**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, and a review of policies and procedures, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary and comfortable living environment, by failing to 1) Keep resident care equipment functioning for one resident (#8) whose bed controls did not work, and 2) Keep the rooms clean for four (Residents #54 #39, #302, #59) of five residents receiving enteral nutrition, in a total survey sample of 36 residents and a facility census of 102. The facility failed to clean and maintain the enteral nutrition (tube feeding) pumps and poles, walls, floors and floor boards surrounding the air conditioning (AC) units and the AC units themselves in four resident rooms. These concerns could negatively impact residents' enjoyment of their environment. A clean living environment is necessary to reduce the spread of infection and promote the highest well-being of the facility's residents. The findings include: A tour of the facility was conducted on 03/18/2025 at 10:30 AM with the following findings: In room [ROOM NUMBER]C, Resident #54's enteral nutrition pump and pole were observed with dried-on enteral food product on them. (Photographic evidence obtained) In room [ROOM NUMBER]A, Resident #83's floor had a large rust stain on the tile floor under the AC. (Photographic evidence obtained) At 10:43 AM, Resident #8 stated her bed did not rise when the remote control was pressed. She was asked to press the button on the remote control and nothing happened. In room [ROOM NUMBER]C, Resident #52's wall around the AC unit was in disrepair. The paint had bubbled up and cracked around the unit. (Photographic evidence obtained) In room [ROOM NUMBER], Resident #30's AC unit had dirt and black biological growth on the vent and a small pile of sand under the AC unit. The unit cover was broken and hanging away from the wall. (Photographic evidence obtained) In room [ROOM NUMBER], Resident #78's AC unit had black biological growth under the AC unit. (Photographic evidence obtained) In rooms 210B and 102A and B, Residents #39, #302, and #59's enteral nutrition pumps and poles were observed with dried-on, encrusted enteral food product on them. (Photographic evidence obtained) A review of Resident #54's 03/20/2025 physician's order revealed: Enteral Feed Order every shift. Isosource 1.5, 45 ml (milliliters)/hour (hr.) x 20 hours. On at 2:00 PM, off at 10:00 AM. (Copy obtained) A review of Resident #39's 03/20/2025 physician's order revealed: Enteral Feed Order every shift. DiabetiSource 1.2 at 45 ml/hr. x 20 hours. On at 2:00 PM, off at 10:00 AM. (Copy obtained) A review of Resident #302's 03/20/2025 physician's order revealed: Enteral Feed Order every shift for nutrition. DiabetiSource 1.2 at 70 ml/hr. continuous. (Copy obtained) A review of Resident #59's 03/20/2025 physician's order revealed: Enteral Feed Order every shift. Isosource 1.5 at 60 ml/hr. x 24 hours. (Copy obtained) During a follow-up tour on 03/20/2025 at 10:33 AM with the Maintenance Director, he stated the staff were trained to enter work orders into the electronic building management system the facility used to track maintenance requests and work orders. The following observations were made: In room [ROOM NUMBER]C, Resident #54's enteral nutrition pump and pole were observed with dried-on enteral nutrition product on them. In room [ROOM NUMBER]A, Resident #83's floor had a large rust stain on the floor under the AC unit. Resident #83 stated when it rained, the ceiling leaked in her room. The maintenance director stated sometimes the drip pan on the AC unit would leak, and the pan was rusty so the water was a brown color that stained the floor. Resident #8's bed did not rise when the remote control was pressed. The maintenance director laid down on the floor, so he could see under the bed. He tried to fix the problem, but then stated he would have to take the bed out of the room to work on it. In room [ROOM NUMBER]C, Resident #52's wall around the AC unit was in disrepair. The paint had bubbled up and cracked around the unit. In room [ROOM NUMBER], Resident #30's AC unit had dirt and black biological growth on the vent and a small pile of sand under the AC unit. The unit cover was broken and hanging away from the wall. The Maintenance Director took the cover and re-attached it to the unit. In room [ROOM NUMBER], Resident #78's AC unit had black biological growth underneath of it. In rooms 210B and 102A and B, Residents #39, #302, and #59's enteral nutrition pumps and poles were observed with dried-on, encrusted enteral food product on them. All of the above identified concerns were confirmed with the Maintenance Director during the follow-up tour. He reviewed the work orders in the electronic building management system on his phone and stated he had not been notified of any of the problems identified. He confirmed that any staff member could enter a work order in the system. During an interview with the Supervisor of Housekeeping on 03/20/2025 at 11:02 AM, she was informed of the above identified concerns for housekeeping. She left the interview to inspect the rooms. She returned to the interview at 12:10 PM and confirmed that the enteral nutrition product had been stuck to the poles and pumps for some time. She stated, It's like glue. I have to scrape it off when it dries on. She confirmed it was the responsibility of the housekeeping department to clean the enteral food product off the poles when it spilled/splattered. During an interview with the Administrator at 03/20/2025 at 11:20 AM, she stated the maintenance of the AC units and the repair of the walls around them should be done. There was a plan for building renovations to begin in May 2025, but the ongoing maintenance should still be done. The staff were to enter the identified problems in the electronic building management system so the Maintenance Director would see that there was a work order that needed to be completed. A review of the facility's policy and procedure titled Preventative Maintenance Program (implemented 2016, revised 01/05/2024) revealed: A preventative maintenance program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff and the public. 1. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance services to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner. 2. The Maintenance Director shall assess all aspects of the physical plant to determine if preventative maintenance is required. Required preventative maintenance may be determined from manufacturer's recommendations, maintenance requests, grand rounds, life safety requirements, or experience. 4. The Maintenance Director shall develop a calendar to assist with keeping track of all tasks. 5. Documentation shall be completed for all tasks and kept in the Maintenance Director's office for at least three years. (Copy obtained) A review of the facility's policy and procedures titled Routine Cleaning and Disinfection (Undated), revealed: It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible. 4. Routine surface cleaning and disinfection will be conducted with a detailed focus on visibly soiled surfaces and high tough areas to include: IV poles. 13. Cleaning of walls, blinds and window curtains will be conducted when visibly soiled. (Copy obtained) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and reviews of the facility's Infection Control Program and Hand Hygiene policies, the facility's staff failed to offer or assist residents with hand hygiene before meals for five (Residents #66, #63, #102, #57, #29) of five residents who received meal trays and were unable to perform hand hygiene independently in a manner to prevent cross contamination. The findings include: On 03/17/2025 at 12:20 PM, an observation was made of lunch meals served in the south dining room. The staff was observed using hand hygiene before serving trays to residents but none of the residents were offered hand hygiene before their meal was served. On 03/19/2025 at 12:14 PM, an interview was conducted with Resident #66. When asked, she stated she was not offered hand hygiene before meals. Her roommate, Resident #102, a new admission on [DATE], stated she was not offered hand hygiene either. On 03/19/2025 at 12:18 PM, an observation was made of lunch meals served in the north dining room. The staff was observed using hand hygiene before serving trays to residents but none of the residents were offered hand hygiene before their meal was served. On 03/20/2025 at 12:10 PM, Resident #57 was asked whether she was offered hand hygiene before meals. She stated it had never been offered. On 03/20/2025 at 12:12 PM, Resident #29 was asked whther she was offered hand hygiene before meals. She stated hand hygiene had not been offered to her before any meal. On 03/20/25 at 12:21 PM, Certified Nursing Assistant (CNA) A was interviewed. When asked about resident hand hygiene before meals, she stated she did ask the residents about hand hygiene before mealtime most of the time. On 03/20/25 at 12:26 PM, Therapist B was interviewed. When asked about hand hygiene for residents before meals, she stated it was not offered but should be. On 03/20/25 at 12:27 PM, CNA C was interviewed. When asked about hand hygiene for residents before meals, she stated she would usually wash the residents' hands before serving them. On 03/20/2025 at 12:32 PM, a hand hygiene policy for residents was requested from the Director of Nursing. On 03/20/2025 at 1:46 PM, a hand hygiene policy for residents was requested from the Administrator. On 03/20/2025 at 2:40 PM, Resident #63 was asked if she was offered hand hygiene before her meals. She stated no, she could not do it herself and needed assistance with the task. On 03/20/2025 at 2:45 PM, the facility's policy and procedure titled Activities of Daily Living (ADLs) - Maintain Abilities (issued: 3/2/19, revised: 3/2/19) was provided for review. It contained no specific language for resident hand hygiene before meals; however, paragraph number three read: The facility will provide care and services for the following activities of daily living: a: Hygiene - bathing, dressing, grooming, oral care, and hand hygiene. (Photographic evidence obtained) On 03/20/2025 at 3:09 PM, an interview was conducted with the Director of Nursing (DON) regarding hand hygiene for residents before meals. When asked about the process for hand hygiene before meals, she stated the ADL (activities of daily living) policy was what they used for this procedure; there was no separate policy for mealtime hand hygiene. She stated, Staff is expected to offer the resident hand hygiene and assist dependent residents with hand hygiene before meals. When asked if she completed any surveillance for hand hygiene for residents, she stated she had not. .

Based on kitchen food service observations, staff interviews, facility document review, and facility policy and procedure review, the facility failed to prepare, distribute and serve food in accordance with professional standards for food service safety, by failing to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness. The facility failed to ensure that the dietary staff practiced proper procedures for hand hygiene, disposable glove use, and proper sanitation practices when cleaning the meat slicer in the kitchen. Appropriate hand hygiene, food handling, and sanitation is important in health care settings serving nursing home residents due to the risk of serious complications from foodborne illness as a result of their compromised health status. Unsafe food handling practices represent a potential source of pathogen exposure. The findings include: During the initial kitchen tour on 03/17/2025 at 10:44 AM, the dish machine was observed with the Certified Dietary Manager (CDM). Dietary Aide G tested the machine with a test strip. The dish machine was a high-temperature machine. The machine was operated through both cycles four times, and the temperature gauge for the rinse cycle did not reach 180' F (Fahrenheit) during any of the cycles. The wash cycle temperature was 160' F. The rinse cycle only reached 173' F. Dietary Aide G stated the required temperature should be 180' F. During an interview with the CDM at 10:50 AM, she stated the dish machine was working fine this morning, and she did not understand why it was not reaching the required temperature now. She confirmed the rinse cycle should reach 180' F. During a second tour of the kitchen on 03/19/2025 at 11:20 AM, the lunch meal service was observed. From 11:20 AM to 11:40 AM, Dietary [NAME] E, the evening cook, was observed washing the meat slicer off with soapy water and a rag. She did not remove any parts of the slicer. She finished cleaning it, wiped it off, and covered it with a plastic bag. She then rolled it into the dry storage room and returned to the kitchen to assist with the lunch meal service. On 03/19/2025 at 12:00 PM, Dietary [NAME] E was observed changing gloves without washing her hands. She was preparing pureed food in a blender. During an interview with Dietary [NAME] E on 03/19/2025 at 1:43 PM, she expressed that she would need to use the translator on her phone because her first language was Russian. She used a translator to understand the questions she was being asked. She stated she remembered changing gloves when she was preparing the pureed beef in the blender. She confirmed that she did not wash her hands in between. She confirmed she had been trained to wash her hands between glove changes. The CDM was standing nearby and nodded her head in agreement. On 03/19/2025 at 12:10 PM, Dietary [NAME] F was observed changing gloves without washing her hands. During an interview with Dietary [NAME] F on 03/19/2025 at 1:38 PM, she stated she had gravy dripping off of her glove. She did not want to walk all the way across the kitchen to take her gloves off and wash her hands, so she just took the dirty glove off, discarded it and donned a new pair of gloves. She did not want to leave the tray line to go wash her hands, so she just continued serving the meals. On 03/19/2025 from 1:20 PM to 1:41 PM, observations of the dish washing operations were made. Dietary Aide G was observed donning gloves and then began washing off dirty dishes and stacking them in dish machine racks. She loaded the trays into the dish machine and ran them through. She then pulled the tray of clean dishes out of the machine and went back over to the dirty side of the dish room and continued to rinse dirty dishes from the lunch meal service. At 1:24 PM, she went to the clean side of the dish room and pulled the trays out of the dish machine. She did not change gloves in between or wash her hands. She then proceeded to unload the clean dishes from the racks placing them on a cart with other clean dishes. After she finished unloading the clean dishes, she returned to the dirty dishes and continued to rinse and load them in racks. Another aide brought over two large orange trays and asked her to run them through the machine. She took them and ran them through. She then removed them from the machine with the same gloves on and put them up against the wall to drip dry. She returned to the dirty side and continued to rinse and rack the dirty dishes. At 1:28 PM, she returned to the clean side and pulled a rack of clean dishes out of the machine. She continued to wash the dishes going back and forth between the clean and dirty side without changing gloves or washing her hands. During an interview with the CDM on 03/19/2025 at 1:38 PM, she observed Dietary Aide G washing dishes without stopping to change her contaminated gloves and wash her hands. The CDM confirmed that the aide should not be going back and forth between the dirty and clean side without washing her hands and changing her gloves. She was then asked to observed the meat slicer in the dry storage room. She went to the meat slicer and removed the plastic cover. The food support plate and underside of the blade were encrusted with food debris. (Photographic evidence obtained) The CDM confirmed that the meat slicer was still not clean. At 1:51 PM, the CDM provided the policy and procedure and trainings for the dietary staff on hand washing and glove use. She was informed of the observations during the lunch meal service of Dietary [NAME] F not changing gloves when required (moving from one task to another) without washing hands in between. She confirmed that she should wash her hands between glove changes. A review of the Food and Nutrition Services In-Services sign-in sheet revealed that Dietary Cooks E and F, and Dietary Aide G received training on 12/02/2024 on hand hygiene. (Copy obtained) A review of the manufacturer's specifications for cleaning the meat slicer revealed: Cleaning and Sanitizing the Slicer: 3. Use a clean cloth to remove all coarse residual food and liquids from the slicer surfaces. Sanitize all the removable parts and the slicer. 10. In a clean basin or sink, in a solution of clean warm water and correctly diluted sanitizing solution, soak and wash the removable parts. Remove the parts form the basin or sink and allow them to air dry. 11. Wipe the slicer with correctly diluted sanitizing solution. The slicer shall be cleaned and sanitized at intervals to comply with national state and/or local health codes. (Copy obtained) A review of the facility's procedure for properly cleaning a food slicer (Undated) revealed: To properly clean a food slicer, disassemble it, wash all parts with hot, soapy water, rinse thoroughly, and sanitize with a food-safe solution, then dry all components before reassembling. 2. Disassembly: Remove removable parts: Disassemble the slicer by removing the blade, carriage, food pusher, and any other removable parts. 3. Cleaning: Wash with hot, soapy water: Wash all disassembled parts with hot soapy water, using a soft-bristled brush to remove any stubborn food particles. Clean the blade thoroughly, paying attention to both sides and any crevices. Ensure the carriage is thoroughly cleaned to remove any residue or buildup. After washing, sanitize all parts with a food-safe sanitizer according to the manufacture's instructions. Rinse all parts thoroughly with clean water to remove any sanitizer residue. Dry all parts thoroughly. Clean after each use. Regularly clean the slicer after each use to prevent food buildup and bacterial growth. (Copy obtained) A review of the facility's policy and procedure titled Infection Control - Food Handling (issued 03/02/2019, revised 03/02/2019) revealed: 1. Food staff are to wash hands when: before putting on gloves; when changing tasks, after handling soiled dishes, utensils and equipment. 4. Single use gloves are not to be used for more than one task. Change gloves and perform hand hygiene between tasks. (Copy obtained) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and interviews, the facility failed to develop a discharge plan that addressed all of the resident's needs post discharge, by failing to reconcile medication after discharge for one (Resident #1) of three residents reviewed for discharges, from a total sample of 8 residents. The findings include: A review of Resident #1's medical record revealed an admission date of 10/16/24, and the resident was discharged home on [DATE]. The resident's medical diagnoses included Nonrheumatic mitral valve insufficiency, Fibromyalgia, Chronic Systolic (congestive) Heart Failure, and Major depressive disorder. An admission Minimum Data Set (MDS) assessment, dated 10/22/24, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 points, indicating intact cognition. A review of Resident #1's physician orders dated 10/16/24 revealed the following medications Apixaban (Eliquis) 5 milligrams (mg) two times a day (BID) for cardiac arrhythmia, Furosemide (Lasix) 20 mg every day (QD) for cardiac Arrythmia, Metoprolol 25 mg BID for blood pressure, Sertraline 50 mg QD for depression, Celecoxib 100 mg BID for pain, and Amiodarone 200 mg BID for cardiac Arrythmia. A review of the Resident #1's Interdisciplinary discharge summary note dated 10/24/24 included a statement that read, medications were released to family per state regulations. (Photographic evidence obtained) Per the discharge orders, the resident was to go home without medications and the pharmacy for ordering medications was listed. (Photographic evidence obtained) Medications were not sent home with resident. A signed copy of the last page of the medication list was in the medical record (Photographic evidence obtained). Further record review for Resident #1 found no documentation that a discharge meeting was held with the resident. On 12/19/2024 at 1:32 PM, an interview was conducted with Employee A, Licensed Practical Nurse (LPN). She was asked to explain the facility's process for reconciliation of post-discharge medications. She stated that during the discharge process, the nurse will educate the resident/family on discharge medications, use of equipment, and making sure they call their primary physician for follow-up. During this time, the nurse will also answer any questions they may have. The discharge paperwork is printed out by the nurse and given to the resident on the day of discharge. The nurses go over their medications and how to take them, each department will go over their part of the discharge. Nurses will call the resident's pharmacy to order any prescriptions they may need. The physician's discharge orders are reviewed by the nurse, to determine if the resident has orders to go home with medications, prescriptions or just a medication list. The nursing staff also check to see if home health services needs to be set up and they will call the residents' provider of choice if they have one. Finally, the nurse will put a note in the resident electronic record that the discharge has been completed, questions answered, and paperwork is given to the resident. On 12/19/2024 at 2:40 PM, an interview was conducted with the Social Services Director (SSD) regarding the discharge process. She stated that discharge planning starts on admission. She is usually made aware of the possibility of long-term or short-term residents. Upon receiving the projection discharge, the date is put on the discharge calendar, and the interdisciplinary team (IDT) is notified during clinical meeting. The clinical team (Nurses) and provider manage the discharged medications. The residents are told they cannot be discharged with controlled substances. The residents do not get a copy of the discharge order, but they get a copy of the IDT discharge summary. The nurse completes the discharge and has the resident sign the IDT discharge summary. The resident receives a signed copy and then a copy will be uploaded by the nurse into the record. She explained that Medicare residents will have their left-over medication sent back to the pharmacy and medications will be called into their pharmacy of choice. If a person is on Medicaid, usually the resident will go home with left over medications. Social services coordinates contacting providers for services and the residents can ask to use their preferred provider. Should the resident have a question after going home, they can call the social services here for assistance. The SSD stated she did not document in the medical record her conversations with the resident post discharge. On 12/19/2024 at 3:30 PM, an interview was conducted with Director of Nursing (DON). The DON stated that she had been in the position less than a month. When asked about medications and discharges, the DON stated the facility will send narcotics home with residents along with regular medications according to what insurance they currently have. They go by Medicare and Medicaid guidelines. She stated the nurse discharging the resident should explain discharge instructions, go over the medication list, inform the residents of any medical equipment that was ordered, and review any home health needs that were ordered. The nurse should also answer all the residents' or resident representative questions before they leave the building. She confirmed that Resident #1 was not sent home with the medication because of the type of insurance resident had and was not sure how she would verify if the orders were sent to the pharmacy. When asked what the facility protocol was for ensuring that residents who were discharged without the medication received the medication at home. She said she was not sure and would have to follow up. On 12/19/24 at 4:48 PM, a follow up interview was conducted with the DON. She explained that she spoke with Resident #1's physician who told her that no orders were sent to the pharmacy because the resident was not on narcotics. The DON confirmed that there was no process in place for residents that were discharged home without medication. On 12/19/2024 at 5:00 PM, an interview was conducted with the Administrator. She was asked to explain the facility process for discharge medications. She stated that they are identified in the discharge paperwork. She explained that if the resident or family member asked them, they would contact the residents' physician on discharge for him to call in the needed prescriptions for the residents. She acknowledged that they do not document their attempts to contact the physician, and do not have a means to ensure the prescriptions were called in for the resident. The facility policy titled Transfer and Discharge Requirements revised 3/2/19. The Policy indicated that the facility would ensure residents are treated equally regarding transfer, discharge and the provision of services, regardless of their payment source in accordance to state and federal regulations. The policy indicated that 3. Information provided to the receiving provider must include a minimum of the following: a. Contact information of the practitioner responsible for the care of the resident; b. Resident representative information including contact information; c. Advance Directive information; d. All special instructions or precautions for ongoing care, as appropriate; e. Comprehensive care plan goals; f. All other necessary information, including a copy of the resident's discharge summer and any other documentation, as applicable, to ensure a safe and effective transition of care. (Photographic evidence obtained)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and facility policy review, the facility failed to ensure enteral tube syringes were replaced daily for four (Residents #4, #8, #6, and #7) of five residents receiving enteral tube feedings (TF) and failed to ensure the enteral feeding bag for one (Resident #7) resident receiving enteral TF was dated/timed to reflect contents were less than or up to 24 hours old for residents, from a total sample of 8 residents. This could result in the residents not receiving appropriate care and/or clinical complications. The findings include: 1. On 2/22/24 at 10:25 AM, Resident #4 was observed supine in bed, with head of bed (HOB) elevated between 30 and 45 degrees. Her TF syringe was on an overbed table, not dated. (Photographic evidence obtained) A review of the medical record for Resident #4 revealed she was admitted on [DATE] with diagnoses that included anoxic brain damage, diabetes type 2, tracheostomy, and gastrostomy. Resident's enteral feed order dated 2/1/24, revealed every shift Diabetisource 1.2 @ 65 ml/hr. x20 hrs. on at 1400, off at 1000. A review of the most recent minimum data set (MDS) assessment, dated 2/6/24, revealed the resident was comatose and totally dependent for all care. Physician's order dated 1/1/24 revealed change enteral syringe every 24 hours and as needed. (Copy obtained) During an interview with Licensed Practical Nurse (LPN) A on 2/22/24 at 11:05 AM, she was asked who was responsible for changing TF supplies. She replied, the 11-7 shift was responsible to change out the TF bags/solution and syringe, and they are supposed to be dated. 2. On 2/22/24 at 12:35 PM, Resident #8 was observed in bed with eyes closed. Her TF was dated 2/22/24. A review of the medical record for Resident #8 revealed she was admitted on [DATE] with diagnoses that included type 2 diabetes mellitus with diabetic neuropathy, anemia, hemiplegia and hemiparesis, tracheostomy, and gastrostomy status. Resident's enteral feed order dated 12/18/23, revealed every shift recommend Diabetisource 1.2 @ 100 ml/hr. x20 hrs., on at 12 pm, off at 8 am flush 50 ml/hr. every 4 hr. A review of the most recent MDS assessment dated [DATE], revealed, not comatose, clear speech, adequate hearing and vision, understands and is understood, with a brief interview for mental status (BIMS) score of 15 out of 15, indicating cognitively intact. Physician's order dated 2/3/24 revealed change enteral syringe every night shift. (Copy obtained) 3. On 2/22/24 at 12:45 PM, Resident #6 was observed in bed with HOB elevated. His TF syringe was on an overbed table, not dated. (Photographic evidence obtained). A review of the medical record for Resident #6 revealed he was admitted on [DATE] with diagnoses that included gastrostomy status, aphasia following cerebral infarction, hemiplegia, severe protein-calorie malnutrition, and type 2 diabetes mellitus. Resident's enteral feed order dated 9/11/23, revealed every shift Diabetisource 1.2 at 45ml/hr. x 20 hrs., on at 2 pm, off at 10 am. Resident's review of the most recent MDS assessment, dated 1/9/24, revealed the resident had severe hearing impairment but has a cochlear implant, impaired vision but can see large print, is rarely understood but understands simple commands and responds appropriately, not comatose; unable to assess BIMS due to verbal difficulties. Physician's order dated 2/10/24, revealed change enteral syringe every night shift. (Copy obtained) 4. On 2/22/24 at 12:50 PM, Resident #7 was observed in bed, eyes closed; lips were dry and crusted, TF pump was off, Isosource bag was dated 2/21/24 (photo), resident did not respond to verbal stimuli. His TF syringe was on an overbed table, not dated. (Photographic evidence obtained). A review of the medical record for Resident #7 revealed he was admitted on [DATE] with diagnoses that included hemiplegia and hemiparesis, dysphagia, oropharyngeal phase, and aphasia. Resident's enteral feed order dated 5/9/23, revealed every shift Isosource 1.5 at 65 ml/hr. x 20 hrs. off 1000, on 1400. A review of the most recent MDS assessment dated [DATE], unclear/garbled speech, usually understands and is sometimes understood, not comatose, unable to conduct BIMS due to garbled speech. Physician's order dated 2/9/24, revealed change enteral syringe every night shift. (Copy obtained) On 2/22/24 at 3:56 PM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC revealed that the tube feeding was a closed system. The bags are prefilled and are usually changed out on the night shift. When asked why the TF would be dated with yesterday's date, she replied, most likely because the 24 hours wasn't up. When asked how anyone would know if the bags did not have a time hung on them. She stated, the bags can actually be hung for 36 hours and would be changed out by then. When asked how they could be sure, the RNC did not respond. A review of the facility's policies and procedures titled: Quality of Care (revised 3/2/19), revealed the following: Page 3-4, Item 10. Tube feeding Management/Restore Eating Skills. The facility will ensure that a resident who has been able to eat enough alone or with assistance is not fed by enteral methods unless the resident's clinical condition demonstrates that enteral feeding was clinically indicated and consented to by the resident; and a resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including by not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers. (Copy obtained) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and medical record review, the facility failed to ensure tracheostomy/respiratory care was provided to two (Residents #4 and #8) of two resident reviewed for respiratory care, by failing to follow physician orders for tracheostomy care, suction and/or oxygen tubing. This could result in the residents not receiving appropriate care and/or clinical complications. The findings include: 1. A review of the medical record for Resident #4 revealed she was admitted on [DATE] with diagnoses that included anoxic brain damage, diabetes type 2, tracheostomy, and gastrostomy. A review of the most recent minimum data set (MDS) assessment, dated 2/6/24, revealed the resident was comatose and totally dependent for all care and unable to assess Brief Interview for Mental Status (BIMS). On 2/22/24 at 10:25 AM, Resident #4 was observed supine in bed (lying on her back), with head of bed elevated between 30 and 45 degrees. A tracheostomy collar was in place with oxygen (O2) flow set at 12 liter per minute (LPM). The tracheostomy collar was humidified and corrugated tubing with drain bag attached to the bed frame higher than the tubing causing excess water to pool in tubing rather than drain bag (and was not dated). The suction setup located on bedside table revealed the tubing was open to air, was not bagged and was dated 2/7/24. The sterile water bottle on overbed table at foot of bed was open to air and was not dated. One time use cardboard with plastic liner suction container was observed on overbed table with clear fluid. (Photographic evidence obtained) Review of Resident #4's physician's orders revealed the following: 1/1/24-Trach-resident has 8.5 trach; obtain O2 sats every shift, notify Medical Doctor of (oxygen) saturations <90%; humidified oxygen 28%/ 5 liters per minute via trach collar; may suction every 2 hours as needed. 1/6/24-Change corrugated tubing and trach mask weekly every Saturday night shift. 1/6/24-Change humidity bottle weekly every Saturday night shift. 1/1/24-Change internal cannula daily. 1/1/24-Change nebulizer set-up weekly every Saturday night shift. 1/6/24-Change O2 tubing connecting to O2 concentrator every Saturday night shift. 1/6/24-Change suction cannister and tubing weekly every Saturday night shift. 1/6/24-Change yanker suction weekly every Saturday night shift. On 2/22/24 at 11:05 AM, an interview was conducted with Licensed Practical Nurse (LPN A). She stated that trach collars are changed weekly, and inner cannula are changed daily. She explained that she performed this task when she first comes on duty. The bedside suction machine with tubing is changed weekly at night but cannister is only changed when full. The suction kits are for one-time use only and the sterile water is to be dated after being opened. The trach collar is to be at 28% or 8 LPM; is humidified with tubing changed weekly with tubing to be at lowest point of gravity. 2. A review of the medical record for Resident #8 revealed she was admitted on [DATE] with diagnoses that included type 2 diabetes mellitus with diabetic neuropathy, anemia, hemiplegia and hemiparesis, tracheostomy, and gastrostomy status. A review of the most recent MDS assessment dated [DATE], revealed, not comatose, clear speech, adequate hearing and vision, understands and is understood, with a BIMS score 15 of 15, indicating cognitively intact. On 2/22/24 at 12:35 PM, Resident #8 was observed in bed, eyes closed, roused to verbal stimuli; nasal cannula in place; O2 tubing not dated, O2 set at 2.5 LPM. (Photographic evidence obtained) Review of Resident #8's physician's orders revealed the following: 12/9/23-Change oxygen set up and bag weekly, every Sunday night shift, place in labeled O2 bag and tie to handle of O2 concentrator. 1/25/24-Oxygen continuous at 2 LPM via nasal cannula. On 2/22/24 at 1:45 PM, a joint interview was conducted with the Director of Nursing (DON) and the Regional Nurse Consultant (RNC). They explained the O2 tubing is changed weekly by nurses on the night shift and is to be dated. Nurses are responsible to check liter flow every shift and certified nursing assistants (CNA) are not allowed to adjust liter flow. A review of the facility's policies and procedures titled: Quality of Care (revised 3/2/19), revealed the following: Page 4, Item 12. Respiratory/Tracheostomy Care and Suctioning, The facility will ensure that residents who need respiratory care, including tracheostomy care and tracheal suctioning, is provide such care consistent with professional standards of practice, the comprehensive person-centered care plan and resident goals and preferences. (Copy obtained) .

Based on observations and interview, the facility failed to ensure current and accurate nurse staffing information was posted (facility name, the current date, the total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift) on a daily basis at the beginning of each shift. The findings include: On 2/22/24 at 9:00 AM, the posted nurse staffing information was observed displayed on a table across from the reception desk. The staffing information was dated 2/21/24 with a census of 99. (Photographic evidence obtained) On 2/22/24 at 10:05 AM, a second observation of the posted staffing information (in the same area) located across from the reception desk was dated 2/21/24 with a census of 99. On 2/23/24 at 9:15 AM, the posted staffing information was observed displayed on the reception desk. The staffing information was dated 2/22/24 with a census of 94. (Photographic evidence obtained) On 2/23/24 at 9:54 AM, the posted staffing information was observed to have been moved from the reception desk to the table across from desk. The form was dated 2/22/24 with a census of 94. On 2/23/24 at 10:40 AM, the posted staffing information observed for a second time on table across from reception desk. The form was observed dated 2/22/24 with a census of 94. On 2/23/24 at 11:00 AM, an interview was conducted with the Administrator. When asked what the current census was for the day, he stated, 96. When asked who updates the daily posted staffing, he stated, The staffing coordinator does. When asked when the daily staffing should be posted/updated. He stated early morning, Before our morning meeting, which is held at 9:00 AM. It should be updated around 7:45-8:00 AM, then we can discuss it during morning meeting and make any updates if necessary. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure three (Resident #6, #7, and #8) of eight sampled residents had access to the call light while in bed. The findings include: 1. On 2/22/24 at 12:45 PM, Resident #6 was observed in bed with head of bed elevated, resident did not speak but nodded his head after greeting the resident. The call light was clipped to itself on the wall. (Photographic evidence obtained). When asked if he could get to his call light, the resident shook his head in a no response. A review of the medical record for Resident #6 revealed he was admitted on [DATE] with diagnoses that included gastrostomy status, aphasia following cerebral infarction, hemiplegia, severe protein-calorie malnutrition, and type 2 diabetes mellitus. A review of the resident's most recent minimum data set (MDS) assessment dated [DATE] revealed, severe hearing impairment with a cochlear implant, impaired vision but can see large print, is rarely understood but understands simple commands and responds appropriately, not comatose; unable to assess Brief Interview for Mental Status (BIMS) due to verbal difficulties. On 2/23/24 at 9:45 AM, Resident #6 was observed lying in bed, eyes open. His call light was observed clipped to itself on the wall behind his bed, out of his reach. When asked if he could reach his call light if he needed to call for help. He did not answer verbally, he was observed to shake his head in a no response. 2. On 2/22/24 at 12:42 PM, Resident #7 was observed in bed, eyes closed; lips were dry and crusted, call light button was lying on the floor, clipped to the top sheet (Photographic evidence obtained). The resident did not respond to verbal stimuli. A review of the medical record for Resident #7 revealed he was admitted on [DATE] with diagnoses that included hemiplegia and hemiparesis, dysphagia, oropharyngeal phase, and aphasia. A review of the most recent MDS assessment dated [DATE], revealed unclear/garbled speech, usually understands and is sometimes understood, not comatose, unable to conduct BIMS due to garbled speech. On 2/22/24 at 3:45 PM, an interview was attempted with Resident #7 in his room. After greeting the resident, he attempted to speak. His speech was garbled, but he was able to indicate that he was not able to reach/find his call light. The call light remained on the floor. (Photographic evidence obtained). 3. On 2/22/24 at 10:50 AM, an interview was conducted with Certified Nursing Assistant (CNA) A regarding call lights. She explained that CNAs are to supposed to make sure the residents have their call lights within reach every time they go into the room. On 2/22/24 at 12:35 PM, Resident #8 was observed in her bed. The call light was draped over the night stand not within reach (Photographic evidence obtained) When the resident was asked where her call light was, she pointed to night stand and stated, They always forget to give it back to me. A review of the medical record for Resident #8 revealed she was admitted on [DATE] with diagnoses that included type 2 diabetes mellitus with diabetic neuropathy, anemia, hemiplegia and hemiparesis, tracheostomy, and gastrostomy status. A review of the most recent MDS assessment dated [DATE], revealed, not comatose, clear speech, adequate hearing and vision, understands and is understood, with a brief interview for mental status (BIMS) score 15 of 15, indicating cognitively intact. On 2/22/24 at 1:45 PM, a joint interview was conducted with the Director of Nursing (DON) and Regional Nurse Consultant (RNC) regarding call lights. During the interview, they stated that all staff should make sure the resident has access to their call light. On 2/22/24 at 2:40 PM, during an interview with Licensed Practical Nurse (LPN) B, she stated that it was everyone's responsibility to make sure call lights were within the residents' reach. On 2/22/24 at 3:00 PM, during an interview with CNA B, she stated that anytime a staff member goes into the residents room, they are supposed to check to see that the call light is withing the residents reach. On 2/22/24 at 3:27 PM, CNA C was asked who is responsible to make sure call lights are within reach, she replied All of us. On 2/22/24 at 4:30 PM, an interview was conducted with the administrator regarding the call light Performance Improvement Project (PIP) initiated in January 2024. The administrator was asked to provide a copy of plan, he replied, he would need to look for it. The PIP was received on 2/22/24 at 10:56 PM. After reviewing the document, the plan did not include a plan for education/in-service to staff or how deficiencies would be addressed. A review of facility Performance Improvement Project: Call lights: Initiated on 1/15/24 revealed: Objective and Goal: Staff responsiveness to patient -initiated call lights is highly important 2. Call light audits will be reviewed for and within the residents reach for safety (Ongoing)

Based on interviews, medical record review, and facility policy and procedure review, the facility failed to ensure residents were free from any significant medication errors, by failing to administer medications within the specified timeframe based on physician's scheduling orders for ten (Residents #1, #3, #4, #5, #9, #10, #11, #12, #13, and #14) of fourteen sampled residents, from a total census of 101. Failure to administer medications in a timely manner can result in a resident's inability to maintain the proper level of medication in the bloodstream to be effective; reduced functional ability; lower quality of life; hospitalization, disease progression, and/or death. The findings include: On 1/9/24 at 9:30 AM, the administrator was requested to provide a copy of current Quality Assurance and Performance Improve (QAPI)/Performance Improvement Project (PIP) being conducted at the facility. On 1/9/24 at 11:01 AM, the administrator was again requested to provide just a list of the current PIPs. On 1/9/24 at 11:20 AM, the administrator provided a list of the QAPI/PIPs that were either initiated or in the process since October 2023. The list did not contain any PIPs to address medication administration. (Copy obtained) On 1/9/24 at 12:25 PM, an interview was conducted with Director of Nursing (DON). The DON stated that an ad hoc PIP had been initiated in December for medication administration. When she was asked why it was not on the list, she said, because it was an ad hoc PIP and had not gone to QAPI in December. 1. A review of Resident #1's medical record revealed an admission date of 10/8/23 and discharge date of 11/26/23 with diagnoses that included hemiplegia/hemiparesis following CVA affecting left non-dominant side, facial weakness, muscle weakness, difficulty walking with lack of coordination, dysphagia and gastrostomy. On 1/10/24 at 9:00 AM, the Director of Nursing (DON) was requested to provide Resident #1's Medication Administration Audit (MAA) report for the period 11/1/23 through 11/30/23. The 79-page report was received at 9:25 AM. (Copy obtained) A review of Resident #1's MAA Report from 11/1/23 through 11/26/23, revealed that his medications were administered outside of the acceptable two-hour administration window (one hour before to one hour after) on 21 of 30 days as follows: On 11/1/23, the medication Gabapentin (pain) was scheduled for 8 AM, it was administered at 9:34 AM. On 11/4/23, Gabapentin was scheduled for 8 AM, it was administered at 10:31 AM. The following medications were scheduled for 9 AM, they were administered between 10:32 and 10:36 AM: Escitalopram Oxalate (depression), Carbidopa-Levodopa (Parkinsons), Cholecalciferol (deficiency), Ascorbic Acid Tablet (deficiency), Lorazepam (anxiety), Lisinopril (hypertension), Rivaroxaban (Cerebrovascular Accident -CVA), and Famotidine (Gastroesophageal reflux disease-GERD). On 11/5/23, Gabapentin was scheduled for 8 AM, it was administered at 11:34 AM. The following medications were scheduled for 9 AM, they were administered between 11:34 and 11:37 AM: Escitalopram Oxalate, Carbidopa-Levodopa, Cholecalciferol, Ascorbic Acid Tablet, Lorazepam, Lisinopril, Rivaroxaban, and Famotidine. On 11/6/23, Gabapentin was scheduled for 8 AM, it was administered at 9:59 AM. On 11/8/23, Gabapentin was scheduled for 8 AM, it was administered at 9:14 AM. On 11/9/23, Gabapentin was scheduled for 8 AM, it was administered at 9:32 AM and was scheduled for 20:00 PM, it was administered at 22:34 PM. Famotidine was scheduled for 21:00 PM, it was administered at 22:36 PM. On 11/10/23, Gabapentin was scheduled for 8 AM, it was administered at 14:04 PM; it was scheduled again for 20:00 PM and was administered at 21:40 PM. The following medications were scheduled for 9 AM, they were administered at 14:04 PM: Escitalopram Oxalate, Carbidopa-Levodopa, Cholecalciferol, Ascorbic Acid, Lorazepam, Lisinopril, Rivaroxaban, and Famotidine. Carbidopa-Levodopa was scheduled for 18:00 PM, it was administered at 21:40 PM. On 11/11/23, Gabapentin was scheduled for 8 AM, it was administered at 9:38 AM. On 11/12/23, Gabapentin was scheduled for 8 AM, it was administered at 9:33 AM. On 11/13/23, Gabapentin was scheduled for 8 AM, it was administered at 16:32 PM. The following medications were scheduled for 9 AM, they were administered between 16:32 and 16:41 PM: Escitalopram Oxalate, Carbidopa-Levodopa, Cholecalciferol, Ascorbic Acid, Lorazepam, Lisinopril Rivaroxaban, and Famotidine. On 11/14/23, Gabapentin was scheduled for 8 AM, it was administered at 9:34 AM. Carbidopa-Levodopa was scheduled for 17:00 PM, it was administered at 18:51 PM. On 11/16/23, Gabapentin was scheduled for 8 AM, it was administered at 9:37 AM. Carbidopa-Levodopa was scheduled for 17:00 PM, it was administered at 18:54 PM. On 11/17/23, Gabapentin was scheduled for 8 AM, it was administered at 9:01 AM; it was scheduled again at 20:00 PM and was administered at 22:24 PM. The following medications were scheduled for 21:00 PM, they were administered at 22:24 PM: Mirtazapine, Lorazepam, and Famotidine. On 11/18/23, Gabapentin was scheduled for 8 AM, it was administered at 13:25 PM. The following medications were scheduled for 9 AM, they were administered between 13:25 and 13:45 PM: Escitalopram Oxalate, Carbidopa-Levodopa, Cholecalciferol, Ascorbic Acid, Lorazepam, Lisinopril, Rivaroxaban, and Famotidine. Carbidopa-Levodopa was scheduled for 17:00 PM, it was administered at 18:44 PM On 11/19/23, Gabapentin was scheduled for 8 AM, it was administered at 12:32 PM. The following medications were scheduled for 9 AM, they were administered at 12:32 PM: Escitalopram Oxalate, Carbidopa-Levodopa, Cholecalciferol, Ascorbic Acid, Lorazepam, Lisinopril, Rivaroxaban, and Famotidine. Carbidopa-Levodopa was scheduled for 17:00 PM, it was administered at 18:50 PM On 11/20/23, Gabapentin was scheduled for 8 AM, it was administered at 9:25 AM. On 11/21/23, Gabapentin was scheduled for 8 AM, it was administered at 10:58 AM. The following medications were scheduled for 9 AM, they were administered between 10:58 and 11:09 AM: Escitalopram Oxalate, Carbidopa-Levodopa, Cholecalciferol, Ascorbic Acid, Lorazepam, Lisinopril, Rivaroxaban, and Famotidine. Carbidopa-Levodopa was scheduled for 17:00 PM, it was administered at 18:09 PM On 11/22/23, Gabapentin was scheduled for 8 AM, it was administered at 10:16 AM. The following medications were scheduled for 9 AM, they were administered between 10:19 and 10:27 AM: Escitalopram Oxalate, Carbidopa-Levodopa, Cholecalciferol, Ascorbic Acid, Lorazepam, Lisinopril, Rivaroxaban, and Famotidine. On 11/23/23, Gabapentin was scheduled for 8 AM, it was administered at 9:28 AM; it was scheduled again at 20:00 PM and was administered at 21:11 PM. On 11/24/23, Gabapentin was scheduled for 8 AM, it was administered at 9:12 AM. Carbidopa-Levodopa was scheduled for 17:00 PM, it was administered at 19:18 PM On 11/26/23, Gabapentin was scheduled for 8 AM, it was administered at 9:04 AM. (Copy obtained) 2. A review of Resident #3's medical record revealed an admission date of 11/2/23 and discharge date of 11/17//23 with diagnoses that included hepatic encephalopathy, depression, anxiety, persistent mood disorder. On 1/10/24, the DON was requested to provide Resident #3's MAA Report for the period 11/1/23 through 11/30/23. The 48-page report was received at 9:31 AM. (Copy obtained) A review of Resident #3's MAA Report from 11/2/23 through 11/17/23, revealed that her medications were administered outside of the acceptable two-hour administration window (one hour before to one hour after) on 14 of 16 days as follows: On 11/2/23, the following medications were scheduled for 21:00 PM, they were administered between 22:25 PM and 22:26 PM: Propranolol HCI (htn), Magnesium Oxide (deficiency), Pantoprazole Sodium (Gerd) and Rifaximin (liver cirrhosis). On 11/3/23, Lactulose (hepatic encephalopathy) was scheduled for 12:00 PM, it was administered at 13:43 PM. On 11/4/23, the following medications were scheduled for 9 AM, they were administered between 10:41 and 10:43 AM: Furosemide (chronic obstructive pulmonary disease-COPD), Clonazepam (anxiety), Rifaximin, Propranolol HCI, and Pantoprazole Sodium. On 11/5/23, Lactulose was scheduled for 8:00 AM, it was administered at 11:30 AM. The following medications were scheduled for 9 AM, they were administered at 11:32 AM: Furosemide, Rifaximin, Propranolol HCI, and Pantoprazole Sodium. On 11/6/23, Lactulose was scheduled for 8:00 AM, it was administered at 9:51 AM. The medication was scheduled again for 12:00 PM, it was administered at 14:59 PM. On 11/8/23, Lactulose was scheduled for 12:00 PM, it was administered at 13:42 PM. On 11/9/23, Lactulose was scheduled for 8:00 AM, it was administered at 9:21 AM. Prednisone (Thrombocytopenia) was scheduled for 8:00 AM, it was administered on 9:19 AM. Rifaximin was scheduled for 21:00 PM, it was administered at 22:31 PM. On 11/10/23, Lactulose was scheduled for 8:00 AM, it was administered at 9:49 AM. The medication was scheduled again for 12:00 PM, it was administered at 14:03 PM. Prednisone was scheduled for 8:00 AM, it was administered on 9:48 AM. The following medications were scheduled for 21:00 PM, they were administered at 22:34 PM: Propranolol HCI, Magnesium Oxide, and Pantoprazole Sodium. On 11/11/23, Lactulose was scheduled for 8:00 AM, it was administered at 9:13 AM. Prednisone was scheduled for 8:00 AM, it was administered on 9:10 AM. On 11/12/23, Lactulose was scheduled for 12:00 PM, it was administered at 13:17 PM. On 11/13/23, Prednisone was scheduled for 8:00 AM, it was administered on 10:30 AM. Rifaximin was scheduled for 9:00 AM, it was administered on 16:26 PM. Lactulose was scheduled for 12:00 PM, it was administered at 16:27 PM. On 11/14/23, Rifaximin was scheduled for 9:00 AM, it was administered on 13:14 PM. Lactulose was scheduled for 12:00 PM, it was administered at 13:14 PM On 11/15/23, Lactulose was scheduled for 8:00 AM, it was administered at 9:02 AM. Prednisone was scheduled for 8:00 AM, it was administered on 9:05 AM. On 11/17/23, Furosemide was scheduled for 9:00 AM, it was administered at 14:08 PM. Lactulose was scheduled for 17:00 PM, it was administered at 23:59 PM. (Copy obtained) 3. A review of Resident #4's medical record revealed an admission date of 5/17/23 with diagnoses that included intracerebral Hemorrhage, cirrhosis of liver, weakness, difficulty walking, muscle wasting, cognitive communication deficit, Anemia, alcohol dependence, falls, ascites, nicotine dependence, unspecified dementia, hypotension, hypokalemia On 1/10/24, the DON was requested to provide Resident #4's MAA Report for the period 12/1/23 through 12/31/23. The 65-page report was received at 9:26 AM. (Copy obtained) A review of Resident #4's MAA Report from 12/1/23 through 12/31/23, revealed that his medications were administered outside of the acceptable two-hour administration window (one hour before to one hour after) on 9 of 31 days as follows: On 12/2/23, the following medications were scheduled for 21:00 PM, they were administered between 22:29 PM and 22:30 PM: Levetiracetam (seizures) and Memantine HCI (dementia). On 12/8/23, Melatonin was scheduled for 22:00 PM, it was administered at 23:06 PM On 12/11/23, the following medications were scheduled for 9:00 AM, they were administered between 13:31 PM and 13:32 PM: Furosemide, Metoprolol Succinate (htn), Levetiracetam (seizures), Thiamine HCI (supplement), Spironolactone (diuretic), Folic Acid (supplement), Memantine HCI (dementia), and Ferrous Sulfate (supplementation). On 12/14/23, the following medications were scheduled for 9:00 AM, they were administered between 13:54 PM and 13:59 PM: Furosemide, Levetiracetam, Metoprolol Succinate, Thiamine HCI, Spironolactone, Folic Acid, Memantine HCI, Ferrous Sulfate, and Andro Gel Transdermal (testosterone). On 12/16/23, the following medications were scheduled for 21:00 PM, they were administered at 22:05 PM: Levetiracetam and Memantine HCI. On 12/18/23, the following medications were scheduled for 21:00 PM, they were administered at 22:49 PM: Levetiracetam and Memantine HCI. On 12/21/23, Memantine HCI was scheduled for 9:00 AM, it was administered at 10:29 AM. On 12/26/23, the following medications were scheduled for 9:00 AM, they were administered between 11:43 AM and 11:49 AM: Furosemide, Levetiracetam, Metoprolol Succinate, Thiamine HCI, Spironolactone, Folic Acid, Memantine HCI, Ferrous Sulfate, and AndroGel Transdermal. On 12/29/23, the following medications were scheduled for 9:00 AM, they were administered between 10:36 AM and 13:12 PM: Furosemide, Levetiracetam, Metoprolol Succinate, Thiamine HCI, Spironolactone, Folic Acid, Memantine HCI, Ferrous Sulfate), and Andro Gel Transdermal. (Copy obtained) 4. On 1/10/24, the DON was requested to provide Resident #5's MAA Report for the period 12/14/23. The 12-page report was received at 9:31 AM. (Copy obtained) A review of Resident #5's MAA Report on 12/14/23, revealed that her medications were administered outside of the acceptable two-hour administration window (one hour before to one hour after) as follows: On 12/14/23, Metformin HCI (diabetes) was scheduled for 8:00 AM, it was administered at 10:25 AM. The following medications were scheduled for 9:00 AM, they were administered between 10:29 AM and 10:40 AM: Scopolamine Base Patch (tracheal secretions), Potassium Chloride Liquid (hypokalemia), Carvedilol (htn), Sacubitril-Valsartan (htn), and Insulin Glargine Subcutaneous Solution (type 2 diabetes mellitus). Humalog Injection Solution (diabetes) was scheduled for 11:30 AM, it was administered at 12:54 PM. (Copy obtained) 5. On 1/10/24, the DON was requested to provide Resident #9's MAA Report for the period 1/1/24 through 1/7/24. The 28-page report was received at 11:51 AM. (Copy obtained) A review of Resident #9's MAA Report from 1/1/24 thru 1/7/24, revealed that her medications were administered outside of the acceptable two-hour administration window (one hour before to one hour after) on 3 of 7 days as follows: On 1/1/24, Gabapentin was scheduled for 17:00 PM, it was administered at 22:08 PM. Melatonin was scheduled for 20:00 PM, it was administered 22:08 PM. Clonazepam, Sennosides-Docusate Sodium (constipation), and Hydralazine HCI (hypertension) were scheduled for 21:00 PM, they were administered at 22:08 PM. On 1/2/24, Melatonin was scheduled for 20:00 PM, it was administered at 23:22 PM. Clonazepam, Sennosides-Docusate Sodium, and Hydralazine HCI were scheduled for 21:00 PM, they were administered at 23:22 PM. On 1/5/24, Cyanocobalamin (VitB 12) was scheduled for 10 AM, it was administered at 11:24 AM. (Copy obtained) 6. On 1/10/24, the DON was requested to provide Resident #10's MAA Report for the period 1/1/24 through 1/7/24. The 40-page report was received at 11:49 AM. (Copy obtained) A review of Resident #10's MAA Report from 1/1/24 thru 1/7/24, revealed that his medications were administered outside of the acceptable two-hour administration window (one hour before to one hour after) on 6 of 7 days as follows: On 1/1/24, Gabapentin was scheduled for 16:00 PM, it was administered at 17:17 PM. Apixaban was scheduled for 21:00 PM, it was administered at 22:35 PM. On 1/2/24, Gabapentin was scheduled for 16:00 PM, it was administered at 17:17 PM. On 1/3/24, Gabapentin was scheduled for 8:00 AM, it was administered at 9:36 AM. Invega Sustenna Intramuscular Suspension (Schizoaffective disorder) was scheduled for 9:00 AM, it was administered at 11:44 AM. The following medications were scheduled for 17:00 PM, they were administered at 22:18 PM: Lamotrigine (mood), Calorically Dense Oral Supplement, and Mirtazapine. On 1/4/24, Gabapentin was scheduled for 16:00 PM, it was administered at 17:28 PM On 1/5/24, Gabapentin was scheduled for 8:00 AM, it was administered at 11:40 AM and scheduled again for 16:00 PM, it was administered at 17:36 PM. The following medications were scheduled for 9:00 AM, they were administered between 11:39 AM and 11:40 AM: Magnesium Oxide (deficiency), Apixaban, Topiramate (brain injury), Ferrous Sulfate, Mirtazapine, Bupropion HCI ER (depression). On 1/7/24, Gabapentin was scheduled for 8:00 AM, it was administered at 9:13 AM, and was scheduled again at 12:00 PM, it was administered at 13:07 PM. (Copy obtained) 7. On 1/10/24, the DON was requested to provide Resident #11's MAA Report for the period 1/1/24 through 1/7/24. The 29-page report was received at 11:50 AM. (Copy obtained) A review of Resident #11's MAA Report from 1/1/24 thru 1/7/24, revealed that his medications were administered outside of the acceptable two-hour administration window (one hour before to one hour after) on 5 of 7 days as follows: On 1/2/24, the following medications were scheduled for 8:00 AM, they were administered at 9:04 AM: Phenytoin Sodium Extended (seizure disorder), Famotidine (indigestion), and Memantine HCI (anxiety). On 1/3/24, the following medications were scheduled for 20:00 PM, they were administered at 22:22 PM: Phenytoin Sodium Extended, Ropinirole Hydrochloride (multiple sclerosis), Famotidine, and Levetiracetam (epilepsy). On 1/4/24, the following medications were scheduled for 8:00 AM, they were administered between 9:17 AM and 9:19 AM: Phenytoin Sodium Extended, Levetiracetam Famotidine, and Memantine HCI. On 1/5/24, the following medications were scheduled for 8:00 AM, they were administered at 11:04 AM: Phenytoin Sodium Extended, Levetiracetam, Famotidine, and Memantine HCI. Escitalopram Oxalate scheduled for 9:00 AM, it was administered at 11:04 AM. On 1/7/24, the following medications were scheduled for 8:00 AM, they were administered at 10:23 AM: Phenytoin Sodium Extended, Levetiracetam, Famotidine, and Memantine HCI. Escitalopram Oxalate scheduled for 9:00 AM, it was administered at 10:23 AM. (Copy obtained) 8. On 1/10/24, the DON was requested to provide Resident #12's MAA Report for the period 1/1/24 through 1/7/24. The 33-page report was received at 11:56 AM. (Copy obtained) A review of Resident #12's MAA Report from 1/1/24 thru 1/7/24, revealed that her medications were administered outside of the acceptable two-hour administration window (one hour before to one hour after) on 5 of 7 days as follows: On 1/1/24, Fluoxetine HCI (depression) was scheduled for 9:00 AM, it was administered at 10:52 AM. The following medications were scheduled for 21:00 PM, they were administered at 22:04 PM: Arginine (supplement), Apixaban (blood thinner), Sennosides-Docusate Sodium (constipation), Ferrous Sulfate (supplementation), and Trazodone HCI (depression). On 1/2/24, Acetaminiphen-Codeine (pain) was scheduled for 0:00 AM, it was administered at 3:25 AM On 1/5/24, the following medications were scheduled for 9:00 AM, they were administered at 15:02 PM: Ferrous Sulfate, Apixaban, Fluoxetine HCI, ProHeal (nutritional supplement), and Acetaminiphen-Codeine. ProHeal was scheduled again at 13:00 PM, it was administered at 15:02 PM. On 1/6/24, ProHeal was scheduled for 17:00 PM, it was administered at 18:22 PM. Ascorbic Acid was scheduled at 20:00 PM, it was administered at 21:29 PM. On 1/7/24, Acetaminiphen-Codeine was scheduled at 0:00 AM, it was administered at 2:04 AM. (Copy obtained) 9. On 1/10/24, the DON was requested to provide Resident #13's MAA Report for the period 1/1/24 through 1/7/24. The 31-page report was received at 11:57 AM. (Copy obtained) A review of Resident #13's MAA Report from 1/1/24 thru 1/7/24, revealed that his medications were administered outside of the acceptable two-hour administration window (one hour before to one hour after) on 5 of 7 days as follows: On 1/1/24, Percocet (pain) was scheduled for 8:00 AM, it was administered at 9:03 AM. On 1/2/24, Percocet was scheduled for 0:00 AM, it was administered at 1:07 AM On 1/3/24, Percocet was scheduled for 8:00 AM, it was administered at 9:33 AM. Hydralazine HCI was scheduled for 8 AM, it was administered at 9:26 AM. Rosuvastatin Calcium (hyperlipidemia) was scheduled at 17:00 PM, it was administered at 19:05 PM. On 1/4/24, Percocet was scheduled for 8:00 AM, it was administered at 9:05 AM. Percocet was scheduled for 12:00 PM, it was administered at 13:26 PM. Percocet was scheduled for 16:00 PM, it was administered at 17:36 PM. Hydralazine HCI was scheduled for 8 AM, it was administered at 9:06 AM. Hydralazine HCI was scheduled for 12 PM, it was administered at 13:25 PM. Hydralazine HCI was scheduled for 16:00 PM, it was administered at 17:35 PM. On 1/5/24, Percocet was scheduled for 20:00 PM, it was administered at 21:19 PM. (Copy obtained) 10. On 1/10/24, the DON was requested to provide Resident #14's MAA Report for the period 1/1/24 through 1/7/24. The 41-page report was received at 11:57 AM. (Copy obtained) A review of Resident #14's MAA Report from 1/1/24 thru 1/7/24, revealed that his medications were administered outside of the acceptable two-hour administration window (one hour before to one hour after) on 5 of 7 days as follows: On 1/2/24, Sucralfate was scheduled for 16:30 PM, it was administered at 17:53 PM. On 1/3/24, Linaclotide (constipation) and Amlodipine Besylate (htn) were scheduled for 8:00 AM, they were administered at 12:15 PM. The following medications were scheduled for 9:00 AM, they were administered between 12:15 PM and 12:21 PM: Calorically Dense Supplement, Sennosides-Docusate Sodium, and Apixaban. Sucralfate was scheduled for 16:30 PM, it was administered at 17:37 PM. On 1/4/24, Linaclotide and Amlodipine Besylate were scheduled for 8:00 AM, they were administered at 9:11 AM. Sucralfate was scheduled for 11:30 AM, it was administered at 15:24 PM. Calorically Dense Supplement was scheduled for 13:00 PM, it was administered at 15:23 PM. On 1/6/24, Linaclotide and Amlodipine Besylate were scheduled for 8:00 AM, they were administered at 9:17 AM. Mirtazapine and Melatonin were scheduled for 22:00 PM, they were administered at 1:26 AM. Apixaban was scheduled for 21:00 PM, it was administered at 23:39 PM. On 1/7/24, Linaclotide was scheduled for 8:00 AM, it was administered at 9:18 AM. (Copy obtained) On 1/10/24 at 9:30 AM, the Medication Administration Audits for Residents #1, #3, #4, #5, #9, #10, #11, #12, #13, and #14 were reviewed with the DON. The audits revealed repeated medication administration errors (timeliness of administration) for Residents #1, #3, #4, #5, #9, #10, #11, #12, #13, and #14. On 1/10/24 at 12:40 PM, an interview was conducted with Licensed Practical Nurse D, regarding medication administration. She stated that nurses are to document medication administration at the time of administration. She explained that the facility protocol states medication administration can be given one hour before to one hour after the scheduled time and if administration is late to call the physician and document in Electronic Medical Records (EMR). On 1/10/24 at 12:50 PM, an interview was conducted with LPN I, regarding medication administration. She explained that nurses can give medication one hour before or one hour after the scheduled time and if given late they call the physician and family and document it in EMR. She stated that medication administration documentation is to be done at time of administration. A review of the facility's policy titled, 6.0 General Dose Preparation and Medication Administration (1/2022) revealed the following: Page 2, item 5.4 Administer medications within time frames specified by Facility policy or manufacturer's information. (Photographic evidence obtained) .

Based on observations, medical record review, interviews, and a review of the facility's policy and procedure for pressure ulcers, the facility failed to ensure that a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing, by failing to apply physician-ordered bilateral heel protectors for one (Resident #88) of two residents selected for a review of pressure ulcers, out of nine residents with pressure ulcers, from a total sample of 43 residents. The findings include: An observation of Resident #88 was made on 4/24/23 at 11:57 a.m. He was in is his room. A family member was at bedside and was interviewed concerning the resident's care. She stated the resident had dressings on both heels for pressure ulcers and was receiving hospice services. His dressings were always done and the wound care physician saw him. The family member's concern was that Resident #88 had two sets of booties/heel protectors for his feet and they had both disappeared. They have been missing for at least three weeks. She stated she had searched the room numerous times. Dressings were observed on both heels, but there were no heel protectors applied. Resident #88 was observed on 4/25/23 at 8:30 a.m. lying in his bed. Dressings were observed on both heels, however, no booties/heel protectors were applied, nor was a pillow under his ankles to offload the pressure to his heels. Resident #88 was observed on 4/26/23 at 8:49 a.m. lying in his bed. Dressings were observed on both heels, however, no booties/heel protectors were applied, nor was a pillow under his ankles to offload the pressure to his heels. His right foot was hanging off the side of the bed. The resident's family member was interviewed again on 4/26/23 at 12:00 p.m. She stated again that Resident #88 had not had his booties/heel protectors for several weeks and there were two pairs that were ordered by the hospice provider. She stated, He does not have them on again today. A review of Resident #88's medical record revealed an admission date of 4/15/22 with diagnoses including cerebrovascular accident (CVA - stroke), hemiplegia (weakness/immobility on one side), and diabetes mellitus. The resident was noted with an acquired pressure ulcer on his right heel on 8/12/22, and his left heel on 10/5/22. Wound dressings were ordered and dated 4/25/23. A review of the resident's active physician's orders revealed an order for bilateral heel booties every shift for heel protection, dated 8/16/22. A new order was placed on the chart on 4/27/23, instructing staff to 'Float heels using either prevention boots or other offloading boots or pillows being sure the patient's heels are not touching the pillow or directly on the mattress while in bed.' A review of a Wound Progress note, dated 4/25/23, revealed a right heel wound, Stage IV, with bone exposed and a left heel wound, Stage III. The right heel was improving but the left heel was not improving, it was staying the same. An interview was conducted with Certified Nursing Assistant (CNA) B on 4/26/23 at 2:02 PM. She stated the resident used a mechanical lift to transfer, he did not stand, and he required total assistacen from staff for transfers and toileting. He could feed himself. She stated he did have pressure ulcers on his heels, and his heels should be offloaded. He did take his feet off of the pillow when she tried to use one. She reported she was not aware of booties/heel protectors having been ordered for this resident. If he is turned on one side, he will turn right onto his back. I have been trying to offload his heels, but he likes to have one foot off the bed. She reported not seeing any boots/booties/heel protectors for his feet. An interview was conducted with Licensed Practical Nurse (LPN) C on 4/26/23 at 2:07 PM. She reported being unable to find any booties/heel protectors in the resident's room, and that the CNA just asked her about the resident's heel booties. The LPN stated the booties would have to be ordered. The Central Supply clerk came by and reported that heel booties were available in supply. LPN C stated, He (Resident #88) is supposed to have heel protectors on, and I will put them on as soon as I receive them. The LPN confirmed he was not currently wearing the booties to protect his heels. A review of the facility's policy and procedure for Treatment Services to Prevent/Heal Pressure Ulcers (Revised 3/2/19), read: The facility will ensure a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers. A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice to promote healing, prevent infection and prevent new ulcers from developing. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, and interviews, the facility failed to ensure that three (Residents #42, #8, and #18) of 12 residents receiving oxygen, from a total sample of 43 residents, had physicians' orders for the oxygen (Resident #42), and received oxygen at the flow rate ordered by the physician (Residents #8, and #18). The findings include: 1. On 4/24/23 at 2:45 p.m., Resident #42 was observed lying in bed wearing a nasal cannula. His oxygen concentrator was located at bedside, and the oxygen flow rate was set at 3 LPM. (Photographic evidence obtained) A review of Resident #42's physician's orders revealed no order for oxygen. (Photographic evidence and copy obtained) A medical record review revealed that Resident #42 was admitted to the facility on [DATE] and then readmitted on [DATE]. His diagnoses included COPD with (acute) exacerbation; dependence on supplemental oxygen; shortness of breath; generalized anxiety disorder, and major depressive disorder. A review of the April 2023 Medication Administration Record (MAR) revealed no oxygen monitoring. (Copy obtained) A review of the Quarterly Minimum Data Set (MDS) assessment, dated 3/29/23, revealed Resident #42 had a Brief Interview for Mental Status (BIMS) score of 13 out of a possible 15 points, indicating Resident #42 was cognitively intact. The assessment also documented that he was receiving oxygen therapy. A review of Resident #42's care plan, with a revision date of 1/17/23, revealed he had oxygen therapy related to COPD and shortness of breath (SOB). Interventions included administration of medications as ordered by the physician. Monitor/document side effects and effectiveness. Oxygen settings. Oxygen via nasal cannula per Medical Doctor (MD) orders. On 4/27/23 at 11:11 a.m., LPN D reported that nursing was responsible for ongoing monitoring of oxygen therapy, ensuring the resident was provided the correct flow rate and weekly oxygen tube changes. Correct oxygen settings were identified on the order in the electronic medical record. Correct oxygen settings were communicated from one staff person to another in shift change reports. When asked what happened when there were discrepancies found in residents' physicians' orders, he replied, Call the nurse practitioner and clarify the order, review what the order states, review changes that need to be made, and correct the order. On 4/27/23 at 11:22 a.m., the Director of Nursing (DON) confirmed that Resident #42's correct oxygen flow rate settings were identified in the physician's order in [the electronic medical record]. 2. On 4/24/23 at 1:58 p.m., an observation was made of Resident #8 lying in bed with oxygen being provided via nasal cannula. The oxygen flow rate was set at 3 Liters per minute (LPM). When the resident was asked what her flow rate setting should be, she was unsure. (Photographic evidence obtained) An observation was made of the resident lying in her bed on 4/25/23 at 8:30 a.m. Her oxygen flow rate was still set at 3 LPM. (Photographic evidence obtained) An observation was made of the resident lying in her bed on 4/26/23 at 8:33 a.m. Her oxygen flow rate was still set at 3 LPM. At 9:55 a.m. on 4/26/23, her oxygen flow rate was set at 2 LPM. (Photographic evidence obtained) A medical record review was conducted, which noted an admission date of 6/25/20 with a readmission on [DATE]. The resident's diagnoses included chronic obstructive pulmonary disease (COPD) and hypoxemia. A 3/16/23 physician's order noted the resident's oxygen flow rate was to be set at 2 LPM via nasal cannula. The resident's care plan, updated on 2/20/23, revealed a focus area for emphysema and COPD. Oxygen was to be administered as ordered by the physician. An interview was conducted with Licensed Practical Nurse (LPN) A on 4/26/23 at 10:00 a.m. The LPN reviewed Resident #8's oxygen order in the electronic medical record and reported the oxygen should be infusing at 2 LPM. She stated she hadn't changed the oxygen setting this morning. She entered the resident's room and checked the oxygen concentrator to ensure that the oxygen flow rate was set at 2 LPM. When she was shown the photographs of the resident's oxygen setting over the last three days (3 LPM), she stated the oxygen setting in the photographs was inaccurate and the staff must not be getting at eye level when setting the flow rate. A review of the facility's policy and procedure for Respiratory/Tracheostomy Care and Suctioning (Revised 3/26/21), read: The facility will ensure residents who need respiratory care are provided such care consistent with professional standards of practice, the comprehensive person centered care plan, and resident goals and preferences. Under number 4 was written: Based upon the resident assessment attending physicians orders, and professional standards of practice, the facility in collaboration with the resident/resident's representative will develop a care plan that includes appropriate interventions for respiratory care. 3. A review of the medical record revealed that Resident # 18 was admitted to the facility on [DATE], with diagnoses including COPD with acute exacerbation, generalized anxiety disorder, and major depressive disorder. On 4/24/23 at 11:39 a.m., the resident's oxygen concentrator was observed to be set at a flow rate of 4 LPM. The resident verbalized the flow rate should be set at 2 LPM and expressed she did not adjust the flow rate herself. She reported she was not physically capable of reaching the dial to adjust the flow rate. On 4/25/23 at 10:30 a.m., the resident's oxygen flow rate was observed to be set at 4 LPM. On 4/26/23 at 11:47 a.m., the resident's oxygen flow rate was observed to be set at 3 LPM. On 4/26/23 at 2:46 p.m., the resident's oxygen flow rate was observed to be set at 2 LPM. On 4/27/23 at 1:52 p.m., LPN E explained that the resident's oxygen was ordered at 2 LPM PRN (as needed) and was administered for low oxygen saturation. She reviewed the resident's record and verified the record documented an oxygen order for a flow rate of 2 LPM PRN and for oxygen saturations below 90. She expressed she was not aware that the resident's oxygen was set at a flow rate of 3 or 4 LPM, and explained that CNAs did not adjust flow rates, as oxygen was considered a medication and CNAs did not administer medications. If a CNA observed an oxygen flow rate set outside of the prescribed amount, they should report it to the nurse. Nurses should be checking oxygen flow rates during medication passes. A review of Resident #18's physician's orders revealed an order written on 3/28/23 for oxygen at two liters per minute via nasal cannula PRN for shortness of breath and oxygen saturations below 90. An order written on 4/25/23 required oxygen saturations to be taken every shift and PRN. Call medical doctor (MD) if saturations are below 90. .

Based on observation and interviews, the facility failed to post the following Nurse Staffing information on a daily basis as required: (i) Facility name. (ii) The current date. (iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: (A) Registered nurses. (B) Licensed practical nurses or licensed vocational nurses (as defined under State law). (C) Certified nurse aides. (iv) Resident census. During a tour of the facility on 4/24/23 at 11:13 a.m., the Daily Staffing Projection posted in a shadow box near the entrance of the facility was observed. The date of the Nurse Staffing information was 3/20/23. (Photographic evidence obtained) During an interview with Workforce Coordinator F on 4/27/23 at 10:19 a.m., she stated she had been performing her duties since October 2022. She stated she was responsible for posting the daily staffing projection, and in her absence, the Senior Human Resource Manager was responsible for ensuring the information was updated. She was advised of the 4/24/23 observation of the out-of-date posted staffing information and she acknowledged it was out of date. She stated she had been on leave starting the day after that information was posted, she recently returned to work, and the staffing information had since been corrected. During an interview with the Senior Human Resources Manager on 4/27/23 at 10:36 a.m., he stated he was aware of the requirement for the daily posted staffing. He confirmed that Workforce Coordinator F was responsible for updating the daily posted staffing and that he served as a back-up in her absence. He stated she had been out on leave and he was not aware that the staffing had not been changed. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review and facility policy and procedures, the facility failed to provide assistance with showers for one (Resident #12) of five sampled residents reviewed for activities of daily living (ADLs), out of a total sample of 33 residents. The findings include: An interview was conducted with Resident #12 in room [ROOM NUMBER]A on 8/30/21 at 2:26 PM. He stated the only concern he had with the facility was with showers. He had only received a shower seven times since he moved into the facility. He was supposed to get one twice weekly, but the last time he got a shower was around August 3rd. Review of the shower schedule for the north hallway revealed Resident #12 was scheduled for showers on Tuesday and Friday during 3-11 PM shift. (Photographic evidence obtained) A record review for Resident #12 revealed an admission date of 12/11/20, with diagnoses of hemiplegia and hemiparesis following other cerebrovascular disease affecting left dominant side, major depressive disorder, other lack of coordination, muscle weakness, chronic obstructive pulmonary disease (COPD), adjustment disorder with depressed mood. A review of the quarterly minimum data set (MDS) assessment, dated 8/25/21, revealed Resident #12 had a Brief Interview for Mental Status (BIMS) score of 14, indicating cognitively intact. The assessment also documented his need for total dependence with toilet use and bathing with one-person physical assist. Resident #12 was care planned on 12/11/20 for ADL self-care performance deficits related to limited mobility and musculoskeletal impairment. Approaches included bathing/showering: avoid scrubbing and pat dry sensitive skin, provide sponge bath when a full bath or shower cannot be tolerated, resident is totally dependent on one staff to provide bath/shower per request, schedule, and as necessary. A review of Resident #12's [NAME] dated 9/1/21 revealed: Shower - provide sponge bath when a full bath or shower cannot be tolerated. Resident is totally dependent on one staff to provide bath/shower per request, schedule, and as necessary. (Photographic evidence obtained) Review of the certified nursing assistant (CNA) task documentation revealed Resident #12 received a shower four times between 7/1/21 and 8/31/21. (Photographic evidence obtained) On 9/1/21 at 10:55 AM, Resident #12 was outside his room. He was asked if the staff had given him a shower or bath today, he replied, the last time I got a shower was around August 3rd. When he was asked if he refuses to take a shower, he replied, No, I do not. On 9/1/21 at 2:48 PM, an interview was conducted with Employee D, Certified Nursing Assistant who was assigned to take care of Resident #12. She stated, Resident #12 gets a bed bath each day and as needed. He is scheduled to get a shower on Tuesday and Friday during the 3-11 PM shift. If a resident refuses a shower, then we are supposed to document it in the computer and on the shower sheet. On 9/1/21 at 03:28 PM, an interview was conducted with Employee E, LPN/North Wing Unit Manager. She reviewed the north wing shower schedule book and confirmed that Resident #12 was scheduled for Tuesday and Friday during the 3-11 PM shift. She reviewed the completed shower task documentation on the computer and confirmed that for the past thirty days, Resident #12 had only received a shower on 8/17/21, 8/18/21 and 8/26/21. When she was asked if there was any documentation, he refused to take a shower in the past thirty days, she said, Yes, once on 8/17/21. Employee E, LPN stated the aides should be documenting all showers in the computer and confirmed the documentation for Resident #12 was not sufficient to confirm that showers were being provided as scheduled. On 9/2/21 at 11:45 AM, an interview was conducted with the Director of Nursing (DON). She stated that Resident #12 is usually outside smoking until later in the evening and when he comes in, he doesn't want to take a shower. When she was asked what should happen if a resident refuses to take a shower, she stated, staff should document the refusal in the computer and on the shower sheet. The DON reviewed Resident #12's completed shower task documentation sheets for July and August 2021 and confirmed that showers were not being provided as scheduled and there was no documentation that he was refusing them. Review of the facility's Policy and Procedure for Activities of Daily Living (ADLs), revised on 3/2/19, revealed the facility will provide care and services for the following activities of daily living: a. Hygiene - bathing, dressing, grooming, and oral care. (Photocopy obtained) .

Based on observation, interview, record reviews and a review of the policy and procedure for respiratory care, the facility failed to ensure that one (Resident # 89) of seven residents on oxygen therapy, received the correct number of liters of oxygen ordered by the physician, in a total sample of 33 residents. This could result in the resident not receiving appropriate care and/or clinical complications. The findings include: On 8/30/21 at 2:20 PM, Resident #89 was observed lying in bed with oxygen via nasal cannula. An observation of his oxygen concentrator revealed the oxygen flow was set at 2.5 liters/minute (LPM). A review of Resident #89's medical record noted an admission date of 3/2/21 and a diagnosis of chronic obstructive pulmonary disease (COPD) as well as acute respiratory failure with hypoxia. A review of the physician's order written on 3/3/21 revealed, Oxygen (O2) at 2 LPM/nasal cannula (NC) as needed (prn) for shortness of breath (SOB) O2 oxygen saturation (sat) <92% every 8 hours as needed for SOB. On 9/1/21 at 11:30 AM, Resident #89 was observed lying in bed with oxygen via nasal cannula. An observation of his oxygen concentrator revealed the oxygen flow was set at 3 LPM. (Photographic evidence obtained) On 9/1/21 at 4:09 PM, Resident #89 was observed for a third time in his room with oxygen via nasal cannula. An observation of his oxygen concentrator revealed the oxygen flow was set at 3 LPM. An interview was conducted with Employee G, Licensed Practical Nurse (LPN), and Resident #89's assigned nurse on 9/1/21 at 4:11 PM. When she was asked to check the oxygen setting on Resident #89's oxygen concentrator, she reported it was set at 3 LPM. When she was asked how many LPM the resident was supposed to receive, she replied, 2 LPM and adjusted the oxygen level to 2 LPM. When she was asked who is responsible for checking the oxygen setup, she said, the nurses are responsible for ensuring the correct settings, but she had been off for the last 3 days. A review of the quarterly minimum data set (MDS) assessment, dated 8/10/21, revealed Resident #89 had a Brief Interview for Mental Status (BIMS) score of 7, indicating severely impaired cognition. The assessment also documented he was receiving oxygen and hospice care. A review of Resident #89's care plan revealed, he has oxygen therapy related to COPD, history of respiratory failure, congestive heart failure (CHF), and SOB. Interventions included: change residents position every 2 hours to facilitate lung secretion movement and drainage. Give medications as ordered by physician. Monitor/document side effects and effectiveness. Observe for signs or symptoms of respiratory distress and report to physician PRN. Oxygen settings: Oxygen via nasal cannula per physician orders. A review of the Respiratory/Tracheostomy Care and Suctioning policies and procedures with revised date of 3/2/19, read: The intent of this policy is that each resident receives necessary respiratory care and services that is in accordance with professional standards of practice, the resident's care plan, and the resident's choice. The facility will ensure that a resident, who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences. (Copy obtained) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review, the facility failed to maintain a medication error rate of less than five percent. During the medication administration observations, there were three errors and a total of thirty-five opportunities, resulting in an error rate of 8.57%. The findings include: On [DATE] at 9:19 AM, an observation of medication administration was conducted with Employee H, Licensed Practical Nurse (LPN). While trying to obtain one loratidine 10 milligram (mg) tablet, three tablets poured into the medication cup. The nurse then used a spoon to separate one pill and disposed the other two loratidine tablets in a trash container attached to the medication cart. During this observation, three residents were close to where the nurse threw out the pills. On [DATE] at 9:30 AM, during an interview with Employee H, LPN, she confirmed the disposal of two loratidine tablets into the garbage container. She stated that since the medication was not a narcotic it was not an issue. When she was asked about the facility policy on medication disposal, she stated that narcotics are disposed in a solution for destroying medication and should be signed off by two nurses. She added, she was not sure about the process for non-controlled medication and that she had always disposed the medication in the garbage bag. On [DATE] at 10:00 AM, an observation of medication administration was conducted for Resident #4 with Employee E, LPN. Resident #4 had a physician's order for calcium acetate (used to prevent high blood phosphate levels in patients who are on dialysis due to severe kidney disease), 667 mg (milligram) capsule, give two capsules by mouth twice a day every Monday, Wednesday and Friday related to end stage renal disease, give with breakfast and dinner. Employee E, LPN administered one capsule of calcium acetate 667 mg to Resident #4, while the resident was in the hallway awaiting transportation to the dialysis center. On [DATE] at 10:06 AM, Employee E, LPN was observed entering room [ROOM NUMBER]-A to administer medication and left the cart unlocked. On [DATE] on 12:50 PM, an interview was conducted with Employee E, LPN. She acknowledged only one calcium acetate 667 mg capsule was administered to Resident #4, instead of the physician's order for two capsules. She also confirmed the medication cart was left unlocked before entering room [ROOM NUMBER]-A. When she was asked about the administration time for the medication, she did not see anything wrong with the time. After reviewing the medication administration record (MAR) for Resident #4, the nurse confirmed the medication was not administered with his breakfast. On [DATE] at 1:45 PM, an interview was conducted with the Director of Nursing (DON) regarding the findings of the medication administration observations. She stated that nurses were required to enter medication orders as they are prescribed to the MAR and if something is not clear, they should consult the physician for order clarification. When she was asked about the orders for Resident #4, she stated, he was to receive calcium acetate 667 mg (Phosphate binder) 2 capsules two times a day on dialysis day and three times a day for non-dialysis days. When asked about the time for administration, she confirmed that the medication should be offered with meals. She stated that since the direction to administer with meals were at the end of the order it was not clear if it was to be administered with meals on non-dialysis day. She added, she would get the nurse practitioner to clarify the order and add breakfast and dinner to the order. When she was asked what the facility policy on medication destruction was, she stated all medication should be disposed in the medication destruction solution. Controlled medication destruction should be witnessed by two nurses and documented. She mentioned that the nurse observed during medication observation thought that only narcotics needed to be destroyed with the medication destruction solution and therefore, an in-service was conducted. A review of the facility's policy and procedure titled, Disposal/Destruction of Expired of Discontinued Medication, last revised on [DATE], read: 13. Wasted medications are defined as medication contaminated or refused that require disposal. Facility should not place wasted medications back in the original containers. 13.2. Wasted single doses of medication for disposal should be disposed of in a manner that limits access to them by authorized personnel or residents. 13.3 wasted single doses of medication may be flushed or placed in public sewage only if permitted by applicable law. (In Florida: A single dose of wasted medication should be secured until the dose is flushes or placed in public sewage.) A review of the facility's policy and procedure titled, Infection Control- Medication Administration, revised [DATE], read: It is the policy of the facility to ensure that appropriate infection prevention and control measures are taken to prevent the spread of infection in accordance with State and Federal Regulation and national guidelines. 4. Verify medication is being provided at the right time per physician orders/medication administration record (MAR), verify dosage, and verify route of administration (i.e., orally, intravenous, or subcutaneous). 5. Verify medication is being provided at the right time per physician orders/ medication administration record. (Copies obtained) .

Based on observations and interviews, the facility failed to store, prepare and serve food in accordance with professional standards for food service safety, by failing to maintain the kitchen in a safe and sanitary manner for the 102 residents who were currently residing in the facility. The findings include: During a visit to the kitchen on 8/30/21 at 10:25 AM, an observation of three air conditioner (AC) vents was found to be dirty and have a black substance on them. The ceiling around each vent was also found to have a black substance. One of the AC vents was near the steam table where food is served. During an interview with Employee A, Certified Dietary Manager at the time of the observation, he confirmed the findings and stated, he would talk with maintenance about it. (Photographic evidence obtained) During a second visit to the kitchen on 8/31/21 at 3:35 PM, two of the three AC vents remained dirty with black substance on them. The ceiling around each vent continued to have a black substance. During an interview with Employee C, Regional Certified Dietary Manager at the time of the observation, he confirmed the vents were not clean and the ceiling needed to be repaired. (Photographic evidence obtained) On 8/31/21 at 3:38 PM, the Administrator entered the kitchen and stated the maintenance staff came in last night and cleaned them. He was shown the vents and confirmed they could be cleaned better. On 9/1/21 at 11:45 AM, the three AC vents were observed dripping water near the serving line, near the food cart and over the dishwashing area. During an interview with Employee B, Dietician at the time of the observation, he confirmed the AC vents were dripping water. (Photographic evidence obtained) On 9/2/21 at 1:30 PM, a follow up visit to the kitchen was conducted with Employee C, Regional Certified Dietary Manager and Administrator. The Administrator stated repairs were made to the air conditioning and ventilation system which appeared to eliminate the dripping condensation from the vents. Administrator also stated, they had plans to make repairs to the ceiling area in the kitchen. .