**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, records review, and interviews, the facility failed to ensure it timely answered call lights in response to residents' needs for 3 of 24 sampled resident, Residents #13, #38, and #55. The findings included: 1. Record review revealed Resident #38 was admitted to the facility on [DATE]. On the most recent Minimum Date Set (MDS) assessment, the Brief Interview for Mental Status (BIMS) was documented as a score of 15 of 15, indicating the resident was alert and oriented to person, time, and place (cognitively intact). On 08/20/24 at 1:25 PM, an interview was conducted with Resident #38 who stated she had voiced multiple complaints regarding the call light response to staff. Resident #38 said at times when the call lights is activated, the Certified Nursing Assistant (CNAs) could be observed passing by the room, but they do not bother to come in the room to check. Resident #38 complained that this situation is usually worse on the weekend. In a followup interview with Resident #38 on 08/21/24 at 11:07 AM, during the environmental tour with the Maintenance Staff and Housekeeping Staff present, Resident #38 reiterated that at times, it takes staff 45 minutes to one-hour to answer the call light. Resident #38 stated that the concerns have been reported to the nurses. Resident #38's call light was checked at this time, and it was noted to be functioning well. 2. Record review revealed Resident #13 was admitted to the facility on [DATE]. Review of the MDS revealed the BIMS score was 15 of 15, indicating intact cognition. On 08/19/24 at 10:20 AM, Resident #13 stated the call lights are not answered on time, especially during the night or the 11:00 PM to 7:00 AM shifts. Resident #13 said it sometimes takes 30-60 minutes to have the call light answered. On 08/21/24 at 10:56 AM during the environmental tour, Resident #38 restated the concern regarding call light response, especially at night. Resident #38 said that the call light response time was a chronic situation. Resident #38 stated she had complained to the Director of Nursing (DON) many times regarding that issue. Resident #38 said this issue was also discussed during resident council meetings. 3. Record review revealed Resident #55 was admitted to the facility on [DATE]. Review of the BIMS score for Resident # 55 noted the score was 1 of /15 indicting intact cognition. On 08/19/24 at 11:42 AM, Resident #55 also stated that the call light is usually answered about an hour later, especially at night during the 11:00 PM to 7:00 AM shifts. During a follow-up interview with Resident #55 on 08/21/24 at 10:49 AM, Resident #55 said she usually used the call light when she needed to be changed. When questioned about the time the interview was being conducted with the surveyor, Resident #55 answered correctly, stating the exact time observed on the clock on the wall.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to follow the physicians' orders for wound treatment and failed to provide wound care in a timely manner for 1 of 2 sampled residents, reviewed for wound care, Resident #18. The findings included: Record review for Resident #18 revealed the resident was admitted to the facility on [DATE] with the following diagnoses: Acute Osteomyelitis, Left ankle and Foot; Acquired absence of other left toe(S); Type 2 Diabetes Mellitus; and Dependence on Renal Dialysis. Review of Section C of the Minimum Data Set (MDS) dated [DATE] revealed Resident #18 had a Brief Interview for Mental Status (BIMS) of 15, which indicated that he was cognitively intact. Review of Section M revealed that Resident #18 had one unstageable pressure injury presenting as a deep tissue injury (DTI), surgical wound. Review of the Physician's orders showed Resident #18 had an order for left dorsal foot and left lateral foot wound, Cleanse with Normal Saline (N/S) apply skin prep to peri wound non border foam abdominal and wrap with Kling; daily on the day shift. Review of the Care Plan dated 06/06/24 documented Resident #18 has a pressure ulcer to left plantar foot wound, left dorsal foot wound, left heel DTI and has a surgical wound to his Left lateral foot, r/t [related to] History of ulcers, Immobility. Goals were to show signs of healing and remain free from infection. Interventions were to administer treatments as ordered and monitor for effectiveness; Assess / record / monitor wound healing daily; report improvements and declines to the MD; Monitor dressing every shift to ensure it is intact and adhering. During an interview conducted on 08/20/24 at 10:36 AM, Resident #18 stated that he had an amputation of left pinky toe and believed that the dressing should be changed daily. He was concerned that the dressing has not been changed recently, and his left heel was bothering him. During an observation conducted on 08/20/24 at 10:40 AM of Resident #18's left foot revealed the foot was wrapped with a Kling dressing, taped and was dated 08/17/24 7-3 shift. Photographic Evidence Obtained. On 08/20/24, review of the August 2024 Treatment Administration Record (TAR) revealed the nurse signed for Resident #18's wound treatment on 08/17/24 and 08/18/24. No signature was recorded for 08/19/24 wound treatment. Review of the Nursing progress note dated 08/17/24 revealed the dressing change was done to Resident #18 lower extremity. The documentation inlcuded, Wound was observed: beefy red area with some bleeding. Resident #18 was medicated prior to dressing change. No other documentation regarding the left foot wound was found after 08/17/24. An interview was conducted on 08/21/24 at 3:44 PM with the Wound Care Nurse (WCN). She stated that she has worked at the facility for 15 years as the WCN. She noted that on 05/17/24, Resident #18 returned from the hospital after the amputation of the left pinky toe. She stated that the surgical wound was healing nicely, and some redness appeared in the area, and Resident #18 was seen by the wound doctor. She acknowledged that on Monday 08/19/24 she did not see Resident #18's wound nor had she changed the dressing. She noted that the floor nurses are aware to do the wound treatment if she did not. Upon review of the photograph of Resident #18's dressing, the WCN acknowledged that the dressing had not been changed since 08/17/24. The WCN stated that for Resident #18, she did the wound treatment on 08/20/24 and she thought that the old wound dressing was dated 08/19/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of policy and procedure, record review, observation and interview, the facility failed to administer the correct type of Aspirin medication, as per physician's order for 1 of 5 sampled residents observed during a Medication Administration Observation, Resident #94. The findings included: Review of the facility policy and procedure on 08/19/24 at 2:30 PM, titled, Specific Medication Administration Procedures, provided by the facility's Regional Nurse, reviewed May 2022 documented, in part, in the Policy Statement: Administration Procedures for all Medications - To administer medications in a safe and effective manner. Procedures: .C. Review five (5) rights (3) times: 1) Prior to removing the medication package/container from the cart/drawer: a. Check Medication Administration Record (MAR)/Treatment Administration Record (TAR) for order e. Prepare resident for medication administration. 2) Prior to removing the medication from the container. a. Check the label against the order on the [DATE]: After the dose has been prepared and before returning the medication to storage .H. When applicable, explain to resident the type of medication being administered . Record review revealed Resident #94 was admitted to the facility on [DATE] with diagnoses which included Cerebral Infarction due to Embolism of Unspecified Cerebral Artery, Endocarditis and Heart Valve Disorders in Diseases Classified Elsewhere, Non-ST Elevation (NSTEMI) Myocardial Infarction, Presence of Prosthetic Heart Valve, Hemiplegia and Hemiparesis following Cerebral Infarction affecting right dominant side, Cardiomegaly, Hypertension, Anemia, Diabetes Mellitus Type II, Acute Kidney Failure, Syncope and Collapse and Hydronephrosis with Renal and Ureteral Calculous Obstruction. She had a Brief Interview Mental Status (BIM) score of 15, indicating she was cognitively intact. On 07/09/24, the physician's order documented, Aspirin oral tablet Delayed Release 81mg; to give one (1) tablet by mouth one (1) time a day for Coronary Artery Disease (CAD). During a Medication Administration Observation conducted on 08/19/24 at 9:17 AM of Resident #94, Staff F, Registered Nurse (RN), was observed preparing and placing a chewable pink-colored Aspirin 81mg tablet, ordered daily, in the medication cup along with all of the resident's eight (8) other oral medications. She administered all nine (9) medications, in the medication cup to the resident; instead of preparing and administering the yellow-colored Aspirin 81 mg Delayed Release / Enteric coated tablet, as per the physician's order. Staff F did not separate this chewable Aspirin medication into a different cup, and did not first provide any direction to Resident #94 to inform her that the chewable pink-colored Aspirin 81mg tablet (that was incorrectly administered) should have been chewed. Photographic Evidence Obtained. An interview was conducted with Resident #94 on 08/19/24 at 9:35 AM, in which she was asked, in general, how important was to her that she always receive her correct medications, and she indicated that it was very important to her and added that it would bother her if this was not done. An interview was conducted with Staff F on 08/19/24 at 10:15 AM regarding the pink-colored Aspirin Chewable 81 mg, that she was observed administering to Resident #94, instead of the ordred yellow-colored Aspirin 81 mg Delayed Release/Enteric coated tablet. Staff F acknowledged the difference between the two (2) types of Aspirin and indicated that the correct Aspirin medication should have been administered as ordered. During an interview conducted on 08/19/24 at 1:41 PM with the facility Pharmacist, he acknowledged the difference between the yellow-colored Aspirin 81 mg Delayed Release / Enteric coated tablet and the pink-colored Aspirin Chewable 81 mg. The Pharmacist indicated that both medications are the same type of drug, same dosage and same route, but do not have the same methods of absorption. He stated the correct type of Aspirin medication should have been administered as ordered. A side-by-side direct observation and record review was conducted with the facility's Regional Nurse, in which the difference between the two (2) forms of Aspirin were revealed as 1) yellow-colored Aspirin 81 mg Delayed Release / Enteric coated one (1) tablet oral daily; and 2) pink-colored Aspirin Chewable 81 mg one (1) tablet oral daily. They both had the same name, same dosage, same timing and same route, but with the difference being that of color and method of absorption. The Director Of Nursing (DON) acknowledged that on 08/21/24 at 1:41 PM that the correct type of Aspirin medication should have been administered, as ordered, and this was not done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure accurate records related to dressing change for 1 of 2 sampled residents reviewed for wound care, Resident #18; and failed to ensure complete and adequate documentation for 1 of 1 sampled resident reviewed as deceased in the facility, Resident #99. The findings included: Review of the facility's policy titled, Documentation of Progress, dated [DATE], included the following: Documentation of a resident's condition will provide an accurate and timely record of their progress taking into consideration their acuity and length of stay. 1. Record review for Resident #18 revealed that the resident was admitted to the facility on [DATE] with the following diagnoses: Acute Osteomyelitis, Left ankle and Foot; Acquired absence of other left toe(S); Type 2 Diabetes Mellitus; Dependence on Renal Dialysis. Review of Section C of the Minimum Data Set (MDS) dated [DATE] revealed that Resident #18 had a Brief Interview for Mental Status (BIMS) of 15, which indicated that he was cognitively intact. Review of Section M revealed that Resident #18 had one unstageable pressure injury presenting as deep tissue injury (DTI), surgical wound. Review of the Physician's Orders showed that Resident #18 had an order for left dorsal foot and left lateral foot wound: Cleanse with Normal Saline (N/S) apply skin prep to peri wound non border foam abdominal and wrap with Kling; daily on the day shift. During an interview conducted on [DATE] at 10:36 AM, Resident #18 stated he had an amputation of left pinky toe and believed that the dressing should be changed daily. He was concerned that the dressing had not been changed recently, and his left heel was bothering him. During an observation conducted on [DATE] at 10:40 AM of Resident #18's left foot revealed the foot was wrapped with a Kling dressing and the tape was dated [DATE] 7-3 shift. Photographic Evidence Obtained. On [DATE], review of the August Treatment Administration Record (TAR) revealed that the nurse signed for Resident #18's wound treatment on [DATE] and [DATE]. No signature was recorded for [DATE] wound treatment. On [DATE], review of the August TAR revealed the Wound Care Nurse (WCN) signed on [DATE] and [DATE] acknowledging that Resident #18 received wound treatment on those days. An interview was conducted on [DATE] at 3:44 PM with WCN. She acknowledged that on Monday [DATE] she did not see Resident #18's wound nor changed the dressing. She noted that the floor nurses are aware to do the wound treatment if she does not. In addition, the WCN stated that for Resident #18, she did the wound treatment on [DATE] and she thought that the old wound dressing was dated [DATE]. She acknowledged signing in the TAR for the treatment on [DATE] even though she did not change the dressings that day. 2. Record review for Resident #99 revealed that the resident was admitted to the facility on [DATE] with the following diagnoses: Acute on Chronic combined systolic (congestive) and Diastolic (Congestive) Heart Failure; Congestive Obstructive Pulmonary Disease; Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris Cardiomyopathy; Dementia; and Personal History of Malignant Neoplasm of Breast. Review of Section C of the Minimum Data Set (MDS) dated [DATE] revealed Resident #99 had a Brief Interview for Mental Status (BIMS) score of 15, indicating she was cognitively intact. Review of Section GG revealed that Resident #99 required partial / moderate assistance for all her Activities of Daily Living (ADLs) and had a wheelchair. Review of Section J revealed that Resident #99 was not under Hospice Care. Review of the Physician's Orders showed that Resident #99 had an order for Advanced directive, Do Not Resuscitate (DNR). Review of the Recreational Services Note dated [DATE] documented Resident #99 preferred to be in her room watching TV and to maintain daily routine of reading and relaxing with her husband. Review of the Psych note dated [DATE] documented Resident #99 had a history of multiple medical problems and increased depression. She was cooperative with care and remains motivated to get well. Review of the Nursing Progress note dated [DATE] documented Resident #99 expired at 12:30 PM, MD [Medical Doctor] and Family notified, but no documentation recorded on [DATE] into [DATE]. An interview was conducted on [DATE] at 1:45 PM with Social Services Director. He stated that he was not aware that the nurses only documented that in their notes (referring to the note dated [DATE]). He acknowledged Resident #99's daughter was at the facility when the resident passed, but he did not write any documentation regarding Resident #99's passing. An interview was conducted on [DATE] at 2:50 PM with the Director of Nursing (DON). She stated that she was not in the facility when Resident #99 expired. She acknowledged Resident #99 was doing well and no health declined noted prior to [DATE]. She noted that Resident #99 was provided care on that day as documented in the Task by the Certified Nursing Assistant (CNA). She dis not have any other documentation of what transcribed on [DATE]. She stated that she was very upset with the nurse because of the lack of documentation on the passing of Resident #99.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to follow Enhanced Barrier Precautions (EBP) during medication administration for 1 of 11 sampled residents reviewed for EBP, Resident #53; failed to ensure Personal Protective Equipment (PPE) gowns were available on the 2nd floor for 8 of 11 residents who were on EBP; failed to have appropriate signage posted to indicate precautions for 1 of 11 sampled residents reviewed for EBP, Resident #53; failed to properly utilize hand hygiene and discard a used lancet after Blood Glucose check during medication administration observation for 1 of 1 sampled resident, Resident #3; and failed to ensure a sanitary environment during perineal care for 1 of 1 sampled resident reviewed for Urinary Tract Infection (UTI), Resident #56. The census at the time of the survey was 90 residents. The findings included: Review of the facility's policy, titled, Enhanced Barrier Precautions, dated 09/01/22, included in part the following: EBP [Enhanced Barrier Precautions] is used to reduce the spread of Multidrug-Resistant Organisms (MDROs) among residents by utilizing gloves and gowns for high contact resident care activities. Procedure: 1. Identify residents who are appropriate for EBP including: b. Residents who have a wound and/or indwelling medical devices. 2. Place an identification outside the resident room to include type of precaution, required PPE [Personal Protective Equipment], and high-contact areas that require use of PPE. 4. Educate the staff on EBP including but not limited to: a. Use of PPE b. High-contact care activities. Review of the facility's policy, titled, Hand Hygiene, dated 02/05/21, included iin part the following: Hand hygiene should be performed: After contact with inanimate objects (including medical equipment) in the immediate patient vicinity. After glove removal. 1. Record review for Resident #53 revealed the resident was admitted to the facility on [DATE] with the following diagnoses: Dysphagia following Cerebral Infarction; Type 2 Diabetes Mellitus with Hyperglycemia; Gastrostomy status; and Hypoxic Ischemic Encephalopathy. Review of Section C of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #53 had a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. Review of the Physician's Orders showed Resident #53 had an order dated 08/16/24 for Nothing by mouth (NPO) every shift for PEG [Percutaneous Endoscopic Gastrostomy] Tube; Enteral feed order every shift continuous enteral feeding: Glucerna 1.5 at 80ml/hour x 20 hours; Enhanced Barrier Precautions for PEG Tube, every shift (dated 08/19/24). Review of the Care Plan dated 08/16/24 documented Resident #53 required EBP: PEG tube feeding. Goals were for EBP will be maintain for the duration of stay and/or until medical device is discontinued. Interventions were to educate staff on EBP including use of PPE, high contact care activity, hand hygiene, and resident activity; Place an identification outside resident room to include type of precaution required PPE, and high contact areas they require use of PPE. During an observation conducted on 08/21/24 at 8:06 AM, noted Staff L, Licensed Practical Nurse (LPN), entered Resident #53's room. He was observed entering Resident #53's room with medications without donning proper PPE. Further observation revealed Staff L was administering Resident #53's medication via PEG tube without a PPE gown. An interview was conducted on 08/21/24 at 1:28 PM with Staff L who stated he has been working at the facility for 3 years, and was the assigned nurse for Resident #53. Staff L stated EBP is assigned to residents with wounds, PEG tubes, Dialysis sites, etc. he stated EBP signage are placed outside their doors to make sure staff utilize proper PPE. When asked about Resident #53, he stated that the resident should be under EBP because he has a PEG tube and staff would wear PPE only if there was exposure to bodily fluids, however there was no need for PPE during medication administration. During an interview conducted on 08/21/24 at 4:30 PM, the corporate nurse acknowledged that PPE is to be donned during medication administration for residents with a PEG tube. 2. During the initial tour of the facility's 2nd floor conducted on 08/19/24 at 9:40 AM, it was observed that there were 11 brown and white plastic containers in the hallways for the residents on EBP. Further observation of these containers revealed that they were to contain PPE for the EBP residents. The observation revealed there were no gowns noted to be in 8 of these containers. During the morning of 08/19/24, no observation was noted of staff donning on PPE to provide morning care for the residents under EBP. On 08/19/24 at 12:54 PM, another observation was conducted of the PPE plastic containers and no gowns were found in these 8 containers. Again, staff were observed not donning on PPE to provide after-lunch care to the residents under EBP. During an observation conducted on 08/20/24 at 8:44 AM of the 2nd floor of the facility, the PPE plastic containers were inspected and again no gowns were found in the containers. Staff I, Registered Nurse (RN), and the Infection preventionist (IP), noticed the surveyor inspecting the PPE containers and a few minutes later, Staff I was observed stocking the containers with PPE gowns. An interview was conducted on 08/20/24 at 9:20 AM with the Director of Maintenance. He stated that it was his fault as to why the PPE kits were not replenished. He acknowledged he received the order for the gowns and did not get the order to Central supply in time for the kits to be restocked on the floor by staff. An interview was conducted on 08/22/24 at 12:33 PM with Staff I, RN. He stated he realized there were no PPE gowns in the plastic containers when he noticed the surveyor looking in the containers on 08/20/24. He stated he is the Infection Preventionist and is responsible for making sure that the containers are restocked, and the Certified Nursing Assistants (CNAs) are the ones that usually stock them. An interview was conducted on 08/22/24 at 1:06 PM with Staff G, CNA, who stated she has been working at the facility for 1 year. She stated that EBP in-service education was recently provided, and PPE is required when providing care to residents with IVs [intervenous], wounds, and PEG tubes. She acknowledged working on Monday 08/19/24 on the 2nd floor and did notice that there were no PPE gowns in the containers. She stated she was not assigned to any residents under EBP and did not require PPE gowns. 3. During the initial tour of the facility's 2nd floor conducted on 08/19/24 at 9:40 AM, obsrvtions noted that several residents had EBP signage posted outside of their doors. Further observation revealed that Resident #53 did not have a EBP signage posted outside of his room. Review of the Physician's Orders showed that Resident #53 had an order dated 08/16/24 for Nothing by mouth (NPO) every shift for PEG Tube; Enteral feed order every shift continuous enteral feeding: Glucerna 1.5 at 80ml/hour x 20 hours; Enhanced Barrier Precautions for PEG Tube, every shift (dated 08/19/24). During an observation conducted on 08/20/24 at 8:44 AM of the 2nd floor of the facility, Resident #53's room still had no EBP signage posted on the door or anywhere inside the room. During an observation conducted on 08/21/24 at 1:05 PM of the 2nd floor of the facility, Resident #53's room continued without EBP signage posted on the door or anywhere inside the room. During an interview conducted on 08/21/24 at 1:28 PM with Staff L, he stated EBP is assigned to residents with wounds, PEG tubes, Dialysis sites, etc. Staff L stated Resident #53 should be under EBP because he has a PEG tube. At this time, Staff L realized there was no EBP signage posted on Resident #53's door. An interview was conducted on 08/21/24 at 1:36 PM with Staff H, CNA, who stated she has been working at the facility for 4 months, and that Resident #53 was on her schedule assignment. Staff H stated she received in-service education for infection control, but could not recall as to why residents would be under EBP. She noted she follows the instructions on the precaution's signage posted outside of the rooms when providing care to the resident. Staff H acknowledged that there was no EBP sign posted outside of Resident #53's room. 4. A medication administration observation was conducted for Resident #3 on 08/20/24 at 4:02 PM with Staff K, LPN, who stated she has worked at the facility for 1 year. Staff K was observed entering the resident's room for a Blood Glucose (BG) check. Upon entering the room, she donned gloves, without performing hand hygiene, and performed the BG check. While holding the used lancet in her left gloved hand, she removed the glove, wrapping the used lancet in the glove, and then held it with her right gloved hand. Staff K walked out of the resident's room still holding the glove-wrapped used lancet in her right gloved hand. She then proceeded to remove the right glove and throw both gloves with the used lancet into the medication cart trash container. Without performing hand hygiene, Staff K moved to her computer and started her documentation. An interview was conducted on 08/20/24 at 5:07 PM with Staff K who was questioned on where she had disposed of the used lancet after the BG check. Staff K stated that she disposed it in the sharp's container on her medication cart. Staff K was asked to check the discarded gloves in her trash container. Without donning gloves, Staff K removed the used gloves from the trash container and found the used lancet inside the gloves. She then discarded the used lancet in the sharp's container. 5. Review of the facility policy and procedure on 08/21/24 at 2:35 PM, titled, Policies and Procedures---Perineal Care, provided by the Director of Nursing (DON) revised 09/05/17, documented, in part, in the Policy Statement: Procedure .Wash, rinse and dry the skin .exposed skin surfaces are soiled Review of the facility policy and procedure on 08/21/24 at 2:45 PM, titled, Policies and Procedures---Personal Protective Equipment Program, provided by the Director of Nursing (DON), revised 03/01/15, documented, in part, in the Policy Statement: Policy the objectives of the Personal Protective Equipment (PPE) Program is to protect employees from the risk of injury by creating a barrier against workplace hazards Record review revealed Resident #56 was readmitted to the facility on [DATE] with diagnoses that included Calculus of Kidney, Severe Sepsis without Septic Shock, Obstructive and Reflux Uropathy, Major Depressive Disorder, Heart Failure, Acute and Chronic Respiratory Failure with Hypoxia, Fracture of Unspecified Part of Neck of Left and Right Femur, Presence of Cardiac Pacemaker, Morbid (Severe) Obesity, Hypertension, and Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Non-Dominant Side. the resident's Brief Interview Mental Status (BIMS) score was 15, indicating the resident was cognitively intact. On 08/14/24, a Physician ordered Eccolab Urine Culture documented, Enterococcus Faecium; with a colony count of: >100,000 cfu/ml. On 08/16/24, the Physician's Order Summary Report documented, Nitrofurantoin Monohyd Macro oral capsule 100mg to give one (1) capsule by mouth two (2) times for Urinary Tract Infection (UTI) for seven (7) days. On 07/03/24, the UTI care plan documented, Focus: the resident has a UTI requiring Antibiotics. Interventions: . Good hygiene practices. Goal: the resident's UTI infection will resolve without complications by the review date. A peri-care observation was conducted on 08/21/24 at 10:10 AM with Resident #56. The resident's pericare was being performed by Staff G, Certified Nursing Assistant (CNA), who washed her hands for 35-40 seconds. Staff G was assisted by Staff H, CNA, who also washed her hands for 35-40 seconds. There was no protective gown donned by Staff G or Staff H prior to performing the peri-care. Staff G raised Resident #56's bed to her (staff) waist level and both Staff G and H went to the bathroom to wash their hands, obtained water (2 basins) for the cleaning, and added some peri-wash soap (Rinse-free) to the water. Staff G again washed her hands and gathered her supplies and donned a clean pair of gloves. It was observed that Resident #56 had had a bowel movement (not cleaned before the periocare). Staff G gently washed Resident #56's peri area from front to back on each separate side of the resident's labia, while the resident was lying on her back. Staff G was observed cleaning the resident, washed her hands, changed her gloves, and used a clean wash cloth and a package of Procare Large Adult Washcloths, and continued to do peri-care. Staff G then cleaned and dried the area 3 separate times. Staff G then removed the old gloves, sanitized and washed her hands, and applied a clean pair of gloves. Staff G turned the resident, cleaned and dried her buttock area from front to back with the Procare Large Adult Washcloths. Staff G obtained 2 clean basins of water, rinsed and dried Resident #56's Peri-area a second time after utilizing the peri-wash and using the Peri-clean spray 3 separate times in the peri-area. Throught the pericare, it was observed that Staff G's long hair braids were unsecured, loose, and hanging down freely in very close proximity to the resident and touching Resident #56's bed sheets, bedding, contaminated diaper and exposed skin, during the peri-care observation. This created the potential for resident-to-employee (vice versa) cross-contamination. Staff G then removed the used gloves, washed her hands, applied a clean pair of gloves and then turned Resident #56 and gently washed her buttock area from front to back, rinsed and then dried the area. She changed the 2 basins of water in between. Staff G was observed replacing Resident 56's diaper, after applying barrier cream to the resident's bottom and peri-area. Staff G then washed her hands for 35-40 seconds. Resident #56's skin was observed with slight redness with mild skin irritation. The resident had expressed this as a concern during the care. On 08/21/24 at 10:50 AM, an interview was conducted with Staff G, Staff H, Staff I, the Second Floor Registered Nurse, Unit Manager, and with Staff J, the covering RN/Director Of Nursing, regarding the above observations. Each acknowledged that staff members hair should not be allowed to come into contact with the resident's exposed skin during procedures. The DON acknowledged on 08/21/24 at 1:28 PM that a sanitary environment should always be maintained during the resident's care to avoid any type of cross-contamination, and this was not done.

Based on observations, interviews and record review, the facility failed to prepare and serve food in a sanitary manner in accordance with professional standards for food safety. The findings included: 1. On 08/19/24 at 8:48 AM, during the initial kitchen tour accompanied by Staff A, Cook, the Dietary Manager and the Registered Dietitian (RD), the following were noted: a. the handles of a spoodle and three spatulas were damaged to a point that they were no longer easily cleanable. b. there was an accumulation of food residues on the blade and the mounting bracket of the table mounted manual can opener. c. there was an accumulation of dust on the air conditioning vent over the food assembly area. d. the wall over and around the door to the walk-in cooler was damaged and tiles were missing. 2. The facility's policy, titled, Handwashing / Hand Hygiene, with a reference date of August 2019, documented, in part: this facility considers hand hygiene the primary means to prevent the spread of infections. The policy did not specifically address hand hygiene in the kitchen and for food safety concerns. During the follow up kitchen tour, on 08/21/24 at 10:52 AM, accompanied by the Dietary Manager and the RD/Licensed Deitician, the following were observed: a. Staff B, Dietary Aide, was observed entering the kitchen and proceeded through the kitchen to the locker room, went in the office, and left the kitchen through a back door to go on a break. Upon returning to the kitchen, the Dietary Aide did not perform hand hygiene prior to donning clean single use gloves after her hands had been potentially contaminated. The Dietary Manager acknowledged that she did not perform hand hygiene prior to donning the gloves. b. Staff C, Dietary Aide, was observed walking from the three-compartment sink, where the Dietary Aide was manually washing and sanitizing utensils and equipment, to the hand washing sink, upon reaching the hand washing sink, Staff C used paper towel to dry her hands without washing them and returned to the ware washing area. Staff C was observed returning from the ware washing area and again drying her hands without washing them in the dedicated hand washing sink. Staff C was observed preparing coffee to be served during the lunch meal, then proceeded across the kitchen to answer the telephone, and then returned to the coffee station. Staff C was then observed donning a clean pair of single use gloves without performing appropriate hand hygiene after her hands had been potentially contaminated at any time during the observation. Staff C acknowledged she did not perform hand hygiene prior to donning the gloves. c. Staff D, Dietary Aide, was observed was observed handling a wet floor sign that was on the floor and then proceeded to handle a cart. Staff D was then observed donning a clean pair of single use gloves without performing hand hygiene after her hands had been potentially contaminated. Staff D acknowledged she had not performed hand hygiene prior to donning the gloves. d. Staff A, Cook, was observed cleaning a cart with a wet towel with her bare hands. Staff A then donned a clean pair of single use gloves without performing hand hygiene after her hands had been potentially contaminated. Staff A acknowledged she did not perform hand hygiene prior to donning the gloves. e. Staff E, Dietary Aide, was observed returning to the kitchen from a service area where the ice machine was located. Staff E was observed donning a pair of clean single use gloves without performing hand hygiene after her hands had been potentially contaminated. Staff E acknowledged she did not perform hand hygiene. The surveyor intervened, and the [NAME] and the Dietary Aides were stopped from continuing working and instructed to perform hand hygiene by the Dietary Manager.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to follow-up on monitoring residents with a change in condition for 1 of 2 sampled residents reviewed for death in the facility, Resident #1. The findings included: Resident #1 was admitted to the facility on [DATE], with diagnoses to include Syncope (fainting), Heart Attack, Chronic Pulmonary Edema (fluid in lungs), Diabetes, Heart Disease, and Alcohol Use. Review of the admission progress note dated [DATE] at 7:08 AM documented the resident was admitted to the facility and was receiving oxygen at 2 liters a minute via nasal canula. The progress note further documented the resident's vital signs were within normal limits, and the resident was very drowsy and lethargic, hard to arouse, and appeared confused. Review of Resident #1's physician orders revealed orders dated [DATE] revealed an order for vital signs every shift. Further review of Resident #1's records revealed the last documentation of the resident's condition / vital signs was on [DATE] at approximately 8:30 PM. Review of the progress note documented the following: On [DATE] at 5:08 PM, the resident's oxygen level appeared to be below normal range (no oxygen level documented). Physician was notified, oxygen increased to 4 liters minute, and endorsed to oncoming nurse. On [DATE] at 11:00 PM, patient in stable condition; Awake, alert and oriented times one; Lungs were clear bilaterally; Oxygen 2 liters via nasal cannula noted; Tolerating well. No signs or symptoms of distress noted, voiced and/or reported. On [DATE] at 1:00 AM, nursing aide conducted rounding; No signs or symptoms of distress noted, voiced and/or reported; and monitoring ongoing. On [DATE] at 3:00 AM, lab rounded and ordered labs were drawn / collected by phlebotomist. Writer (nurse) conducted rounding; No signs or symptoms of distress noted, voiced and/or reported. The lab results had a collection time of 4:55 AM. On [DATE] at 5:00 AM, routine medications administered; No signs or symptoms of distress noted, voiced and or reported. On [DATE] at 5:30 AM, aide conducted AM care; No signs or symptoms of distress noted voiced and or reported. On [DATE] at 6:40 AM, Advanced Registered Nurse Practitioner (ARNP) rounded and found patient unresponsive; code called and 911 notified. On [DATE], at 6:45 AM, CPR (Cardiopulmonary Resuscitation) started, and Emergency Medical Services (EMS) and police arrived. The resident expired on [DATE] at 6:48 AM. Review of the Physician Services history and physical progress note dated [DATE] at 6:45 AM, documented a chief complaint of weakness. Resident presented to the hospital after found outside supermarket with a pint of vodka near. Unsure of downtime. Was medically managed for a heart attack and was transferred to the facility for rehabilitation. Resident #1 was found unresponsive on rounds, 911 and code blue called at 6:44 AM. An interview was conducted with the Nurse Practitioner (NP) via telephone on [DATE] at 12:00 PM. The NP stated she was rounding on the resident on [DATE] at 6:44 AM, and found the resident unresponsive, cold, and rigor mortis (rigidness) had set in. The NP stated the resident had obviously been deceased for a while. The NP stated none of the nursing staff could tell her when the resident was last seen/assessed, but just stated they had 'just seen the resident'. The surveyor questioned the NP on the laboratory results documented as collected on [DATE] at 4:55 AM. The NP stated she questions the validity of the results documented for Resident #1, are they Resident #1's. The NP stated the lab results for Resident #1 were impossible due to the condition the resident was found by the NP on [DATE] at 6:44 AM (less than 2 hours later). On [DATE], an attempt was made to call the assigned night nurse and CNA (Certified Nursing Assistant) but there were no return calls. An interview was conducted with the Director of Nursing (DON) on [DATE] at 3:30 PM. The DON stated she was unaware of the above. The DON stated she was told that a resident had expired, and the resident was being seen by the NP at the time. The DON acknowledged there were no documented vital signs / condition of the resident for night shift, after the change in condition documented on evening shift. The DON acknowledged Resident #1 had a roommate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) During the initial tour of the facility conducted on 06/19/23 at 9:39 AM, the surveyor observed Resident #66 lying in bed with his breakfast tray. Resident #66 was holding his milk carton in both hands and, with his mouth around the top of the milk carton, was slurping milk out of a small hole he had made in the top of the milk carton. Upon further observation, the surveyor noted there was no cup or straw provided on the breakfast tray for Resident #66 to utilize to drink his milk. The surveyor asked Resident #66 if he was normally provided a cup or straw to use for his milk. Resident #66 responded that the kitchen never provided him with a cup or straw for his milk. When asked if it bothers him that he was not provided a cup or straw to drink his milk from, he continued drinking his milk as described above and shrugged his shoulders. Resident #66 was admitted to the facility on [DATE]. Resident #66 had a medical history significant for Diabetes, Dysphagia, Gastro Esophageal Reflux Disease, Obesity, Dementia, Glaucoma, and Depression. A Quarterly Minimum Data Set (MDS) was documented on 03/21/23. This MDS documented Resident #66 had a Brief Interview of Mental Status score of 10, which suggests moderate cognitive impairment. For functional status, this MDS documented Resident #66 required set up help with supervision for eating meals. An observation was made on 06/21/23 at 8:40 AM of Resident #66 with his breakfast tray. A Certified Nursing Assistant was assisting him in setting up his food and drinks. There was no cup for his milk. The surveyor returned to Resident #66's room at 9:03 AM to make an observation of his breakfast tray to see the amount of milk consumed, but the tray had been removed and Resident #66 was asleep. An observation was made on 06/22/23 at 8:06 AM of Resident #66 with his breakfast tray. The facility's Assistant Director of Nursing was present at the bedside and was assisting Resident #66 with dining at this time. The surveyor noted there was no cup provided for his milk. He did not say anything about his milk not having a cup, and the milk was not yet open. The surveyor returned to Resident #66's room at 8:21 AM to make an observation of his breakfast tray to see the amount of milk consumed, but the tray had been removed and Resident #66 was asleep. Based on observations, interviews, and record review the facility failed to assist residents during meals in a dignified manner for 2 of 4 residents observed for dignity (Residents #82 and #66) and the facility failed to provide privacy for 1 of 4 residents observed for dignity (Resident #90). The findings included: 1) Record review for Resident #82 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Legal Blindness, Dysphagia, Oropharyngeal Phase, and Moderate Protein-Calorie Malnutrition. Review of the Minimum Data Set (MDS) for Resident #82 dated 03/24/23 revealed the resident had a Brief Interview of Mental Status score of 15 indicating an intact cognitive response. Revealed in Section G for dressing, eating, toilet use, and personal hygiene all had a self-performance of total dependence with support of one person assist. Review of the Care Plan for Resident #82 dated 03/27/23 with a focus on the resident has an ADL (Activity of Daily Living) self-care performance deficit related to activity intolerance, fatigue, impaired balance, musculoskeletal impairment, pain shoulder and knees. The goal was for the resident to improve their current level of function in bathing and dressing through the next review date. The interventions included: Encourage the resident to discuss feelings about self-care deficit daily. Encourage the resident to participate to the fullest extent possible with each interaction. Praise all efforts at self-care. During an observation conducted on 06/19/23 at 9:55 AM, Resident #82 was in bed while a staff member was standing over the resident while feeding the resident her breakfast. There was an empty chair in the room on the opposite side of the bed. During an interview conducted on 06/19/23 at 10:00 AM with Staff F Certified Nursing Assistant (CNA) who was standing over Resident #82 feeding the resident breakfast, she was asked does she always stands over the resident when feeding her, she said yes. When asked if she ever sits to feed the resident, she said she always feeds the resident like this. During an interview conducted on 06/19/23 at 11:00 AM with Resident #82 when asked how it makes her feel when the staff stand over her to feed her breakfast, she said they are always in a rush. 3) Review of Resident #90's clinical record documented an admission on [DATE] with no readmissions. The resident diagnoses included Cognitive Communication Deficit, Dementia, Systemic Inflammatory Response Syndrome, History of Falling, and Muscle Weakness. Review of Resident #90's Minimum Data Set (MDS) admission assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 11 indicating that the resident had moderate cognition impairment. The assessment documented under Functional Status that the resident needed extensive assistance to total assistance from the staff to complete the activities of daily living (ADLs). Review of Resident #90's care plan titled The resident has an ADL self-care performance deficit related to activity intolerance, Dementia .limited mobility . initiated on 05/26/23 documented an intervention that read provide resident with extensive assistance with the ADLs . On 06/19/23 observations from 10:40 AM to 12:02 PM, revealed Resident #90's room door wide opened. The resident was in bed lying down over her left side, wearing a gown, an adult brief and was uncovered (no sheet or a blanket ) from her waist down. On 06/19/23 at 10:45 AM, an interview was conducted with Resident #90 who stated she was having pain and pointed to her naked right thigh. The resident was asked if she was hot because she was uncovered and stated No. The resident stated that there was nothing to see. On 06/19/23 at 11:11 AM, observation revealed Staff L, Certified Nursing Assistant (CNA) walked by Resident #90's wide opened door and resident uncovered from her waist down wearing an adult brief exposed to the hallway and did not attempt to close the resident door or to cover the resident. On 06/19/23 at 11:12 AM, observation revealed Staff C, Registered Nurse (RN) walked by Resident #90's wide opened door and resident uncovered from her waist down wearing an adult brief exposed to the hallway and did not attempt to close the resident door or to cover the resident. On 06/19/23 at 11:12 AM, observation revealed the Director of Nursing (DON) walked by Resident #90's wide opened door and resident uncovered from her waist down wearing an adult brief exposed to the hallway and did not attempt to close the resident door or to cover the resident. On 06/21/23 at 9:53 AM, an interview was conducted with Staff C, RN who stated that Resident #90 uncovered herself and was confused at times. Staff C was apprised that the resident was not care plan for any behaviors related to not keeping her cover on. Staff C was apprised that the resident was uncovered showing her adult brief to the hallway for about 1.5 hours on 06/19/23 and the staff did not attempt to put the covers back on or to close the door. On 06/22/23 at 11:44 AM, during an interview, the DON was apprised of findings (photographic evidence showed). The DON Stated she did not notice Resident #90 was uncovered with her door wide open. The DON stated the resident was not care plan for the behavior. On 06/22/23 at 12:05 PM, an interview was conducted with Staff L, CNA who stated Resident #90 likes to keep her covers off but did not notice the resident was uncovered on 06/19/23. Review of Resident #90's care plans lacked evidence of a care plan related to the resident behavior problem on keeping her sheets on while the room door was open.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide residents with preferences for being out of bed for 1 of 1 residents reviewed for Preferences (Resident #47). The findings included: During tours of the facility conducted on 06/19/23 at 10:51 AM and 12:55 PM, Resident #47 was observed lying in bed. Resident #47's family member was at her bedside during the second observation. Resident #47's family member stated she had a concern about Resident #47 not being out of bed unless the family specifically requested it. When asked how long this has been going on, Resident #47's family member said approximately 6 months. She also stated she has two siblings and they each switch off coming to the facility, so one of them is at the facility with Resident #47 daily. During this interview, the surveyor observed a wheelchair in the far corner of the room. The surveyor asked Resident #47's family member if this was her wheelchair. Resident #47's family memberr confirmed that that was Resident #47's wheelchair in the corner of the room. Resident #47 was last readmitted to the facility on [DATE]. Resident #47 had a medical history significant for Stroke, Limb Contracture, Aphagia, Gastrostomy Status, Dementia, Psychosis, and Depression. A Quarterly Minimum Data Set (MDS) was documented on 04/05/23. This MDS documented Resident #47 had a Brief Interview of Mental Status score of 99, which suggests severe cognitive impairment. This MDS documented Resident #47 was totally dependent on two or more staff for transfers. A review of Resident #47's Care Plan revealed there was no care plan in place regarding the preference of being out of bed. Review of Resident #47's Physician Orders revealed a Tube Feeding order was written on 05/16/23. Allow for activity participation per family request was written as the last line of this order. Additional observations were conducted on 06/20/23 at 6:27 AM and 12:48 PM, 06/21/23 at 8:08 AM and 12:53 PM, and 06/22/23 at 8:11 AM and all revealed Resident #47 lying in bed. During the observation conducted on 06/21/23 at 12:53 PM, another daughter of Resident #47's was at her bedside. This daughter shared the same concern about Resident #47 not being out of bed during the day. She stated the family must call the facility and specifically request that Resident #47 be taken out of bed and put in her wheelchair. She further stated if they do not call ahead, Resident #47 is not taken out of bed by the staff. An interview was conducted with Staff R, Certified Nursing Assistant (CNA) on 06/22/23 at 8:51 AM. Staff R stated she does not normally care for Resident #47, but that the CNA who normally does care for her gets her out of bed every day. When asked why Resident #47 had been observed in bed all four days of the survey, Staff R stated the CNA who normally cares for Resident #47 was not working during the survey week so the CNA who was caring for her must not be getting her out of bed. When asked if it was normal practice to leave residents in bed when the normal CNA is not working, Staff R did not respond verbally but shrugged her shoulders and walked away. An observation was conducted on 06/22/23 at 12:40 PM of Resident #47. She was up in her chair watching television. Resident #47 appeared to be comfortable, happy, and relaxed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Record review for Resident #25 revealed the resident was admitted to the facility on [DATE]with diagnoses that included: Emphysema, Anxiety Disorders, Unspecified Psychosis Not Due to A Substance or Known Physiological Condition. Review of the Minimum Data Set for Resident (MDS) revealed in Section C a Brief Interview of Mental Status score of 14 indicating cognitive intact response. Review of the Physician's Orders for Resident #25 revealed an order dated 05/04/21 for 0-no behavior, 1-agitation, 2-combative, 3-verbally inappropriate, 4-sexualy inappropriate, 5-crying, 6-calling out, 7-screaming, 8-hallucinations, 9-delusions, 10-resists care, 11-socially inappropriate, 12-other see progress notes every shift. Review of the Physician's Orders for Resident #25 revealed an order dated 05/04/21 to monitor for side effects related to use of antianxiety medications. My initials indicate absence of signs and symptoms of side effects. Review of the Physician's Orders for Resident #25 revealed an order dated 05/04/21 for side effects (Psychoactive med use) 0-none, 1-movement side effects- see progress notes, 2-nonmovement side effects - see progress notes every shift. Review of the Physician's Orders for Resident #25 revealed an order dated 05/03/21 for Buspirone HCL tablet 15mg give 1 tablet by mouth two times a day for anxiety. Review of the Physician's Orders for Resident #25 revealed an order dated 05/23/21 for Seroquel tablet 100mg give 1 tablet by mouth at bedtime for psychosis. Review of the Physician's Orders for Resident #25 revealed an order dated 06/30/21 for side effects (antianxiety med use): 0-none, 1-movement side effects- see progress notes, 2-nonmovement side effects - see progress notes every shift. Review of the Physician's Orders for Resident #25 revealed an order dated 03/25/23 for Ativan oral tablet 0.5mg give 1 tablet by mouth two times a day for anxiety/agitation. Review of the Physician's Orders for Resident #25 revealed an order dated for10/06/22 for Psych consult for medication review and as needed. Review of the Care Plan for Resident #25 dated 05/04/21 with a focus on the resident using anti-anxiety medications related to anxiety disorder with agitation. The goal was for the resident to be free from discomfort or adverse reactions related to anti-anxiety therapy through the next review date. The interventions included: Administer anti-anxiety medications as ordered by physician. Monitor for side effects and effectiveness every shift. Monitor resident for safety. The resident is taking anti-anxiety meds which are associated with an increased risk of confusion, amnesia, loss of balance, and cognitive impairment that looks like dementia and increases the risk of falls, broken hips, and legs. Review of the Care Plan for Resident #25 dated 05/04/21 with a focus on the resident using psychotropic medications and a mood stabilizer related to Schizoaffective Disorder. The goal was for the resident to be/remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction, or cognitive/behavioral impairment through review date. The interventions included: Administer psychotropic medications as ordered by physician. Monitor for side effects and effectiveness every shift. Review of the Care Plan for Resident #25 dated 02/08/23 with a focus on the resident wishes to remain in the facility for LTC (long term care). The goals included: the resident will verbalize/communicate an understanding of the discharge plan and describe the desired outcome by the review date. The interventions included: Encourage the resident to discuss feelings and concerns with impending discharge. Monitor for and address episodes of anxiety, fear, and distress. Establish a pre-discharge plan with the resident/family/caregivers and evaluate progress and revise plan. Record review for Resident #25 revealed no preadmission screening and resident review (PASARR). During an interview conducted on 06/19/23 at 1:30 PM with Social Service Director he acknowledged that there was no PASARR for Resident #25. He stated the resident was admitted from home on hospice services and the hospice services does not perform a PASARR. During an interview conducted 6/20/23 at 11:27 AM with the Social Services Direct, he stated when a resident comes from another hospital or another facility the facility requires a PASARR be completed, if the resident comes from home or hospice, they do not have a PASARR. He stated that he cannot do a PASARR screening because he is not a Master of Social Work (MSW) or Licensed Clinical Social Worder (LCSW). He has a Bachelor of Social Work (BSW). He attended an In-service provided by a hospice company and he was informed that when a resident is admitted from home with hospice to the facility, they do not require PASARR based on Medicaid and Medicare guidelines. He was asked to clarify if this meant that the hospice did not need PASARR, he said yes, and they led him to believe that the facility did not need to perform PASARR for the resident. He went on to explain that if a resident exhibits any behaviors, a psychiatrist/psychologist would be consulted to see the resident. The resident would then be seen by the psychiatrist/psychologist within a few days and no longer than a week. When asked if a resident is being admitted and does not have a PASARR, and requires one to be completed, how does this get accomplished since he does not have the credentials to do so, he stated since it is out of his scope of practice to perform the PASARR he would contact a sister facility to get the appropriate person to complete a PASARR for that resident. He said when he had performed an audit of Resident #25's chart and realized that there was no PASARR, he reached out to hospice for a PASARR and was told by hospice that the resident would not be required to have a PASARR because they are on hospice. Based on this information provided to him by hospice, he did not think the resident needed a PASARR and did not contact the appropriate person from sister facility to do the PASARR. 3) Record review for Resident #38 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Cerebral infarction, Respiratory Failure, and Tracheostomy Status. Review of the Minimum Data Set (MDS) for Resident #38 revealed in Section C a Brief Interview of Mental Status could not be performed due to the resident is rare/never understood. Review of the Care Plan for Resident #38 dated 04/21/23 revealed the resident had a care plan dated 04/21/23 with a focus on the resident wishes to remain in the facility for LTC (long term care). Goals included: The resident will verbalize, communicate an understanding of the discharge plan, and describe the desired outcome by the review date. The interventions included: Encourage the resident to discuss feelings and concerns with impending discharge. Monitor for and address episodes of anxiety, fear, and distress. Review of the Care Plan for Resident #38 dated 04/26/23 with a focus on the resident has impaired cognitive function or impaired thought processes related to difficulty making decisions due to diagnosis. The goal included: The resident will be able to communicate basic needs on a daily basis through the review date. The resident will develop skills to cope with cognitive decline and maintain safety by the review date. The resident will improve their current level of cognitive function through the review date. The interventions included: Administer medications as ordered. Monitor/document for side effects and effectiveness. Discuss concerns about confusion, disease process, Nursing Home placement with resident/family/caregivers. Record review for Resident #38 revealed there was no PASARR Level I Screen performed. Based on record reviews and interviews, the facility failed to act on request for Level II Pre-admission Screening and Resident Review (PASARR) for a resident determined to have 'Serious Mental Illness' for 1 of 3 residents reviewed for PASARR (Resident #11). The facility failed to have a PASARR screening completed upon admission for 2 of 3 residents reviewed for PASARR (Resident #38 and 25). The findings included: 1) Resident #11 was admitted on [DATE]. According to an admission Minimum Data Set (MDS), dated [DATE], Resident #11 had a Brief Interview for Mental Status (BIMS) score of 13. Resident #11's diagnoses at the time of the assessment included: Anemia, Hypertension, Hemiplegia, Seizure disorder, Malnutrition, Schizophrenia, Long-term and current drug therapy. Resident #11's care plan initiated on 05/07/23, documented, the resident uses psychotropic medications r/t Schizoaffective Disorder, Schizophrenia, Bipolar. The goals of the care plan included: The resident will be/remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment through the review date with a target date of 08/25/23. The resident will reduce the use of psychotropic medication through the review date. With a target date of 08/25/23. Interventions to the care plan included: Administer psychotropic medications as ordered by physician. Monitor for side effects and effectiveness Q-shift. Consult with pharmacy. MD to consider dosage reduction when clinically appropriate at least quarterly. Educate the resident/family/caregivers about risks, benefits, and the side effects and/or toxic symptoms. Monitor/document/report PRN any adverse reactions of psychotropic medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing. Dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps, nausea, vomiting, behavior symptoms not usual to the person. Monitor/record occurrence of for target behavior symptoms such as pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others etc. and document per facility protocol. Resident #11's orders included: Olanzapine oral tablet 15 mg - Give one tablet by mouth at bedtime for bipolar - 05/06/23. In Section IV 'PASRR Screen Completion' of a Level I PASARR completed by a long term care facility where the resident resided prior to being admitted , dated 07/25/22, documented, Individual may not be admitted to an Nursing Facility. Use this form and required documentation to request a Level II PASRR evaluation because there is a diagnosis of or suspicion of - Serious Mental Illness. During an interview conducted on 06/19/23 at 1:30 PM with Social Service Director he acknowledged that there was no Level II PASARR for Resident #11 and stated that he was unaware that the resident required a Level II PASARR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide showers based on shower schedule and resident preferences for Resident 2 of 4 residents reviewed for Activities of Daily Living (ADLs) (Residents #7 and 32). The facility failed to ensure proper nail care for 1 of 4 residents reviewed for ADL Care (Resident #90). The findings included: The facility's policy Bathing/Showering dated 11/30/14 and most recently revised on 04/20/22 did not address residents' refusal to be bathed/showered. 1) Resident #7 was admitted to the facility on [DATE]. According to a Quarterly Minimum Data Set (MDS), dated [DATE], Resident #7 had a Brief Interview for Mental Status (BIMS) score of 15, indicating that the resident was 'cognitively intact'. The MDS documented that the resident required: 'Limited assistance' and 'one person physical assist' for bed mobility and transfer, and required 'extensive assistance' and 'one person physical assist' for walk in corridor, toilet use, personal hygiene. The MDS documented that Resident #7 was 'frequently incontinent of urine and bowel. Resident #7's diagnoses at the time of the assessment included: Anemia, Heart failure, Hypertension, Orthostatic hypotension, Depression, Chronic lung disease, Hereditary and idiopathic neuropathy, muscle weakness, lack of coordination, abnormalities of gait and mobility, constipation, Paroxysmal atrial fibrillation, cognitive communication deficit, malaise. Resident #7's care plan, initiate on 10/17/18 most recently revised on 01/09/23, documented, the resident has an ADL self-care performance deficit rt impaired balance, Limited Mobility. Interventions to the care plan included: Avoid scrubbing & pat dry sensitive skin. Provide sponge bath when a full bath or shower cannot be tolerated. During an interview with members of the Resident Council, on 06/20/23 at 3:37 PM, Resident #7 stated, I can't get my showers like I like to. We are scheduled for certain times, but my shower I get on the 3-11 - when I ask for a shower, they just say that 'I am too busy.' The second floor shower schedule documented that Resident #7 was to have showers on Wednesdays and Saturdays on the 3PM to 11PM shift. Review of progress notes revealed no documentation of Resident #7 refusing showers. Review of Resident #7's electronic health record revealed that resident received shower three times during the previous 30 days, with the remaining days being given bed baths. Review of progress notes revealed that there was no documentation of resident refusing to be showered. During an interview, on 06/21/23 at 4:31 PM Staff J, CNA, when asked about providing showers to Resident #7, the CNA replied, Every month we rotate and we have different residents. Yesterday Resident #7 refused and I told the nurse and I signed the shower sheet. She got a shower this morning. Sometimes she has showers in the morning. Sometimes she tells me that she had a shower in the morning. During the interview with Staff J, the ADON was at the nurse's station where the interview was being conducted and stated, there is no shower book that they sign off on when they shower or refuse. 2) Resident #32 was admitted to the facility on [DATE]. According to an annual MDS, dated [DATE], Resident #32 had a BIMS score of 15, indicating that Resident #32 was 'cognitively intact'. The MDS documented that the resident required: 'extensive assistance' and 'one person physical assist' for bed mobility, walk in room and corridor, dressing, toilet use and personal hygiene and required 'limited assistance' and 'limited assistance' and 'one person physical assist' for transfer. The assessment documented that Resident #32 was ''always incontinent of urine and bowel. Resident #32's diagnoses at the time of the MDS included: Anemia, Heart failure, Hypertension, Orthostatic hypotension, Diabetes, Seizure disorder, Chronic lung disease, [NAME] Syndrome, Muscle weakness, Lack of coordination, Abnormal posture, Unsteadiness on feet, Hypokalemia. Resident #32's care plan, initiated on 03/07/19 and most recently updated on 09/22/21, documented, The resident has an ADL self-care performance deficit r/t Limited Mobility Right resting hand splint. Interventions to the care plan included: Bathing/Shower: Avoid scrubbing & pat dry sensitive skin. Bathing/Showering: Provide sponge bath when a full bath or shower cannot be tolerated. Bathing/showering: The resident is totally dependent on staff to provide bath/shower as schedule and as necessary. During a meeting with members of the Resident Council, on 06/20/23 at 3:37 PM, Resident #32 voiced concerns regarding not having enough staff to provide showers on the 3-11 shift. The Second Floor Shower Schedule documented that Resident #32 is to have showers on Tuesdays and Fridays on the 3-11 shift. Review of progress notes revealed that resident refused shower on 06/20/23, with no other documentation of resident refusing to be showered. Review of Resident #32's electronic health record showed the resident received 2 showers in the previous 30 days, with the remaining days being given a bed bath. During an interview, on 06/21/23 at 4:35 PM, with Staff K, CNA, when asked about providing showers for Resident #32, Staff K replied, I give her a shower on Saturday. I don't have her every day. She doesn't' refuse. 3) Review of Resident #90's clinical record documented an admission on [DATE] with no readmissions. The resident diagnoses included Cognitive Communication Deficit, Dementia, Systemic Inflammatory Response Syndrome, History of Falling, and Muscle Weakness. Review of Resident #90's Minimum Data Set (MDS) admission assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 11 indicating that the resident had moderate cognition impairment. The assessment documented under Functional Status that the resident needed extensive assistance to total assistance from the staff to complete the activities of daily living (ADLs). Review of Resident #90's care plans lack evidence of a care plan related to the resident behavior problem related to the refusal of fingernail care. Review of Resident #90's care plan titled The resident has an ADL self-care performance deficit related to activity intolerance, Dementia .limited mobility . initiated on 05/26/23 documented an intervention that read provide resident with extensive assistance with the ADLs . On 06/19/23 at 11:05 AM, observation revealed Resident #90 in bed, alert with her eyes open. Further observation revealed the resident's long (about 2 inches) unkempt fingernails with chipped bright red nail polish and some nails with no nail polish. The resident agreed to have pictures taken and stated it will be nice to have the polish removed. Furthe, observation revealed the resident pulling on her long fingernails and stated they were too long. The resident stated she would like them trimmed a little. On 06/21/23 at 9:53 AM, a side by side review of Resident #90's fingernails was conducted with Staff C, Registered Nurse (RN). Staff C stated the resident had been in the facility for a week. Observation revealed the resident's fingernails were trimmed but the nails polish was not removed. Photographic evidence taken on 06/19/23 of the resident's long and unkempt fingernails was shown to Staff C. Staff C stated that activities staff did cut the resident fingernails on Monday. During the review, the resident stated that her fingernails were looking dangerous. On 06/21/23 at 10:26 AM, an interview was conducted with Staff N, CNA assigned to Resident #90. Staff N stated the resident was confused sometimes and that her finger nails were very long. Staff N stated she was supposed to inform the nurse about resident's fingernails being very long but did not remember if she did it or not. Staff N stated it was their responsibilities to cut the residents fingernails. On 06/22/23 at 11:37 AM, during an interview, the DON was apprised of Resident #90's unkempt long fingernails. Photographic evidence shown.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide adequate podiatry care for 2 of 2 residents reviewed for Podiatry Care, (Residents #34 and 90). The findings included: 1) During the initial tour of the facility conducted on 06/19/23 at 10:12 AM, Resident #34 stated that he wanted to participate in physical therapy sessions but that his feet bothered him. During this interview, Resident #34 lifted his bedsheets and showed his feet to the surveyor. The surveyor observed that Resident #34's toenails were very long, thick, and overgrown. The surveyor asked Resident #34 if his toenails caused him discomfort. Resident #34 stated not really, but my feet hurt when I stand up. When asked when he was last seen by a podiatrist, Resident #34 stated I'm not sure, but I think about 2 months ago. Resident #34 was admitted to the facility on [DATE]. Resident #34 had a medical history significant for Weakness, Unsteadiness on Feet, and Chronic Pain. A Quarterly Minimum Data Set (MDS) was documented on 05/26/23. This MDS documented Resident #34 had a Brief Interview of Mental Status score of 15, which suggests he was cognitively intact. This MDS documented Resident #34 was totally dependent on two or more staff members for transfers and that he was not able to walk. Review of Resident #34's electronic medical record revealed there was no Care Plan in place regarding podiatry care and no Physician Order for a Podiatry Consultation. Review of Resident #34's paper medical record revealed two old Podiatry Notes. One note was written on 04/27/22 and stated Resident #34 was seen for risk for toenail debridement. The other note was written on 11/03/21 and stated Resident #34 was seen for treatment of painful and elongated toenails. There were no further podiatry notes found in the paper or electronic medical records. 2) Review of Resident #90's clinical record documented an admission on [DATE] with no readmissions. The resident diagnoses included Cognitive Communication Deficit, Dementia, Systemic Inflammatory Response Syndrome, History of Falling, and Muscle Weakness. Review of Resident #90's Minimum Data Set (MDS) admission assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 11 indicating that the resident had moderate cognition impairment. The assessment documented under Functional Status that the resident needed extensive assistance to total assistance from the staff to complete the activities of daily living (ADLs). Review of Resident #90's care plans lack evidence of a care plan related to the resident behavior problem related to the refusal of toenails care. On 06/19/23 at 11:05 AM, observation revealed Resident #90's lying down in bed, uncovered from her waist down. Further observation revealed the resident's toe nails were elongated and unkempt. Consequently, an interview was conducted with the resident who stated they (facility staff) had not done her toe nails. The resident stated they are ugly looking. On 06/21/23 09:53 AM, a side by side review of Resident #90's toenails was conducted with Staff C, Registered Nurse (RN). Staff C stated the resident had been in the facility for a week. Staff C added that the facility had a Podiatrist that comes and does every new resident toe nails. Staff C confirmed Resident #90's elongated toe nails and added that she will add the resident's name to the podiatrist list for her to be seen. On 06/21/23 at 10:26 AM, an interview was conducted with Staff N, CNA assigned to Resident #90. Staff N stated the resident was confused sometimes. Staff N was asked if she noticed the resident's long toe nails. Staff N stated she was supposed to inform the nurse about resident's long nails but did not remember if she did it or not. On 06/22/23 at 11:37 AM, an interview was conducted with the DON who was apprised of Resident #90's elongated toe nails observed on 06/19/23 (Photographic evidence showed). The DON stated Resident #90 admission assessment dated [DATE] documented that the resident had long toe nails but had not been seen by the podiatrist until 06/21/23. The DON stated that an audit was done on 06/21/23 to check all residents that needed toe nail care. The DON stated she asked the podiatrist to provide, if any visits, documentation done prior to 06/21/23. At the end of the survey, there were no other podiatrist visit documentation provided. On 06/22/23 at 12:00 PM, surveyor was approached by the facility's Regional Nurse who stated that the facility had identified Resident #90's toe nail care was needed. The Regional Nurse and the DON were apprised that Resident #90's elongated toe nails were observed by the surveyor on 06/19/23 and should had been identified prior by the staff. On 06/22/23 at 12:05 PM, an interview was conducted with Staff L, CNA who stated she noticed Resident #90's long toe nails and had not tell anybody because the nurse does a head to toe assessment on admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to provide appropriate device in the form of a smoking apron to prevent injury and skin damage to 1 of 1 resident reviewed for smoking (Resident #11). The findings included: The facility's policy, 'Smoking - Supervised', dated September 2018 and most recently revised on 02/01/20, documented, The Center will provide a safe, designated smoking area for residents. Residents will be supervised during smoking. Smoking is only allowed in designated areas and oxygen is not permitted. The Center will have safety equipment available in designated smoking areas including: smoking blankets, smoking aprons, a fire extinguisher and non-combustible self-closing ashtrays. Procedures: 1. Residents that smoke will be evaluated on admission/re-admission, quarterly, and with a change in condition to determine if additional adaptive or safety equipment is needed. Resident #11 was admitted to the facility on [DATE]. According to an admission Minimum Data Set (MDS) dated [DATE], Resident #11 had a Brief Interview for Mental Status score of 13, indicating that the resident was 'cognitively intact'. The MDS documented that Resident #11 required 'limited assistance' and 'one person physical assist' for bed mobility, transfer, toilet use and personal hygiene. Resident #11's diagnoses at the time of the assessment included: Anemia, Hypertension, Hemiplegia, Seizure disorder, Malnutrition, Schizophrenia, Long-term and current drug therapy. Resident #11's care plan, dated 05/07/23, documented, The resident is a smoker. The goals of the care plan included: *The resident will not suffer injury from unsafe smoking practices through the review date with a target date of 08/25/23. *The resident will not smoke without supervision through the review date with a target date of 08/25/23. Interventions to the care plan included: *Instruct resident about smoking risks and hazards and about smoking cessation aids that are available. *Instruct resident about the facility policy on smoking: locations, times, safety concerns. *Monitor oral hygiene. *Notify charge nurse immediately if it is suspected resident has violated facility smoking policy. Observe clothing and skin for signs of cigarette burns. *The resident requires a smoking apron while smoking. A 'Smoking - Safety Screen', dated 05/05/23 documented that Resident #11 was unable to light own cigarette. In the section of the assessment titled, Resident Need for Adaptive Equipment, it noted a smoking apron and one-on-one supervision. On 06/19/23 at 10:35 AM, 8 residents, including Resident #11, were observed on the smoking patio, outside of the main dining room on the first floor. The Activities Director brought the smoking material to the patio for the residents and assisted them with lighting their cigarettes. It was noted that none of the residents were provided with smoking aprons. On 06/21/23 at 10:55 AM Resident #11 was observed on the smoking patio with other residents and the Activities Director, smoking. It was noted that none of the residents were provided a smoking apron. On 06/21/23 at 1:40 PM, residents were observed on smoking patio with Activities Director, Resident #11 was observed to not be provided with a smoking apron. When asked about smoking aprons provided to the residents, the Activities Director stated that the aprons were in the cart on the bottom shelf, when I am here, it's me that takes them out. Then lit another cigarette for a resident who appeared uncoordinated. I don't know what the policy for smoking aprons is. During an interview, on 06/21/23 at approximately 3:30 PM, with the Therapy Director, when asked about Resident #11's being able to smoke safely, the Therapy Director state that the resident would not be able to smoke safely based on how the resident's hands shake and the limited dexterity in his hands. On 06/21/23 at approximately 4:00 PM, residents were observed being escorted to the smoking patio by the Activities Director. It was noted that Resident #11 was wearing a smoking apron. During an interview, on 06/21/23 at 4:45 PM, with Resident #11, when asked about being provided a smoking apron, Resident #11 stated that the facility had not offered or provided a smoking apron prior to this day.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews, the facility failed to follow the facility's Urinary Catheter Care policy, and failed to ensure the staff followed hand hygiene practices consistent with accepted standards of practice during foley/peri-care provided to 1 of 1 resident sampled for urinary catheter care review (Resident #3). The findings included: Review of the facility policy titled Catheter Care, Urinary revised on 09/05/17 documented .remove catheter securement device .reattach catheter securement device . The policy did not address the use of enhanced barrier precautions when providing urinary catheter care. Review of the Center for Disease Control and Prevention (CDC)-Hand Hygiene Guidance last reviewed on 01/30/20 documented .Healthcare Personnel should use an alcohol based hand rub or wash with soap and water for the following indications: .immediately after glove removal . Review of Resident #3's clinical record documented an admission on [DATE] with no readmissions. The resident diagnoses included Chronic Kidney Disease, Urinary Tract Infection, Malignant Neoplasm of other parts of Uterus, Intra-Abdominal and Pelvic swelling, Diabetes, Dementia, Cardiomyopathy, Chronic Obstructive Pulmonary Disease (COPD) and Cerebral Infarction. Review of Resident #3's MDS admission assessment dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 13 indicating that the resident had little to no cognition impairment. The assessment documented under Functional Status that the resident needed extensive assistance to total assistance from the staff to complete the activities of daily living. Review of Resident #3's care plan titled Enhanced Barrier Precautions initiated on 05/08/23 documented the resident requires enhanced barrier precautions related to wounds and foley catheter. The care plan interventions included use of gloves and gown for high contact care activities as ordered. Include .hygiene, incontinence care and toileting .enhanced barrier precautions use as ordered to reduce the spread of Multidrug-resistant organism . Review of Resident #3's care plan titled The resident has an indwelling foley catheter .initiated on 05/08/23 documented position catheter bag and tubing .away from the entrance room door . Review of Resident #3's physician orders documented Indwelling catheter care every shift. Review of Resident #3's physician orders dated 06/13/23 documented urinalysis, culture and sensitivity (U/A C & S) and Ceftriaxone sodium (antibiotic) 1 gram inject intramuscular one time only for 1 day empirically. On 06/19/23 at 11:48 AM, observation revealed a CDC signage that read STOP- Enhanced Barrier Precautions .providers and staff must also: wear gloves and a gown for the following high-contact resident care activities .device care .urinary catheter . On 06/19/23 at 11:59AM, observation revealed Resident #3 in bed with a urinary drainage bag hanging down from her right side of the bed facing the room door with no privacy pouch covering the bag. An interview was conducted with the resident who stated she was in the facility getting rehabilitation and came from the hospital with a foley in. During the interview, Staff O, RN came in looked at the resident urinary drainage bag and confirmed the resident had an indwelling catheter. On 06/20/23 at 9:27 AM, observation revealed Resident #3 in bed with a urinary drainage bag hanging down from her right side of the bed facing the room door with no privacy pouch covering the bag. On 06/21/23 at 11:01 AM, Resident #3's urinary catheter care performed by Staff Q, CNA was conducted. Staff Q asked the resident what she wanted her to do and the resident replied to wash her private area only. Staff Q performed hand washing, donned gloves, did not don a gown as per the door signage and proceeded to performed Resident #3's urinary catheter care, a high-contact care activity per the door signage. Further observation revealed Staff Q removed her gloves, donned another pair of gloves without performing hand hygiene and proceeded to rinse the resident private area. Further, observation revealed Staff Q removed her gloves, donned gloves without performing hand hygiene for a second time then proceeded to reposition Resident #3. Staff Q did not remove the catheter securement device during the care as per the facility policy. On 06/22/23, Staff Q, CNA was not available for an interview. On 06/22/23 at 10:43 AM, an interview was conducted with the Director of Nursing (DON) who stated Resident #3's daughter wanted the resident to have a urinalysis and a culture. The DON stated that the resident did not have symptoms of a Urinary Tract Infection (UTI) and added that the resident had a history of UTI prior to the admission. On 06/22/23 at 1:40 PM, during an interview, the Assistant Director of Nursing/Infection Preventionist (ADON/IP) was apprised of urinary care observation and Staff Q not performing hand hygiene twice after removing her gloves. A side by side review of the Enhanced Barrier Precautions signage was conducted with ADON/IP. The ADON/IP confirmed that Staff Q should have wore a gown during Resident #3's urinary/foley care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews, the facility failed to monitor the resident's weight as evidenced by six (6) pounds weight loss in 12 days for 1 of 1 resident sampled for nutrition review (Resident #143). The findings included: Review of the facility's policy titled Weighing the Resident revised on 05/06/22 documented residents will be weighed unless ordered otherwise by the physician: on admission/readmission, weekly for 4 weeks, monthly thereafter, as needed .weights will be documented .in the clinical record . Review of Resident #143's clinical record documented an admission on [DATE] with no readmissions. The resident diagnoses included Fracture of Right Femur, Rheumatoid Arthritis, Emphysema, Chronic Obstructive Pulmonary Disease (COPD), Asthma, Chronic Kidney Disease, Depression, Gastro-Esophageal Reflux Disease (GERD), Irritable Bowel Syndrome and Long Term Use of Systemic Steroids. Review of Resident #143's Minimum Data Set (MDS) admission assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 15 indicating that the resident had no cognition impairment. The assessment documented under Functional Status that the resident needed extensive assistance from the staff to complete the activities of daily living. Review of Resident #143's care plan titled Resident is at risk for altered nutrition .as evidenced by actual/potential weight loss/gain related to therapeutic diet, BMI status, current diagnoses, altered laboratories .initiated on 06/09/23, with no revisions, documented an intervention that read .weigh per facility protocol . Review of Resident #143's weight on 06/09/23 was 117 pounds. The review revealed that the resident was not weighted as per facility's protocol. Review of Resident #143's physician order dated 06/05/23 documented No added salt diet. Review of Resident #143's physician order dated 06/09/23 documented nutritional supplement 120 millimeters (ml) three times a day and snacks two times a day for nutritional supplement. On 06/20/23 at 8:02 AM, observation revealed Resident #143 in bed, breakfast tray on the table across from her and the resident was shaking her head from side to side. Consequently, an interview was conducted with the resident who stated that she was not a morning person and had spoken with the dietitian about her preferences. The resident was attempting to open her carton of milk and was not able to and asked for help. The resident added she was not eating because of the type of food the facility was given to her. On 06/21/23 at 9:55 AM, an interview was conducted with Staff M, Restorative Aide/Certified Nursing Assistant (CNA) who stated she did restorative care and weighs all facility's residents including new admissions. Staff M added that (today) she was doing resident care and that she does that when someone calls off or was on vacation. Staff M stated she also goes with the resident to their appointments when there is not a family member to go with them. Staff M stated that she did new admissions weight on the next day and if the resident was admitted during the weekend, she did the weight on Monday. Staff M added that the resident assigned CNA will do the weight if the nurse ask for it. Staff M stated the facility protocol for weights was to do it when the residents first come in, then every week for four (4) weeks, then monthly if the resident was not losing. Staff M stated she put the residents' weight reading on the census sheet for the day, then on a weight sheet that she gives to the dietitian who will enter the readings into the system. Subsequently, a side by side review of Staff M weight log sheet documented Resident #143 weight 117 on 06/09/23. Staff M was asked for weekly weight for the resident and stated she had not done resident's weights because she had been out to appointments with residents assigned to resident care. Staff M was asked to weight Resident #143 today. On 06/21/23 at 10:17 AM, an interview was conducted with Staff N, CNA who stated she worked day shift most of time, floated from unit to unit and had 10 residents assigned to her. Staff N stated Resident #143 did not have a good appetite and ate 50% of her meal most of the time. Staff N stated she had never been assigned to do weights and added that someone was assigned when Staff M was not in the facility. On 06/21/23 at 11:41 AM, an interview was conducted with the Dietary Technician Registered (DTR) who stated she was covering the facility once a week. The DTR stated she monitored resident's weights trend, intakes and supplements. The DTR stated she got the residents weights on a piece of paper provided to her, then she entered the readings on the resident electronic record. The DTR stated that the facility protocol was to obtain residents weight for the first three days of admission, then weekly for one month and monthly thereafter. The DTR added that if a resident loses weight, they will be put back on weekly weights as needed. A side by side review of Resident #143's weight's record was conducted with the DTR. The DTR stated that the resident was admitted on [DATE] and came in with her weight at 117 pounds, believed it was done at the hospital. The DTR stated the facility documented the hospital weight because the resident did not know her weight. The DTR confirmed that the resident weight was documented as 117 pounds on 06/09/23 four (4) days after admission. The DTR stated resident was missing three (3) weights readings. The DTR stated Resident #143's Initial Nutritional Evaluation was done on 06/09/23 and that the resident's preferences were discussed. The evaluation documented .no edema noted .skin intact .eating 50% of meals with assistance from staff for tray set up and requires supervision . On 06/21/23 at 12:45 PM, a side by side review of the facility's snacks labeling list was conducted with the DTR. The review revealed the resident was not listed to have a twice a day snack as ordered. The DTR stated the Dietitian put the order in and the Dietary Manager will be able to see it. On 06/21/23 at 12:20 PM, an interview was conducted with Resident #143 who stated she usually weights 112-115 pounds and that she was weighted when she came in to the facility and her weight was 117 pounds. The resident stated she was not given a snack between meals and that last night she asked for a snack because dinner was early around 5:00 PM. The resident showed fruits given to her and added she got graham crackers last night and the packaging had someone else's name, not her name. On 06/21/23 at 12:25 PM, a side by side review of Resident #143's weight taken by Staff M, CNA was conducted. The resident was weighed via a mechanical lift. Staff M stated the resident was weighed via mechanical lift on 06/09/23. Observation revealed Resident #143's weight of 111.2 pounds. The review revealed a weight loss of six (6) pounds in 12 days. On 06/21/23 at 12:40 PM, during an interview, the DTR was informed of Resident #143's weight of 111.2 pounds (today). The DTR stated the resident had a 4.9% weight loss in 2 weeks. A side by side review with the DTR of Resident#143's skilled nursing note dated 06/06/23, 06/07/23 and 06/13/23 revealed documentation of no edema present. On 06/21/23 at 2:59 PM, an interview was conducted with Staff C, RN and was asked what type of snacks she gave Resident #143 and she stated that she gave an Ensure supplement between breakfast and lunch. Staff C stated that the resident drank it. Review of the resident's physician orders lack evidence of an order for Ensure supplement. On 06/21/23 at 3:05 PM, a side by side review of the facility' pantry was conducted with Staff O, RN who stated there was no snacks in the pantry and added that the kitchen staff pass the snacks out to the residents. On 06/21/23 at 3:10 PM, an interview was conducted with Staff N, CNA who stated that she did not give Resident #143 a snack this morning. On 06/22/23 at 9:02 AM, an interview was conducted with the Dietary Manager who stated that Resident #143 was getting fruit twice a day as a snack. The DM added that the resident wanted to get better and wanted to eat healthy. The family wanted her to eat fruits.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure tube feeding tubing was changed in a timely manner and failed to ensure tube feeding was administered per physician orders for 4 of 4 residents reviewed for Tube Feeding (Resident #47, 67, 20, and 40). The findings included: Review of the facility policy titled Enteral Feeding-Enteral Nutrition Pump, revision date 11/12/18 revealed the following: Closed System Enteral Feeding Containers and tubing can hang safely for up to 48 hours. Use only 1 feeding set per container. 1) During the tour of the facility conducted on 06/19/23 at 10:51 AM, the surveyor observed that Resident #47 was lying in bed with eyes closed. Upon closer observation, Resident #47 had a bottle of Jevity 1.5 (formulary type) tube feeding that was labeled as started on 06/18/23 but was untimed and was infusing at 50 milliliters/hour (mL/hr). Further observation revealed the water flush bag was dated 06/17/23 at 2:00 PM. The tube feeding was at the 350mL mark out of a 1,000mL capacity bottle. Review of Resident #47's Physician Orders revealed an order was written on 05/16/23 for Enteral Feed every shift continuous enteral feeding: formula-Jevity 1.5; Rate-50mL/hr x20hr start at 4:00 PM and run until (1000mL) has infused. Flush with water: amount-40mL/hour x20 hours (800mL). An observation was conducted on 06/20/23 at 6:27 AM of Resident #47's tube feeding. Jevity 1.5 was infusing, the bottle was dated/timed 06/19/23 at 4:00 PM. The water flush bag was still dated 06/17/23. The tube feeding was at the 850mL mark out of a 1,000mL capacity bottle. Based on the surveyor's calculations, the bottle should have only had approximately 275mL left. An interview was conducted with Staff E, Licensed Practical Nurse (LPN) on 06/20/23 at 6:32 AM regarding tube feeding. The surveyor asked Staff E how often tube feeding tubing and bags are changed at the facility. Staff E stated the tube feeding tubing and bags are changed daily. When shown Resident #47's water flush bag as dated 06/17/23, Staff E stated the facility had a shortage of tube feeding sets, but that she had not noticed that the water flush bag was dated from 06/17/23. She stated she would change it immediately. When asked why the tube feeding amounts did not seem to add up (when the bottles were timed versus how much tube feeding was left) Staff E stated she did not know. An observation was conducted on 06/21/23 at 8:08 AM of Resident #47's tube feeding. Jevity 1.5 was infusing, the bottle was dated/timed 06/20/23 at 4:00 PM. The water flush bag was dated 06/20/23 as well. However, the bag had a sticky-spot where the sticker had been previously, indicating this bag may have been the same bag as before with a different sticker. The tube feeding was at the 500mL mark out of a 1,000mL capacity bottle. Based on the surveyor's calculations, the bottle should have only had approximately 200mL left. An observation was conducted on 06/22/23 at 8:11 AM of Resident #47's tube feeding. This observation was of a bag instead of a bottle. The bag was labeled Jevity 1.5 and dated 06/21/23 but was not timed. The bag had approximately 650mL left inside. If the tube feeding was started at 4:00 PM on 06/21/23 per the physician's order, there should have only been approximately 200mL left. An interview was conducted with the facility's Assistant Director of Nursing (ADON) on 06/22/23 at 8:18 AM. The surveyor asked how long the facility has been out of the tube feeding sets with the spike for the bottles and she stated she did not know but that it had been at least a few weeks. An observation was conducted on 06/22/23 at 12:40 PM of Resident #47-her tube feeding pump was off and disconnected. A secondary interview was conducted with the facility's ADON on 06/22/23 at 12:49 PM. She stated she was told that the tube feeding tubing has been on back order for approximately 3 weeks. 2) During the initial tour of the facility conducted on 06/19/23 at 11:07 AM, the surveyor observed that Resident #67 was lying in bed with eyes closed. Upon closer observation, Resident #67 had a bottle of Glucerna 1.5 (formulary type) tube feeding that was labeled as started on 06/19/23 but was untimed and was infusing at 70mL/hour. Further observation revealed the water flush bag was dated 06/17/23 at 4:00 PM. The tube feeding was at the 850mL mark out of a 1,000mL capacity bottle. Review of Resident #67's Physician Orders revealed an order was written on 11/09/22 for Enteral Feed every shift continuous feeding: formula-Glucerna 1.5, Rate 70mL/hour x18 hours start at 4:00 PM time and run until 1260mL has infused. Flush with water amount 50mL/hour x18 hours (total 900mL). An observation was conducted on 06/20/23 at 6:22 AM of Resident #67's tube feeding. Glucerna was infusing, the bottle was dated 06/19/23, untimed. The water flush bag was still dated 06/17/23. The Glucerna bottle had approximately 425mL left. If the tube feeding was started at 4:00 PM on 06/19/23 per the physician order, there should have only been approximately 20mL left. An interview was conducted with Staff E, Licensed Practical Nurse (LPN) on 06/20/23 at 6:32 AM regarding tube feeding. The surveyor asked Staff E how often tube feeding tubing and bags are changed at the facility. Staff E stated the tube feeding tubing and bags are changed daily. When shown Resident #47's water flush bag as dated 06/17/23, Staff E stated the facility had a shortage of tube feeding sets, but that she had not noticed that the water flush bag was dated from 06/17/23. She stated she would change it immediately. When asked why the tube feeding amounts did not seem to add up (when the bottles were timed versus how much tube feeding was left) Staff E stated she did not know. An observation was conducted on 06/21/23 at 8:10 AM of Resident #67's tube feeding. Glucerna was infusing, the bottle was dated/timed 06/20/23 at 4:00 PM. The water bag was dated 06/20/23 as well. However, the bag had a sticky-spot where the sticker had been previously, indicating this bag may have been the same bag as before with a different sticker. The tube feeding was at the 350mL mark out of a 1,000mL capacity bottle. Based on the surveyor's calculations, the bottle should have been changed at this time. An observation was conducted on 06/22/23 at 8:13 AM of Resident #67's tube feeding. Glucerna 1.5 was infusing, dated 06/21/23 4:00 PM. The tube feeding was at the 200mL mark out of a 1,000mL capacity bottle. Based on the surveyor's calculations, the bottle should have been changed at this time. An interview was conducted with the facility's Assistant Director of Nursing (ADON) on 06/22/23 at 8:18 AM. The surveyor asked how long the facility has been out of the tube feeding sets with the spike for the bottles and she stated she did not know but that it had been at least a few weeks. An observation was conducted on 06/22/23 at 12:42 PM of Resident #67-her tube feeding pump was off and disconnected. 3) During the initial tour of the facility conducted on 06/19/23 at 12:54 PM, the surveyor observed that Resident #20 was lying in bed with eyes closed. Upon closer observation, Resident #20 had a tube feeding pump at the bedside but no tube feeding hanging or infusing. Review of Resident #20's revealed an order was written on 09/20/22 for Enteral Feed every shift continuous enteral feeding: formula-Jevity 1.5, rate 60mL/hour x20 hours. Start at 2PM and run until 1200mL has infused. Flush with water amount 50mL/hour x20 hours (1000mL). An observation was conducted on 06/20/23 at 6:24 AM of Resident #20's tube feeding. An unmarked tube feeding bag was hanging and infusing at 60mL/hr. The water flush bag was dated/timed 06/20/23 12:00 AM but the tube feeding bag had no markings present. The tube feeding was at the 700mL mark out of 1,000mL capacity bag. Based on the surveyor's calculations, this is close to being accurate. An interview was conducted with Staff E, LPN on 06/20/23 at 6:35 AM regarding Resident #20's tube feeding. The surveyor asked Staff E why the tube feeding bag was unmarked. Staff E stated I must have forgotten to label it. I will label it right now. An observation was conducted on 06/21/23 at 8:12 AM of Resident #20's tube feeding. Jevity was written on the tube feeding bag, dated/timed 06/21/23 at 12:00 AM. The tube feeding was at the 700mL mark out of 1,000mL capacity bag. Based on the surveyor's calculations, there should have only been approximately 500mL left in the bag. An observation was conducted on 06/22/23 at 8:15 AM of Resident #20's tube feeding-Jevity was written on the bag, dated 06/21/23, untimed. The amount in the bag was approximately 300mL. If the tube feeding was started at 2:00 PM on 06/21/23 per the physician order, the bag should have been changed at this time. An observation was conducted on 06/22/23 at 12:45 PM of Resident #20-a new bottle of tube feeding was hanging, dated/timed 06/22/23 2:00 PM but the pump was off and the tube feeding was not connected to the resident. 4) Record review for Resident #40 revealed the resident was admitted to the facility on [DATE] with most recent readmission on [DATE]. The diagnoses included Hemiplegia and Hemiparesis Following Unspecified Cerebrovascular Disease Affecting Right Dominant Side, Dysphagia, Aphagia, Dementia, and Displacement of Other Gastrointestinal Prosthetic Devices, Implants and Grafts Subsequent Encounter. Review of the Minimum Data Set (MDS) for Resident #40 dated 04/29/23 revealed in Section C a Brief Interview of Mental Status score of 09 indicating moderate cognitive impairment. Review of the Physician's Orders for Resident #40 revealed an order dated 06/19/23 for one time a day for nutritional supplement enteral feeding: formula: Glucerna 1.5; rate: 55ml/hr x 20 hours; ; start at 2:00 PM time and run until 1,100ml has infused; tube type PRG. Flush with water: amount: 75ml/hr x 20 hours (total 1500ml/day). Review of the Care Plan for Resident #40 dated 01/08/12 with a focus on resident is at risk for altered nutrition and hydration status as evidenced by actual/potential weight loss/gain related to enteral feeding, NPO status, therapeutic diet, BMI status, current diagnoses, PMH (past medical history), altered labs, impaired skin. Re-admit hospital stay 10/09/22 - 10/19/22 to rule out PEG tube site necrosis. Dx/PMH include GI Bleeding, PEG tube re-insertion, Hemiplegia, Dysphagia, CAD (Coronary Artery Disease, CHF (Congestive Heart Failure), DM (Diabetes Mellitus), Anemia and other medical diagnoses.The goals included: Nutrition and hydration status will be maintained AEB (as evidenced by) moist mucus membranes, adequate hydration, and normal labs. No intolerance to current TF (tube feeding) regimen as ordered through next review date. The interventions included: Administer medications as ordered. Monitor/Document for side effects and effectiveness. RD (Registered Dietician to evaluate and make diet change recommendations PRN (as needed). Monitor and provide TF and flushes via PEG as ordered. Record review for Resident #40 revealed the only documentation related to the resident's tube feeding was on the medication administration record (MAR) revealing the tube feeding was signed off at 2:00 PM. There was no documentation of the amount of tube feed the resident actually received. On 06/19/23 at 1:00 PM an observation was made of Resident # 40 lying in bed with eyes closed, upon closer observation the resident had a bottle of Glucerna 1.5 (formulary type) of tube feeding that was labeled as started on 06/18/23 at 6:00 PM and infusing at 55 ml/hr (milliliters per hour) via an electric pump (indicating a total volume of tube feeding infused should be 935 milliliters). The tube feeding was at the 200-milliliter mark out of a 1,000-milliliter capacity bottle. On 06/20/23 at 6:50 AM an observation was made of Resident #40 lying in bed with eyes closed, upon closer observation the resident had a bag of tube feeding labeled as Glucerna 1.5 (formulary type) of tube feeding as started on 06/19/23 (there was no start time on the label), and it was infusing at 55ml/hr via an electric pump. The tube feeding was at the 800-milliliter mark out of a 1,000-milliliter capacity bag. On 06/21/23 at 8:30 AM an observation was made of Resident #40 lying in bed, upon closer observation the resident had a bag of tube feeding labeled Glucerna 1.5 (formulary type) of tube feeding that was labeled as started on 06/20/23 (there was no start time on the label), and it was infusing at 55ml/hr via an electric pump. The tube feeding was at the 300 mark out of a 1,000-milliliter capacity bag. During an interview conducted on 06/20/23 at 6:55 AM with Staff E Licensed Practical Nurse (LPN) who was asked about the time the tube feeding was started, she stated she did not hang the tube feeding, it was started before she arrived on 06/19/23 at 11:00 PM. When asked if the tube feeding had been off during her shift, she said no. She acknowledged that the tube feeding did not have a start time, it only had a start date of 06/19/23. When asked if the tube feeding was infusing at 55 mls/hour for her entire shift why was there 800mls left in the 1,000ml capacity bag. She stated she had no idea why. She acknowledged that there should only be 560mls left in the bag currently but there was actually 800mls indicating that the resident had not received the correct amount of tube feeding. When asked why the resident had a tube feeding bottle on 06/19/23 and a tube feeding bag on 06/20/23 she said the facility ran out of the tubing that could be used with the tube feeding bottles and only had the tubing that has a bag and has to be filled with the tube feeding. During an interview conducted on 06/21/23 at 11:30 AM the Dietetic Technician from a sister facility stated she has been with the company since February 2023. She said she comes to this facility once a week for 1 day to help with nutrition for new admissions. She said the previous dietician was only at the facility for 1 month and left on 06/09/23. When asked if there is anything that she cannot do, she cannot do anything with dialysis or tube feedings or write TPN orders. She said she can monitor for weight trends and monitor for tolerance of tube feeding for residents. She looks to see if nurses documented any kind of GI (gastrointestinal) upset such as nausea or vomiting. She monitors how much tube feeding the residents are receiving by spot checking the tube feeding to make sure it is hung and infusing at the correct rate as per orders. Typically, the nurses will report any issues with tube feeding to her or to the DON (Director of Nursing) who will in turn relay the information to her. As far as the exact amount infused that is for nursing to document.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to administer scheduled medications in a timely manner for 1 resident reviewed for pain management (Resident #60) and for 1 resident reviewed for insulin (Resident #3). Medications are administered within (60 minutes) of scheduled time. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the facility. The findings included: Review of the facility's policy titled, Medication Administration - General Guidelines with a revised date of December 2019 included: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. 1) Record review for Resident #60 revealed the resident was admitted to the facility on [DATE] with the most recent readmission on [DATE]. The diagnoses included: Fracture of Sacrum, Fracture of Pubis, Displaced Fracture of Base of Neck of Right Femur, Pain in Left Hip, Pain in Left Leg, Disorders of Bone Density and Structure, Muscle Weakness, Abnormal Posture, Personal History of Poliomyelitis, Multiple Fractures of Pelvis, Fibromyalgia, and Malignant Neoplasm of Cervix. Review of the Minimum Data Set (MDS) for Resident #60 dated 04/29/23 revealed in Section C a Brief Interview of Mental Status (BIMS) score of 15 indicating a cognitive response. Review of the Physician's Orders for Resident #60 revealed an order dated 06/14/23 for Oxycodone HCL 20mg given by mouth every 4 hours for non-acute pain (scale 6-10). Review of the Care Plan for Resident #60 dated 08/15/22 with a focus on the resident having chronic pain related to terminal condition, and multiple fractures. The goals included: The resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. The resident will not have discomfort related to side effects of analgesia through the review date. The interventions included: Administer analgesia as per orders. Give ½ hour before treatments or care. Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Monitor/record/report to nurse resident complaints of pain or requests for pain treatment. Review of the medication administration record (MAR) for Resident #60 from 06/14/23 to 06/22/23 revealed the resident received the medication every 4 hours as scheduled (1:00 AM, 5:00 AM, 9:00 AM, 1:00 PM, 5:00 PM, and 9:00 PM). Review of the Medication Monitoring/Control Record for Oxycodone HCL 20mg every 4 hours for Resident #60 it revealed the medication was signed off on 06/20/23 at 5:00 AM and then again at 8:10 AM Upon review of a more detailed report the administration summary (report of the time the medication was actually signed off as administered) for Resident #60 from 06/14/23 to 06/21/23 for the medication Oxycodone HCL 20mg revealed the following: On 06/15/23 for the scheduled time of 9:00 PM the medication was administered at 11:21 PM. On 06/16/23 for the scheduled time of 5:00 AM the medication was administered at 6:26 AM. On 06/19/23 for the scheduled time of 9:00 AM the medication was administered at 11:01 AM On 06/19/23 for the scheduled time of 1:00 PM the medication was administered at 2:57 PM On 06/19/23 for the scheduled time of 9:00 PM the medication was administered at 10:26 PM On 06/20/23 for the scheduled time of 5:00 AM the medication was administered at 8:03 AM On 06/20/23 for the scheduled time of 9:00 AM the medication was administered at 8:10 AM On 06/21/23 for the scheduled time of 5:00 AM the medication was administered at 6:26 AM This indicated that 8 times out of 44 opportunities (18%) the resident received the medication outside of the 60 minutes scheduled time and on 06/20/23 the resident received the medication twice in 7 minutes. During an interview conducted on 06/19/23 at 10:10 AM with Resident #60 who stated her pain medication was recently changed from as needed to routine every 4 hours and some of the nurses do not give her the pain medication on time. She said like today she has not received her pain medication scheduled for 9:00 AM, it is over an hour late. During an interview conducted on 06/22/23 at 2:15 PM with Staff S Licensed Practical Nurse, when asked about Resident #60 and her Oxycodone HCL 20 mg, the nurse stated that the medication was PRN (as needed) and was changed recently to schedule every 4 hours because the resident was asking for the pain medication very regularly every 4 hours. When asked if before administering the medication she verifies to see when the last time the resident received the medication, she said she does and she checks it on the narcotic count sheet (Medication Monitoring/Control Record) for the resident. During an interview conducted on 06/22/23 at 5:10 PM with the Director of Nursing (DON) when asked about the Oxycodone HCL 20mg medication scheduled every 4 hours for Resident #60, she said they had reviewed the medications and there was no issue. When it was pointed out that about 8 times the medication was given outside of the 60-minute scheduled time, she said that is just the time they sign off on the medication, that may not be the actual time it was given, the nurses may get caught up with something and the documented time may not be accurate. She was also made aware the report of the administration summary report indicated the resident received the medication 7 minutes apart on 06/20/23. 2) Review of Resident #3's clinical record documented an admission on [DATE] with no readmissions. The resident diagnoses included Chronic Kidney Disease, Urinary Tract Infection, Malignant Neoplasm of other parts of Uterus, Intra-Abdominal and Pelvic swelling, Diabetes, Cardiomyopathy, Chronic Obstructive Pulmonary Disease (COPD) and Cerebral Infarction. Review of Resident #3's MDS admission assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 13 indicating that the resident had little to no cognition impairment. The assessment documented under Functional Status that the resident needed extensive assistance to total assistance from the staff to complete the activities of daily living. Review of Resident #3's care plans lacked evidence of the resident's medication administration preferences or refusal of the medications. Review of Resident #3's clinical record nursing notes lacked documentation of the physician notification of the resident refusing her pain patch or the administration of medications later than scheduled times. Review of Resident #3's physician order documented the following: 1-Aspirin 81 mg daily dated 05/07/23. 2-Budesonide inhalation suspension 0.25 mg/2ml inhale two times a day for shortness of breath dated 05/06/23. 3- Coreg (Carvedilol) 3.125 mg two times a day for hypertension dated 05/07/23. 4-Dorzolamide Ophthalmic solution 1 drop in both eyes three times a day for Glaucoma dated 05/06/23. 5-Entresto tablet 49-51 mg every 12 hours for heart failure dated 05/16/23. 6-Famotidine 20 mg daily for Gastro-Esophageal Reflux (GERD) dated 05/06/23. 7-Iron Sulfate 325 mg daily. 8-Fluticasone-Salmeterol (Advair) buccally two times a day for Asthma dated 05/07/23. 9-Lactulose 30 ml daily for constipation dated 05/17/23 10-Lidoderm patch (Lidocaine) to lateral right hip one time a day for right hip pain dated 05/30/23 11-Multivitamins daily dated 05/06/23. 12-Sodium Chloride tablet 1 gram two times a day dated 05/06/23. 13-Torsemide 10 mg daily for hypertension dated 05/24/23. On 06/19/23 at 11:48 AM, during observation of the administration of Resident #3 Insulin Lispro-Pen two (2) units performed by Staff O, RN, it was observed that Staff O brought into the resident's room a medication cup with several pills in the cup. Consequently, an interview was conducted with Staff O who stated that those pills were the resident's 9:00 AM scheduled medications. On 06/20/23 at 10:44 AM, observation of medication administration for Resident #3 performed by Staff O, was conducted. Staff O stated she had not given any medications (today) to the resident. Staff O added that the resident did not like to take her medications right after breakfast because it made her sick in her stomach. Observations revealed Staff O poured the following medications: Aspirin chewable 81 mg, Budesonide inhalation suspension 0.25 mg/2 ml ampule (to prevent symptoms of Asthma), Lidocaine 4% patch (to help relief pain), Coreg 3.125 mg (to treat mild, moderate or severe heart failure), Dorzolamide 2% eye drops (to decrease the pressure in the eye), Entresto 49-51 mg (to treat a type of long-term heart failure in adults), Iron 325 mg, Famotidine 20 mg (to prevent and treat heartburn), Advair 250/50 inhaler (to treat difficulty breathing, wheezing, shortness of breath, coughing, and chest tightness caused by asthma), Lactulose 10 gm/15 ml-30 ml (to treat constipation), Multivitamins with minerals, Sodium Chloride 1 gm tablet (an electrolyte replenisher), and Torsemide 10 mg (to treat high blood pressure). On 06/20/23 at 11:13 AM, Staff O, RN entered Resident #3's room, performed hand hygiene and then proceeded to assist the resident with the medications administration. The resident refused to take the Lidocaine patch and the Lactulose. Staff O stated that the resident refuses her pain patch to be put on until her daughter comes and washes her up. An interview was conducted with Resident #3 who stated her daughter came in and washed her up on 06/19/23 evening. Subsequently, a side by side review of the resident's left side was conducted with Staff O. The review revealed a green patch on the resident's left knee. Staff O stated she did not know what it was and stated that the resident's daughter comes in and put patches on her. During the review, the resident stated that the patch was brought up to her by her son and the daughter placed it on in her left knee on 06/19/23. On 06/20/23 at 11:27 AM, Staff O, RN left the resident's room to get her stethoscope. Staff O returned to Resident #3's room at 11:29 AM, performed hand hygiene, donned gloves, auscultated the resident's lungs, then poured the Budesonide inhalation suspension 0.25 mg/2 ml ampule into the resident inhalation canister. The medication was scheduled for 9:00 AM. Staff O came out of the resident's room to document the medication administration into the electronic record. Observation revealed the medication screen was reddish/pinkish color. Staff O was asked why the medication screen was pinkish color and not green and she replied she was late because she was nervous. Staff O was apprised that on 06/19/23 she was also late giving Resident #3's medications. Staff O replied she was nervous. During the interview, Staff O stated she had 3 other residents that she had not given their scheduled 9:00 AM medications as of yet. On 06/22/23 at 11:51 AM, an interview was conducted with the DON who was apprised of medication administration observation findings for Resident #3. The DON stated Resident #3's daughter came in on 06/21/23 and the green patch was removed. The DON confirmed there was no documentation in the resident's record of notification to the physician of the resident refusing her 9:00 AM scheduled pain patch or 9:00 AM medications given outside the scheduled time on 06/19/23 and 06/20/23. On 06/22/23 at 4:44 PM, a side by side review of Resident #3's June 2023 MAR for Coreg, one of the resident's medication scheduled for 9:00 AM on 06/19/23 and 06/20/23 was conducted with the DON. The review revealed that Resident #3 medications scheduled for 9:00 AM were documented as administered at 11:43 AM. The DON reviewed the resident clinical record and stated there was no nursing documentation related to the administration of resident's medications later than schedule time or a physician notification.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4) During a tour of the facility conducted on 06/20/23 at 6:06 AM, an observation was made of an unlocked, unattended medication cart in the hallway of the first floor Unit C. Further observation revealed a resident in the hallway, propelling himself past the open medication cart in his wheelchair. Staff D, Licensed Practical Nurse was at the nurses station at the time of this observation, approximately 100 feet away from the medication cart. The surveyor waited 6 minutes for Staff D to return to the medication cart. When she saw the cart was unlocked, she locked it immediately. There was also a piece of paper containing resident's information on the top of the medication cart. Staff D confirmed that she was the only nurse on the first floor for the night shift and that she was responsible for this medication cart. Photographic evidence obtained. 5) During a tour of the facility conducted on 06/20/23 at 8:38 AM, an observation was made of an unlocked, unattended medication cart in the hallway of the first floor Unit C. Staff C, Registered Nurse was inside a resident's room at the time of this observation, approximately 50 feet away from the medication cart. The surveyor waited 3 minutes for Staff C to return to the medication cart. When she saw the cart was unlocked, she locked it immediately. Staff C confirmed that she was responsible for this medication cart. Photographic evidence obtained. Based on observations, interviews, and record review the facility failed to secure 3 of 6 medication carts, failed to secure 1 treatment cart, and failed to secure meds at the bedside for 1 of 19 sampled residents (Resident #143) The findings included: Review of the facility's policy titled, Storage of Medications with a revised date of January 2018 included: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. 1) Record review for Resident #343 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Displaced Intertrochanteric Fracture of Right Femur, Pain in Right Hip, and Anxiety Disorder. Review of the Minimum Data Set (MDS) for Resident #343 dated 06/13/23 revealed in Section C a Brief Interview of Mental Status (BIMS) score of 10 indicating moderate cognitive impairment. Review of facility documentation revealed there are 18 out of 92 Residents in the facility who are mobile and have a BIMS score of 12 or less indicating moderate to severe cognitive impairment. On 06/19/23 at 1:35 PM an observation was made on the first floor across from the nurse's station of a treatment cart left unlocked and unattended which contained various cream/ointment/solution medications. One of the residents (Resident #343), who was in a wheelchair approached the treatment cart and started pulling one of the drawers of the treatment cart open. The surveyor gently closed the treatment cart drawer and informed the resident that if she needs something the nurse should be able to help her. The Surveyor stayed with treatment cart and asked a staff member walking by for the nurse. During an interview conducted on 06/19/23 at 1:40 PM with Staff C Registered Nurse (RN) who was asked why the treatment cart on the first floor across from the nurse's station with medications was left unlocked and unattended, she stated she had just gone into the treatment room to get a medication for one of the residents and must have forgotten to lock the treatment cart. When asked which resident it was that was near the treatment cart, she stated the resident is confused, and it is not her resident but was able to obtain the name of the resident. 2) On 06/20/23 at 6:29 AM an observation was made on the first floor across from the nurses' station of a treatment cart left unlocked and unattended which contained various cream medications. During an interview conducted on 06/20/23 at 6:33 AM with Staff D Licensed Practical Nurse (LPN) who stated she has been with the facility for almost 2 years. When she was asked why the treatment cart on the first floor across from the nurse's station was left unlocked and unattended, she said she had no idea, she said it must have been left unlocked by the previous shift because she was the only nurse on the first floor, and she did not need to go into the treatment cart during her shift. 3) On 06/20/23 at 6:48 AM an observation was made of the C Hall odd medication cart left unlocked and unattended. During an interview conducted on 06/20/23 at 6:50 AM with Staff E Licensed Practical Nurse (LPN) who was asked why the C Hall odd medication cart was left unlocked and unattended, she stated that she just forgot to lock it. 6) Review of Resident #143's clinical record documented an admission on [DATE] with no readmissions. The resident diagnoses included Fracture of Right Femur, Rheumatoid Arthritis, Emphysema, Chronic Obstructive Pulmonary Disease (COPD), Asthma, Chronic Kidney Disease, Depression, Gastro-Esophageal Reflux Disease (GERD), Irritable Bowel Syndrome and Long Term Use of Systemic Steroids. Review of Resident #143's Minimum Data Set (MDS) admission assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 15 indicating that the resident had no cognition impairment. The assessment documented under Functional Status that the resident needed extensive assistance from the staff to complete the activities of daily living. Review of Resident #143's care plans lacked evidence of a self-administration of medications care plan. The resident's record lacked evidence of a physician orders for the resident to perform self-administration of medications. On 06/19/23 at 9:58 AM, observation revealed Staff L, CNA coming out of Resident #143's room and stated the resident was asleep. On 06/19/23 at 10:01 AM, observation revealed Resident #143 in bed, eyes opened. An interview was conducted with the resident who stated she had been in the facility for about two weeks getting rehabilitation. Further observation revealed one opened bottle of Acetaminophen (Pain reliever) extra strength 500 milligrams (mg) capsules, one opened bottle of Theraworx for muscle cramp and spasm relief spray, one opened bottle of PreserVision eye vitamin with minerals supplement on top of the resident's night stand. During the observation the resident pulled an opened bottle of Systane lubricant for dry eye relief. The resident stated she had to take the PreserVision supplement for Macular Degeneration and that she could not wait for them (facility staff) to bring them to her. The resident added the facility did not have her Asthma medication and she had been using her own inhaler. The resident pulled a plastic bag with a prescribed medication Anoro inhalation powder. The resident was asked if the nurse knew that she was taking the medications in her room and she stated she was not sure. Photographic evidence obtained. On 06/20/23 at 8:05 AM, observation revealed Resident #143's in bed eating breakfast. Further observation revealed one opened bottle of Acetaminophen (Pain reliever) extra strength 500 milligrams (mg) capsules, one opened bottle of Theraworx for muscle cramp and spam relief spray, one opened bottle of PreserVision eye vitamin with minerals supplement continue to be on top of the resident's night stand. On 06/20/23 at 10:36 AM, a side by side review of Resident #143's medications on top of the night stand was conducted with Staff C, RN. Staff C stated that they follow the resident's hospital discharge list and the resident needed to tell them if they were taking anything else. Staff C lifted the acetaminophen bottle, an albuterol inhaler and a box of PreserVision supplements from the resident night stand and stated that she did not know that the resident had medications in the room. Staff C then pulled a plastic bag from underneath the resident's bed that contained the Anoro inhalation powder. Staff C stated the resident was not allowed to have those medications in the room and that she will call the physician for orders. On 06/22/23 at 11:51 AM, an interview was conducted with the DON and she was apprised of Resident 143's medications in her room. The DON stated the resident was not care plan to have medications at the bedside and Staff C, RN got a physician order and medications were removed from the room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to prepare, store and serve food in a sanitary manner and in accordance with professional standards. The findings included: 1). During the initial kitchen tour on, 06/19/23 at 9:24 AM, accompanied by the Dietary Manager, the following were noted: a. the surface of the top of the counter mounted toaster was showing signs of wear and peeling b. there was an accumulation of food residue on the blade of the counter mounted manual can opener. At the conclusion of the initial kitchen tour, the Dietary Manager acknowledged understanding of the concerns. 2). On 06/20/23 at 9:10 AM, Resident #85 was provided lunch to take to dialysis that consisted of a sandwich that was made up of sliced deli meat and cheese, 2 containers of apple juice and graham crackers. It was noted that there was no cooling medium in the soft-sided cooler that was provided to the resident to maintain foods at safe temperatures. During an interview with Staff A, Dietary Aide, when asked about ice packs to keep the lunch at a safe temperature, the Dietary Aide stated, we don't use ice packs. The Dietary Manager acknowledged understanding of the concern and then proceeded to the freezer and returned with an ice pack and prepared a new meal for the resident to take with her. 3). During the follow up kitchen tour, on 06/21/23 at 11:18 AM, accompanied by the Dietary Manager and the Senior Dietary Manager, the following were noted: a. Eating utensils (forks, knives, spoons) that were being placed on the tables in the Main Dining Room for the residents were not store inverted in a manner that the food and mouth contact surfaces of the utensils were facing up. b. An oven mitt noted to be torn to a point that was uncleanable with the potential to cross contaminate food and non-food contact surfaces. c. Staff B, Diet Aide, was observed handling single use lids with her bare thumb directly in contact with the bottom of the lid that would be in direct contact with the fluid in the cup that was being served. d. The Dietary Manager was observed taking temperatures of the foods in the hot holding unit by sticking the entire probe of the digital metal stemmed probe style thermometer into the products to a point that the [NAME] of the thermometer was directly in the products. The Dietary Manager then disinfected the probe with an alcohol swab but did not disinfect the [NAME]/handle of the thermometer prior to inserting to get the temperature of other products. At the conclusion of the follow up tour of the kitchen, the Dietary Manager and the Senior Dietary Manager acknowledged understanding of the concerns. 4). During an observation of the second floor unit pantry, on 06/22/23 at 10:57 AM, accompanied by the Dietary Manager, upon entering the pantry, there was a strong odor indicative of mold. It was noted that there was an accumulation of a black mold like substance inside of the cabinet underneath the hand washing sink. The Maintenance Director was made aware of the concern with the second floor unit pantry.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, observations and interviews, the facility failed to provide care and services as per the Wound Care Specialist report / orders for 2 of 4 sampled residents, Resident #3 and #4. The findings included: Review of the facility policy provided by the Director of Clinical Services, titled, Clinical Guidelines Skin & Wound effective date 04/01/17, documented, .monitor resident's response to treatment and modify treatment as indicated . 1. Review of Resident #3's clinical record documented an initial admission to the facility on [DATE] and a latest readmission on [DATE]. The resident's diagnoses included Hemiplegia, Hemiparesis affecting left side following Cerebral Infarction, Atrial Fibrillation, Contracture of Left Shoulder, Left Hand and Left Elbow, Parkinson's Disease, Chronic Obstructive Pulmonary Disease (COPD), Diabetes Mellitus, Atherosclerotic Heart Disease and Dementia. Review of Resident #3's care plan, titled, The resident has a chronic rash of the upper/lower back with interventions to include .avoid scratching and keep hands and body parts from excessive moisture . Review of Resident #3's Minimum Data Set (MDS) significant change assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 15 indicating the resident had no cognition impairment. The assessment documented under Functional Status the resident was dependent on the staff for his activities of daily living except eating. Review of Resident #3's physician order dated 01/17/23 documented, CalProtect External ointment (zinc oxide) apply to sacrum topically every shift for rash/redness. A physician order dated 04/04/23 documented, Zinc Oxide External Ointment 20% apply to hip topically every day-shift for scratches. Review of Resident #3's Wound Care Specialist (WCS) visit report, titled, Wound Evaluation & Management Summary dated 03/17/23, documented, in part, Focused wound exam (site 1) non-pressure wound buttock partial thickness, wound size 2 x 2 centimeters (cm), depth no measurable, wound progress: improved . Summarized wound care assessment and individualized treatment plan for site 1 documented continue Zinc ointment every shift for 30 days .Coordination of Care section documented: data and history pertinent to this patient's care were obtained via nursing staff. This patient's care was discussed with another healthcare provider nursing staff member during the visit .This documentation has also been made available for access to the appropriate personnel and placement in the medical record .evaluation by wound care specialist within 7 days with further intervention as indicated. Review of Resident #3's Wound Care Specialist (WCS) visit report, titled, Wound Evaluation & Management Summary dated 03/24/23 documented, in part, Focused wound exam (site 1) non-pressure wound buttock partial thickness, wound size 3 x 3 cm, depth no measurable, wound progress: deteriorated .Summarized wound care assessment and individualized treatment plan for site 1 documented add Antifungal prescription - Clotrimazole 1% cream twice a day for 30 days, discontinue Zinc ointment .Coordination of Care section documented: data and history pertinent to this patient's care were obtained via nursing staff. This patient's care was discussed with another healthcare provider nursing staff member during the visit .This documentation has also been made available for access to the appropriate personnel and placement in the medical record .evaluation by wound care specialist within 7 days with further intervention as indicated. Review of Resident #3's Wound Care Specialist (WCS) visit report, titled, Wound Evaluation & Management Summary dated 03/31/23, documented, in part, .has a non-pressure wound to the left hip for at least 1 day duration . Focused wound exam (site 1) non-pressure wound buttock partial thickness, wound size 2.5 x 2.5 centimeters (cm), depth no measurable, wound progress: improved . Focused wound exam (site 2) non-pressure wound of the left hip partial thickness, wound size 5 x 5 centimeters (cm), depth no measurable .Summarized wound care assessment and individualized treatment plan for site 1 documented continue Antifungal prescription- Clotrimazole 1% cream twice a day for 23 days .Summarized wound care assessment and individualized treatment plan for site 2 documented add Zinc ointment once daily for 30 days .Coordination of Care section documented: data and history pertinent to this patient's care were obtained via nursing staff. This patient's care was discussed with another healthcare provider nursing staff member during the visit .This documentation has also been made available for access to the appropriate personnel and placement in the medical record .evaluation by wound care specialist within 7 days with further intervention as indicated. Review of Resident #3's March and April 2023 Treatment Administration Record (TAR) was conducted. The review revealed lack of administration / documentation of Clotrimazole cream as documented on the WCS report dated 03/24/23 for site 1 to the resident's non-pressure wound to the buttock (site 1); and the lack of administration / documentation of Zinc Oxide documented on the WCS report dated 03/31/23 for site 2 to the resident's non-pressure wound of the left hip identified by the WCS on 03/31/23. On 04/04/23 at 2:52 PM, an interview was conducted with Staff A, Licensed Practical Nurse (LPN), who stated she only applied CalProtect cream to Resident #3 today after morning care. A side-by-side review of the resident's sacrum area was conducted with Staff A. The review revealed resident's area with a white color substance in the sacrum / buttock area. Staff A stated she applied the cream to all the sacrum area. During the review, observation revealed Staff A fastening Resident #3's briefs back together. Further observation revealed the resident had two briefs on. Staff A confirmed the resident had two briefs on and stated the resident was not supposed to have two briefs on. Staff A stated she will inform the Certified Nursing Assistant (CNA) to remove one. On 04/04/23 at 3:01 PM, an interview was conducted with Staff B, CNA, who stated she was assigned for the first time to care for Resident #3 today. Staff B stated the resident had a bowel movement, a lot, and she put on two briefs. Staff B stated she did it to prevent the resident from getting his hand into the poop and added she just left one brief open. Staff B was apprised that Staff A and the surveyor checked Resident #3's brief and both were fastened together. Staff B was informed of the resident's skin issue due to moisture. Staff stated that two briefs were not a good idea then. On 04/05/23 at 10:13 AM, a telephone conference call interview with the Director of Clinical Services (DCS) and the WCS was conducted. The WCS was asked about his report visit dated 03/24/23 for Resident #3 (site-1) non-pressure wound buttock and his treatment plan to add Antifungal prescription - Clotrimazole 1% cream twice a day for 30 days and discontinue Zinc ointment. The WCS was apprised the change in treatment plan was not started until 04/04/23. The WCS stated it was possible that he did not tell the nurse of the new treatment and added 'it will be my fault'. The WCS stated he remembered talking to the nurse about the resident scratching. On 04/05/23 at 11:09 AM, a joint side-by-side review of Resident #3's WCS visit note for 03/24/23 and 03/31/23 was conducted with the DCS and the Wound Care Nurse (WCN). During the review, the WCN was asked what her process was related to retrieving the WCS visit report. The WCN stated the WCS comes to the facility to see the residents with wounds every Friday. The WCN stated she does rounds with the WCS on Fridays, and on Monday she goes to the computer to see if the WCS uploaded the visit report. The WCN stated the WCS was supposed to send the report on the same day of the visit and added the WCS tries to send the report by Monday. The WCN stated that if during the round with the WCS he say that he is going to change the treatment, she will enter a telephone order in the computer, and if no changes, she leave it as is. The WCN stated that sometimes she had to call the WCS to obtain the visits report. The WCN was asked to read the WCS visit report under Coordination of Care that documented .this patient's care was discussed with another health care provider Nursing Staff Member during the visit . During the interview, the WCN stated that her understanding of the WCS statement was that he has talked to her about the orders when he wants to change the treatment. The WCN stated that also could be other staff members, like another nurse when she is off. The WCN stated sometimes he puts the new treatment in the note and sometimes he says continue the same treatment and move on to the next patient. The WCN was apprised that Resident #3's WCS visit report dated 03/24/23 documented a change of treatment. The WCN stated she did not pull Resident #3's note for the visit on 03/24/23 because during the visit the WCS said to continue with the same treatment. The WCN was apprised that Resident #3's WCS visit report dated 03/31/23 documented a change of treatment and a new site to be treated. The WCN stated that she did not make rounds with the WCS on 03/31/23 for residents on the second floor (Resident #3 was located on the second floor) and was not aware that a new site was identified and a new order was written for the resident for the visit on 03/31/23. The WCN stated she saw the WCS visit report today (04/04/23) for the first time. During the interview, the WCN stated the WCS was going to have to write the order because he tells her to continue the same treatment and then he writes something different. The WCN stated she was responsible to retrieving and reviewing the WCS reports. During the interview, the DCS stated the nurses have to rely on the WCS report. The DCS added that the staff would continue with the WCS treatment plan until they received the note. The DCS stated she had told the WCS many times to write the change on treatment on a telephone order and not to give a verbal order to the WCN. The DCS was apprised that Resident #3's non-pressure wound to the buttock deteriorated as per the WCS on 03/24/23 and he changed the treatment plan. The DCS was also apprised that the resident developed a new site identified by the WCS on 03/31/23 and the WCN was not aware of the new site and new treatment. The resident's new site was not addressed until 04/04/23. 2. Review of Resident #4's clinical record documented an admission on [DATE] with no readmissions. The resident's diagnoses included Acquired Deformity of Right Lower Leg, Pressure Ulcer to sacrum stage 4 and Legal Blindness. On 04/04/3 at 11:45 AM, observation revealed Resident #4 lying down on her left side in bed with a soft mattress, no air machine was noted attached to the bed. An interview was conducted with the resident who stated the staff was doing her wound care daily and they were keeping her informed of the progress. Observation revealed the resident was not wearing any boots to her heels. On 04/04/23 at 12:01 PM, an interview was conducted with the WCN who stated Resident #4's wound care orders were to cleanse the sacrum wound with normal saline, apply TheraHoney (Manuka Honey-generic from) and cover with border gauze. Observation of Resident #4's sacral wound care performed by the WCN and assisted by the Staffing Coordinator/CNA was conducted. Observation revealed the WCN cleaned the sacral wound with normal saline solution, applied Manuka Honey and applied a dry dressing. During the observation, the WCN stated Resident #4's left buttock surgical wound had re-opened and she would call the physician for a wound care order. The WCN added that per WCS, it was resolved on 03/31/23 (last Friday). The WCN was asked if Resident #4 was on an air mattress and stated the resident was on a pressure relieving mattress. The WCS stated it was the mattress the facility was using for residents with sacrum wounds. The WCN was asked if there were any residents on an air mattress, who stated she believed she had one resident on an air mattress. The WCN was asked if the facility was using heel boots to offload residents' heels and stated no. The CNA / Staffing Coordinator was asked to remove Resident #4's non-skid socks and it was noted the resident's left heel had redness. The WCN stated that Resident #4 had a non-blanchable pressure injury to the left heel. The WCN confirmed Resident #4 had a DTI (Deep Tissue Injury) on left heel (deep tissue injury are caused by pressure to the area). During the examination, the resident complained of a little pain. The WCN stated the resident had a physician order for skin prep to bilateral heel every shift (physician order dated 03/17/23). The WCN was asked to research the air mattress type and 'Group 2' mattress and to get back to the surveyor. On 04/05/23 at 1:45 PM, during an interview, the WCN stated that air mattresses are Group 3. On 04/04/23 at 12:38 PM, an interview was conducted with Staff C, CNA, who stated Resident #4 was dependent on staff for turning and repositioning and was using a wedge pillow to keep the resident on her side. Review of Resident #4's Wound Care Specialist (WCS) visit report, titled, Wound Evaluation & Management Summary dated 03/17/23, documented, in part, Focused wound exam (site 3) pressure wound sacrum full thickness, wound size 2.3 x 1.5 x 0.2 cm, wound progress: improved .Summarized wound care assessment and individualized treatment plan for site 3 documented TheraHoney for 30 days and skin prep to the periwound daily for 13 days .Recommendations: Prevalon boots, Group 2 mattress, off-load wound .Coordination of Care section documented: data and history pertinent to this patient's care were obtained via nursing staff. This patient's care was discussed with another healthcare provider nursing staff member during the visit .This documentation has also been made available for access to the appropriate personnel and placement in the medical record .evaluation by wound care specialist within 7 days with further intervention as indicated. Review of Resident #4's Wound Care Specialist (WCS) visit report, titled, Wound Evaluation & Management Summary dated 03/24/23, documented, in part, Focused wound exam (site 3) pressure wound sacrum full thickness, wound size 1.5 x 1.7 x 0.2 cm, wound progress: improved .Summarized wound care assessment and individualized treatment plan for site 3 documented continue TheraHoney for 23 days and skin prep to the periwound daily for 30 days .site 4- Post surgical wound of the left buttock resolved on 03/24/23 .Recommendations: Prevalon boots, Group 2 mattress .Coordination of Care section documented: data and history pertinent to this patient's care were obtained via nursing staff. This patient's care was discussed with another healthcare provider nursing staff member during the visit .This documentation has also been made available for access to the appropriate personnel and placement in the medical record .evaluation by wound care specialist within 7 days with further intervention as indicated. Review of Resident #4's Wound Care Specialist (WCS) visit report, titled, Wound Evaluation & Management Summary dated 03/31/23, documented, in part, Focused wound exam (site 3) pressure wound sacrum full thickness, wound size 1.4 x 1.5 x 0.2 cm, wound progress: improved .Summarized wound care assessment and individualized treatment plan for site 3 documented continue TheraHoney for 16 days and skin prep to the periwound daily for 23 days .Recommendations: Prevalon boots, Group 2 mattress .Coordination of Care section documented: data and history pertinent to this patient's care were obtained via nursing staff. This patient's care was discussed with another healthcare provider nursing staff member during the visit .This documentation has also been made available for access to the appropriate personnel and placement in the medical record .evaluation by wound care specialist within 7 days with further intervention as indicated. On 04/05/23 at 11:15 AM, during an interview, the DCS was asked about Group 2 mattresses and stated she will ask the WCS. The DCS stated the WCS informed her that Group 2 mattresses are air mattress. The DCS was informed that Resident #4 did not have an air mattress. Definition of Group 2 mattress as recommended by the WCS is a mattress generally designed to either replace a standard hospital or home mattress or as an overlay placed on top of a standard hospital or home mattresses. On 04/05/23 at 4:10 PM, a side-by-side review of Resident #4's WCS report was conducted with the WCN. The WCN was apprised she had not applied skin prep to the resident periwound during the wound care observation as per WCS report. The WCN stated that during rounds, the WCS did not apply skin prep to the surrounding area of the wound and added 'it is what it is'.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to accurately code discharge assessments for 1 of 3 sampled closed records reviewed, Resident #85. The findings included: Record review for Resident # 85 revealed the resident was admitted on [DATE] with a readmission on [DATE] and was discharged to home on [DATE]. The diagnoses included Rhabdomyolysis, Alcohol Abuse, Anxiety and Schizoaffective Disorder. The discharge (d/c) documented the return was not anticipated. Further reivew of the Minimum Data Set (MDS) dated [DATE] revealed in Section A that the d/c status was to ans acute hospital, and Section C revealed a brief interview for mental status (BIMS) of 15 indicating intact cognitive response. Record review for Resident #85 revealed a social worker progress note, dated 12/06/21. The note documented that Social Services spoke with patient to see how the patient was doing; the Patient stated that she is doing good, and that she is looking forward to being discharged home. Resident #85 also stated that at this time, she has no concerns for social services. Social Services documented, will continue to follow up with patient throughout the discharge process. Review of the general progress note, dated 12/06/21, for Resident #85 revealed: 'Patient discharged home today. No signs of acute distress. No pain or discomfort. No skin issue noted. She left with her caregiver. All personal belonging sent with patient. Staff accompanied patient to car.' During an interview conducted on 02/15/22 at 10:50 AM with the Director of Nursing (DON), she stated that the MDS person's last day was Friday and the new MDS person starts later this week. She stated she is filling in for now. She stated she believed that Resident #85 was discharged to home. When explained per the MDS dated [DATE], the 'D/C Return was not expected', Section A revealed, d/c status as acute hospital, she stated she will look into the matter and get back to me. During an interview conducted on 02/15/22 at 12:38 PM with the DON, she stated that for Resident # 85, the 'D/C return not expected', MDS dated [DATE], revealed the d/c status of acute hospital was a data entry error and has now been fixed, so that the discharge status is community.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to conduct quarterly fall risk assessments for 1 of 3 sampled residents reviewed for accidents, Resident #54. The findings included: Review of the facility's policy, titled, Clinical Guideline - Fall Management, revised on 03/01/20, documented the following: Residents to be evaluated for fall risk on admission / re-admission, quarterly, significant change, and following a fall. Review of the record showed that Resident #54 was re-admitted to the facility on [DATE] with diagnoses that included: Unspecified Fall, History of Falling, Blindness in One Eye, Unsteadiness on Feet, and Muscle Weakness. Review of Section C of the Minimum Data Set (MDS), dated [DATE], documented Resident #54 had a Brief Interview for Mental Status score of 14, which indicated that she was cognitively intact. Review of Section J of the MDS, dated [DATE], documented that Resident #54 had one fall since admission / prior assessment. Review of the Care Plan, dated 11/22/21, documented Resident #54 was at a high risk for further falls; and interventions were to follow the facility fall protocol. Review of the Fall Log, dated January 2022, documented that Resident #54 had a fall on 01/25/22. Review of the Fall Risk Evaluations showed that evaluations were completed for Resident #54 on 04/03/20, 01/25/22, and 02/01/22. During an interview on 02/15/22 at 8:55 AM, Resident #54 stated that she had a fall while in the facility about 1 month ago. When asked how she fell, Resident #54 stated that her doctor increased her pain medications, which caused her to feel dizzy and she fell over while trying to get out of bed. During an interview on 02/16/22 at 10:27 AM, the Director of Nursing (DON) stated that fall risk assessments were conducted for all residents upon admission and were updated on a quarterly basis and following a fall. According to her, fall risk assessments would be documented under the assessments tab in PointClickCare (electronic charting system). When asked about the fall risk assessments for Resident #54, the DON confirmed that fall risk assessments were completed on 04/03/20, 01/25/22, and 02/01/22. She further stated that Resident #54's fall risk assessments were to be updated every 4 months and that the system would tell you when they are due. The DON then confirmed that Resident #54 did not have any fall risk assessments between 04/03/20 and 01/25/22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During observations, interviews and record reviews, the facility failed to secure 1of 6 medication carts observed; and failed to secure medications that were observed at the bedside for 3 of 78 sampled residents observed during the initial screening process, Residents #5, #43, and #81. The findings included: Review of policy, titled, Medication Storage in the Facility, dated April 2018, revealed medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedure B) only licensed nurses, pharmacy personnel and those lawfully authorized to administer medications (such as medication aides) permitted to access medications. Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. Review of policy, titled, Self-Administration of Medication at Bedside, with a revision date of 08/22/17, revealed the resident may request to keep medications at bedside for self-administration in accordance with Resident Rights. Criteria must be met to determine if a resident is both mentally and physically capable of self-administering medication and to keep accurate documentation of these actions. Procedures included verify physician's order in the resident's chart for self-administration under consideration, complete self-administration of medications evaluation, if kept at bedside, the medication must be kept in a locked drawer. 1. During an observation on 02/15/22 at 11:54 AM, the A-wing medication cart on second floor was with the bottom right drawer extended out of the front of the medication cart about 6-8 inches. This drawer contained ipratropium bromide solution 6 boxes, fluticasone propionate 1, budesonide 1, Pulmicort 1, menthol 5% patch 1. There were no residents observed in hallway. During an interview conducted on 02/15/22 at 11:58 AM with Staff C-LPN (Licensed Practical Nurse)when asked about the open drawer to the medication cart, she stated I did not realize it was not pushed in all the way when I locked the cart. 2. Record review for Resident #5 was admitted on [DATE] with the most recent readmission on [DATE], diagnoses included Chronic Obstructive Pulmonary Disease, Acute and Chronic Respiratory Failure and Morbid Obesity. The annual minimum data set (MDS), dated [DATE], revealed in section C, a brief interview of mental status (BIMS) score of 15 indicating intact cognitive response. There was no physician order for self-administration, nor was there a completed self-administration of medication evaluation, and medications were not locked at the bedside. An observation was made on 02/13/22 at 10:57 AM in Resident #5's room during medication pass of an open package with 1 ampule of Ipratropium Bromide and Albuterol Sulfate inhalation solution 0.5mg and 3mg/3ml that was sitting on the resident's nightstand. During an interview conducted on 02/13/22 at 11:00 AM with Resident #5 when asked about the ampule of Ipratropium Bromide and Albuterol Sulfate inhalation solution on her bedside table, she said I have no idea what you are talking about. During an interview conducted on 02/13/22 at 10:58 AM with ADON (Assistant Director of Nursing)when asked about the ampule of Ipratropium Bromide and Albuterol Sulfate solution at the bedside for Resident #5, she stated it should not be there, it must have been left by the night shift. 3. Record review for Resident #43 was admitted on [DATE] with most recent readmission on [DATE] with diagnoses that included Parkinson's Disease, Acquired absence of Right Above the Knee, Dementia, Acquired absence of Left Leg below Knee. The quarterly minimum data set (MDS), dated [DATE], revealed in section C a brief interview for mental status (BIMS) score of 15 indicating intact cognitive response. There was no physician order for self-administration, nor was there a completed self-administration of medication evaluation, and medications were not locked at the bedside. An observation was made on 02/13/22 at 10:20 AM in Resident #43's room on his dresser a tube of hydrocortisone cream. During an interview conducted on 02/13/22 at 10:23 AM with Resident #43 when asked about the tube of hydrocortisone cream, he stated the staff put the cream on the end of my legs because I have phantom pain sometimes and it cools them down. During an interview conducted on 02/15/22 at 9:15 AM with Staff C-LPN, Staff C-LPN stated none of her residents are supposed to have medications at the bedside. When shown the medications for Resident #43, she stated again I never saw this here. During an interview conducted on 02/15/22 at 9:25 AM with Staff D-CNA (Certified Nursiong Assistant) when asked about cream at the bedside, she stated she only puts on cream for incontinence care and lotion for dry skin, I never put on any medicated cream, that is the nurses' job to put it on the resident, I do my job, and they (nurses) do their job. 4. Record review for Resident #81 was admitted on [DATE] with most recent admission on [DATE] with diagnoses that included Paraplegia, Anxiety, Syringomyelia and Syringobulbia, Lack of coordination, Acute Kidney Failure. The 5-day MDS, dated [DATE], revealed in section C, a BIMS score of 15, indicating intact cognitive response. There was no physician order for self-administration, nor was there a completed self-administration of medication evaluation, and medications were not locked at the bedside. An observation was made on 02/13/22 at 10:14 AM in Resident #81's room of a bottle of BHR Arthritis Pain Relief in a basket on the resident's bed. During an interview conducted on 02/13/22 at 10:20 AM with Resident #81 when asked about the bottle of arthritis pain relief, she stated she has it in case she needs it. When she was shown the medications at the bedside for Resident #81, she stated I never saw those there before. During an interview conducted on 02/15/22 at 9:15 AM with Staff C-LPN, Staff C-LPN stated none of her residents are supposed to have medications at the bedside.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the influenza vaccine to a resident who consented to receive the influenza vaccine for 1 of 5 sampled residents reviewed for influenza and pneumonia vaccinations, Resident #4. The findings included: Resident #4 was admitted to the facility on [DATE] with diagnoses that included COVID-19, Hypertension and Cellulitis. A review of the medical record for Resident #4 revealed a signed Informed Consent for the Influenza vaccine, dated 11/06/21. An interview was conducted with the Director of Nursing (DON) on 02/15/22 at 3:00 PM regarding the status of the influenza vaccine for Resident #4 that the resident consented for. The DON stated that she will look into it because the immunization is not in the resident's chart. On 02/15/22 at 3:20 PM, the DON stated Resident #4 had not received the influenza vaccine and acknowledged that he should have received it when he consented to it.

Based on observations and interviews, the facility failed to maintain food safety requirements with storage, preparation, and distribution in accordance with professional standards for food service safety which included: failure to maintain sanitary conditions and failure to maintain adequate holding temperatures. The findings included: 1. During the initial tour of the kitchen conducted on 02/13/22 at 8:48 AM, accompanied by the Food Service Director (FSD), the following were noted: a. At the request of the surveyor, the FSD checked the chemical concentration of the sanitation bucket located near the 3 compartment sink using the facility's test strips. The concentration was recorded between 0-150 parts per million (ppm). The FSD stated that the chemical concentration should have been around 200 ppm and that he had not had any issues with the sanitizer before. He then emptied and refilled the bucket with sanitizing solution and re-checked the chemical concentration. The concentration was still recorded between 0-150 ppm. b. At the request of the surveyor, the FSD checked the chemical concentration of the sanitation bucket located underneath the hot holding table using the facility's test strips. The concentration was recorded between 0-150 ppm. c. At the request of the surveyor, the FSD checked the chemical concentration of the sanitation bucket located underneath the hot holding table using the facility's test strips. The concentration was recorded between 0-150 ppm. d. At the request of the surveyor, the FSD checked the chemical concentration of the sanitation bucket located underneath the microwave using the facility's test strips. The concentration was recorded between 0-150 ppm. e. At the request of the surveyor, the FSD checked the chemical concentration of 2 sanitation buckets located underneath the coffee machine using the facility's test strips. The concentrations were recorded at 0 ppm. He then emptied and refilled one bucket with sanitizing solution and re-checked the chemical concentration. The concentration was still recorded at 0 ppm. The FSD then acknowledged that the concentrations of all sanitation buckets were too low to sanitize food contact surfaces. f. In the dry storage area, twenty 46 fluid ounce Sahara Burst apple juice cartons had a use by date of 01/29/22, seven 46 fluid ounce Sahara Burst apple juice cartons had a use by date of 01/28/22. g. In the walk-in refrigerator, 2 plastic bags of pureed food items were missing a label identifying the products and expiration dates, 1 pan of chicken was missing a label identifying the expiration date, and one opened package of bacon was missing a label identifying the expiration date. The FSD reviewed the package of opened bacon with two surveyors and stated that he could not find the expiration date. 2. Review of the facility's recipe titled, Baked Peach Slices Puree, dated 06/23/20, documented the following: If served cold, chill to 41 F or lower and hold at 41 F or lower for service. If served warm, reheat to a minimum temperature of 165 F or higher. Hold at a minimum required temperature or higher for service. Follow hot holding temperature of 135 F or 140 F based on facility policy. During an observation of the lunch tray line conducted on 02/15/22 at 11:42 AM, the FSD calibrated the facility's digital thermometer and checked the temperatures of the lunch items at the request of the surveyor. The temperature test revealed that the temperature of the baked peaches was 72 degrees Fahrenheit (F) and that the temperature of the pureed baked peaches was 69 degrees F. This showed that the baked peaches and pureed baked peaches were not at the regulatory temperature of 41 degrees F or below or 135 degrees F or above. When asked how the baked peaches were prepared, Staff A-Cook, stated that the peaches were baked in the oven and then placed in individual serving cups on a utility cart around 7:30 AM - 8:00 AM. When asked, Staff A-Cook stated that she did not know if the baked peaches were kept in a cooler or hot holding unit. According to her and the FSD, the baked peaches were to be served at room temperature. Staff B, Dietary Staff, stated that she was the one who prepared the baked peaches and pureed baked peaches. According to her, the peaches were baked in the oven, placed in individual serving cups, and stored on a utility cart in the food preparation area. Staff B-Dietary Staff confirmed that the baked peaches had been left out at room temperature since about 8:30 AM and had not been kept in a cooler or hot holding unit.