40 PM, a side-by-side review of Resident #15's November 2023 and January 2024 MAR for Carvedilol medication administration documentation, with the Nursing Supervisor, who confirmed Resident #15 received the medication when the nurses were supposed to hold it as per physician order. A joint interview was conducted with the Director of Nursing (DON) and the Nursing Supervisor, who both stated that a check mark written on the residents' MAR indicated the medication was administered. The findings were discussed with the DON and the nursing supervisor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews, the facility failed to ensure facility staff followed proper indwelling (Foley) catheter and pericare techniques consistent with accepted standards of practice and failed to follow the facility's Catheter Care and Perineal Care policy as observed during Foley/peri-care provided to 1 of 1 sampled resident reviewed for urinary catheter care review, Resident #10. The findings included: Review of the facility's policy, titled, Catheter Care, Indwelling, with no revision date documented, .attach the catheter to the resident's inner thigh using a leg strap .prevent the catheter .drainage bag from touching the floor .check the resident frequently .if the resident has a leg urine collection bag .when re-attaching the leg bag do the following: wrap the elastic leg straps around the resident's calf .when opening the drainage tubing junction, both ends must be kept sterile and both ends are to be cleaned with isopropyl alcohol before they are reconnected . Review of the facility's policy, titled, Perineal Care, with no revision date documented, .hold the shaft of the penis with one hand and wash with the other, beginning at the tip and working in circular motion from the center to the periphery .use a clean section of the washcloth for each stroke by folding each used section of the wash cloth inward. A separate washcloth may be used for each stroke . Review of Resident #10's clinical record documented an admission on [DATE] and no readmissions, and with diagnoses that included Hydronephrosis with Renal and Ureteral Calculous Obstruction, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Hydroureter, Malignant Neoplasm of Overlapping Sites Of Rectum, Anus and Anal Canal. Review of Resident #10's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 13, indicating that the resident had little to no cognition impairment. The MDS revealed the resident was dependent on the staff for his care. Resident #10's care plan, titled, I have an Indwelling Catheter due to bilateral Hydronephrosis, BPH (Benign Prostatic Hyperplasia) with urinary retention, slowing of urinary system, initiated on 07/16/22 and revised on 01/02/24, was reviewed. Review of Resident #10's Physician orders dated 07/16/22, documented, Catheter Care every shift. Review of Resident #10's Physician orders dated 11/04/23, documented, Foley Catheter reason / Diagnosis-Neurogenic Bladder. On 01/24/24 at 8:47 AM, observation revealed Resident #10 sitting up in a recliner. An interview was conducted with the resident who stated that he had the indwelling / Foley catheter for three (3) years. The resident stated the catheter was necessary and he did care for it himself. Further observation revealed the resident's Foley drainage bag to his right with cloudy yellow urine, the bag was touching the floor, and it did not have a privacy pouch. The resident lifted his gown, and the catheter was noted loose, and was not anchored to his right thigh, as per the facility's policy. The bag was placed facing the resident's room door. The resident gave a verbal consent for surveyor observation of his Foley care. On 01/24/24 at 8:57 AM, an interview was conducted with Staff D, Licensed Practical Nurse (LPN), who stated the Certified Nursing Assistants (CNA) do the catheter care for Resident #10. On 01/25/24 at 8:38 AM, observation revealed Resident #10 sitting in a recliner chair. The resident Foley drainage bag was resting on the floor, and it did not have a privacy pouch. On 01/25/24 at 8:45 AM, an interview was conducted with Staff E, CNA, who stated that Resident #10 was assigned to her an she was the regular CNA assigned to him. Staff E stated that she always does his Foley care. On 01/25/24 at 9:58 AM, observation of pericare / Foley care for Resident #10 performed by Staff E, CNA and assisted by Staff F, CNA started. Staff E proceeded to remove the resident's pull-up. Observation revealed the catheter was not anchored to his thigh. Staff E placed the drainage bag on top of the bed, donned gown, and gloves. Observation revealed a table with the following items: disposable wash cloths, a bottle of body wash and a bottle of perineal cleanser, a bottle of hand sanitizer and a leg bag. No alcohol pads were noted on the table. During the observation, Staff E stated that she put the leg bag on during the day. Observation revealed Staff E pulled the resident's penis foreskin and a moderate amount of a white matter was noted. Staff E stated that the white matter was the barrier cream they applied to the skin. Staff E wiped the resident's meatus area and above the foreskin multiple times with the same wipe creating a potential for cross contamination. Staff E then proceeded to wipe the Foley tubing with a wipe from the top to the bottom and then from bottom to top with the same wipe. Observation revealed Staff E was not turning the wipe for each stroke, as per the facility's policy. Staff E then cleaned Resident #10's left buttock from the hip down to the rectal area and then up using the same wipe multiple times without turning the wipe with each stroke. Observation revealed Staff E retrieved a new leg bag, removed the bag tubing cap and rested the bag tubing on top of the resident's sheet. Staff E then detached the Foley catheter from the drainage bag and cleaned the catheter opening with a paper towel soaked with soap and water multiple times without turning the sheet of paper. The catheter opening and the leg bag tubing were exposed to the air for approximately 28 seconds. Staff E did not provide Resident #10's peri /Foley care properly and did not anchor the resident's Foley catheter as per facility's policy. On 01/25/24 10:58 AM, a joint interview was conducted with Staff E, CNA and Staff F, CNA. Staff E was apprised that she used the same wipe to clean the meatus, the top of the foreskin and under the foreskin multiple times and back and forth. Staff F stated that she was supposed to use one wipe, clean and throw it away. Staff E was apprised that she cleaned the catheter tubing using one wipe from top to bottom twice without turning the wipe. Staff E stated that the resident's drainage bag should have had a privacy pouch and added she did not know why he did not have one. Staff E was asked regarding the resident's catheter to anchored to his thigh and stated the resident goes to the bathroom by himself. Staff E acknowledged Resident #10's Foley catheter was not anchored and it was supposed to be. On 01/25/24 at 3:01 PM, during a joint interview, the Director of Nursing (DON) and the nursing supervisor were apprised of the observation findings. The supervisor stated the CNAs were to clean the resident's buttock from the bottom upward.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of policy and procedure, observation and interview, the facility failed to ensure it secured and floor stock medications and prescription cream wound care treatment medications for four (4) of 4 sampled residents reviewed, Resident #6, Resident #204, Resident #19, and Resident #14, on 1 of 3 Wound Care Carts, [NAME] wing Bayshore unit. The findings included: Review of the facility policy and procedure on 01/25/24 at 3:19 PM, titled, Medication .Management, provided by the Administrator, revised 10/19, documented in the Policy Statement: To strive to ensure safe and efficient administration of medications to residents 6.medications for selected residents will be secured within the locked drawer . 1. On 01/22/24 at 10:22 AM, during an observational room tour, it was noted there was an un-attended, unlocked, unsecured and easily accessible Wound care Treatment cart for the [NAME] wing Bayshore Drive Hallway. The wound care cart contained prescription tubed, cream, topical medications for four (4) residents, along with floor stock medications for one (1) of three (3) Wound care carts, that included the following: a. Resident #6 - Voltaren cream, Betamethasone cream, Ketoconazole cream, [NAME] cream. b. Resident #204 - Acetate cream-Hydrocortisone. c. Resident #19 - Santyl cream. d. Resident #14 - Clobetasol solution. e. Wound care items not secured included: Triad cream stock medication tube, A & D ointment packets x 8, betadine iodine packets and skin prep wipes and wound care supplies. Photographic Evidence Obtained. An interview was conducted on 01/22/24 at 10:23 AM with the Director of Nursing, regarding the unlocked Wound Care Treatment located on the [NAME] wing Bayshore Hallway and she stated that, she had forgotten to check this one (1). She acknowledged the Wound Care Treatment Cart with residents' prescription cream medications must be kept locked and secured at all times. This was not done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of policy and procedure, observation, interview and record review, the facility failed to ensure that it followed regular, routine Safety/Service Maintenance Checks for 3 of 6 sampled residents observed for 'active' routine and 'as needed' Nebulizer Treatment Therapy, Resident #23, Resident #18 and Resident #48. The findings included: Review of the facility policy and procedure on 01/25/23 at 1:53 PM, titled, Use and Care of Equipment, provided by the Administrator, revised 11/20, documented in the Policy Statement: To strive to provide .resident equipment .per Guidelines 1. Resident #23 was re-admitted to the facility on [DATE] with diagnoses that included Atrial Fibrillation, Obstructive Sleep Apnea, Pleural Effusion, Lobar Pneumonia, Chronic Obstructive Pulmonary Disease (COPD) and Unspecified Dementia. The documented Brief Interview Mental Status (BIMS) score was 8, idicating the residentwas moderately impaired. During an initial observational tour conducted on 01/22/24 at 10:41 AM, Resident #23's room was observed to have a Therapy Equipment Tech Services/Lincare Services Nebulizer machine with an outdated (almost two (2) years past due) Safety / Calibration Service Check date. The last service date was February 27th 2021, and a due date of February 2022. Photographic Evidence Obtained. On 01/23/24 at 10:04 AM, Resident #23's room was still observed to have a Nebulizer machine with an outdated (almost two (2) years past due) Safety / Calibration Service Check date of February 27th 2021, and a due date of February 2022. On 01/23/24 at 1:44 PM, Resident #23's room was observed again to have the same Nebulizer machine with an outdated (almost two (2) years past due) Safety / Calibration Service Check date of February 27th 2021, and a due February of 2022. On 01/24/24 at 11:52 AM, Resident #23's room was again observed to have the Nebulizer machine with an outdated (almost two (2) years past due) Safety / Calibration Service Check date of February 27th 2021, and a due date of February 2022. On 12/17/23, the initial physician's order for Resident #23 indicated an order for Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083% 3 milliliter inhale orally via nebulizer two (2) times a day for COPD/SOB (Shortness of Breath). Record review of the Medication Administration Record (MAR) for Resident #23 for December 2023 and January 2024 revealed that Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083% 3 milliliter inhale orally via nebulizer two times a day for Chronic Obstructive Pulmonary Disease / SOB related to COPD, with a start date of 10/26/23; and initialed and signed off as being administered to the resident by licensed nursing staff. Further record review of the Respiratory Care Plan for Resident #23, initiated 09/25/17, showed the Problem List: Resident has potential for altered respiratory status/difficulty breathing related to Congestive Heart Failure, SOB, Anxiety, Allergic Rhinitis, COPD; Interventions: Administer medications / inhalers as ordered. Monitor for effectiveness and side effects; and Goals: Resident will have no complications related to SOB through review date. 2. Resident #18 was readmitted to the facility on [DATE] with diagnoses that included Pneumonia, Diastolic Congestive Heart Failure (CHF), Pleural Effusion, Cough, Shortness of Breath and Atrial Flutter. The record documented a BIMS score of 8, indicating moderate cognitive impairment. During a observational tour conducted on 01/22/24 at 11:06 AM, Resident #18's room was observed to have a Therapy Equipment Technician Services Nebulizer machine with an outdated (almost two (2) years past due) Safety / Calibration Service Check date of February 27th 2021 and a due date of February 2022. Photographic Evidence Obtained. On 01/23/24 at 10:17 AM, Resident #18's room was still observed to have the Nebulizer machine with an outdated (almost two (2) years past due) service date of February 27th 2021 and a due date of February 2022. On 01/23/24 at 1:44 PM, Resident #18's room was still observed to have a Nebulizer machine with an outdated/almost two (2) years past due service date of February 27th 2021 and a due date of February 2022. On 01/24/24 at 11:56 AM Resident #18's room was observed again to have a Nebulizer machine with an outdated (almost two (2) years past due) service date of February 27th 2021 and a due date of February 2022. On 12/05/23, the initial physician's order for Resident #18's dcocumented an order for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 3 milliliter inhale orally via nebulizer two times a day for Shortness of Breath (SOB)) Wheezing related to COPD. Record review of the Medication Administration Record (MAR) for Resident #18's for December 2023 and January 2024 revealed that Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083% 3 milliliter inhale orally via nebulizer two times a day for Cough, had a start date of 12/08/23; and it was initialed and signed off as being administered to the resident by licensed nursing staff. Further record review of the Respiratory Care Plan dated initiated 10/27/23 for Resident #18's showed the Problem List: Resident is at risk for altered respiratory status/difficulty breathing related to history of Pneumonia, Cough, Pleural Effusion, Wheezing and SOB; Interventions: Administer medications / inhalers as ordered .give breathing treatment as ordered; and Goals: Resident will have no complications related to SOB through review date. On 01/24/24 at 12:38 PM, an interview was conducted with Staff C, Registered Nurse (RN), who acknowledged Resident #23 was currently receiving Nebulizer treatments of Albuterol Sulfate Nebulization Solution inhaled orally via nebulizer two (2) times a day for COPD and SOB, and verified the order. During the interview, the nurse acknowledged and read aloud the following label attached to the outside of the Nebulizer machine as: Service date of February 27th 2021 and due date February 2022, 2 years outdated. Staff C stated the Nebulizer treatments are given on either the 11PM-7AM shift or on the 3PM-11PM shifts by other nurses. Staff C was asked 'Who do you report the outdated inspection date for the nebulizer equipment to, in order to ensure that the resident's Nebulizer equipment is currently operating properly', and replied she would remove the machine and try to get a replacement. She then stated she would report this to either the Maintenance Director or to the Director Of Nursing (DON). She acknowledged that this had not previously been done by her. 3. Resident #48 was re-admitted to the facility on [DATE] with diagnoses that included Cerebral Atherosclerosis, Wheezing, Encephalopathy, Atrial Fibrillation, Hypoxemia, Pleural Effusion and Dementia. The record documented a BIMS score of 00, indicating severe cognitive impairment. During an observation conducted on 01/23/24 at 1:44 PM, Resident #48's room was observed to have a 'Therapy Equipment Tech. Services / Pioneer' Nebulizer machine with an outdated (almost two (2) years past due) Safety / Calibration Service Check date of February 27th 2021, and a due date of February 2022. Photographic Evidence Obtained. On 01/24/24 at 11:29 AM, Resident #48's room was still observed to have a Nebulizer machine with an outdated (almost two (2) years past due) Safety / Calibration Service Check date of February 27th 2021, and a due date of February 2022. On 12/11/23, the initial physician's order for Resident #48 documented an order for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) three (3) ml inhale orally in the morning for SOB related to Hypoxemia. Record review of the MAR for Resident #48 for December 2023 and January 2024 revealed that Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083% three (3) milliliter inhale orally via nebulizer two (2) times a day for COPD/SOB, with a start date of 12/12/23; and was initialed and signed off as being given to Resident #48 by licensed nursing staff. Further record review of the Respiratory Care Plan dated initiated 07/28/23 for Resident #48 showed the Problem List: Resident is at risk for altered respiratory status/difficulty breathing related to history of SOB/Hypoxemia, Pleural Effusion, Wheezing; Interventions: Administer medications/breathing treatment as ordered. Monitor for effectiveness and side effects; and Goals: Resident will have no complications related to SOB through review date. On 01/24/24 at 1:07 PM, an interview was conducted with Staff D, Licensed Practical Nurse (LPN), who acknowledged Resident #48 was currently receiving Nebulizer treatments of Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML one (1) vial inhale orally every twelve (12) hours as needed for SOB/Wheezing. During the interview, the nurse acknowledged and read aloud the following label attached to the outside of the Nebulizer machine as: Service date of February 27th 2021, and a due date February 2022, two (2) years outdated. Staff D stated the Nebulizer treatments are given on the 7AM-3:30PM shifts. Staff D was asked Who would she report the outdated nebulizer equipment to in order to ensure that the resident's Nebulizer equipment was currently operating properly, and replied she would remove the machine and try to get a replacement, and then she would also report this to either the Maintenance Director, or the DON. She acknowledged that this had not previously been done by her. During a telephone interview conducted on 01/25/24 at 1:15 PM with both the Field Lead Biomedical Technician of fifteen (15) years, along with the facility's Regional Clinical Director, the Field Lead Biomedical Technician was asked about what types of services need to be checked with regard to residents' Nebulizer machines. He stated that Nebulizers check are performed for electrical safety purposes in order to verify that these are functioning correctly to avoid the risk of electric shock for both resident and the individual administering the nebulizer treatments. He staed this should be done on a yearly or biannual basis. The Field Lead Biomedical Technician ended the conversation by clearly stating that after one (1) year, the Nebulizer machine would no longer be in compliance. Upon request, the facility was unable to provide the surveyor with any specific documentation of the Manufacturer's Recommendations pertaining to the Nebulizers currently being utilized by residents residing in the facility. The three (3) outdated Nebulizer machines with stickers were not removed from the three (3) residents' bedsides and replaced with an updated Nebulizer machine, until after surveyor intervention. The DON recognized and acknowledged on 01/24/24 at 2:24 PM that all 3 residents ordered Nebulizer treatment medications were being administered to them on a regular, routine basis, via the outdated Nebulizer machines in their rooms. She also acknowledged that the service and due dates for Safety / Calibration recorded on the outside of the Nebulizer machines, with regard to service / maintenance were outdated/past due. The DON indicated that she should have reported this to both the Administrator and the Maintenance Director to notify them since these Nebulizer machines needed to be checked, serviced and monitored on an annual basis. This was not done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide wound care as ordered by the physician for 1 of 3 sampled residents reviewed for wound care and failed to notify the physician of ordered treatment not being available (Resident #16). The findings included: A review of the facility's policy, titled, Physician Notification, dated 11/11 and revised 06/14, documented: The licensed nurse is responsible for notifying the resident's physician at minimum when there is the inability to obtain or administer on a prompt and timely basis prescribed medications, equipment, supplies, or services. Resident #16 was admitted to the facility on [DATE]. Record review revealed a comprehensive assessment, dated 05/27/22, documented the resident had moderate cognitive impairment, and required limited one-person assist with activities of daily living. A review of the facility's incident log revealed Resident #16 had an injury of unknown origin on 05/15/22. A review of Resident #16's progress notes revealed a note, dated 05/15/22 at 3:52 PM, that documented: Had a quiet day. Dressing to right lower leg dry/intact, no pain related to incident. A progress note, dated 05/18/22 at 4:44 PM, documented as a late entry for 05/15/22 3P-11P: Received resident in bed, post right lower leg skin tear, no complaints of any pain. Treatment in place (There was no specification of what treatment was in place). Further review of Resident #16's records did not address the condition of the resident's wound to the right lower leg until, an order dated 05/20/22 for a wound care consult for right leg wound. Resident #16 was evaluated by wound care (WC) on 05/26/22 per wound care note. The wound care note (WCN) addressed the wound as unhealthy, with excessive necrotic (dead) tissue. An order for Therahoney (a debridement agent) to right leg wound topically every evening shift for wound care. Cleanse with normal saline, apply Therahoney, and cover the dry dressing. A review of Resident #16's Medication Administration Record (MAR) revealed Therahoney was documented as not given on 05/26/22, 05/28/22, 05/29/22, 06/02/22, 06/06/22-06/08/22, until discontinued on 06/09/22. A progress note dated 05/29/22 at 7:13 PM documented Therahoney was not administered due to awaiting from pharmacy. Further review of Resident #16's record did not reveal any documentation of the condition of the resident's right leg wound. A WCN dated 06/02/22 documented the wound as unhealthy, with excessive necrotic tissue, improvement of wound quality was noted. The plan was to continue current treatment autolytic debridement being utilized (Therahoney). A progress note dated 06/06/2022 10:23 PM documented: Spoke to pharmacy again. Therahoney still on back order. Further review of Resident #16's record did not reveal any documentation of the condition of the resident's right leg wound. A WCN dated 06/09/22 documented Resident #16's right leg wound noted with deterioration based on an increase in devitalized (dead) tissue noted. Will change treatment to Santyl (another debridement agent) daily and will debride (surgically cut out dead tissue) upon obtaining consent. A WCN dated 06/16/22 documented debridement was completed. A moderate amount of necrotic tissue was removed. Due to the extent of necrotic tissue and patient tolerance of debridement it is planned to return in 1 week for further debridement if needed. An interview was conducted with the Director of Nursing (DON) on 09/09/22 at 1:00 PM. The DON was questioned if the physician was notified the ordered treatment of Therahoney was not available for administration since ordered on 05/26/22. The DON acknowledged the note on 06/06/22 of the pharmacy with back order of the medication/treatment. The DON further acknowledged the lack of documentation of Resident #16's wound condition, and the ultimate deterioration of the resident's right leg wound, requiring surgery. The DON stated they must have had the medication (Therahoney) at one time, due to the documentation of it being administered on the resident's MAR on 05/27/22, 05/30/22, 05/31/22, 06/01/22, 06/03/22, 06/04/22, and 06/05/22. An telephone interview was conducted with a company's pharmacy technician on 09/09/22 at 1:30 PM. The tech stated an order was received from the facility for Therahoney on 05/26/22. The tech further stated the medication was not in stock, and there was a back order. The tech stated they ordered the medication from another supplier on 05/27/22, which generally takes 7-10 days to receive. The tech stated the ordered Therahoney was delivered to the facility on [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement interventions to prevent falls with injury, for 1 of 2 sampled residents reviewed for falls (Resident #16); and failed to investigate 2 of 2 sampled residents reviewed for falls (Resident #16 and Resident #29). The findings included: A review of the facility's policy, titled, Falls Reduction and Management, revised 11/20, documented: To strive to identify residents at risk for falls and reduce the incidence of falls by identifying environmental, interpersonal and/or functional triggers and causes of fall and implementing person- centered interventions to reduce risks. To strive to ensure that the resident environment remains as free of accident hazards as possible, and that each resident receives adequate supervision, functional support, and assistance devices to prevent and/or minimize accidents. The policy further documented if the resident does fall, the licensed nurse will follow all policies and protocols relevant to incident reporting and complete the Incident report and the Fall Huddle Investigation Worksheet. 1. Resident #16 was admitted to the facility on [DATE]. Record review revealed a comprehensive assessment dated [DATE], documented the resident had moderate cognitive impairment, and required limited one-person assist with activities of daily living. Record review revealed Resident #16 was care planned for fall risk related to cognitive decline and decline in function, sometimes refused to sit in a regular chair in the dining room and sat on the walker seat. On 09/02/22, the resident had a fall with injury. Resident #16's interventions included: anticipate needs and provide safe environment with even floors free from spills and/or clutter, adequate, glare-free light, a working and reachable call light, the bed in low position at night, side rails as ordered, handrails on walls, personal items within reach. A review of the facility's incident log revealed Resident #16 had 4 unwitnessed falls on 06/29/22, 07/13/22, 08/11/22, and 09/2/22. A progress note dated 06/29/22 at 4:32 PM documented: 'Resident was found in sitting position by her bedside reported by one of our staff members during lunchtime, no injury noted. No call light was activated. Resident was in bed prior her fall. Assisted to transfer via mechanical lift, full ROM (range of motion) with no limitation, denies any pain and discomfort. Resident is encouraged to use her call light for assistance, POA (Power of Attorney) and MD (Medical Doctor) are notified. Call light within easy reach with bed in the lowest position.' No further documentation was found regarding Resident #16's condition post fall. A progress note dated 07/13/22 at 7:38 PM documented: 'Resident sat in bed in lowest position. Slid off bed and sat on floor. Skin tear noted to right elbow. First aid applied. MD [medical doctor]and POA [power of attorney] notified.' No further documentation was found regarding Resident #16's condition post fall. A progress note dated 08/11/22 at 11:40 PM documented: 'At about 11 PM, Patient was found on the floor alongside of her bed by the incoming nurse while rounding. No apparent injury noted at that time. At about 11:24 PM, called assigned doctor, message left on his answering machine. Responsible party is aware. Safety precautions maintained. Call light within easy reach.' A progress note dated 08/12/22 at 6:06 AM documented: S/P (status post) fall resident continues with frequent observation by staff, denied any pain during the shift, no acute distress noted. V/S (vital signs) stable. No redness or swelling noted on the skin. Safety maintained, call light in reach. Nursing care continue.' A progress note dated 09/02/22 at 3:25 AM documented: 'While CNA [Certified Nurse Assistant] made round, observed resident laying on the floor prone position with left arm against the W/C (wheelchair) wheel. Resident stated, I was trying to walk to the bathroom, and I lost my balance and fell on the floor. Complete assessment initiated resident unable to moved left shoulder, complaint of pain and discomfort, V/S stable. Resident was alert and responsive. 911 called and transfer resident to Hospital for further evaluation. MD was notified. Resident family made aware. Resident left the facility via stretcher with 3 paramedics in stable condition.' An interview was conducted with Staff Z, a Registered Nurse (RN), on 09/08/22 at 2:50 PM. Staff Z stated when a resident has a fall, the resident is assessed for injuries, assisted back to bed/chair, an incident report is completed, the physician and family is notified, and the resident is assessed for 3 days each shift and documented in progress notes. An interview was conducted with Staff Y, RN, on 09/08/22 at 3:00 PM. Staff Y stated when a resident falls, do an assessment, do an incident report, notify physician and family. Staff Y further sated neurological checks are started, if needed, and interventions such as moving the resident closer to the nurses station, frequent checks, and involve family should be initiated. An interview was conducted with the Director of Nursing (DON) on 09/08/22 at 4:00 PM. The DON stated incident reports regarding falls were reviewed in morning meetings with department heads, and they discuss what happened, what to do / interventions to be put in place. The DON acknowledged there was no investigation of Resident #16's falls documented. The DON stated investigations were done internally but was not able to provide documentation of such. The DON further acknowledged the fall Resident #16 sustained on 09/02/22 that involved a wheelchair in the resident's room, when the resident ambulated using a walker. Resident #16 was not provided a safe environment free from clutter. 2. Resident #29 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident as mild to moderately cognitive impaired and required limited to extensive one-person assist with activities of daily living. Resident #29 was care planned for at risk for falls related to history of confusion and limited physical mobility. On 08/16/22, the resident had a fall with no injury. A progress note dated 08/16/2022 at 1:26 PM documented: 'Resident alert and oriented to person and place with forgetfulness. Assessment done. No apparent injuries noted. Denies any pain or discomfort at this time. Able to move all extremities without difficulty. MD notified. Health care surrogate notified. Vital signs stable.' There was no evidence of an investigation for Resident #29's fall found.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to document the needs to be met by the use of siderails, failed to attempt alternative interventions, assessment of resident for risk of entrapment, obtain informed consent, determine the resident's risks versa benefits, identify potential areas of entrapment and ensure compatibility of mattress with frame, for 1 of 1 sampled resident reviewed realted to siderails, (Resident #36). This deficiency has the potential to affect all residents because all facility beds have side rails attached. The findings included: Review of the facility Policy and Procedure, titled, Side/Bed Rail Usage (S-04WB), issued 11/2016 and last revised 8/2021, defined a bed rail as any adjustable metal or rigid plastic bar that attach to a bed. It read: They are available in a variety of types, shapes, and sizes ranging from full to one-half, one-quarter, or one-eighth lengths. Also, some bed rails are not designed as part of the bed by the manufacturer and may be installed on or used along the side of a bed. The procedure instructs the community to assess all residents for the use of side rails upon move-in to the community by completing the Side Rail Assessment. Then attempt to offer side rail alternatives prior to using or installing a side rail. It also instructs the licensed nurse to review the risks and benefits of side/bed rails with the resident or the resident's representative and obtain consent. Then provide written documentation describing the risks/benefits and safety of side rails use (See Appendix A - which was not attached for surveyor review). Additionally, the nursing and maintenance departments will: Look for risk of entrapment from the side (bed) rails at the time of installation and ongoing with the use of one or more rails; Ensure the bed's dimensions are appropriate for the resident's size and weight; and verify proper maintenance and function of the rails. Follow the manufacturer's recommendations and specifications for installing and maintaining side (bed) rails. When purchased separately, the maintenance will ensure that the side (bed) rail, mattress and bed frame are compatible. Review of the Side Rail Assessment Med, documented in part: F: 066 used in the facility and specified in the procedure, revealed 17 questions to be answered by the nurse, however the information requested does not comply with the current regulation by considering the resident's diagnoses, symptoms, height and weight, medications, ability to toilet, ability to communicate, mobility/ability to use or risk of falling. The assessment also does not tally or compute the information in a manner that assists staff to determine the risk of entrapment. It only asks the nurse if the mattress fits the bed properly to prevent entrapment. Review of the medical record for Resident #36 revealed an admission date for this stay on 12/27/21 with the most recent readmission on [DATE]. Relevant diagnoses included Cerebrovascular Disease, Depression, Anxiety, Muscle Weakness, Dementia, Long Term Use of Anticoagulants (blood thinners), Essential Tremor and Epilepsy (recurrent seizures). Current medications included Phenobarbital twice daily and Divalproex in the evening to control seizures, Escitalopram for depression and scheduled Lorazepam for anxiety. Review of the most recent comprehensive MDS assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 12 out of 15 indicating a mild cognitive decline. The same assessment also revealed the resident required extensive assistance from one person to turn or reposition in bed, transfer from the bed, dress, toilet, and complete personal hygiene. The resident's care plan mentions side rail use as an intervention for her ADL deficit. It read: Quarter side rails up for safety during care provision, to assist with bed mobility. Observe for injury or entrapment related to side rail use. Reposition as necessary to avoid injury. Under the Seizure Disorder/Epilepsy focus, one of the two goals was to remain free from injury related to seizure activity. The side rails were not included in this section nor were they ever observed to be padded to protect the resident with involuntary movements. On 09/06/22, during the initial screening process, bilateral siderails were observed on all the residents' beds in the 200 Hall. Some were raised/in use and others were in the down position and covered by bedding when the beds were made. On the same day at 3:00 PM, large metal slatted 3/4 length siderails and an air mattress were observed on the bed for Resident #36. Photographic Evidence Obtained. On 09/07/22 at 3:45 PM, during an interview with the MDS (Minimum Data Set) Nurse, she was asked where to find the siderail consent forms for the residents. She responded, We don't have consent forms for side rails because they aren't restraints, so they aren't necessary. She called the DON (Director of Nursing) by phone to confirm this and then said her answer was correct by reaffirming, We don't have consent forms because they aren't restraints, so they don't need them, and all the beds here have them [siderails]. We don't need consents. On 09/07/22 at 3:55 PM, during an interview with the Director of Nursing (DON), she verbalized they don't have consent forms but there is a consent in the siderail assessment in the EHR (electronic health record). On 09/07/22 at 4:55 PM, during an interview with Resident #36, she said she doesn't use the rails to move around in bed and they have to put them down for her because she cannot operate them herself. She also doesn't know why they are on the bed and said, I guess they came with it. On 09/08/22 at 11:40 AM, the facility policy and procedure, titled, Side/Bed Rail Usage and the Guide to Bed Safety brochure, was reviewed. The policy indicated the brochure is to be provided to residents/staff around the time of admission. Regular maintenance records were requested for review. The NHA (Administrator) was not able to explain why the large metal side rails were on Resident #36's bed. On 09/08/22 at 12:25 PM, the NHA reported the bed and large siderails had been brought in by hospice for this resident but neither she or the DON were aware they were in the building. Resident #36 was admitted to hospice on 01/09/22 and discharged from hospice on 08/31/22 therefore, the bed and siderails had been delivered sometime between those dates and not yet picked up after her discharge from hospice services. The NHA said the bed had been replaced the evening before with a facility bed (which has quarter rails and photographic evidence was obtained). The NHA also acknowledged that for any side rail, the proper documentation needed to be completed. On 09/09/22 at 1:15 PM the NHA and the DON were interviewed about the facility siderail use. The DON reported the consent is usually verbal and she notes who she speaks with on the side rail assessment. A pamphlet titled A Guide to Bed Safety written in 2000 and last revised 4/2010 is provided to residents or family during admission but the DON confirmed she does not read it or review it with anyone, and this is not always done prior to admission. In addition, the Social Services/Admissions Director also helps with admissions and obtains some signatures, but this could be days after admission. The DON confirmed that alternative interventions are not tried and/or documented prior to side rail installation because the siderails are already on the bed. She also confirmed she completes all the side rail assessments found in the EHR and she was not familiar with the weight restrictions for any of the beds. Both the DON and the NHA agreed the assessment does not help to determine any risk of entrapment. They confirmed that all the facility beds have side rails on them, as they came that way from the manufacturer. When asked how they determined the mattresses were compatible with the beds and siderails they advised that would have been determined at the corporate level with the vendors at the time of purchase. The DON confirmed any siderails used for residents with seizures or involuntary movements should be padded going forward. Regarding the use of any specialty mattresses like an air mattress, scoop, or bolster mattress, they advised the facility maintenance department should be measuring gaps when they replace the mattress to assess for entrapment risks. The NHA was also certain there wasn't any education provided to staff on the risks of injury or death, the zones of entrapment and safe use of side rails. On 09/09/22 at 1:50 PM, the Director of Facility Maintenance was interviewed. He reported checking five rooms/beds weekly which results in all beds being checked approximately every three and a half months. He checks electrical cords, connections, controls, and the security of the siderails. If a staff member reports an issue, he also has that documented on a work order. However, when asked about checking the Zones of Entrapment he said he did not know what that meant. He further stated he does not measure distances between the mattresses and siderails or headboard or anywhere else when replacing a standard mattress with a specialty mattress. The Director of Facility Maintenance reported three different models of beds in the building and all of them have side rails. A Work Order Report documenting Annual Bed and Side Rail Inspection was provided which lists the Seven Zones of Entrapment but does not include any measurements or parameters. He said he just looks at the gaps. This form is completed once yearly and only notes the comments as good and yes the assessment was completed. Review of the manufacturer's instructions for all three models revealed varying maintenance schedules from monthly to annually and weight totals between 450-500 pounds including the mattress, bedding, and head/foot boards. One model specified a mattress width and depth for use as well as suggesting the bed be left in the flat position when unattended to reduce the risk of entrapment. Another warned of risk of injury when raising or lowering of the bed which creates gaps, increasing the risk. All three contained warnings and referrals to the FDA (Food and Drug Administration) Recommendations regarding risk of entrapment with use. On 09/09/22 at 3:31 PM, during an interview with the Social Services Worker, she confirmed that she does not read or review the bed safety pamphlet with residents or family members on admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to secure medications for 2 of 24 sampled residents reviewed, (Residents #214 and #42). The findings included: Review of the facility's policy titled, Self-Administration of Medication, with a revision date of 04/2018, revealed the following: Policy to strive to ensure that the resident is properly prepared and clinically appropriate to self-administer medications. Prior to participating in the self-administration of medication program, the resident will be observed by the nursing supervisor and/or charge nurse using the Self-Medication Administration Evaluation Form. The physician's order must state resident may self-administer medications if the evaluation by the interdisciplinary team (IDT) is satisfactory. The care plan must reflect the resident's ability to self-administer medications. All medications to be self-administered will be stored in a locked medication drawer in the resident's room or another designated area. 1. Record review for Resident #42 revealed the resident was admitted on [DATE] with a recent readmission on [DATE]. The diagnoses included Malignant Neoplasm of Head, Face and Neck, Type 2 Diabetes, and Chronic Kidney Disease. The Minimum Data Set (MDS) dated [DATE] revealed in Section C a brief interview for mental status (BIMS) score of 15 indicating intact cognitive response, bed mobility, transfers and dressing all had self-performance of limited assistance with support of one-person physical assist. Review of the Physician's Orders for Resident #42 revealed an order dated 08/05/22 for Saline drops: 2 drops to use as needed. Pt may use at bedside. Review of the care plans for Resident #42 revealed there was no care plan for medication at bedside or self-administration of medication. Review of the Self-Administration of Medication Evaluation form dated 08/05/22 for Resident #42 revealed under the physical evaluation portion, Can correctly self-administer eye drops/ointments, was N/A (not applicable). On 09/06/22 at 10:20 AM, an observation was made of over-the-counter eyedrops unsecured at the bedside for Resident #42. Photographic Evidence Obtained. On 09/07/22 at 09:30 AM, a second observation was made of over-the-counter eyedrops at the bedside unsecured for Resident #42. During an interview conducted on 09/06/22 at 10:25 AM with Resident #42, when asked about the unsecured eye drops at her bedside, she stated she uses those when she needs them and was never instructed to lock them up. During an interview conducted on 09/09/22 at 11:40 AM with Staff A Registered Nurse (RN), when asked about Resident #42 having medication at the bedside, she stated the resident has eyedrops at the bedside that she uses as needed. During an interview conducted on 09/09/22 at 12:00 PM with Director of Nursing (DON) when asked about residents self-administering medication at the bedside, she stated the facility only needed a physician's order for resident to have medication at the bedside for self-administration. When asked if the medications need to be secured (in a locked drawer/box) she stated no, the resident can just keep them in their bedside drawer. When asked if the resident needed to be evaluated for self-administration of medications, she replied 'yes of course'. 2. Record review for Resident #214 revealed the resident was admitted on [DATE] with most recent readmission on [DATE]. The diagnoses included Chronic Obstructive Pulmonary Disease, Adult Failure to Thrive, Unspecified Visual Loss, and Cognitive Communications Deficit. The Minimum Data Set (MDS) dated [DATE] revealed in Section C a brief interview of mental status (BIMS) score of 15, indicating intact cognitive response. The MDS dated [DATE] revealed in section G bed mobility, transfers, dressing, and personal hygiene all had a self-performance of extensive assistance with support of one-person physical assist. Record review for Resident #214 revealed no order for medication at the bedside or to self-administer medication. Record review for Resident #214 revealed no care plan for medication at bedside or self-administration of medication. On 09/06/22 at 11:50 AM, an observation was made of over-the-counter eyedrops and prescription medication for Ciclopirox 8% Nail lacquer unsecured at the bedside for Resident #214. Photographic Evidence Obtained. On 09/07/22 at 11:00 AM, an observation was made of over-the-counter eyedrops and prescription medication for Ciclopirox 8% Nail lacquer unsecured at the bedside for Resident #214. Photographic Evidence Obtained. During an interview conducted on 09/06/22 at 11:55 AM with Resident #214, when asked about the unsecured medications at the bedside, she replied those are from home and she doesn't need to lock them up. During an interview conducted on 09/09/22 at 11:45 AM with Staff A Registered Nurse (RN), when asked about Resident #214 having medication at the bedside, she stated I do not think she has medications at the bedside. She verified this was correct according to the resident's orders.