Based on observations record review an interview, the facility failed to safeguard and ensure privacy of residents' confidential Electronic Health Records (EHR); as evidenced by one out of four of the facility's medication carts' computer screen was left unlocked and unattended revealing residents' information. There were 88 residents residing in the facility at the time of the survey. The findings include: Observational tour of the facility on 02/25/25 at 07:21 AM revealed, the computer screen on unattended Medication Cart Two located on the South station was left unlocked with residents' Electronic Medication Administration Records (EMAR) visible. There were no nurses or other staff attending to the cart at the time. Interview on 02/25/25 at 08:20 AM, Registered Nurse (Staff B) stated: I know my EMAR screen on the South Medication Cart is supposed to be locked, I was rushing to go help a resident and forgot to lock the cart. Interview on 02/26/25 at 09:45 AM, the Director of Nursing was informed of the privacy and Health Insurance Portability and Accountability Act (HIPAA) concerns identified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to follow infection prevention and control procedures for Resident #183. As evidenced by Resident #183's Spirometer was observed at Resident #183's bedside with no protective covering. The findings included: On 02/24/25 at 07:52 AM, Resident #183 was observed in bed asleep, there was a Spirometer with no protective covering on the overbed table. Observation in Resident #183's room on 02/24/25 at 10:09 AM, the uncovered Spirometer was on the bedside table. Observation on 02/25/25 at 09:00 AM, Resident #183 was in her room sitting in wheelchair; the Spirometer on the bedside table was not in a protective covering. Resident #183 revealed she used the Spirometer occasionally. Interview on 02/25/25 at 09:13 AM, Licensed Practical Nurse (LPN), (Staff A) revealed she is assigned to Resident #183, and the Spirometer should be stored in a dated zippered bag when not in use for infection control reasons/issues. Review of Resident #183's medical records revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Chronic Obstructive Pulmonary Disease. Interview on 02/26/25 at 09:47 AM, the Director of Nursing (DON) revealed; when a resident's equipment is not being used, it is supposed to be stored in a [brand zippered bag] with the date it is replaced for infection control purposes and to protect the resident. Review of the facility policy and procedure titled Infection Prevention and Control, Revision date December 2023 states: The facility adopted infection prevention and control policies and procedures are intended to help maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. Policy Interpretation and Implementation: All personnel are trained on infection prevention and control policies and procedures upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to promote one (resident #18) out of 21 sampled residents dignity during dining. As evidenced by observations of staff standing over resident #18 while assisting to eating. This has the potential to affect the 43 residents residing in the facility who require assistance with feeding at the time of survey. The findings included: Observation on 09/25/23 at 8:23 AM in room [ROOM NUMBER] Staff C, a Certified Nursing Assistant (C N A) was observed standing while assisting resident #18 with breakfast. Observation on 09/27/23 at 1:00 PM in room [ROOM NUMBER] Staff A, a Registered Nurse (RN) was observed standing while assisting resident #18 with lunch. Record review of the Demographic face sheet revealed, resident #18 was admitted on [DATE] and re-admitted on [DATE] with diagnoses that included Dementia, Gastro-esophageal reflux disease, and Type 2 Diabetes. Record review of the quarterly Minimum Data Set (MDS) dated [DATE], Section C for cognitive patterns revealed a Brief Interview Mental Status score of 6, indicating resident #18 was severely cognitively impaired. Section G for functional status revealed resident #18 required extensive assistance by one person for all Activities of Daily Living (ADL). Section K for Weight Loss revealed resident #18 had no weight loss of 5% or more in the last month or 10% or more in last 6 months. Record review of the Care Plan dated 09/12/2023 revealed, Problem: Self-care deficit as evidenced by the need of assistance secondary to: Impaired mobility related to diagnosis of Dementia, Cerebrovascular Accident, left hemiplegia, Altered Mental Status, Hypertension. Interventions: Assist with Activities of Daily Living (ADLS) every shift and allow enough time for participation in care. Provide privacy and always maintain dignity. Staff to anticipate resident's needs with ADL's. Announce and introduce self while providing care and medications as ordered; observe for side effects and effectiveness. Breakdown tasks into subtasks and provide periods of rest as needed. Do frequent rounds. Encourage/remind resident to ask for assistance as needed. Explain procedures prior to beginning tasks or physical contact. Gather and set up supplies for care. Keep call light within reach and answer promptly. Observe for decline in ADL function; report to the physician as indicated. Praise her for all efforts. Provide assistance for transfer as indicated. Provide Range of Motion (ROM) during care. Physical therapy/ occupational therapy/ speech therapy screen prn. Interview on 09/25/2023 at 08:25 AM, Staff C stated, sometimes she stands and sometimes she sits. Staff C reported, she is aware that she should be sitting while assisting residents to eat. Interview on 09/25/2023 at 12:55 PM, Staff A stated, she is aware it is a dignity issue to stand over residents while assisting with meals. Staff A reported, moving forward she will sit while assisting any resident to eat. Review of the facility's policy and procedure entitled, Assistance with Meals (revised March 2022) revealed, the Policy statement: Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Policy Interpretation and Implementation: Residents requiring full assistance: 2. Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, for example: a. not standing over residents while assisting them with meals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the safety of a one vulnerable resident (#335) out of one (1) resident's reviewed for smoking. As evidenced by Resident #335 smoking in the facility's patio area without a smoking assessment or care plan and having cigarettes and a cigarette lighter in their personal belongings. There were 87 residents residing in the facility at the time of survey. The findings included: On 09/25/23 at 09:35AM, resident #335 was observed smoking on the smoking patio, with staff and family members in attendance. On 09/26/23 at 10:48 AM, resident #335 was observed in a wheelchair in the hallway returning from rehabilitation therapy, and stated she will not be smoking today because she has visitors. On 09/27/23 at 10:30 AM, resident #335 was observed in therapy exercising and stated, on admission she did not smoke because she did not feel like smoking, but recently she has been anxious and have been smoking 2-3 cigarettes a day. On 09/27/23 at 11:10 AM, observation of the smoking area revealed, 1 self-closing ashtray, 1 red self-closing metal bin, 1 fire blanket, and 1 fire extinguisher observed. The resident was not observed to be smoking at the time. On 9/28/23 at 12:20 PM, resident#335 was observed in a wheel chair on the patio smoking with a family member. A self closing astray was on table in front of the resident, and facility staff were in attendance on the patio. Interview on 09/25/23 at 01:11 PM via translator (Another surveyor on the team) the resident stated, she only smokes in the morning sometimes, she usually goes out to smoke after therapy, she keeps all of her smoking items with her. Resident #335 showed the surveyor her cigarettes in a small wallet case, and stated she also kept her cigarette lighter with her, but this morning on 9/25/23 after she came back from smoking, the social worker took her lighter away and told her the lighter will be kept at the nurses' station. The resident was very upset that the social worker took away her lighter today. Resident #335 reported, that they told her she has to pick her lighter up at the nurse's station. The resident refused to continue to be interviewed. Interview on 09/27/23 at 09:32 AM, with the Minimum Data Set (MDS) coordinator revealed, when asked about the Tobacco use coded-No in section J of the resident's MDS, it was reported, at the time of the resident's admission there was a smoking assessment completed on 8/29/23 on which the resident stated that she was not a smoker, and the MDS assessment was completed on 8/31/23 based on the information received from the smoking assessment on which the resident stated that she was not a smoker. On 9/25/23 another smoking assessment was completed for the resident and a smoking care plan was created. Interview on 09/27/23 at 09:43 AM, with the Social Services Director(SSD) revealed, when asked if Resident #335 is a smoker, it was reported, on admission, the assessment was completed and the resident stated that she did not smoke. The SSD stated when I was on the patio supervising another smoker on Monday (9/25/23), the resident came to the patio and stated she was there to smoke. I explained, to the resident information about our smoking policy. I went back to her later and explained to the resident in detail about the policy, the resident then gave me the lighter she had in her possession, I placed the lighter in the nurse's station with the resident's name. When the resident wants to smoke, she has to get her lighter and cigarettes from the nurse's station. We have designated smoking times and staff that goes out to supervise the residents. We established a smoking schedule with this resident for 1:00pm after lunch and after dinner and if she wanted to smoke at any other time, she would have to approach one of the staff and ask to go smoke. The Assistant Director of Nursing (ADON) completed another smoking assessment for the resident and a smoking care plan was implemented on 9/25/23. Since admission I have never had any reports from staff that this resident goes out to the patio to smoke. The first time I saw this resident was on Monday on the smoking patio, stating that she was there to smoke. Prior to this, I did several in-services with the nurses to let them know when they do their assessments on admission, ask the residents if they are a smoker, if they are, complete a smoking assessment and let me know if the resident is a smoker. We communicate with the staff to let them know what residents are smokers and there is a smoking binder on each nursing station that has a lists of the residents who smoke. As we receive new admissions and discharges, we update the smoking list in the binders at the nursing stations as needed. On 9/25/23, the resident had a room change because she requested a private room. Interview on 09/27/23 at 10:05 AM with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) revealed, none of the staff including myself has never seen this resident smoking, on Monday 9/25/23 is the first time anyone has ever seen this resident smoking and we implemented a smoking assessment and a care plan for this resident immediately. This resident upon admission was not a smoker and she stayed in her room most of the time, when the DON was informed, by the surveyor that this resident had a pouch with a lighter and cigarette, the DON stated, the lighter and cigarettes' are now stored at the nursing station and the resident has to go to the nurses' station to retrieve her smoking materials to smoke with a staff member for supervision. Interview on 09/27/23 at 10:30 AM with the resident #335 while in therapy exercising it was stated via another surveyor translating, on admission, she did not smoke when she first came to the facility because she did not feel like smoking, but recently she has been anxious and has been smoking 2-3 cigarettes a day. Interview on 09/27/23 at 11:40 AM with the resident in her room with her son, via translation with another surveyor revealed, when asked how long she has been smoking at the facility, the resident reported, she started about 2 weeks ago, and the resident's son stated his mom has smoked her whole life. Interview on 09/28/23 at 07:55 AM, the Registered Nurse, from the South Unit (Staff A) via translator reported, she has never seen this resident smoking. Interview on 09/28/23 at 07:56 AM, the Registered Nurse, from the South Unit (Staff B) via translator reported, yesterday was the first day I was assigned to this resident, I saw her smoking yesterday, and her smoking supplies are stored at the nursing station. On 09/28/23 at 10:47 AM, the MDS Coordinator brought a signed statement of an interview with the resident that documented, the resident stated upon admission she forgot that she was a smoker and she never smoked until she got anxious a few days ago. Record review of Resident #335's Smoking Assessment documented-Resident was admitted on [DATE], smoking assessment completed on 8/29/23 documented no tobacco use, smoking assessment completed 9/25/23 documented- Resident uses Tobacco, Has the cognitive ability to smoke safely, Has the visual ability to smoke safely, Has physical dexterity and physical ability to smoke safely, Resident may smoke independently or with set up, Resident requires use of cigarette holder, and Security-All lighters, matches, lighting materials are kept in a secure location. Review of the medical records for Resident #335 revealed, the resident was admitted to the facility on [DATE]. Clinical diagnoses included but were not limited to: Displaced subtrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing, Depression and Anxiety Disorder. Review of the Physician's Orders Sheet for September 2023 revealed, Resident #335 had orders that included but were not limited to: Amitriptyline Oral Tablet 50 milligram (MG)-Give 1 tablet by mouth two times a day related to Depression. Clonazepam Oral Tablet 1 Milligram (MG)-Give 1 tablet by mouth two times a day related to Anxiety Disorder. Record review of Resident # 335's admission Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented Brief Interview of Mental Status Score 14, on a 0-15 scale indicating the resident is cognitively intact. Section E for behaviors documented rejection of care occurred 1-3 days. Section G for Functional Status documented Extensive assistance for Activities of daily living with one person assistance, except for eating, requiring setup only. Section H for Bowel and Bladder documented occasionally incontinent of bladder, always incontinent of bowel. Section J for Health Conditions documented no tobacco use. Section N for Medications documented resident received anticoagulants, antianxiety, antidepressant, diuretic in the last 7 days. Section O for Special Treatments, Procedures, and Programs documented resident received Occupational, Physical, and Psychological Therapy in the last 7 days, and Section P for restraints documented no physical restraints or elopement alarms used. Record review of Resident # 335 's Care Plans dated 9/25/23 revealed: Resident has desire to smoke. Resident will comply with smoking policy and rules through next review date. Resident will remain safe and free from injury during smoking episode through next review date. Interventions include- Smoking assessment, Smoking material should be kept at the nurse's station, supervise when smoking at all times, explain smoking policy and rules as needed, explain smoking policy to resident and family as needed, redirect resident to smoking area as needed, and smoking as per smoking schedule. Review of the facility's policy and procedure titled Smoking Policy-Residents effective date 09/15/2022 states: The center will establish and maintain a safe designated smoking area and safe smoking practices for the residents. Smoking is only allowed in the designated smoking areas of the facility and during designated smoking times. Smoking is not allowed during inclement weather. Oxygen is not permitted within 50 feet from the designated smoking areas. The center will have safety equipment available in designated smoking areas including fire blanket, smoking aprons, fire extinguisher, and non combustible self-closing ashtrays. Procedures: Residents that wish to smoke will have an initial smoking assessment, quarterly, with a change in condition, and as needed to determine if assistance and /or supervision is required for smoking. The center will retain and store all smoking materials, including matches, lighters, cigarettes, cigars, and any other smoking implement for all residents who wish to smoke.

Based on observation, interview, and record review, the facility failed to follow physician's orders for oxygen therapy administration for one out of four sampled residents (Resident #34) reviewed for oxygen therapy. The findings included: Observation on 09/25/2023 at 08:13 AM, revealed Resident #34 had her breakfast set up on the bedside table, and the resident was sleeping. Further observation revealed, the oxygen level was infusing at 3.5 liters per minute via nasal cannula. Observation on 09/26/2023 at 08:43 AM, revealed Resident #34 in bed awake. Observed the resident's oxygen level was at 3.5 liters per minute via nasal cannula. Observation on 09/27/2023 at 08:10 AM, revealed Resident #34 in her bed with the bedside table in front of her. Observed the resident's oxygen level was between 3 - 3.5 liters per minute infusing via nasal cannula. Observation on 09/28/2023 09:13 AM, revealed, resident #34 was sleeping, and the oxygen level was at 3.5 liters per minute infusing via nasal cannula. Review of the Resident #34's physician's orders revealed an order dated 07/21/2022 for oxygen (O2) at 2 liters per minute via nasal canula every shift for Shortness of breath for respiratory distress related to chronic obstructive pulmonary disease (unspecified). Review of Resident #34's medical diagnoses revealed, acute respiratory failure with hypoxia, history of right hip fracture and fall, Chronic obstructive pulmonary disease, hypertension, anemia, Alzheimer, hyperlipidemia. Review of Resident #34's care plan dated 07/18/2023 revealed, the resident has a potential for complications of respiratory distress. The facility's interventions included, Change oxygen tubing weekly and PRN (as needed) every night shift and Sunday; administer medications as ordered; O2 sats (saturated) as ordered; administer O2 as ordered. On 09/28/2023 at 10:05 AM, Staff C (Licensed Practical Nurse) stated, I think the oxygen level is supposed to be 2 liters, but I'm not sure. I will look at the computer. He then stated, I don't see it. I can't find the order. On 09/28/23 at 10:09 AM, observed the facility's staff educator came and helped Staff C to look for the physicians order. On 09/28/23 at 10:12 AM, the facility's staff educator stated, The order is in there. It's 2 liters per minute for shortness of breath. Review of the facility's policy and procedures relating to Oxygen Administration, dated October 2010 revealed: Purpose - The purpose of this procedure is to provide guidelines for oxygen administration. Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess any special needs of the resident. 3. Assemble the equipment and supplies as needed. Steps in the procedure: 8. Turn on the oxygen. Unless otherwise ordered, start the flow of oxygen at the rate of 2 to 3 liters per minute. 9. Place appropriate oxygen device on the resident (i.e., mask, nasal cannula and/or nasal catheter). 10. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered. 13. Observed the resident upon setup and periodically thereafter to be sure oxygen is being tolerated (see assessment).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review the facility failed to ensure the Preadmission Screening and Resident Review (PASRR) Level II for serious mental illness (SMI) or intellectual disability (ID) was requested at the time of admission for one resident (Resident # 23) out of three residents reviewed. There were 84 residents residing in the facility at the time of the survey. The findings included: On 09/19/2022 at 09:24 AM, Resident #23 was observed lying in her bed, awake. No distress noted. Observation of Resident #23 on 09/20/2022 at 08:23 AM revealed the resident was receiving hospice care. Observation of resident on 09/22/2022 at 09:01 AM. Resident was lying on her bed, sleeping. Record review of admission Record revealed the resident was admitted to the facility on [DATE]. Medical diagnoses included, but were not limited to, Degenerative Disease of Nervous System, Unspecified and Schizoaffective Disorder, Unspecified. Record review of Resident # 23's PASRR Level I dated 07/13/2022 revealed identification of a serious mental diagnosis under section 1A. Section 1B was not checked for Serious Mental Illness (SMI). Section 2, revealed for question number 1- Is there an indication the resident had or may have a disorder resulting in functional limitations in major life activities that would otherwise be appropriate for the individual's developmental stage? Response documented was Yes. Question number 2B for concentration, persistence, and pace: The individual has serious difficulty in sustaining focused attention for a long enough period to permit the completion of tasks, manifests difficulties in concentration, inability to complete simple tasks within an established time period, makes frequent error, or requires assistance in the completion of these tasks, documented response indicated Yes. Section 3 was not completed. Section 4 revealed the individual had no diagnosis or suspicion of serious mental illness (SMI)or intellectual disability (ID) indicated. Level II PASRR evaluation not required. Review of physician's orders dated 07/13/2022 revealed the resident was receiving Quetiapine Fumarate Tablet 25 milligrams. Give 1 tablet by mouth two times a day related to Schizoaffective Disorder, Unspecified. Review of the Medication Administration Record (MAR) for September 2022 revealed Resident #23 was receiving Quetiapine Fumarate Tablet 25 milligrams. Give 1 tablet by mouth two times a day related to Schizoaffective Disorder. The resident was monitored for Medication Management: Diagnosis Schizoaffective disorder every shift, resident had restlessness throughout the days. Record review of admission Minimum Data Set (MDS) Section A (A1500) for Preadmission Screening and Resident Review (PASRR), dated 07/20/2022 revealed: Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? No was the response documented. Review of the admission MDS Section C for Cognitive Patterns, dated 07/20/2022 revealed the Brief Interview for Mental Status (BIMS) Summary Score was left blank. Review of the admission MDS Section D for Mood, dated 07/20/2022 revealed the interview could not be conducted because the resident was rarely and never understood. Review of the admission MDS Section I for Active Diagnoses documented the resident's diagnosis was Schizoaffective disorder. Review of the admission MDS Section N for Medications, dated 07/20/2022 revealed the resident was receiving antipsychotics seven (7) days in a week. Review of Resident #23's Care Plans initiated on 07/14/2022 with next review date of 10/12/2022 revealed the resident was at risk for exhibiting behavioral problems. Diagnosis: Schizoaffective Disorder and Anxiety. Per Medication Administration Record (MAR) documentation, the resident exhibited restlessness on 07/15/2022 and 07/18/2022. Goal: The resident will not exhibit any behavior symptoms through the next review date. Interventions: Approach with kindness. Assess her when exhibiting behavior problems. Encourage family for frequent visitation. Medicate as ordered by physician. Praise all efforts. Provide emotional support. Psychiatrist/Psychologist consult as needed. Review of Psychiatrist consultation revealed the resident was seen on 08/23/2022. The resident's diagnosis was Schizoaffective Disorder. Resident unable to be in a less restrictive environment. Physician recommended to continue with the same medications. Interview with Staff A, Licensed Practical Nurse (LPN) on 09/22/22 at 11:17 AM. Staff A revealed the resident was well, when the resident was admitted , did not eat well, but now the resident eats very well. The resident was not aggressive or combative with the staff. The only medication that the resident had was Seroquel 25 milligrams twice a day. The resident's condition improved since she was admitted . Staff made frequent rounds to checked on the resident because the resident was not able to call the light for assistance. The resident cooperated when the care was provided, hospice staff comes to provide care. Interview with Staff B, a Certified Nursing Assistant (CNA) on 09/22/2022 at 11:41 AM. Staff B reported that the resident was not aggressive when the care is provided. The resident sometimes refused to be assisted, but she waited for a while and then the resident permitted to be assisted. Interview with the Social Services Director on 09/22/2022 at 12:03 PM. The Social Services Director stated that she was not in charge to make decisions to request Level II PASRR for a resident. The Interdisciplinary Team (IDT) had meetings to discuss the resident's diagnosis and the decision was made among the members of the team. The Director of Nursing (DON) was in charge of requesting a Level II PASRR. Interview with the Director of Nursing on 09/22/22 at 12:47 PM, revealed the resident was admitted on [DATE]. The Level I PASRR was done by the hospice care company. She stated the PASRR was reviewed by the IDT. We did not realize that the resident had diagnosis in section I and other indications in section II, it was a mistake not to request a Level II PASRR. Review of facility Policies and Procedures for Preadmission Screening Resident Review (PASRR) revised 11/01/2011. Purpose: Preadmission Screening and Resident review (PASRR) is a Federal requirement which is designed to prevent inappropriate placements of individuals in Skilled Nursing Facilities (SNFs). Regardless of payor source, all individuals seeking admission to a Medicaid certified SNF must be screened for possible Serious Mental Illness (MI) and /or Mental Retardation (MR) or related condition, prior to admission. Procedure: 2- If the PASRR indicates MI and/or MR or a related condition appears to exist, the individual must be referred to the appropriate state agency by the acute care hospital staff for further evaluation (Level II Evaluation and Determination) before the individual is admitted unless specific exclusionary criteria stated on the PASRR is met. If the SNF allows the admission prior to the completion of the Level II Evaluation and Determination, then the SNF will notify the appropriate state agency. .