Based on record review and staff interview, the facility failed to provide the appropriate transfer/discharge notice to the resident and their responsible party and failed to notify the Office of the State Long-Term Care Ombudsman of a resident's discharge for one resident (#98) of two sampled residents reviewed for transfer and hospitalization. The findings included: A record review was conducted for Resident #98 which revealed a pink form titled SNF (Skilled Nursing Facility) to ED (Emergency Department) Handoff dated 12/29/23. The form indicated the resident was being transferred to the ED for abnormal vital signs and altered mental status. Review of the record revealed the resident did not return to the facility. Review of the Agency for Health Care Administration (AHCA) Nursing Home Transfer and Discharge Notice, form 3120-0002, listed Resident #98's name, the facility name, address, facility contact person and telephone number, and the signature of the Unit Manager (UM). All other areas of the form were blank to include the resident's representative contact information, date the notice was given, the effective date and the reason for the discharge. A review of the AHCA form Long Term Ombudsman Program Request for Review of Nursing Home Discharge or Transfer Form, form 3120-0004, revealed the form contained no resident information and was completely blank in all areas except for a check mark indicating check if this involves an emergency discharge or transfer. The form was signed by the UM and the words verbal consent were written in the resident or resident representative area. Review of the Fair Hearing Request for Transfer or Discharge from Nursing Home was completely blank of all resident information, was signed by the UM and offered that verbal residents written above the resident/representative signature line. A review of Resident #98's admitting diagnoses included: Unspecified Fall, Subsequent Encounter Unspecified Injury of Head, Abnormalities of Gait and Mobility, Unspecified Dementia, Psychotic Disturbance, Mood Disturbance, and Anxiety. A review of progress notes for Resident #98 revealed the following: 12/21/23 admission Note Text: admitted from the hospital via wheelchair and 1 transporter. No complaints of pain or discomfort. Skin assessment completed. Dressings to right and left arm changed. Daughter in to sign consents 12/22/23 Note Text: Monitoring device placed to right ankle for an elopement risk of 9. 12/22/23 Note Text: Monitoring device expiration date 09/20/26. right ankle. 12/27/23 Late Entry: Note Text: Plan of Care meeting: Team Members present: Therapy, Social Services, Resident declined, Family Member present via phone. Advance Directive: DNR (Do Not Resuscitate); Discharge plan: Resident lives at an assisted living facility (ALF). Resident was assisted prior with showers and dressing as needed. Family Member is looking into Memory Care if needed. Declined consult services at this time. No concerns at this time. Resident/representative has reviewed medication list and care plan with nurse. Resident has not displayed exit seeking behaviors prior to admission per the resident representative. 12/28/23 Late Entry: Note Text: Attendees: Director of Nursing (DON), Risk Manager, Unit Manager, Registered Dietician, Social Services Director (SSD), Minimum Data Set (MDS) Coordinator, Wound Care Nurse, Activities Director, and Rehab Director. Discussion about Accidents and Incidents: None, Weight/Diet/Adaptive Equipment, Skin Condition, Bowel and Bladder, Psychotropic Medications, Therapy to include Physical, Occupational and Speech, Fall Interventions, and Monitoring Device with Exit Seeking Behaviors. 12/29/23 Family Member and Medical Doctor made aware of resident being transferred to hospital for 140 heart rate and 44 respiration transferred to hospital. Did not return to facility. Family requested a locked unit for resident. On 02/22/24 at approximately 11:34 AM, an interview was conducted with the DON during which she stated when a resident is transferred to the ED (Emergency Department) there are usually two or three nurses working to complete the required transfer/discharge forms. She stated if the resident is transferred before the forms are completed, they will fax them to the ED. At this time, she was shown the blank forms that were signed by the Unit Manager she stated, Oh this is not good. She verified the forms should be completely filled out and stated, This is unacceptable. On 2/22/24 at approximately 1:00 PM, the SSD stated she sends a fax to the Office of the State Long-Term Care Ombudsman on the first of each month with a list of residents who had been discharged from the facility for the preceding month. She provided a copy of a fax confirmation dated 1/1/24 at 9:52 AM. Attached to the fax confirmation page was a Discharge Report for the dates 12/1/23 to 12/31/23. Resident #98's name was not included on the list. The SSD confirmed Resident #98's name was not on the list that was faxed to the Ombudsman's office on 1/1/24. The SSD proceeded to run the Discharge Report again for the same dates and the resident's name appeared. The SSD was not sure why the resident's name did not appear in the original report but stated she would fax it to the ombudsman again today (2/22/24).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to revise the care plan for one resident (#13) of 20 sampled residents whose care plans were reviewed, to reflect the current interventions to manage healing and prevention of pressure ulcers. Findings included: Resident #13 was originally admitted on [DATE] and the most recent admission was 1/20/23. The resident was hospitalized on [DATE] with no pressure ulcer present upon transfer to the hospital Resident #13's pertinent diagnoses included Parkinsonism (an umbrella term that refers to brain conditions that cause slowed movements, stiffness and tremors); Chronic Obstructive Pulmonary Disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs); severe protein-calorie malnutrition; hypo-osmolality (increased body fluid volume and decreased solute volumes in the blood) and hyponatremia (abnormally low sodium levels in the blood); oropharyngeal phase dysphasia (swallowing disorder); unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety; hypertension (high blood pressure), orthostatic hypotension (a medical condition wherein a person's blood pressure drops when standing up or sitting down); hyperkalemia (below normal blood potassium level); legal blindness; muscle weakness; Vitamin B12 deficiency; benign paroxysmal vertigo (an inner ear disorder that causes a spinning sensation); Vitamin D deficiency; unspecified glaucoma (a group of eye conditions that damage the optic nerve); spinal stenosis, cervical region (the narrowing of one or more spaces within the spinal canal in the neck); anxiety disorder; unspecified macular degeneration (a vision impairment resulting from deterioration of the central part of retina). According to Resident #13's Minimum Data Set (MDS) Significant Change in Status Assessment, with an Assessment Reference Date (ARD) of 8/29/23, the resident had a Brief Interview for Mental Status (BIMS) score of 3, indicating she had severely impaired cognitive status and had no indicators of delirium. The assessment revealed Resident #13 required extensive assistance with bed mobility, transfer, eating, toilet use, personal hygiene with one person assist. For walking in room and on corridor, this activity did not occur and she required limited assistance with locomotion on and off the unit. Resident #13 was occasionally incontinent with urine and always continent with bowel. The MDS indicated that she had no prognosis of a condition or chronic disease that may result in life expectancy of less than 6 months. The resident had no swallowing disorder, her height was 60, there was no weight documented (due to hospice) and there was no weight loss or gain or it was unknown in last month or 6 months. Resident #13's assessment indicated she had no pressure ulcer; was at risk for developing a pressure ulcer, had no unhealed pressure ulcers. In addition, the MDS indicated that the resident had a pressure reducing chair device and bed; no turning/repositioning program; no nutrition or hydration interventions related to pressure ulcer management; and ointments/medications were applied to her skin other than to feet. According to Resident #13's Quarterly MDS, with an ARD of 11/29/23, the resident had a Brief Interview for Mental Status (BIMS) score of 4, indicating she had severely impaired cognitive status and had no indicators of delirium. The assessment revealed resident #13's interim performance for self-care included substantial/maximal assistance with toilet hygiene, personal hygiene; dependent with eating; putting on/taking off footwear; partial/moderate assistance with rolling left and right in bed, sit to lying, lying to sitting on side of the bed, sit to stand, chair/bed to chair transfer, and toilet transfer. The assessment indicated it was not applicable for the resident to walk 10 feet; the resident could wheel 50 feet with 2 turns in a wheelchair and wheel 150 feet with partial/moderate assistance. Resident #13 was occasionally incontinent with urine and always continent with bowel. The MDS indicated she had no prognosis of a condition or chronic disease that may result in life expectancy of less than 6 months. The resident had no swallowing disorder, her height was 60, she weighed 107 lbs., and there was no weight loss or gain or it was unknown in last month or 6 months. Resident #13's assessment indicated she had no pressure ulcer; was at risk for developing a pressure ulcer, had no unhealed pressure ulcers. In addition, the MDS indicated the resident had a pressure reducing chair device and bed; no turning/repositioning program; no nutrition or hydration interventions related to pressure ulcer management; and ointments/medications were applied to her skin other than to feet. Resident #13's care plan initiated on 5/4/23 and revised on 11/27/23, included a focus related to pressure ulcer management - resident was at risk for impairment to skin integrity related to impaired physical mobility, fragile skin, incontinent of bowel and bladder, need for assistance with bed/functional mobility, circulatory deficiencies, end stage disease process. The care plan included two goals: The resident's will have no complications related to skin injury type through the review date. Among the many care plan interventions included, there was an intervention for The resident needs pressure reducing mattress, pillows, padding etc., to protect the skin while in bed/chair. There was a physician's order on the February 2024 Treatment Administration Record for use of pillow under legs to suspend heels off of bed - every shift for pressure ulcer management, left heel. According to the most recent Skin/Wound Weekly Evaluation V3 - V 2, dated 2/15/24, for wound #1 - left posterior heel, documented the following: acquired during admission on [DATE], which was a pressure ulcer; SDTI [suspected deep tissue injury]; improving; dry, intact non blanching dark maroon discolored tissue; no drainage, no odor, length 2.0 cm x width 2.6 cm x depth 0 cm; peri-wound tissue is pink, firm blanching tissue, no erythema; well defined wound border; no infection; skin prep to area every shift, no dressings; showing improvement, no erythema at peri tissue. The Skin/Wound Weekly Evaluation V3 - V 2, dated 2/15/24, for wound #2 - left buttock wound, documented the following; acquired during admission on [DATE]; pressure ulcer; SDTI; improving; epithelial tissue present; dry, 100% pink exposed tissue; no drainage, no odor, length 1.0 cm x width 0.4 cm x depth 0.1 cm; peri-wound tissue is pink, blanching tissue intact; well defined wound, improved; no infection; nurses to apply Baza protect 12% moisture barrier cream to area every shift, no dressings. improved, healing. The Skin/Wound Weekly Evaluation V3 - V 2, dated 2/15/24, for wound #3 - right buttock, documented the following; acquired during admission on [DATE]; pressure ulcer; SDTI; healed; dry, 100% intact closed tissue; no drainage, no odor, intact pink, blanching, no swelling; no open wound; no inflammation; nurses to apply Baza protect 12% moisture barrier cream to area every shift, no dressings. closed intact tissue; nursing continues to apply Baza Protect cream, follow up often. During an observation on 2/21/24 at 8:24 AM, Resident #13 was lying in her bed awake. She had a blanket over her and her legs and feet were angled toward her right. There was no pillow under her feet to offload and she was wearing socks on her feet. She had a scoop mattress on her bed. She is a very thin female with no fat tissue over her bony prominences. On 2/21/24 at 8:40 AM, Resident #13 had finished her breakfast. She said she ate half of her breakfast sandwich. She had enough to eat. She said she hasn't got her appetite back. She was lying in bed on her back with her knees bent and angled toward her right. There was no pillow under her feet to off load her feet. She was asked if she had a pillow under her feet and she said no and doesn't want a pillow. Resident #13 was asked if she had any bed sores and she said yes - on her foot. She was asked if she would like a pillow under her feet to make the sore better and she said no. During a wound care observation with the facility Wound Care Licensed Practical Nurse (LPN) on 2/21/24 at 10:15 AM, the LPN washed hands and put on gloves, explained procedure to the resident, removed resident's brief (noted to be clean/not soiled), right buttock noted to have a small area (approximately 2 inch x 2 inch) with 2 small dry skin/scabbed areas. Left buttock intact small area of very light redness. Interview with the Wound Care LPN during the observation revealed that she had a deep tissue injury and they have been applying barrier cream with zinc every shift. The LPN applied the barrier cream and checked with the resident again regarding discomfort and she denied any discomfort. The LPN explained the resident is on a scope mattress due to some falls and the special overlay mattress does not work. He further explained that Resident #13 is on scoop mattress and she really has improved. She had been on hospice but was discharged from their care at some point. Normally she is up during the day and is able to self-propel her wheelchair. The LPN uncovered her feet, and there was a small plaid blanket at foot of bed, per resident sometimes staff put that under her feet. The LPN removed the left foot sock and the heel noted to have a small 1 inch x 1 inch light maroon colored area blanchable skin around and the LPN indicated Resident #13 had a Deep Tissue Injury and now is improving to point the center is much lighter. The wound care LPN commented that resident appears to have good perfusion to her extremities which has allowed for healing. The left heel was intact and no redness and the LPN applied skin prep to areas, allowed to dry and reapplied socks on both feet. The LPN placed a pillow between knees and the right foot was noted floating, while the resident was lying on the right side. During an observation on 2/22/24 at 9:12 AM, Resident #13 was in bed positioned on her right side and her knees were bent. She said she needed to use the bathroom. The surveyor pushed the call bell for her and the Unit 3 Secretary came in. The Unit 3 Secretary was told Resident #13 needed to use the bathroom. The Unit 3 Secretary was asked if Resident #13 had a pillow offloading her heels and she lifted the resident's blanket and there was a folded wool blanket between her legs and her heels were not offloaded. The side of her heels was touching the mattress. An interview with Staff I, LPN at 9:13 AM, the surveyor reported the resident doesn't have a pillow under her feet and the resident said yesterday that she didn't like the pillow under her feet. Staff I, LPN was told the resident's feet were not offloaded during observations for two days. She said she would look into it. Interview with Certified Nursing Assistant (CNA), Staff G on 2/22/24 at 12:58 PM, revealed that for the Resident #13's pressure ulcers, the resident's feet should be floated with the pillow between her legs; however the resident doesn't like it and doesn't like a pillow on her back. She said that the Wound Care LPN would put a blanket between the resident's legs. Interview with the facility Wound Care Nurse, LPN, on 2/22/24 at 1:18 PM revealed that Resident #13 has 3 wounds - all deep tissue injury. The bilateral buttocks are fragile healed and he will continue to monitor until resolved. The resident is still getting the moisture barrier cream. The left heel should have a pillow to offload. He stated the resident is more mobile now and she kicks off her pillow. They have been using a blanket for the last 3 days to offload her feet. The pillow is used under left leg, as tolerated. The heel is improving and as she becomes more mobile, they will discontinue it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and meal tray identification, the facility failed to provide the correct therapeutic diet to one resident (#55) of two residents reviewed for nutritional status who was at nutritional risk. Findings included: Resident # 55 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE]. Resident #55's pertinent diagnoses included: encephalopathy (diffuse disease of the brain that alters brain function or structure that causes altered mental state and confusion), cerebral infarction [a brain lesion in which a cluster of brain cells die when they don't get enough blood] due to occlusion or stenosis of small artery; post COVID-19; dysphagia [swallowing difficulty] following cerebral infarction; acute respiratory failure with hypoxia [low levels of oxygen in your body tissues]; Type 2 Diabetes Mellitus with diabetic neuropathy [A group of diseases resulting from damaged or malfunctioning of nerves that causes weakness, numbness and pain in hands and feet]; muscle weakness; cerebral ischemia (acute brain injury that results from impaired blood flow to the brain); oropharyngeal dysphagia; delusional disorders (maintaining fixed false beliefs even when confronted with facts, usually as a result of mental illness); unspecified dementia without behavioral disturbance, mood disturbance and anxiety; disorder of kidney; hyperlipidemia (high cholesterol); hypo osmolality [increased body fluid volume and decreased solute volumes in the blood] and anemia (a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues); Cardiomegaly (enlarged heart); major depressive disorder; paranoid personality disorder; essential hypertension (high blood pressure); spinal stenosis (the narrowing of one or more spaces within the spinal canal). The resident developed a Stage III pressure ulcer on the left sacrum/coccyx. The resident's current diet order was a No Added Salt, pureed texture, honey thickened consistency liquids, fortified foods each meal. This was ordered on 1/3/2024. Additionally, a Magic Cup [a nutritional supplement for added calories and protein, that can be eaten as a pudding or frozen as an ice cream] three times a day on each meal tray was ordered on 11/20/23. According to Resident #55's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/17/23, the resident had a Brief Interview for Mental Status (BIMS) score of 5, indicating that she had severely impaired cognitive status and had no indicators of delirium. The resident's mood symptoms indicated that the resident had no poor appetite or overeating. The resident required extensive assistance with eating with one person physical assist. The assessment revealed that the resident had no swallowing disorder, weight was 157 lbs., Height was 62, the resident had no weight loss or gain or it was unknown and the resident was receiving a mechanically altered diet and therapeutic diet while a resident. Resident #55 did not have any oral/dental issues and the resident had received Speech Therapy and Occupational Therapy services. According to Resident #55's Quarterly MDS with an ARD of 12/18/23, the resident had a BIMS score of 2, indicating that she had severely impaired cognitive status and had no indicators of delirium. The assessment revealed resident #55's interim performance for self-care showed dependence with eating. The assessment revealed that the resident had loss of liquids/solids from mouth when eating, holding food in mouth/cheeks or residual food in mouth after meals, coughing or choking during meals or when swallowing medications, and complaints of difficulty or pain when swallowing. The resident weighed 154 lbs., Height was 62, the resident had no weight loss or gain or it was unknown. Resident #55 did not have any no broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or loose) or mouth or facial pain, discomfort or difficulty with chewing. Resident #55's care plan initiated on 3/8/23 and revised on 12/18/23, included a focus related to nutrition - the resident has nutritional problem or potential nutritional problem related desirable weight loss in 6 months, dependent upon staff at meals, Type 2 Diabetes Mellitus; hypertension, depression, history of cerebral vascular accident, spinal stenosis, anxiety, medication changes and paranoia. The care plan included two goals: Be able to control what resident has in mouth. Loss of control of food or liquid in mouth can result in aspiration/choking. The resident will maintain adequate nutritional status as evidenced by maintaining weight with less than 5% weight gain in 30 days, less than 7.5% weight gain in 90 days and less than 10% weight gain in 180 days. Among the many care plan interventions included, there was an intervention to provide, serve diet as ordered. Monitor intake and record each meal. Pureed [consistency food], honey [thickened] liquids, no straws. On 02/20/24 at 6:13 PM, Resident #55 was observed with her evening meal. The Certified Nursing Assistant (CNA) positioned the resident upright in the bed. The tray ticket showed Resident #55 was served a Pureed, CCHO [Controlled Carbohydrate], low cholesterol, small portion diet with honey thickened juice and water. The ticket also indicated that Resident #55 liked a Magic Cup. On 02/22/24 at 9:07 AM, Resident #55 was lying in bed and her breakfast tray was on the over the bed table. The resident was waiting for staff to feed her. The tray ticket showed the resident was served a Pureed, CCHO [Controlled Carbohydrate], low cholesterol, small portion diet with honey thickened juice and water. Photographic evidence obtained. The 9/15/23 Nutrition Screening & Data Collection for Skilled Nursing Facilities SCii, included a Registered Dietitian (RD) note that documented, Weight has been trending up and was greater than 10% gain in 6 months. She is dependent upon staff at meals and consumes 76 to 100% of meals. Tolerates diet as ordered. Intact skin. Receives daily multivitamin/minerals with Januvia [anti-diabetic medication used to treat Type 2 Diabetes], Levemir [long-acting insulin], Humalog [fast acting insulin] provided for glucose control. A statin [a medication that lowers cholesterol levels in the blood] for HDL [High Density Lipoprotein, a type of fat in the blood] provided as well as daily multivitamin/minerals. Recommend to continue plan of care. Follow as needed. The 11/20/23 Nutrition Assessment indicated Resident #55 lost weight while at the hospital. This included an RD note that documented, Dysphagia diagnosis, she attends the dependent dining room at meals and consumes variable portions. Communicates needs at times and is often confused. Receives Januvia for glucose control. On 11/20/23, a Mini Nutritional Assessment was conducted and the score was 7, indicating that the resident was possibly malnourished. A Nutrition/Dietary Note (Summit) dated 1/23/24, documented, Weight note and wound note: Current weight is 152.6 lbs. and stable. NAS diet, pureed consistency, honey thickened liquids, and fortified foods each meal. Supplements of Magic Cup three times a day with all meals and Magic Cup three times daily between meals. Skin: Left sacral/coccyx stage 3 ulcer is fragile healed. Since wound is healed, suggest to decrease Magic Cups to only three times a day at meals. Also the fact that her weight has been fluctuating may be explained by her going out to the hospital. Her oral intake is usually averaging 50% or more of meals. Will follow as needed. The following is Resident #55's weight history for the past 6 months: 1/2/2024 17:02, 152.6 lbs., Mechanical Lift 12/11/2023 14:51, 153.6 lbs., Mechanical Lift 12/1/2023 14:38, 162.2 lbs., Mechanical Lift 11/20/2023 10:54, 158.6 lbs. Mechanical Lift 11/19/2023 15:32, 158.0 lbs., Mechanical Lift 11/17/2023 15:54, 158.2 lbs., Mechanical Lift 11/1/2023 16:34, 176.6 lbs., Wheelchair 10/1/2023 10:43, 177.8 lbs., Wheelchair 9/1/2023 13:00, 170.8 lbs., Wheelchair 8/1/2023 17:48, 160.6 lbs., Wheelchair The resident's height was 62 and her Body Mass Index was 27.9, which was in an acceptable range for elderly individuals. Based on the resident's weight history, on 12/01/23, the resident weighed 162.2 lbs. On 01/02/2024, the resident weighed 152.6 pounds which is a (-)5.92 % significant weight loss in a month. On 10/01/2023, the resident weighed 177.8 lbs. On 1/02/24, the resident weighed 152.6 pounds which is a (-)14.17 % weight loss in 3 months. According to Resident #55's medical record, the resident's last hospitalization was 11/9/23 and the resident had pneumonia in December 2023. On 2/22/24 at 9:45 AM, during an interview with the facility RD, Resident #55's diet order was discussed and the RD was informed that the diet order on the tray ticket did not match the diet order that was prescribed. The RD said she would look into that. The RD stated that the resident was not receiving fortified foods, because the off-site kitchen did not prepare fortified foods.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to document observed wandering behaviors to ensure an accurate medical record for one (Resident #46) of one resident observed with wandering behaviors. Findings included: A review of Resident #46's medical record revealed Resident #46 was admitted to the facility on [DATE] with diagnoses of Hemiplegia and Hemiparesis following non-traumatic subarachnoid hemorrhage affecting right dominant side, difficulty walking, and cognitive communication deficit. A review of Resident #46's physician's orders revealed an order, dated 11/14/2023 for a wander management bracelet to the resident's left wrist. A review of Resident #46's care plan revealed a Focus area, initiated 11/14/2023, Resident #46 is an elopement risk related to being disoriented to place. Interventions included to distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, or book and observe the wander management device for proper placement and function as ordered. A review of Resident #46's quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 2/13/2024, revealed under Section C - Cognitive Patterns, a Brief Interview for Cognitive Status (BIMS) score of 3, indicating severe cognitive impairment. The MDS assessment also revealed under Section E - Behaviors, Resident #46 did not display wandering behaviors during the assessment period. An observation was conducted on 2/19/2024 at 1:07 PM of Resident #46 propelling herself in her wheelchair into another resident's room. Resident #46 was observed crawling into another resident's empty bed and covering herself with a blanket. Resident #46 was redirected by staff back into the unit hallway. An observation was conducted on 2/20/2024 at 12:07 PM of Resident #46 propelling herself in her wheelchair down a unit hallway opposite of where the resident's room was located. Resident #46 was observed propelling herself into another resident's room and stopping in the entrance to the room before being redirected by facility staff. An observation was conducted 2/21/2024 at 1:45 PM of Resident #46 propelling herself in her wheelchair down a unit hallway opposite of where the resident's room was located. Resident #46 continued to propel herself aimlessly down the length of the unit hallway. An interview was conducted on 2/21/2024 at 4:24 PM with Staff D, Registered Nurse (RN). Staff D, RN stated Resident #46 wandered throughout the facility and often went into other resident's room, but was easily redirected by facility staff. An interview was conducted on 2/22/2024 at 9:54 AM with Staff E, Certified Nursing Assistant, who was sitting behind the nurses station with Resident #46. Staff E, CNA stated Resident #46 was pleasantly confused and normally wanders around the facility. Staff E, CNA also stated she informs the nurse on duty of any of Resident #46's wandering behaviors so it can be documented. An interview was also conducted with Staff F, Licensed Practical Nurse (LPN), who was also behind the nurse's station with Staff E, CNA and Resident #46. Staff F, LPN stated Resident #46 would often wander into other resident's rooms and climb into empty beds, but was easily redirected by facility staff. Staff F, LPN also stated the resident had a behavior folder in her medical record where any behaviors are documented. A review of Resident #46's Point of Care (POC) response history for the dates of 1/22/2024 to 2/21/2024 revealed under the task Behavior Monitoring & Interventions no observations of Resident #46's wandering behaviors were documented. An interview was conducted on 2/22/2024 with the facility's Director of Nursing (DON). The DON stated any behaviors a resident displays are to be documented every shift in the resident's behavior monitoring record. During the interview, Resident #46 was observed propelling herself past the DON's office, located in the hallway on the opposite side of the facility to Resident #46's room. The DON stated Resident #46 wandered the facility often and the resident's wandering behaviors should be documented in the resident's record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to provide resident centered restorative services to maintain or improve mobility for three residents (#62, #47, and #46) of three residents sampled for restorative services. Findings included: A review of Resident #62's medical record revealed Resident #62 was admitted to the facility on [DATE] with diagnoses of osteoarthritis of the left hip and bilateral knees, muscle weakness, need for assistance with personal care, and reduced mobility. A review of Resident #62's physician's orders revealed an order, dated 1/30/2024 for restorative services for active range of motion (AROM) to bilateral lower extremities (BLE), wheel chair mobility, and active range of motion to bilateral upper extremities (BUE). The order did not reveal a frequency of how often Resident #62 was to receive restorative services. An interview was conducted on 2/19/24 at 4:13 PM with Resident #62 in the resident's room. Resident #62 was observed up in her wheelchair near her bed. Resident #62 stated she was supposed to be receiving restorative therapy and she was not receiving restorative services on a consistent basis. A review of Resident #62's quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 2/5/2024, revealed under section O - Special Treatments, Procedures, and Programs, Resident #62 received Range of motion (active) under the Restorative Nursing Program for one session of at least 15 minutes during the past 7 calendar days. A review of Resident #62's Physical Therapy Discharge Summary revealed Resident #62 received therapy from 12/14/2023 to 1/17/2024 and was discharged to the facility's Restorative Program on 1/17/2024 for range of motion (ROM). The summary also revealed under the section titled Functional Maintenance Prognosis Resident #62's prognosis to maintain current level of functioning (CLOF) was excellent with consistent staff support. A review of the facility's Restorative Program record revealed the following: - Resident #62 did not receive restorative services during the week of 1/22/2024 to 1/28/2024. No refusal of services were documented. - Resident #62 received restorative services one time during the week of 1/29/2024 to 2/4/2024. No refusal of services were documented. - Resident #62 received restorative services one time during the week of 2/12/2024 to 2/18/2024. No refusal of services were documented. A review of Resident #62's Point of Care (POC) history for the dates of 1/21/2024 to 2/20/2024 revealed the following for the task Restorative: ROM (Active) and AROM to BLE/BUE: - 1/29/2024 at 2:59 PM: 15 minutes. - 2/6/2024 at 4:15 PM: 15 minutes. - 2/7/2024 at 4:58 PM: 15 minutes. - 2/9/2024 at 1:56 PM: 15 minutes. - 2/18/2024 at 2:17 AM: 2 minutes. No refusals were documented in the record. The POC history also revealed for the dates of 1/21/2024 to 2/20/2024 the following for the task Restorative: wheelchair mobility using BUE: - 1/29/2024 at 2:59 PM: 15 minutes. - 2/6/2024 at 4:15 PM: 15 minutes. - 2/7/2024 at 4:58 PM: 15 minutes. - 2/9/2024 at 1:56 PM: 15 minutes. - 2/18/2024 at 2:18 AM: 2 minutes. No refusals were documented in the record. A review of Resident #46's medical record revealed Resident #46 was admitted to the facility on [DATE] with diagnoses of Hemiplegia and Hemiparesis following non-traumatic subarachnoid hemorrhage affecting right dominant side, difficulty walking, and muscle weakness. A review of Resident #46's physician's orders revealed an order, dated 1/4/2024 for restorative services for AROM to BUE/BLE and ambulation with rollator walker (RW) at facility level. The order did not reveal a frequency of how often Resident #46 was to receive restorative services. A review of Resident #46's quarterly MDS assessment, with an ARD of 2/13/2024, revealed under section O - Special Treatments, Procedures, and Programs, Resident #46 received Range of motion (active) under the Restorative Nursing Program for three sessions of at least 15 minutes during the past 7 calendar days. A review of Resident #46's Physical Therapy Discharge Summary revealed Resident #46 received therapy from 11/11/2023 to 12/4/2023 and was discharged to the facility's Restorative Program on 12/4/2023 for ambulation and ROM. The summary also revealed under the section titled Functional Maintenance Prognosis Resident #46's prognosis to maintain CLOF was excellent with consistent staff support. A review of the facility's Restorative Program record revealed the following: - Resident #46 received restorative services two times during the week of 1/22/2024 to 1/28/2024. An entry for 1/24/2024 was marked bed. - Resident #46 received restorative services one time during the week of 1/29/2024 to 2/4/2024. No refusal of services were documented. A review of Resident #46's POC history for the dates of 1/22/2024 to 2/21/2024 revealed the following for the task Restorative: Ambulation with RW at facility level: - 1/23/2024 at 4:05 PM: 15 minutes. - 1/24/2024 at 2:59 PM: Resident not available. - 1/28/2024 at 2:40 AM: 2 minutes. - 1/30/2024 at 6:07 PM: Not applicable. - 2/6/2024 at 4:15 PM: Not applicable. - 2/7/2024 at 4:57 PM: 15 minutes. - 2/9/2024 at 1:55 PM: 15 minutes. - 2/13/2024 at 1:07 PM: 15 minutes. - 2/14/2024 at 5:31 PM: 15 minutes. - 2/20/2024 at 5:57 PM: 15 minutes. - 2/21/2024 at 2:59 PM: 15 minutes. No refusals were documented in the record. The POC history also revealed for the dates of 1/22/2024 to 2/21/2024 the following for the task ROM (Active)to BUE/BLE: - 1/23/2024 at 4:05 PM: 15 minutes. - 1/24/2024 at 2:59 PM: Resident not available. - 1/28/2024 at 2:40 AM: 2 minutes. - 1/30/2024 at 6:08 PM: 15 minutes. - 2/6/2024 at 4:15 PM: 15 minutes. - 2/7/2024 at 4:57 PM: 15 minutes. - 2/9/2024 at 1:56 PM: 15 minutes. - 2/13/2024 at 1:07 PM: 15 minutes. - 2/14/2024 at 5:31 PM: 15 minutes. - 2/20/2024 at 5:57 PM: 15 minutes. - 2/21/2024 at 2:59 PM: 15 minutes. - 2/21/2024 at 3:52 PM: 15 minutes No refusals were documented in the record. A review of Resident #47's medical record revealed Resident #47 was admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy, abnormalities of gait and mobility, difficulty walking, unsteadiness on feet, muscle weakness, and Hemiplegia and Hemiparesis following cerebral infarction affecting right dominant side. A review of Resident #47's physician's orders revealed an order, dated 1/26/2024 for restorative services for ambulation and AROM to BLE. The order did not reveal a frequency of how often Resident #47 was to receive restorative services. A review of Resident #47's Physical Therapy Discharge Summary revealed Resident #47 received therapy from 11/20/2023 to 1/24/2024 and was discharged to the facility's Restorative Program on 1/24/2024 for gait and therapeutic exercise. The summary also revealed under the section titled Functional Maintenance Prognosis Resident #47's prognosis to maintain CLOF was good with consistent staff follow-through. A review of the facility's Restorative Program record revealed the following: - Resident #47 did not receive restorative services during the week of 1/22/2024 to 1/28/2024. No refusal of services were documented. - Resident #47 did not receive restorative services during the week of 1/29/2024 to 2/4/2024. No refusal of services were documented. - Resident #47 received restorative services two times during the week of 2/12/2024 to 2/18/2024. No refusal of services were documented. A review of Resident #47's POC history for the dates of 1/23/2024 to 2/22/2024 revealed the following for the task Ambulation with RW with contact guard assist (CGA) of 1: - 1/26/2024 at 4:25 PM: 3 minutes. - 1/27/2024 at 4:28 PM: 2 minutes. - 1/28/2024 at 2:25 AM: 2 minutes. - 1/29/2024 at 9:08 PM: 2 minutes. - 1/30/2024 at 7:16 PM: 2 minutes. - 2/2/2024 at 6:59 PM: 2 minutes. - 2/3/2024 at 7:08 PM: 2 minutes. - 2/4/2024 at 5:19 PM: 2 minutes. - 2/5/2024 at 7:25 PM: 2 minutes. - 2/6/2024 at 4:16 PM: 15 minutes. - 2/7/2024 at 4:58 PM: Refused. - 2/8/2024 at 4:56 PM: 2 minutes. - 2/9/2024 at 3:38 PM: 2 minutes. - 2/12/2024 at 8:59 PM: 2 minutes. - 2/13/2024 at 5:09 PM: 2 minutes. - 2/14/2024 at 5:32 PM: Refused. - 2/15/2024 at 5:43 PM: 15 minutes. - 2/16/2024 at 9:03 PM: 2 minutes. - 2/17/2024 at 4:33 PM: 2 minutes. - 2/18/2024 at 4:19 PM: 2 minutes. - 2/19/2024 at 8:55 PM: 3 minutes. - 2/21/2024 at 2:59 PM: 15 minutes. - 2/21/2024 at 9:22 PM: 2 minutes. The POC history also revealed for the dates of 1/23/2024 to 2/22/2024 the following for the task ROM (Active)to BLE: - 1/26/2024 at 4:25 PM: 3 minutes. - 1/27/2024 at 4:28 PM: 2 minutes. - 1/28/2024 at 2:25 AM: 2 minutes. - 1/29/2024 at 9:08 PM: 2 minutes. - 1/30/2024 at 7:16 PM: 2 minutes. - 2/2/2024 at 6:59 PM: 2 minutes. - 2/3/2024 at 7:08 PM: 2 minutes. - 2/4/2024 at 5:19 PM: 2 minutes. - 2/5/2024 at 7:25 PM: 2 minutes. - 2/6/2024 at 4:16 PM: 15 minutes. - 2/7/2024 at 4:58 PM: Refused. - 2/8/2024 at 4:56 PM: 2 minutes. - 2/9/2024 at 3:38 PM: 2 minutes. - 2/12/2024 at 9:00 PM: 2 minutes. - 2/13/2024 at 5:09 PM: 2 minutes. - 2/14/2024 at 5:32 PM: Refused. - 2/15/2024 at 5:43 PM: 15 minutes. - 2/16/2024 at 9:03 PM: 2 minutes. - 2/17/2024 at 4:33 PM: 2 minutes. - 2/18/2024 at 4:19 PM: 2 minutes. - 2/19/2024 at 8:55 PM: 3 minutes. - 2/21/2024 at 2:59 PM: 15 minutes. - 2/21/2024 at 9:23 PM: 2 minutes. An interview was conducted on 2/21/2024 at 11:06 AM with Staff A, Assistant Director of Nursing (ADON). Staff A, ADON stated the facility had 16 total residents on the restorative program and the program was offered to the residents three times a week. Staff A, ADON also stated residents refused the services at times and refusals would be documented in the resident's record. During a follow up interview at 12:15 PM, Staff A, ADON reviewed Resident #62's restorative therapy documentation and was not able to state why the resident was not offered restorative services three times a week. Staff A, ADON stated the documentation showing Resident #62 was offered restorative therapy should be in the resident's medical record. An interview was conducted on 2/21/2024 at 12:18 PM with Staff B, Restorative Certified Nursing Assistant (RCNA). Staff B, RCNA stated residents on restorative therapy are offered services three times a week, which is documented in the electronic medical record and on the restorative therapy record. Staff B, RCNA also stated only 16 residents can participate in the restorative program at a time and resident's waiting for restorative services could be waiting for up to a month before they receive restorative therapy due to the facility only having one restorative aide. An interview was conducted on 2/21/2024 at 1:50 PM with Staff A, ADON. Staff A, ADON stated the facility has a waiting list for residents who are ordered restorative therapy and they are only able to assist 16 residents at a time with restorative therapy. Staff A, ADON also stated she was not aware certain residents were only being offered therapy one or two times a week and stated she should be notified of any residents who refuse restorative therapy or if the resident is offered less than three times a week. An interview was conducted on 2/21/2024 at 2:27 PM with the facility's Director of Nursing (DON) and Staff A, ADON. The DON stated orders are received when a resident discharges from therapy for restorative therapy which indicate the focus area and amount of repetitions the resident is to perform during therapy. Staff A, ADON stated they were instructed by their corporate team to not have instructions related to the duration of therapy put into the resident's order for restorative therapy or a how often the resident is to receive the services. The DON stated the facility process is to only take 16 residents at one time for restorative services and they rarely have residents who have orders for restorative therapy who do not receive restorative therapy. An interview was conducted on 2/22/2024 at 8:47 AM with Staff C, Physical Therapist (PT). Staff C, PT stated restorative therapy is limited to 16 residents in the facility at any given time and the nursing staff determine which resident's continue to receive restorative therapy based on the resident's goals. Staff C, PT also stated the goal of restorative therapy is to ensure the resident does not decline after receiving therapy services and for the resident to maintain ROM and the ability to ambulate. Staff C, PT stated after a resident receives physical therapy, they place a referral to the restorative nursing program into the referral bin, which is then picked up by the restorative CNA. The therapy department will review the resident's program and train the RCNA on the restorative needs of the specific resident. Staff C, PT stated residents should receive restorative therapy as much as they are able to tolerate and the restorative nurse should ask the resident how often they would like to participate in the therapy. Staff C, PT also stated it would take the RCNA longer than 2 or 3 minutes to complete a restorative session and there is a difference between normal ROM performed during care and the specific restorative therapy routine the resident is to receive. A review of the facility policy titled Restorative Nursing, with no effective date, revealed restorative nursing programming refers to a formal nursing program which includes interventions that serve to assist the resident in restoring or attaining the ability to live as independently and as safely as possible. The program focuses on achieving optimal physical, mental, and psychosocial functioning. The Restorative Nursing Program is individualized and goal oriented based on the resident's identified strength and needs. It includes measurable objectives and interventions that are documented in the resident's medical record and outlined in the plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety as indicated by the following: - Refrigerated, ready-to-eat, Time/temperature Control for Safety foods were stored too long under refrigeration and not date-marked to indicate when the food must be consumed or discarded. - The kitchen area was not protected from contamination from unauthorized employees entering the area and not wearing hair restraints. - Stored packaged food was not protected from potential cleaning chemical contamination in the food storage room. - The surface material of equipment was not kept in good condition and was not smooth and easily cleanable. - Clean eating equipment was not stored in a manner to prevent contamination of the mouth/food contact surfaces. - Clean equipment was not stored to protect from contamination from the outside environment and wildlife. - Food was not labeled to its identity. - Staff did not know how to calibrate the food thermometer and did not calibrate the thermometer before use. - Food contact and non-food contact surfaces of equipment were not visibly clean to sight and touch. - Food service staff did not properly wash their hands before donning clean gloves. - Exposed food was not protected from contamination. - Exposed food and clean equipment and utensils were not protected from contamination in that trash cans were not covered during meal service. - The automatic paper towel dispenser above the hand sink located in the Island View dining room kitchen did not function. - The freezer compartment of the refrigerator in the 1 & 2 Nourishment Room was not maintaining temperature to keep frozen food frozen. These practices have the potential to cause foodborne illness to 104 of 104 residents in the facility, who consume the facility's food. Findings included: During the Initial Kitchen Tour in the nursing home warming kitchen on 02/19/24 at 9:44 AM, there was a block of sliced American pasteurized cheese wrapped in plastic wrap (not the original packaging) with a hand written date of 2/8/24, stored in the white Hotpoint refrigerator/freezer unit. There also was no label on the cheese packaging. Photographic evidence obtained. The American cheese was stored more than 7 days under refrigeration (American cheese is not exempt from date-marking). At 10:01 AM, there was an insect electrocution device mounted on the kitchen wall behind the juice dispenser and above a preparation counter, which was not conducive to preventing dead insects and insect fragments from being impelled onto or falling on exposed food and clean equipment. Photographic evidence obtained. At 10:05 AM an unauthorized nursing staff with long hair entered kitchen without a hair restraint to get a cup of coffee. Continuing the Initial Kitchen Tour at 10:03 AM, in the room where the hand washing sink was located, there were cleaning chemicals stored with canned sodas in this area. Photographic evidence obtained. At 10:07 AM, during the Initial Kitchen Tour, the drawer face (or front) of the left drawer of the white kitchen counter cabinet was missing, exposing the unfinished wood, which was not easily cleanable. Photographic evidence obtained. At 10:09 AM, there were 2 stacks of 13 maroon colored insulated plate bases that had multiple scratched and gouged edges on the surface on each of them. Additionally, there was a silverware caddy with multiple knives and forks stored in it, that were positioned with the mouth/food contact surface upright. Photographic evidence obtained. At 10:15 PM, There was a bag of dry cereal that was stored on a counter that was not labeled to its identity. Photographic evidence obtained. During the Initial Tour, at 10:12 AM, there was a rusted white wire shelf in the Artic Air double door refrigerator unit. Photographic evidence obtained. During a follow up visit to the kitchen on 2/21/24 at 11:59 AM, Dietary Aide, Staff H (a contract employee) was taking temperatures of hot food held on the steam table before the lunch meal service. He kept putting his thermometer in a Styrofoam cup with cold water (no ice) after he took the temperature. He said he did this to bring down the temperature of the thermometer. He was recording these temperatures in the temperature log. At 12:16 PM, Dietary Aide, Staff H was asked how he calibrated his thermometer and he said, what's that? The facility Registered Dietitian, who was standing nearby said that they use ice water to calibrate the thermometers. Dietary Aide, Staff H said he uses water (without ice). He did not calibrate the thermometer to check its accuracy before taking hot food holding temperatures. The surveyor asked for a cup of ice water to check the accuracy of the facility thermometer and the surveyor's thermometer. The facility thermometer read 34 degrees Fahrenheit (F), and not 32 degrees F. During this time a mobile plastic open side standard service cart with packaged food stored on top of it, had a buildup of soil on one side of the cart. The cart was stored next to the steam table. Photographic evidence obtained. Additionally, all the metal steam table pans were dented on the edges and were not flush to the steam table wells (these were property of the off-site kitchen). Photographic evidence obtained. There were multiple insulated dome plate covers with the surfaces scratched and gouged stored on a shelf. Photographic evidence taken. On 2/21/24 at 12:18 PM during the lunch meal service, Dietary Aide, Staff H used hand sanitizer from a dispenser on the wall in the kitchen before donning his gloves. He was told he must use soap and water to wash his hands. The Dietary Manager (a contract employee) said a few minutes later that ServSafe [food safety training and certification program that was developed and run by the National Restaurant Association] says you can use hand sanitizer for changing gloves. During a follow up visit to the warming kitchen on 2/21/24 at 02:12 PM, after the lunch meal service was completed, there were 4 plates of plated food from lunch stored on the shelf above the steam table. The exposed food was not covered or held in temperature control. Photographic evidence obtained. There was a shelf over the steam table in which there was an accumulation of black food matter underneath the shelf. Photographic evidence obtained. There was a white powdery/flake-like substance on the milk crates used to store cases of carbonated beverages in the room where the hand sink is located. Photographic evidence obtained. There were 2 clean enclosed tray delivery carts stored outside of the kitchen when not in use. The Dietary Manager said one cart was broken. The area outside was not screened in and not protected from contamination. Photographic evidence obtained. There were clean insulated dome plate covers that in which the outer surface was scratched, worn, and gouged. These were no longer a smooth, easily cleanable surface. During follow up visit to the warming kitchen on 2/22/24 at 8:50 AM, there was no trash can available to dispose of used paper towels after using the hand sink. The only trash can in the kitchen was across on the other side. There was no cover on the trash can and the breakfast meal service was in process. Photographic evidence obtained. During the lunch service on 2/22/24 at 12:23 PM in the independent Island View dining room, there were several insulated dome plate covers that had worn surfaces. Photographic evidence obtained. There was silverware stored with food/lip surface positioned up in a caddy. Photographic evidence obtained. The automatic paper towel dispenser did not work, so staff used napkins to dry their hands after washing them at the hand sink in the dining room kitchen area. There was a block of wrapped American pasteurized cheese slices wrapped in plastic wrap that was stored in the [NAME] refrigerator/freezer unit in the dining room kitchen area. The date handwritten on the American cheese packaging was illegible. Photographic evidence obtained. At 12:34 PM, the trash can in the Island View dining room near the kitchen serving line had no cover on it and the lunch meal service was in progress. There were several nursing staff who were not wearing hairnets who entered the Island View Kitchen area with clean equipment and clean utensils present. On 02/22/24 at 8:59 AM, in the Warming kitchen, there was a squirrel observed eating food from soiled eatingware that was stored a mobile sheet pan rack cart located in the area outside the kitchen. This is the area where clean enclosed tray delivery carts were observed to be stored on 2/21/24. Photographic evidence obtained. A few minutes later, the cart was taken by a kitchen staff member to the off-site kitchen. On 2/21/24 at 2:02 PM, the refrigerator compartment of the Insignia refrigerator/freezer unit in the Station 3 Nourishment Room had a container of a Thick and Easy supplement that was opened and not date marked. The temperature on the dial thermometer located in the freezer compartment of the Insignia refrigerator/freezer unit in the Station 1 & 2 Nourishment Room on 2/21/24 at 2:29 PM read (+) 12 degrees F. The freezer compartment had a box of individual 4 ounce containers of ice cream stored in it. The individual ice cream containers were not firm to touch. Photographic evidence obtained.

Based on interviews and record review, the facility failed to develop and implement appropriate plans of actions to correct identified quality concerns related to resident falls. This concern has the potential to affect all residents in the facility. The findings include: On 2/22/24 at approximately 12:39 PM, an interview was conducted with the Risk Manager in the presence of the Regional Nurse Consultant. During the interview the Risk Manager stated that he has been in is position since September 2023 and that part of his position was quality improvement. He stated that as part of his performance improvement efforts he tracks falls in the facility by nursing station. At this time he presented a graph titled Falls by Unit that included the number of falls that had occurred in each month of 2023 for Station 1 (25 falls), Station 2 (26 falls), and Station 3 (181 falls). The graph demonstrated that 87% of the falls that had occurred in the facility in 2023 had occurred on Station 3. The graph also supported that Station 3 had 25 falls in the month of November while stations 1 and 2 had zero. When asked if he had investigated why station 3 had such a large number of falls he stated that station 3 was the short term rehabilitation unit and he expected there to be more falls. When asked if he had offered training to staff on fall prevention, observed staff for care concerns or developed a performance improvement plan (PIP) to address fall concerns he stated No. A review of the job description for Director of Risk Management revealed, Responsible for the facility Risk Management program, functioning under the direction of the facility Administrator. Under essential functions was included Plans develops, organizes, evaluates and directs the facility safety programs, including the evaluation and establishment of safety objectives. Performs routine chart audits in order to analyze and identify areas of improvement. Uses this information to structure and accomplish targeted staff training as indicated. Prepares written weekly Risk Management Report designed to identify risk and report on preventive action plans. Reviews with the Administrator and establishes goals. Serves as a liaison with the Director of Nursing to ensure nursing department involvement of risk identified and awareness of goals established for quality improvement. A review of the Policy for Quality Management revealed that the facility will have an internal Quality Assurance and Performance Improvement (QAPI) Program designed to provide a comprehensive approach to ensure high quality care and services. The policy identifies that QAPI is an ongoing program that is comprehensive, dealing with the full range of services offered by the facility. The QAPI program will address all systems of care and management practices, aiming for safety and high quality while emphasizing autonomy and choice in daily lift for residents. It utilizes the best available evidence to define and measure goals. Feedback, data systems and monitoring includes the facility will put systems in place to monitor care and services through the use of multiple sources. Performance Indicators will monitor a wide range for care and outcomes and findings will be compared to benchmarks or targets established for performance. Performance Improvement Projects (PIPs) involves gathering information systematically and intervening for improvement with a written work plan by the project team and a timeline. Systemic analysis and systemic action the facility will model and promote systems thinking, practice root cause analysis and take action at the systems level.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on of observations, interview and policy review the facility failed to ensure a clean and sanitary homelike environment related to a spot on the wall and baseboard in two places for one resident room (48) of twenty-six rooms observed on Station 3 for three days (01/04/22, 01/05/22 and 01/06/22) of four days. Findings included: On 01/04/22 at 9:15 a.m., an initial observation was conducted of resident room [ROOM NUMBER] on the hall of Station 3. During the observation a spot was seen on the wall in the middle of the room, which extended down to the baseboard in two places. (Photographic Evidence Obtained) A subsequent observation was conducted on 01/04/22 at 12:47 p.m. During the observation a family member in the room visiting the resident was interviewed. The family member indicated the resident was admitted on the evening of 12/31/21, and further revealed he never sees anyone cleaning the room. The family member stated, The housekeeping could be better. During the interview the family member revealed he had not spoken to anyone in the facility regarding the spot on the wall that extended down to the baseboard and could be seen in two places. He further revealed since he had complained about other housekeeping issues since the resident's admission, he did not want to continue to complain to the facility and stated, I am tired of talking to them. On 01/05/22 at 9:00 a.m., an observation was conducted of Resident room [ROOM NUMBER] which revealed the spot on the wall and on the baseboard in two places. During a follow-up observation and interview, on 01/05/22 at 3:11 p.m., of Resident room [ROOM NUMBER], the spot was observed on the wall and baseboard, and the resident's family member indicated he had not mentioned to the facility the dirty spot on the wall. On 01/06/22 at 10:18 a.m. an observation was made of the resident room and a chair was placed in front of the spot on the wall and baseboard. The resident was not in the room at the time. On 01/06/22 at 11:55 a.m., another subsequent interview and observation was conducted in Resident room [ROOM NUMBER]. The resident's visitor stated, I am upset by the spot on the wall. I called him (the resident's spouse) and he told me its been here ever since she came. During an interview with the Nursing Home Administrator (NHA) on 01/06/22 at 12:03 p.m., she confirmed the spot on the wall that extended down to the baseboard in two places, while the resident's visitor was in the room. The NHA indicated she would have housekeeping address the spot and the visitor in the room told the NHA the spot on the wall, and the two on the baseboard were not from the present resident in the room. The NHA acknowledged the visitor and stated Ok. On 01/06/22 at 12:51 p.m., an interview was conducted with the Environmental Services Director (EVS) who revealed the floors, and bathrooms should be cleaned every day. He further indicated if the housekeeping staff see the spot, they should clean it, its part of the cleaning process. A review of facility policy titled, Environmental Services-Cleaning Schedules Respiratory, read under Policy: Cleaning Schedules shall be developed and implemented to ensure that our health center is maintained in a clean and comfortable manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility failed to ensure appropriate and sanitary storage of respiratory equipment of an oxygen nasal cannula for one resident (#193) of sixteen residents who use oxygen for four of four days (01/04/22, 01/05/22, 01/06/22 and 01/07/22). Findings included: On 01/04/22 at 11:38 a.m., an observation was conducted of Resident #193's room. During the observation the oxygen nasal cannula and tubing was located on top of the oxygen concentrator and not stored appropriately in a storage bag. (Photographic Evidence Obtained) On 01/05/22 at 9:44 a.m. an observation was conducted of Resident #193's nasal cannula and tubing to be on top of the concentrator. Resident #193, who was sitting in a wheelchair and watching television, indicated she put it there when she was done wearing it because there wasn't a plastic storage bag by the concentrator to put it in. An observation was conducted on 01/06/22 at 10:17 a.m., of Resident #193's oxygen tubing and nasal cannula wrapped around the top of the unit. The resident was not in the room at the time. The plastic storage bag used to store the nasal cannula and tubing was not on or near the oxygen concentrator. A subsequent observation was conducted on 01/06/22 at 3:16 p.m. of Resident #193's oxygen tubing and nasal cannula to be located on top of the oxygen concentrator, and there was no plastic storage bag located on or near the oxygen concentrator. On 01/07/22 at 9:15 a.m. an observation was made of Resident #193 sitting in a wheelchair watching television. The oxygen tubing and nasal cannula was seen draped over the resident's bed and stored appropriately a plastic storage bag. The resident was asked if the staff place her oxygen tubing in a plastic storage bag after she was done wearing it since she has been admitted , and Resident #193 pleasantly stated, No, never seen one. Record review of Resident #193's admission Record indicated she was admitted on [DATE] and re-admitted on [DATE] with multiple diagnoses that included acute respiratory failure with hypoxia, anemia and heart failure. Review of an active physician order, dated 12/27/21, for Resident #193 read: Oxygen@ (at) 1-2 Liters/Minute (L/Min) via Nasal Cannula (NC) continuous inhalation at night to keep Saturation (Sats) >92% every evening and night shift for low O2 Sats at night. Review of the Minimum Data Set (MDS), dated [DATE], identified in Section C, Cognitive Patterns that Resident #193's Brief Interview for Mental Status (BIMS) score was 14, on a 15 point scale, indicating the resident was cognitively intact. Further record review of Resident #193's care plan, dated 01/04/22, revealed she was care planned to wear oxygen NC as ordered and tolerated. On 01/07/22 at 9:23 a.m., an interview was conducted with Staff B, Registered Nurse (RN)/Unit Manager (UM) for Station Three. During the interview Staff B confirmed the presence of the nasal cannula and tubing on top of the oxygen concentrator, in Resident #193's room. Staff B stated, It is the nurse's responsibility to store the oxygen tubing in the plastic bag. Staff B revealed she would obtain a new nasal cannula, and a plastic storage bag from the supply room, and change the present nasal cannula. An interview was conducted with the Director of Nursing (DON) on 01/07/22 at 9:40 a.m. The DON stated, When it's not being used, and is PRN (as needed) or used overnight, it has to be stored in the plastic storage bag to be protected. A review of facility policy titled, Respiratory Therapy Equipment, Page 01 of Page 02, read as follows: Oxygen Administration 7. Keep Oxygen cannula and tubing used PRN (as needed) in a plastic bag when not in use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a PRN (as needed) psychotropic medication order was limited to a 14 day duration for one resident (#26) of five residents reviewed. Findings included: Record review revealed Resident #26 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, and anxiety disorder according to the resident face sheet. Continued review of the Physician's Order Summary revealed an order for Xanax (Alprazolam) 0.25 milligram (mg) 1 tab orally (PO) every 4 hours as needed for anxiety, with a start date of 11/24/21; the end date was listed as 'indefinite.' On 01/05/22 at 12:35 p.m. Resident #26 was observed sitting upright in bed and eating lunch. The resident was groomed and paying attention to the television. An interview was attempted; however, the resident was not interviewable. In an interview with Staff A, Licensed Practical Nurse (LPN) on 01/05/22 at 12:58 p.m., the LPN confirmed the resident was on PRN Xanax and gets it occasionally. The LPN stated the resident will occasionally get 'shaky' and that is when she gives her the Xanax. Staff A, LPN confirmed the medication does help sometimes, and the resident has been on the PRN Xanax for a while. Review of the Medication Administration Record (MAR) revealed Xanax was administered as follows: November 2021: -11/24/21, 11/25/21, 11/26/21, 11/29/21, and 11/30/21. December 2021: -12/01/21, 12/03/21, 12/06/21, 12/07/21, 12/09/21, 12/11/21 (2 doses), 12/24/21, and 12/27/21. -January 2022 (to date): 01/03/22, and 01/06/22. Review of the Pharmacy Medication Regime Reviews revealed a recommendation dated 11/30/2021, which read: -This resident is currently receiving the following psychotropic (non-antipsychotic) medication on a PRN basis: Alprazolam 0.25 mg every 4 hours as needed for anxiety. Please evaluate the resident for the appropriateness of this medication. If it is to be extended, please document the rationale in the resident's medical record and indicate the duration of the PRN order. The recommendation was signed by an unreadable signature with a note that read: - okayed to cont [continue] on tel [telephone] 12/2/21 at 11pm. There were no pharmacy recommendations for December 2021. On 01/07/22 at 10:33 a.m. in an interview with the Director of Nursing (DON), she confirmed the November 2021 pharmacy recommendation was received and the physician was informed. The DON confirmed there was no rationale documented in the record for continuation of the medication, nor was there an end date on the order. On 01/07/21 at 10:47 a.m. an interview was conducted with the facility's Consultant Pharmacist via telephone. She confirmed she issued a pharmacy recommendation in November 2021 related to the PRN Xanax order, and stated it was the expectation the order have a justification for continuation and an end date documented in the medical record. Review of a facility-provided policy titled, Behavior Monitoring and Psychoactive Medication Management, undated, did not address the use of PRN psychotropic medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations interviews and record reviews the facility failed to ensure necessary services to maintain a rehabilitation device in a sanitary manner for four days (01/04/22, 01/05/22, 01/06/22 and 01/07/22) for one resident (#34) out of 29 sampled residents. Findings included: Review of the admission Record for Resident #34 showed the resident was admitted to the facility on [DATE] with diagnoses to include anterior displaced Type II dens (odontoid bone) fracture, subsequent encounter for fracture with routine healing, spondylolysis of cervical region, repeated falls, pain in right shoulder and other abnormalities of gait. A review of the Quarterly Minimum Data Set (MDS) for Resident #34, dated 11/09/21, Section C Cognitive Patterns showed a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate impairment. Section G Functional Status showed Resident #34 required extensive assistance for activities of daily living (ADLs) including bed mobility, transfers, locomotion in and off unit, eating, toilet use and personal hygiene. Review of the current physician orders for Resident #34 printed on 01/06/22 showed Resident #34 wears a clavicle neck brace with active orders dated 08/03/21. The physician orders included the following: *Rigid collar on neck on at all times, check skin around and under collar every shift for monitoring. *Apply [name of product] dressings to L (left) clavicle under neck brace for patient comfort. Change on shower days, every evening shift every Tuesday and Friday. The physician orders did not indicate the process for care, cleaning, or replacement of the cervical collar brace and brace pads. On 01/04/22 at 1:20 p.m., an observation was made of Resident #34 in his room. Resident #34 was having lunch and was noted with soup spilling in his neck collar as he ate his lunch. On 01/05/22 at 12:26 p.m., an observation was made of Resident #34's cervical neck collar with food and residue from his meal. The neck padding was noted with an orange color from the soup he had been drinking. Resident #34 was observed spilling soup on himself during the meal. The neck brace pads inserted on the inside of the cervical collar were noted with a wet sponge like material from the soup. On 01/05/22 at 1:57 p.m., an interview was conducted with Staff C, Certified Nursing Assistant (CNA). Staff C stated he worked closely with the resident. Staff C stated Resident #34 does not require assistance with ADLs and typically requires cueing and supervision for meals only. On 01/05/22 at 2:00 p.m., Resident #34 was observed in his room, neck collar observed with food residue. An immediate interview was conducted with Resident #34. Resident #34 was asked if he had received assistance with cleaning his neck collar after meals. Resident #34 stated that Staff C, CNA had wiped it down with a towel. When asked if the neck padding was wet, Resident #34 said, Yes, a little. It gets wet when I drink anything. On 01/06/22 at 09:12 a.m., Resident #34 was observed having finished breakfast meal. Resident #34's neck collar was observed with food residue and an appearance of heavily stained brown marks. On 01/06/22 at 09:12 a.m., an interview was conducted with Staff C. Staff C made an observation of Resident #34's neck collar with food remnants and food stains on the cervical collar and padding. Staff C stated he would wipe it down. When asked how often the cervical collar brace and pads was cleaned, Staff C said, I wipe it down with a washcloth after meals. Staff C was observed with a wet towel and wiped down the collar. Staff C said, I don't know when it is supposed to be changed. Maybe the nurse does it. Staff C confirmed he had not noted the cervical collar padding being washed. On 01/07/22 at 10:59 a.m. Resident #34 was observed in his room. Resident #34's neck collar padding was noted with brown and orange stains. Resident #34 stated he heard they have ordered a new padding for him. Resident #34 said, It will be nice to have it changed. It will get rid of the smell. Sometimes it [cervical collar padding] smells like the food I ate. Review of a Treatment Administration Record (TAR) dated 12/1/21 to 12/31/21 showed an order to apply [name of product] dressing to L clavicle under neck brace for patient comfort every evening shift every Tuesday and Friday with missing documentation on 12/3, 12/7, 12/10, 12/14, 12/17, 12/21 and 12/24. The TAR did not show documentation related to process for care, cleaning, or replacement of the cervical collar brace and brace pads. A care plan for Resident #34 showed an ADL Focus initiated on 08/18/21. The Focus stated Resident #34 has a self-care performance deficit related to dementia, impaired balance, limited range of motion, (ROM) pain, fracture, cardiac deficits, arthritis, neuropathy, spondylolysis, and incontinence. The goal indicated the resident would improve current level of function through the next review. Interventions included to adjust provisions for ADLs to compensate for resident's changing abilities, encourage participation, wear collar as ordered, encourage to use bell for assistance, monitor for changes as needed, praise all efforts at self-care and Physical Therapy (PT)/ Occupational Therapy (OT) to eval and treat per doctor's orders. The care plan did not indicate expectations for care, cleaning or replacement of cervical collar brace and brace pads. On 01/06/22 at 1:45 p.m., an interview was conducted with Staff D, Licensed Practical Nurse (LPN). Staff D stated the nurses are supposed to apply [name of product] dressing twice a week. Staff D confirmed there was no process to clean or replace the collar padding. Staff D said, We kind of just wipe it off as needed, we sponge wash. When asked who was responsible for ensuring the collar was clean and sanitary, Staff D stated anyone can do it. Staff D stated usually the aides wipe it off after meals. Staff D said she would expect the collar to be changed or cleaned especially if it looks soiled. Staff D said, It should be clean and sanitary. An interview was conducted on 01/06/22 at 1:58 p.m. with Staff B, Registered Nurse (RN)/Unit Manager. Staff B stated Resident #34 used to be in therapy, and they would clean and maintain the neck brace. Staff B stated Resident #34 used to have a second padding for replacement, but she did not know what happened to it. Staff B confirmed it had been months since the padding was replaced or washed. Staff B said, It has to be months since he was in therapy. Staff B stated she spoke to the Director of Rehabilitation (DOR) about ordering a replacement. Staff B stated the expectation would be to maintain the collar in a clean manner. Staff B said, .it should be cleaned more often especially if he is spilling food on himself. It does not look good. We will fix that. A follow-up was conducted on 01/06/22 at 2:36 p.m. with the DOR. The DOR stated Resident #34 was no longer on therapy case load and was discharged around August 2021. The DOR stated Resident #34 had a spare neck brace padding that was changed and laundered when he was in therapy. The DOR stated during meals they used to place a washcloth on the padding to absorb the food spills. DOR stated Resident #34 was put on a restorative program for ROM. When asked who should be caring for the neck brace and padding, the DOR stated nursing should be caring for braces or splints. The DOR said, There was definitely a break down on the process. The expectation would have been that the brace replacements pads are laundered. The DOR stated wearing a wet or stained neck brace was a dignity issue. The DOR said, It is not sanitary. The DOR stated central supply had ordered replacement padding for the cervical neck brace. An interview was conducted on 01/07/22 at 9:53 a.m. with the Director of Nursing. (DON). The DON said, I looked at the resident's orders. There should be an order to care for the collar. DON stated when Resident #34 was transferred to restorative nursing they should have picked him up. The DON said, I agree, we dropped the ball. He should not be in a wet collar after meals. Review of an undated facility policy titled, Restorative nursing - ADL's assistance (bathing, dressing, and grooming), showed the facility will provide restorative programming to assist residents in attaining and maintaining the highest practicable level of function. The benefits of restorative ADL programming may include increased resident self-esteem as well as improve cognition, social acceptance, strength, balance, and coordination. Under the procedure the policy section, it stated #1. (c.) grooming includes maintaining personal hygiene or use of adaptive equipment. #8. The dressing and grooming programs should be carried out at least 6 days a week with daily being optimal. Review of the job description titled, Licensed Practical Nurse, revised 03/02, showed the basic function is to deliver nursing care to residents of the facility. Essential functions noted to include: #2 Delivers nursing care to patients/ resident. #3. Makes observations and reports pertinent information related to the care of the resident. #4. Implements the resident plan of care and evaluates the resident responses.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to honor residents' rights to dignity for 1 of 35 (#83) sampled residents, related to the dining experience and the height of the table. Findings included: Observations in the restorative dining room for the midday meal on 1/21/20 at 12:29 PM revealed that Resident #83 was noted to be seated in her wheelchair at a table with 3 other residents. The table was noted to be at a height of the resident's chin. The resident ate her entire meal in this position. Continued observations at this time revealed that there were 4 staff persons present in the dining room; none of the staff present made any attempt to adjust the resident's position at the dining table. Observations in the restorative dining room for the midday meal on 1/23/20 at 12:01 PM revealed that Resident #83 was seated in her wheelchair at a table with 3 other residents. Resident #83 was noted to be seated at a table that was at the height of the resident's chin. An interview with the Registered Dietician at this time revealed that she was not sure of what the process was to seat residents appropriately during dining, and confirmed that the resident was too low at the dining table. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], indicated that the resident had a BIMS score of 3, and required supervision with setup help only for eating. Review of the facility policy titled Meal Service with a date of 2016 revealed that 4. Residents will be properly positioned in chairs, wheelchairs or geri-chairs at an appropriate distance from the table. Tables will accommodate wheelchairs. Continued review of the facility policy revealed that 6. A seating chart will be used to ensure that residents sit at a table that can accommodate their wheel-chair or geri-chair Review of the Nursing Home Residents' Rights brochure present in the admission packet revealed that Each resident shall have the right to : Receive adequate and appropriate health care, protective and support services within established and recognized standards. Review of the undated policy titled Resident Rights revealed the following: (3)The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when doing so would endanger the health or safety of the resident or other residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop a care plan that included instructions needed to provide care, related to the use of an elastic wrap bandage for 1 of 35 (#149) sampled residents. Findings included: Observations of Resident #149 on 1/22/20 at 8:41 AM revealed that the resident had an elastic wrap bandageto her left hand. It was noted that there was no medical tape on the bandage that would indicate when the elastic wrap bandage was placed on her hand. An interview with the resident at this time revealed that this bandage was old and was ok as it keeps her hand warm. Review of the resident's record revealed that this resident was admitted to the facility on [DATE]. Review of Resident #149's current care plan revealed no care plan in place for, and no mention of the use of, the elastic wrap bandage. Review of #149's record revealed that there was no current order for the use of a bandage to her hand. Review of an admission nursing note, dated 1/8/20 15:05, revealed nwb to lue d/t s/p fall with left wrist fx. Left wrist wrapped with ace wrap. skin underneath intact and clear. There was no other nursing notes related to the use of the elastic wrap bandage An interview 1/23/20 at 9:34 AM with Staff B, Licensed Practical Nurse, revealed that the resident wears the elastic wrap bandage for comfort and that it is not indicated by her physician to use it and that there is no order for the use of the elastic wrap bandage. On 1/23/20 at 10:15 AM, Resident #149 was observed wheeling herself out of her room. The resident was noted to be wearing the elastic wrap bandage. The elastic wrap bandage was noted to be dirty. An attempt to interview the resident at this time was unsuccessful, as the resident fanned this surveyor away and said it's fine. In an interview on 1/23/20 at 10:15 AM with Staff A, Certified Nursing Assistant, she reported and produced a clean elastic wrap bandage in the resident's room. Staff A made no attempts to encourage the resident to change the dirty elastic wrap bandage to the clean one. An interview on 1/24/20 at 11:24 AM with the DON revealed that she was not aware of the resident using an elastic wrap bandage and not aware of how the use of the elastic wrap bandage is to be monitored, related to cleanliness and to ensure that it is not applied too tight. The DON reported that her expectation is that the nurse would be following up on the use and cleanliness of the elastic wrap bandage. On 1/24/20 at 1:07 PM, the DON provided a physician's order, dated 1/24/20, to monitor circulation to left hand every shift, and a second physicians order to change (elastic) wrap to left hand as needed for soilage. Review of the facility care plan titled Person Centered Care Planning, with a revised date of 12/2016, revealed that When admitted , each resident will have physician orders, dietary needs, medications, treatments, and preliminary discharge plans reviewed by the IDT and will have an interim care plan developed within 24 hours of admission, along with input from the resident and/or representative. This assures that the resident's immediate needs are met and his/her preferences are considered. This plan will be implemented as needed until the staff can conduct a comprehensive assessment and develop a complete interdisciplinary plan of care.

Based on observation, interview and record review, facility failed to ensure residents were free of accidents hazards, related to bed not maintained in the low position while in bed, for 1 of 35 (#52) sampled residents. Findings included: On 01/21/20 at 11:15 am, Resident #52 was observed in bed at a high position. Resident #52 was observed awake with an uncontrollable cough. Resident #52 did not respond on command, but continued coughing. On 01/24/20 at 11:30 am, Resident #52 was observed in an elevated bed asleep. The resident did not awake when his name was called to arouse him. On 01/24/20 at 01:35 pm, an interview with Staff I, Licensed Practical Nurse, revealed Resident #52's bed level is changed during meal-times. Staff I stated The part of the meal tray that has the wheels cannot fit under the bed. We lift the bed so the tray can fit properly. On 01/24/20 at 01:52 pm, Resident #52 was observed in bed with the bed in high position. The resident was observed asleep with head of bed raised. On 01/24/20 at 01:57 pm Staff J, Licensed Practical Nurse accompanied surveyor into the resident's room. Staff J confirmed that Resident #52's bed was in the high position. Staff J stated that We reposition him throughout the day. Staff J stated, This is not the low position, but let me find the remote and I'll lower it. Review of Resident #52's facesheet revealed an admission date of 9/04/2017 with recent admission date of 1/13/2020. Pertinent medical diagnoses of Encephalopathy, Parkinson's disease, dysphagia, cognitive communication deficit, muscle weakness and Dementia as of 1/13/2020. Review of Resident #52's physician's orders revealed the resident's bed was to be in low position when the resident is in bed for every shift. Order start date was 1/13/2020. The policy was requested related to physician orders being followed. The facility was unable to provide it. Record Review of Resident #54's care plan revealed the resident is at risk for falls related to confusion, Gait/balance problems, incontinence, unaware of safety needs, ASHD, CAD and weakness. Interventions included but not limited to Anticipate and meet the resident's needs. Date initiated was 05/02/2018 with Revision date of 10/11/2019. Review of Policy titled Summit Care Risk Management-Fall Risk Reduction Program, with Effective date of July 2015, Page 3 Section B. Reducing risk, 1. General safety precautions and interventions that may be used for all at-risk residents include but are not limited to: c) Maintaining bed in low position.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and medication storage, the facility failed to ensure that one (high hall) out of three medications carts were stored according to professional principles, related to the cart contained: medication without a resident identifier, medication without an active Physician order, and a torn controlled substance card holding a pill in place with a piece of tape, out of a total of six medication carts identified by the facility. Findings Included: On [DATE] at 11:45 a.m. the medication cart on high hall was observed, alongside Licensed Practical Nurse I (LPN I). A box contained a label for albuterol for 7 days. LPN I indicated that the last day for the medication was on [DATE]. She confirmed no active order was in place (photographic evidence was obtained). One box of debrox ear drops were noted that had a written date of [DATE]. The box had been opened, with the bottle tip missing its plastic seal. The box did not contain a resident identifier. LPN I confirmed the observation and said that ear drops are not for universal usage. An aerosol inhaler titled Flonase was dated for [DATE]. LPN I, at that time, reviewed current Physician orders for the resident. She confirmed that there was not a current order. The locked box was observed with a bubble card labeled for the controlled substance: Ativan 0.5 mg to give by mouth 3 times daily as needed for anxiety. The card contained handwritten discontinue (d/c) on the top left-hand corner. LPN I said that it was discontinued a few days ago. After a record review, it was determined by LPN I and the Unit Manager that it was stopped on [DATE]. Upon further review of the medication card, the back of the card revealed a piece of tape that covered the #3 pill location. A pill was identified being held in place with the tape that covered the torn package. On [DATE] at 12:30 p.m. an interview was conducted with the Director of Nursing about the medication carts storing medications without orders alongside active ordered medications. She did not respond. On [DATE] at 5:25 p.m. an interview was conducted with the facility Pharmacist. She indicated that the medications in the carts should be removed in a reasonable manner after there is no longer an active Physician order. She stated One week is a reasonable amount of time. In an ideal world it would be taken out of the cart when the order is completed. The Pharmacist was asked about the medication card for Ativan that indicated it was a controlled substance. The back of the card contained a piece of tape covering a torn opening of the packaging. The Pharmacist stated That should not happen. The medication should have been wasted with another nurse, indicating it should not be covered with a piece of tape. The facility provided a copy of their policy titled Disposition of Controlled Drugs, dated on February 2014: All controlled substance prescriptions that are no longer active orders due to discontinuation, discharge or death of a resident shall be destroyed in the facility by the Consultant Pharmacist, the Director of Nursing, and the Facility administrator or his (her) designee. Procedure: Discontinued Medications and deceased Residents: The remaining medications, the Control Drug Count Sheet and a copy of the Disposition of Medication form and Controlled Drug Disposition form shall be stored in a secure area that is not accessible to the nursing staff and is separate from the currently ordered medications.

Based on observation, interview and medical record review, the facility failed to ensure that dental services were provided to one (#4) out of thirty-five residents for over for twenty months. Findings Included: On 01/22/20 at 10:17 a.m., Resident #4 was observed lying in bed. He was asked if he had any problems chewing or swallowing. He made eye contact with stimuli. His lower bottom teeth were crooked and yellow in appearance. The lower left was lacking teeth. He was asked if he had any pain or soreness in his mouth, as he continued to watch the surveyor and not respond. On 1/23/2020 at 10:15 a.m., a wound care observation was conducted with the facility Wound Care Licensed Practical Nurse (WN). Resident #4 was observed lying in his bed and appeared comfortable when approached. He appeared receptive to the observation, as he did not demonstrate nor verbalize his rejection to the WN when he was asked. The WN went to his bedside as she asked him if he was in any pain. He only looked at her without any change noted to his face. She asked him for second time if he was in pain. Again, he just looked at her without any facial changes. The WN then informed the resident that if he had pain during the procedure, she would stop and have the nurse get him something. Resident #4's care plan indicated he was dependent for all care and services. The resident's last Brief Interview for Mental Status (BIMS), dated 1/2/2020, indicated it was not conducted due to the resident's severe impairment. Social service note, dated on 1/2/2020 at 1637, note text Resident #4 ( ) shows no significant changes for this quarterly review. He requires extensive assist with his ADLs. He has short term memory (STM) and long-term memory (LTM) impairment. Resident #4 has severe cognitive impairment, is rarely understood and sometimes understands. He does not verbalize often. Regarding mood assessment, staff interview conducted. Regarding consult, he's on a rotating schedule to be seen by podiatry (11/ 1/19) and eye doctor (9/12/19). Resident #4 is a long-term care resident and his family considers the Springs his home and does not want to be asked to return to the community on all assessments. He attends activities and is more a passive participant. His advanced directives include DNR code status. Social services to provide services as needed to share that his psychosocial needs are met. The quarterly review omitted dental services. On 1/23/2020 at 4:00 p.m.,the Social Worker Director (SWD) was asked for copies of the last visit to Resident #4 by the dentist. She confirmed his insurance was Medicaid. The last dental visit provided by the SW was dated on May 10, 2018. The SWD confirmed that was the last time Resident #4 had been seen by the dentist. On 01/24/20 at 12:49 p.m. the Nursing Home Administrator was asked about Resident #4 not having any dental services since 2018. She stated, He was admitted with missing teeth. And he does not complain of any mouth pain. They did not want dental services. She was informed that he had not responded to the surveyor when he was approached. She said, He doesn't know you. She was informed that he had not responded the day prior to the wound nurse, when asked a simple a yes or no question. She said I don't know about that. On 01/24/20 2:07 p.m. an interview was conducted with the SWD and the Social Worker Assistant (SWA). As they both indicated at that time, they did not have any communication issues with the resident's granddaughter. They were able to get in contact with her. The SWD said the granddaughter lives out of state, and does not participate in the care plan meetings. On 1/24/2020 at 2:10 p.m. a phone call was placed to Resident #4s' granddaughter, and she was receptive to the interview. She was asked if she was aware that her grandfather had not been seen for routine dental screenings since 2018. She said that she sends over all of his money that he gets every month to the facility. She stated $5000.00 a month. The granddaughter said that I would think he would have dental benefits. He has VA benefits; it should be covered. They tell me if he sees the dentist, they will have to take away from the money I send them. The granddaughter raised her voice and stated, I don't have any extra money to send for the dentist. She was asked who had told her she would be responsible for the additional payment. She indicated it was the facility social workers. The granddaughter was asked if she wanted her grandfather to have dental services; she stated, I would love for him to have dental services On 1/24/2020 at 3:10 p.m. the SWD said that He will tell us if he has pain. But he doesn't have any pain. She was asked how she was able to tell he did not have dental pain. She said you can tell by his face. The SWD was asked about the dental visit that was dated May 10,2018. It was listed next visit: FMD Initially/Prophy After. She indicated that is put on all the residents' visits and did not indicate anything. FDM: Full Mouth Debridement (FMD) for Periodontal Evaluation - Dental Procedure Code Description. The American Dental Association describes a full mouth debridement as the gross removal of plaque and calculus that interfere with the ability of the dentist to perform a comprehensive oral evaluation. Prophy: Prophylactic | Definition of Prophylactic by Merriam-Webster 1 : guarding from or preventing the spread or occurrence of disease or infection prophylactic therapy. 2 : tending to prevent or ward off : preventive. www.merriam-webster.com > dictionary > prophylactic The Social Worker Assistant (SWA) was asked why Resident #4 had not been seen for yearly screenings. She stated, He doesn't have any issues to see a dentist. She confirmed his last BIMS score was zero, indicating he was severely impaired. The facility provided their policy titled Social services/Nursing-Dental Services that contained a revision date on October 2017. Policy: the facility will assist residents in obtaining both routine and 24-hour dental care. When necessary or requested, the facility will assist in making appointments by arranging transportation to and from the dental service location. The facility will try to minimize the financial burden on the resident by finding the lowest cost or no-cost transportation option to dental health care appointments. Routine dental services mean an annual inspection of the oral cavity for signs of disease, diagnosis of dental disease, dental radiographs as needed, dental cleaning. For Medicaid paid residents, the facility will provide all emergency dental services in those routine dental services to the extent covered under the Medicaid state plan. The facility will inform the residents of the deduction for the incurred medical expense available under Medical state plan and will assist the resident in the reapplying for deduction.

Based on observation, interview and record review, the facility failed to maintain the kitchen in a clean and sanitary manner, related to the dish machine, cleaning of dish cloths and a stove backsplash. Findings included: Observations of the facility kitchen on 1/21/20 at 9:52 AM revealed that the dish machine had a dirty dish curtain stored on top of the dish machine and hanging over the clean side of the dish machine. Closer observations of the dish machine revealed that around the opening of the clean side of the dish machine was a white chalky substance. (Photographic evidence obtained) Continued observations at this time revealed a tray came out of the clean side of the dish machine, containing what was supposed to be clean cutlery. Closer observation of the tray revealed that there were 3 dish cloths mixed into the cutlery. When questioned why the dish cloths were mixed in with the cutlery, the Certified Dietary Manager (CDM) immediately pulled them out of the tray and mumbled those should not be in there. An interview, on 1/21/20 at 9:55 AM, with the CDM revealed that she would ensure that the dish machine is clean. She reported that she was not sure why the staff were washing the dirty dish cloths with the cutlery. She reported that the kitchen staff wwould be trained in the appropriate way to wash the cutlery and the dish cloths separately. Observations on 1/23/20 at 11:13 AM during the comprehensive tour of the kitchen revealed that this kitchen houses a 6 burner stove with an attached backsplash. Closer observations of the backsplash revealed that it was covered with brown/black greasy build-up which was easily removed with the tip of a pen. (Photographic evidence obtained.) Interview with the CDM at this time revealed that she was unsure as to when the backsplash to the stove was last cleaned. Review of the Daily/Weekly Cleaning List for Cooks does not reflect if or when the dish machine should be cleaned. Continued review of the list revealed that it indicated that the stove top should be cleaned, but does not indicate if or when the backsplash should be cleaned. A request was made for a policy for cleaning and maintaining the dish machine and the stove backsplash; these policies were not provided.

Based on observation, interview and record review, the facility failed to maintain all kitchen equipment in a safe operating condition, related to 2 of 6 (top left, top middle) burners on the stove and a reach-in refrigerator located in the satellite kitchen. Findings included: Observations of the main kitchen and the satellite kitchen during the comprehensive tour of the kitchen on 1/23/20 at 11:13 AM revealed that the main kitchen houses a 6-burner stove. Close observation of the stove revealed that the top left burner and the top middle burner did not have pilot lights lit. Continued observations of the stove at this time revealed that the Dining Service Director lit both burners with a cigarette lighter. Both burners were turned on and then turned back off. The pilot light on the back center burner remained lit; however there was no pilot light on the rear left burner. The Dining Service Director reported that this was the second time this week that he had to light the pilot lights. Continued interview with the CDM and the Dining Service Director revealed that they both were not sure when the last time the pilot lines had been cleaned, and they were both unsure if this concern had been reported for repair. Continued comprehensive inspection revealed that this facility houses a satellite kitchen. It was noted that the satellite kitchen housed 4 reach-in refrigerators. Closer observation of 1 reach-in refrigerator that had dished canned fruit and cake stored in it, had a a broken rubber gasket approximately 12 inches long. Closer observation revealed that for this 12-inch area, the gasket was not attached to the refrigerator door and did not allow a positive suction to allow temperatures to be maintained (Photographic evidence obtained). Observation of the thermometer located inside the refrigerator revealed a reading of 44 degrees. The temperature of a bowl of apples was read at 58 degrees. Interview with the CDM at this time revealed that the items in this fridge were prepped this morning. Review of the facility's instructions for inspecting kitchen small appliances revealed that staff are to 1. Visually inspect all appliances for damage 5. Test functionality of appliances and proper operation of all controls.

Based on observation, interview and medical record review, the facility failed to ensure that a standard infection control was utilized during incontinent care with one (#30) resident out of 35 sampled residents; that a blood monitoring device was cleaned and disinfected in-between three (60, 9 & 17) residents out of a total of nine residents with blood monitoring orders; contaminated dressing of bodily fluids were removed after completion from one (#4) resident environment; and that supervision was provided to one (#23) of one resident with conjunctivitis to prevent recontamination. Findings included: 1. On 1/21/2019 at 10:50 a.m., Resident #30's bedroom door was closed. As the door was knocked on, a faint response stating just a minute could be heard. At that exact time, a nurse was present and stated the resident was being provided with care. She said we could go in. On entrance to the bedroom, a pair of pants, a soiled incontinent product, a towel and wash cloth laid strewn on the floor bare surface. The nurse said softly, Let me get some gloves. The curtain divider was partially obscuring the resident as she was getting assistance with her incontinent product. The Certified Nursing Assistant (CNA) then assisted Resident #30 into her wheelchair and said that the resident will start taking off her clothes on her own after an incontinent episode, indicating she had reached her just in time. The resident smiled at that time when she was approached. She was asked if she was going to activities. While still smiling, she said I can't hear you. Her left hearing aid was not hooked over the top of her ear; it dangled toward the top of her shoulder. The CNA, with the same gloves on, repositioned the hearing aid over the top of the oxygen tubing that was also positioned behind the left ear. She then bent down and picked up the washcloth and additional linen off the floor and placed it inside of the bag. The assistant then removed the gloves from her hands and exited the bedroom, walking right past the sink that was next to the doorway. The assistant walked down the hallway and used a punch pad to access the biohazard room that was across from the Unit One nursing station; opened the door with her right hand and tossed the bag into a bin; turned around and exited the room. The biohazard room was observed with a sink and faucet. An interview was conducted with the assistant at that time; she said she was Certified Nursing Assistant D. She was asked about hand hygiene practice after leaving Resident #30's bedroom. She stated I left the room with dirty linen. I always do it that way. Leave the room with dirty linen. Then I wash my hands. 2. On 1/22/2020 at 4:12 p.m., medication observation pass was conducted with Licensed Practical Nurse G (LPN G). She said Resident #60 was due for her blood glucose monitoring. LPN G entered the resident's bedroom and washed her hands for nine seconds and returned to the medication cart. She removed a container of bleach wipes and took it into the resident's bedroom and set it on top of her over-the-bedside table. She removed one of the wipes from the container and cleaned the top of the table, then used a paper towel to dry the tabletop. LPN G then removed the container of bleach wipes from the bedroom and placed it on top of the medication cart's bare surface. LPN G removed the glucose device from the drawer of the medication cart and cleaned the device for twenty-five seconds and placed it inside of a plastic cup. LPN G said that the device needed to dry for four minutes. Resident #60 was alert and receptive to the observation of the procedure. After the resident's blood glucose was obtained, the nurse returned to the medication cart and cleaned the device for four seconds, and placed it inside of a plastic cup. At 4:35 p.m., Registered Nurse E said that Resident #9 had an ordered blood glucose check at the time. Resident #9 was receptive to the observation process. After the procedure was performed, RN E went to the sink and set the device on top of the sink edge while she performed hand hygiene. She then picked up the device and returned to the medication cart. RN E cleaned the device for five seconds and placed it in the bottom drawer and said it would dry. At 4:48 p.m. LPN G said she had a second blood glucose monitoring that could be observed for Resident #17. She removed the meter from the medication cart and placed it on top of the cart. She confirmed the meter had not been used after Resident #9. LPN G gathered the supplies that were needed for the procedure, and entered the bedroom with the container of bleach wipes. The container was set on top of the resident's over-the-bedside table. The tabletop was cleaned with a bleach wipe. LPN G then removed the container from the bedroom and placed it back inside of the medication cart's bottom right hand drawer. LPN G cleaned Resident #17's finger and used the lancet to obtain a blood sample. As LPN G picked up the meter and brought it towards the resident's finger, she was asked to stop. LPN G was asked to leave the bedroom at that time; as she did the Director of Nursing was standing in the hallway. LPN G was asked about the process of cleaning the glucose device. She said after the device is used, it is to be cleaned and dried for four minutes. She was asked what the cleaning instructions for the bleach wipes indicate. She stated, We used to clean the device for four minutes, but it wrecked the machines. She indicated the last time she had cleaned the machine for the manufacturer's recommended time was when you guys were here. The DON indicated the glucose device needs to be cleaned per the bleach wipes instructions. At 5:33 p.m. an interview was conducted with Registered Nurse H; she said that the normal procedure for cleaning the blood glucose device is by using a bleach wipe. You clean it twice, as she demonstrated, wiping the front and back of the device, and letting it dry for four minutes. She was asked if she had any training on the device; she said that an in-service was held and she was trained by the risk manager. On 01/23/20 11:31 a.m., an interview was conducted with the Risk Manager. She said that she had trained the licensed staff on cleaning the blood glucose meters. She stated I might have gotten it mixed up and said the dry time was four minutes, not the wet time. On 1/24/2020 at 12:42 p.m. the DON provided a list of current residents that resided in the facility with an active order for blood glucose monitoring. The list contained a total of nine residents. The facility provided a copy titled Maintenance that contained a revision date of February 2017. Cleaning and disinfecting guidelines due to CMS's F-tag 441 guideline on infection control, it is (company name)'s policy to advise healthcare professionals to clean and disinfect blood glucose meters between each resident test to avoid cross-contamination issues. Our cleaning and disinfecting guidelines are as follows: option 1: Cleaning and disinfecting can be completed by using a commercially available EPA-registered disinfectant detergent or germicidal wipe. To use a wipe, remove from container and follow product label instructions to disinfect the meter. Take extreme care not to get liquid in the test strip and key code ports of the meter. Many wipes act as both a cleaner and disinfectant, so if blood is visibly present on the meter, two wipes must be used; use one wipe to clean and a second wipe to disinfect. The facility policy,Nursing - Blood Glucose Meter Cleaning and Disinfecting with a revision date of February 2017: The facility will prevent the spread of infection by cleaning and disinfecting blood glucose meters according to the manufacturer's recommendations between resident use. Procedure: Blood glucose meters will be wiped with PDI super Sani-cloth (bleach) germicidal disposable wipes after each use. The meter will be wiped down completely and left wet for two (4) minutes to remain a wet surface when allowed to air dry according to the manufacturer's directions each time it is and disinfected. If the meter is visibly soiled with blood, the blood will be cleaned off with one germicidal wipe and the meter will be disinfected with a second germicidal wipe and allowed to air dry before next use. The facility bleach wipe container of Sani-cloth bleach germicidal disposable wipe indicated on the front label that it disinfects in four minutes. Directions for use: to clean, disinfect and deodorize; use a wipe to remove heavy soil unfold clean wipe and thoroughly wet surface treated surface must remain visibly wet for a full four (4) minutes. Use additional wipes if needed to assure continuous four-minute wet contact time. (Photographic evidence obtained). 3. On 1/23/2019 at 10:15 a.m., a wound care observation was conducted with the facility Wound Care Licensed Practical Nurse (WN). Resident #4 was observed lying in his bed and appeared comfortable when approached. He appeared receptive to the observation as he did not demonstrate or verbalize his rejection to the WN when he was asked. The WN went to his bedside as she asked him if he was in any pain. He only looked at her without any change noted to his face. She asked him for second time if he was in pain. Again, he just looked at her without any facial changes. The WN then informed the resident if he had pain during the procedure, she would stop and have the nurse get him something. The supplies were placed on top of a paper towel border on top of the resident's bedside table. The supplies consisted of 4 x 4 gauze dressings, two normal saline ampules, two tubes of santly ointment in a plastic bag, one Q-tip applicator, calcium alginate rope and allevyn life foam dressing, and one pair of scissors in a plastic bag. With the assist of a nursing assistant, Resident #4 was positioned to his right hip. The WN removed the old dressing from the resident's left ischium. An odor was immediately present. The WN confirmed the odor as musty and said that he had just finished an antibiotic. The old dressing was noted with a moderate amount of drainage that was presented as pink, with scattered yellow drainage. The dressing was disposed of, along with her gloves, in a garbage can that was next to the bedside. The wound opening appeared the size of a quarter with an irregular shaped border. The edges of the wound presented as macerated between two to four o'clock. The surrounding skin was pink and intact with old scar tissue just lateral to the left side of the wound opening. The wound bed had appeared white in color and noted to tunnel between 12 and 3. The depth was not able to be determined due to the extent of the tunneling. After the dressing was completed, the WN washed and dried her hands. She then removed the tube of santly that had not been used as it remained inside of a plastic bag, never opened, and returned it to the treatment cart. The supplies that were used, along with the soiled wound dressing, were left in the bedroom in the garbage can. Medical record review for Resident #4 indicated an order for Levaquin tablet 750 mg give 1 tablet by mouth one time a day for wound for two weeks with a stop date (D/C) date on 1/22/2020. The DON was asked for a copy of the facility procedure related to the disposal of soiled wound dressings. The facility provided a copy of their policy titled Dressings, Soiled/Contaminated with a revision date of August 2009. Policy statement: All soiled/contaminated dressings must be handled in a safe and sanitary manner and must be incinerated or disposed of following decontamination or containment. Policy of Interpretation and Implementation 1. Disposable items such as bandages, applicators, gauze pads, etc., that are soiled or contaminated with infective material, blood, or bodily fluids must be placed in a plastic bag and removed from the resident's room upon completion of any procedure. 4. On 1/22/20 at 1:18 p.m., Resident #23 was in the hallway propelling his wheelchair and was receptive when approached. He was observed with both of his eyes red in color and the upper eye lashes containing a moderate amount of crusted dark yellow matter. He was asked if his eyes his eyes hurt. He stated, It feels like I have sand in them. On 01/23/20 at 11:10 a.m. Resident #23 was in his bathroom as Certified Nursing Assistant K (CNA K) was in the bedroom. She was asked how much assistance was given to Resident #23 related to his morning care. She stated, He is very independent with his own care. We will change the linen on his bed and make his bed. At that time, Resident #23 exited the bathroom and smiled. Both of his eyes were pink in color. The upper and lower eye lashes presented with a moderate amount of dark yellow colored crusted residual. He said that he had washed his face and eyes. But it hurts having to rub them. CNA K said You have to hold the washcloth to the eyes for a while to loosen up. She added They drain a lot just like . (his roommate). She was asked how long his eyes had been draining; she indicated she was not for sure how long, as she only works as needed. The medical record was reviewed and revealed he had been residing at the facility for a year. Physician orders were reviewed that were dated on 1/15/2020 for Tobramycin solution 0.3% 1 drop in both eyes two times day for DX (diagnosis) conjunctivitis until 1/23/2020. Further review of Physician Progress note dated on 12/10/2019 Subjective: Patient is being seen today for left eye conjunctivitis. This began yesterday; patient had had drainage and crusting. Plan start patient on TobraDex 2 drops 3 times daily for 5 days. Progress Physician orders contained an order for tobramycin solution 0.3% instill 2 drops in left eye twice a day five days dated on 12/10/2019. This indicated Resident #23 had been treated for two months for conjunctivitis. On 01/23/20 at 12:35 p.m., an interview was conducted with the Director of Nursing, who is also the facility Infection Control Preventionist, related to Resident #23's eye infection. She said, When it was first identified, we had him stay in his bedroom for over the weekend. The DON was asked if the medical record had reflected this. She said that it did. The medical record for Resident 23's stay in his bedroom over the weekend could not be located. At 12:40 p.m., Resident #23 was in his bedroom and was receptive to an interview along with the DON. He was asked if his eyes were feeling better. He then picked up a washcloth that was lying inside of a plastic container/bin that was sitting on top of his bed. The container had also contained his shaving cream and other personal hygiene items. He said I have a new washcloth. Resident #23 was asked about his new washcloth, and he said that sometimes they run out of washcloths. He pointed to a used washcloth that was hanging off his dresser drawer handle. He said that he uses it sometimes more than once. The DON indicated if he had been reusing his washcloths, he could possibly re-contaminate his eyes. She confirmed that this is the second time he had been treated for conjunctivitis. On 01/24/20 at 10:40 a.m., the DON said that she had talked with several of the staff members that take care of Resident #23. They had confirmed they were aware Resident #23 reuses his washcloth, and that they remove it. She also said that Resident #23's physician had seen Resident #23 and reordered his eye drops for 5 more days. On 1/24/2020 at 11:00 a.m., Resident #23's bedroom was noted with a used washcloth for a second day hanging off his dresser drawer handle (photographic evidence obtained). Pink eye (conjunctivitis) Is an inflammation or infection of the transparent membrane (conjunctiva) that lines your eyelid and covers the white part of your eyeball. When small blood vessels in the conjunctiva become inflamed, they're more visible. This is what causes the whites of your eyes to appear reddish or pink. Pink eye is commonly caused by a bacterial or viral infection, an allergic reaction. Though pink eye can be irritating, it rarely affects your vision. Treatments can help ease the discomfort of pink eye. Because pink eye can be contagious, early diagnosis and treatment can help limit its spread. Symptoms: The most common pink eye symptoms include: Redness in one or both eyes Itchiness in one or both eyes A gritty feeling in one or both eyes A discharge in one or both eyes that forms a crust during the night that may prevent your eye or eyes from opening in the morning Tearing Preventing the spread of pink eye Practice good hygiene to control the spread of pink eye. For instance: Don't touch your eyes with your hands. Wash your hands often. Use a clean towel and washcloth daily. Don't share towels or washcloths. Change your pillowcases often. https://www.mayoclinic.org/diseases-conditions/pink-eye/diagnosis-treatment/drc-20376360.