**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility's policy and procedure, and staff interview, the facility failed to ensure 5 (Resident #75, #76, #77, #78, and #79) of 5 residents sampled who were admitted during the 2023 to 2024 influenza season received education regarding the benefits and potential side effect of the influenza immunization and were offered the influenza immunization. The failure to offer and provide influenza immunization education puts the residents at risk of developing influenza. The findings included: Review of the facility Influenza Vaccination policy and procedure created 9/16/15 and reviewed on 10/22/23, stated during the annual influenza season, patients, staff member, and volunteer workers would be offered an influenza vaccination unless such immunization is medically contraindicated, or the individual had already been immunized during this time period. Prior to the administration of the influenza's vaccine, the person receiving the immunization, or his/her legal representative, will be provided with a copy of Center for Disease Control (CDC) current vaccine information statement relative to the influenza vaccination. Vaccine information statements (VIS) would as appropriate, be supplemented with visual presentations or oral explanations to assist vaccine recipients in understanding the benefits and potential side effects of the influenza vaccine. Individuals being offered the influenza vaccine, or their legal representative, would be required to sign a consent form or declination form prior to the administration or refusal of the vaccine. The completed, signed, and dated record would be filed in the resident's medical record. 1. On 5/30/24 review of Resident #75's medical record revealed the resident was admitted to the facility on [DATE]. The medical record lacked documentation Resident #75 had received a copy of the CDC's current vaccine information related to the influenza immunization vaccination to include the benefits and potential side effect of the influenza vaccination and the required signed consent form or declination form to the administration or refusal of the vaccine. 2. On 5/30/24 review of Resident #76's medical record revealed the resident was admitted to the facility on [DATE]. The medical record lacked documentation Resident #75 had received a copy of the CDC's current vaccine information related to the influenza immunization vaccination to include the benefits and potential side effect of the influenza vaccination and the required signed consent form or declination form to the administration or refusal of the vaccine. 3. On 5/30/24 review of Resident #77's medical record revealed the resident was admitted to the facility on [DATE]. The medical record lacked documentation Resident #75 had received a copy of the CDC's current vaccine information related to the influenza immunization vaccination to include the benefits and potential side effect of the influenza vaccination and the required signed consent form or declination form to the administration or refusal of the vaccine. 4. On 5/30/24 review of Resident #78's medical record revealed the resident was admitted to the facility on [DATE]. The medical record lacked documentation Resident #75 had received a copy of the CDC's current vaccine information related to the influenza immunization vaccination to include the benefits and potential side effect of the influenza vaccination and the required signed consent form or declination form to the administration or refusal of the vaccine. 5. On 5/30/24 review of Resident #79's medical record revealed the resident was admitted to the facility on [DATE]. The medical record lacked documentation Resident #75 had received a copy of the CDC's current vaccine information related to the influenza immunization vaccination to include the benefits and potential side effect of the influenza vaccination and the required signed consent form or declination form to the administration or refusal of the vaccine. On 5/30/24 at 9:36 a.m., interview with the Director of Nursing (DON)/Infection Preventionist (IP) confirmed the facility's Immunizations - Influenza policy stated all residents in the facility during annual influenza season were required to receive a copy of the CDC's current vaccine information related to the influenza immunization vaccination to include the benefits and potential side effect of the influenza vaccination and the required signed consent form or declination form to the administration or refusal of the vaccine, and copy of the form would be filed in the resident's medical record. After having reviewed the medical record for Residents #75, #76, #77, #78, and #79, the DON confirmed the residents were admitted to the facility during the annual influenza season. She said she was unable to find documentation the residents had received the CDC's current vaccine information with the benefits and potential side effect of the influenza vaccination. She further said she was unable to find the required consent form or declination form for the administration or refusal of the influenza vaccine in the resident's medical record as required. She said the nursing department does not complete immunization education with the residents or their legal representative if they are in the facility during the annual influenza season. She said the immunization education for the resident is completed by the admission Coordinator or the MDS (Minimum Data Set) Coordinator for each resident. The DON confirmed she is the facility's IP. She said she was unaware the mandatory immunization education documentation and the signed consent form or the declination form to the administration or refusal of the vaccine was not in the resident's medical record as required. On 3/30/24 at 10:37 a.m., interview with the MDS Coordinator confirmed she or the admission Coordinator were required to provide each resident or their legal representative a copy of the CDC's current vaccine information related to the influenza immunization vaccination to include the benefits and potential side effect of the influenza vaccination. She said they were also required to obtain a signed consent form or declination form for the administration of the vaccination or the refusal the vaccine and keep a copy of the form in the resident's medical record. She confirmed after a review of Residents #75, #76, #77, #78, and #79's medical records, they were admitted to the facility during the annual influenza season. She further said she was unable to find documentation the residents had received the CDC's current vaccine information with the benefits and potential side effect of the influenza vaccination. She also said she was unable to find the required consent form or declination form for the administration or refusal of the vaccine in the resident's medical record as required.

Based on observation, facility policies and procedures, staff, resident, and family member interviews, the facility failed to ensure residents' right to receive visitors at the time of their choosing for 3 (Resident #239, #236, and #28) of 5 sampled residents. The findings included: Facility policy titled Right to Access and Visitation dated 10/3/2022, stated: Resident's family members are not subject to visiting hour limitations or other restrictions not imposed by the resident, with the exception of reasonable clinical and safety restrictions, placed by the facility based on recommendations of CMS (Center for Medicare and Medicaid Services), CDC (Center for Disease Control), or the local health department. And the facility will ensure all visitors enjoy full and equal visitation privileges consistent with resident preferences. The facility admission packet document titled skilled nursing facility rights stated, you have the right to spend private time with visitors at any reasonable hour. The skilled nursing facility must permit your facility to visit at any time as long as you want to see them. On 2/13/23, 2/14/23, and 2/15/23 at 9:00 a.m., a sign was observed posted on the facility's entrance door stating, Visitation hours Monday-Friday 8:30 a.m.- 7:45 p.m. and Saturday and Sunday 8:30 a.m.-3:45 p.m. On 2/16/23 at 10:15 a.m., a sign read, Visitation hours Monday-Friday 8:30 a.m.- 7:45 p.m. and Saturday and Sunday 8:30 a.m.-3:45 p.m. The above hours are when reception is on duty to properly check you in according to COVID protocols. The door is locked at other times. Please inform us if you desire any exceptions to these hours . Inside the front doors at the front reception desk, a sign was posted that stated, Visiting hours were Monday-Friday 8:30 a.m.-7:45 p.m. and Saturday and Sunday 8:30 a.m.-3:45 p.m. The sign also noted the front doors will remain locked when visiting hours are over. No visitors will be allowed in the building except during the posted schedule. No Exceptions! On 2/13/23 3:47 p.m., resident #239 stated he was surprised by having limited visitation hours yesterday. He stated his friend told him there was a card that said visitation ended at 3:45 p.m., which was pretty early. Maybe they don't enforce them. I just thought that was early. On 2/15/23 1:41 p.m., resident #236 stated he would like his caregiver to have additional visitation time. They both live out of town, and visiting hours end at 4:00 p.m., because the receptionist leaves and the doors are locked. Both stated they would prefer the flexibility to have visitation later in the day on the weekends. On 2/14/23 at 4:26 p.m., Licensed Practical Nurse (LPN) Staff nurse A stated if the resident has family that wants to spend the night, they are allowed since everyone is in a private room. On 2/15/23 at 8:41 a.m., the receptionist pointed to the sign at the desk with the visitation hours and showed hours end at 3:45 p.m., on weekends. She stated if someone wants to stay past the posted hours, they need to let the staff know in advance since the receptionist leaves at 4:00 p.m. On 2/15/23 at 9:05 a.m., LPN Staff C stated visitation ends at 7:45 p.m., during the week and 3:45 p.m. on weekends. When visitation is about to end, an overhead announcement is made that the door will be locked so families know to head out. On 2/15/23 at 2:37 p.m., The Social Service Director (SSD) stated visitation hours were posted. The main reason for nighttime is because the doors automatically lock, so they have to push the call bell to ring. On the weekend it's a shorter time visit. We do have flexibility if someone asks, we do allow them. I have only been asked once or twice. I have never seen staff ask anyone to leave. We allow visitors to spend the night if the administration approves it in advance. The room isn't ideal for long-term visitation. On 2/15/23 at 5:04 p.m., the administrator stated visitation is from 8:30 a.m. to 7:45 p.m., and ends at 3:45 p.m., on weekends. Visitors can still come buzz and come in anytime. We tell people that all the time. We had extended hours on Superbowl Sunday and New Year's Eve. On 2/16/23 at 12:16 p.m., the activity director confirmed, visitation ends at 3:45 p.m., but on Superbowl Sunday, some of the spouses wanted to stay late, so we gave them permission to stay. On 2/15/23 8:42 a.m., Resident #28 said the limited visitor hours bother him because his son comes to see him and then in an hour he is told he has to leave. He said his son works and he just cannot visit anytime during the day. Resident #28 said his son has a family and obligations that limit the time he can visit and if the hours were longer he could see him more. On 2/15/23 at 1:33 p.m., during a telephone interview Resident #28's son said the limited weekend visitation hours are a problem. He said there is an announcement and visitors have to leave at 3:45 p.m. He said he thinks the weekend hours should be longer and does not understand the limit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review and policy review the facility failed to address a significant change in weight in a timely manner for 1 (Resident #182) of 3 residents reviewed for weights. The findings included: Review of facility policy titled, Weight Monitoring Policy, reviewed 10/24/2022 which stated: Policy: Based on the resident's comprehensive assessment, the facility will ensure the resident maintains acceptable parameters of nutritional status, such as body weight, unless the resident's clinical condition demonstrates that this is not possible. Policy Explanation and Compliance Guidelines: 2. The newly recorded resident weight should be compared to the previous recorded weight. A significant change in weight is defined as: (a) 5% change in weight in 1 month (30 days); (b) 10% change in weight in 6 months (180 days) 3. Documentation (a) The physician should be informed of a significant change in weight and may order nutritional interventions. Review of facility policy titled Notification of Change Policy reviewed 10/25/2022 which stated: Policy: The facility will inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or appropriate family member(s) of the following: . 2. A significant change in the physical, mental, or psychosocial status of the resident. Policy Explanation and Compliance Guidelines: 1. In the case of a competent resident, the facility will contact the resident's physician and appropriate family members . 5. Document in the resident's clinical record the date and time of the notification. On 2/13/2023 at 10:20 a.m., Resident #182 was observed with bilateral foot and ankle edema (swelling), and intermittent cough. Resident #182 daughter was present in the room and said, I did not realize how swollen her feet were until today. We tried to put her shoes on, and they did not fit. On 2/14/2023 at 11:00 a.m., clinical record reviewed for Resident #182. Resident was admitted to the facility on [DATE] for rehabilitation after a right hip fracture. Diagnoses listed included heart failure. Resident #182 had an admission weight completed on 2/2/2023 documenting weight 114.0 pounds. On 2/10/2023 the resident's weight was documented at 124.6 pounds. This weight change of 10.6 pounds showed a significant weight gain of 9.3% over an eight day period. No documentation was found in the clinical records, including progress notes, assessment notes and change in condition notes reviewed to show the physician was informed of the significant weight change. There was no documentation of additional interventions implemented to manage the significant weight increase. The Comprehensive care plan initiated on 2/6/2023 did not address the risk for edema for resident. On 2/13/23 documentation in the clinical record noted Resident #182 developed a cough on 2/12/2023 and edema to both lower extremities on 2/13/2023. On 2/15/23 at 9:06 a.m., Certified Nursing Assistant (CNA) Staff G said residents are weighed on admission and then are weighed weekly unless they have an order for daily weights. CNA Staff G said the nurses check the weights to see if there is a concern. On 2/15/23 at 9:28 a.m., Registered Nurse (RN) Staff F said the residents are weighed on admission and then weekly unless ordered due to a medical diagnosis such as congestive heart failure patients might have daily weights. If there is a weight change of three or more pounds they contact the physician and document the notification in the progress notes. RN Staff F reviewed Resident #182 weight history and confirmed the significant weight gain. RN Staff F said, It absolutely should have been addressed earlier. I don't know why it wasn't. On 2/15/23 at 9:43 a.m., the Director of Nursing (DON) said if there is a significant weight change, the nurse is expected to notify the physician and document the notification. The DON reviewed Resident #182's clinical record and confirmed there was no documentation the nurse notified the physician for the 9.3% weight gain on 2/10/2023. The DON said the expectation is that they would have been notified and it would have been documented. The DON confirmed the resident developed cough and edema after the significant weight gain and required a chest X-ray and Lasix medication which were both ordered on 2/13/2023. On 2/16/23 at 9:16 a.m., the Registered Dietician (RD) said she saw the significant weight gain during her routine weights review. She had not received any communication regarding the weight gain.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide care and services to prevent the development of pressure ulcers in 1 (Resident #28) of 1 resident with an in-house acquired pressure ulcer. The findings included: Review of Resident #28's Hospital Transfer Form (Agency for Health Care Administration (AHCA) Form 5000-3008) dated 1/11/23 revealed Resident #28 had an incision and drainage of a right foot infection and wore a surgical boot. Resident #28 did not have any pressure ulcers listed on the transfer form. Review of the Hospital Physical Therapy Treatment Record History of Present illness dated 1/9/23 revealed Resident #28 had surgery to the right foot on 12/30/22 and instructions for surgical shoe at all times. Physical Therapy goals included surgical shoe at all times for ambulation, bed mobility, and transfers starting 1/3/23 and ending 1/17/23. Review of the clinical record revealed Resident #28 had an admission date of 1/11/23. The admission Minimum Data Set (MDS) assessment with an assessment reference date of 1/17/23 noted Resident #28's cognition was intact. Resident #28 did not have any behaviors. The assessment noted the resident had a surgical wound but no unhealed pressure ulcer. Resident #28 required extensive assistance of two staff members for dressing. Review of the Occupational Therapy (OT) Notes for Resident #28 from 1/12/23 - 2/3/23 revealed documentation lists surgical shoe on right foot for ambulation. under precautions. Review of the OT Notes for Resident #28 signed 2/16/23 revealed precautions, Do not use surgical shoe when ambulating per physician order dated 2/3/23. Review of the facility physician's orders, Medication Administration Records (MARS), Treatment Administration Records (TARS), Care Plans and progress notes revealed no nursing directions or interventions for Resident #28's surgical shoe. Review of the Nursing Skin/Wound Progress Note dated 1/31/23 at 7:23 p.m., revealed Resident #28 had an unstageable pressure ulcer to the right Achilles. Review of the Wound Physician's Initial Wound Evaluation dated 2/2/23, Resident #28 has an unstageable wound (due to a device/dressing) of the right upper heel for at least 14 days duration. On 2/13/23 at 4:02 p.m., Resident #28 said he had a bandage on the back of his heel. He said he wore a black surgical boot when he was admitted to the facility. On 2/14/23 at 3:47 p.m., Certified Nursing Assistant (CNA) Staff H said Resident #28 has a wound on the right heel. Staff H said Resident #28 wore the surgical shoe when he was admitted to the facility. On 2/15/23 at 11:12 a.m., the Director of Nursing confirmed Resident #28's unstageable pressure ulcer was acquired at the facility. On 2/15/23 at 2:20 p.m., the Wound Care Physician who saw Resident #28 initially on 2/2/23, confirmed Resident #28 had an unstageable pressure ulcer that was caused by the surgical shoe. On 2/15/23 at 2:38 p.m., Resident #28 said he wore the surgical shoe for about three weeks. Resident #28 stated, If the facility told him to do something he did it, and if they told him not to do it, he stopped. Why would I want to wear that surgical shoe if I didn't need to? A surgical shoe was observed in the resident's room. On 2/15/23 at 6:36 p.m., the Minimum Data Set (MDS) Coordinator said there was no nursing documentation indicating how long Resident #28 was wearing the surgical shoe. The MDS Coordinator said the surgical shoe was not in the physician's orders, the Medication Administration Records (MARS), the Treatment Administration Records (TARS) or the care plans for Resident #28. On 2/16/23 at 9:30 a.m., CNA Staff I said she takes care of Resident #28, and he wore the surgical shoe when he was admitted . She said Resident #28 showers every day. She assisted Resident #28 with dressing, including putting on the surgical shoe. On 2/16/23 at 10:21 a.m., the Director of Nursing confirmed there was no physician's order for Resident #28 to wear the surgical shoe. She said there should have been an order with time frames and when to stop wearing it, but there were not. She said there were no directions for the surgical shoe in the care plan or the CNA [NAME] (contains resident's care information) .