**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of facility policy, the facility failed to immediately notify a resident representative about a change in condition for one resident (Resident # 2) out of three residents sampled for changes in condition. Findings included: Review of an admission record revealed Resident # 2 was admitted to the facility on [DATE] with diagnoses of cerebral infarction and history of falling. Review of an order summary dated 3/1/2025 showed, apply steri strips to wounds on right forehead. Monitor every shift until healed. Review of a clinical note dated 3/1/2025 at 12:53 a.m. showed, Resident found lying on the floor in [room number]. Laceration noted to right forehead and right shoulder, steri strips applied, [physician] notified. daughter to be notified in the morning. Review of an eINTERACT Change in Condition Evaluation dated 3/1/2025 at 5:32 a.m. revealed under Section A. Signs and Symptoms Identified, Resident # 2 had a fall in the morning and obtained a skin wound or ulcer. Review of section B6. Skin Status Evaluation showed Resident # 2 skin changes were a laceration and skin tear on the right shoulder and above the right eye. Review of a System Note dated 3/1/2025 at 6:23 a.m. showed Resident #2 was sent to the hospital on 3/1/2025 at 6:15 a.m. for a head injury. During an interview on 4/22/2025 at 1:25 p.m. with the Nursing Home Administrator (NHA), Risk Manager (RM), and Director of Nurses (DON), the RM stated Resident # 2 had a fall on 3/1/2025 at 12:54 a.m. The resident was found lying on the floor next to the air conditioner in the room next door to her room. She sustained a laceration on her right forehead and on her shoulder. The nurse assessed the resident, conducted neurological checks, and steri-strips were applied. The nurse documented the resident did not have any signs of pain, mood, or behavior after the fall. Her vital signs were in normal limits before the resident went out to the hospital. The nurse documented she notified the on-call physician and noted she would notify the daughter in the morning. The RM stated when she asked the nurse why she waited four hours later to notify the daughter, the nurse stated she did not feel there was anything critical going on with the resident that she needed to wake the daughter up at the time. The RM stated when the daughter was notified about the fall, she came to the facility to see her mother and requested her mother be sent out to the hospital because she was concerned about the bruise she saw on her mother. Review of the facility policy titled Incidents and Accidents, last reviewed on 10/14/2024, showed the following: Compliance Guidelines: 11. The resident's family or representative will be notified of the incident/accident and any orders obtained or if the resident is to be transported to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of facility policy, the facility failed to immediately notify a resident's primary care provider to receive instructions for a change in condition for one resident (Resident # 2) out of three residents sampled for changes in condition. Findings included: Review of an admission record revealed Resident # 2 was admitted to the facility on [DATE] with diagnoses of cerebral infarction and history of falling. Review of an order summary dated 3/1/2025 showed, apply steri strips to wounds on right forehead. Monitor every shift until healed. Review of a clinical note dated 3/1/2025 at 12:53 a.m. showed, Resident found lying on the floor in [room number]. Laceration noted to right forehead and right shoulder, steri strips applied, [physician] notified. daughter to be notified in the morning. Review of an eINTERACT Change in Condition Evaluation dated 3/1/2025 at 5:32 a.m. revealed under Section A. Signs and Symptoms Identified, Resident # 2 had a fall in the morning and obtained a skin wound or ulcer. Review of section B6. Skin Status Evaluation showed Resident # 2 skin changes were a laceration and skin tear on the right shoulder and above the right eye. Review of a System Note dated 3/1/2025 at 6:23 a.m. showed Resident #2 was sent to the hospital on 3/1/2025 at 6:15 a.m. for a head injury. During an interview on 4/22/2025 at 1:25 p.m. with the Nursing Home Administrator (NHA), Risk Manager (RM), and Director of Nurses (DON), the RM stated Resident # 2 had a fall on 3/1/2025 at 12:54 a.m. The resident was found lying on the floor next to the air conditioner in the room next door to her room. She sustained a laceration on her right forehead and on her shoulder. The nurse assessed the resident, conducted neurological checks, and steri-strips were applied. The nurse documented the resident did not have any signs of pain, mood, or behavior after the fall. Her vital signs were in normal limits before the resident went out to the hospital. The nurse documented she notified the on-call physician and noted she would notify the daughter in the morning. The RM stated when she asked the nurse why she waited four hours later to notify the daughter, the nurse stated she did not feel there was anything critical going on with the resident that she needed to wake the daughter up at the time. The RM stated when the daughter was notified about the fall, she came to the facility to see her mother and requested her mother be sent out to the hospital because she was concerned about the bruise she saw on her mother. The RM stated the daughter was very upset she was not notified about her mother at the time of the incident. The RM stated when she called the nurse to interview her, the nurse stated she never spoke to the resident doctor that night, but she left a voice message on the doctor's phone. The nurse stated she called the on-call number and left a message with the on-call service. The RM stated the nurse's story kept changing, so they reported her license to the board and she was terminated because she would not cooperate with the investigation. The DON stated the nurse documented in her progress note she notified the doctor, but she did not notify the doctor and the on-call doctor services said they did not have a record of a message from that night. The DON stated when she reached out to the resident's provider, he said he was on call that night and he would have gotten the message but he did not receive a call or have a message from the facility about Resident #2's fall. Review of the facility policy titled Incidents and Accidents, last reviewed on 10/14/2024, showed the following: Compliance Guidelines: 9. The nurse will contact the resident's practitioner to inform them of the incident/accident, report any injuries or other findings, and obtain orders, if indicated, which may include transportation to the hospital dependent upon the nature of the injury(ies).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to provide physician follow-up for catheter care and recurrent urinary tract infection (UTI) in a timely manner for two residents (#165 and #60) out of three residents sampled. Findings include: On 7/25/2024 at 4:24 p.m., an interview was conducted with the facility's Infection Control Preventionist (ICP) regarding antibiotic stewardship related to antibiotics as a prophylaxis. The ICP stated there were a few residents in the facility on long term prophylaxis antibiotics and there is a justification in the resident's chart to indicate the rationale. The ICP stated the residents' urologists are the primary physicians who will place the orders. 1. Resident #165 was admitted on [DATE] with a primary diagnosis of nontraumatic subarachnoid hemorrhage from unspecified intracranial artery. Secondary diagnoses included Type 2 Diabetes without complications, obstructive and reflux uropathy unspecified, Benign Prostatic Hyperplasia with lower urinary tract symptoms, cystitis unspecified without hematuria, and major depressive disorder recurrent unspecified. A review of the July 2024 physician orders showed the following: -catheter change every month and as needed (PRN), -Foley care every shift and PRN, -irrigate Foley catheter PRN every 24 hours as needed for catheter blockage or leakage, -Methenamine Hippurate tablet five 1 gram by mouth two times a day for recurrent UTIs. A review of Resident #165's Minimal Data Set (MDS) dated [DATE] under Section C- Cognitive Patterns has a Brief Interview for Mental Status (BIMS) of 15 indicating cognition is intact. Section H- Bladder and Bowel has resident with an indwelling catheter. Section H0200 Urinary Toileting Program marked as NO for trial of a toileting program. A review of Resident #165's 3008, dated 8/25/2022, showed the resident had urinary retention requiring intermittent catheterization's. A review of a urology note, dated 12/02/2022, for Resident #165 showed the following: He had a stroke and was unable to void, he was supposed to be straight catheterized but they were not doing this at his facility and he ended up hospitalized with retention and Urosepsis from Klebsiella. I will write an order to change his catheter at his facility now and once a month with a 16 French Foley. I will also start him on prophylactic Methenamine to prevent further infections. Follow up in three months to reassess. A review of Resident 165's medical record revealed no further follow up to a urologist was noted until 7/17/2024. A review of Resident 165's physician progress notes, dated 7/17/2024, showed the following: Urology F/U [follow up] [physician name]: Retention, Void trial Resident #165 had three positive urinary tract infections (12/07/2024,10/07/2023 and 12/01/2022) for Proteus Mirabilis (a member of the bacterial family Enterobacteriaceae or E. coli). A search from the NIH (National Institute for Health), National Library of Medicine at (https://www.ncbi.nlm.nih.gov/books/NBK442017/) states proteus mirabilis is a gram-negative bacterium which is well known pathogen of the urinary tract, particularly in patients undergoing long-term catheterization [photographic evidence of article]. 2. Resident #60 was admitted to the facility on [DATE] with a primary diagnosis of urinary tract infection site not specified. Secondary diagnoses included atrial fibrillation, nonrheumatic aortic valve stenosis, peripheral vascular disease, fall, Type 2 Diabetes Mellitus with diabetic neuropathy, depression, and flaccid neuropathic bladder not elsewhere classified. A review of the July 2024 physician orders showed the following: -catheter change every month and PRN for malfunction or dislodgement -irrigate Foley catheter with 30-60 milliliters of normal saline as needed for blocked catheter A review of Resident #60's MDS, dated [DATE], revealed: -Section C- Cognitive Patterns a BIMS of 14 indicating cognition was intact. -Section H- Bladder and Bowel resident with an indwelling catheter. -Section H0200 Urinary Toileting Program marked as NO for trial of a toileting program. On 7/25/2024 at 2:00 p.m., an interview was conducted with Staff A, Registered Nurse (RN)/Unit Manager. Staff A stated a family member makes the arrangements for a resident to follow-up with doctor appointments. She stated follow-up appointments had not been arranged with a urologist regarding Resident #60's indwelling catheter. A review of the facility's policy titled Resident Rights, dated 1/22/2024, revealed the following: Policy: The resident has a right to a dignified existence self-determination, and communication with and access to persons and services inside and outside the facility. Planning and implementing care: The resident has the right to be informed of, and participate in, his or her treatment, including the right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition. A review of the facility's policy titled Urinary Catheters, dated 10/24/2023, revealed the following: Policy explanation and compliance guidelines: .4. Physician should document within the order for the use of the catheter, the diagnosis or clinical conditions making catheterization necessary. i. Documentation is the medical record should reveal attempts to manage the incontinence and increase bladder function without the use of an indwelling catheter; Bladder training programs, prompted voiding schedules or external catheters ii. Documentation in the medical record should reveal continual assessment for use of the catheter. iii. The plan of care should address catheter use, hydration programs and strategies to prevent urinary tract infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to assess and monitor a dialysis catheter per facility policy for one resident (#191) out of one resident sampled for dialysis. Findings included: On 07/24/24 at 11:48 a.m. Resident #191 was observed sitting in a bedside chair in the room. The resident's shirt was protruding on the upper right chest wall area. The resident lifted his shirt up to show surveyor his dialysis catheter site located on the upper right chest wall. The resident stated he has been off dialysis for a couple weeks and was supposed to get his shunt out soon. A review of the medical record revealed Resident #191 was admitted to the facility on [DATE] with diagnoses including End Stage Renal Disease (ESRD), urinary tract infection, and Type II Diabetes Mellitus with diabetic neuropathy. A review of the Form 3008, dated 04/23/24, showed the following: -Section V treatment devices IV [Intravenous Therapy]/PICC [Peripherally Inserted Central Catheter]/ Portacath. Access box is check-marked with type listed as right subclavian D.L [double lumen] dialysis site. Review of the physician orders for July 2024 revealed: - No Blood Draws or BP[Blood Pressures] on RUE[Right Upper Extremity] due (Dialysis port). - Change dressing (RU [Right Upper] chest dialysis port). every day shift every Wed [Wednesday]for (RU chest dialysis port) Dressing change protocol. AND as needed for (RU chest dialysis port) Dressing change protocol. When soiled or dislodged. Dated 07/24/24 at 1:08 p.m. - Monitor area (RU chest dialysis port) for s/s [signs and symptoms] of infection (redness, heat, drainage or bleeding). every shift for (RU chest dialysis port). Dated 07/24/24 at 1:02 p.m. Review of the Minimum Data Set (MDS), dated [DATE], revealed: - Section O showed special treatments, procedures and programs section J1. Dialysis marked yes, section 01. IV marked yes. - Section M showed the application of nonsurgical dressing marked yes. - Section C showed a Brief Interview for Mental Status score of 15 indicating no cognitive impairment. Review of the nurse's progress notes, for July 1, 2024, through July 23, 2024, revealed no daily assessment or monitoring documentation of a dialysis shunt site. Review of the nurse progress note on 07/24/24 at 1:12 p.m. showed Order for site being monitored q [every] shift for s/s of infection obtained and weekly dressing change and PRN if is soiled or dislodged. Orders entered in [electronic health system]. Staff will monitor. Review of the care plan, dated 04/25/24, revealed: - A focus of Resident has potential for spread of MDRO [multidrug-resistance organism] related to presence of dialysis port (an indwelling medical device; chronic wound, infection or colonization with a CDC targeted MDRO when Contact Precautions do not apply) Date Initiated: 04/29/2024 Revision on: 07/24/2024. - A focus of RESOLVED: Receives dialysis r/t [related to]: ESRD [End stage Renal Disease] Date Initiated: 04/25/2024 Revision on: 07/24/2024 Resolved Date: 07/24/2024. An interview was conducted on 07/24/24 at 12:43 P.M. with Staff A, Registered Nurse (RN). She stated Resident #191's dialysis catheter was still in place. She stated she would expect an order in place to check the port site until it is removed and stated there was no order currently in place. An interview was conducted on 07/24/24 at 1:24 PM with the Director of Nursing (DON). She stated Resident #191 was last dialyzed on 07/01/24 and his dialysis catheter was still in place. She stated her expectation would be a physician's order in place for monitoring the dialysis site and a dressing change order for the duration of the dialysis catheters presence. Review of the facility policy titled Dialysis Communication and Site monitoring, dated 11/28/2016 and reviewed on 10/24/2023, revealed the following: .Procedure #6 The shunt site is to be assessed daily and documented in the clinical chart. If there is any change or problems noted with the shunt site, these are to be documented in the medical record with a nurse note and the MD is to be notified for follow up. Procedure #7 If dialysis does not occur for any reason, the facility will: notify MD for further orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #101 was admitted to the facility on [DATE] with diagnoses to include sleep apnea and acute tracheitis without obstruction. An observation was conducted on 7/22/2024 at 10:56 a.m. revealed Resident #101 was lying in bed, with the ventilator display reading PEEP OFF. A review of Resident #101's physician orders for July 2024 revealed the following: -7/22/2024 1:00 p.m. for ventilator alarms on, six times a day for alarm check. -7/22/2024 for PEEP (positive end expiratory pressure) alarm set at +20 and -20 (high and low setting at which the alarm will activate) every day and night shift for monitor settings. -7/23/2024 7:00 a.m. for PEEP alarm set at +11 and -6 every day and night shift for monitor settings. (Photographic Evidence Obtained) A review of Resident #101's progress notes revealed: -7/23/2024 6:43 p.m., Incident SBAR (situation, background, assessment, and recommendation) Nurse's Description: On 7/22/2024 noted PEEP alarm reading off on the ventilator, setting in place. Resident's description of what happened: n/a Witnesses? Yes/No: Staff K, Respiratory Therapist (RT) Injuries?: None Immediate Actions taken: Assessment of child complete, vital signs stable, oxygen saturation 99%. No noted Respiratory distress. No ill effects noted. Alarm turned on. Predisposing factors: Notifications: Medical Director notified. Family member notified. During an interview on 7/23/23 at 10:00 a.m. with Staff H, Respiratory Therapist, he stated that ventilator alarms go off frequently. He stated if he is with another child, the nurses check on the child that has the alarm and notify him if they need any further assistance. Staff H stated most alarms reset themselves and can be caused by movement, coughing, or sometimes mucous obstructions. He stated an alarm can be flashing on the ventilator screen but does not indicate it is a current alarm. The previous alarm will flash on the screen until it is cleared. Staff H stated this way; anyone can tell what alarm the child had last. He stated he did not know if there was any memory on the ventilator that stored previous alarms. Staff H stated he would not turn off any alarm unless ordered by a doctor because every alarm has a reason. 4 Resident #130 was admitted to the facility on [DATE] with diagnoses to include pneumothorax, other chronic respiratory diseases originating from perinatal period, paralysis of vocal cords and larynx, disturbances of salivary secretion, tracheostomy, and dependence on respirator (ventilator). An observation was conducted on 7/22/2024 at 10:56 a.m. Resident #130 was lying in bed. Resident #130's ventilator display read PEEP OFF. A review of Resident #130's physician orders for July 2024 revealed: -7/22/2024 1:00 p.m. for ventilator alarms on, six times a day for monitor alarms. -7/23/2024 7:00 a.m. for PEEP alarm set at +11 and -3. A review of Resident #130's progress notes revealed: -7/23/2024 7:02 p.m., Incident SBAR Nurse's Description: On 07/22/2024 noted PEEP alarm reading off on the ventilator, settings in place. Resident's description of what happened: N/A Witnesses? Yes/No: Staff K, RT Injuries?: NONE Immediate Actions taken: Assessment of child complete, vital signs stable, oxygen saturations 99%, no noted respiratory distress, no ill effects noted. Peep alarm turned on. Predisposing factors: Notifications: Medical Director notified. Family member notified. Review of the facility's policy titled Mechanical Ventilator, dated 7/22/24, revealed the following: Policy Residents who require mechanical ventilation will be cared for in accordance to Federal, State and local guidance and with current standards of practice. Definition: Mechanical Ventilation may be defined as a life support system designed to replace or support normal ventilator lung function . Compliance Guidelines: 1. The facility will ensure that there is sufficient numbers of trained, competent, qualified staff, consistent with State practice acts/laws when providing mechanical ventilation. 2. The facility will identify who is responsible for the following: c. Setting the ventilator: d. Monitoring the ventilator; e. Response to ventilator alarms; 3. The physician/ practitioner will write an order for the mechanical ventilation to include at a minimum the mode, rate, tidal volume, oxygen concentration, and desired level of positive end expiratory pressure (PEEP), and pressure support, if applicable. (Include any other pertinent information for the order.) 5. Appropriate staff will be trained and maintain competency in the use of mechanical ventilation to include: c. Use and maintenance of the ventilator system according to manufacturer's instructions g. Responding to alarms . Based on observations, interviews, and record review, the facility failed to ensure the positive end-expiratory pressure (PEEP), a pressure applied by the ventilator at the end of each breath to prevent the collapse of the tiny air sacs in the lung, alarm was audible in accordance with professional standards for four residents (#61, #184, #101, and #130) out of thirteen residents requiring mechanical ventilation support. Findings Included: 1. On 7/22/24 at approximately 9:55 a.m. Resident #61 was observed lying in bed with a tracheostomy tube connected to a LTV 1150 mechanical ventilator. A red-letter sign displaying PEEP OFF was observed on the front panel screen. According to the ventilator manufacturer the PEEP display on the LTV 1150 mechanical ventilator shows the pressure in the airway circuit at the end of expiration. Resident #61 was admitted to the facility on [DATE]. Resident #61's active diagnoses included metachromatic leukodystrophy (a rare genetic disorder that affects the brain and nervous system), cerebral palsy, and seizures. Resident #61's Minimum Data Set (MDS) assessment, dated 7/1/2024, revealed the following: -Section GG, Functional Abilities and Goals, showed impairment to both arms and legs, severely cognitively impaired and uses a wheelchair for mobility. Resident #61 required a helper for all activities of daily living, including rolling in bed and transferring from bed to wheelchair. -Section O, Special Treatments, Procedures, and Programs showed Resident # 61 requires oxygen therapy, invasive mechanical ventilation, tracheostomy care and suctioning. Review of Resident # 61's orders, active as of 7/24/24, showed the following: -End-tidal carbon dioxide (ETCO 2), (adequacy with which carbon dioxide (CO 2) is carried in the blood back to the lungs and exhaled), check once per shift and as needed. -Fraction of inspired oxygen (FiO2), (the concentration of oxygen to maintain sat [oxygen saturation], a measurement of how much oxygen is in the blood) greater than 92%. -Lavage and suction every shift for increased secretions, pressure alarm on when in room for respiratory care, dated 11/5/22. -Ventilator heater on when in room every shift for vent care, dated 11/05/22. -Ventilator settings Tidal Volume (VT) 330, respiratory rate (RR) 12, pressure Support (PS) 10, PEEP 6, check and document every four hours what actual settings six times per day for respiratory care, dated 4/27/22. -Ventilator alarm six times a day for monitor alarms [sic], dated 7/22/24. -PEEP alarm set at (+) 10, (-) 3 every shift, dated 7/23/24. Review of Resident # 61's care plan, dated 4/21/22, focused on potential impaired gas exchange due to dependence tracheostomy and ventilator. The goal was to maintain a patent airway and oxygen saturation levels greater than 94%. The interventions included monitor for signs and symptoms of respiratory infections/ distress, ventilator orders per medical doctor (MD) orders. 2. On 7/22/24 at 10:10 a.m. Resident #184 was observed lying in bed with a tracheostomy tube connected to an LTV 1150 mechanical ventilator. A red-letter sign displaying PEEP OFF was observed on the front panel screen. According to the ventilator manufacturer the PEEP display on the LTV 1150 mechanical ventilator shows the pressure in the airway circuit at the end of expiration. Resident #184 was admitted to the facility on [DATE]. Resident #184's active diagnoses included respiratory failure with hypoxia (low blood oxygen), Hypoxic ischemic encephalopathy (HIE) (brain injury that happens around birth when oxygen or blood flow to the brain is reduced or stopped), cerebral palsy, epilepsy, and intellectual disabilities. Resident #184's MDS, dated [DATE], revealed the following: Section C, cognitive patterns, showed cognitive skills for daily living is severely impaired, Section GG, Functional Abilities and Goals, showed impairment of both arms. A helper does all the effort with all activities of daily living including rolling in bed. Resident #184 uses a wheelchair for mobility. Section O, Special Treatments, Procedures, and Programs showed Resident # 184 requires oxygen therapy, invasive mechanical ventilation, tracheostomy care and suctioning. Review of Resident #184's active orders as of 7/1/24 showed orders to include: -ETCO2 check once each shift and as needed, -Fi02 to maintain sats greater than 92% every shift, -give cough assist for three cycles every six hours, -lavage and suction every shift as needed for increased secretions, -pressure alarm on when in room every shift, dated 1/4/24, -respiratory treatments two times per day, -vent heater when in room, -ventilator settings check and document six times per day what actual settings are RR 10, PC 15, inspiratory time 1.0, PS 10, PEEP 12 -Fi02 to maintain sats greater than 92% six times per day for respiratory care. Review of Resident # 184's care plan, undated, focused on tracheostomy, the goal is Resident #184 will not have signs or symptoms of infection. The interventions include lavage and suction for increased secretions. A second care plan focused on Resident #184's oxygen therapy. The goal is Resident #184 will not have signs or symptoms of poor oxygen absorption. The interventions include monitor for signs and symptoms of respiratory distress and report to the medical doctor. During an interview on 7/22/24 at 11:00 a.m. Staff L, Licensed Practical Nurse (LPN) said she did not know why the ventilator PEEP alarms were turned off. During an interview on 7/22/24 at 11:05 a.m. Staff I, LPN, Unit Manager (UM), referred the question to the respiratory therapist. During an interview on 7/22/24 at 11:18 a.m. Staff E, Respiratory Therapist (RT) confirmed the PEEP alarms were off. Staff E, RT said the alarm is triggered when resident's hiccups or when there is water in the high pressure tubing and pointed to a clear plastic tubing connected to the blue corrugated ventilator tubing. Staff E said the RT checks the ventilators every four hours. During an interview on 7/22/24 at 1:06 p.m. with the Director of Nursing (DON), Regional Nurse Consultant (RNC) and the Nursing Home Administrator (NHA), the NHA said the facility's leadership team is aware of the concerns related to the PEEP alarms and they are in discussions and will implement corrective measures today. During an interview on 7/22/24 at 3:18 p.m. with the Pediatric Medical Director, Nursing Home Administrator (NHA), Director of Nursing (DON), Regional Nurse Consultant (RNC) and Assistant Nursing Home Administrator ANHA). The Pediatric Medical Director stated, If the PEEP alarm is the only thing off, other alarms would trigger. He said, The PEEP is an extra caution alarm, if disconnected other alarms would alert staff. The Pediatric Medical Director said he expects RTs to follow orders and adjust per orders. He said alarms are there for a reason To protect the patient. During an interview on 7/23/24 at 12:45 p.m. with Staff H, Respiratory Therapist (RT), said he is familiar with the LTV 1150 mechanical ventilator, and it is the only ventilator currently in use at the facility. Staff H, RT said the low PEEP alarm indicates the resident is losing pressure, this affects oxygenation and may be triggered by disconnection from the machine, a mucus plug or improper seal of the tracheostomy tube cuff. He stated the high PEEP alarm may indicate there is air trapping which could be caused by a mucus plug, coughing, hiccups or high inspiratory pressure. He stated when the PEEP alarm is triggered by the ventilator the resident is assessed to identify issues with the resident, tracheostomy tube or the ventilator. The RT stated the resident may require suctioning, check the cuff, or administer a breathing treatment. Staff H, RT said, I would never turn off alarms, not my practice unless there is a doctor's order, this is for safety. He said the Florida Board of Respiratory Care does not endorse turning off ventilator alarms without a physician's order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to identify, assess, and respond in a timely manner to a resident's change in condition related to a wound for one (Resident #1) of four residents reviewed. Findings included: Resident #1 was admitted to the facility on [DATE] with a primary diagnosis of nondisplaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing. Review of a care plan dated 03/15/24 showed Resident #1 had alteration in skin integrity related to incontinence, impaired mobility, a sacrum pressure ulcer, and a left heel skin tear posterior right lower leg. Interventions included to assist with transfers and positioning during rounds as resident allows cushion in wheelchair, dermatology consult, dietary consult as ordered, educate resident on the importance of offloading and pressure reduction as appropriate, encourage fluid intake with and between meals and increase protein in diet, and float heels while in bed as resident will allow. Observe and assess skin for signs/symptoms of redness, drainage, blisters, or evidence of skin breakdown. Observe and assess wound/ulcer for signs/symptoms of increased redness, swelling, warmth or purulent drainage. Apply skin prep heels x 21 days. Follow treatment per MD (Medical Doctor) orders and weekly skin checks. A focus in the care plan dated 10/13/23 showed Resident #1 was receiving an anti-coagulant with interventions to evaluate for bruising. On 04/22/24 at 11:59 p.m., an interview was conducted with Resident #1's family member/ POA (Power of Attorney). He stated on 03/12/24 he was at the facility visiting Resident #1. He stated while visiting with the resident in the dining room, he had noticed the resident had a wound that was weeping at the back of her right leg. He stated he reported his concerns to the nurses, and they did not respond. He said, they were not aware, they did nothing. They did not even attempt to come and see what the issue was. The wound on the back of her leg was filled with puss and was draining to her socks. Her socks were soaking wet. The family member said, We are not trying to be adversarial. It was neglectful. The draining fluid was running down to her socks. This didn't occur overnight. They said this was happening because of the Velcro on her left boot. They don't analyze or accept anything. It's systemic. We notified Staff A, Registered Nurse (RN)/ Unit Manager. My partner went to the desk and notified her. The family member stated Staff B, RN was also at the desk. He stated they never came to look at the resident's leg. The family member stated they were at the facility until after 6 p.m. and the nurses never came to assess the resident. The family stated this was not the first time they failed to identify a concern. He stated sometime in February he had notified the facility of an infection to the resident's right thumb. He stated no one was aware and no one had done anything about it. On 04/23/24 at 11:47 a.m., an interview was conducted with Staff B, RN. She stated she remembered the family coming up to the desk. She said, it must have been a Tuesday night I believe the 12th between 3 p.m. and 4 p.m. The family brought her [Resident #1] to the desk. She was in her wheelchair and reported there was some drainage on her leg. At the time [Staff A, RN] was going to be coming on shift. She said she would look at the leg when she got the resident in bed or as soon as possible . The family was still visiting when I left. Staff B stated the next day [03/13/24], she did rounds and noticed the resident had redness, serious drainage and weeping from the back of her leg. She stated she discussed this with Staff A. She stated Staff A was not going to pick up the resident for wound care, but she was going to put her on antibiotics. Staff B confirmed there were no notes indicating this conversation and course of treatment. She said, I do not see it under progress notes, we discussed it with the wound care nurse who no longer works at the facility.[Staff A] was to obtain orders. On 04/23/24 at 1:02 p.m., an interview was conducted with Staff A, RN/UM. She stated early in March the family was visiting. She stated they had reported Resident #1 had a skin tear to the right calf, and it was weeping. She stated the resident caused the injury. Staff A said, I was walking down the hall, there was another person with the family member. They said, [Resident #1] had something on her foot. I went and looked at her leg, she was in a wheelchair, she was wet. I asked the CNA [Certified Nursing Assistant] to change her and put her in bed. [Staff B, RN] was with me, we both looked at her. Staff A stated the resident crossed her foot with the boot she was wearing at that time and caused the injury. Staff A stated she obtained an order for wound care and doxycycline for 10 days. Review of a progress note documented by Staff A, RN on 03/14/24, showed Nurse's Description: CNA on duty notified writer that resident has an area that it look little red and is moist, writer went into the resident's room and skin tear is observed in the posterior part of the right lower leg, area looks little red, moist, mild clear drainage with no odor noted. MD [Medical Doctor] made aware about the new skin area and order to clean are with NS (Normal Saline) pad and dry, apply xeroform and cover with bordered gauze was given. Also, to monitor site for s/s (signs or symptoms) of infection and ABT (antibiotic) BID (two times daily) x 10 days was given due to the little redness and the clear drainage. All the orders are placed in [a software documentation program]. Wound care performed and well tolerated. Resident observed on daily basis to try to cross the right leg over the left leg. Resident uses a Podus boot on the left foot and the Velcro part touches and rubs the same area that was reported as per CNA on duty. POA made aware and no questions or concerns were expressed at this time. Staff will continue to monitor. Resident's description of what happened: None. Witnesses? Yes/No: None. Injuries: Skin tear posterior right lower leg. Immediate Actions taken: Assessment performed. MD made aware, new orders obtained and placed in PCC. Wound care performed. POA made aware. Predisposing factors: Resident has active wounds. Resident is on diuretics, cardiac meds, and anticoagulants. Assist x 1 for transfers and ADLs (Activities of Daily Living). Resident seen by therapy for wheelchair positioning. Resident observed in daily basis to try to cross the right leg over the left leg. Resident uses a Podus boot on the left foot and the Velcro part touches and rubs the same area that was reported as per CNA on duty. Notifications: MD made aware and POA notified. This documentation confirmed Staff A,RN responded to the change in condition on 03/14/24 and not 03/12/24 when she was first notified. Review of Resident #1's skin assessment dated [DATE] revealed there were no concerns documented related to the right foot infection. Review of a progress note documented by Staff A, RN, dated 02/01/24 showed, Clinical Note Text: Resident's son approached writer regarding his mom right thumb being red close the nail. Area looks little red, no open area, no drainage or bleeding. Resident denied pain and stated it just bothered when it's being touch. Finger nail observed to start having slight change in color and texture. MD made aware and new orders were given to start ABT and Dermatology consult. New orders placed in [a software documentation program]. POA made aware and no questions or concerns were expressed at this time. Staff will continue to monitor. A progress note dated 02/01/24 showed, Infection note: Note Text: Abt/Rt thumb in progress. First dose pulled via EDK (Emergency Drug Kit). No adverse effects noted. C/o (complaint of) pain this shift, Tramadol given + effect. VS WNL (vitals within normal limits). All safety measures in place with call light within reach. On 04/23/24 at 2:10 p.m. an interview was conducted with Staff A, RN, The Director of Nursing (DON) and the Regional Nurse Consultant (RNC). The DON stated when the thumb incident was reported they educated all staff about monitoring and assessing residents. She stated if the CNAs found any concerns with the skin, they should document in the task log. She stated the task log asks the question if there are new changes. This would mean a new change to the staff documenting. If they answer Yes, the system will send a notification to some key staff members such as the DON and the Unit Managers. She confirmed the family had notified them of the two incidents. On 04/23/24 at 2:15 p.m., The DON reviewed a document titled, Follow -up Question Report, dated 02/01/24 to 02/07/24 and 03/10/24 to 03/15/24. The DON confirmed the CNA's had not reported any changes to the resident's skin. She confirmed they had not received any alerts on changes to the resident. On 4/23/24 at 10:02 a.m., an interview was conducted with Staff C, RN QIC (Quality Infection Control) nurse. She stated she had started education for the nursing staff on identifying change in condition, addressing family concerns in a timely manner. She stated she understood the family's concern. She said, What might have appeared normal to a nurse would be perceived differently by a family member. I understand. The nurse should have taken the time to go see the resident. An interview was conducted with the Nursing Home Administrator (NHA) on 04/23/24 at 11:02 a.m. She stated they will address the change in condition concerns. The nurse should have contacted the family. The nurse should have responded to the family in a timely manner. We will educate about assessing resident's needs. Review if a facility policy titled, Change in a resident's condition, dated 10/22/23, showed a change noted in a resident's condition is reported as soon as practical to charge nurse. The procedure showed A. notify the charge nurse when any condition occurs in the resident including but not limited to (1.) anything that seems different than usual. (11.) change in skin color or condition; red areas on skin, skin tears, bruises. C. Evaluate reported changes in resident condition performed by a licensed nurse. D. Report findings to Health Care Provider and resident representative, as indicated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and policy review, the facility failed to ensure clean and sanitary equipment and floors for two of two units and eleven of seventeen rooms where tracheostomy residents reside. Findings included: An observation was conducted on 4/22/24 at 1:14 p.m. in room [ROOM NUMBER] of an oxygen concentrator that had dried liquid splatter on it as well as dust. The suction canister base and motor had debris and dust. There was a fan clipped to a pole at the bedside that was covered in dust. (Photographic evidence obtained.) An observation was conducted on 4/22/24 at 1:18 p.m. in room [ROOM NUMBER] of a IV (Intravenous) pole that had dried splatter on the base. The suction canister and motor set up had dust and debris on it. (Photographic evidence obtained.) An observation on 4/23/24 at 9:56 a.m. revealed the equipment in rooms [ROOM NUMBERS] remained in the same condition as they were on 4/22/24 at 1:14 p.m. Additional rooms of residents that had tracheostomies were toured on 4/23/24 from 11:30 a.m. to 12:00 p.m. with the following observations: -room [ROOM NUMBER] had an IV pole with dried splatter on the base. (Photographic evidence obtained.) -room [ROOM NUMBER] had a fan at the bedside with dust on it and black marks on the floors. (Photographic evidence obtained.) -room [ROOM NUMBER] had black spots and stains on the floor, a dirty IV pole, a crib bed with dust and debris on the railings, a plastic crib covering with dried liquid, brown splatter on the wall. (Photographic evidence obtained.) -The floor outside the 600 Unit nurses' station was dirty with black marks and spills. (Photographic evidence obtained.) -room [ROOM NUMBER] had a fan at the bedside with dust on it, a piece of tape attaching two pieces of flooring, dirty/stained floors, a dirty IV pole base, trash on the floor, a call light cord that had visible dirty, and a side table with spots/stains and a pink liquid spilled. (Photographic evidence obtained.) -room [ROOM NUMBER] had a dresser with broken drawers and a suction canister base and motor that had dust and debris. (Photographic evidence obtained.) -room [ROOM NUMBER] had a tablet and black stand on wheels that was visibly soiled. (Photographic evidence obtained.) -room [ROOM NUMBER] had a black stand on wheels that was visibly soiled. (Photographic evidence obtained.) -room [ROOM NUMBER] had a basin with towel under a ventilator hose to catch dripping water. The towel had black dirt partially covering the top, an IV pump had dried splatter, and there was another basin catching water dripping from a ventilator hose. -room [ROOM NUMBER] had a cough assist machine that had dried splatter and debris on the top. An interview was conducted on 4/23/24 at 12:12 p.m. with Staff D, Licensed Practical Nurse (LPN). Staff D identified herself as a unit manager (UM) on the 300 unit. Staff D said housekeeping wiped down all the surfaces of equipment in resident rooms. She said nurses should also wipe equipment down if they see that it is dirty. Staff D said nurses also change ventilator tubing and suction canisters weekly and should clean soiled items. She said IV poles were swapped out when they were obviously soiled and the dirty ones were taken out back and sprayed down. She added that housekeeping wiped the poles down and nurses or certified nursing assistants (CNA) could also wipe the poles down if they were soiled. Staff D was observed going to room [ROOM NUMBER] and looking at the fan at the bedside and the suction canister set up. Staff D said, it is disgusting. She said it was not acceptable to have equipment in this condition in resident rooms. She removed the fan and said it needed to go in the trash it was so dirty. An interview was conducted on 4/23/24 at 12:19 p.m. with the interim Director of Nursing (DON.) She stated she did not know who was responsible for cleaning the equipment in resident rooms and she would look into it. She agreed the medical equipment in resident rooms should not have splatters and dust on it. At 12:46 p.m. the DON said nursing and respiratory should be cleaning the suction and IV equipment in the resident rooms. An interview was conducted on 4/23/24 at 12:59 p.m. with the Environmental Services (EVS) Director. She said when it came to medical equipment housekeeping was hesitant to touch it because they did not want to mess anything up, especially if it was being used by a resident. A follow-up interview was conducted on 4/23/24 at 1:01 p.m. with Staff D, LPN/UM. Staff D agreed with the EVS Director and said she believed housekeeping thought nursing cleaned the equipment and nursing thought housekeeping cleaned it. She said it fell through the cracks but was being cleaned now. A follow-up interview was conducted on 4/23/24 with the EVS Director. She said the facility did not have a policy on floor maintenance. She said they rotate doing deep cleaning on the floors in each room. She said the black marks on the floors were stains and she could not get them up. She agreed it did not look good and was not acceptable in resident areas. She was shown the area by the 600 unit nurses station, she said she would try to deep clean that area. Review of a facility policy titled Maintaining a Safe, Clean, Comfortable, and Homelike Environment, reviewed 3/20/24, showed the following: Policy This facility will accommodate, to the extent possible, a personalized, homelike environment that recognizes the individuality and autonomy of each resident. Policy Explanation and Compliance Guidelines . 6. Report any furniture disrepair to Maintenance promptly. 7. Maintain a clean, comfortable, and homelike environment (i.e. ceiling tiles, wallpaper, floor times.) 8. Report any unresolved environmental concerns to the Administrator. Review of a facility policy titled Cleaning and Disinfection of Resident-Care Equipment, reviewed 10/25/23, showed the following: Policy: Resident-care equipment can be a source of indirect transmission of pathogens. Reusable resident-care equipment will be cleaned and disinfected in accordance with current CDC recommendations in order to break the chain of infection. Policy Explanation and Compliance Guidelines: 1. Staff shall follow established infection control principles for cleaning and disinfecting reusable, non-critical equipment. General guidelines include: . b. Each user is responsible for routine cleaning and disinfection of multi-resident items after each use, particularly before use for another resident. c. Direct care staff are responsible for cleaning single-resident equipment when visibly soiled, and according to facility protocol.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure an allegation of abuse and neglect was reported to the governing agency in accordance with the State law for one resident (#2) out of fourteen residents sampled regarding a resident who reported their foot had been caught under a wheelchair and was reporting new onset of pain in that leg. Findings included: On 08/18/2022 at 9:55 a.m., an observation was conducted of Resident #2. She was observed in bed and agreed to answer questions. She reported she had fractured her right leg recently. She stated the cast was just removed, last Friday. She stated an aide was pushing her [on 06/24/2022] and should have had the leg rests on, and they did not. She stated her right leg fell under the wheelchair. She stated it took 2 weeks before she was able to go to the hospital. She stated they (the facility staff) thought I was faking it. She stated her whole leg was in a cast. She stated she thought the man who pushed her in the wheelchair was a volunteer. She reported she currently had pain level of 10 on a scale of 1-10, with 10 being the most severe pain. On 08/18/2022, at 11:30 a.m., Resident #2 was observed with Staff C, Licensed Practical Nurse (LPN). Staff C, LPN stated she was familiar with Resident #2. She stated the resident fractured her right tibia. She stated she was really not sure what happened because she had heard several stories. She stated one version was a volunteer was pushing the resident and the resident's leg went under the wheelchair. A review of Resident #2's admission Record revealed the resident was admitted on 01/2013 with diagnoses including: Diabetes Mellitus due to underlying condition with diabetic nephropathy, acute ischemic heart disease, heart failure, and chronic obstructive pulmonary disease. A review of Resident #2's Annual Minimum Data Set (MDS), dated [DATE], revealed in Section C: Cognitive Function, a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. Section B: Hearing, Vision, and Speech revealed the resident had no impairment and assessed the resident with clear speech-distinct intelligible words; makes self-understood; and understands others-clear comprehension. Section G: Functional Status, revealed Resident #2 required support of two persons for transfer, bed mobility, and dressing. A review of Resident #2's Care Plan revealed the following: Focus: Self-care deficit: Requires assist with ADL's (Activity of Daily Living) due to decreased mobility, initiated on 03/08/2022. Interventions included: Extensive to total, 2 person assist for bed mobility, initiated on 03/11/2022, revision on 08/01/2022. Extensive to total assist with transfers; 2 persons, initiated on 03/11/2022, revision on 08/01/2022. Leg rests are to be on when she is up in w/c, initiated 08/03/2022 Uses a full body mechanical lift for transfers, initiated on 03/11/2022. Uses a manual wheelchair, initiated on 03/11/2022. Focus: Resident has potential for falls related to: unable to bear weight and non-ambulatory, initiated 03/08/2022. Interventions included: 4P's rounding (Check resident for any pain concerns, positioning needs, that personal items are within reach and that personal needs are being met), initiated 03/08/2022. A review of Resident #2's Medication Administration Record (MAR) for 06/2022, reflected a physician order for Tramadol HCL (Hydrochloride) 50 mg (milligram) tablet, give 50 mg orally every 4 hours as needed for pain. A review of the MAR reflected from 06/01/2022 through 06/23/2022, Resident #2's daily administration of the Tramadol fluctuated between 0 to 2 pills daily for pain levels ranging between 4 and 7 out of 10. On 06/24/2022, the resident was administered Tramadol 4 times at 5:12 a.m. for a pain level of 5, at 9:50 a.m. for a pain level of 4, at 4:42 p.m. for a pain level of 8, and at 9:11 p.m. for a pain level of 0. Resident #2 was administered Tramadol for pain on: 6/26, 6/27, 6/28, 6,29, and 6/30 once daily with a pain rating of between 4 and 6. A review of the MAR for 07/2022 revealed Resident #2 continued to receive Tramadol 50 mg for pain as follows: 7/1--at 6:31 a.m. pain level of 7, at 10:37 a.m. pain level of 5, at 4:13 p.m. pain level of 3, at 11:40 p.m. pain level of 7 7/2-at 4:29 a.m. pain level of 10, at 9:30 a.m. pain level of 4, at 4:30 p.m. for pain level of 3 7/3-at 9:37 a.m. pain level of 4, at 7:38 p.m. for pain level of 7, 7/4-at 9:55 a.m. pain level of 4 7/5-at 9:32 a.m. pain level of 4 7/6-at 6:36 a.m. pain level of 3, at 9:29 p.m. pain level of 6 7/7-at 5:29 a.m. pain level of 6, at 10:44 a.m. pain level of 4 7/8-at 6:32 a.m. pain level of 6, at 8:29 p.m. pain level of 6 7/9-at 5:02 a.m. pain level of 6, at 10:04 a.m. pain level of 4 7/10-at 10:06 a.m. pain level of 4 (then sent out to hospital) A review of Resident #2's Progress notes was conducted for the time period of 06/01/2022 to 08/15/2022 which revealed the following: 06/24/2022 9:25 p.m.: [Staff J, Registered Nurse RN]: While completing Tx [treatment] to buttocks Resident stated when being pushed out of her room earlier, the foot rests were not put on, and her R [right] foot went under the w/c [wheelchair]; unable to determine exact situation as resident changing situation if asked multiple times; checked R knee/leg and no swelling, dis-alignment, or redness; able to turn without pain; provided pain medication at resident request. Will have following nurse continue to monitor. 06/27/2022 5:58 a.m. [Staff K, LPN]: C/O [complaint of] Right leg pain. 06/29/2022 2:38 p.m. Psychotherapy progress note .Stated she is still having a lot of leg, foot, and back pain 07/5/2022 2:35 a.m. Tramadol HCL 50 mg given for pain per resident request for bilateral leg pain. 07/06/2022 2:09 p.m. Psychotherapy progress note .Indicated she is having trouble with her legs and has pain when being changed . 07/09/2022 7:22 a.m. [Staff L, LPN] C/O rt leg pain, repositioned without success. Tramadol HCL 50 mg given. 07/09/2022 4:49 p.m. [Staff L, LPN] C/O rt leg pain, repositioned without success. Tramadol HCL 50 mg given 07/09/2022 5:39 p.m. [Staff L, LPN] Resident c/o rt lower leg pain. Call placed to [doctor]. Per call on call obtain x-ray rt knee, rt tibia/fibula, rt foot. Portable x-ray required resident is non ambulatory. 07/10/2022 1:07 p.m. Radiology Results: Results of Right knee, tib/fib and foot x-ray returns with findings of acute proximal tibia fracture. Called on call provider, LM [left message] on personalized VM [voice mail] requesting return call to writer. 07/10/2022 1:32 p.m. Called [Doctor] on call provider number . no answer, left message on personalized voice mail requesting return call to writer regarding radiology results and orders. 07/10/2022 2:33 p.m. Called on call provider for [Doctor] .Left message on personalized voice mail to report tibial fx findings and to obtain orders. 07/10/2022 3:26 p.m. [Doctor] on call ARNP [Advanced Registered Nurse Practitioner] returned call, new orders given to send to ED [Emergency Department] for further eval and Tx of tibial fx. Guardian numbers called x 2 each with no answer. No voicemail set up to leave message. 07/10/2022 3:40 p.m. Resident was sent to [local Hospital] at 07/10/2022 4:00 p.m. for tibial fx 07/10/2022 10:26 p.m. (Incident note) At approx. 8:45 p.m. resident returned to facility with a ½ brace wrapped with ace bandage to RT leg. Resident denies pain at time of arrival. Resident states, I'm so glad I am back. Discharge instructions: No weight bearing to Rt Leg. Follow-up with Dr [Orthopedic] .address within 3-5 days. Script for Norco 5/325 mg every 6 hours as needed for acute pain x 3 days. MD and Guardian aware of resident's return. On 08/18/2022 at 2:29 p.m., an interview was conducted with Staff A, LPN, UM (Unit Manager). She stated if a resident complains of leg pain the nurses are to find out what the pain is from, medicate for pain, let the doctor know, and let the family know. A review of Resident #2's progress notes was conducted with Staff A, LPN, UM, specifically the 06/24/2022 nurse note and the 06/27/2022 nurse note. Staff A, LPN confirmed both entries were missed opportunities to notify the physician and complete an assessment. She said, the resident would complain of pain, but the right leg pain was unusual. On 08/19/2022 at 10:05 a.m. an interview was conducted with Staff B, Certified Nursing Assistant (CNA). She reported she was familiar with Resident #2 and she normally had the same assignment which included Resident #2. She stated before Resident #2 broke her leg they would get her out of bed a lot and she would be put in the manual wheelchair. She stated the chair had regular foot rests. She stated she would always put the leg rests on and sometimes she would put a pillow on because her feet would dangle and angle out. She stated the resident was not able to self-propel and she would need someone to push her. She stated the wheelchair leg rests are extended now since the resident had a broken leg. She said she was not working on 06/24/2022. She stated during a Hoyer lift transfer recently, she did not recall a date, the resident complained about her leg hurting. She stated the resident was crying, I mean crying. She stated she told the nurse, who was an agency nurse, but she did not know the name of the nurse. She stated after the leg event, Resident #2 did not want to get out of bed. Staff B, CNA stated no one had interviewed her or asked her for a statement related to the 6/24/2022 incident involving Resident #2. She denied any additional training related to the incident. On 08/19/2022 at 3:28 p.m., Staff I, CNA was interviewed by phone. She confirmed she was working on 06/24/2022 on the 7 a.m.- 3 p.m. shift and was assigned to care for Resident #2. She stated she assisted Resident #2 on 06/24/22 with care and getting the resident ready to go out of the building. Staff I, CNA, stated she did not take the resident to the main lobby, but recalled one of the people who come and get the residents for the activities came down. She stated it was either a younger guy or the young lady with blond hair but she did not know them. She stated the people just come around and get the residents to take them where they are going. She stated she remembered asking the resident if she needed her leg rests because she always asks. The person said, she will be ok and took her. I do not recall putting the leg rests on the wheelchair. She stated no one had called her about any event on 06/24/2022, this was the first time anyone had reached out. On 08/19/2022 at 2:21 p.m., a phone interview was conducted with Resident #2's Physician. He confirmed he was familiar with Resident #2. He confirmed Resident #2 had an X-Ray on 07/09/2022, was sent to the hospital on [DATE], and she returned with a soft cast to the right leg. He stated he was driving and did not have the medical record in front of him, so specifics, he would have to review in the medical record. He stated he did not recall being notified of the event on 06/24/2022 with Resident #2, the report of the resident's pain, or the allegation her right foot had gone under the wheelchair. He stated, they [facility staff] are instructed to call about ALL problems, we are in the building 2-3 times per week, we are very responsive. He confirmed an X-ray could have been ordered for Resident #2's leg for her pain at the time of the event on 06/24/2022. He confirmed it was a missed opportunity to order the x-ray to identify the fracture at that time. A review of a Resident #2's X-Ray, Radiology Interpretation, date of exam 07/10/2022, reflected the following significant findings: Right Knee, 3 views: Findings: Multiple views of the right knee show a fracture of the proximal tibia. Diffuse osteopenia is present. Moderate osteoarthritis is seen in the tri-compartment joint spaces. There are no joint bodies. There is no knee region soft tissue swelling. There is no joint effusion. There are no radiopaque foreign bodies. Impression: Acute fracture of the proximal tibia. Right Tibia and Fibula, two views: Findings: A fracture of the proximal tibia is visualized. Diffuse osteopenia is present. The joint spaces are preserved. No radiopaque foreign body is seen in the soft tissues. The soft tissues are unremarkable. Impression: Acute fracture of the proximal tibia. On 09/01/2022 at 12:00 p.m. an interview was conducted with the Radiologist. He stated the fracture for Resident #2 was acute and unlikely to be over three weeks old due to no callus formation. He stated on an older person with a lot of osteopenia, like Resident #2, makes a fracture slow to heal and he confirmed the fracture would have occurred within a three-week time period prior to the xray. A review of the facility Report Tracking Log for June 2022 listed no entries. A review of the facility Report Tracking Log, for July 2022 listed the following entries: Resident #2, abuse, date of event 07/10/2022; date of AHCA 1 day 07/10/2022; date of the AHCA 5-day report 07/14/2022. On 08/19/2022 at 12:01 p.m. and again at 2:55 p.m. an interview was conducted with the NHA. The NHA confirmed she was the Abuse Coordinator and Risk Manager for the faciltiy. The NHA stated she was notified of the incident with Resident #2, that occurred on 06/24/2022, on 07/10/2022 at 2:27 p.m. by Staff M, LPN, House Supervisor who called her. She stated it was a Sunday and she immediately came in. The NHA said, she called the Director of Operations and the Regional Clinical Nurse to let them know there was an allegation and a fracture with Resident #2. She stated she told them she going to the building to investigate. The NHA said Staff M, LPN and I went in to interview Resident #2 together. The NHA stated Resident #2 indicated during her interview about the fracture, it was an accident where she put her foot down while being pushed by a volunteer. The NHA confirmed no one had witnessed the event. The NHA stated however, we were unable to validate any volunteer pushing her on said day, 06/24. She stated during the interview with the resident, even though she has a BIMS of 11, she appeared quite lucid at the interview. The NHA stated the resident appeared alert and oriented with no nonsensical conversation. She stated Resident #2 reported she had an incident on 06/24/2022, and she remembered this because it was her special day. The NHA said Resident #2 told her she put her right foot down while being transported to the reception area by a volunteer and she did not think anything serious about it, but, as time has gone on, it had started to hurt more. The NHA stated the resident told her it was her fault for putting her foot down, and when she told the pusher to stop, he did. The NHA stated she thought the resident's right leg had fallen to the bar under the wheel chair. The NHA stated the resident described the male as short and blond and said he could be a volunteer. The NHA confirmed the facility had surveillance cameras, and said I did not check the cameras, I think the cameras only go back one week. A review of the facility policy and procedure, Abuse, Neglect & Exploitation, effective November 2017, revised January 2022, documented the policy: Each resident has the right to be free from abuse, including verbal, sexual, physical, and mental abuse, neglect, corporal punishment, involuntary seclusion, misappropriation of property, exploitation, and any physical or chemical restraint not required to treat the resident's medical symptoms. This prohibition applies to everyone, including, but not limited to, facility staff (employees, consultants, contractors, volunteers, and other caregivers who provide care and services to residents on behalf of the facility), other residents, staff of other agencies serving the resident, family members, legal guardians, friends, or other individuals. This includes mental abuse that is facilitated or caused by facility staff using any type of equipment (e.g., cameras, smart phones, and other electronic devices) to take, keep, use, or distribute photographs, videos, or other recordings, including posting on social media, or in any manner that demean or humiliate a resident(s). Anytime that the nursing facility receives an allegation of abuse, including those involving the posting of an unauthorized photograph or recording of a resident on social media, the facility must comply with the reporting and investigation procedures set forth in this policy and with any state-specific policy and take steps to prevent further potential abuse. Compliance with reporting the reasonable suspicion of a crime must also be followed. Definitions included: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being . Mental Abuse may occur through either verbal or non-verbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation . Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility abuse prohibition plan included: Training: Facility shall develop, implement, and maintain an effective training program for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers consistent with their expected roles . Prevention of Abuse, Neglect, Exploitation of Residents and Misappropriation of Resident Property. The facility will utilize the following techniques for prevention of abuse, neglect, exploitation of residents, and misappropriation of resident property included: . React to all allegations or questions from residents, family members, employees, or visitors. Take appropriate actions when abuse, neglect, exploitation, or misappropriation is suspected. Provide instructions to staff on care needs of residents. Assess, monitor, and develop appropriate plans of care for residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors, . residents with communication disorders and those that require heavy nursing care and/or are totally dependent on staff. Identification of Abuse, Neglect, Exploitation and Misappropriation included: The facility will identify factors indicating possible abuse, neglect, exploitation of residents, or misappropriation of resident property, including, but not limited to, the following possible indicators: Resident, staff, or family report of abuse. Physical injury of a resident, of unknown source. Failure to provide care needs such as feeding, bathing, dressing, turning & positioning. Resident Protection after Alleged Abuse, Neglect, Exploitation, or Misappropriation: The facility will make reasonable efforts to protect any and all residents after alleged abuse, neglect exploitation, or misappropriation. Examples of ways to protect a resident from harm during an investigation of abuse, neglect, and exploitation may include, but are not limited to: Evaluate resident and ensure necessary medical care or treatment is provided and notify treating physician as appropriate. Response and Reporting of Abuse, Neglect, Exploitation, and Misappropriation: Anyone with knowledge or concerns about the care of a resident in the facility must report suspected abuse to the Facility administrator, abuse agency hotline, or file a complaint with the state survey agency and adult protective services (if applicable under state law) immediately (but not later than 2 hours after an allegation is made if the events that lead to the allegation involve abuse or result in serious bodily injury) or not later than 24 hours if the events that lead to the allegation do not involve abuse and do not result in serious bodily injury. Reporting and investigation should be done in accordance with state law/regulation. When abuse, neglect, or exploitation is suspected, the Administrator or designee should: Respond to the needs of the resident and protect them from further incident (document); Notify the Director of Nursing and Administrator (document); Initiate an investigation immediately; Notify the attending physician, resident's family/legal representative and Medical Director. Obtain witness statements, following appropriate policies. Suspend the accused employee pending completion of the investigation. Remove the employee from the resident care areas immediately. Contact the state agency and local Ombudsman office to report the alleged abuse. Monitor and document the resident's condition, including the response to medical treatment or nursing interventions, and document actions taken in steps above in the medical record. Investigation of Alleged Abuse, neglect, Exploitation, and Misappropriation: When suspicion of abuse, neglect, exploitation, or misappropriation or reports of abuse, neglect, exploitation, or misappropriation occur, an investigation is immediately warranted. Once the resident is cared for and initial reporting has occurred, an investigation shall be conducted. Components of an investigation shall include when appropriate; Interview the involved resident, if possible, and document all responses. If resident is cognitively impaired, interview the resident several times to compare responses. Interview all witnesses separately. Include roommates, residents in adjoining rooms, staff members in the area and visitors in the area. Obtain witness statements, according to appropriate policies. All statements should be signed and dated by the person making the statement. Document the entire investigation chronologically. After completion of the investigation, the results of the investigation and any reports or witness statements shall be provided to the facility's Quality Assurance and performance Improvement Committee for further evaluation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and record review, the facility failed to develop care planning problem areas with goals and interventions related to 1. hand covers for one (Resident #58) of three sampled residents related to hand devices; 2. anticoagulant use for one (Resident #107) of five sampled residents; 3. padded side rails for one (Resident #16) of one sampled resident ; and 4. nebulizer medications for one (Resident #175) of three sampled residents for nebulizer use. Findings included: 1. On 6/5/2022 at 10:00 a.m., Resident #58 was observed seated and positioned in his wheelchair at the 300 unit nurses' station. He was observed dressed for the day and well groomed. On 6/5/2022 at 10:03 a.m., Resident #58 started shaking his hands and arms up over his head and making loud grunting noises. The resident had cognitive impairments and he could not speak and or communicate with conversation. Both of his hands and fingers were covered with what appeared to be white socks. On 6/5/2022 at 10:08 a.m., while Resident #58 was still waiving his hand and grunting, Staff B, Registered Nurse (RN) was observed standing at a medication cart about five feet across from him. After about two to three minutes of the resident shaking his hands and grunting, Staff B was heard saying, Oh you want those off, I'm sorry honey; I can't take them off. Resident #58 was not observed trying to take off the hand coverings, but continued to shake his hand and arms over his head. About a minute after Staff B spoke to Resident #58, he stopped waiving his hands and became quiet. On 6/5/2022 at 11:15 a.m. and 12:00 p.m., Resident #58 was observed seated in his wheelchair in the same position at the 300 unit nurse station. He was not wearing the socks or hand covers on either of his hands. Resident #58 was not touching his face or head, and was not presenting with any other type of behaviors, pain or discomfort. On 6/6/2022 at 2:55 p.m., Resident #58 was observed in his room and in an enclosed netted bed. He was observed dressed for the day and was resting with his eyes closed. The resident was not wearing sock/ hand coverings on either of his hands. On 6/7/2022 at 7:30 a.m., Resident #58's room was entered and he was noted in his enclosed netted bed, dressed for the day and lying on his side with his eyes closed. The room was generally dark. Staff A, CNA was in the room assisting Resident #58's roommate. Upon interview with Staff A, she revealed she had Resident #58 routinely on her assignment and knew him well. Staff A confirmed Resident #58 was not wearing socks or hand coverings and did not know he ever wore hand covers that resembled socks. She revealed at times, they gave him things to hold on to and grip, but had never seen socks placed on his hands and fingers. On 6/7/2022 at 8:00 a.m., the 300 unit manager Staff C was interviewed. She revealed Resident #58 wore hand coverings on both hands at times and that they were tube socks. She revealed they had placed the socks on him so he did not bite his hands. She said Resident #58's mother and physician were both aware and consented to this trial to see if it helped. Staff C stated the socks/hand coverings were not Restraints. She said, the resident could and had been educated and observed removing them either by wiping his upper chest area to roll the socks off, or using his mouth to pull them off. She revealed Resident #58 had gone through a recent psychotropic medication change, and he had not been presenting with biting behaviors. Staff C could not remember exactly when they started using the socks/hand covers for both of his hands, but did indicate it had been at least two weeks. Staff C confirmed there was no actual order or care plan for use of the sock/hand covers and expressed they had been doing a trial run. Staff C confirmed most of the other direct care staff on the 300 unit had not been made aware of the use of the socks nor had they been made aware of who was responsible to put them on and monitor him with them on. Review of Resident #58's electronic medical record revealed he was admitted to the facility on [DATE]. Review of the admission diagnoses sheet revealed diagnoses to include, but not limited to: Chronic respiratory disease, Intraventricular (Non-traumatic) Hemorrhage, grade 1 of newborn, Convulsions, Cerebral Palsy, and Seizures. Review of the Minimum Data Set (MDS) Quarterly assessment, dated 3/18/2022 revealed Cognition - Brief Interview for Mental Status BIMS score = Not assessed. However, the assessment revealed resident was severely impaired with decision making skills; Behaviors - behavior symptoms not directed towards others e.g. physical symptoms such as hitting, scratching; this behavior was documented as occurred daily; Activities of Daily Living ADL - Total dependence with two person assist with Bed Mobility, Transfers, Dressing, Eating, Toilet use and Personal Hygiene; Restraints - Documented as none used, to include limb restraint. Review of the Physician's Order Sheet (POS) for the month of 6/2022, did not indicate an order related to the use of socks on hands to prevent biting hands, prior to 6/5/2022. However, there was an order with a start date of 6/3/2022 which indicated to target anxiety behaviors (restless, unable to focus, difficulty sleeping), note biting hands when anxious (has formed callous area to knuckles), note if target behaviors were present every shift; every shift for anti-anxiety medication use. Review of the nurses' progress notes dated from 3/1/2022 through 6/7/2022, revealed the following notes related to biting behaviors: 3/31/2022 12:53 p.m. - Behavior note: Reported to staff resident noted with increased aggression, spoke with Unit Manager, Social Services then notified, spoke with MD for new order for Psych eval. and treat. There was nothing in the note that indicated resident was biting his hands. 4/7/2022 10:59 a.m., - Behavior note: Alert, up in wheelchair, resident grabbing staffs clothing while feeding him. Grabbing stethoscope and glasses. As needed Ativan given with relief. Taken to activities where he remains alert, calm, and cooperative. There was nothing in the note that indicated resident was biting his hands. 5/20/2022 14:36 (2:36 p.m.), - Behavior note: Noted resident biting hand more so today, along with kicking leg. Reported yesterday resident had been yelling out, and physically destroyed his own keyboard in room. Psych contacted today, informed of increased behaviors. New orders for Valium twice daily, continue Valporic acid, and as needed Ativan. Resident had been given Tylenol earlier this a.m. for possible discomfort without effect. This was the only note from progress notes dated 3/1/2022 through to 6/7/2022 that identified resident was biting his hand. 5/26/2022 15:25 (3:25 p.m.), - Clinical note: MD in to see resident regarding behavior and of Valium effectiveness, writer discussed with MD if we could remove the previous benzodiazepine (Ativan) so resident is not on both Medications. MD agreed and gave Valium 5 mg q 8 hour as need for breakthrough behavior. Mother notified. This note did not indicate what type of behaviors the MD was evaluating for. On 6/7/2022 8:22 a.m., - Behavior note: Resident has behaviors i.e., biting hands, scratching self, throwing objects, kicking and can be resistive to care rendered, when resident becomes agitated and scratching self and or biting hands. May apply socks/hand protectors bilaterally on resident to prevent harm. Family and MD has been made aware. On 6/7/2022 8:32 a.m., Behavior note: Called resident's mother regarding behaviors and hand protectors. Mother stated nurse called her several days ago and informed her. On 6/7/2022 at 10:30 a.m., an interview with the 300 Unit Manager, Staff C confirmed she had put in Behavior notes related to Resident #58 biting his hands, and other behaviors on 6/5/2022, after Resident #58 was observed wearing socks/hand covers. Review of the 5/2022 monthly Medication Administration Record and Treatment Administration Record revealed: No behavior monitoring related to behaviors of biting hands. Review of the 6/2022 monthly Medication Administration Record did not indicate biting behaviors until after 6/5/2022. Review of Resident #58's current Care Plans with the next review date of 6/20/2022, revealed the following areas to include but not limited to: 1. Focus area: Behaviors, self abusive, biting self, banging feet on the bedrails and wheelchair, initiated on 4/4/2022, with interventions to include: Administer and monitor effectiveness and side effects of medications as per MD orders; Intervene as needed to protect the rights and safety of others. Approach calmly. Divert attention, remove from situation and take to another location; On 6/5/2022, this intervention was developed: May apply hand protectors that can be removed by the resident i.e (socks) to prevent physical injury to self, resident may remove. 2. Focus area:Resident is resistive to care related to anxiety, initiated on 6/5/2022, with interventions to include but not limited to when resident is causing self injury due to anxiety i.e. biting, scratching, etc. may apply hand protectors that can be removed by resident (may use socks). On 6/7/2022 at 1:00 p.m., an interview with the 300 Unit Manager and review of the medical record revealed a new care plan was developed with interventions to include: Use of hand protectors/socks if resident is biting hands or scratching self, initiated 6/7/2022, with interventions to include but not limited to: Nurse to apply hand protectors/socks as needed. On 6/8/2022 at 11:00 a.m., an interview with the MDS/Care Plan Coordinator confirmed they (the facility) did not develop a care plan problem area with goals and interventions related to socks/hand coverings when Resident #58 presented with hand biting behaviors. She revealed she was aware of the behavior, but was not aware staff were using socks/hand covers to prevent him from biting his hands 2. A review of the Resident #107's admission Record revealed an admission date of 04/11/22 with diagnoses to include but not limited to chronic embolism and thrombosis of unspecified deep veins of unspecified lower extremity. A review of the Minimum Data Set (MDS) assessment dated [DATE], Section C: Cognitive Patterns revealed a Brief Interview for Mental Status (BIMS) score of 12, which indicated Resident #107 had moderately impaired cognition. Section N: Medications revealed Resident #107 received anticoagulant medications six times a week. A review of the care plan dated 04/12/22 revealed no focus area, goals, or interventions related to the use of anticoagulants. A review of Resident #107's current Physician orders revealed an order dated 06/01/22, for Apixaban tablet 5 mg two times a day for deep vein thrombosis (DVT). On 06/07/22 at 9:25 a.m., Resident #107 was observed in bed. There was no bruising or skin discoloration noted. On 06/08/22 at 10:39 a.m., an interview was conducted with Staff R, Licensed Practical Nurse (LPN) and the Nursing Supervisor. They confirmed Resident #107 received Apixaban, and monitoring was not completed related to the use of it. They stated that there was no specific reason to monitor for the use of Apixaban. On 06/08/22 at 12:25 p.m., an interview was conducted with the MDS Coordinator. She confirmed the resident did not have a focus area in the care plan for anticoagulant use and he should have had one. She stated the care plan should have been updated upon admission. She confirmed if a new order was received for the medication, a nurse should have added it to the care plan. 3. On 6/7/2022 at 11:00 a.m., 12:00 p.m., and 1:00 p.m. Resident #16 was observed in her room and lying flat in bed pushing her left foot and leg between the space of the bottom left side rail and rubbing her left foot and lower leg against the metal frame of the left side rail. The bed was observed to have both lower and upper side rails up in position with only the right-side rail blue pad attached and the left side rail pad removed. Review of the admission Record revealed Resident #16 was admitted to the facility for long term care on 10/23/2000. Resident #16 had diagnoses to include seizures and convulsions. Review of the Order Summary Report, as of 6/8/2022, revealed the active physician orders for Resident #16 to include, Full Padded elevated bilateral side rails, check and reposition Q2 (every two) hours when in bed with an order start date of 2/1/2022. On 6/7/2022 at 12:59 p.m., Staff E, Certified Nursing Assistant (CNA) was interviewed. He confirmed when he received his assignment to care for Resident #16 the left blue pad was not attached to Resident #16's left side rail. He also confirmed he did not know where the left blue side rail pad was, and he did not know why the blue pads should be attached to Resident #16's side rails. Staff E confirmed he was not made aware of the expectation of the blue pads on the side rails for Resident #16. On 6/7/2022 at 1:15 p.m. Staff D, Licensed Practical Nurse (LPN) was interviewed and confirmed he took care of Resident #16 frequently. He confirmed he was aware of Resident #16's needs and the expectation regarding the blue pads for the side rails. Staff D confirmed whenever Resident #16 was in bed both left and right blue side rail pads must be attached to the side rails for the resident's safety. He confirmed it was the nurses' and CNAs' responsibility to ensure both blue pads were attached to Resident #16's side rails on each shift every day. Staff D revealed at the start of his shift the left blue pad was on Resident #16's bed, and he was not aware that the pad was missing. Staff D went to Resident #16's room and confirmed the blue left pad was not on Resident #16's side rail. Review of the current care plans with a next review date of 9/3/2022, revealed the following problem areas: a. At risk for injury related to involuntary movement in bed R/T (related to) TBI (traumatic brain injury), date initiated 3/11/2022. Goal: will have no injury to involuntary movements, date initiated 3/11/2022, revision on 6/6/2022, target date, 9/3/2022. Interventions: daily observation by CNA, padded side rails, date initiated 3/11/2022. b. Resident has potential for alteration in skin integrity related to incontinence, dependent with bed mobility, date initiated 2/25/2022. Goal: resident's skin will remain intact, date initiated 2/25/2022, revision on 6/6/2022, target date 9/3/2022. Intervention: pads/bolsters (bolsters) on bed to protect from injury related to spasticity and involuntary movement. 4. On 06/08/2022 at 8:59 a.m., an observation was made of Resident #175's room. During the observation respiratory equipment of a blue nebulizer and facemask were noted to be placed in a plastic storage bag. A record review for Resident # 175 indicated she was admitted on [DATE] with multiple diagnoses that included a Chronic Obstructive Pulmonary Disease (COPD). The review of the quarterly Minimum Data Set (MDS) dated [DATE], identified in Section C, that resident # 175's Brief Interview For mental Status (BIMS) score was 0, (indicating severe cognitive impairment). On 06/06/2022 at 11:10 a.m., an interview was conducted with Staff H, Licensed Practical Nurse (LPN)/Unit Manager (UM). Staff H, (LPN/UM) confirmed Resident #175 received respiratory nebulizer treatments. Record review of Physician Orders for Resident #175 revealed an active order for IPRAT-ALBUT 0.5-3(2.5) MG/3 ML Inhale three (3) milliliters (ml) orally as needed for Chronic Obstructive Pulmonary Disease (COPD,) after Breakfast and Lonhala Magnair 25 MCG/ML STAR, Give 1 vial orally two (2) times a day for COPD. Both medications are used via respiratory (nebulization) facemask device. Resident #175's comprehensive care-plan dated 02/18/2022 was reviewed and did not reveal a focus area or intervention related to receiving respiratory nebulizer breathing treatments for diagnosis of COPD. An interview was conducted on 06/07/2022 at 4:06 p.m., with the Director of Minimum Data Set (MDS) who was responsible for updating care plans. During the interview, she confirmed Resident #175 was not care-planned for nebulizer usage. During the interview she revealed it was every staff's job to update the care plan, and the intervention should go under the Focus area of COPD. The Director of (MDS) updated the resident's care plan. The intervention read meds as ordered. On 6/8/2022 at 1:00 p.m. the Director of Nursing provided the Comprehensive Care Plans policy and procedure with last review date January 2022, for review. The policy stated: The resident has the right to participate in care planning and treatment and changes in care and treatment. The procedure section of the policy revealed: 1. Initial care plans are opened upon admission 2. Start care planning process with the resident during the initial care conference to include IDT and resident and or representative. Continue care planning with the resident after comprehensive assessment and as changes in resident status or resident goals may occur. 6. Review care plans ongoing after each MDS assessment and as indicated with change in the resident's status. 7. Periodically review care plans by the interdisciplinary team after each assessment and as indicated with change in the resident's status. The protocol section of the policy revealed the following: 2. Other care plans that may need to be initiated on admission could include the following: a. Behaviors b. Medications c. Safety concerns 5. The care plan is reviewed with the first comprehensive MDS assessment and is revised towards a goal, changes in goals, revision of interventions or other pertinent updates.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to accurately assess and document the presence of one pressure ulcer and two areas of deep tissue injury for one (Resident #1) of sixteen residents with pressure ulcers. Findings included: Resident #1 was admitted on [DATE]. The admission Record included diagnoses not limited to spastic quadriplegic cerebral palsy, unspecified hydrocephalus, and dependence on respirator (ventilator) status. On 6/5/22 at 11:48 a.m., an observation was conducted of Resident #1 as he laid in bed. The resident did not acknowledge verbal stimuli, was receiving breathing assistance from ventilator, and extremities were covered with blankets. On 6/6/22 at 9:18 a.m., Resident #1 did open his eyes in response to verbal stimuli. His extremities were covered with blankets. On 6/7/22 at 1:10 p.m., the resident was sitting up in a wheelchair, a television was playing and the resident was covered with blankets. During an interview, on 6/7/22 at 1:51 p.m., Staff J, Licensed Practical Nurse (LPN) stated that staff used to do weekly skin assessments on paper but now they did them electronically and it was incorporated with a daily (progress) note. The LPN stated if any skin condition was noted, staff were to complete an incident report and notify the supervisor. The following progress notes were documented in regards to Resident #1: - A progress note dated 5/1/22 at 8:37 a.m., identified Resident #1 was hospitalized . - On 5/11/22 at 3:41 p.m., a note identified wound care was completed and included areas not limited to an unstageable grey hard blistered to left toes and abrasion to the top of left foot. - On 5/11/22 at 4:20 p.m., a note written by a LPN indicated skin is intact and was admitted due to cellulitis of left foot. - On 5/13/22 at 3:02 p.m., staff noted that the physician was notified regarding bilateral swelling to lower extremities and an order was obtained for [brand name] wraps - A Skin/Wound note, on 5/14/22 at 5:13 p.m., identified Reddened/purple discoloration on crease of patient's right front ankle appears to be from [brand name] wrap. Not open at this time, skin prep applied. Blister present on end of patient's left great toe, skin intact. Skin prep applied to area. [brand name] wrap in place to bilateral legs, circulation good, capillary refill brisk less than 2 seconds on all toes. The note did not indicate that the physician or responsible party was notified of a change in the residents' skin condition. - A physician note, dated 5/15/22 at 12:35 p.m., indicated that the resident was admitted to the acute care facility for bilateral lower extremity edema left greater than right, diagnosis with lymphedema and cellulitis of left lower extremity. The note did not identify that the physician was aware of a change in the residents' skin condition. A review was conducted of the Skin Issue Identification form that was completed on 5/20/22 at 12:25 p.m., by the Unit Manager, Staff K. The form identified the resident had a tracheotomy, gastrostomy (G-tube), and bilateral edema - [brand name] wraps in place. The form did not identify any further skin issues. The system note, dated 5/20/22 at 10:36 a.m., did not indicate Resident #1 had bilateral lower extremity (BLE) edema or any other skin conditions. On 5/22/22 at 10:48 a.m., a system note written by nursing did not indicate Resident #1 had BLE edema and that skin intact and clear. On 5/23/22 at 10:48 a.m. and 7:51 p.m., nursing staff documented Skin intact and clear. Neither note identified if the resident had BLE edema. On 5/24/22 at 11:51 a.m., Staff J documented Skin intact and clear and did not indicate if the resident had BLE edema. On 5/25/22 at 3:51 p.m., nursing staff documented Skin warm and pink. Normal turgor noted. The note did not identify if the skin was intact or if there was evidence of BLE edema. On 5/25/22 at 7:23 p.m., a clinical note indicated that Resident #1's [brand name] wrap was removed from right foot and a 5 centimeter (cm) x 3.5 cm discoloration wound was noted and orders were received. The note did not indicate if any other skin condition or BLE edema was present. An administration note, on 5/25/22 at 10:09 p.m., identified [brand name] wraps for compression both lower extremities two times a day for compression. A review of the clinical progress notes and assessments from 5/15 to 5/25/22 did not indicate any further documentation regarding Resident #1's reddened/purple discoloration on the right front ankle or blister on the end of left great toe. A review of nursing documentation indicated that an assessment was completed, on 5/27/22 at 1:06 a.m., on Resident #1. The assessment did not identify if the resident had any BLE edema and noted skin warm and pink. On 5/27/22 at 11:06 a.m., nursing documentation indicated skin intact and clear. On 5/28/22 at 1:22 p.m. and 8:19 p.m., nursing staff noted that Resident #1's skin intact and clear. A system note, dated 5/29/22 at 7:37 p.m., identified that the residents' skin intact and clear. The Wound Care providers' Initial Evaluation note, dated 5/30/22 at 11:54 a.m., identified an unstageable area to Resident #1's right dorsal proximal foot, which measured 3.6 cm x 5.4 cm x 0.1 cm. The tissue contained 20% granulation, 30% slough, 30% necrotic, and 20% dark. The treatment was for Santyl and a dry clean dressing every day. The note instructed to offload area aggressively and no ace wraps. The note did not identify any pressure ulcer to the residents left great toe. On 6/1/22 and 6/2/22 nursing staff continued to document that Resident #1's skin was intact and clear. Neither 6/1/22 or 6/2/22 notes indicated the status of Resident #1's BLE edema. A provider note, on 6/3/22 at 10:00 p.m., indicated that the physician was aware of Resident #1 developing an ulcerative lesion on the right foot which was being treated with [brand name] and that Compression stockings on both lower extremities are noted and extremities are spastic swelling of the lower extremities are also improved. A review of progress notes from 6/4, 6/5, 6/6, and 6/7/22 identified that nursing staff had documented that Resident #1's skin was intact and clear. The Wound Care providers' note, dated 6/6/22, identified that the unstageable wound to Resident #1's dorsal proximal right foot was smaller but wound base declined. The wound measured 3.2 cm x 4.6 cm x 0.1 cm. The tissue was 20% granulation, 20% slough, and 60% necrotic. The provider instructed offload area aggressively, absolutely NO [brand name] wraps. On 6/8/22 at 8:54 a.m., an interview was conducted with Staff K, Registered Nurse/Unit Manager (RN/UM). The UM reported Resident #1 had been recently hospitalized and [brand name] wraps ordered on bilateral lower extremities for lymphedema. Staff K reviewed the progress notes and assessments and stated she was unaware that the progress notes were generated by the daily assessments. The UM reviewed nursing notes from 6/6 and 6/7/22 that indicated skin intact and confirmed the information was incorrect. She said her expectation was after the nurse completed daily wound care a note would be produced indicating what the wound looked like and that the dressing change had been done. Staff K identified that the Wound Care nurse did weekly wound assessments and the floor nurse was responsible for daily wound care. On 6/8/22 at 9:32 a.m., during an interview with Staff L, Wound Care Nurse (WCN), she reported wound care rounds were completed with the wound care provider on Mondays. In regards to Resident #1, the wound to the right ankle was discovered on 5/25/22 when staff removed the elastic wrap from the area. The WCN described the area as unstageable pressure ulcer that was darkened and open. The nurse reiterated the pressure ulcer on the resident's ankle was discovered on 5/25/22 was assessed by the provider on the following Monday (May 30, 2022). Staff L reported the facility process was Certified Nursing Assistants (CNA) did a skin assessment tool and when an issue was observed they notified the nurse. The nurse notified the family (if a new area), the physician, and sometimes will notify her, the WCN. She stated she received a weekly skin list if anything new, she compared it to the previous week. The WCN stated she was notified on the 5/25/22 of a reddened area. The staff member reviewed the written note from 5/14/22 that identified Reddened/purple discoloration on crease of patient's right front ankle appears to be from [brand name] wrap. Not open at this time, skin prep applied. Blister present on end of patient's left great toe, skin intact. Skin prep applied to area. [brand name] wrap in place to bilateral legs, circulation good, capillary refill brisk less than 2 seconds on all toes. She stated she would not have necessarily been notified of the area. The WCN confirmed that the blister to the residents left great toe should have been on her weekly skin list. An observation was conducted, on 6/8/22 at 11:35 a.m., with the WCN of Resident #1's bilateral lower pedal areas. The left lower extremity was wrapped with an elastic bandage with a corner of the bandage covering the great toe. The WCN moved the bandage away from the great toe and an area of purplish/black discoloration approximately the size of a nickel was observed. The WCN palpitated the area and stated it was hard. The observation revealed that both feet of the resident was extremely edematous and non weeping. The right foot had a white border dressing to the top of the ankle. The observation identified a dark purple area to the residents' right fifth toe, approximately a size of a dime. This area had not been identified in any documented assessment or progress note. The WCN confirmed that the areas on the right fifth toe and the left great toe should have been noted and a treatment in place for them. The staff member stated that the resident moved both feet back and forth on the bed sheets and that the areas should be noted. A review of the Weekly Facility Pressure Ulcer Tracking Report, dated 5/30/22, indicated that Resident #1 acquired an unstageable ulcer on 5/25/22 to the right dorsal proximal foot. The report did not identify any other pressure-related areas for the resident. The Weekly Facility Skin Report, dated 6/3/22, indicated the resident had a dark scabbed area to the right dorsal foot that was in-house acquired. The report did not identify any other altered skin integrity areas for the resident. A review of policy 01B039 - Pressure Ulcer/Pressure Injury Prevention and Management, reviewed 10/24/2021, indicated that The purpose of this procedure is to provide guidelines for prevention of avoidable pressure ulcers/pressure injury and the promotion of healing of existing pressure ulcer(s)/pressure injury(s). The procedure identified that the facility should establish and utilize a systemic approach for pressure ulcer/pressure injury(s) prevention and promotion of pressure ulcer/pressure injury healing that includes efforts to identify risk, stabilize, reduce or remove underlying risk factors, monitor the impact of the interventions, and modify the interventions as appropriate. The policy indicated that staff were to Conduct a weekly full body skin assessments by a licensed or registered nurse and conducted a full body skin inspection by nursing assistants during bathing and any concerns reported to the resident's nurse immediately after the task. Nursing assistants also inspect skin during AM/HS cares and report any concerns to nurse immediately after the task, and Measure the wound upon identification of a new pressure ulcer/pressure injury and initiate a weekly wound monitoring sheet and implement initial treatment per physician's order. The procedure for the Assessment and Treatment of an Existing Pressure Ulcer/Pressure injury instructed staff to: - a. Differentiate the type of ulcer/injury (pressure related versus non-pressure related - arterial, venous, diabetic). - b. Determine the ulcer/injury stage (I, II, III, IV, deep tissue injury, unstageable due to slough or eschar). - c. Describe and monitor the ulcer's/injury's characteristics. - d. Monitor the progress weekly towards healing. - e. Determine if infection is present. - f. Assess, treat, and monitor pain, if present. - g. Monitor dressings and treatments weekly. - h. Evaluating the effectiveness of current interventions. - i. Modify or replace interventions as needed. - j. Evaluate the effectiveness of new interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure respiratory equipment was stored in a sanitary manner for three (Residents #194, #175 and #90), and failed to have a physician's order for the use of oxygen for one (Resident #194) of five residents sampled for respiratory care. Findings included: 1. On 06/05/2022 at 9:35 a.m., an observation of Resident #194's room included a nasal cannula and oxygen tubing on the bedside table, attached to a portable oxygen tank, and not stored appropriately. (photographic evidence obtained) On 06/05/2022 at 12:31 p.m., an observation revealed Resident # 194 was receiving 3 liters of oxygen via a nasal cannula and an oxygen concentrator in the 800 Hall dining room. On 06/06/2022 at 8:53 a.m., Resident # 194's room was observed. During the observation a nasal cannula and oxygen tubing were seen on the bedside table, and not stored appropriately. Immediately after the observation, Resident #194 was seen in the dining room seated in a wheelchair. The resident was receiving 3 liters of oxygen via a nasal cannula and an oxygen concentrator. On 6/7/2022 at 8:03 a.m., Resident # 194 was observed sleeping in bed, she was receiving 3 liters of oxygen via a nasal cannula and an oxygen concentrator. Review of active Physician Orders as of 06/07/2022, for Resident # 194 revealed there was not an order to receive oxygen at 3 liters via a nasal cannula. A review of the resident's care plan with revision date of 03/11/2022 read, under interventions, to Administer O2 [oxygen] as ordered for SATS of 90% or less. On 6/7/2022 at 4:05 p.m., an interview conducted with Staff H, Unit Manager (UM) for the 800 Hall. She confirmed Resident #194 did not have a physician's order to receive oxygen. 2. On 6/5/2022 at 2:24 p.m., an observation of Resident #175's room revealed an unbagged nebulizer face mask on the resident's bedside table. The resident was asleep in her wheelchair. A record review for Resident # 175 indicated she was admitted on [DATE] with multiple diagnoses that included a Chronic Obstructive Pulmonary Disease (COPD). The review of the quarterly Minimum Data Set (MDS) dated [DATE], identified in Section C, that resident # 175's Brief Interview for Mental Status (BIMS) score was 0, (indicating severe cognitive impairment). On 06/06/2022 at 11:10 a.m., an interview was conducted with Staff H, Licensed Practical Nurse (LPN)/Unit Manager (UM). Staff H confirmed Resident #175 received respiratory nebulizer treatments. She verified respiratory devices were changed every week and stored in a plastic bag. 3. An observation conducted on 06/05/2022 at 9:26 a.m., revealed Resident #90's respiratory facemask was left unbagged on top of the nebulizer machine. On 6/6/2022 at 8:38 a.m., an observation and interview was conducted with Resident #90. An unbagged nebulizer facemask was observed on top of the nebulizer machine, not stored appropriately. During the interview with the resident, she said the staff did not store the facemask in a plastic bag. During an observation conducted on 6/7/2022 at 3:51 p.m., with Staff H she verified resident #90's face mask was on top of the nebulizer machine and was not stored appropriately. Staff H stated It's supposed to be in a plastic infection control bag. Record review of Resident #90's active physician orders revealed Albuterol Sulfate Nebulization Solution (2.5 MG/3 ML) 0.083% 2.5 mg inhale orally via nebulizer every 4 hours as needed for inhalation, dated 03/31/2022. An interview was conducted with the Director of Nursing on 6/7/2022 at 4:41 p.m. During the interview, the DON was informed of all observations made for Residents #90, #194,and #175 and was shown Photographic Evidence Obtained from the observations. The DON stated, We need to do in-servicing of the staff on how they need to store nebulizer respiratory devices when not in use. I am going to go speak to the UM and figure out what has been going on with the order for oxygen for [Resident # 194]. A request was made for a policy related to the storage of Respiratory Equipment of Nebulizer Equipment, the facility provided a policy, titled Nebulizer Treatments, Dated 10/25/2021, Version #1: one page, read as follows Policy: To provide residents with appropriate nebulizer treatments administered in a safe, effective manner in accordance with physician orders and current clinical standards. According to the NIH (National Heart, Lung and Blood Institute) NIH Publication no. 21-HL-8163, Dated October 2021, Pages 01-02, How to Use a Nebulizer (nih.gov), reads A nebulizer is a machine that delivers a fine steady mist of medication through a mouthpiece or mask. Between Uses: Store nebulizer parts in a dry, clean plastic storage bag.

Based on observations, record reviews, and interviews, the facility failed to ensure that the medication error rate was less than 5.00%. Thirty-two medication administration opportunities were observed and five errors were identified for one (Resident #110) of six residents observed. These errors constituted a 15.63% medication error rate. Findings included: On 6/7/22 at 2:24 p.m., an observation of medication administration with Staff M, Licensed Practical Nurse (LPN), was conducted with Resident #110. The staff member dispensed the following medications: - Vitamin D3 125 microgram/5000 unit tablet - Famotidine 20 milligram (mg) tablet - Levetiracetam 100 mg/milliliter (mL) liquid - 2.5 mL (250 mg) - Phenobarbital 20 mg/5 mL elixir - 7.5 mL (30 mg) - Clonazepam 1 mg tablet - Polyethylene glycol 1450 powder - 17 grams - diluted in approximately 4 ounces of water The staff member identified that the medications other than Clonazepam were late (as evidence by the patient profile being colored red). Staff M reported she was not used to the unit and was recently moved from night shift to day shift. A review of Resident #110's June Medication Administration Record (MAR) identified that the following observed medications of were due at 9:00 a.m., 5 hours and 24 minutes prior to the observation of the administration: - Cholecalciferol 5000 unit tablet - Give 1 one tablet via G-tube one time a day for Vitamin D deficiency. - Famotidine 20 mg tablet - Give 1 tablet via G-tube every 12 hours for GERD. - Levetiracetam 100 mg/mL solution - Give 250 mg via G-tube two times a day for diagnosis: seizure disorder. - Phenobarbital 20 mg/5 mL with sugar - Give 7.5 mL via G-tube every 12 hours for seizures. - Polyethylene Glycol 1450 powder - Give 17 gram via G-tube every 12 hours for constipation - Hold for loose stools. On 6/7/22 at 3:04 p.m., the staff member completed the administration of medications and the start of Resident #110's nutrition. Staff M confirmed the physician was not notified that Resident #110's medication was late. The staff member stated the procedure was to call the physician prior to administration of late medications. The facility provided a copy of a Clinical note, dated 6/7/22 at 3:10 p.m. (after the observation) that Resident #110's Medications given late, the physician was notified, and orders were to received to monitor for seizure activity. The policy - Medication Administration Skilled Nursing Facility (SNF), reviewed 10/21/21, identified that medications will be administered to residents as prescribed by the physician or only by persons lawfully authorized to do so in a safe and prudent manner. The procedure indicated that If a dose of a regularly scheduled medication is held, refused, or given at a time other than the prescribed time documentation in the electronic record will be done. The documentation is to include a reason for refusal (no reason given is adequate if applicable), as well as evidence to show that education was completed as appropriate.

Based on observation, interview, and policy review, the facility failed to follow their policy to store medications in a secure manner by leaving six medications unattended, with no facility staff in the vicinity of one room for (Resident #110) of six resident rooms sampled on the 600 Hall. Findings included: On 06/7/2022 at 2:02 p.m., an observation was made of Resident #110's room. During the observation Staff F, Agency Licensed Practical Nurse (LPN), walked out of Resident #110's room leaving six medications, in three (3) small clear medication cups, two large plastic cups, and one syringe on his bedside table. An immediate interview was conducted with Staff F, Agency (LPN) who confirmed the presence of the unsecured medications in Resident #110's room. (Photographic Evidence Obtained.) On 06/08/2022 at 12:38 p.m., an interview was conducted with the Director of Nursing, (DON. During the interview the DON was informed of all observations made. The DON indicated that she was not aware medications were left in Resident #110's room, on the bedside table by Staff F, Agency LPN. The DON was asked what her expectation was, and she stated, Do not walk away from medications. A facility provided policy titled, Medication Storage (Medication Cart/Narcotics) with revision date January 2022, Page 01 of 02 Page, was reviewed and revealed: Policy: It is the Policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendation and sufficient to ensure temperature and security. Policy Explanation and Compliance Guidelines General Guidelines: c. During medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart.

Based on record review and interview the facility failed to designate a healthcare professional with specialized training as the Infection Control Preventionist (ICP) for the facility. Findings included: During an interview with the Interim Infection Control Preventionist (ICP)/Occupational Therapist Registered (OTR), on 6/6/22 at 3:30 p.m., the ICP said she was not certified in Infection Control and was working under the certification of the Registered Nurse/Regional Health Service Director (RHSD). The Interim ICP reported she had been interim since January (2022). An interview was conducted, on 6/8/22 at 12:03 p.m., with the Interim ICP and the RHSD. The RHSD reported she was in the building every two weeks. The Interim ICP stated any infection control training had been on the job. The RHSD admitted to certification in California and was the Health Service Director for Florida and California. The RHSD stated that we are working on it regarding the Interim ICP being the dedicated Infection Preventionist and the DON and ADON becoming certified as well. A review of a facility-provided job description titled Infection Preventionist reviewed 8/26/21, revealed the IP purpose of this position is to plan, organize, develop, coordinate, and direct all in service educational programs monitor the infection control. The required Knowledge, Skills and Abilities of the IP was to have completed specialized training in infection prevention and control. The policy, Infection Preventionist, reviewed 10/22/21, defined a Qualified Professional as a professional licensed in nursing or certified in infection control and prevention services. The explanation and compliance guidelines of the policy indicated The facility will designate a qualified individual as Infection Preventionist (IP) whose primary role is to coordinate and be actively accountable for the facility's infection prevention and control program. The faciltiy would ensure that the IP was adequately qualified and met eligibility requirements such as: - a. Current licensure in nursing; - b. Primary professional training in nursing, medical terminology, microbiology, epidemiology or other related field; - c. Education, training, experience or certification in infection control and prevention; - d. Completed specialized training in infection prevention and control through accredited continuing education. - e. Works at least part-time at the facilty.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and the Plan of Correction (POC) review, the facility failed to ensure it had a functioning Quality Assurance (QA) Committee. The facility was actively involved in the effective creation, implementation, and monitoring of the plan of correction for deficient practice identified during a recertification survey, on [DATE] and was cited at F759. On [DATE] a revisit survey was conducted and the facility was recited at F759. The facility had developed a Plan of Correction with a completion date [DATE]. The facility had not comprehensively implemented the plan of correction for the identified quality deficiencies. Findings Included: A review of the facility's policy and procedure for Quality Assurance & Performance Improvement Program (QAPI), effective [DATE], last reviewed [DATE], revealed the following: Our Quality Assurance and Performance Improvement Program (QAPI) represent our facility's commitment to continuous quality improvement. The program ensures a systematic performance evaluation, problem analysis and implementation of improved strategies to achieve our performance goals. The Policy Explanation and Compliance Guidelines: A. The facility shall implement a QAPI Program designed to ensure the provisions required by The Patient Protection and Affordable Care Act of 2010, section 6102( c ). B. The facility shall establish an interdisciplinary QAPI Committee. The committee shall consist of at a minimum, a chairperson, director of nursing services, physician, and three other facility staff members. Additional staff members may be included when their expertise is needed. C. The QAPI Committee shall select additional members to participate in various subcommittees based upon the Performance Improvement Project (POP) topic and participant expertise. These projects may include clinical and non-clinical opportunities to improve. D. The QAPI Committee shall communicate its activities, and the progress of its subcommittee PIPs, to the administrator or executive director a minimum of quarterly by formal meeting. Additional team communication may occur via email or conference call. E. The QAPI Committee shall meet at least quarterly to review facility data, identify opportunities for improvement, and review the activities of its PIP sub-committees. The committee shall maintain written meeting agendas, minutes, and periodically provide activity reports upon request to the administrator. F. The QAPI Committee's oversight responsibilities shall include, but are not limited to the following: 1. Annual review of the facility QAPI Program. 2. Establishment of PIP subcommittees. 3. Ensure the subcommittee has the adequate resources to conduct their project. 4. Submit findings of performance improvement projects to the chairperson that includes a summary of QAPI performance improvement project activities and findings. 5. Utilize facility data to identify opportunities to improve systems and care. Data may include, but is not limited to: grievance logs, medical record review, skilled care claims, fall log, pressure ulcer log, treatment logs, staffing trends, incident and accident reports, quality measures, survey outcomes, etc. Procedure: Establishment of Facility QAPI Plan: The QAPI Committee shall establish an initial facility plan in its first QAPI meeting. Revision of Facility QAPI Plan: The QAPI Committee will review the plan annually and make necessary revisions. Revisions shall reflect the findings, discussions, meeting, surveys, interaction with executive leadership, etc. of the previous year. The plan may be modified during the year, with expanded executive committee approval as needed. Annual Report to the Executive Director: The committee chair (if other than the executive director or administrator) shall submit an annual summary report of the QAPI activities to the administrator or executive director. The report may be requested more frequently. QAPI Sub-Committees: Each Sub-committee shall be guided by a QAPI Committee member who will facilitate coordination of the PIP and ensure each Subcommittee is adequately resourced. Upon conclusion of the PIP, the Sub-committee shall provide the QAPI Committee with a report, which contains a summary and analysis of activities and recommendations for improvement. Clinical and Non-Clinical Performance Improvement Projects: The facility shall conduct PIPs designed to achieve and sustain performance improvement over time. PIPs shall be designed to have an expected favorable outcome. The QAPI Sub-committee shall implement PIPs using relevant data collection and analysis with appropriate intervention strategies to improve facility performance. The QAPI Committee will review the outcome of the PIP and may recommend further assessment of problem areas or corrective systemic interventions. The QAPI Committee shall maintain written documentation of meetings, findings, and progress, and make recommendations. A review of the policy entitled Medication Administration Skilled Nursing Facility (SNF), reviewed [DATE], revealed the following: . medications will be administered to residents as prescribed by the physician or only by persons lawfully authorized to do so in a safe and prudent manner . 3. Medications are administered in accordance with the written orders of the attending physician. The facility plan of correction identified an In-service education to licensed staff on [DATE] with ongoing instruct on medication administration guidelines per facility protocols along with a Medication Administration Competency. 1) On [DATE] at 9:30 a.m. an observation of medication administration was conducted alongside Staff N, Licensed Practical Nurse (LPN). Staff N stated she just started and she was not scheduled to work at the facility today and stated, I was just called in. Staff N prepared the following medications for Resident #9: one Ferrous Sulfate 325 mg (milligrams), one Cilostazol 100 mg, one Amlodipine 2.5 mg, two Lisinopril 10 mg, one Loratadine 10 mg, one Buspar 150 mg ER, and a Novolog flex pen. The Novolog (insulin) pen dose selector was set to 5 units. Staff N, LPN confirmed a total of seven pills. The oral medications were administered to the resident and the insulin pen was administered to the resident in the left upper arm. A medication reconciliation was conducted which revealed the following Physician orders: Cholecalciferol 25 mcg (micrograms) 1000 Units give 1 tablet by mouth one time a day for weakness and fatigue start date [DATE], due at 0900. The medication was not observed to have been administered.; Novolog (insulin aspart) flex pen solution Pen-Unit/ML (milliliters) inject 5 units subcutaneously with meals for Diabetes Melilites (DM) start date [DATE]. The inulin was scheduled to be administered at 7:30 a.m. An interview was conducted with Staff N, LPN on [DATE] who confirmed the inulin was late because the resident had already eaten his breakfast. A review of the manufacturer's instructions for the Novolog Insulin flex pen revealed the following: Giving the air shot before each injection. Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to make sure you take the right dose of insulin: G. Turn the dose selector to select 2 units. H. Hold your Novolog Flex Pen with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. Keep the needle pointing upwards, press the push-button all the way in. the dose selector returns to 0, A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than 6 times. 2) On [DATE] at 10:05 a.m. a medication administration was observed with Staff O, LPN as he prepared the following medications for Resident #8. Staff O, LPN stated, I'm running late, and said it was related to computer issues. He stated I was here on time this morning but my password for the computer system had expired. It took over two hours to reset my password. Staff O prepared the following medications: one Multivitamin with mineral, one Vitamin D 5000 units, one Ferrous Sulfate 325 mg, one Tamsulosin 0.4 mg, one Metoprolol 25 mg, one Norco 10/325 mg. Staff 0 stated the next dose of Ferrous Sulfate is already due at noon and then confirmed an order for Pro-Stat was not available on the medication cart. Staff O entered Resident #8's bedroom and administered the oral medications. Staff O performed a blood glucose reading with a result of 298. Staff O stated the order for blood glucose reading was scheduled at 8:00 a.m. Staff O returned to the resident room and administered Novolog (insulin) 65 units to the resident at 10:22 a.m. Staff O confirmed the inulin was given late. Resident #8 was overheard telling Staff O,LPN, I haven't received my IV yet. Staff O told the resident he would be getting it ready next. At 10:41 a.m. Staff O, reentered Resident #8's bedroom and placed a bag of solution on the IV pole. The tubing was connected to the bag and then attached to the resident's right upper arm peripherally inserted central catheter (PICC). The bag of solution read Vancomycin 1000 mg. The resident dressing on the PICC was not dated, Resident #8 stated out loud they don't like to put dates on it. Then they'll have to change it more often. Staff O stated, I'll be back later and change the dressing. A medication reconciliation was conducted which revealed the following Physician orders: Novolog N suspension 100 units inject 65 units subcutaneously two times a day for DM dated [DATE] scheduled at 7:00 a.m.; Vancomycin HCL solution 1000 mg/ml use 1 gram intravenously two times a day for gram positive bacteria for 4 weeks dated [DATE] scheduled at 8:00 a.m.; Pro-Stat sugar free one time a day for hypoalbuminemia 30 ml one time a day (1x/day) dated [DATE] scheduled at 9:00 a.m. On [DATE] at 1:37 p.m. an interview was conducted with the Director of Nursing (DON). The DON stated, it is getting better now as were trying to use less agency. When informed of the concerns related to the observations during the administration of medications he stated, That is a problem, that would be a concern if that was what you saw. The DON said he uses an insulin pen. He said he doesn't prepare his pen with an air shot. He stated, the air shot is only performed when the pen is first used. On [DATE] at 2:32 p.m. Staff P, Supervisor confirmed training was provided on the insulin flex pen. She stated they had a tutorial a while back. Staff N was present and confirmed she did not perform the air shot prior to administering Resident #8's insulin. Twenty-six medication administration opportunities were observed, and six errors were identified for two (#8 and 9) of three residents sampled. These errors constituted a 21.43% medication error rate. On [DATE] at 3:40 p.m. an interview was conducted with the Nursing Home Administrator (NHA) to review the Quality Assurance and the facility Plan of Correction. The NHA confirmed they conduct monthly QA meetings. The meetings include discussions on the survey results, and the plan of correction. The NHA stated the committee discussed how they are progressing with the monitoring and if there any need to change the plan in any way. The NHA stated We felt we had substantial compliance.

Based on observations, interviews and medical record review, the facility failed assure that medications were secure and inaccessible to unauthorized staff and residents for prescribed and discontinued medications and creams for one resident (#36) of thirty-five sampled residents. Findings included: On 2/15/2021 at 11:55 a.m. Resident #36's was observed in bed and being visited by a family member. An interview at that time with Resident #36's family member revealed that she visits daily and is involved with the care and services and decision making for Resident #36. She pointed out the back of Resident #36's legs, and the healing rash. She revealed that the facility staff apply creams and an ointment to it. She showed the creams that were used on the rash and picked them up off of the room sink counter. A continued observation revealed two tubes and one jar of prescribed creams to include: one 1.59 oz (ounce) tube of Betamethasone Dipropionate Cream, one 30-gram (gm) tube of Nystatin Cream, and one jar of Triamcinolone 0.1% cream 454 gm. All three were observed with prescription labels. (Photographic Evidence was Obtained) A continued interview with Resident #36's family member revealed she was not aware if all the creams were used or not, but knew that at one time; they were all used. She further confirmed that, as far as she knew, all the creams were left in the room all the time. On 2/15/21 at 1:30 p.m. on Staff A, 300 Unit Registered Nurse (RN) was asked to come to Resident #36's room. The sink area in the room, next to the bed, was observed with several types of medications which included: one 1.59 oz tube of Betamethasone Dipropionate Cream, one 30 gm tube of Nystatin Cream, and one jar of Triamcinolone 0.1% cream 454 gm. Staff A, RN stated that the medication creams should not have been in the room and should have been properly stored in the medication cart. She confirmed that the creams were prescribed and labeled from the pharmacy and none of the creams were brought in by the family member. She continued to say that those types of medications should be properly stored in the medication cart, and not within reach of any resident, nor should they be stored in the room. She revealed that possibly the nurse from the previous shift may have left them in the room. A review of Resident #36's medical record revealed an admission date to the 300 unit for long term care on 6/10/2016. A review of the current Physician Order Sheet dated 2/2021 revealed active orders for: - Triamcinolone acetonide 0.5% topical ointment (1 application) Ointment (gram) topical as needed three times daily starting 3/18/2019 - Triamcinolone acetonide 0.1% topical cream (1) cream (gram) topical everyone day starting 3/1/2020 The current active physician orders for 2/2021 did not include: - 1.59 oz tube of Betamethasone Dipropionate Cream. - 30 g tube of Nystatin Cream. A review of the facility policy titled, Medication Storage (Medication Cart/Narcotics), last review date of 1/2021 revealed, It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure temperature and security. The policy continued to indicate the Policy Explanation and Compliance Guidelines as: 1. General Guidelines: A. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls . C. During medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart.

Based on observation, interview, and record review the facility did not ensure food equipment was stored and handled in a sanitary manner related to cleaning and sanitization of food contact equipment and serving utensils. Findings included: During the comprehensive kitchen tour on 02/17/21 at 10:28 a.m. with the Certified Dietary Manager (CDM), Staff C, Chief was observed in the process of cleaning the deli slicer. Staff C, Chief began disassembling the slicer and stated the facility procedure is to clean and sanitize the slicer after each use. Staff C stated the deli blade and stand are cleaned and sanitized on the countertop area. Staff C used a dry cloth to remove large food debris from the blade and stand before retrieving a butter knife to assist with scrapping off additional food debris from the front and back portion of the equipment blade. Staff C sprayed [Brand Name] sanitizer onto the deli slicer and immediately wiped the sanitizer from the equipment. Staff C, Chief walked away from the deli slicer and the CDM confirmed the cleaning and sanitization of the equipment was completed. Staff C, Chief did not use soap, water, or re-spray the [Brand Name] sanitizing spray after immediately wiping off the sanitizer during the cleaning process. Upon examination of the deli slicer post-cleaning and sanitizing, old food debris chunks were still present on the back-blade portion at the top section. The CDM confirmed the food debris on the deli slicer post-cleaning and confirmed the equipment would be considered a food contact surface. The CDM confirmed she was aware of the foodborne illnesses that are associated with deli meats and improper cleaning of food-contact surfaces. During an observation on 02/17/21 at 10:37 a.m., a stand mixer was stored underneath a plastic covering. The CDM confirmed the stand mixer was considered clean. The CDM removed the plastic covering and upon examination of the mixing stand, old food debris was observed on the underside of the stand mixer above the mixing bowl. The CDM confirmed the food debris presence and instructed Staff C, Chief to re-clean the equipment. During an observation on 02/17/21 at 11:28 a.m., facility kitchen staff were observed preparing the food service line for lunch. Staff D, [NAME] was wearing gloves, leaned against the stove top with hands placed directly on the stove area. Behind Staff D, two ladles were placed directly onto the counter area. Staff D, without changing his gloves, began removing bowls from the storage rack, flipping them over, and touching the inside of the bowl with his fingers before placing the bowls onto the food service line. Staff C asked Staff D if he had ladles to serve the soup with. Staff D, [NAME] proceeded to grab the ladles from the countertop to show Staff C and placed them down onto the bowl storage rack without a clean barrier. Staff C placed the ladles into the food items on the steam table without re-cleaning the equipment. During an observation on 02/17/21 at 11:30 a.m., Staff B, [NAME] walked away from the food service line to a wire rack. Staff B returned from the wire rack carrying approximately six food serving scoops. Staff B held the serving scoops in his hands by his waist. As Staff B walked back to the food service line, the scoops continually brushed against his pants and shirt. Staff B walked past Staff C, Chief resulting in the scoops held in the left hand to brush against the clothing of Staff C, Chief. Staff B placed the scoops directly into the food stored on the steam table, without cleaning or sanitizing the food equipment. Staff B began scooping and preparing resident food trays. During an interview on 02/17/21 at 11:40 a.m. The CDM and Staff C, Chief confirmed that once the food serving equipment touched another surface, it should be re-sanitized prior to being placed inside of the food. A review of the manufacturer instructions for use of the [Brand Name] sanitizing spray revealed, Sanitizing Food Contact Surface Directions . Prior to application, review, gross food particles and soil by pre-wash, pre-scrape, or pre-flus, and when necessary pre-soak. Thoroughly wash or flush equipment with a good detergent or compatible cleaner followed by a potable water rinse before applying sanitizer. Apply [Brand Name] Sanitizer to pre-cleaned hard non-porous surfaces with cloth, mop sponge, or sprayer or by immersion. Surfaces must remain wet for 60 seconds (one minute) Allow to air dry before reuse. A policy review of Sanitation of Dining and Food Service Areas, dated January 2021, revealed, Culinary services staff will maintain the sanitation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule . Employees will be trained on how to perform cleaning tasks and any protective equipment that is required to be worn during these tasks as appropriate. According to the Food and Drug Administration (FDA) Food Code 2017, page 148, revealed, . Equipment food-contact surfaces and utensils shall be sanitized . Utensils and food-contact surfaces of equipment shall be sanitized before use after cleaning . Page 504-505, under Section: Equipment revealed, . a chemical sanitizer will not sanitizer a dirty dish As a result, pathogenic microorganisms may be transferred to foods that are prepared on such surfaces Equipment or utensils may not be cleaned if inappropriate or insufficient amounts of cleaners or detergents are used .