Based on observation, interview, and record review, the facility staff failed to treat residents with dignity and respect as evidenced by addressing them as, feeders, and not allowing a resident's choice to ambulate freely while waiting for meals, for 4 of 17 residents on the locked memory care unit, (#104, #94, #122 and #61). Findings: 1. On 8/20/24 at 11:16 AM, Certified Nursing Assistant (CNA) K was overheard to question, [Activity Personnel M's name], are you going to feed [resident #104]? Activity Personnel M replied, Sure, who do you want me to feed? CNA K answered, Resident 104. Then CNA K repeated, Resident 104 is a feeder. A short time later, CNA K was asked whether it was appropriate for staff to call residents, Feeders, while speaking about the residents. CNA K replied, I said that? I didn't even realize I said it. She then stated she was aware it was a dignity issue to identify residents using that term. 2. On 8/20/24 at approximately 11:30 AM, Activity Personnel M repeatedly called out resident #94's last name when the resident was starting to leave the lunch area. Activity Personnel M stated she called the resident by her last name because the resident responded when called by her last name instead of her given name. She explained when she called a resident by their last name, it was just a way of referring to them. Activity Personnel M elaborated that this resident used to be on another unit and was called by her last name there as well. On 8/21/24 at 12:40 PM, Nurse Supervisor O stated she herself did not call resident #94 by her last name but referred to her with the prefix or courtesy title of Ms. in front of her last name. In the resident's medical record, it stated this resident preferred name was a shortened version of her first name. 3. On 8/20/24 at 3:50 PM, resident #122 was observed as she tried to leave the dining room area with one sock in her hand. Activity Personnel M asked the resident where she was going and encouraged her to instead stay seated. Resident #122 continued to leave and CNA K redirected resident #122 back to her seat to watch TV. On 8/22/24 at 4:10 PM, Activity Personnel M stated resident #122 had decreased balance and needed someone to walk with her. She explained, if there was another CNA close by, she would have asked them to stay with the other residents and would have walked with the resident. She was surprised to learn that another CNA was close-by who also redirected the resident to sit back down. 4. On 8/20/24 at 3:52 PM, resident #61, using her walker, headed toward the unit's exit door and stated she was looking for her jacket. CNA L stated, I will find your jacket, go sit in your chair. A short time later at 4:10 PM, resident #61 got out of her chair and started walking with her walker and again asked about her jacket. CNA L redirected resident #61 back to the chair and parked her walker to the side of the chair telling her dinner would be there soon even though it was over an hour until dinner was scheduled for that unit. CNA L stated she redirected the resident to sit in the chair instead of allowing her to walk around because she was afraid the resident would fall. On 08/22/24 at 1:38 PM, Nurse Supervisor N stated if a resident was able to walk on their own safely, CNAs were expected to let them walk or if not safe, instead walk with them. She stated resident #61 did not usually go far, was pretty safe to ambulate on her own, and realized her limitations. Nurse Supervisor N explained resident #61 didn't usually try to leave but would use her walker to go to her room. Nurse Supervisor N stated she trained the CNA's that it was important for residents to be able to walk and wander, otherwise they would get restless and eventually would forget how to walk. On 8/21/24 at 1:18 PM, the Lakeside Unit Manager stated if a resident got up to walk around, CNA's were expected to assist them as needed because walking around was good for them. It maintained their mobility and gave them a sense of well-being. On 8/22/24 at 3:45 PM, the Activities Director stated If you don't use it, you will lose it, when discussing the importance of residents being allowed to walk when they wanted to walk. On 8/22/24 at 3:21 PM, Nurse Supervisor N, stated she trained the CNAs to treat residents with dignity. She explained, some of the staff had worked on this unit for many years and perhaps had developed habits that were difficult to break. The facility's Policy on Dignity dated 2/27/20 stated residents would be cared for in a manner that promoted and enhanced quality of life, dignity, respect and individuality. This policy indicated residents would be called by their name of choice, in a manner to promote dignity and would be assisted in the activities of their choice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its abuse prohibition policy and procedures related to an allegation of mistreatment by 1 of 2 residents reviewed for abuse, of a total sample of 51 residents, (#146). Findings: Review of the medical record revealed resident #146, an [AGE] year-old female, was admitted to the facility on [DATE]. Her diagnoses included metabolic encephalopathy or a brain disorder, and adult failure to thrive. Review of the Minimum Data Set (MDS) Quarterly assessment with assessment reference date of 7/12/24 revealed resident #146 had clear speech and was usually able to express her ideas and wants. The resident's Brief Interview for Mental Status score was 15/15 which indicated she was cognitively intact. The MDS assessment revealed during the 14-day lookback period, resident #146 showed no evidence of acute onset mental status change. She exhibited no behavioral symptoms and did not reject evaluation or care that was necessary to achieve her goals for health and well-being. The document revealed the resident required substantial to maximal assistance to roll from left to right in bed and to maintain personal hygiene. She was totally dependent on staff for toileting hygiene and bathing. On 8/19/24 at 2:28 PM, resident #146 described an incident that occurred with a Certified Nursing Assistant (CNA) within the previous two to three days, during the day shift. The resident said, She was very rough while turning me. She does not tell me when she is doing anything. The resident explained the CNA habitually rolled her quickly from side to side without warning her or explaining what she was going to do, and was not gentle. When asked if she reported the incident to anyone, resident #146 confirmed she asked someone to get the head nurse to come to her room. The resident could not recall the name of the CNA who was rough with her nor the name of the nurse who responded. She stated she told the nurse the CNA was rough with her and she did not want that person assigned to her again. On 8/19/24 at 2:41 PM, the Riverside Unit Manager (UM) stated she was not aware of an allegation of rough treatment by resident #146. On 8/19/24 at 2:44 PM, resident #146 repeated the allegation as she informed the Riverside UM that a CNA was rough with her during care. The resident told the UM that the CNA had been rough with her several times before, but she finally had enough that day, and decided to tell a nurse. On 8/19/24 at 2:47 PM, when asked about the facility's policy to prevent abuse, the Riverside UM stated the nurse who resident #146 spoke with should have reported the information to the supervisor. She acknowledged any employee who was made aware of a grievance, concern, or an allegation of mistreatment, abuse, or neglect should report it to a supervisor immediately to ensure the information was properly passed along to facility administration. On 8/19/24 at 2:51 PM, the facility's Administrator was informed of resident #146's allegation of rough care by a CNA. He confirmed staff were expected to follow all policies and procedures for prevention of abuse and neglect. On 8/19/24 at 3:39 PM, the Administrator stated he interviewed resident #146 and she confirmed she felt abused while she was being repositioned in bed by a CNA. He explained the resident was able to describe the CNA, and after review of the schedule, the preliminary investigation showed the resident referred to CNA J. The Administrator said, [The resident] said a nurse came in and she explained everything to the nurse. It was not reported to us. He stated his expectation was the nurse should have reported the allegation so it could have been thoroughly investigated by the Risk Manager (RM). The Administrator verified residents did not have to use the word abuse to ensure an allegation was investigated. He explained at the very least, the concern should have triggered the grievance process, and it would have been escalated to an abuse investigation if indicated. On 8/19/24 at 5:32 PM, the Administrator stated the facility's investigation showed resident #146's assigned nurse on the day of the incident was Licensed Practical Nurse (LPN) B. He explained LPN B denied the resident told her she was abused by CNA J. He acknowledged even if the word abuse was not used, it was not LPN B's decision whether it was an abuse situation or not. He said, But the nurse wrote it up as a grievance on Friday and we just haven't had time to go over them yet. You guys showed up this morning. However, the Administrator reviewed the grievance log and confirmed resident #146's concern was not recorded on the document. On 8/20/24 at 10:07 AM, LPN B confirmed she was resident #146's assigned nurse on the day of the alleged abuse incident. She recalled she responded to the resident's call light and was also told by CNA J that the resident wanted to speak to her. LPN B stated the resident seemed a little confused and said she did not care for the CNA's personality as she, did not seem to be that nice. She denied the resident reported the CNA was rough with her. LPN B explained resident #146 sometimes had memory problems and was only alert and oriented 60% to 70% of the time. LPN B refuted the Administrator's statement and denied she wrote a grievance form on the day of the incident. She recalled the resident expressed the concern towards the end of the day shift, and instead of writing a grievance form, she called the facility's Social Services Director (SSD) and left a message for her regarding resident #416 not caring for CNA J's personality. LPN B then corrected herself and stated she actually had a telephone conversation with the SSD, who told her thanks for the information and she would take care of it. LPN B stated the SSD did not ask if CNA J was removed from resident #146's assignment. She acknowledged she did not document her conversations with either the resident or the SSD in the medical record. LPN B scrolled through her personal phone and provided the SSD's telephone number. On 8/20/24 at 10:23 AM, the facility's SSD stated the telephone number provided by LPN B was her personal cell phone number. However, she denied receiving a telephone call from LPN B regarding any issues concerning resident #146. She reviewed her cell phone log for Friday 8/16/24 and emphasized there were no calls from LPN B. The SSD stated she was not aware of the incident involving resident #146 and CNA J until the facility was informed by the State Survey Agency on 8/19/24. She verified resident #146 was cognitively intact and her complaint of unsatisfactory care or rough treatment should have been recorded and reported. The SSD explained there are evening supervisors in the building every day, and on the weekends there are both a weekend supervisor and a manager on duty. The SSD stated LPN B should have reported the resident's concerns to the supervisor on site. Review of the facility's policy and procedure for Resident Mistreatment, Neglect and Abuse Prohibition, dated 1/24/23, revealed the facility was committed to protecting the physical and emotional well-being of every resident. The document indicated the definition of abuse was the willful infliction of injury or intimidation that resulted in physical harm, pain, or mental anguish. The document revealed mandated reporting was a legal obligation to formally report suspected or witnessed abuse or mistreatment of residents. Residents and staff would be able to report any concerns, incidents, or grievances, and supervisory and administrative staff would provide regular direct/indirect supervision of nursing home employees and resident care. The policy read, All employees are required to immediately report the facts of known or suspected instances of abuse to their direct supervisor on duty, Abuse Coordinator, Administrator, and/or Director of Nursing (either directly or anonymously), so that the facility responsibilities to protect residents and promptly investigate occurrences can be met.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement the comprehensive care plan related to interventions to prevent falls and injuries for 1 of 5 residents reviewed for accidents, of a total sample of 51 residents, (#51). Findings: Review of the medical record revealed resident #51, a [AGE] year-old female, was admitted to the facility on [DATE]. Her diagnoses included syncope and collapse, dementia, anemia, vertigo, anxiety, and stroke. The Minimum Data Set (MDS) Quarterly assessment with assessment reference date of 6/13/24 revealed resident #51 had a Brief Interview for Mental Status score of 6 which indicated she had severe cognitive impairment. The document revealed the resident exhibited fluctuating inattention and disorganized thinking that varied in severity. The MDS assessment indicated the resident displayed no behavioral symptoms and did not reject evaluation or care that was necessary to achieve the resident's goals for health and well-being. Resident #51 had functional limitation in range of motion with impairment of both lower extremities. She was dependent on staff for toileting hygiene, lower body dressing, and transfers between her bed and wheelchair. The MDS assessment revealed resident #51 had one fall with no injury since admission or the prior assessment. Review of the medical record revealed resident #51 had a care plan for risk for falls related to impaired mobility, weakness, history of falls, vertigo, and vision impairment, initiated on 6/15/22 and edited on 7/08/24. The goal was the resident would have a reduced risk for injury related to falls. The care plan approaches included keep the resident's bed in a low position for safety, apply hipsters while in bed, encourage use of geri-sleeves, provide a perimeter mattress with raised sides, and place bilateral floor mats when she was in bed. The care plan indicated staff could remove the hipsters to perform skin checks and hygiene. Hipster garments look like shorts with pads on the hip areas to protect bones from injuries associated with falls. Geri-sleeves are a stocking-type garment for the extremities that protects against injuries such as skin tears. On 8/20/24 at 1:16 PM, resident #51 was observed in her room with her bed in low position. A handwritten sign posted on the wall above the bed revealed instructions to ensure the bed was lowered to the floor as the resident experienced increased anxiety since she fell out of bed. Photographic evidence was obtained. There were two floor mats leaning against the wall next to the door and the resident did not wear geri-sleeves on her arms. Certified Nursing Assistant (CNA) A explained she completed personal hygiene care for the resident after lunch and left her in bed to rest. She acknowledged she did not place the floor mats on both sides of the bed before she left the room. When asked if the resident wore a hipster garment, CNA A said, We don't put the hipsters on anymore.they are uncomfortable. We told the daughter and she said it's ok. CNA A explained sometimes resident #51 would remove the geri-sleeves, but she did not respond when asked if she applied them this morning. CNA A stated the facility's system for communication of care directives for each resident was a paper form located in a plastic sleeve on the back of the room door. Review of the Resident Care Card/Information Sheet for resident #51 revealed a section designated for Fall Management that included one approach, use of a one-way glide device in her wheelchair. The document did not reflect any of the fall and injury prevention interventions listed in the comprehensive care plan. The active care plan approaches of right and/or left fall mats, low bed, and hipsters were not checked off on the document, and the need for geri-sleeves was not noted. On 8/20/24 at 1:23 PM, the Risk Manager (RM) confirmed the facility did not have a fully electronic care card system and CNAs were expected to obtain care instructions from the paper form that was kept in the resident's room. On 8/20/24 at 4:49 PM, CNA C stated she was on staff for over seven months and was resident #51's regularly assigned evening shift CNA. During joint observation of resident #51, she validated the resident still did not wear geri-sleeves and she had not attempted to apply them since her arrival at 2:00 PM. When asked if she usually applied the resident's hipsters, CNA C said, I don't know what they are. On 8/20/24 at 4:54 PM, the Riverside Unit Manager (UM) was informed of concerns regarding the CNAs' access to and knowledge of fall prevention interventions to ensure the care plan approaches were appropriately implemented for resident #51. She was told the resident's fall mats, hipsters, and geri-sleeves were not in place during the day shift, and the resident still did not have geri-sleeves or hipsters placed for the evening shift. The UM acknowledged if the regularly assigned CNA did not know what hipsters were, then she probably had not been providing the garment for the resident. She stated her expectation was staff would ask the assigned nurse for clarification if they did not understand care directives. On 8/20/24 at 4:56 PM, the Riverside UM entered resident #51's room and described the hipster garment to CNA C. They both searched the resident's shelves, dresser drawers, and closet, but neither staff member was able to locate hipsters. The UM stated CNAs were to follow instructions on the resident's care cards. She retrieved resident #51's care card and verified the comprehensive care plan interventions were not transcribed to the document. On 8/21/24 at 12:13 PM, the Lead MDS Coordinator explained fall prevention interventions were usually added to residents' care plans by the RM. She confirmed floor nurses and UMs could initiate care plan interventions and they were responsible for updating the CNA care card to reflect revised approaches. The Lead MDS Coordinator stated care plan interventions would not be effective if they were not documented and made available to direct care staff. On 8/21/24 on 1:54 PM, in a telephone interview, resident #51's daughter explained she was familiar with her mother's care as she visited at least five days a week and she was also the primary contact person. She confirmed her mother had a couple falls from bed so she created and placed the sign above her mother's bed to remind staff to keep it in a low position. The resident's daughter said, I still find the bed in a high up position sometimes. When asked if her mother tolerated the hipsters as an intervention to prevent injury, resident #51's daughter stated she did not understand the question. After being given a description of the garment, the daughter said, That all sounds good, but I have never heard of that. On 8/22/24 at 1:34 PM, the Director of Nursing (DON) stated her expectation was nurses would initiate appropriate fall prevention interventions immediately after a fall. She explained when the interdisciplinary team met to identify the root cause of a fall, interventions might be modified if necessary. The DON stated the RM was responsible for adding new interventions to residents' care cards and UMs were responsible for auditing the care cards to ensure accuracy. The DON acknowledged the purpose of a complete and accurate care card was to ensure residents received appropriate care. Review of the facility's policy and procedure for Comprehensive Care Plans (undated) revealed each resident would have an individualized, comprehensive care plan developed to meet his/her medical and nursing needs. The policy indicated the comprehensive care plan would incorporate identified problem areas, risk factors, wishes regarding care and treatment goals, and reflect current standards of practice. The document read, Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes. The facility's policy and procedure for Using the Care Plan, dated 1/30/24, read, The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care and services to the resident. The policy indicated care cards would list necessary care plan interventions for CNA would be updated as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide adequate activities of daily living (ADL) care related to personal hygiene for 1 of 1 resident reviewed for ADLs, of a total sample of 51 residents, (#146). Findings: Review of the medical record revealed resident #146, an [AGE] year-old female, was admitted to the facility on [DATE]. Her diagnoses included metabolic encephalopathy or a brain disorder, and adult failure to thrive. Review of the Minimum Data Set (MDS) Quarterly assessment with assessment reference date of 7/12/24 revealed resident #146 had clear speech and was usually able to express her ideas and wants. The resident's Brief Interview for Mental Status score was 15/15 which indicated she was cognitively intact. The MDS assessment revealed during the 14-day lookback period, resident #146 showed no evidence of acute onset mental status change. She exhibited no behavioral symptoms and did not reject evaluation or care that was necessary to achieve her goals for health and well-being. The document revealed the resident required substantial to maximal assistance to maintain personal hygiene. Review of the medical record revealed resident #146 had a care plan for ADLs, initiated on 7/14/23. The document indicated she was unable to complete ADLs independently due to weakness and dementia, preferred to wear gowns and kept her fingernails long. The goal was resident #146 would have her ADL needs met daily, with staff assistance. The approaches included, assist with hygiene as needed. A care plan for behaviors related to cognitive impairment, initiated on 7/26/23, had the goal that the resident would have fewer episodes of resisting care. The care plan approaches directed staff to divert the resident's attention, re-approach her later when agitated, discuss behaviors when unacceptable, reinforce positive behaviors, and anticipate her needs. On 8/19/24 at 11:16 AM, resident #146 lifted both hands to show that all fingernails were long and dirty. The resident's fingernails extended approximately one-half inch or more past her fingertips and there was a significant amount of a dark brown to black substance packed tightly under all fingernails. Resident #146 unsuccessfully attempted to use the tip of one fingernail to dislodge the substance under another fingernail. The resident explained she liked her fingernails long but would never keep them as dirty as they were if she had a choice. She emphasized she definitely did not want to eat with fingernails that looked the way they did. Resident #146 could not recall when she last received nail care and said, It has been a while. She stated the situation was not really the fault of staff as they were often too busy to do little things like clean her hands and trim her fingernails. The resident explained she planned to ask someone to give her a basin so she could soak her fingernails. Certified Nursing Assistant (CNA) A entered the room and stated she was not assigned to resident #146, but overheard the conversation, and would provide nail care for her. CNA A validated the resident's fingernails were long and very dirty. She confirmed all CNAs were responsible for personal hygiene care, and residents should receive nail care at least twice weekly on shower days. On 8/19/24 at 2:27 PM, resident #146 unwrapped small chocolates and held them in her fingers as she ate them. She showed her fingernails and stated she was happy they were finally clean. The resident confirmed she liked her fingernails, to be a little long, but nothing like this. Resident #146 held a chocolate between her right thumb and index finger to demonstrate how difficult it was to grasp food, and keep the nails clean when her fingernails were that long. On 8/19/24 at 2:39 PM, the Riverside Unit Manager (UM) stated nail care should be done with daily ADL care, by staff on any shift. She said, There is no reason nail care should not be done regularly. On 8/19/24 at 2:42 PM, resident #146 informed the Riverside UM that a CNA soaked her fingernails earlier in the day. She told the UM the CNA had to, dig out the dirt, and she now wanted her fingernails trimmed shorter. The resident informed the UM she could pay for a manicure if necessary, but the UM reassured her that cleaning and trimming her nails were regular tasks to be performed by CNAs. Review of the CNA Shower Sheet/Skin Inspection forms for August 2024 revealed CNA documentation that resident #146 received bed baths on 8/07/24, 8/10/24, 8/13/24, and 8/17/24. The forms indicated the resident, refused nail care. Review of nursing progress notes for August 2024 revealed no evidence nurses were made of aware of multiple refusals of care by resident #146. There was no documentation to show nurses noted the condition of the resident's fingernails during daily interactions with her. The progress notes did not indicate nurses instructed CNAs to perform nail care or that they implemented any of the care plan approaches developed to address refusals of care. Review of the facility's policy and procedure for Supporting Activities of Daily Living, revised on 1/25/23, revealed residents who were unable to independently perform ADLs would receive the services necessary to maintain good grooming and personal hygiene.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an individualized activities program was provided for 1 of 2 residents reviewed for Activities, of a total sample of 51 residents, (#156). Findings: Review of the medical record revealed resident #156, an [AGE] year old female was admitted to the facility on [DATE] with diagnoses of left hip fracture, difficulty in walking, cognitive communication deficit, psychotic disturbance, dementia, Alzheimer's Disease, mood disorder, depression, and anxiety. The Minimum Data Set (MDS) Modified admission assessment with an Assessment Reference Date (ARD) of 7/14/24 identified during the look back periods, resident #156 often required help with reading. The Brief Interview for Mental Status score of 3 out of 15 indicated the resident was severely cognitively impaired. The assessment showed she had inattention that fluctuated, and she often felt lonely or isolated from those around her. No behaviors or rejections of evaluation or care were noted. The resident's Functional Abilities and Goals of everyday activities showed she was dependent on staff to eat, complete Activities of Daily Living (ADL), mobility functions, walk or transport herself out of her room, and she was always incontinent of bladder and bowel functions. The Preferences for Customary Routine and Activities section documented it was very important for the resident to listen to music she liked, keep up with the news, do favorite activities, go outside for fresh air in good weather, and do things with groups of people. The Comprehensive Care Plan's focuses included impaired ambulation, inability to independently complete ADLs, decreased strength/endurance, adverse effects of psychotropic medications, memory problems, confusion and forgetfulness. Interventions included staff to encourage visits from family, friends, and volunteers and involve her in facility activities. Another focus for a risk for decline in mood/behavior related to depression had an intervention to assist in setting a structured routine; reinforce physical activity, socialization, and encourage visits from family, friends, and volunteers. The Recreation/Wellness Problem created by the Activities Director read, Dependent of staff for activities, cognitive stimulation, and social interaction . Approach adapt activities of preference to cognitive level and skill function. Allow patient/resident to be a spectator in activities. Invite to food related activities . Provide activities in an outside setting . Verbally check with patient/resident/or family frequently to determine satisfaction in activities. On 8/20/24 at 10:29 AM, resident #156 was observed alone in her room approximately 50 feet from the nurse's station. She was sitting in a wheelchair with her head down towards her lap. She looked up and asked, Where are all the girls? The handwritten Activity admission 72 Hour Note completed by the Activities Director showed information was obtained from resident #156's family. It was noted the resident's former vocation was a realtor, and it was very important for her to have music (oldies), keep up with the news, go outside on walks, paint, play bingo, card games, and bridge, and see comedy. The form read, Loves to be around people . going out to lunch with friends . On 8/20/24 at 11:19 AM, the resident was observed in her room awake and lying in bed. The resident looked anxious and restless while she repeatedly pulled at the bed cover. On 8/21/24 at 11:24 AM, the Activities Director explained she was responsible for the facility's Activities program. She said the department coordinated and provided activities for residents, and she conducted interviews with residents and/or their family to develop and implement individualized care plans. On 8/21/24 at 11:35 AM, the Activities Assistant explained resident #156 sometimes participated in manicures and she enjoyed socializing with the ladies. She stated, She looks through a book or she watches TV (television). On 8/21/24 at 12:04 PM, five residents were observed in the Bayside dining room for lunch. Certified Nursing Assistants (CNAs) P and Q assisted the residents with eating. CNA P explained resident #156 ate in her room and he was provided a list of residents who needed assistance to get to the dining room for meals by the Bayside Unit Manager. On 8/21/24 at 12:15 PM, the Bayside Unit Manager said the Dietary Menu Development Coordinator provided a list of residents that ate in the dining room, and it was kept at the nurse's station for the CNAs. On 8/21/24 at 1:52 PM, CNA P explained he often had resident #156 on his assignments, and was not aware of what activities she liked. He could not recall any times she participated in group activities. The CNA stated, That's a good question; I usually get her up in a chair and have her in the hallway but today I had to go to the dining room. On 8/22/24 at 1:27 PM, the Dietary Menu Development Coordinator explained that Unit Managers provided a list of residents on their unit who ate in the group dining room to the Registered Dietician. She said she didn't have input for who goes on the list, and she only typed it up and gave it to the Unit Managers. Review of the list of residents who ate in group dining provided by the Bayside Unit Manager included 7 residents on the unit who participated in group dining. Resident #156 was not on the list. On 8/22/24 at 9:27 AM, an overhead announcement was heard for group activities on the Bayside Unit. At 10:13 AM, the Bayside Unit Manager said the Activities staff had not arrived yet for group activities. At 10:35 AM, no residents were observed in the unit's TV/group room/common area. On 8/22/24 at 10:38 AM, resident #156 was observed sitting in her room in a wheelchair pulling at her clothing. The TV was not on nor were there any reading materials observed within reach of the resident. The resident stated, I don't know if my daughter is coming. In a telephone interview with resident #156's daughter, she recalled that about one month prior, the Activities Director asked her a lot of questions about her mother's normal preferences and activities. She was distressed when she explained she had asked nursing staff to take her mother to the dining room and help her participate in group activities. She said two days prior, she wheeled the resident down to an exercise class. She said she watched through the window and saw her participating while she had her hands up and seemed to enjoy it. She stated, I have seen them maybe a total of three times get her out of her room and they put her in that room where the TV is and leave her there; it makes her feel better to be out of her room and socialize; they don't take her outside, she likes that very much; she always enjoyed going out and eating with friends; she is still able to socialize if she's in the right environment; even when I wheel her down the hall she starts talking to people and she lights up, I think, there's my mom. On 8/21/24 at 11:24 AM, the Activities Director said the CNAs were responsible for assisting residents out of their rooms for activities. She did not explain why resident #156 spent most of her time in her room. On 8/22/24 at 1:30 PM, the Bayside Unit Manager explained residents who needed assistance with eating or who preferred to, ate in the group dining area. She said it was important to assist the residents to ensure they were eating well, getting adequate nutrition, and they could socialize. She said resident #156 normally did not come out of her room and she ate her meals there because that was her daughter's preference. She stated, I'm not sure why she hasn't been in the day room; I will look into that. On 8/22/24 at 10:42 AM, the Social Services Director explained it was important for residents to have activities for emotional support and adjustment disorders. She said going outside, getting involved with activities, and socializing helped with residents' depression, eating, and sleeping. She stated, Isolation can cause people to be depressed or withdraw even more; it's important to stimulate them and try to get them involved in interactions. Review of the facility's standards and guidelines dated 2/27/20 and titled 2.8 Activities Programs read, . Our activities programs are designed to encourage maximum individual participation and are geared to the individual resident's needs. Our activity programs consist of individual and small and large group activities that are designed to meet the needs and interest of each resident .Social activities are scheduled to increase self-esteem, to stimulate interest and friendships, and to provide fun and enjoyment .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure oxygen was administered as ordered by the physician, in accordance with professional standards, for 2 of 3 residents reviewed for respiratory care, of a total sample of 51 residents, (#57 and #77). Findings: 1. Review of the medical record revealed resident #57, a [AGE] year-old female, was admitted to the facility on [DATE]. Her diagnoses included hypertensive heart disease with heart failure, history of COVID-19, and cardiomegaly or an enlarged heart. Resident #57 had a terminal condition, end-stage heart disease, with a projected life expectancy of six months or less. The Minimum Data Set (MDS) Annual assessment with assessment reference date (ARD) of 7/08/24 revealed the resident's Brief Interview for Mental Status (BIMS) score was 12 which indicated the resident had moderate cognitive impairment. The MDS assessment indicated resident #57 displayed no behavioral symptoms and did not reject evaluation or care that was necessary to achieve her goals for health and well-being. The document revealed the resident received oxygen therapy. According to the American Heart Association, oxygen therapy is one of the treatments used to improve the quality of life for persons with a diagnosis of heart failure. Delivery of concentrated oxygen to the lungs increases the amount of oxygen in the blood and improves shortness of breath, (retrieved on 8/26/24 from www.heart.org/en/health-topics/heart-failure/treatment-options-for-heart-failure/medications-used-to-treat-heart-failure). Review of the medical record revealed resident #57 had a care plan for the risk for complications related to cardiac disease, initiated on 8/21/20. The interventions included observe for signs and symptoms of cardiac complications such as chest pain and shortness of breath, and administer oxygen as ordered. A care plan for risk of complications related to respiratory disease, initiated on 7/17/24, revealed resident #57 was dependent on supplemental oxygen. The goal was the resident would not develop signs and symptoms of respiratory complications. The interventions instructed nursing staff to monitor for respiratory concerns including shortness of breath and administer oxygen as ordered. Review of resident #57's medical record revealed a physician order dated 8/20/20 for oxygen at 2 liters per minute (L/min) via nasal cannula, every shift, 7:00 AM to 7:00 PM, and 7:00 PM to 7:00 AM. On 8/19/24 at 11:06 AM, resident #57 was in bed and wore a nasal cannula. The tubing was connected to an oxygen concentrator at the right side of her bed, out of the resident's reach, which was set at a flow rate of 1 L/min. An Advanced Practice Registered Nurse entered the room and explained whenever she assessed the resident, the concentrator was usually set at 1 L/min. She suggested it was possible the attending physician's order was to titrate the resident's oxygen flow rate between 1 and 2 L/min. On 8/19/24 at 11:07 AM, Licensed Practical Nurse (LPN) D confirmed she was resident #57's assigned nurse. She checked the physician order for oxygen therapy and stated the resident's oxygen flow rate should be 2 L/min. She inspected the oxygen concentrator and validated the machine was set at a flow rate of 1 L/min. LPN D explained nurses were required to document on the resident's oxygen use once per shift and she would could do that at any time between 7:00 AM and 7:00 PM. LPN D verified she administered resident #57's scheduled morning medication earlier in the shift, but she did not check the oxygen concentrator while she was at the resident's bedside. On 8/20/24 at 4:32 PM, the Riverside Unit Manager (UM) validated it was important to follow physician orders for oxygen administration. She stated her expectation was the nurse would check the flow rate at the beginning of the shift or at the time of administration of morning medications. The UM explained resident #57 required oxygen therapy as she has a history of the respiratory virus, COVID-19, and had been dependent on oxygen for several years due to a diagnosis of heart failure. 2. Review of the medical record revealed resident #77, a [AGE] year-old female, was admitted to the facility on [DATE] and re-admitted on [DATE]. Her diagnoses included dementia, anemia, and insomnia. Resident #77 had a terminal condition, cerebral atherosclerosis, with a projected life expectancy of six months or less. The MDS Annual assessment with ARD of 6/14/24 revealed resident #77 had a BIMS score of 15 which indicated she was cognitively intact. The MDS assessment revealed the resident had no acute onset mental changes, no behavioral symptoms, and did not reject evaluation or care that was necessary to achieve her goals for health and well-being. The document showed the resident received oxygen therapy. Review of the medical record revealed resident #77 had a care plan for risk for complications related to respiratory disease, initiated on 1/11/24. The goal was the resident would not develop signs or symptoms of respiratory complications. The approaches included observe for signs and symptoms of respiratory complications and administer oxygen as ordered. Review of resident #77's medical record revealed a physician order dated 3/14/24 for oxygen at 2 L/min via nasal cannula, to keep oxygen saturation levels above 92% every shift, 7:00 AM to 7:00 PM, and 7:00 PM to 7:00 AM. Review of the Medication Administration Record (MAR) for August 2024 revealed from 8/01/24 to 8/19/24 there was no documentation of resident #77's oxygen saturation levels. On 8/19/24 at 11:13 AM, resident #77 was seated in a wheelchair beside her bed. She had a nasal cannula in place connected to an oxygen concentrator located out of reach, behind the wheelchair. The oxygen flow rate was set at 3 L/min. On 8/19/24 at 11:20 AM, LPN D, resident #77's assigned nurse, reviewed the physician orders and stated the resident's oxygen flow rate was supposed to be 2 L/min. On 8/19/24 at 11:22 AM, LPN D validated resident #77's oxygen concentrator was incorrectly set at 3 L/min. On 8/20/24 at 4:38 PM, the Riverside UM reiterated nurses should check oxygen concentrators when they entered residents' rooms. She explained oxygen orders were listed on the electronic MAR and were easily visible when nurses prepared medications for administration. The UM stated resident #77 required oxygen therapy related to a history of COVID-19. On 8/22/24 at 12:24 PM, the Riverside UM confirmed the physician order for oxygen therapy indicated nurses were to assess resident #77's oxygen saturation levels every shift. The UM validated the resident's oxygen level was not routinely monitored prior to 8/19/24 when noted by State Survey Agency staff. She explained the MAR was revised on 8/20/24 to reflect the requirement for documentation of oxygen saturation levels every shift. On 8/22/24 at 1:30 PM, the facility's Director of Nursing (DON) provided a record of resident #77's oxygen saturation levels from June to August 2024. The document revealed between 6/01/24 and 8/17/24, the residents oxygen level was checked only seven times during the 11-week period. The DON acknowledged nurses did not obtain and document the resident's oxygen saturation levels as ordered. Review of the facility's policy and procedure for Oxygen Administration, dated 1/30/24, revealed the purpose was to provide guidelines for safe oxygen administration. The policy instructed nursing staff to review the resident's physician order or protocol for oxygen administration, check the tubing and start the flow of oxygen at the ordered rate. The document read, Observe the resident upon setup and periodically thereafter to be sure oxygen is being tolerated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to administer medications according to physician orders to prevent medication errors for 2 of 5 residents reviewed during the Medication Administration task, of a total sample of 51 residents, (#33 & #62). There were 4 errors in 29 opportunities for a medication error rate of 13%. Findings: 1. Review of the medical record revealed resident #33, a [AGE] year-old male, was admitted to the facility on [DATE]. His diagnoses included unspecified pain and constipation. Resident #33 had a care plan for risk of developing pain related to a thigh wound, acid reflux, and a potential for abnormal bowel pattern, initiated on 7/03/23. The goal was the resident would experience pain reduction or relief. The care plan approaches instructed nurses to administer pain medications according to the physician's order. Review of the Physician Order Report revealed resident #33 had an order dated 3/13/24 for Colace 100 milligrams (mg) twice daily for constipation, scheduled at 9:00 AM and 5:00 PM. The document showed an order dated 3/21/24 for Ibuprofen 400 mg twice daily for pain, scheduled at 9:00 AM and 5:00 PM. On 8/19/24 at 4:24 PM, Licensed Practical Nurse (LPN) D stood at her medication cart. She stated she was ready to administer resident #33's scheduled 5:00 PM medication. She removed a blister pack from the drawer and placed one tablet of Ibuprofen 400 mg in a medication cup. She reviewed the electronic Medication Administration Record (MAR), closed her computer screen, and entered the resident's room to administer the tablet. After resident #33 swallowed the tablet, LPN D returned to the medication cart to record the medication administration task as completed. During the process of reconciling resident #33's physician orders with the MAR, there was a discrepancy identified. The MAR showed LPN D's initials to validate she administered two medications, the scheduled 5:00 PM doses of one tablet Ibuprofen 400 mg and one capsule Colace 100 mg. On 8/20/24 at 4:23 PM, the Riverside Unit Manager (UM) was informed resident #33's medical record showed LPN D administered his Colace 100 mg capsule although it was not given during observation of medication administration. She stated the nurse could have realized she forgot the medication and then returned to administer it at a later time. The UM provided a record of the actual administration time of Colace 100 mg. Review of the detailed Administration History revealed LPN D documented administration of both scheduled medications, Ibuprofen 400 mg and Colace 100 mg, on 8/19/24 at 4:27 PM. The UM stated her expectation was nurses would administer scheduled medications as ordered, and accurately record administration at the time it occurred. On 8/22/24 at 3:05 PM, LPN D validated she administered only one tablet during the medication administration observation on 8/19/24. She was unable to explain why she documented administration of two drugs instead of one. 2. Review of the medical record revealed resident #62, an [AGE] year-old female, was admitted to the facility on [DATE] and re-admitted on [DATE]. Her diagnoses included atrial fibrillation, hypertension, anemia, generalized muscle weakness, and long-term use of anticoagulant or blood thinner medication. Resident #62 had a care plan for risk for abnormal bleeding or hemorrhage because of anticoagulant use, initiated on 3/20/23 and reviewed/revised on 5/21/24. The goal was the resident would be free from signs and symptoms of abnormal bleeding. The approaches included administer anticoagulant medication as prescribed. Review of the medical record revealed a care plan for risk of complications related to cardiac disease diagnoses including hypertension and atrial fibrillation, initiated on 3/20/23. The goal was the the resident would not develop signs or symptoms of cardiac complications. The approaches instructed nurses to administer medications as ordered. Resident #62 had a care plan for receiving crushed medication related to difficulty swallowing whole tablets, initiated on 10/25/23. The goal was the resident would tolerate crushed medications without difficulty. The approaches included crush medications as ordered and, Meds may be crushed (if med crushable) and administered as a single oral bolus as the benefits outweigh the risks of individual administration [due to] difficulty swallowing. Review of the Physician Order Report revealed resident #62 had physician orders dated 5/07/24 for Dabigatran etexilate 150 mg twice daily for atrial fibrillation, one tablet Daily Multivitamin supplement once daily, and Ferrous sulfate 325 mg once daily for anemia. On 8/20/24 at 9:35 AM, LPN E prepared to administer resident #62's scheduled morning medications. She retrieved blister packs from a drawer of the medication cart and place medication including one capsule Dabigatran etexilate 150 mg, one tablet Daily Multivitamin with Minerals, and one tablet Ferrous sulfate 325 mg in a medication cup. LPN E explained resident #62 had difficulty swallowing and her medication had to be crushed and given in food, either applesauce or pudding. She proceeded to crush all the tablets and placed them in another medication cup, then she opened the capsule and sprinkled its contents on top of the crushed tablets. LPN E mixed the medication into the resident's preferred food and administered the medication. On 8/20/24 at 11:21 AM, and 11:47 AM, after reconciliation of resident #62's medication orders with the MAR, LPN E was asked to compare the resident's order for a Daily Multivitamin to the bottle she had in the medication cart. She read the bottle and confirmed she administered a Multivitamin with Minerals. She checked the unit's medication room and stated there was no plain multivitamin available. LPN E stated she had not noticed the discrepancy during medication administration. She acknowledged it was essential to read containers carefully and compare them to physician orders prior to administration. She was asked to retrieve the bottle of Dabigatran and joint review of the label revealed the instruction, Swallow capsule whole. LPN E stated she had not noticed the warning. She verified she should have called the physician regarding the resident's inability to swallow the capsule and requested another form or type of medication. LPN E checked the bottle of Ferrous Sulfate and stated there were no instructions regarding not crushing the drug. When prompted to pour a Ferrous Sulfate tablet from the bottle, she noted it had a shiny coating. On 8/20/24 at 11:50 AM, LPN E contacted the facility's pharmacy to clarify medication administration instructions for resident #62 related to her inability to swallow medications whole. During the conversation on speakerphone between pharmacy representatives and LPN E, she was told Dabigatran capsules should not be opened and Ferrous Sulfate tablets should not be crushed. The pharmacy representative recommended contacting the resident's physician to obtain appropriate orders. On 8/20/24 at 1:26 PM, the Central Supply staff stated the facility's formulary included only Multivitamins with Minerals tablets, not Daily Multivitamins. He explained if a resident needed a plain multivitamin, nurses would have to get it ordered from the pharmacy or he could obtain it from a local pharmacy. On 8/20/24 at 4:09 PM, the Riverside UM acknowledged all nurses should follow the facility's policies and procedures and accepted standards of nursing practice for medication administration. She stated her expectation was nurses would read all medication labels carefully and follow the five rights of medication administration. The UM confirmed resident #62's nurses should have identified potential concerns related to crushing her medication and opening the capsule, and called the physician, researched drug manufacturers' instructions, or called the pharmacy. Review of the facility's policy and procedure for Medication Administration - General Guidelines, revised in January 2018, revealed medications would be administered as prescribed in accordance with good nursing principles and practices. The document listed the five rights of medication administration as the right resident, right drug, right dose, right route, and right time. The policy instructed staff to practice a triple check method that involved first selecting the medication and checking the label, container, and contents for integrity, and comparing it to the MAR. The second check was to be done during preparation of the dose by removing the drug from container and verifying it against the label and MAR. The third check was to occur during completion of dose preparation when nurses would re-verify the label against the MAR. The policy read, If it is safe to do, medication tablets may be crushed or capsules emptied out when a resident has difficulty swallowing. The document instructed nurses to check with the pharmacist before opening capsules or crushing tablets to identify alternative medications if indicated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain proper infection control practices during distribution of lunch trays and set up of lunch meals on 1 of 2 hallways, (400 hallway), on 1 of 4 units, (Riverside Unit). Findings: On 8/19/24 at 11:47 AM, Certified Nursing Assistant (CNA) J distributed lunch trays on the 400 hallway. Without performing hand hygiene, she removed a tray from the meal cart, entered room [ROOM NUMBER], and placed it on a table. CNA J touched the table, removed lids from containers, and then exited the room without using hand sanitizer. CNA J returned to the meal cart, retrieved another tray, and entered room [ROOM NUMBER]. She placed the tray on the table beside bed A, uncovered food items, and set up the meal. During the process, she touched the table and the back of the resident's chair. CNA J did not perform hand hygiene prior to exiting the room and she returned to the meal cart to continue distributing lunch trays. Next, she retrieved a tray and returned to room [ROOM NUMBER] where she placed it on the table beside bed B. CNA J removed the plate cover, opened a box of milk, and removed plastic lids from other containers on the tray to complete meal set up. As she exited the room, the resident in bed A reminded her he did not get a box of milk on his tray. CNA J acknowledged the request, and again left the room without performing hand hygiene. She then used both hands, one on each meal cart, to pull the carts further down the hallway. CNA J left the carts, walked to the nourishment room to retrieve a box a milk, and found there was no milk in the refrigerator. As she walked to the main kitchen to get a box of milk, CNA J commented on the warm temperature in the hallway and wiped sweat from her forehead by moving her left forearm to the back of her hand and her fingers across her forehead. On 8/19/24 at 11:53 AM, CNA J stood at the kitchen door and received a box of milk from dietary staff. She held the box in her left hand as she walked back towards the Riverside Unit. On the way back to the 400 hallway, CNA J raised her right arm and again wiped away sweat by dragging her right forearm to the back of her hand and fingers across her forehead. She entered room [ROOM NUMBER], placed the box of milk on the table beside bed A, and used both hands to open the box. She removed the wrapper from a straw and inserted the straw into the milk. On 8/19/24 at 11:56 AM, CNA J exited room [ROOM NUMBER] and did not perform hand hygiene before returning to the meal cart to continue distribution of residents' meal trays. She retrieved another tray, entered room [ROOM NUMBER], and placed it on the table beside bed A. CNA J uncovered the meal, removed the lid on the juice container, opened the box of milk, and poured the contents into a specialty cup. As she exited the room, CNA J raised her hand to touch her hair. Next, she retrieved another meal tray from the cart and returned to room [ROOM NUMBER] to place it on the table beside bed B. She adjusted the back of the resident's wheelchair, then touched the tray and picked up the packet of utensils without performing hand hygiene. On 8/19/24 at 12:00 PM, when CNA J walked towards the meal cart to retrieve another tray, she was prompted to pause the distribution of lunch meal trays. She was informed of concerns regarding the omission of hand hygiene prior to touching items on residents' lunch meal trays, after touching surfaces in residents' rooms, and after touching her skin and hair. CNA J validated she did not perform hand hygiene before touching each resident's tray and items on the tray. On 8/19/24 at 12:02 PM, the Riverside Unit Manager (UM) stated her expectation was all staff would sanitize their hands frequently during meal distribution to reduce the spread of germs. The UM verified there were easily accessible hand sanitizer dispensers in the hallways and resident rooms. The facility's policy and procedure for Assistance with Meals, revised on 1/18/18, read, All employees who provide resident assistance with meals will be trained and shall demonstrate competency in the prevention of foodborne illness, including personal hygiene practices and safe food handling. Review of the facility's policy and procedure for Handwashing/Hand Hygiene, dated 1/30/24, revealed the facility considered hand hygiene to be the primary means to prevent the spread of infections. The policy noted hand hygiene products and supplies including soap and alcohol-based hand rub or hand sanitizer would be accessible and convenient for staff to promote compliance with proper infection control practices. The document indicated staff would perform hand hygiene after contact with objects in the resident's immediate vicinity, before handling food, and before and after assisting a resident with meals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to secure one (1) treatment cart to prevent unauthorized access and promote resident safety, (Riverside), and failed to properly store medications and bottles of liquids in four (4) medication carts and one (1) treatment cart, (Bayside, Oceanside, and Riverside), for 6 of 8 carts inspected during the Medication Storage task, of a total of 14 medication/treatment carts. Findings: 1. On 8/19/24 at 10:15 AM, the 300 hallway treatment cart was observed between rooms [ROOM NUMBERS], on the Riverside Unit. The drawers faced the hallway and the lock protruded from the cart to indicate it was unlocked. All drawers opened smoothly and the contents of each drawer were easily accessible. On 8/19/24 at 10:18 AM, Licensed Practical Nurse (LPN) F verified the treatment cart was unlocked, which allowed all drawers to be opened. She looked to the left of the cart and confirmed there was at least one confused resident in the hallway by the cart. She acknowledged there were other confused residents near the nurses' station. Observation of the treatment cart drawers revealed they contained medications and treatment supplies including scissors, prescription ointments and lotions, and wound cleanser solutions which could be toxic if ingested. LPN F confirmed she had the key for the treatment cart and was responsible for its security. She explained she had not accessed the treatment cart since the start of the shift at 7:00 AM. She stated the cart was probably unlocked since the overnight shift. LPN F acknowledged medication and treatment carts should never be unlocked and unattended. She said, We want to prevent patients or anybody else getting into the carts. Most items are by prescription which means only the nurse should have access to them. 2. On 8/20/24 at 9:53 AM, LPN E retrieved a bottle of liquid protein supplement from the Riverside Unit 300 hallway medication cart. There was a significant amount of hardened sticky residue in lines that extended from the top of the plastic bottle to its base. The dried liquid was noted on all sides of the container. LPN E attempted to scrape the residue off the plastic bottle and said, It's so bad. It's hard to come off. She stated each nurse was responsible for cleaning any spills that occurred when the thick liquid was poured from the bottle. 3. On 8/21/24 at 1:26 PM, Registered Nurse (RN) I confirmed she was responsible for the Bayside Unit high-600 hallway medication cart. During inspection of the cart, RN I discovered two boxes of skin protectant in the bottom right drawer. She confirmed treatment supplies were not to be stored in a medication cart. In another drawer, a plastic bottle of liquid protein had dark, dried, spilled residue stuck to the sides. RN I started to pick at the hardened substance on the bottle but she was unable to get it all off. She explained all nurses were responsible for cleaning bottles after use. Observation of the drawer revealed there was residue from the bottle of liquid protein in a circular shape. RN I stated she noticed the substance stuck in the bottom of the drawer, and although she tried to scrape it off with scissors, she was never able to get it out. 4. On 8/21/24 at 1:39 PM, RN I stated she would return the two boxes of skin protectant to the Bayside Unit 600 hallway treatment cart. She opened the bottom drawer of the treatment cart to show a bottle of Betadine antiseptic solution lying on its side. A large amount of the dark brown liquid contents of the bottle had spilled in the drawer and there was residue dried onto the sides of the bottle. RN I reached in and discovered the bottle was stuck to bottom of drawer in the hard, dried pool of liquid. 5. On 8/21/24 at 2:12 PM, during inspection of the Oceanside Unit 100 hallway medication cart, LPN H removed an old, soiled, almost opaque plastic bag that contained a bottle of liquid iron supplement. There was dark brown, spilled medication on the sides of the bottle that partially covered the label, and dried residue in the bottom of the plastic bag. An old rubber band was stretched around the plastic bag to secure it to the bottle. LPN H explained the night nurse usually deep-cleaned the medication cart on a Sunday night. She acknowledged the bottle should have been cleaned and placed in a clean plastic bag. 6. On 8/22/24 at 11:45 AM, during inspection of the Riverside Unit 400 hallway medication cart, LPN G opened a drawer that contained five prescription inhalers, one COVID-19 test kit, and six syringes of normal saline flush. There was no divider in the drawer and the inhalers were adjacent to two large containers of germicidal wipes. LPN G confirmed cleaning supplies should not be stored in the same drawer as medication. Review of the facility's policy and procedure for Storage of Medications, revised in January 2018, revealed medications and biologicals were to be stored safely, securely, and properly. The document indicated medication supply should be accessible only to licensed nursing personnel and pharmacy personnel. The policy revealed medication rooms, carts, supplies would be locked when not attended. The document indicated potentially harmful substances including cleaning supplies and disinfectants should be clearly identified and stored separately from medication. The policy revealed deteriorated medications and soiled containers would be removed from the cart, disposed of, and re-ordered as indicated.

Based on observation and interview, the facility failed to ensure food items were stored in a manner to prevent contamination by keeping them sealed, dated and discarded before their expiration date. This failure had the potential to negatively effect 158 of 158 residents who consumed food items by mouth. Findings: 1. On 8/19/24 at 10:20 AM, during the initial kitchen inspection with the Certified Dietary Manager (CDM), the walk-in freezer was observed to contain multiple cardboard shipping boxes in which the interior bag holding food items was unsealed, leaving the food items open to the air. These unsealed and undated items were beef patties, Rib type-meat, Plant-Based Chick-N-Strips, eggs, and pancakes. A box of popsicles was observed with a large build-up of ice encasing approximately half the popsicles in the box. In the walk-In refrigerator, there was a half-pan of cooked rice dated 8/14. The CDM confirmed the date on the half-pan of rice and stated their policy was to discard prepared food after three days, and discarded the rice. A package with approximately 8-10 sausage patties were also found open to the air, unsealed with no date to indicate when it was opened. In addition, previously opened containers of soup base and parmesan cheese were also found undated. The CDM acknowledged these findings and threw the food items away. In the dry storage area, a box with an unsealed, open plastic bag was found. The plastic bag contained thickening agent which was not sealed or dated. The CDM confirmed the open plastic bag and stated he would have a staff member repackage this dry food item properly. 2. On 8/21/24 at 1:43 PM, the walk-in freezer and refrigerator were re-inspected with the CDM. In the walk-in refrigerator, again a half-pan of cooked rice and an opened container of Parmesan cheese were found undated. Also a full pan of leftover ham was observed with the plastic wrap open/unsealed. Review of the facility's Dietary Services policy for Food Receiving and Storage dated 1/30/24 revealed dry foods stored in bins would be removed from original packaging, labeled and dated. The policy also indicated all food stored in the refrigerator and freezer would be covered, labeled, and dated, and other opened containers of food and beverages must be dated, sealed, or covered and held no longer than 72 hours.

Based on observation, interview, and record review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee developed and implemented timely and appropriate plans of action to prevent repeat deficient practices related to Activities of Daily Living (ADLs) for Dependent Residents and Activities to Meet Resident Interest or Needs. Findings: Review of the facility's survey history revealed repeat deficiency concerns for ADL care and activities during the past 5 years, and again during current survey. The concerns for ADL care specifically nail care and activities to meet the residents' interests and needs to attain their highest practicable well-being would reflect the third time in five years deficiencies were cited for these areas of concern. On 8/22/24 at 4:00 PM, the Administrator and Risk Manager spoke about the facility's QAPI program. The Administrator verified they completed a plan of correction for ADLs and activities last year and did not currently have any Performance Improvement Plans (PIPs), or other audits for the areas of concern regarding ADL care and activities to meet resident needs and interests. The Administrator was asked how the QAPI committee addressed and/or prevented repeat concerns and deficiencies. The Administrator said, the committee looked at the concerns monthly after receiving deficiencies until they felt the facility was in substantial compliance with the regulation. The Administrator acknowledged the facility had not considered looking at the repeated deficiencies again before the next survey cycle or any alternative measures to help ensure the facility did not continue to have repeated deficiencies with their annual surveys. Review of the facility Quality Assurance and Performance Improvement Plan date 1/1/24 read, The purpose of QAPI in our organization is to take a proactive approach to continually improve .Criteria for prioritizing and selecting PIPs are bases on prevalence .The key elements of the QAPI program will be reviewed to assure that they are occurring, that the program is efficient .Ongoing training needs will be identified and addressed .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to complete Minimum Data Set (MDS) assessments within required timeframes for 3 of 4 residents reviewed for MDS comprehensive assessments from a total sample of 62 residents, (#60, #123, #154). Findings: Resident #60 was admitted to the facility on [DATE] with diagnoses of hypertension, hyperlipidemia, thyroid disorder, and stroke. A review of the MDS annual comprehensive assessment dated 9/17//22 revealed the assessment's final completion was dated 11/2/2022. On 11/2/2022 at 10:10 AM, the Registered Nurse (RN) MDS Coordinator stated the annual comprehensive MDS must be completed within 14 days after the assessment reference date (ARD), or 10/5/2022. She verified the MDS assessment was in progress and was not completed timely. Resident #123 was admitted to the facility on [DATE] with diagnoses including dementia, aphasia, and schizophrenia. A review of the MDS annual comprehensive assessment dated [DATE] revealed the assessment completion date was 10/6/2022. On 11/2/2022 at 10:11 AM, the RN MDS Coordinator stated the annual comprehensive MDS was required to be completed within 14 days after the ARD, or 9/30/2022. She verified the MDS was completed on 10/6/2022 and was late. Resident #154 was admitted to the facility on [DATE], discharged on 5/3/2022, and readmitted on [DATE] with diagnoses that included atrial fibrillation, hypertension, urinary tract infection, hip fracture, malnutrition, and chronic lung disease. A review of the admission comprehensive MDS dated [DATE] showed the MDS completion date was 5/30/2022. On 11/3/2022 at 10:09 AM, the RN MDS Coordinator verified the admission comprehensive MDS required completion within 13 days after the admission date, or 5/25/2022. She verified the MDS was completed on 5/30/2022 and was late. The facility's Nursing Services Policy and Procedure Manual revised 1/13/2021 page 3 titled, MDS Completion and Submission Timeframes (2.) contained the regulatory timeframes and read, timeframes will be observed by the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to electronically transmit Minimum Data Set (MDS) assessments timely for 2 of 4 residents reviewed for MDS assessments, from a total sample of 62 residents, (#105, #123). Findings: Resident #105 was admitted to the facility on [DATE]. A review of the resident's medical record revealed the MDS comprehensive annual assessment dated [DATE] had not been transmitted. On 11/2/2022 at 10:10 AM, the Registered Nurse (RN) MDS Coordinator reviewed the resident's medical record and stated the assessment dated [DATE] was not transmitted timely. Resident #123 was admitted to the facility on [DATE]. On 11/2/2022 at 10:10 AM the RN MDS Coordinator reviewed the resident's medical record and stated the assessment dated [DATE] had not been transmitted. She validated the assessment should have been transmitted 14 days after completion. The facility's Nursing Services Policy and Procedure Manual revised 1/13/2021, page 3 titled, MDS Completion and Submission Timeframes item 2 contained the regulatory timeframes and noted, timeframes will be observed by the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #176 was admitted to the facility on [DATE] with diagnoses including heart failure, chronic kidney disease, arteriosclerotic heart disease, type 2 diabetes, and acute pulmonary edema. Review of resident #176's medical record revealed a physician order dated 9/28/22 to discharge home with son on 10/01/22. A nursing progress note dated 10/02/22 read, Resident discharged to home with sister and niece at 11:30 this morning. Review of the MDS discharge assessment with assessment reference date 10/02/22 inaccurately reflected the resident was discharged to an acute hospital on [DATE]. On 11/02/22 at 1:35 PM, the MDS Director reviewed resident #176's discharge assessment and acknowledged the assessment reflected a discharge to an acute hospital rather than home. She explained the assessment was inaccurate. The facility policy and procedure Resident Assessment Instrument revised 1/17/18 read, All persons who have completed any portion of the MDS Resident Assessment Form must sign such document attesting to the accuracy of such information. Based on interview, and record review, the facility failed to accurately complete the Minimum Data Set (MDS) assessment for life expectancy for 1 of 5 residents reviewed for unnecessary medications, (#81) and failed to accurately reflect the discharge status for 1 of 3 residents reviewed for discharges, (#176), of a total sample of 62 residents. Findings: 1. Review of resident #81's medical record revealed she was 98-years-old, admitted to the facility on [DATE] with a recent readmission of 10/04/22. Her diagnoses included chronic kidney disease stage 4, schizoaffective disorder, dementia, and history of malignant neoplasm of skin. Review of the resident's physician orders revealed an order dated 8/22/22 that read, Terminal condition cerebral atherosclerosis. Given the information available, and per my examination, the patient has a life expectancy of 6 months or less. The resident's care plan for terminal/end stage diagnosis of cerebral atherosclerosis was created on 8/22/22. Review of the resident's admission MDS, with Assessment Reference Date (ARD) of 8/26/22 revealed the question in Section J1400 Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months?' was coded 0 indicating No. On 11/03/22 at 9:44 AM, the MDS Assistant Coordinator explained she gathered information from the resident's clinical records, including the physician's order sheet, and do a seven day look back to complete the assessment. The resident's admission MDS with ARD of 8/26/22, and the resident's physician's order dated 8/22/22 were reviewed with the MDS Assistant Coordinator. She acknowledged the resident had an active physician's order for a terminal condition and life expectancy of 6 months or less, and that Section J1400 was coded with a 0 meaning No. The MDS Assistant Coordinator stated the MDS assessment was coded incorrectly, and the section for prognosis should have been coded with a 1, indicating yes for life expectancy of 6 months or less. The Center for Medicare and Medicaid Services Resident Assessment Instrument Version 3.0, revised October 2019 Section J1400 directions for coding read, Code 0, no: if the medical record does not contain physician documentation that the resident is terminally ill and the resident is not receiving hospice services. o Code 1, yes: if the medical record includes physician documentation: 1) that the resident is terminally ill; or 2) the resident is receiving hospice services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to develop a comprehensive care plan for activities within seven days after completion of the comprehensive assessment for 1 of 12 residents reviewed for activities, of a total sample of 62 residents, (#81) . Findings: Review of resident #81's medical record revealed she was admitted to the facility on [DATE] with a recent readmission of 10/04/22. Her diagnoses included chronic kidney disease, stage 4, schizoaffective disorder, dementia, and history of malignant neoplasm of skin. Review of the resident's admission Minimum Data Set (MDS) assessment, with Assessment Reference Date (ARD) of 8/26/22 revealed the resident's cognition was impaired with a Brief Interview Of Mental Status (BIMS) score of 08/15. Section F Preferences for customary routine and activities revealed it was very important for the resident to have books/listen to music/do things with groups of people/ go outside to get fresh air when the weather was good and participate in religious services. Review of the resident's care plans revealed a care plan for Recreation/Wellness that noted the resident prefers independent and some group activities, with start date of 10/10/22. A prior care plan for activities could not be identified. On 11/03/22 at 11:23 AM, and 11/03/22 at 12:45 PM, the Activities Director explained that on admission, an interview was conducted with the resident and/or the responsible person to obtain activity preferences. She stated a care plan was developed by her based on the assessment as soon as possible after the completion of the MDS assessment. The resident's care plan for Recreation/Wellness with start date of 10/10/22 was reviewed with the Activities Director. She explained she could not recall if a prior care plan for activities was developed and stated she could not access or find it in the resident's electronic medical record. On 11/03/22 at 1:10 PM, the MDS Coordinator stated comprehensive care plans were developed within seven days of completion of the MDS assessment, and activities care plans were developed by the Activities Director. The resident's clinical records were reviewed with the MDS Coordinator and she said a prior care plan for activities could not be found for resident #81. The MDS Coordinator stated the only care plan developed for activities was created on 10/10/22. She said the resident's admission MDS's ARD was 8/26/22, and the resident's care plan for activities should have been developed before 10/10/22. The facility's policy Care Planning-Interdisciplinary Team revised on 1/13/2021 read, A comprehensive care plan for each resident is developed within seven (7) days of completion of the resident assessment (MDS).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to consistently provide nutritional supplements ordered for a newly admitted resident diagnosed with moderate protein malnutrition for 1 of 1 resident reviewed for nutritional status in a total sample of 62 residents, (#479). Findings: Resident #479 was admitted to the facility from the hospital 10/25/22. His admission diagnoses included moderate protein-calorie malnutrition, stage IV lung cancer, shortness of breath, multiple sclerosis, and major depressive disorder. On 10/31/22 at 10:57 AM, resident #479 verbalized he did not receive the nutritional protein supplemental drink, Ensure that he was promised by the dietician when admitted to the facility. The resident indicated he had specifically requested the Ensure brand because it tasted better and he would drink it. He explained he needed the extra protein and calories because of his cancer diagnosis. The resident verbalized he had asked to receive the Ensure between meals and before bedtime. The resident then conveyed, . I haven't been receiving it. It's all messed up. I keep asking for it, but don't get it. One person tells me that I need a doctor's order for it, and the other says that I don't need a doctor's order. It's all very frustrating. The resident explained they gave him some drink that was not Ensure which did not taste good, and was not given at the times he requested. There was not any evidence of any type of nutritional supplemental drinks in his room at this time. Review of resident #479's initial nutritional assessment dated [DATE] indicated he was to receive a regular diet with house supplements. The assessment revealed the resident had lost over 36 pounds in the past 6 months, had a current weight of 152 pounds, and had moderate protein malnutrition. The assessment included lab values from 10/26/22 that noted his Protein Albumin was low. The assessment showed the resident's average food intake was less than 50% for most meals. The assessment indicated the resident had increased nutrient needs due to cancer and multiple sclerosis diagnoses. The nutritional interventions included house supplements 4 ounces (oz) two times a day (BID). A follow-up Registered Dietician's note dated 10/28/22 at 9:02 AM read, . House supplement initiated to assist in meeting needs The assessment did not indicate the type or name of nutritional supplement recommended or when it was ordered. Resident #479's Medication Administration Records (MARs) showed an order dated 10/26/22 for house supplement, Boost 4 ounces by mouth twice a day to be given between 9 AM to 10 AM and between 2 PM to 3 PM. The October and November 2022 MARs revealed the resident was not given the supplement Boost until 10/28/22, two days after it was ordered. The MAR noted an order was placed for a second nutritional supplement, Ensure Plus 8 oz., on 10/31/22 which was scheduled to be given twice a day, between 12 PM - 1 PM and 5 PM - 6 PM. There were not any nursing initials to reflect the resident was given the Ensure Plus until the morning of the following day, 11/1/22. Resident #479's nutritional care plan initiated 10/25/22 and revised on 10/31/22 showed the resident was at risk for altered nutritional status due to his diagnoses. Approaches dated 10/25/22 included house supplements 4 oz twice daily, and Ensure Plus 8 oz twice daily. On 11/2/22 at 12:50 PM, resident #479 was observed resting in bed. His lunch meal tray sat on the over bed table. The resident had eaten about 1/3 of the hamburger patty and nothing else on his plate. There was not any Ensure observed on his meal tray, overbed table or anywhere in his room. At this time the resident reported that he was not given any Ensure to drink since yesterday morning. On 11/2/22 at 1 PM, the resident's Certified Nursing Assistant, (CNA) C stated she was not aware the resident was to receive Ensure. CNA C said nutritional supplements like Ensure were not stocked in the unit's pantry and it was usually sent by the kitchen on the resident's meal tray. On 11/2/22 at 1:05 PM, the resident's assigned Registered Nurse, (RN) R reviewed the MAR for 11/2/22 11 AM - 12 PM scheduled Ensure Plus administration that showed RN R documented the resident received Ensure Plus and consumed 100%. RN R stated, No, she had not given the Ensure to the resident. She said she thought the CNA C had given it to him along with his meal tray. At this time, CNA C informed RN R that Ensure was not delivered on his lunch meal tray and she was not aware the resident was supposed to receive it. RN R explained she had not checked with the CNA if the resident had received and/or drank the Ensure before documenting he consumed 100% of it. On 11/2/22 at 1:30 PM, the Director of Nursing (DON) explained nurses and not the CNAs were responsible to make sure residents' nutritional supplements were given and documented the percentage consumed. The DON acknowledged resident #479's Ensure 8 oz. was scheduled for 11 AM - 12 PM and 5 PM - 6 PM which indicated it should come on his meal tray from the kitchen. Review of resident #479's admission dietary communication sheet dated 10/25/22 with the DON did not reflect the use of nutritional supplements for the resident. At 1:45 PM, the Certified Dietary Manager (CDM) stated the kitchen had not received a dietary communication slip for Ensure Plus 8 oz. to be included on the resident's meal trays. The CDM acknowledged Ensure was not stocked in the nursing unit pantries for resident use. On 11/2/22 at 1:55 PM, the Registered Dietician (RD) stated she was informed on 10/31/22, that resident #470 was not eating well and did not like the Boost supplement. She said she obtained an order for Ensure Plus 8 oz. to be given with the resident's lunch and evening meals as he needed more calories and protein. She said she forgot to generate a dietary communication slip to inform the kitchen to send Ensure on the resident's meal trays. The RD explained the nutritional supplements required an order and it was not the facility's process to stock Ensure in the unit pantries.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of resident #130's medical record revealed he was admitted to the facility on [DATE] with diagnoses including bladder spasms, bladder neck obstruction, retention of urine, and urinary tract infection. The most recent MDS significant change assessment with an Assessment Reference Date of 8/23/2022 indicated the resident had an indwelling urinary catheter. The current comprehensive care plan included focus areas for prophylactic antibiotic therapy, chronic urinary tract infection (UTI), need for assistance with activities of daily living (ADL), and risk for infection due to use of a foley catheter. The interventions included enhanced barrier precautions, changing the catheter and drainage bag as needed, and proper placement. Active orders for medications and treatments included Bactrim DS 800-160 milligrams (mg), 1 tablet every 12 hours for chronic UTI, ordered 8/25/2022 with no stop date. urinary catheter care every shift, ordered 9/1/2022, indwelling catheter change as needed 16 French with 30 cc, bladder neck obstruction for anticipated blockage, thick/heavy sediment, leakage or accidental removal as needed ordered 8/12/2022, observe catheter for leakage, blockage and sediment every shift if unable to clear blockage with irrigation, change catheter as needed, document observation of urine and catheter in comments box every shift ordered 8/16/2022, and change catheter drainage bag as needed ordered 9/1/2022 On 10/31/2022 at 10:40 AM, the resident's indwelling urinary catheter drainage bag was observed on the resident's right bedside lying in direct contact with the floor. On 10/31/2022 at 4:00 PM, the resident's indwelling urinary catheter drainage bag was observed on the resident's right bedside lying in direct contact with the floor. On 10/31/2022 at 4:03 PM, Registered Nurse (RN) G explained the protocols and expectations for care of an indwelling urinary catheter included catheter checks every shift, observation for signs and symptoms of UTI, and proper placement and care of the drainage bag. She stated the CNA duties included emptying the drainage bag and reporting any issues to the nurse. She stated the drainage bag is, not be touching the floor. On 10/31/2022 at 4:10 PM, Certified Nursing Assistant (CNA) H explained the change of shift/rounding routine had been completed. She did not recall seeing resident #130's indwelling urinary catheter. She explained CNA duties included checking the bag's volume, urine color abnormalities, tangled tubing, correct height, bag placement on the bed frame, and, it must not be lying on the floor. On 11/1/2022 at 10:56 AM, RN Unit Manager I stated the expectations for nurse monitoring of an indwelling urinary catheter included cleaning, checking for leaks, color, clarity, and sediment, changing the bag and catheter, and flushing. She stated, the bag is to be placed on the bedrail where it can rest and the nurse and CNA are responsible for checking the bag placement as it should not be on the floor. The facility's Nursing Services Policy and Procedure Manual for Solaris HealthCare (revised 1/17/2018, 2/10/2019, 1/7/2020), page 9-273 titled Catheter Care, Urinary under the section Infection Control item 2b states, Be sure the catheter tubing and drainage bag are kept off the floor. Based on observation, interview, and record review, the facility failed to implement appropriate transmission-based precautions (TBP) for Extended Spectrum Beta-Lactamase (ESBL) for 1 of 2 residents (#115) reviewed for Urinary Track Infection (UTI) and failed to ensure an indwelling urinary catheter drainage bag was not placed on the floor to prevent infection for 1 of 2 residents reviewed for indwelling urinary catheter (#130) out of a total sample of 62 residents. Findings: 1. Review of resident #115's medical record revealed she was admitted to the facility on [DATE] with diagnoses including Cerebral Vascular Accident (CVA), Urinary Tract Infection (UTI), neuromuscular dysfunction of bladder and chronic kidney disease. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] documented she had moderate cognitive impairment, required total assistance with toileting and was always incontinent of bladder. Review of resident #115's plan of care dated 10/28/22 showed she had an active urine infection. The goal included that she would have no signs or symptoms of active infection related to UTI within 14 days. Approaches dated 10/31/22 included Contact Precautions due to ESBL in urine, to administer medications as ordered, observe for side effects related to antibiotic therapy (ABT) and to encourage fluids. Review of resident #115's physician orders dated 10/29/22 included the antibiotic, Augmentin 500-125 milligrams (mg) by mouth (po) twice daily (bid) for 7 days for UTI. Review of resident #115's lab urine culture with sensitivity was collected on 10/25/22. On 10/27/22 the final urine report documented greater than (>)100,000 colony-forming unit (CFU)/milliliter (ml) Escherichia Coli, ESBL. Review of resident #115's Event Report dated 10/28/22 documented UTI with acute dysuria or acute pain, culture source was urine, and Contact TBP. On 10/28/22 Enhanced Barrier Precautions and then on 10/31/22 Contact Precautions due to ESBL in urine. In the notes section revealed on 10/28/22 at 4:54 PM urinalysis results reviewed by physician and new orders received for Augmentin 500 mg BID for 7 days. Review of the Medication Administration Record (MAR) documented resident #115 received the first dose of Augmentin 500 mg po bid on 10/29/22 at 9 AM. Review of resident #115's progress notes revealed on 10/24/22 a new order received from nephrologist for urinalysis for upcoming appointment and to fax results to physician. On 10/28/22 at 4:54 PM, urinalysis results reviewed by physician and new order received for Augmentin 500 mg po BID for 7 days. On 10/31/22 at 11:29 AM, an observation of resident #115's room revealed a sign on the door for Enhanced Barrier Precautions. On 11/01/22 at 10:15 AM, Personal Protective Equipment (PPE) was observed hanging on resident #115's room door with a sign for Contact Isolation. Two isolation bins were observed on resident #115's side of the room. On 11/01/22 at 10:16 AM, the 400 Unit Manager explained that resident #115's urine had been collected for culture and sensitivity on 10/25/22 and the results of UTI with ESBL were reported on 10/27/22. The 400 Unit Manager stated it was the responsibility of the nurse and the Unit Manager to review the laboratory results in a timely manner and then notify the physician for orders. On 11/02/22 at 5:14 PM, the 400 UM stated resident #115 was placed on Enhanced Barrier Precautions on 10/28/22 with no PPE or isolation bins in the room. It was not until 11/01/22 (5 days later) that the correct precautions for ESBL in urine were implemented. The Contact Isolation sign and PPE was placed on the room door and isolation bins were placed in her room. The 400 Unit Manager explained on 10/28/22 the wrong sign (Enhanced Barrier Precautions) had been placed on the room door. Resident #115 should have been placed on Contact Precautions with correct sign, PPE and bins in the room. On 11/01/22 at 10:26 AM, the Infection Control Practitioner (ICP) stated she was aware that resident #115 had a UTI with ESBL. She explained the resident should have been placed on Contact Isolation on 10/27/22 when the results of her urine indicated ESBL. It was not until 11/01/22 when the required Contact Isolation was put in place. The ICP indicated the nurse was responsible for reviewing all laboratory reports, calling the physician and implementing new orders. I don't know why the nurse did not recognize the need to set up Contact Isolation for a resident with ESBL since the nurse obtained the ABT order for Augmentin for the UTI. It was the 400 Unit Manager who realized the Contact Isolation was not set up for resident #115. On 11/01/22 at 10:54 AM, the Director of Nursing (DON) stated the Infection Tracker Form documented Contact Isolation on 10/28/22 but resident #115 was only on Enhanced Barrier Precautions. Resident #115 should have been on Contact Isolation with PPE in place. Review of the Centers for Disease Control and Prevention (CDC) Enhanced Barrier Precaution Form posted on the resident #115's room door documented Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and Staff Must Also: Wear gloves and gown for the following High-Contact Resident Care Activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, Device Care or Use: central line, urinary catheter, feeding tube, tracheostomy and Wound Care: any skin opening requiring a dressing. Do not wear the same gown and gloves for the care of more that one person. Review of the Facility's Policy Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated 8/16/2022. read, . This document is intended to provide guidance for Personal Protective Equipment (PPE) use and room restriction in nursing homes for preventing transmission of Multi Drug Resistant Organisms (MDROs) . Examples of MDROs Targeted by the Centers for Disease Control and Prevention (CDC) include . ESBL - producing Enterobacterales . Contact Precautions are one type of Transmission-Based Precaution that are used when pathogen transmission is not completely interrupted by Standard Precautions alone. Contact Precautions are intended to prevent transmission of infectious agents, like MDROs, that are spread by direct or indirect contact with resident or resident's environment. Contact Precautions require the use of gown and gloves on every entry into a resident's room. The resident is given dedicated equipment (e.g., stethoscope and blood pressure cuff) . Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO's to staff hands and clothing .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure nail care was provided for 3 of 6 dependent residents, (#1, #4, #119) and failed to ensure facial hair was removed for 1 of 6 dependent residents, (#479) reviewed for Activities of Daily Living (ADL) out of a total sample of 62 residents. Findings: 1. Review of resident #1's medical record documented she was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbances, anxiety disorder, Transient Ischemic Attack (TIA) and major depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] documented resident #1 had short-term and long-term memory problems, severely impaired cognitive skills for daily decision making and she required total assistance of one staff member with personal hygiene and bathing. Review of resident #1's comprehensive ADL care plan dated 12/09/19 documented she required total assistance from staff with ADLs. On 11/01/22 at 10:05 AM, and on 11/02/22 at 10:05 AM, the resident's fingernails to both hands were noted to be long and jagged. Review of the 400 unit shower schedule documented resident #1 received bed baths or showers on Monday and Thursday on the 2 PM - 10 PM shift. 2. Review of resident #4's medical record showed she was admitted to the facility on [DATE] with diagnoses of fractured right femur, major depressive disorder, dementia, anxiety disorder and TIA. Review of the quarterly MDS assessment dated [DATE] documented resident #4 had short-term and long-term memory problems and severely impaired skills for daily decision making. She required total assistance of one staff member with personal hygiene and bathing. Review of resident #4's comprehensive ADL care plan dated 04/01/21 documented she required staff assistance with ADL's. On 10/31/22 at 1:24 PM, 11/01/22 at 10:02 AM, and on 11/02/22 at 9:54 AM, resident #4's fingernails to both hands were noted to be long and jagged. Review of the 400 unit shower schedule documented resident #4's showers were on Tuesdays and Fridays on the 6 AM -2 PM shift. 3. Review of resident #119's medical record documented he was admitted to the facility on [DATE] with diagnoses including cerebral ischemia, major depressive disorder, assistance with personal care, and vascular dementia. Review of the quarterly MDS assessment dated [DATE] noted he was cognitively intact and required extensive assistance with personal hygiene and bathing. Review of resident #119's comprehensive ADL care plan dated 09/14/20 showed he was unable to complete ADL's independently related to weakness, and end stage diagnosis. The goal included to have ADLs met daily with staff assistance. The approach was for one person to assist with ADLs and ADL assistance was expected to fluctuate due to his end stage diagnosis. Observations conducted on 10/31/22 at 10:00 AM, 11/01/22 at 9:58 AM, and on 11/02/22 at 9:51 AM revealed resident #119's fingernails were long, and jagged with a brown substance under the fingernails. Review of the 400 Unit shower schedule indicated resident #119's showers were to be given on Wednesdays and Saturdays on the 2 PM - 10 PM shift. On 11/02/22 at 10:15 AM, Registered Nurse (RN) D stated all staff were responsible for residents' ADLs. She explained the Certified Nursing Assistants (CNAs) were responsible for providing ADL care daily. She explained each resident had a schedule and would receive 2 bed baths or showers per week based on the schedule. RN D said ADL care included brushing teeth, shaving, dressing, nail and hair care. On 11/02/22 at 11:43 AM, the 400 Unit Manager stated residents received a bed bath or shower 2 days per week based on unit schedule or preference. She noted ADL care included a head to toe bed bath or shower, hair and nail care, and shaves. It is the same with a shower and fingernails are to be kept clean, short, and trimmed. On 11/02/22 at 11:55 AM observations of resident #1, #4 and #119's fingernails were completed with the 400 Unit Manager. She stated all 3 residents' fingernails needed to be cut and cleaned. On 11/03/22 at 12:54 PM, CNA F stated routine resident care included cleaning of face, hands, teeth, toileting, dressing, and incontinent care. She indicated bed baths and/or showers were done 2 times a week per schedule or resident preference. We wash the body, wash and dry hair, nail care, and shaves. Review of the Facility's Guideline CNA Sheet/Skin Inspection, dated January 18, 2017, read, Purpose: Documentation of showers and skin inspection completed with showers. Procedure: . 4. CNA is to trim nails with shower . If resident is diabetic or on anti-coagulants file nails only. Notify nurse if resident refuses nail care. 4. Resident #479 was admitted to the facility on [DATE] with diagnoses that included cancer of the main bronchus, shortness of breath, chronic pain syndrome, and multiple sclerosis. Review of resident #479's admission Observation Nursing assessment dated [DATE] revealed the resident was alert and oriented to person, place, time, and situation. Review of his baseline care plan dated 10/25/22 for activities of daily living included approaches to assist the resident with bathing, grooming, dressing, and personal hygiene as needed. On 10/31/22 at 10:57 AM, resident #479 was observed sitting in a wheelchair by his bed. He was unshaven with facial hair about 1/3 inch to 1/2 inches long. On 11/1/22 at 1:20 PM, and on 11/2/22 at 12:50 PM, resident #479 remained unshaven. He indicated he needed help to shave as he tired easily and was short of breath. He said he had not shaved since he came to the facility and staff had not offered to assist him. On 11/2/22 at 1 PM, the resident's CNA C and CNA B said shaving would typically be done during shower days which were scheduled twice per week, and sometimes during morning care. CNA C indicated she did not know resident #479 well, and had not asked him if he wanted to be shaved today. At this time, CNA C went to the resident's room and confirmed the resident wanted help to be shaved a little later in the day. At 5 PM, the resident was still not shaved. On 11/3/22 at 11:45 AM, resident #479's CNA documentation for the level of assistance required for personal hygiene was reviewed with the Minimum Data Set (MDS) Coordinator. The ADL flowsheets revealed that from 10/26/22 through 11/2/22 the resident consistently required limited to extensive assistance with personal hygiene and bathing care. There was not any documentation that indicated he had refused to be shaved. On 11/3/22 at 3 PM, the Director of Nursing (DON) said staff were expected to offer and/or provide shaving needs with showers twice per week and as needed. Review of the facility's ADL Supporting Policy and Procedure read, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide an ongoing program of activities to meet the preferences and needs for 6 of 12 residents reviewed for activities of a total sample of 62 residents, (#10,#21,#51,#118,#137,#139). Findings: 1. Resident #10 was admitted to the facility on [DATE] with diagnoses of dementia, brief psychotic disorder, and memory loss. Review of the resident's Minimum Data Set (MDS) quarterly assessment with Assessment Reference Date (ARD) 7/13/22, revealed the resident had a Brief Interview for Mental Status (BIMS) score of rarely or never understood which indicated she had severe cognitive impairment. The assessment indicated it was somewhat important for the resident to listen to music, do her favorite activities, and go outside to get fresh air. Resident#10 required extensive assistance of two persons for transfers and total assist of one person for locomotion. Review of resident #10's Activity care plan included interventions to adapt activities of preference to cognitive level and skill function. Observe resident's response to activities. On 11/01/22 at 3:53 PM, resident#10 was observed lying in bed with her eyes open, looking at the ceiling. There was no music playing in the room. On 11/02/22 at 3:44 PM, the resident was observed lying in bed looking at the ceiling. There was no music or television on in the room. On 11/03/22 at 9:19 AM, resident#10 was observed lying in bed looking at the ceiling. There was no television or music in the room. 2. Resident #21 was admitted to the facility on [DATE] with diagnoses of dementia, pain, and pressure ulcer. Review of the resident's MDS significant change assessment with ARD of 9/16/22, indicated the resident was rarely or never understood which indicated she had severe cognitive impairment. The assessment indicated it was very important for her to have books, newspapers, and magazines to read and it was somewhat important for her to keep up with the news and to go outside for fresh air. Resident #10 required extensive assistance of two persons for transfers and was totally dependent on staff for locomotion. Review of the resident's Activity care plan included interventions to adapt activities of preference to cognitive level and skill function. Observe resident's response to activities. Provide small group activities such as music and crafts. On 11/01/22 at 12:21 PM, resident #21 was observed lying in bed, with no activities observed. On 11/01/22 at 3:53 PM, the resident was observed lying in bed with her eyes open, looking at roommate's television. At this time, there was a music activity taking place in the dining room. On 11/02/22 at 3:44 PM, the resident was observed lying in bed looking around the room. There was no music or television in the room. 3. Resident #51 was admitted to the facility on [DATE] with diagnoses of schizoaffective disorder, dementia, and cirrhosis of the liver. Review of the resident's MDS assessment for change in condition with ARD of 9/13/22 indicated resident #51's BIMS was 09 which indicated significant cognitive impairment. The assessment noted she required supervision of one person for bed mobility, transfers, and walking. Review of resident #51's Activity care plan included interventions to adapt activities of preference to cognitive level and skill function. On 11/01/22 at 12:02 PM, resident #51 was observed in the dining room sitting in a chair with no activities being provided. On 11/02/22 at 10:13 AM, the resident was observed sitting in the day room with the television on but no activities provided. On 11/02/22 at 2:06 PM, the resident was sleeping in her chair in the day room and no activities. On 11/02/22 at 3:56 PM, the resident remained sleeping in her chair in the the day room with television on and no activities being provided. On 11/03/22 at 9:27 AM, resident #51 slept in her chair in the day room with television on and no activities in progress. 4. Resident #118 was admitted to the facility on [DATE] with diagnoses of schizoaffective disorder, dementia, and depression. Review of the resident's MDS quarterly assessment with ARD of 9/14/22 revealed the resident had a BIMS score of 5 which indicated she had severe cognitive impairment. The assessment indicated she required supervision of one person for transfers and walking. Resident #118's Activity care plan included interventions to adapt activities of preference to cognitive level and skill function. Observe resident's response to activities. Invite/encourage resident to attend/participate in offered live music programs. On 11/01/22 at 12:19 PM, resident#118 was observed lying in bed with her eyes closed with no activities in progress. On 11/01/22 at 3:54 PM, resident#118 was observed lying in bed while live music activity in progress in the dining room. On 11/02/22 at 10:08 AM, the resident sat in the day room with no activities. The television was on but the resident was not watching it. On 11/03/22 at 9:27 AM, resident#118 was observed sitting in day room with no activities. 5. Resident #137 was admitted to the facility on [DATE] with diagnoses of congestive heart failure and bipolar depression. Review of the resident's MDS quarterly assessment with ARD of 10/13/22 revealed the resident had a BIMS score of 04 which indicated severe cognitive impairment. Review of resident #137's Activity care plan included interventions to adapt activities of preference to cognitive level and skill function. Observe resident's response to activities. On 11/02/22 at 10:08 AM, resident#137 was observed sitting in the day room, with no activities. The television was on but the resident did not pay any attention to it. On 11/03/22 at 9:27 AM, resident#137 was observed sitting in day room with no activities. 6. Resident #139 was admitted to the facility on [DATE] with diagnoses that included dementia, depression, delusional disorder, and schizoaffective disorder. Review of the resident's MDS quarterly assessment with ARD of 9/09/22 revealed the resident had a BIMS score of 99 which indicated she had severe cognition impairment. Review of resident #139's Activity care plan included interventions to adapt activities of preference to cognitive level and skill function. Observe resident's response to activities. On 11/01/22 at 12:39 PM, resident #139 was observed in her room with no activities noted. On 11/01/22 at 3:52 PM, the resident was observed lying in bed with eyes closed. On 11/02/22 at 10:10 AM, resident#139 was observed lying in bed with eyes closed. On 11/02/22 at 11:22 AM, the resident was observed lying in bed with eyes closed and lunch tray on the over bed table next to her bed untouched. On 11/02/22 at 3:43 PM, the resident was observed lying in bed with her eyes closed. On 11/02/22 at 2:35 PM, Certified Nursing Assistant (CNA) Q stated they used to have a full-time activity person on the unit but now they only had someone from activities department occasionally. She added there also used to be three CNAs on the unit and it was much more manageable to provide activities for all the residents. She said there was no time for CNAs to provide activities as most of the residents needed a lot of care. On 11/03/22 9:30 AM, Registered Nurse (RN) N stated, we used to have an activity CNA who was in the day room with the residents all the time but not anymore. On 11/03/22 at 10:26 AM, CNA P said they had a CNA who stayed in the day room with the residents and did activities, but we don't have her anymore. She said, We try to do the best we can with providing some sort of activities but we are too busy providing care and do not really have time to sit in the day room and do any activities with them. I love these residents but I feel so bad because I just do not have time to give them what they need. On 11/03/22 at 11:23 AM, the Activities Director (AD) stated when new residents were admitted , she interviewed the resident or family member to determine their activity preferences and develop a plan of care. She said, if the resident was bed bound, we do friendly room visits, lotion therapy, read to them, talk to them. Make sure they are comfortable. We have 1 on 1 logs for documenting what was done during room visits. She stated activities department had 3 staff and one of them was full time on the memory care unit. On 11/03/22 at 11:54 AM, the memory care Unit Manager stated the memory care unit did not have a full time activities person. She said the CNA staff tried to provide activities when they had some spare time. Observation of the Memory Care unit from 10/31/22-11/03/22 revealed an activities staff on the unit on 10/31/22 who handed out popcorn and put a movie on the television and left the unit. On 11/01/22 live music was provided in the dining room from 3:00 PM-4:00 PM. On 11/02/22 an activity staff sat at a table with three residents. One of the residents was sleeping in her chair and the other two had ice cream with the associate. Review of the activities calendar indicated the residents should have had an activity almost every hour. None of the activities listed on the calendar were being followed. Review of the residents' 1 to 1 logs for activities revealed no activities provided to any of the residents at any time from 10/22/22-11/02/22. All documentation indicated the residents were either asleep or refused. The activities logs were not documented in chronological order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow physician orders for splint application for 2 of 2 residents reviewed for limited Range Of Motion (ROM) of a total sample of 62 residents, (#117, #143). Findings: 1. Record review of resident #117's clinical records revealed the resident was a [AGE] year-old female, admitted to the facility on [DATE], with a recent readmission on [DATE]. Her diagnoses included hemiplegia and hemiparesis following cerebral infraction affecting right dominant side, major depressive disorder, and stiffness of unspecified joint. An active physician's order dated 9/23/22 noted right resting hand splint to be donned and doffed daily as needed. Special instructions read Clarify duration and frequency when entering order. Review of the resident's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date of 10/11/22 indicated the resident was rarely/never understood and required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. The resident's Occupational Therapy Discharge Summary with dates of service from 6/17/22 to 9/13/22, read, Patient will tolerate RHS [right hand splint] to R [right] hand for 4 hours for contracture management. On 10/31/22 at 10:48 AM, 10/31/22 at 3:54 PM, on 11/01/22 at 9:32 AM, 11/01/22 at 11:10 AM, 11/01/22 at 3:42 PM, and on 11/02/22 at 11:35 AM, resident #117 was observed in bed. Her right hand was contracted, and she was not wearing a splint. A splint was observed in the wall mounted container to the right of the resident's bed. On 11/01/22 at 3:26 PM, Licensed Practical Nurse (LPN) L stated resident #117 had two strokes and her right hand was contracted. The LPN indicated Restorative Nursing Program (RNP) was working with resident for donning/doffing of her splint. On 11/01/22 at 3:46 PM, the Oceanside Registered Nurse (RN) Unit Manager (UM) stated splint orders were usually placed by therapy, and she confirmed resident #117 had an active order dated 9/23/22 for right resting hand splint to be donned and doffed daily as needed. The UM said if the task was done, documentation would be in the facility's electronic documentation system. She noted RNP was responsible for donning /doffing of the resident's splint, and for completing documentation regarding splinting. On 11/01/22 at 4:08 PM, Certified Nursing Assistant (CNA) M stated she had not seen the resident with splints. CNA M said RNP would don and doff the resident's splint. On 11/01/22 at 4:25 PM, and on 11/02/22 at 9:55 AM, the MDS Coordinator, and the Assistant MDS Coordinator stated donning/doffing of splints were done by the RNP Certified Nursing Assistants (CNA). The MDS Coordinator explained when therapy gave an order for RNP, the RNP CNA would take the order to the Assistant MDS Coordinator, who would then enter the order in the resident's clinical records, notify the resident's family/responsible person, and develop a care plan that addressed the splint. The MDS Coordinator said she would document a weekly note, and document evaluation of the splint/RNP, and both she and the Assistant MDS Coordinators would discuss the resident's progress with the RNP CNAs. She stated resident #117's order for splint was a general nursing order and was never for RNP. On 11/02/22 at 10:48 AM, the Director of Rehab stated resident #117 was on Occupational Therapy (OT) caseload from 6/17/22 to 9/13/22. She explained the resident was hospitalized on [DATE], and on readmission to the facility on 9/29/21, she was referred to RNP, for upper extremity strengthening. She said the splint order dated 9/23/22 was pulled over from the resident's physician's orders prior to hospitalization. The Director of Rehab said a new therapy screening should have been done on the resident's return to the facility, but the evaluation was not done. She stated Rehab services were contracted to the facility, and they had very limited services of OT for the last couple of months. She added that OT was coming in a couple hours per week, due to limited staff. She indicated that based on the resident's history, an OT screen to evaluate for continued need for splint application should have been completed. On 11/02/22 at 11:37 AM, the Oceanside Registered Nurse/ Unit Manager (RN/UM) stated there was some talk about the resident's splints not being placed, and she was told by staff the resident had refused splint application. She said on 7/25/22 there was an order by therapy to don/doff splint daily as needed, and documentation for Special Instructions were to clarify duration and frequency when entering order. The UM stated resident #117 was hospitalized from [DATE] to 9/23/22, and on readmission, she reinstated the previous order for splint application. The resident's clinical records were reviewed by the RN/UM, and she stated that as far as she knew, there was no documentation to indicate the resident's right-hand splint was placed, or that the splint order was clarified as directed. She noted the resident should have been screened by OT, to ensure the splint was still appropriate, and if it was not, the order should have been discontinued. On 11/02/22 at 12:16 PM, the Director of Nursing (DON), stated the resident's splint order was placed by the prior OT who no longer worked at the facility, and was reactivated by the Oceanside UM on the resident's readmission to the facility. She explained no follow up was done to ensure the resident was re-screened by OT on her return from the hospital. The DON verbalized that if the OT screen was done, they would have made a referral for continued/discontinued use of her splints. She said therapy gave orders for splinting, and the UMs were responsible to check orders, and obtain clarification as needed. The DON noted resident #117 had not worn her right-hand splint since her readmission to the facility, and documentation could not be identified to indicate splints were applied on an as needed basis. She explained the order should populate on the resident's Treatment Administration Record (TAR), and verbalized the order was not a good order and should have been clarified. She stated MDS/RNP reported to her, and she was responsible to oversee the RNP. On 11/02/22 at 2:51 PM, the Director of Rehab stated OT was initiated for resident #117 on 5/04/22 for right hand weakness, and discharged from OT on 9/14/22, but a RNP was not developed for splint application. She said the resident's right-hand splint was ordered and started by OT on 5/30/22 to be donned/doffed by therapy. She confirmed that an OT screen was not completed for the resident status post her hospitalization, and verbalized that an OT screen should have been completed, and the order regarding the resident's right-hand splint should have been clarified or discontinued. 2. Record review revealed resident #143 was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, generalized anxiety disorder, aphasia, and generalized muscle weakness. A physician order dated 4/08/22 indicated the resident was referred to restorative nursing for resting hand/elbow splint to his right upper extremity 3 hours per day. Review of the resident's quarterly MDS with ARD of 9/07/22 revealed the resident's cognition was severely impaired, with a Brief Interview for mental Status (BIMS) score of 00/15. The resident was assessed to require extensive assistance for bed mobility, dressing, and personal hygiene, and was totally dependent on staff for toilet use. The assessment showed the resident had functional limitation in range of motion (ROM) to one side of his upper and lower extremities The resident's care plan ADL (Activities of Daily Living) Functional/rehabilitation Potential created on 3/03/22 indicated the resident was unable to complete activities of daily living independently due to cardiovascular accident with right sided hemiplegia and hemiparesis. Approaches listed included, 4/07/22 RNP for splint application to right upper extremity, which was noted as discontinued on 9/13/22. OT Treatment Encounter Notes dated 4/05/22 indicated discharge from OT services and splint wear schedule was discussed with the resident. OT positioned splint on RUE [right upper extremity]. Patient tolerated splint for 3 hours without s/s [signs/symptoms] of irritation or redness. The OT Discharge summary dated [DATE] revealed discharge status and recommendations were, Orthotic Management: Splint/orthotic recommendation: RUE splint for 3 hours/day without s/s of irritation or redness for contracture management RNP for contracture management including splint wear schedule. Progress note dated 9/16/22 read, decreased tolerance of PROM (passive range of motion) to RUE noted and refusing application of splint. Therapy referral placed. Progress note documented by RNP and dated 10/21/22 read, Resident is participating in the Restorative Program for PROM BLE (bilateral lower extremity), RUE . He also has a RUE splint. He is tolerating the program fair. Continue current plan. On 10/31/22 at 11:00 AM, and on 11/01/22 at 3:39 PM, resident #143 was lying in bed on his back, his right hand was contracted, and the resident was not wearing a splint. On 11/01/22 at 3:37 PM, LPN L stated the resident was admitted to the facility with contracture of his right hand, and RNP was to do splinting for 3 hours daily. On 11/01/22 at 3:46 PM, the Oceanside RN/UM stated resident #143 had physician's order for RNP to don/doff his right hand/elbow splint 3 hours daily. She stated MDS had responsibility for the RNP, and if the task was done, it would be documented in the electronic clinical record. On 11/01/22 at 4:25 PM, the MDS Coordinator, and the Assistant MDS Coordinator stated donning/doffing of splints were done by the RNP Certified Nursing Assistants (CNA). The MDS Coordinator explained that when therapy gave an order for RNP, the RNP CNA would take the order to the Assistant MDS Coordinator, who would then enter the order in the resident's clinical records, notify the resident's family/responsible person, and develop a care plan that addressed the splint. The MDS Coordinator said she would document a weekly note, and document evaluation of the splint/RNP, and both she and the Assistant MDS coordinator would discuss the resident's progress with the RNP CNAs. The resident's physician orders were reviewed with the MDS Coordinator. She confirmed an order was in place for splint application for the resident. She said, if the resident refused splints, a referral would be placed to Rehab for screening/reassessment. Observations on various occasions of resident # 143 with contracted right hand, and not wearing a splint was shared with the MDS Coordinators. The Assistant MDS Coordinator stated a progress note on 9/16/22 revealed decreased tolerance and refusal of splint, but another progress note on 10/20/22 indicated the resident was tolerating splinting. On 11/02/22 at 10:02 AM, the MDS Coordinator stated review of clinical records for the resident showed he had been refusing splinting. She recalled a couple of weeks ago the RNP CNAs, said the resident's splint was not fitting as before. She verbalized the RNP CNAs would report any concerns to the MDS Coordinator, who would then report to Rehab. The MDS Coordinator said she did not know if concerns with the resident's splint was reported to Rehab. On 11/02/22 at 10:31 AM, the Director of Rehab stated RNP would report any concerns of a splint not fitting to therapy. She stated that during the morning clinical meetings, refusal of splints would be discussed. She said she was not aware resident#143 was refusing, his right hand/elbow splint, and was told about the splint not fitting this morning (11/02/22). She said if it was reported before, the therapist would do a reassessment/screening to determine if the resident needed further therapy and if retraining of staff was required. She verbalized the resident's splint was ordered to prevent further contractures, and to increase ROM. She explained that if the splint was not being applied, the resident could have possible further contractures, and would not be able to perform tasks as he previously did. On 11/02/22 at 12:12 PM, the DON stated a referral for resident #143 was made to Therapy on 9/16/22 due to the resident's complaint of pain, and staff not being able to apply his splint. She verbalized she would have to speak to the rehab director to see what was done with the referral. The DON stated the MDS Coordinators had responsibility for the restorative program, and would be the ones to follow up with Rehab for any concerns/issues with the program. On 11/02/22 at 4:09 PM, the DON provided resident #143's Care Plan History for date range 3/03/22-11/02/22 which revealed RNP was discontinued for the resident, and an OT referral was placed on 9/13/22. The DON stated the OT screen was not done, but could not say why the screen was not done. She stated the order for splint application for the resident was not discontinued and was still active. On 11/03/22 at 10:32 AM, Restorative CNA K stated resident #143 was oriented x 2 and had a tendency to refuse splinting, stating the splint was uncomfortable for him. CNA K said she reported this to the restorative nurse in September and a request for OT screen was placed. The CNA verbalized she had not placed the resident splint since then.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide Occupational Therapy as needed to address splint application and assessments for 3 of 3 residents reviewed for limited Range Of Motion (ROM) of a total sample of 62 residents, (#117, #143, #175). Findings: 1. Clinical record review revealed resident #117 was a [AGE] year-old female, admitted to the facility on [DATE], with a recent readmission on [DATE]. Her diagnoses included hemiplegia and hemiparesis following cerebral infraction affecting right dominant side, major depressive disorder, and stiffness of unspecified joint. An active physician order dated 9/23/22 read right resting hand splint to be donned and doffed daily as needed. Special instructions read Clarify duration and frequency when entering order. On 11/02/22 at 10:48 AM, the Director of Rehab stated resident #117 had a stroke and had right hand splint provided by therapy to prevent contractures. She verbalized the resident was previously on Occupational Therapy (OT) caseload with start of care on 6/17/22 and was discharged from OT on 9/13/22. She explained the resident was hospitalized on [DATE], and was readmitted to the facility on [DATE], and a new Rehab screening should have been done on the resident's return to the facility, however, the screening by OT was not done. She stated Rehab services were contracted to the facility, and they had very limited services from OT for the last few months. she explained OT was coming into the facility for a couple hours per week, due to limited staff. She indicated that based on the resident's history, she should have had an OT screen to evaluate for continued need for splint application. On 11/02/22 at 11:37 AM, the Oceanside Registered Nurse/ Unit Manager (RN/UM) stated resident #117 was hospitalized from [DATE] to 9/23/22, and on readmission to the facility she reinstated the resident's previous order for splint application. She said the resident should have been screened by OT after her readmission, to ensure the splint was still appropriate. On 11/02/22 at 12:16 PM, the Director of Nursing (DON), stated no follow up was done by nursing or Rehab to ensure the resident was re-screened by OT on her return from the hospital. She noted if the OT screen was done, they would have made a referral for continued/discontinued use of the resident's right-hand splint. On 11/02/22 at 2:51 PM, the Director of Rehab explained all newly admitted or readmitted residents were screened by Rehab for all three disciplines, Physical Therapy, Speech Therapy, and Occupational Therapy. She confirmed that an OT screen was not completed for resident #117 after hospitalization. She noted an OT screen should have been completed, and order regarding the resident's right-hand splint should have been clarified or discontinued. 2. Record review revealed resident #143 was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses including, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, generalized anxiety disorder, aphasia, and generalized muscle weakness. A physician order dated 4/08/22 indicated the resident was referred to restorative nursing program for resting hand/elbow splint to his right upper extremity 3 hours per day. Progress note dated 9/16/22 read, decreased tolerance of PROM [passive range of motion] to RUE [right upper extremity] noted and refusing application of splint. Therapy referral placed. On 11/02/22 at 10:31 AM, the Director of Rehab stated Restorative Nursing Program (RNP) would report any concerns with the plan of care for the residents, and if a splint was not fitting, it should be reported to therapy. She stated she was not aware resident #143 refused his right hand/elbow splint and was told about the splint not fitting this morning, on 11/02/22. She said, if it was reported before, the therapist would do a reassessment/screening to determine if the resident needed further therapy or if retraining of the RNP staff was required. She explained the resident's splint was ordered to prevent further contractures, and to increase ROM. She explained that if the splint was not being applied, the resident could have possible further contractures, and would not be able to perform tasks he previously could. On 11/02/22 at 12:12 PM, the DON stated a referral for resident #143 was made to Rehab on 9/16/22 by RNP due to the resident's complaints of pain, and staff not being able to apply his splint. She verbalized she would have to get with the Director of Rehab to see what was done regarding the referral. On 11/02/22 at 4:09 PM, the DON provided resident #143's Care Plan History for date range 3/03/22-11/02/22 which revealed RNP was discontinued for the resident, and an OT referral was requested on 9/13/22. The DON stated the Director of Rehab was struggling to get OT staff and the resident's OT screen was not done as requested. 3. Resident #175 was admitted to the facility from the hospital on [DATE] with diagnosis that included acute on chronic low back pain syndrome, degenerative lumbar spondylosis without myelopathy, spinal stenosis without neurogenic claudication, and bipolar disorder. On 10/31/22 10:25 AM, interview with resident #175 said that she was upset that she had not received the results and diagnosis from a recent second magnetic resonance imaging (MRI) test done for her right lower back pain that radiated down her leg to her foot. She stated that during hurricane [NAME] she had rammed her car into a parking space's cement stop that could not be seen because it was under water. The resident said the accident had caused her right sided pain and that she had a history of sciatic pain. She reported that she was here at the facility for short-term therapy rehabilitation. Resident #175's admission orders dated 10/3/22 included the following: PT [Physical Therapy] to evaluated and treat as indicated. OT [Occupational Therapy] to evaluate and treat as indicated. Review of therapy evaluations and progress notes for resident #175 revealed that a PT evaluation was conducted on 10/4/22. There was not any evidence that an OT evaluation was conducted. On 11/3/22 at 9:26 AM, interview with OT A said that he worked per diem for the rehabilitation department at the facility. He explained that he worked a couple times a week for 5 to 8 hours at a time and had another full-time job at a home health agency. OT A reviewed the rehabilitation records for resident #175 and acknowledged that the resident had not received an OT evaluation since her admission on [DATE]. He stated that to his knowledge, the facility's therapy department did not currently have a full-time evaluating OT. On 11/3/22 at 9:35 AM , during an interview with the Therapy Director/Certified Occupational Therapy Assistant (COTA), she acknowledged that resident #175's OT evaluation order was dated 10/3/22. She confirmed that an OT evaluation had not yet been done. The Therapy Director reported that around the first of October this year, the facility's contracted therapy company changed. When this happened, the two full time OTs who had previously worked for the old therapy company had resigned. She stated that the facility's therapy department has only one evaluating OT at this time who works on per diem basis. She indicated that because of this, resident #175 did not receive her initial OT evaluation ordered at admission. She said the resident refused many of the PT sessions while waiting on a second Magnetic Resonance Imaging Report. Review of orders revealed that the physician had held therapy orders from 10/6/22-10/10/22, but then reinstated therapy on 10/10/22 without ambulation. The Therapy Director said that the per diem OT would attempt to conduct her OT evaluation today, 11/3/22, and verbalized that she was looking to hire a full time OT. The new therapy company's policies and procedures related to therapy evaluation expectations and timeframes were requested but not readily available upon request. The Therapy Director conveyed on 11/3/22 at about 9:45 AM that the process regarding timeframes to conduct therapy evaluations was within 48 hours of the physician's order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure oxygen concentrator external filters were clean for 4 of 4 residents reviewed for respiratory care out of 30 residents receiving oxygen via concentrators, (#4, #23, #25, #43). Findings: 1. Review of resident #4's medical record revealed she was admitted to the facility on [DATE] with multiple sclerosis (MS), chronic obstructive pulmonary disease (COPD), and cognitive communication deficit. The resident's quarterly Minimum Data Set assessment dated [DATE], noted she was cognitively intact and received oxygen therapy. A care plan for being at risk for impaired gas exchange related to COPD and MS included goal that she would have adequate air exchange and interventions for duo-nebulizer treatments, chest percussion vest, monitor lung sounds, rest periods and respiratory therapy as needed. The resident's physician orders included Oxygen at 2 liters/minute (LPM) via nasal cannula (NC) as needed. On 02/09/21 at 10:20 AM, resident #4 stated, I always wear my oxygen at night which is set at 2 L. On 02/08/21 at 2:19 PM, 02/09/21 at 4:18 PM, and on 02/10/21 at 11:08 AM observations of the resident #4's oxygen concentrator revealed the left external filter's outer edges covered with gray dust. The right external filter was fully covered with large amount of gray dust which was able to be lifted off the filter. On 02/10/21 at 11:10 AM, Licensed Practical Nurse (LPN) A stated the Respiratory Therapist (RT) came in on the weekend and was responsible for changing and dating the O2 tubing. The nurses are responsible for the oxygen concentrators. On 02/10/21 at 2:00 PM, the Director of Nursing (DON) acknowledged the filters covered with dust. She said the Respiratory Therapist worked on the weekends and was responsible for changing the O2 tubing, humidifiers and checking and cleaning the oxygen concentrator filters. When the filters are not kept clean, the resident may not receive adequate level of oxygen. They are breathing in dirty air which is a potential for respiratory infection. On 02/11/21 at 6 PM, a phone interview was conducted with the Respiratory Therapist (RT). The RT stated he had worked weekends at the facility for 21 years. He said he was responsible for changing and dating the oxygen tubing and changing the nebulizer equipment. I believe that someone in the Maintenance Department is responsible for checking the oxygen concentrators on a monthly basis. 2. Resident #23 was admitted to the facility 12/01/20 with diagnoses that included viral pneumonia, and end stage renal disease. A review of the resident's physician's orders dated 12/01/20 read, Oxygen 2 liters per minute (LPM) as needed for shortness of breath or oxygen saturation less than 94% on room air. An observation of the resident's oxygen concentrator was made with the DON on 2/10/21 at 11:47 AM. The concentrator filter was covered with dust. The DON acknowledged the filter was not clean and was covered with dust. 3. Resident #25 was admitted to the facility on hospice services on 12/21/20. Her diagnoses included kidney disease and multiple myeloma. Physician orders dated 12/21/20 included Oxygen at 2 LPM when sleeping for comfort. On 2/08/21 at 2:37 PM, and 2/09/21 at 12:31 PM, resident #25 was received oxygen via nasal cannula. The concentrator filter was noted to be covered with dust. 4. Resident #43 was admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease. His admission physician orders included O2 at 2 LPM via nasal cannula. On 2/09/21 at 11:29 AM, resident #43 was in bed with oxygen being administered via nasal cannula at 2 LPM. The left side of the concentrator filter was noted to be dusty. On 2/10/21 from 11:47 and 12:03 PM, the O2 concentrators for residents #23, #25 and #43 were observed with the Director of Nursing (DON). The DON acknowledged the filters were covered in gray dust. She said the RT was responsible for changing the O2 tubing weekly and cleaning the filters when needed. The Operator's Manual for the oxygen concentrators section 6- Maintenance. The concentrators were designed to minimize routine preventative maintenance. At a minimum, clean the concentrator cabinet filters weekly. Remove the filters and clean at least weekly dependent upon environmental conditions. Clean the cabinet filters with a vacuum cleaner or wash in warm soapy water and rinse thoroughly. Dry the filters thoroughly before reinstallation. Review of the electronic maintenance log showed the oxygen concentrators were maintained monthly, not weekly. They were last noted to be cleaned on 1/09/2021 by the Director of Maintenance. The Cleaning and Disinfection of Oxygen Concentrators Policy Statement revised on 1/12/2021 noted: Resident-care equipment, such as oxygen concentrators will be cleaned and disinfected according to facility cleaning procedure. There was no staff personnel specifically assigned to complete the task. On 2/10/21 At 1:30 PM, the Administrator, DON and the Director of Maintenance explained that maintenance completed a monthly maintenance review of the concentrators which included inspection of the oxygen concentrators, cleaning the filters and changing the filters if needed. They said they were not aware the filters were to be cleaned weekly. The Facility assessment dated /updated and reviewed with Quality Assurance Assessment and Quality Assurance Performance Improvement committee on 12/8/20 noted the facility was able to provide care for residents with respiratory system conditions included Chronic obstructive Pulmonary Disease, Pneumonia Asthma, Chronic lung Disease and Respiratory failure. The facility averaged 20 residents receiving oxygen therapy.