**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to properly position an indwelling urinary tubing to facilitate the flow of urine for one (Resident #46) out of one sampled resident with an indwelling urinary catheter, as evidenced by Resident #46's indwelling catheter tubing was positioned above bladder and kinked. This deficient practice prevented the free flowing of urine that would be accumulated in the bladder causing discomfort and increasing the risk for catheter-associated urinary tract infections and other serious medical issues. There were four residents with indwelling urinary catheters residing in the facility at the time of this survey.The findings include.During an observation on 8/11/25 at 1:01 PM, Resident #46 was standing in his room, a tubing was observed protruding from the top of the Resident's shorts and into a drainage bag that was anchored on the walker (photo evidence). Resident #46 revealed he had an indwelling urinary catheter and complained of blood in the urine. Upon further observation the tubing was kinked, and urine did not appear to be flowing freely. On 8/11/25 at 1:05 PM, Staff J, Licensed Practical Nurse (LPN) was notified of the identified concern. Staff J, LPN completed hand hygiene, put on required Personal Protective Equipment (PPE) and readjusted the tubing so it would no longer be kinked.Interview on 8/11/25 at 1:15 PM, Staff J, LPN stated, [Resident #46] has an indwelling urinary catheter that I flush with water daily. I have not flushed it today. This morning the catheter was not kinking because the resident was wearing a gown. I readjusted the tubing, and I educated the resident.Record review of a demographic sheet revealed Resident #46 was initially admitted on [DATE] and readmitted on [DATE] with diagnosis that included: Benign Prostatic Hyperplasia (BPH) with lower urinary tract symptoms note: BPH with Obstructive Uropathy and Urinary Tract Infection.Record review of a Significant Change in Status Minimum Data Set (MDS) referenced dated 7/30/25 revealed Resident 46 had no cognitive impairment and required supervision or touching assistance for toileting hygiene and an indwelling catheter.Record review of a Care Plan started on 8/4/25, last reviewed/revised on 8/11/25 revealed Resident #46 requires an indwelling urinary catheter related Benign Prostatic Hyperplasia with Obstructive Uropathy, noted unclamping catheter leg holder and touching his Indwelling catheter at times with approaches that included: resident to not play/touch his Indwelling catheter to avoid dislodgement and/or infection. Reeducate resident not to touch indwelling catheter and to keep it below the level of bladder (resident noted to place catheter above the level).Record review of a July 2025 physician's order sheet revealed [indwelling urinary catheter] care as needed, normal saline flush 30 ml (milliliters) every shift.Interview on 8/13/25 at 3:06 PM, the Director of Nursing revealed for a resident with an indwelling urinary catheter, the best method for positioning is to secure the tubing to the thigh and the bag should be positioned downward because back flow can cause an infection. The Surveyor asked the Director of Nursing (DON) if there was any policy pertaining to the proper positioning of an indwelling urinary catheter and the DON stated: No.On 8/14/25at 2:13 PM, the Registered Nurse, Infection Preventionist revealed ways to prevent Urinary Tract infections in residents with indwelling urinary catheters include positioning the catheter tubing below the level of the bladder.Record review of a policy titled, Urinary Catheter Care dated 6/26/15 revealed POLICY: Catheter care is done by the nurse or nursing assistant routinely twice daily on all residents/patients with indwelling catheters.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to implement infection control measures for three (Residents #57, Resident #98 and Resident #106) out of twenty-one sampled vulnerable Residents, as evidenced by Residents #57 and Resident #98 catheter dignity bags touching the floor; and improper hand hygiene during Resident #106's tracheostomy care. These deficient practices increase the risk for life-threatening infections. The findings included: On 08/12/2025 at 2:02 PM Resident #57's urinary catheter drainage bag was observed in a dignity bag on the floor (photo evidence). Resident #57 Review of the medical records for Resident #57 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to urinary tract infection (UTI). Review of the Physician's Orders Sheet for 06/03/2025 revealed that Resident #57 may use external catheter diagnosis (dx) sacral wound. Record review of Resident #57 's Significant Change Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented Brief Interview for Mental Status Score is unknown. Section GG for Functional Abilities documented the resident has impairment to both sides of the upper and lower extremities. Section H for Bladder and Bowel documented Resident #57 bowel was always incontinent. Section I for Active Diagnosis included: Candidiasis, unspecified, Cerebral infarction due to thrombosis of right posterior cerebral artery, Persistent vegetative state, Tracheostomy status, Gastrostomy status, Dependence on respirator [ventilator] status, Urinary Tract Infection (UTI), Pain, unspecified. Record review of Resident #57's Care Plans revealed Resident #57 requires an external catheter and incontinent of bowel related to Multiple wounds. At risk for skin breakdown related to incontinence and UTI. Interventions include - Observe for signs of skin breakdown/irritation and/or decreased blood circulation to penis. Provide care after each incontinent episode, apply skin barrier protector, maintain privacy. Check skin during care, notify provider if any impairment noted. Position bag below level of bladder. Use a catheter strap to reduce pulling. Resident #98 On 08/11/25 at 09:57 AM, Resident #98 urinary catheter drainage bag was observed in a dignity bag on the floor (photo evidence). Review of the medical records for Resident #98 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Traumatic subdural hemorrhage with loss of consciousness of unspecified duration, subsequent encounter. Review of the Physician's Orders Sheet on 07/21/2025 revealed that Resident #98 had an order for External catheter care every shift, diagnosis (Dx): sacral wound. Record review of Resident #98's MDS dated [DATE] revealed: Section for Cognitive Patterns documented the BIMS Score was unknown. Section for Functional Abilities documented the resident is dependent on toileting, showering, upper and lower body dressing and bowel was always incontinent. Section for Active Diagnosis included: Traumatic subdural hemorrhage with loss of consciousness of unspecified duration, subsequent encounter, Encounter for attention to gastrostomy, Dependence on respirator [ventilator] status, encounter for attention to tracheostomy. Record review of Resident #98's Care Plans revealed Resident #98 is incontinent of bowel and bladder, however, requires an external catheter related to Multiple pressure injuries. At risk for skin breakdown r/t to incontinence and at risk for UTI. Interventions include- Provide total assistance for catheter care. Provide care after each incontinent episode, apply skin barrier protector, maintain privacy. -Check skin during care and notify provider if any impairment noted. Position bag below level of bladder. Use a catheter strap to reduce pulling. Interview on 08/13/2025 at 03:13 PM, the Director of Nursing (DON) revealed the urinary catheter should be secured to the thigh. The tubing should be draining down to prevent backflow. the catheter bag should be hanging off the side of the bed in dignity. the catheter or dignity bag should not touch the floor. if the catheter or dignity bag touch the floor the staff should change it. to prevent this from happening at any other time the staff should make sure it is properly anchored. Interview on 08/14/2025 at 02:45 PM with Staff K, Registered Nurse (RN) stated I have been an RN at this facility for three years. When the patient is lying in bed, the [] catheter should be secured to the inside of the thigh and never touch the floor. It should always be placed in a dignity bag, and neither the catheter nor the bag should ever touch the floor. If it does, I fix it immediately, because urine can flow backward and cause infection. Review of the facility’s policy and procedures tilted Infection Prevention and Control Program 02/06/2025 indicate: the purpose - Develops and implements an ongoing infection prevention and control program (IPCP), to prevent, recognize, and control the onset and spread of infection. Establish facility-wide systems for the prevention, identification, investigation, and control of infections of residents, staff and visitors. Develop and implement written policies and procedures for infection control. Ensure staff handle, store, process and transport all linen and laundry in accordance with national standards. Resident #106 During a Tracheostomy Care observation on 08/11/25 at 09:07 AM for Resident #106, Registered Nurse (Staff F) gathered the supplies, entered Resident # 106's room, identified the resident, performed hand hygiene, donned non-sterile gloves, introduced herself, and informed resident of procedure. Staff F revealed Resident # 106 was receiving oxygen (O2) at 10 liters per minute (lpm). Staff F set up sterile area with tracheostomy supplies, removed non-sterile gloves and donned sterile gloves, suctioned resident with new suction tubing, removed trach gauze, cleaned trach stoma with normal saline, peroxide, and sterile gauze, removed soiled inner cannula, discarded it into a red biohazard bag and inserted a new one, Staff F then removed soiled trach collar and discarded it in red biohazard bag, placed a new trach collar on resident, re-connected oxygen tubing , removed gloves and donned new gloves, discarded all other soiled supplies inside red biohazard bag, removed gloves and gown, exited room, discarded red biohazard bag inside red bin in the soiled utility room, washed hands, and documented care on resident's chart. Review of Resident #106's demographic sheet revealed the resident was admitted on [DATE] with diagnoses that included but not limited to Encounter for Attention to Tracheostomy, Chronic Respiratory Failure, Unspecified whether with hypoxia or hypercapnia, and Chronic Obstructive Pulmonary Disease (COPD). Record Review of Physician's Order Sheet for March 2023 revealed Resident #106 had orders that included but were not limited to: Trach care twice daily and as needed. Record Review of a Quarterly Minimum Data Set (MDS) dated [DATE] Section for Cognitive Patterns revealed a Brief Interview of Mental Status (BIMS) summary score was 0 out of 15 which indicated severe cognitive impairment. The section for Functional Abilities revealed the resident was dependent on Activities of Daily Living (ADLs). The section for Special Treatments revealed the resident was receiving oxygen therapy, tracheostomy care and suctioning, and has received respiratory therapy for 7 days for at least 15 minutes in the last 7 days. Record Review of a care plan dated 03/13/2025, revised 06/12/2025 revealed Resident #106 required oxygen therapy related to Tracheostomy dependent, Chronic respiratory failure, Hypoxia, COPD. Goals: Resident will be monitored for signs of hypoxia. Interventions included but not limited to: Administer oxygen as ordered, HOB (Head of Bed) elevated position for optimal breathing, and monitor/document respiratory status every shift. Interview 08/11/2025 at 09:23 AM, Staff F, Registered Nurse (RN) revealed: To prevent infection while performing trach care, it is important to wash your hands before and after the procedure. Every time you remove your gloves you must wash your hands and then apply new gloves. I did not wash my hands after I removed the gloves because I did not touch any surface after removing the gloves. The infection control protocol while performing trach care is to wash hands before and after care. Interview on 0811/2025 at 10:03 AM, Staff G, Charge Nurse was asked about hand hygiene practices; Staff G , Charge Nurse stated: You need to wash your hands before care, whenever you change gloves, and after completion of care. After you remove soiled gloves, you have to wash your hands regardless of whether you touched any surface or anything else. Interview on 08/13/2025 at 03:18 PM the Director of Nursing (DON) stated: Nurses should be washing hands before and after a procedure. They are required to wash their hands after removing gloves and before donning new gloves, there are no exceptions. Interview on 08/14/2025 at 02:37 PM Infection Preventionist Nurse Manager stated: My number one education is always hand washing. When performing trach care, you make sure you wear your gown and gloves. Anytime you remove anything that is dirty, you need to remove your gloves and wash hands before putting on new gloves. Record Review of the facility Infection Control policy titled Hand Hygiene, dated 02/24/2024, revised 08/12/2025 indicates the following: To ensure that JMLTC has a comprehensive Hand Hygiene policy and that all providers, staff employees, contractors, volunteers, students, patients, and visitors are aware of and knowledgeable about the principles of hand hygiene. Procedure: 5 Moments of Hand Hygiene: Before patient contact Before clean/aseptic procedures After body fluid exposure/risk After touching a patient After touching patient surroundings Glove Usage: a. Gloves use does not replace the need for hand hygiene. Hand hygiene must be performed prior to donning gloves and after glove removal. b. Perform hand hygiene (and glove change) when moving from contaminated body site to a cleaner body site.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to provide a safe environment free of potential accidents and hazards for all residents residing in the facility by failing to implement the facility's policy related to accident and hazards for five (Resident #57,Resident #68, Resident #47, Resident #112 and Resident #150) out of 45 residents sampled in the facility; as evidence by: 1) Resident #57's side rail padding was observed on the outer side of the bed rail 2) a bladed box cutter was a observed on Resident # 68's bedside table, 3) No safety floor mat on the left side of Resident # 47's bed, 4) Resident # 112 had no safety floor mat to the right side of the bed and 5) a pack of cigarettes observed in Resident #150's pant pocket. These deficient practices increase the risk of accidents, hazards and fires that could cause serious harm, serious injuries or even fatalities. There were 169 residents residing in the facility at the time of the survey. The findings include. Resident #57 During observation on 08/11/25 at 08:27 AM both of Resident #57's side rails and side pads were in place, but the right-side rail padding was observed on the outer side of the side rail, not in the proper position (photo evidence). On 08/11/25 11:43 AM Resident #57's right side rail padding still observed on the outer side of side rail (photo evidence). Review of the medical records for Resident #57 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to Parkinson disease…Tracheostomy Status, Gastronomy Status, Dependence on respirator(ventilator)status. Review of Resident #57's Physician's Orders Sheet for August 2025 revealed an order dated 08/06/2025 to monitor resident for seizure activity. Special instructions: padded side rails, every shift. Record review of Resident #57 's Significant Change Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented Brief Interview for Mental Status Score is unknown. Record review of Resident #57's Care Plans revealed the Resident is at risk for injuries related to seizure disorder. Interventions include- Pad side rails. Keep bed in lowest position. Monitor resident for seizures activities and obtain new orders as needed and document accordingly. Interview on 08/13/2025 at 03:13 PM the Director of Nursing (DON) stated Side rail padding is in place for a resident with a seizure diagnosis to ensure safety. Nurse managers oversee the unit, while restorative staff occasionally conduct assessments. The current side rail paddings are loose because the straps are not secured close enough to the rails, and the pads are incorrectly positioned on the outside of the railing. The team is exploring better product options. There have been no incidents where the paddings failed to protect the patient during a seizure. An order is not required for side rail padding, as its use is based on nursing judgment. Interview on 08/14/2025 at 02:43 PM with Staff K, Registered Nurse (RN) stated Yes, my patient has side rail padding. The straps should be secured properly to keep the padding in place. The purpose of the pads is to protect the patient from injury. With the padding on, three side rails should be up and one down. I make sure the padding is secure by checking that all straps are tight and correctly positioned. Record Review of the facility policy and procedure titled Bed Safety & Bedrails 07/08/2024 indicate: f. Siderails may be padded for safety and/or appropriate diagnosis e.g. seizure. Resident #68 Observation on 08/11/2025 at 10:51 AM, in Resident #68’s room revealed the resident was not in the room. A box cutter with the blade inside was observed on the Resident’s bedside table. (Photo Evidence) On 08/11/2025 at 10:53 AM, the Charge Nurse was notified and stated: Oh wow, I can't believe he has that. He has been told many times that he is not supposed to have those types of items with him, but he does not listen. The Charge Nurse then removed the box cutter Record Review of Resident #68’s demographic face sheet revealed the resident was admitted on [DATE] with diagnosis that included, but not limited to Quadriplegia, C5-C7 incomplete. Record Review of Quarterly Minimum Data Set (MDS) reference dated 07/03/25 revealed Resident #68 is cognitively intact and has impairment to both sides of upper/lower extremities and used a wheelchair. Record Review of a Care Plan with start date 10/15/2024, last revised on 08/11/2025 revealed Resident #68 had episodes of anger, inappropriate/behavioral symptoms, and becomes angry or upset with staff when providing care. Resident #68 also keeps items such as scissors and cutter inside his room for his personal use. Goal: Resident #68's episode of anger/refusal of care/treatment will decrease through next review date and possible consequences/outcomes of non-compliance. Approach: Educate Resident #68 on safety concerns on facility policies. Interview on 08/12/2025 at 12:46 PM, Resident #68 was asked about the box cutter found in room; Resident # 68 stated: I know I am not supposed to have a box cutter or any type of sharp objects in my room, but I use it to cut my plants in the patio. I bought the box cutter about a month ago when I was out on day pass and I've been using it ever since. Last time I used it was four days ago in the patio, and no one said anything to me, I guess no one saw me. Interview on 08/12/2025 at 01:06 PM, Staff A, Registered Nurse (RN) was asked about the box cutter found on Resident #68's bedside table; Staff A, RN stated: Residents are not allowed to keep any items that may cause harm to them or others, like ropes or knives. I always make rounds in the morning and during shift (every 3-4 hrs.), but I did not see the box cutter in [Resident #68's] room”. Staff A, RN also revealed she does not check Resident #68 when he returns from being out on day pass; she is only supposed to check his skin. Interview on 08/12/2025 at 01:19 PM, Staff B, Certified Nursing Assistant (CNA) stated: The policy in this facility is that residents cannot have lighters, knives or anything else that can be harmful to them. When I perform any care, or make rounds int he morning, I check their beds and bedside table for any harmful items. Staff B, CNA also reported she was not assigned to Resident #68 on the day the box cutter was found in his room. Interview on 08/12/2025 01:29 PM, Staff C, Charge Nurse stated: The protocol for hazardous items is monitoring and checking residents' rooms for dangerous items that would cause harm to them or others. I know you found the box cutter in [Resident #68's] room yesterday but there was nothing on his bedside table when we made rounds that morning. When residents return from day pass, staff always checks their belongings, skin, and pockets. Interview on 08/13/2025 at 03:02 PM, the Director of Nursing (DON) stated: Some items that residents are not allowed to have are guns and knives. We ensure residents are not keeping these items by monitoring all residents daily. Also, when residents go out to the patio, there is always a staff member there to monitor them. If residents go out on pass, the nursing staff checks them and perform a head-to-to-toe assessment upon return. In regard to [Resident #68], we did not know he had a box cutter. Interview on 08/13/2025 at 03:30 PM, when asked about Resident #68's care plan, Staff E, MDS Coordinator stated: [Resident #68's] care plan was last updated on 08/11/2025. We updated it because staff had found a box cutter in his room and was educated (along with staff) in order to be in compliance with the facility's protocols. Record Review of the facility policy and procedure titled Safety/Risk Reduction dated 04/15/25 indicated the following: It is the policy of the facility to provide a safe environment to all residents. A multi-disciplinary team approach accomplishes this goal through systems that identify opportunities to improve and/or represent a risk thus ascertaining that there are systems in place to promote a safe living and working environment. No weapons are allowed on the premises including but not limited to firearms, and hunting knives, etc. Procedure: A. Every identifiable opportunity to enhance and provide a safe and healthy environment will be addressed through the following mechanisms: 2. Monitoring Programs include: Ransom safety checks including room searches, G. All newly admitted resident's belongings are inventoried upon admission and items identified as weapons will be confiscated. A Weapon is defined as any instrument or device designed or used for inflicting bodily harm or physical damage to self or others. Some examples include but not limited to knives, (pocketknives, Swiss army knives), firearms, clubs, brass knuckles, etc. Items will be confiscated and returned to resident at the time of discharge. Resident #47 On 8/11/25 at 12:35 PM Resident #47 was in bed eating lunch independently. One safety floor mat was observed on resident’s left side and none on the right side (Photo evidence) and no staff was present with the resident. On 8/11/25 at 12:50 PM, the assigned nurse Staff I, Registered Nurse (RN) was notified about the identified concern and stated, When we feed residents we remove one floor mat. The surveyor notified Staff I, Registered Nurse that Resident #47 was observed eating independently and Staff I, RN replied, “I don’t know why the floor mat was not present. On 8/11/25 at 12:50 PM Staff D, Certified Nurse Assistant, was also notified about the identified concern and stated, I removed one floor mat to set [Resident #47] up for lunch. I was called away from another staff member to help and didn’t replace the floor mat. Record review of a demographic sheet revealed Resident #47 was initially admitted on [DATE] and readmitted on [DATE] with diagnosis that included: Muscle wasting and atrophy. Record review of an Annual Minimum data set referenced dated 6/2/25 revealed Resident #47 is moderately impaired cognitively and was dependent on Chair/bed-to-chair transfer. Record review of a Fall Evaluation completed on 7/15/25 revealed Resident#47 was at risk for falls. Record review of a Progress note dated 8/3/25 revealed Resident #47 was found lying on floor. Record review of a physician’s order sheet revealed an order dated 8/4/25 directions bilateral floor mattress three times a day each shift. Record review of a Care Plan started on 6/10/25, last reviewed/revised on 8/4/25 revealed Resident #47 was at risk for falls related to: muscle weakness, impaired balance, assistance with transfer and on 08/03/05 Resident #47 observed on floor, no injuries observed and approaches that included: bilateral floor mats as indicated. Record review of a Progress note dated 8/3/25 revealed Resident#47 was found lying on floor. On 8/13/25 at 3:06 PM, the Director of Nursing revealed: The floor mats should be in place when residents are in bed unattended. There is no situation where the floor mats should not be in place while the resident is in bed unattended. Resident #112 On 8/11/25 at 12:51PM Resident #112 was observed in bed. There was one floor mat on the resident's left side (Photo evidence) and no staff present with resident. On 8/11/25 at 12:52 PM the assigned nurse Staff I, RN stated, The Certified Nurse Assistant who assisted [Resident #112] to eat removed the floor mat to assist with lunch and forgot to replace it. I do frequent rounds to monitor. On 8/11/25 at 12:53 PM Staff D, Certified Nurse Assistant was notified about the identified concern and stated, I am assigned to [Resident#112] today. I did not remove the floor mat, and I did not assist the resident for lunch. Staff D then walked away. The Surveyor stayed with Resident #112. Staff I, Registered Nurse approached surveyor and stated, “The Hospice nurse left floor mat after assisting [Resident#112] with lunch and the hospice nurse left the facility.” Record review of Resident #112’s demographic sheet revealed the resident was admitted on [DATE] with diagnosis that included Huntington's disease. Record review of a physician’s order sheet revealed an order dated 2/23/25 directions bilateral floor mattress three times a day. Record review of a Quarterly Minimum data set referenced dated 6/1/25 revealed a Brief Interview for Mental Status score was undetermined and was dependent on Activities of daily living and transfers. Record review of a Fall Evaluation completed on 6/6/25 revealed Resident#112 was at risk for falls. Record review of a Care Plan started on 3/10/25, last reviewed/revised on 7/30/25 indicated Resident #112 had the potential for falls related to: Resident has poor safety awareness, impaired cognition, impaired balance requiring total assistance for transfers and involuntary movements and approaches that included: Bilateral floor mats. Resident #150 On 8/11/25 at 1:20 PM Resident #150 was observed leaving the room with a pack of cigarettes in pants (photogenic evidence). The surveyor interviewed Resident #150 about facility policy for smoking; Resident # 150 stated, I am going to smoke on the patio. I get my cigarettes from the nurse and keep my cigarettes on me for the day and return them at the end of the day. At that time Staff I, RN was notified about the identified concern and stated, [Resident#150] gets cigarettes from staff in the morning and keeps it until the end of the day and return any leftover cigarettes. On 8/11/25 at 1:26 PM Resident #150 was observed on patio smoking. On 8/12/25 at 10:03 AM Resident#150 was taken to the East 2, nursing station by the Administrator, two packs of cigarettes were retrieved from the 7:00 AM to 3:00 PM shift Charge Nurse who took the cigarettes from a locked drawer behind the nursing station. At that time, the East 2’s 7:00 AM to 3:00 PM shift Charge Nurse was interviewed about the facility's smoking protocol and stated, The cigarettes are kept under lock and key. Only a nurse has a key… [Resident#150] returns left over cigarettes at the end of the day. On 8/12/25 at 10:14 AM Resident #150 was escorted back to unit. No cigarettes were returned at that time. Record review of a demographic sheet revealed Resident #150 was admitted on [DATE] with diagnosis that included: Nicotine dependence. Record review of a Quarterly Minimum data set referenced dated 6/19/2025 revealed a Brief Interview for Mental Status score of 2, out of 15 which indicates severe cognitive impairment. Record review of a Care Plan started on 9/30/24, reviewed/revised on 6/23/25 revealed Resident #150 smokes whenever on patio, refuses to wear a smoke protective gown at times and is at risk for self-burn and had approaches that included: Staff will pass out cigarette to resident as needed, staff to closely supervise/assist resident during smoking time, clothing to be checked for holes and changed if any. Record review of a Smoking Assessment completed on 7/8/25 revealed Resident #150 had a Minimal Problem of inappropriately providing smoking materials to others and was determined to be a safe smoker supervisor only. On 8/13/25 at 2:15 PM, the Administrator was notified about the identified concern and stated, The cigarettes should be accounted for, and we should be following our smoking policy. Resident is non complaint.” On 8/13/25 at 2:52 PM, the Risk Manager stated, “I complete investigations and audits. The residents are expected to turn in the cigarettes each time they come upstairs. Even though our policy states all cigarettes should be returned to the unit for [Resident #150] it is not a hazard for him to keep cigarettes in the room because this resident is alert and did not have a lighter.” The Surveyor asked how staff knew no lighter was in the room. No response. Record review of a Policy titled, “Smoking, Vaping, E-Cigarettes &Contraband Revised on 2/1/24 revealed Il. Policy Smoking is prohibited anywhere on JHS property, except for designated areas in the nursing homes. It is prohibited for all employees, visitors, families, volunteers, contracted personnel, vendors or anyone who is not a resident. Smoking is prohibited in any official JHS vehicle. The possession, consumption or sale of alcohol, or contraband on JHS property is prohibited. It is the policy of JHS that items which pose a significant potential danger to Residents, Staff or Visitors be seized and secured by the appropriate department within the facility or law enforcement. SMOKING POLICY: A. Residents shall not keep cigarettes, e-cigarettes, matches nor lighters with them, nor in their rooms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to accurately code the Minimum Data Set (MDS) Assessment Section 0 for one (Resident #136) out of four residents reviewed for resident assessment. There were 166 residents residing at the facility at the time of the survey. The findings included: Record review of Resident #136's admission Minimum Data Set (MDS) dated [DATE] Section O for Special treatments and procedures documented that the resident did not receive any special treatments or procedures. Review of the Physician's Orders Sheet for April 2024 revealed Resident #136 had orders that included but not limited to: Suction Tracheostomy (Trach) as needed and every shift, Trach care every shift and as needed, and Fraction of inspired oxygen (FIO2) at 30% via trach collar every Shift. Further review of the medical records for Resident #136 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia and Encounter for attention to tracheostomy. Record review of Resident #136 's Care Plans dated 03/13/2024 documented: Resident has potential for complications related to tracheostomy. Interventions include but are not limited to: Assess lung sounds every shift. Report any wheezes, crackles, or decreased breath sounds. Assist resident to turn, cough, and deep breath every 2-3 hours and as needed. Monitor and report signs of localized infection (localized swelling, redness, pain or tenderness, heat at the infected area, purulent drainage, loss of function). Monitor and report signs of systemic infection (fever, malaise, change in mental status, anorexia, nausea, headache, lymph node tenderness/enlargement). Provide tracheostomy care every shift and as needed. Provide oral hygiene every shift. Use principles of infection control and universal/standard precautions. Interview 04/04/2024 at 07:33 AM. Registered Nurse, Minimum data Set Coordinator (Staff B), was asked about the resident's MDS admission Assessment section O pertinent data. Staff B stated: I missed that section somehow and I will do a correction right away, we have two MDS coordinators and we have our units that we are responsible for, I am assigned units-east 1, west 2 and south 2, and I am assigned to this resident. When I do my assessment of a resident, I observe the resident, I talk to the staff the CNAs (Certified Nursing Assistants) and the Nurses about the resident before I complete the MDS assessment for the particular resident. Review of the facility's policy and procedure titled Nursing/Treatment-Wound Dressing Changes dated 09/08/2023 indicates: The MDS is used to provide a holistic assessment of each resident to promote optimum quality of care and quality of life. It is also used to identify resident care problems that are addressed in an individualized resident centered care plan, as well as for Medicare reimbursement. It is imperative that all sections are accurately coded by each discipline.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview, the facility failed to implement care plan interventions for one resident (Resident #61) out of eight residents sampled. As evidenced by Resident #61 observed in bed without floor mats in place and out of bed without wearing a helmet. There were 165 residents residing in the facility at the time of survey. The findings included: On 4/01/2024 at 9:36 AM, Resident #61 was observed seated in a wheelchair on the patio near staff. The resident had a splint on the left hand and the left foot was elevated on footrest. On 4/02/2204 at 9:58 AM, Resident #61 was observed self-propelling in wheelchair in the hallway. A splint was on the left hand and the left foot was elevated on the footrest. On 4/03/2024 at 8:34 AM, Resident #61 was observed lying in bed, no bilateral floor mats in place (photo evidence) On 4/04/2024 at 8:37 AM, Resident #61 observed lying in bed, no bilateral floor mats in place (photo evidence) Record review of demographic sheet for revealed Resident #61 was admitted on [DATE] and readmitted on [DATE] with diagnosis that included: Hemiplegia affecting left dominant side and muscle weakness. Record review of quarterly Minimum Data Set (MDS) dated [DATE] section C for cognitive status revealed a Brief Interview for Mental Status (BIMS) score of 15 on a scale of 0-15 suggesting the resident is cognitively intact. Section E revealed no indicators of psychosis, rejection of care or wandering behaviors. Section GG for functional status revealed substantial/ maximal assistance for personal hygiene and toileting, dependent for chair to bed transfer, independent to wheel 150 feet in manual wheelchair. Section J for health conditions revealed one fall since admission with injury. Record review of care plan start date 10/05/2023 revised 3/28/2024 indicate the resident is at risk for further falling related to: Use of Psychoactive medication, transfer assistance, poor balance, impaired cognition, wheelchair dependent, seizure disorder, and previous falls. Interventions included: Low riser bed, floor mats as safety measures. Helmet when out of bed. Record review of physician orders revealed 7/03/2018 maintain fall precautions and 7/31/2018 Fall precautions every shift. On 4/04/2024 at 8:40 AM Staff G, Certified Nursing Assistant (CNA) stated: I have been employed at this facility for 3 years and I am assigned to take care of [Resident #61] today. I am involved in the care plan meeting for [Resident #61]. I am not aware that Resident #61 has interventions for floor mats. On 4/04/2024 at 8:44 AM Staff F, CNA stated: I have been employed here for 4 years and I am taking care of [Resident #61] today. I am involved in the care planning for Resident #6]. I was not advised during care planning that [Residnt#61] has interventions for floor mats. On 4/04/2024 at 8:51 AM Staff D, Licensed Practical Nurse (LPN) stated: I am involved in the care planning process for [Resident#61]. There has never been a discussion about residents needing floor mats or helmet. On 4/04/2024 at 8:53 AM Staff E, Registered Nurse, (RN) stated: I am the nursing manager for the unit East 1. Fall precautions are individualized for each resident's needs. I am involved in the care planning for Resident #61. We have a care plan meeting for [Resident #61] quarterly, annually, and as needed; [Resident#61] has an order for fall precaution. We have not discussed floor mats or helmet use in care planning. On 4/04/2024 at 1:52 PM, the Director of Nursing (DON) stated: The care plan interventions for [Resident#61] falls include floor mats and helmet and were not being implemented by staff due to when [Resident#61] improved significantly and doesn't require the floor mats and helmet anymore. When [Resident #61 was admitted she was using those safety devices. Those interventions should have been removed before today. [Resident #61 has been in facility since 2018 and has not had any recent falls. Record review of policy and procedure for Interdisciplinary Care Planning dated 1/10/2024. Purpose To ensure that each resident receives person centered care based on their individualized Plan of Care, the interdisciplinary Team meets on a routine basis and develop/discusses the plan of care. Key Point: Any member of the care team can and should update the plan of care when new information is appropriate and different from what exists at the time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to obtain a prescribed order for a skin graft dressing change and failed to change the dressing daily per facility protocol for one resident (Resident #31) out of 2 sampled residents. As evidenced by no prescribed orders available for skin graft treatment dressing observed on 04/02/24 on resident anterior left leg initialed and dated 3/30/2024. The findings included: During assessment observation on 04/02/2024 at 08:59 AM Resident #31 was observed with a dressing to the left anterior leg dated 03/30/24, 11-7 PM shift. During observation on 04/03/2024 at 10:58 AM Registered Nurse, Wound Care (Staff C) prepared dressing change supplies, checked the order, entered resident's room, donned gown, washed hands, identified resident, prepared resident for dressing change with the assistance of Registered Nurse (Staff J) washed hands, donned gloves, opened supplies, apply barrier to bed, removed dressing from skin graft sight on anterior left leg, sight observed with redness and dry scabs, washed hands, donned gloves, cleaned area with normal saline x 3, pat dry x 2, washed hands, donned gloves, applied Antibiotic ointment on area and covered with dry dressing dated an initialed 04/03/2023, repositioned resident, discarded supplies in red bag, washed hands, donned gloves, closed red bag, washed hands, took red bag to soiled utility room, discarded red bag in red bin, washed hands, signed off on treatment performed. Review of the medical records for Resident #31 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Pressure ulcer of left hip, stage four (4) Review of the Physician's Orders Sheet for April 2023 revealed Resident #31 had no prescribed order on file for the skin condition dressing treatment to the right anterior leg. Later in the day on 04/02/2024 an order was obtained by Registered Nurse, Wound Care (Staff C) for-Triple Antibiotic ointment; 3.5 milligrams (mg) 400 unit- 5,000 unit/gram; amt (amount): Thin layer; topical. Special Instructions: clean left anterior lateral leg with normal saline, pat dry, apply a thin layer of triple antibiotic ointment and cover with dry dressing daily x 7 days and reassess; diagnosis: open area, once a day. Record review of Resident #31 's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented brief interview for mental status score (BIMS) 00 indicating the resident is cognitively impaired. Section GG for Functional Goals and Abilities documented the resident is dependent for care and Section M for Skin conditions documented no other ulcers, wounds, and skin problems. Record review of Resident # 31's Care Plans Reference Date 03/22/2024 documentation include but not limited to- Problem: Resident has a pressure ulcer to: Left Hip . At risk for further skin impairment r/t (related to) impaired mobility and incontinence. 3/21/2024, Resident noted with open area to the left anterior leg. Interventions include, use of pressure relieving mattress and cushions. Heel protectors on and in place, Weekly skin assessment. Report any signs of further skin breakdown daily. Interview on 04/02/2024 at 03:20 PM Staff C stated: I am the primary wound care nurse at the facility, there is no order for any treatment to the left anterior leg for this resident, the resident has a surgical skin graft on the anterior left leg that gets red sometimes and the floor nurses provide treatment as needed, currently there is no order in the system for treatment to the left leg. In this situation we will consult with the Physician (MD), Nurse Practitioner (ARNP). The Interdisciplinary team, dietary, do a wound care evaluation of the site (Left Leg) to see what type of treatment order is required for the resident. The resident's ARNP or the MD would prescribe the order and of course the nurses will provide the treatment. The surveyor informed Staff C that currently the resident has a dressing to his anterior leg dated 3/30/2024. Staff C was asked how often the dressing would need to be changed, Staff C did not respond. Interview on 04/03/2024 at 11:41 AM Staff C stated. I did an assessment of the resident's left anterior leg area yesterday, document the findings, spoke with the resident's ARNP, received a treatment order for the left anterior leg. I communicated with the floor staff about the resident's new order, called the resident's family (dad) to notify him of the changes, and sent dietary a message regarding the open area to the resident's left anterior leg for supplement review. Review of the facility policy and procedure titled Wound Dressing Changes dated 09/08/2023 states: The following information should be recorded in the resident's medical record: The date and time the dressing was changed, the name and title (Or initials) of the individual changing the dressing and the type of dressing used and wound care given.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Ensure oxygen therapy was being provided at an accurate flow rate of oxygen setting for one resident (Resident # 77) out of ten sampled residents. As evidenced by Resident#77 was observed receiving oxygen via nasal cannula at five Liter Per Minute instead of the prescribed three Liters Per Minute. This practice has the potential to have an adverse effect on residents in the facility that requires oxygen therapy. The findings included: On 04/01/2024 at 9:28 AM Resident # 77 observed in bed with oxygen in progress at five Liters Per Minute (LPM) via nasal cannula (N/C). (photo evidence) On 04/02/2024 at 10:07 AM Resident #77 was observed in bed with oxygen in progress at five LPM via N/C. (photo evidence) Record review of demographic face sheet revealed Resident #77 was admitted on [DATE] with diagnosis that included Chronic Obstructive Pulmonary Disease and Respiratory Syncytial Virus Pneumonia. Record review of Quarterly Minimum Data Set (MDS) 2/28/2024 Section C for cognitive status revealed a Brief Interview for Mental Status (BIMS) score of 7 on a scale of 0-15 indicated moderate cognitive impairment. Section GG for functional status revealed setup clean up assistance for eating and dependent for all other Activities of Daily Living (ADL) and transfer. Section J for Health conditions revealed nothing coded. Section O for special treatments not coded. Record review of Care Plan start date 11/30/2023 requires oxygen therapy as needed: COPD Interventions included: Administer oxygen as indicated via N/C. Monitor/document respiratory status every shift. Explain the importance of keeping oxygen at the prescribed setting. Stress more oxygen may not be better. Record review of physician orders revealed 11/18/2022 oxygen at three liters via N/C as needed (PRN) for Shortness of breath (SOB). On 4/02/2024 at 10:22 AM Staff I, Licensed Practical Nurse (LPN) stated [Resident #77] current oxygen order is three LPM via N/C as needed (PRN). Resident #77 usually uses oxygen while in bed due to complaints of shortness of breath. I have not seen any shortness of breath for this resident. The nurse turns on the oxygen for the resident when needed. Resident #77 also notifies staff when he needs assistance for oxygen. On 4/02/2024 at 10:25 AM. The surveyor and Staff I, LPN entered Resident #77's room, Staff I observed the oxygen level. Staff I stated: The oxygen delivery level for [Resident #77] is currently at five LPM and should be at three LPM according to the physician order. I rounded this morning when I started my shift, checked [Resident #77] and the oxygen tubing but did not check the level of oxygen delivery due to the fact it has never been at the wrong level and all staff are aware of the appropriate level. I will do frequent rounding to ensure oxygen therapy is delivered at the prescribed rate and give report to the oncoming shift. I measure the oxygen saturation daily to make sure resident's oxygen level in within normal parameters. On 4/04/2024 at 9:14 AM; Staff E, Registered Nurse (RN) stated: The protocol for administering oxygen PRN is to first check the order, then check the resident's oxygen saturation level or any observation or report of respiratory difficulty and then administer the oxygen as ordered. Oxygen should not be administered above the prescribed rate. [Resident #77] has an order for oxygen at three LPM via N/C as needed. On 4/04/2024 at 9:34 AM, Staff H, Registered Nurse (RN) stated: I am the nursing supervisor for the building. The protocol for administering oxygen is to follow the physician order. There is no time that it should above the doctors order unless it is an emergency, we immediately inform the physician. On 4/04/2024 at 1:27 PM The Director of Nursing (DON) stated: When there is an order for oxygen administration as needed, the nurses are to first verify the order, complete a respiratory assessment, then apply the oxygen according to physician's order. The only time the oxygen would be applied at a higher level then ordered is during an emergency which is temporary, and the physician would be notified. I will investigate the situation to find out if any harm was done to the resident and then consult with the physician. I will also re-educate staff about following doctors' orders and doing more frequent rounds. Record review of Policy and Procedure for Oxygen Administration revised 7/14/2023 revealed Purpose: 1. The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's order of facility protocol for oxygen administration. Procedure: Verify physician's order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to follow pharmacy procedures for one out of two carts; as evidenced by Licensed Practical Nurse observed administering medications to Resident #111 in the hallway of the one East unit, next to Medication Cart B. There were 166 residents residing in the facility at the time of the survey. The findings included: On 04/03/2024 at 09:20 AM during medication administration observation with Licensed Practical Nurse (Staff A), the surveyor observed Staff A administering medications to Resident #111 in the 1 East unit hallway, next to Cart B Medication Cart. Review of the medical records for Resident #111 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Guillain-Barre syndrome. Interview on 04/03/2024 at 9:30 AM, Staff A stated: This resident wanted his medication right away because he wanted to go to his activities, I know I was not supposed to give the resident his medications in the hallway, I should have taken the resident to his room. Review of the facility's policy and procedure titled Medication Administration and Observation revision date 07/12/2023 states: All medications shall be ordered by an authorized provider and administered in compliance with community standard nursing policy, while accommodating resident's preference/requests