**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to provide administration of intravenous medication in accordance with professional standards of practices for one resident (#11) of four residents sampled. Findings included: On 9/3/2024 at 9:55 a.m. a loud alarm sound was overheard close to the nurse station area. The alarm sound was observed to be emitting from an Intravenous (IV) therapy system pump, which was at Resident #11's bedside down the hallway. At this time, Resident #11 was observed lying flat in bed and with his head propped up on a pillow. Resident #11 stated, The [explicative] thing goes on all the time. He stated the IV system provided an antibiotic to heal a wound infection, and he could not remember exactly how long he has been treated with IV antibiotic therapy. Resident #11 stated the IV machine must have problems to alarm that way. He stated, They [staff] take a long time [to respond]; it happens enough. Further observations, at this time, of the alarming IV therapy system revealed a hanging liquid medication bag with a line leading from it to a pump. The line continued from the pump to the resident's right arm. The loud alarming pump had a read out that showed, Air in the line. Following the interview on 9/3/2024 with Resident #11, the alarm was still sounding and the resident was overheard yelling nurse at 10:13 a.m. Then at 10:14 a.m. the Staff A, Registered Nurse/Unit Manager (RN/UM) walked out from another resident's room over to Resident #11's room. An interview was conducted on 9/3/24 at 10:15 a.m. with Staff A, RN/UM, who exited Resident #11's room. She stated the alarm was sounding and she had to get the air out from the line. She revealed it happens at times and only IV trained nurses can remove the air from the line when air builds up. She was not sure how long the resident was on the IV therapy and was not sure what the medication was or what type of infection he had. On 9/3/2024 at 10:46 a.m. Resident #11's IV pump was again observed and overheard alarming. The pump read, Air in the line. The alarm kept sounding and there were no staff in the area to report to the room to fix the alarm. At 11:00 a.m., 11:02 a.m., and 11:03 a.m. Resident #11 was again overheard calling out loud, Nurse. There were no staff in the area to answer. On 9/3/2024 at 11:06 a.m. a Staff O, Licensed Practical Nurse (LPN) was observed walking down the hallway from another hall, and then went into Resident #11's room to fix the alarm. Staff O was interviewed and replied, I did hear the alarm and I fixed the air line alarm. He was not sure how long the alarm was sounding and expressed that if aides hear the alarm, they are to report it to a nurse immediately. During the interviews with both Staff O, LPN and Staff A, RN/UM on 9/3/2024 they revealed when the alarm sounds and there is air in the line, the system does not provide the fluid antibiotic to the resident. They both confirmed the air in the line has to be flushed out in order for the medication to flow again. Review of Resident #11's admission Record revealed he was admitted to the facility on [DATE] and readmitted from hospital on 8/23/2024. Resident #11's diagnoses included osteomyelitis, urinary tract infection, and prostatic hyperplasia with lower urinary tract symptoms,. Review of the Order Summary Report for the month of 9/2024 revealed the following active physician orders: - Vancomycin HCI IV solution Reconstituted 1 GM (gram) - 1 dose IV BID (two times a day) for infuse 1.25 into vein until 9/9/2024. (Order start date - 9/2/2024). - Cleanse and irrigate wound in Right heel area with normal saline pat dry with gauze, and apply Dakins moistened gauze to wound bed and cover with boarder dressing x shift for wound and as need for if soiled or falling off. (Order date 9/2/2024) - Cefepime HCL IV solution Reconstituted 2 gm - Use 2 gm times 12 hours for wound infection until 9/9/2024. (Order start date - 8/29/2024). - IV - PICC (peripherally inserted central catheter) all types change primary intermittent tubing x 24 hrs (hours) x day shift. (Order date 8/26/2024). - IV - PICC all types change needleless connector on admission, weekly and PRN (as needed) x day shift x Tue and as need (Start date 8/26/2024). - IV - PICC all types monitor site Q (every) shift for signs/symptoms of infection and or infiltration x shift. (Start date 8/26/2024). - IV - PICC change transparent dressing on admission, then weekly and PRN thereafter x day shift and Tue and as need. (Start order date 8/27/2024). Review of the nurse progress notes dated from date of admission 8/6/2024 through to current date 9/5/2024 did not indicate any documentation of concerns related to the IV therapy system, nor any documentation of Resident #11 ever refusing the IV antibiotic therapy. Review of the current care plan, with a next review date 11/19/2024, revealed the following Focus areas: - Diagnosis of Osteomyelitis with interventions in place to include administer IV antibiotics as ordered, monitor for adverse side effects and report findings to MD. - Infection on the right heel/sacrum, with interventions in place to include administer antibiotic as per MD orders. - Infection care plan the resident is on IV antibiotic therapy r/t (related to) infection to right foot. Interventions included administer antibiotic medications as ordered by physician. On 9/5/2024 at 10:00 a.m. an interview was conducted with Staff A, RN/UM. She confirmed Resident #11 has an IV therapy system that provides a liquid antibiotic. She revealed only qualified nurses are able to hang and operate the IV therapy system. Staff A revealed the IV pump will walk you through each step on how to operate it. She was asked what it means when the pump read out reveals; Air in the line. She stated; It means air has accumulated in the line and the line needs to be cleared. Staff A also confirmed that once the IV machine tubing has air accumulated in it, the medication will not flow at all to the resident. She revealed the air has to be flushed for the medication to flow again. Staff A revealed if the air is in the line, a very loud alarm will sound and it will not stop until the air has been flushed properly. She also confirmed the alarm can be overheard outside the room, down the hall and if other staff hear it, they should report it a nurse or herself immediately. A review of the policy titled, Intravenous Therapy, implementation date of 12/2/2022, documented, The facility will adhere to accepted standards of practice regarding infusion practices. Definitions included; Intravenous (IV) therapy is the administration of parenteral fluids or medications through an IV catheter to treat a condition. The compliance guidelines of the policy revealed the following: 8. Whenever possible, an infusion pump will be used when administering intravenous fluid or medications. 9. When an infusion pump is not used, a mechanical flow control device will be used. 10. A doctor's order is obtained before starting IV therapy. 11. IV documentation is recorded in the nurses' notes and/or Medication Administration Record. Under the Procedures Continuous Infusion section following was documented: 8. Spike solution/medication and prime tubing, maintaining spike sterility. Clamp tubing when primed and all air is out of tubing. 13. Observe infusion site for any adverse reactions and stop infusion, if so noted, and notify practitioner. Under the Intermittent Medication Infusion section of the policy, it revealed the following: 5. Check medication expiration date, leaks, cracks, change in clarity, or particulate matter. 9. Prepare infusion by spiking medications, priming tubing, ensuring all air is out of tubing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to monitor the oxygen saturation level for one resident (#9) of one resident sampled for respiratory care. Findings included: On 9/3/24 at 12:25 p.m. Resident #9 was observed lying in bed with eyes closed. An oxygen concentrator was sitting on the floor next to the bedside dresser. Review of Resident #9's admission Record revealed the resident was admitted on [DATE] and 10/1/19. The record included diagnoses not limited to unspecified severity unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, shortness of breath, and unspecified organism other pneumonia. Review of Resident #9's Minimum Data Set assessment, dated 6/16/24, revealed in Section C - Cognitive Patterns the resident was rarely/never understood and had a no score for the Brief Interview for Mental Status. Review of Resident #9's September 2024 Medication Administration Record (MAR) revealed a physician order for Resident with history of shortness of breath while lying flat. Head of bed was elevated this shift to prevent shortness of breath. every shift, start date 3/20/24. The MAR showed for the 12 Da (day shift) and 12 Ng (night shift) from 9/1/24 to 9/4/24 the staff documented four out of seven shifts that the resident's head of bed was elevated and three times it was not. The MAR showed the resident was to be administered oxygen at 2 lpm (liters per minute) via n/c (nasal cannula) as needed for SOB (shortness of breath) related to shortness of breath. The MAR did not reveal the resident had been administered oxygen. Review of Resident #9's June 2024 through September 2024 Treatment Administration Records (TAR) showed an order for Check oxygen saturations q (every) shift every shift. The TAR revealed staff documented a checkmark on each 12 Da and 12Ng shift, without documentation of an oxygen saturation level. The TAR did not have an area to document the saturation level with the order. According to the chart codes, a checkmark equaled administered. Review of Resident #9's care plan revealed a focus showing the resident had oxygen therapy r/t (related to) SOB when lying flat. The interventions included, Give medications as ordered by physician. Observe/document side effects and effectiveness. Review of the policy - Medication Administration, implemented on 3/24/23, instructed staff to Obtain and record vital signs, when applicable or per physician's orders. The policy showed staff were to Sign MAR after administered. For those medications requiring vital signs, record the vital signs onto the MAR. An interview was conducted with the Director of Nursing on 9/4/24 at 4:21 p.m. The DON stated staff should be documenting oxygen saturation levels if they have an order and if the nurse thought the order need to be clarified, the physician should be contacted.

Based on observations, record reviews, and interviews the facility failed to ensure the medication error rate was less than 5.00%. Thirty-six medication administration opportunities were observed and nine errors were identified for two (#27 and #7) of three residents observed. These errors constituted a 25% medication error rate. Findings included: 1. On 9/4/24 at 8:04 a.m. an observation of medication administration with Staff D, Registered Nurse (RN) was conducted with Resident #27. The staff member dispensed the following medications: - Acidophilus lactobacillus otc (over-the-counter) capsule - Amlodipine 10 mg (milligram) tablet - Biotin 1000 mcg (microgram) otc tablet - Loratadine 10 mg otc tablet - Cranberry 2- 450 mg otc tablets - Doxycycline 50 mg capsule - Methenam hiprex 1 gram tablet - Montelukast 10 mg tablet - Valsartan 40 mg tablet - Amoxicillin/Potassium clavulanic 875-125 mg tablet - Tamsulosin 0.4 mg capsule - Lactulose 10 gram/15 milliliter (gm/mL) - 30 mLs. Staff D, RN searched through multiple bottles in the medication cart and reported having to reorder Resident #27's Lactulose. Staff D removed a bottle of Lactulose labeled with a female resident's name (#12) on it and poured 30 mLs of it into a medication cup. The staff member confirmed dispensing 12 tablets and one liquid. The staff member reported on 9/4/24 at 8:15 a.m. of having to borrow Lactulose from Resident #12 as Resident #27 did not have any. The staff member was dressed in personal protective equipment (PPE) necessary for entering the resident's room, Resident #27 was observed swallowing the oral tablets and drinking the liquid medication Lactulose. Review of Resident #27's September 2024 Medication Administration Record (MAR) showed the following order: - Biotin - Give 500 mcg by mouth one time a day for hair and nails. 2. On 9/4/24 at 8:25 a.m. an observation of medication administration with Staff E, RN was conducted with Resident #7. The staff member dispensed the following medications: - Amoxicillin/Potassium clavulanic 875-125 mg tablet - Eliquis 5 mg tablet - Jardiance 10 mg tablet - Metoprolol Succinate 50 mg Extended Release (ER) - Acidophilus lactobacillus 20 mg otc capsule - Felodipine 10 mg ER - Gabapentin 300 mg - 2 capsules - Xifaxan 550 mg tablet - Spirolactone 50 mg tablet - Cranberry 450 mg otc tablet - Cetirizine 10 mg otc tablet - Docusate sodium 100 mg gelcap - Acetazolamide 125 mg tablet - Zinc 50 mg otc tablet - Meclizine 12.5 mg otc tablet - Benzonatate 100 mg capsule Staff E stated the resident was to receive Lactulose, however the resident did not like liquid (medications) and did not have any (Lactulose), but staff were still supposed to offer it. The staff member confirmed dispensing 17 tablets (did not count them), mixed oral medications with applesauce at bedside and assisted the resident with taking them. The resident asked for eye drops. Staff E returned to the cart and removed a bottle of generic Tetrahydrozoline 0.05%, sanitized hands at the cart, donned gloves while standing in the hallway then entered the room. Staff E placed one drop in the right eye and one drop in the left eye. The staff member returned to the cart and documented the Silver Sulfamide cream had been applied, saying they come and get the staff member to apply it when they assist the resident with hygiene. Staff E documented under Lactulose awaiting pharmacy and confirmed the resident was to receive Furosemide, Oyster Shell Calcium, and Vitamin B12 but did not have any and was waiting for pharmacy to deliver. Review of Resident #7's September 2024 Medication Administration Record (MAR) revealed the following medications were to be administered: - Lactulose 10 gm/15 mL - Give 30 mL by mouth three times a day for constipation. The nurse documented 5. Review of the chart codes showed 5=Hold/See Nurse Notes. The order was discontinued on 9/4/24 at 10:08 a.m., approximately 1 hour and 30 minutes after the observation. The order was reinstated to begin on 9/5/24 at 9:00 a.m. - Silver Sulfadiazine Cream 1% - Apply to bilateral buttocks topically every shift for Moisture-Associated Skin Damage (MASD). The Medication Administration Audit Report revealed the cream was applied on 9/4/24 at 8:56 a.m., during the observation period. - Cholecalciferol 1000 unit (Vitamin D3) - Give 1 tablet by mouth in the morning for Vitamin D deficiency. This medication was scheduled during the liberalized medication administration time of 7:15 a.m. to 11 a.m. The Medication Administration Audit Report revealed the medication was administered on 9/4/24 at 2:57 p.m. - Metoprolol Succinate ER tablet 24-hour 50 mg - Give 1 tablet by mouth one time a day for hypertension. Hold if less than systolic blood pressure (SBP) 100, diastolic blood pressure (DBP) 60, heart rate 60. A review of the MAR showed no area to document either blood pressure or pulse. The observation did not reveal Staff E, RN obtained a blood pressure or pulse prior to the administration. An interview was conducted on 9/4/24 at 10:06 a.m. with Staff E. The staff member stated that night shift takes Resident #7's blood pressure and Resident #7 takes it when the resident asks or doesn't feel good. The staff member was unable to provide a blood pressure for the resident. - Oyster Shell Calcium 500 mg tablet - Give 1 tablet by mouth in the morning for Vitamin D deficiency, take with food. This order was discontinued on 9/4/24 at 10:14 a.m., approximately 1 hour and 46 minutes after the observation of medication administration. The September MAR did not show the medication was administered on 9/4/24. - Refresh Tears Ophthalmic solution (Carboxymethylcellulose sodium) - Instill 1 drop in both eyes every 12 hours for dry eyes. The observation revealed Tetrahydrozoline 0.05% eye drops had been administered. - Vitamin B12 500 microgram (mcg) tablet (Cyanocobalamin) - Give 1 tablet by mouth in the morning for Vitamin B12 deficiency. The observation did not show this medication was administered. The Medication Admin Audit Report showed Cyanocobalamin was administered on 9/4/24 at 2:57 p.m. Review of Resident #7's progress notes, on 9/4/24 at 4:10 p.m., did not show the physician had been notified of the lateness of medications or the unavailability of Lactulose. An interview was conducted on 9/4/24 at 4:00 p.m. with the Director of Nursing (DON). The DON was notified of the observation for Resident #27. The DON was notified of the observation with Resident #7 and stated vital signs should be taken within one hour of the Metoprolol. After reviewing the Vital Summary and MAR for Resident #7, the DON confirmed there were no blood pressures recorded for the resident's Metoprolol. The DON stated the physician had been notified at 11:00 a.m. (on 9/4/24) of Resident #7's late medications, confirming there was no note revealing the notification. Review of the policy titled, Liberalized and Standardized Medication Administration Schedules, approved on 4/24/24, revealed, In keeping with the philosophy of person centered care and resident rights, medications will be delivered in a manner that is least restrictive and intrusive while allowing for optimal therapeutic effect of medications. This practice minimizes the number of times the resident's/ patient's schedule must be interrupted for Drug Administration and allows person centered choices as to when to receive their medication unless specific hour of administration is ordered by the medical provider. The liberalized schedules well allow for medication administration during the defined window of time; these are represented by a descriptor (e.g. in the morning) or time frame (e.g. 0400-0700) on the MAR/EMAR. Medications scheduled are considered timely as long as they are administered within one (1) hour before or after the define time or window of time. Review of the policy titled, Medication Administration, implemented 3/24/23, revealed Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. - 8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. - 11. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name form, dose, route, and time. b. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. - 15. If any medication is not available, or the possibility of late administration, the nurse will contact the attending physician. - 18. Sign MAR after administered. For those medications requiring vital signs, record the vital signs on to the MAR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. A review of Resident #27's admission Record revealed an admission date of 7/20/22. Further review of Resident #27's admission Record revealed diagnoses to include: major depressive disorder with an onset date of 7/19/22. A review of Resident #27's active physician orders, as of 9/5/24, revealed medications to include: Sertraline HCI (hydrochloride) 50 MG (milligrams) for depression. Start date 8/1/23. A review of Resident #27's current care plan revealed a focus of, Antidepressant Care Plan, with a date initiated and created on 7/20/22. Further review of the Antidepressant Care Plan focus revealed the following, Resident is at risk for adverse side effects related to use of antidepressant medications, Baseline care plan date 7/20/22. Interventions included the following, Administer ANTIDEPRESSANT medications as ordered by physicians. Monitor/document side effects and effectiveness Q-SHIFT [every shift]. A review of Resident #27's PASRR Level 1, dated 7/22/22, revealed no documentation of a qualifying mental health diagnosis, to include depression. A review of Resident #27's electronic medical record revealed no evidence of an updated PASRR, Level 1 to include the qualifying mental health diagnosis of depression. On 9/5/24 at 9:48 a.m. an interview with the SSD revealed she does the screening for PASRRs and the MDS Coordinator puts them into the electronic medical record. She stated the facility is in the process of auditing PASRRs. The SSD stated Resident #27's PASSR Level 1 should have been updated with the diagnosis of depression. 6. A review of Resident #28's admission Record revealed an admission date of 2/3/23. Further review of Resident #28's admission Record revealed diagnoses to include: major depressive disorder with an onset date of 2/3/23. A review of Resident #28's active physician orders, as of 9/5/24, revealed medications to include: Mirtazapine Tablet 7.5 MG for MAJOR DEPRESSIVE DISORDER, RECURRENT, UNSPECIFIED. Start date 8/5/24. A review of Resident #28's current care plan revealed a focus of, Antidepressant Care Plan, with a date initiated and created on 2/6/23. Further review of the Antidepressant Care Plan focus revealed the following, Resident is at risk for adverse side effects related to use of antidepressant medications. Interventions included the following, Administer ANTIDEPRESSANT medications as ordered by physicians. Monitor/document side effects and effectiveness Q-SHIFT. A review of Resident #28's PASRR Level 1, dated 1/6/23, revealed no documentation of a qualifying mental health diagnosis, to include depression. A review of Resident #28's electronic medical record revealed no evidence of an updated PASRR Level 1 to include the qualifying mental health diagnosis of depression. On 9/5/24 at 9:48 a.m. an interview with the SSD stated Resident #28's PASSR Level 1 needs to be updated with the diagnosis of depression. A review of the facility's policy titled, Resident Assessment - Coordination with PASARR Program, implemented on 9/7/22, revealed the following, This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Further review of the policy under the Policy Explanation and Compliance Guidelines, revealed the following, . 6. The Social Services Director shall be responsible for keeping track of each resident's PASARR screening status, and referring to the appropriate authority. Based on observations, record reviews, and interviews the facility failed to ensure Pre-admission Screening and Resident Reviews (PASRRs) for six residents (#2, #9, #10, #15, #27, and #28) out of twenty sampled residents were accurate at the time of admission and updated when necessary. Findings included: 1. Review of Resident #2's admission Record revealed the resident was admitted on [DATE] and 8/19/24. The record included diagnoses not limited to unspecified recurrent major depressive disorder (onset 3/27/22), generalized anxiety disorder (onset 4/25/22), and unspecified insomnia (7/23/22). Review of Resident #2's PASRR, dated 3/26/22, showed the resident did not have a mental illness (MI) or suspected mental illness (SMI), an intellectual disability (ID) or suspected intellectual disability (SID) per documented history. The screening revealed a Level II PASRR was not required due to no diagnosis or suspicion of a serious MI or ID. Review of Resident #2's medication list docuemented on the Psychology Subsequent Note report, dated 8/26/24, revealed the resident was receiving the antidepressants Bupropion Extended Release and Sertraline, as well as the sedative-hypnotic medication, Zolpidem as needed for insomnia. During an interview on 9/5/24 at 9:54 a.m. the Social Service Director (SSD) reviewed Resident #2's diagnoses and PASRR then stated it definitely should have been redone. 2. Review of Resident #9's admission Record revealed the resident was admitted on [DATE] and 10/1/19. The record included diagnoses not limited to unspecified severity unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (primary diagnosis with onset date of 8/20/14) and unspecified recurrent major depressive disorder (onset 10/1/19). Review of Resident #9's PASRR, dated 10/1/19, showed the resident had the mental illness of depressive disorder and other (specify): dementia. The decision-making revealed the resident was receiving services for MI and the findings were based on medications. The other indications for decision-making revealed the resident did not have a primary diagnosis of dementia, related neurocognitive disorder (including Alzheimer's disease) and the resident did have a secondary diagnosis of dementia or related neurocognitive disorder (including Alzheimer's disease) and the primary diagnosis was a SMI or ID. The screening showed the resident had validating documentation to support the dementia or related neurocognitive disorder (including Alzheimer's disease). The validating documentation was the resident's Brief Interview of Mental Status (BIMS). The instructions showed A Level II PASRR evaluation must be completed if the individual has a primary or secondary diagnosis of dementia or related neurocognitive disorder, and a suspicion or diagnosis of an SMI, ID, or both. A Level II may only be terminated by the Level II PASRR evaluator and accordance with 42 CFR 483. 128(m)(2)(i) or 42 CFR 483.128(m)(2)(ii). The completed screen revealed a Level II PASRR evaluation was not required. An interview was conducted on 9/5/24 at 9:48 a.m. with the SSD. The SSD reported doing the PASRR screenings and MDS (Minimum Data Set team) inputs them. The PASRR was reviewed and the SSD stated a Level II should have been done. 3. Review of Resident #10's admission Record revealed the resident was admitted on [DATE] and included diagnoses not limited to unspecified severity unspecified dementia with other behavioral disturbance (primary diagnosis with an onset date of 7/26/24), cognitive communication deficit, brief psychotic disorder, and mild recurrent major depressive disorder. Review of Resident #10's PASRR, dated 6/28/24, revealed the resident did not have any MI or SMIs, and no IDs or SIDs based on documented history. The decision-making showed the resident had no disorder resulting in functional limitations in major life activities, no interpersonal functioning difficulty, no difficulty in sustaining focused attention for a period long enough to accomplish tasks, or any difficulty in adapting to typical changes. The decision-making showed the resident did not have a primary diagnosis of dementia or related neurocognitive disorder. The completion of the screening determined a Level II evaluation was not required. During an interview with the SSD on 9/5/24 at 9:58 a.m. the SSD reviewed Resident #10's diagnoses and PASRR stating they (the facility) was going through new admissions as a team. The SSD confirmed Resident #10's primary diagnosis was dementia and should have had a Level II done. 4. On 9/3/2024 at 10:00 a.m. Resident #15 was heard yelling out and moaning aloud from behind her closed room door. During an interview at this time, the resident stopped yelling aloud and revealed she wanted staff to come and take her to the shower. Review of Resident #15's admission Record revealed she was admitted to the facility on [DATE]. Review of the admission Record revealed Resident #15's diagnoses to include altered mental status, cognitive communication deficit, dementia, major depression, mood disorder, and schizoaffective disorder. In addition, the medical chart contained a Level 1 PASRR. Further review of the Level I PASRR revealed the MI, Suspected MI Section I (a) showed Resident #15 was checked for diagnoses to include bipolar and schizophrenia. However, major depression was not checked. On 9/5/24 at 10:00 a.m. an interview with the SSD confirmed the current completed Level I PASSR screen did not reflect all the MI, Suspected MI diagnoses. She revealed Resident #15 did show a diagnosis of major depression and the facility should have completed a new PASRR Level 1 to reflect that.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 9/3/2024 at 11:08 a.m. an observation of Resident #28 revealed he was laying down in bed, with the bedsheets pulled to slightly over his waist, and his hands were over the bedsheets. An observation of his hands revealed long fingernails. Observations of his right hand revealed his ring fingernail was splitting horizontally, in the middle of his nail bed. The ring fingernail on his right hand was lifted up from splitting. An observation of Resident #28's left hand revealed his thumb nail was jagged and splitting horizontally from about half of the nail. On 9/4/2024 at 1:24 p.m. Resident #28 was observed sitting in a wheelchair with the bedside table in front of him. Resident #28's family member was observed sitting on the bed beside him. An observation of his hands revealed long fingernails. Observations of his right hand revealed his ring fingernail was splitting horizontally, in the middle of his nail bed. The ring fingernail on his right hand was lifted up from splitting. An observation of Resident #28's left hand revealed his thumb nail was jagged and splitting horizontally from about half of the nail. He stated he didn't want his nails long. Resident #28 stated staff will cut his nails, When they have time. He stated he receives a shower twice a week. Resident #28 stated he received a shower today and his nails were not cut. He stated his nails that are splitting get caught when he's running his hands through his hair. A review of Resident #28's admission Record revealed an admission date of 2/3/23. A review of Resident #28's Order Summary Report revealed the following diagnoses to include: muscle weakness, major depressive disorder, cognitive communication deficit, and Post-Traumatic Stress Disorder, Chronic. A review of Resident #28's Minimum Data Set (MDS) Quarterly Assessment - Section C, Cognitive Patterns, dated 7/22/24, revealed a Brief Interview Mental Score (BIMS) of 13, cognitively intact. A review of Resident #28's current care plan for Activities of Daily Living (ADL) revealed the following, The resident has an ADL self-care performance deficit r/t [related to] weakness, date initiated and created on 02/15/23. Further review of Resident #28's ADL care plan revealed the following interventions, BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Date Initiated: 02/03/2023. A review of Resident #28's current care plan revealed a behavior care plan to include the following, Potential for impaired or inappropriate behaviors related to . Refuses hygiene care (cutting nails), date initiated and created on 06/15/23.Further review of the skin integrity focus revealed the following interventions to include, Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short, date initiated and created on 2/6/23. On 9/4/2024 at 1:59 p.m. an interview with the MDS Coordinator revealed Resident #28's nails have been long since he was admitted to the facility. She stated he refuses that staff trim his nails. The MDS Coordinator said he does allow staff to clean his nails. The MDS Coordinator stated Resident #28's care plan related to nail cutting refusals was created because he will not let anyone cut his nails. She stated the resident doesn't participate in care plan meetings. She said as far as she knows, Resident #28 has never had his nails cut. The MDS coordinator stated staff have never informed her they've cut his fingernails. A review of Resident #28's progress notes, from 8/2/24 to 9/5/24, revealed the following: a) A Skin observation progress note, dated 9/2/24, Resident skin is clear no impairment. Resident nails cleaned and trimmed. Resident prefers long nails. b) A Skin observation progress note, dated 8/30/24, Resident nails cleaned and trimmed Resolved Abrasion Skin impairment resolved on. c) A Skin observation progress note, dated 8/25/24, Resident skin is clear no impairment. resident prefers his nails long. d) A Skin observation progress note, dated 8/23/24, Resident nails cleaned and trimmed scratch to middle of upper back- almost healed. Existing scratch Vertebrae (upper-mid) - Other (specify): abrasion: Width = , e) A Skin observation progress note dated 8/16/24, Resident nails cleaned and trimmed scratch to middle of upper back. Existing scratch Vertebrae (upper-mid) - Other (specify): abrasion: Width = , f) A Skin observation progress note, dated 8/11/24, Resident nails cleaned and trimmed Abrasion to middle of upper back. Existing abrasion Existing scratch Vertebrae (upper-mid) - Other (specify): abrasion: Width = , g) A Skin observation progress note, dated 8/9/24, Resident skin is clear no impairment. Resident declines to have nails trimmed. They are long. h) A Skin observation progress note, dated 8/9/24, Resident nails cleaned and trimmed no new skin issues, lotion ordered to dry skin i) A, Skin observation progress note, dated 8/2/24, Resident skin is clear no impairment. Resident declines to have nails trimmed. They are long. On 9/4/2024 at 2:38 p.m. an interview with Staff H, Certified Nursing Assistant (CNA) revealed if the resident has diabetes, then CNAs don't cut the resident's nails. She stated the specialist cuts the resident's nails, if they have diabetes. Staff H, CNA stated her role is to clean the resident's nails. She stated she cleans the resident's nails by soaking them in water. Staff H, CNA stated there is a staff member dedicated to showers only. She stated, There's a CNA every day to do showers. She said Resident #28 has never asked her to cut his nails. Staff H, CNA confirmed she checks his nails, but said she doesn't know what his nails look like currently. She confirmed Resident #28 received a shower today, but stated it was a different CNA who completed the task. On 9/4/2024 at 3:12 p.m. an interview with Staff C, CNA revealed there's documentation that's completed after providing showers. She stated she lets the CNA know if the resident's nails are cut during showers, so they could document that. Regarding shower sheets, Staff C, CNA said there's a Paper up front and the nurse signs it. She confirmed Resident #28 received a shower today. Staff C, CNA stated she's not sure if staff are able to cut his nails. She said she's never cut his nails. Staff C, CNA stated Resident #28's nail looks, Regular, to her. She stated she uses a rag to clean his nails. Staff C, CNA stated if the resident were to ask her to cut his nails she would confirm if it's okay, before doing so. She stated Resident #28 had never asked her to cut his nails. Staff C, CNA stated she doesn't know why it's documented that his nails were cut/trimmed. She stated again during the interview that the CNA assigned to him would document if his nails were cut. On 9/4/2024 at 4:48 p.m. an interview with the DON revealed Resident #28 sometimes lets staff trim his nails, and sometimes he doesn't. Regarding the skin observation progress note on 9/2/24, the DON confirmed that she documented the note which revealed the following, Resident skin is clear no impairment. Resident nails cleaned and trimmed. Resident prefers long nails. The DON stated the electronic medical record doesn't allow other options other than, Resident's nails cleaned and trimmed. She stated the other option would be his nails were dirty, if she documented she didn't cut his nails. The DON stated the note on 9/2/24 was related to her attempt at intervening with Resident #28. She stated the progress note could be clearer about his nails not being trimmed, but cleaned, on 9/2/24. A review of the facility's Activities of Daily Living (ADLs) policy, reviewed on 9/7/22, revealed the following, The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADL's do not deteriorate unless deterioration is unavoidable. Further review of the policy revealed the following, Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming, and oral care; . Further review of the ADLs policy under Policy Explanation and Compliance Guidelines revealed the following, . 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. 4. On 9/3/2024 at 12:25 p.m. Resident #9 was observed lying in bed with eyes closed. An over-bed table was located out of reach of the resident on the left-side of the bed with a meal tray on top of it. The meal tray contained a covered plate and clear plastic wrapped cups of liquids. On 9/3/2024 at 12:32 p.m. Resident #9 was observed in the same position with the tray covered. The observation revealed no staff member entered the room to assist the resident with the noon meal. On 9/3/2024 at 12:46 p.m. Resident #9 continued to lay in bed with eyes closed, the nearby meal tray was observed with a covered plate, one clear plastic wrapped cup of opaque liquid and one containing a red- colored liquid. The observation revealed no staff member entered the room. On 9/3/2024 at 12:53 p.m. Resident #9 was observed lying in bed with eyes closed, the plate and liquids continued to be covered, and no staff member had entered the room. On 9/3/2024 at 12:58 p.m. Staff C, CNA was observed in the hallway of Resident #9's room picking up lunch trays from residents who had eaten in their rooms. On 9/3/2024 at 1:01 p.m. (36 minutes after the first observation), Staff C entered Resident #9's room and began to verbally and tactile stimulate the resident. The staff member informed the resident it was lunchtime and called out the resident's name. Staff C stated whoever had time was to assist residents with eating and feeding residents. The staff member reported Resident #9 required 100% assistance with eating and was the staff member's only assisted diner but she passing trays on another hall. Review of Resident #9's admission Record revealed the resident was admitted on [DATE] and 10/1/2019. The record included diagnoses of unspecified severity unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of Resident #9's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident was rarely/never understood and did not have a BIMS score. The assessment showed the resident required partial/moderate assistance with eating. Review of the CNA Assignment sheet, provided by the facility on 9/5/2024 at 9:41 a.m., showed the resident was one of four dependent/full assist diners, which was confirmed at that time by the Director of Nursing (DON). An interview was conducted on 9/5/2024 at 9:08 a.m. with the DON. The DON stated (meal) trays for dependent diners should be left on the tray cart until staff could assist (them). The DON provided documentation showing Resident #9 had eaten 76-100% of the observed lunch meal on 9/3/2024 and stated the resident's meal sitting in the room for 36 minutes was not acceptable. During an interview on 9/5/2024 at 9:41 a.m. the DON stated the facility did not have a policy regarding assisting residents with eating or a policy related to dining. On 9/5/2024 at 5:22 p.m. Resident #9's dinner tray was observed, with a covered plate, drink cups covered with a clear plastic wrap, and the resident's eating utensils continued to be wrapped in a paper napkin. The observation showed no staff member was in the room. Staff K, Licensed Practical Nurse (LPN) observed the meal tray a moment later and stated staff were passing (meal) trays and it was the policy for them to pass trays then return to the room and assist the resident. A review of the facility's Activities of Daily Living (ADLs) policy, reviewed on 9/7/22, revealed the following, The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADL's do not deteriorate unless deterioration is unavoidable. Further review of the policy revealed the following, Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming, and oral care; . Further review of the ADLs policy under Policy Explanation and Compliance Guidelines revealed the following, . 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Based on observations, staff and resident interviews, and record review, the facility failed to provide three of twenty sampled residents (#15, #10, and #28) with activities of daily living related to showers/baths (#10, #15) and personal hygiene related to shaving (#15) and eating assistance (#28) as per their request and scheduled timeframes. Findings included: 1. On 9/3/2024 at 10:00 a.m. Resident #15 was heard yelling out and moaning aloud from behind her closed room door. During an interview at this time, the resident stopped yelling aloud and revealed she wanted staff to come and take her to the shower. She revealed she yells out rather than uses the call light, because they (staff) respond faster. Resident #15 revealed she has missed her shower days the past few days, and she has missed many shower days the past couple of months. Resident #15 appeared with disheveled hair and she had long hair growing around her mouth and chin area. Some of the hair on her chin were approximately one inch to one and a half inches long. She was also noted to be wearing a hospital gown. On 9/3/2024 at 12:20 p.m. Resident #15 was in her room. She was still noted lying in bed and wearing a hospital gown. Resident #15's hair was still observed disheveled and she still had long facial and chin hair. Resident #15 stated, I just need a razor if they (staff) won't help me. She replied, I don't like having face hair and I have not had a shower in three days. She revealed there is never enough staff to help her with her personal hygiene or showers. On 9/4/2024 (Wednesday) at 9:30 a.m. Resident #15 was in her room. She was noted in bed lying flat with her head on a pillow and the linen pulled up over her head. She removed the linen from her face area and she was still noted with long facial hair around her mouth and chin area. Resident #15 revealed she still had not bathed. She again confirmed she does not like having mouth and chin hair, and that she could not remove it herself. On 9/4/2024 at 1:32 p.m. Resident #15 was in her room and confirmed again that she had not had a shower or bath yet and someone told her earlier she may get one today. She could not remember who that was. Resident #15 stated she needed a razor so she could shave. She started to tear up and revealed she does not like hair on her face and she could shave it if she had a razor. On 9/4/2024 at 12:40 p.m. Staff C, Certified Nursing Assistant (CNA) explained that she does shower/bathing today for a list of residents. She revealed that she does not assist with showers during meal services and that she will resume with showers/bathing after lunch. Staff C confirmed her entire assignment today was showers/bathing only. She also confirmed she will be giving Resident #15 a shower in a little while and that she is on her list. On 9/5/2024 at 8:07 a.m. Resident #15 was overheard calling out from her room. She was observed wearing a hospital gown and still had a lot of long facial and chin hair. She confirmed she had a shower yesterday (9/4/2024). She was asked if staff offered to clean up the hair on her face and chin and she revealed that the aide did not. She teared up and stated she wanted no hair on her face. She mentioned she has spoken to staff about it, but there are rare times when she is even given a bath/shower. She confirmed she does not like bed baths and would want only showers. She confirmed staff miss her shower days often. Review of Resident #15's admission Record revealed she was admitted to the facility on [DATE]. Resident #15's diagnoses included sepsis, pressure ulcer unspecified stage, cognitive communication deficit, contracture, muscle weakness, abnormalities of gait, altered mental status, dementia, major depression, mood disorder, and schizoaffective disorder. Review of the admission Minimum Data Sheet (MDS) assessment, dated 7/11/2024, revealed in Section E - Behaviors rejection of care was not exhibited. Section GG Functional Abilities and Goals revealed Resident #15 was dependent with substantial/maximal assistance for Shower/Bathing, and dependent on staff for personal hygiene. Review of the nurse progress notes dated from admission on [DATE] to the current date of 9/5/2024 revealed no documentation that reflected missed showers or refusal of showers/personal hygiene. Review of the current care plan, with a next review date of 7/5/2024, revealed the following Focus areas: - ADL the resident has an ADL self - care performance deficit r/t (related to) weakness, AMS (altered mental status), multiple wounds. Interventions included: Bathing/Showers: Resident is totally dependent on 1 staff to provide bathing activity. - Personal Hygiene/Oral Care: The resident is totally dependent on 1 staff for personal hygiene and oral care. Review of the electronic medical record under the Tasks section revealed: Showers scheduled for Wednesdays/Saturdays. Last shower documented was documented on 8/24/2024 at 17:59 (5:59 p.m.). The medical chart contained a skin sheet that identified the resident was provided with a bed bath on 8/24/24. There was no documentation in the medical record to support the resident received a shower on Wednesday 8/28/2024, nor documentation to support the resident received a shower on Saturday 8/31/24. Further review of the Task section revealed no documentation to support Resident #15 was provided with a shower/bath since her admission on Saturday 7/27/24 to include the days of Wednesday 7/31/24, Saturday 8/3/24, Saturday 8/10/24, Wednesday 8/14/24. 2. On 9/3/2024 at 2:00 p.m. Resident #10 was observed seated in her wheelchair and waiting to attend a group activity. An attempted interview was conducted and Resident #10 was able to answer some simple yes and no questions related to her day but was not able to speak to her medical care and services. Review of Resident #10's admission Record revealed she was admitted to the facility on [DATE]. The admission Record revealed diagnoses to include: dementia, muscle weakness, Parkinsonism. Review of the electronic medical record under Tasks section revealed: Receive Showers/Baths on Tuesdays/Fridays. Review of the shower task sheet dated from 7/26/2024 - 9/5/2024 did not support Resident #10 was given a shower/bath on; Tuesday 7/30/2024, Friday 8/2/2024, Tuesday 8/20/2024, There were no notes on this sheet, nor in any nurse progress note of Resident #10 refusing a bath or shower. Review of the current care plan, with a next review date of 10/9/2024, revealed the following Focus areas: - Resident requires assistance with activity participation related to: Cog (cognitive) deficits, Physical limitations, with interventions in place. - ADL the resident has an ADL self- care performance deficit r/t the following areas; Transfer resident utilizes transfer equipment with 2 care givers physical help; Bathing/Showering - Resident is totally dependent on 1 staff to provide bathing activity; Personal Hygiene the resident requires assistance by 1 staff with personal hygiene and oral care. On 9/5/2024 at 10:00 a.m. an interview with Staff A, Registered Nurse/Unit Manager (RN/UM) revealed upon admission, residents are provided with a shower schedule based on their room number. She stated a resident could change the day or add shower days if they request. Staff K explained the direct care staff will look into the resident's record under the Task section or [NAME], to see when the resident is to have their shower/bath. After the shower, staff are to document in that record of completion, or refusal. Staff K revealed if there is a refusal, a nurse will reflect that in the nurse progress notes. Staff K will follow up and monitor a resident's record to see if staff have documented completed or not completed for showers/baths. She revealed there has been a documentation problem the past few months and she, along with the Director of Nursing have been trying to educate staff that they need to document a completed shower, otherwise if it is not documented, it did not happen. Staff K could not provide any other documentation to support Resident #15 and Resident #10 had showers for the above listed showers missed. She also could not provide evidence that Resident #15 and #10 ever refused showers on those days.

Based on observations, interviews and record review the facility failed to implement and maintain an infection prevention and control program to mitigate the spread of infection related to staff not offering hand hygiene to residents prior to a meal and two staff members (R, and G) not performing hand hygiene with the potential to affect a census of 41 residents. Findings included: On 9/3/24 observations of the lunch service in the dining room from 11:51 a.m. to 12:55 p.m. revealed no hand hygiene was offered to multiple residents prior to eating. At 12:01 p.m. Staff E, Registered Nurse (RN) entered the dining room area. At 12:27 p.m. an observation of Staff E, RN revealed she sat down and attempted to assist a resident by setting them up to eat, which included touching utensils and other items on the table and did not perform hand hygiene prior to assisting this resident. At 12:33 p.m. Staff E, RN was observed serving beverages without performing hand hygiene before and after handling the beverages. At 12:38 p.m. an observation of Staff E, RN revealed she was feeding Resident #10, stopped feeding her at 12:41 p.m., and then resumed at 12:48 p.m. Observations of Staff, E feeding Resident #10 revealed she was standing up next to her and no hand hygiene was observed before and after feeding the resident. From 12:51 p.m. to 12:53 p.m. Staff E, RN was observed assisting another resident at a different table with dining. Observations of Staff E, RN revealed no hand hygiene was performed before and after feeding this resident. On 9/4/24 at 11:29 a.m. testing and recording of food temperatures were observed in the satellite kitchen. Staff G, Dietary Aide was designated to test the food temperatures. At 11:36 a.m. observations of Staff G, Dietary Aide revealed she entered the satellite kitchen pushing the meal cart with the food items for lunch. Further observations of Staff G, Dietary Aide, as she prepared to test the food temperatures, revealed she did not practice hand hygiene such as using hand sanitizer or washing her hands. At 11:39 a.m. observations of Staff G, Dietary Aide revealed she handled food on the steam table to include removing a clear, plastic film that was covering the items. Throughout the observation of testing and recording the lunch meal temperatures, Staff G, Dietary Aide touched approximately nine food items and surrounding surfaces/areas without gloves or proper hand hygiene practices. A review of facility policy titled, Infection Prevention and Control Program, last revised July 2023, revealed under the section titled Policy: The facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines.

Based on observations, interviews, and record review, the facility failed to store, prepare and follow professional standards for food service safety in two (main and satellite) of two kitchens, as evidenced by: 1. two trash cans were not sanitarily maintained; 2. food was not maintained for safe consumption to include improper food handling practices; 3. kitchen shelving used for storage of food was observed rusted/oxidized, 4. temperature logs for the refrigerator and freezer were not documented accurately, and 5. one staff member (Q) not donning a hairnet upon entry to the kitchen during two (9/3/24 and 9/5/24) of three days of the survey. Findings included: On 9/3/24 at 9:20 a.m. a tour of the facility's main kitchen was conducted with Staff M, Certified Dietary Manager (CDM). From 9:24 a.m. to 9:38 a.m. observations of trash cans and refuse containers revealed a stand-up trash container with a double flap lid was open with trash/refuse overflowing from it. The trash container was against a food preparation/service table, where were observed preparing food on the stove. The lid and sides of the same trash container were observed with an unidentified liquid and hard food debris. (Photographic Evidence Obtained) An additional observation revealed the trash can near the hand washing sink was gray in color, round and stood approximately three and a half feet high. The lid was observed with a circular cut out to put the garbage/refuse through. Further observations revealed the entire outer container and lid contained a black, brown, and green sticky substance that covered many areas. (Photographic Evidence Obtained) On 9/3/24 at 9:38 a.m. observations of the walk-in refrigerator revealed an uncovered box of four whole cabbages. Staff M, CDM removed one cabbage that appeared wilted and damaged with black coloring on the outside layers. (Photographic Evidence Obtained) He handled the cabbage with ungloved hands, while peeling back the outer parts of it. Further observations revealed Staff M, CDM dropped the cabbage on the refrigerator floor, which appeared soiled with various small particles and debris. He picked up the cabbage and put it back in the box with the other three. During the observation, Staff M, CDM did not discard or wash the cabbage prior to putting it back in the box. On 9/3/24 an observation at 9:39 a.m. of the entry way of the walk-in refrigerator revealed a multi-shelf cart with various pans of prepared food. One of the pans of prepared food items was a sheet cake with approximately three quarters of the cake missing. There was clear plastic wrap on the remaining sheet cake, however, the plastic wrap did not cover the food entirely leaving it exposed to the air. (Photographic Evidence Obtained). Further observations of the walk-in refrigerator revealed multiple shelves on each side. Observations of the shelve racks revealed they were green, plastic coated, and slotted. Further observations of the shelves revealed the green coating on parts of the shelves were worn away and appeared rusted/oxidized. There were no barriers between the rusted/oxidized shelves, and the containers and boxes of food items. (Photographic Evidence Obtained) On 9/3/24 an observation at 9:40 a.m. of the walk-in freezer, located inside the walk-in refrigerator, revealed two frozen pie crusts stacked on top of each other were not covered and exposed to the air. Staff M, CDM confirmed the frozen pie crusts should have been covered, as well as, labeled/dated. He proceeded to remove them. On 9/3/24 at 9:42 a.m. a review of the refrigerator and freezer temperature logs revealed no documentation. Staff M, CDM stated the morning documentation of the refrigerator and freezer temperatures should have been completed by the cook. Staff M, CDM handed the log to Staff P, [NAME] to be completed. On 9/3/24 observations at 9:20 a.m. and 9:43 a.m. of the food preparation table revealed two yellow, whole honeydew melons. One melon was observed with a flat level surface that contained grey and black mold-like debris and spores growing on it. (Photographic Evidence Obtained) An interview with Staff M, CDM revealed the melon was okay to consume and he proceeded to cut off the top of the fruit where the mold spores and debris were located. Further observations revealed, he cut open the melon which appeared to have no mold inside. He stated he received a delivery of fresh produce to include the two melons, and it would be used for consumption on 9/3/24. Staff M, CDM discarded the melon although he confirmed he intended to use it. Further observations of the cutting board on the food preparation table revealed black residue, which derived from the top part of the melon that Staff M, CDM cut off. He attempted to wipe away the black residue with his ungloved hand, however, there were smudges of black residue left on the cutting board. On 9/5/24 at 10:55 a.m. observations in the satellite kitchen revealed a cellphone was laying on the drying rack with items such as cups, portion scoops, and other kitchenware. An interview with Staff G, Dietary Aide revealed it was her cellphone. She stated she knows the phone was not supposed to be there as the dish rack contained clean kitchenware and items that residents utilize during meals. An observation of the main kitchen on 9/5/24 at 11:28 a.m. revealed Staff Q, [NAME] entered the kitchen without a hair restraint. Staff Q, [NAME] was observed walking to what appeared to be a utility closet to include mops and cleaning products. She was observed leaving the closet, shortly after entering, and went to Staff M, Certified Dietary Manager (CDM)'s office. She was observed putting on a hair restraint while in the CDM's office. On 9/5/24 at 11:32 a.m. an observation in the main kitchen of Staff R, Dishwasher and another staff member, revealed a demonstration of the process for determining the sanitizing temperature of the dish machine. Staff R, Dishwasher took a plate out of the dish washing machine that was in the middle of a wash cycle. He tested the sanitizing solution by pressing the litmus strip to the plate, which was wet. Further observations revealed Staff R, Dishwasher put the same plate back in the machine to continue the cycle. During the observation, Staff R, Dishwasher was not wearing gloves, and he did not wash his hands or use a hand sanitizer. An observation at 11:34 a.m. of the dish machine temperature log revealed there was documentation for breakfast, lunch, and dinner on 9/5/24. (Photographic Evidence Obtained) An interview with Staff R, Dishwasher revealed he made a mistake and documented lunch and dinner temperatures before testing the sanitizing solution. He stated he should not have done that. An interview with Staff M, CDM stated he was not aware Staff R, Dishwasher had filled out the dish machine temperatures for lunch and dinner before testing the sanitizing solution. At 11:35 a.m. an observation of the dish machine area revealed a disposable beverage cup from a fast-food establishment located near the three-compartment sink. Staff R, Dishwasher, was observed taking a sip of the beverage and putting it on a cart next to the three-compartment sink, then he proceeded to continue using the dish machine. On 9/5/24 at 11:45 a.m. a review of the refrigerator and freezer temperature log, in the main kitchen, revealed no evidence of morning documentation for that day. Staff M, CDM observed the log and stated the cook should have documented the morning refrigerator and freezer temperatures. Staff M, CDM handed the log to Staff Q, [NAME] and another staff member, to be completed and stated, Second day in a row. On 9/5/24 at 11:03 a.m. an interview with the Registered Dietitian (RD) revealed it is expected if produce has mold, it should be thrown away. She stated the CDM should have called the food supplier company to request a refund for the produce that was damaged and had mold. The RD stated she would have discarded the food that was damaged and had mold. She confirmed it was not safe food handling practices to put food back that fell on the floor. The RD stated the produce that fell on the floor should have been thrown away. A review of the policy regarding receiving food and supplies, revised 4/1/14, contained the following information, Food items should be received and handled in accordance with good sanitary practice. Further review of the policy titled, Receiving Food and Supplies, under procedure, revealed the following, . b. Check for quantity, quality, weight, labels, etc. of all foods ordered. Do not accept and return to the supplier, any item that is: . 4) Damaged produce . A review of the policy titled, Food Preparation, revealed the following, Employees must use appropriate tools to identify and prevent potential hazards in the preparation of food process. Further review of the policy, under procedure, included the following, . 2. The proper cleaning and sanitizing of equipment and work surfaces are key to safe food preparation . A review of the policy titled, Food Storage, revealed the following, Employees use appropriate tools to identify and prevent potential hazards in the storing of food process. Further review of the policy, under procedure, included the following, . 4. In a freezer, for longer-term storage of perishable foods. D. Store frozen foods in their original containers or wrap tightly in moisture-proof material or containers to minimize loss of flavor, as well as discoloration, dehydration (drying out), and absorption of odors. Clearly label containers with the contents, delivery date, and/or use-by date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the Physician was informed of medication refusal over a period of 12 days (08/22/22, 08/23/22, 08/29/22, 08/30/22, 08/31/22, 09/01/22, 09/02/22, 09/03/22, 09/04/22, 09/05/22, 09/06/22, 09/07/22) days for one (#346) of five sampled residents. Findings included: During the medical record review for Resident#346 revealed that she was admitted to the facility on [DATE] with multiple diagnosis but not limited to unspecified fracture of left femur, subsequent encounter for closed fracture with routine healing, Depression, Hyperlipidemia, enterocolitis due to clostridium difficile and anxiety. Review of Resident#346 cognitive status on the most current Minimum Data Set, dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 2, indicating severely impaired. Review of the MAR (medication administration record) revealed the resident had refused several medications and the physician was not notified. Medications included but not limited to: hypertension, depression, high cholesterol, protein liquid and Vancomycin. The following medications were refused by the resident with no notification to the physician. Resident#346 refused: -Metoprolol Succinate ER Tablet Extended Release 24-hour 25 MG (milligrams) related to: Hypertension on the following dates: 8/22, 8/28, 8/30 and 8/31/22. Documentation was not present of notification to the physician. -Vancomycin HCI Suspension 125 mg orally 6 hours for C-diff for 10 days, start date 8/29/22- medication was refused on 9/2 at noon, 9/3 at 0600 and not given at 1800, 9/4 0600 and 1200 refused and refused on 9/7 at 1200. Documentation was not present of notification to the physician. -Mirtazapine Tablet 7.5 MG for depression was refused on 8/30/22, and not provided on 9/1, 9/3 and 9/7/22. Documentation was not present of notification to the physician. -Rosuvastatin Calcium Tablet 5 MG related to Hyperlipidemia refused on 8/30/22. Documentation was not present of notification to the physician. -Protein Liquid two times a day for low albumin levels and promote wound healing for 30 days start date 8/19/22- refused 8/22, 8/28, 8/29, 8/30 and 8/31/22, 9/2, 9/4, 9/5, 9/6 and 9/7/22. Facility failed to notify the physician. -bupropion HCI ER (SR) 150 MG for Depression- refused on 9/2, 9/4, 9/5, 9/6 and 9/7/22. Documentation was not present of notification to the physician. A review of Resident#346 plan of care for Depression indicates as an intervention to administer antidepressant medications as ordered by physician date initiated 8/18/22. Care plan for nutrition with an effective date of 8/18/22 indicates to administer Liquid Protein as ordered. On 9/8/2022 an interview was conducted with Staff H, Licensed Practical Nurse (LPN). He reported the MAR should be coded as a refusal of medication, followed by the medication note and the physician should be notified. On 9/8/2022 at 9:15 a.m. the Director of Nursing (DON) was interviewed. He reported staff must document the refusal and follow up with notification to the physician and document. He was made aware of Resident#346 ongoing refusals for medications and the lack of notification. On 9/09/2022 at 11:27 a.m. a telephone call was made to Resident#346's Physician and a voicemail was left. A return call was received at 12:01 p.m. He confirmed he would need to be notified of medication refusals. At 12:07 p.m. a telephone call was also made to the Nurse Practitioner who reported the facility called her yesterday to have a psychiatry evaluation to determine why the resident was refusing medications. She said the facility notified her of medication refusal in August and September yesterday. A facility policy was requested; however, none was provided by completion of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a report was filed as a formal grievance and acted upon, for one (#37) of 19 sampled residents related to missing clothing. Findings included: During the initial tour conducted on 09/06/22 at 10:41 AM, Resident#37 stated she had no clothes since she arrived. She had notified staff and feels they are not doing anything. Resident#37 reported she had been at the facility since 8/19/22. She stated, No one has gone to get my clothes from my home. With permission from the resident an observation of her closet was made. The closet had one item hanging which was a gray sweater. She stated the sweater did not belong to her. The clothing cabinet drawers were observed empty, she confirmed they have been like that since she arrived to the facility. The resident was observed sitting on the edge of her bed with a white sweatshirt and no bottoms. She confirmed the sweatshirt was brought for her today but did not have any pants on. A record review was conducted for Resident #37 which revealed she had been initially admitted to the facility on [DATE] with a readmission date of 8/19/22 with multiple diagnosis not limited to head injury and lack of coordination. A review of Resident#37 MDS (minimum data set) for cognition dated 8/12/22 revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating cognitively intact. On 09/07/22 at 11:25 AM an interview with Director of Nursing (DON), who confirmed the resident had no clothing, and the facility was aware. The DON reported they have been trying to get clothing for her from her home. The facility was aware of the voiced concern and did not file a concern for the resident until she voiced her concern to the surveyor on 09/06/22. An additional interview with Resident#37 was conducted on 09/08/22 at 10:54 A.M. Resident#37 reported she still did not have any clothing. She said the Laundry did bring her a pink shirt and a pair off leggings, which she was wearing. An observation, with the resident's permission, of her closet revealed one grey sweater, and the drawers were empty. On 09/09/22 at 11:42 A.M. an interview with Social Service Director was conducted. She confirmed she had no prior knowledge of the resident's missing clothing until she was informed by on 9/7/22. She provided a copy of the grievance, completed on 9/7/22 and a letter to the resident's family member requesting clothing, dated 9/7/22. She confirmed she did not attempt to get clothing for the resident prior to 09/07/22 as she was not aware of the issue. A review the facility Grievance policy with a revision date of 2017 indicated residents and their representatives have a right to file a grievance, either orally or in writing, to facility staff or to the agency designated to hear grievances (e.g., the State Ombudsman). The Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an accurate comprehensive assessment for one (#13) of one residents reviewed. Findings Included: Medical record review of Resident #13 minimum data sheet (MDS) dated [DATE] reflected a restraint was used. The restraint was coded as used daily and used in chair or out of bed and coded: Other. On 09/06/2022 at 12:20 p.m. Resident #13 was observed sitting in a high back wheelchair in the dining room eating his lunch. His legs were elevated and resting on foot pedals. No restraints were identified at the time. On 09/07/2022 at 03:37 p.m. an interview was conducted with the Minimum Data Sheet Coordinator (MDSC), who stated the restraint was an abdominal binder for his peg tube. She said the binder was to prevent him from pulling the tube out. The MDSC was asked about the peg tube placement as he was observed eating orally. The MDSC stated his peg tube was removed and did not recall the date. Further review of the MDS dated on 07/04/2022 revealed the box was checked indicating resident had a feeding tube while a resident. Medical record review of a physician progress note dated 06/09/2022 Digestive Disease Reason for appointment 1. Peg tube removal. History of Present Illness Gastrostomy Malfunction: Mr. (Resident #13 name) is here for gastrostomy malfunction. The peg tube was no longer needed because patient is eating without difficulty. Treatment notes: Peg tube was removed without difficulties. On 09/07/2022 at 3:57 p.m. during an interview, the MDSC stated I just pulled over the prior assessment and did not review the areas indicating Resident #13 did not have a peg tube or a restraint during the assessment period on 07/04/2022.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a Baseline admission Care Plan was completed with the input of Resident#37, and that a summary was provided to the resident for one (#37) of 18 sampled residents. Findings included: A review of the Baseline Care Plan policy for the facility dated 8/25/2022 revealed the following: the facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident to meet professional standards of quality of care. UNDER THE HEADING Policy Explanation and Compliance Guideline reads: The base line care plan will be developed within 48 hours of a resident's admission. #3. A supervising nurse shall verify within 48 hours that a baseline care plan has been developed. #4. A written summary of baseline care plan shall be provided to the resident and representative in a language that the resident or the representative can understand. The summery shall include, at a minimum, the following: A.- the initial goals of the resident. B. -a summary of the residents' medications and dietary instructions. C. -services and treatments to be administered by the facility and personnel acting on behalf of the facility. #5-A supervising nurse or MDS coordinator is responsible for providing the written summary of the baseline care to the resident and representative. 6.- The person providing the written summary of the baseline care plan shall: A.- Obtain a signature from the resident/representative to verify that the summary was provided. B.- make a copy of the summary for the medical record. A record review was conducted for Resident #37 which revealed she was initially admitted to the facility on [DATE] with a readmission date of 8/19/22 with multiple diagnosis not limited to head injury and lack of coordination. A review of Resident#37 MDS (minimum data set) for cognition dated 8/12/22 revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating cognitively intact. During an interview with Resident#37 on 9/6/22 at 10:41 a.m. Resident#37 reported she never participated in her plan of care and was not provided with a copy of the treatments and services. A review of the medical record revealed no entries for a baseline plan of care or that a summary was provided to the resident. On 9/9/22 at 9:00 a.m. an interview was conducted with the Director of Nursing (DON). He reported the care plan should be in the electronic medical record. He confirmed the residents' medical record was silent in regard to a baseline plan of care and the resident's participation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 09/06/22 at 12:49 p.m. Resident #10 was observed sitting up in bed, smiled when approached and was receptive to an interview. Her lower legs were noted wrapped with a kerlix dressing. On closer observation the dressing did not contain a date that would indicate when the dressing was last changed. The right dressing contained a dark yellow shadow drainage. Resident #10 had a personal care giver in the bedroom with her at the time. The care giver said she has been caring for the resident three days a week for over two years, and confirmed the dressing to her legs did not contain a date. Medical record review of the admission Record form revealed Resident #10 had resided at the facility just over a year and was geriatric in age. Diagnosis information listed peripheral vascular disease, peripheral vascular angioplasty status, non-pressure chronic ulcer of skin of other sites with fat layer exposed. Review of the wound Visit Report by the Advanced Practical Registered Nurse (APRN) Certified Wound Specialist dated 09/01/2022 revealed assessment of wound #2 left posterior left lower leg chronic full thickness arterial ulcer orders to Cleanse wound with normal saline Apply collagen- with hydrogel gauze and dry dressing (DD) every day (QD). Wound #3 left medial ankle is a chronic full thickness arterial ulcer orders to: Cleanse with normal saline, apply collagen with hydrogel gauze and DD QD Wound #9 Left lateral ankle -there is no change noted in the wound progression. Orders to Cleanse wound with normal saline apply collagen with hydrogel gauze and DD QD Wound #10 Right posterior Lower Leg orders to: Cleanse wound with normal saline apply collagen with hydrogel gauze and DD QD. Review of Resident #10 treatment administration record (TAR) did not reflect the APRN orders from 09/01/2022. It reflected orders that were dated on 08/10/2022 to cleanse left lateral ankle with normal saline (NS) soaked gauze, pat dry, and apply collagen to wound beds, cover with abdominal (ABD) pads and dry dressing (DD)/Kerlex tape; every night shift every 3 day(s) for arterial ulcers start date 08/10/2022. Cleanse Left Medial Ankle with NS-soaked gauze, pat dry, and apply collagen to wound beds, cover with ABD pads and DD/Kerlex tape; every night shift every 3 day(s) for arterial ulcers start date 08/10/2022. Cleanse left posterior lower leg with NS-soaked gauze, pat dry, and apply collagen to wound beds, cover with ABD pads and DD/Kerlex tape; every night shift every 3 day(s) for arterial ulcers start date 08/10/2022. Cleanse Right Posterior Lower Leg ankle with normal saline (NS) soaked gauze, pat dry, and apply collagen to wound beds, cover with ABD pads and DD/Kerlex tape; every night shift every 3 day(s) for arterial ulcers start date 08/10/2022. On 09/07/2022 at 2:45 p.m. an interview was conducted with the Director of Nursing (DON); he confirmed the Wound APRN comes to the facility weekly. He stated last week (09/01/2022) Staff Member H Licensed Practical Nurse had made rounds with her at the time. On 09/07/22 02:59 p.m. an interview was conducted with Staff Member H and indicated he had performed rounds with the Wound APRN. He said during the rounding the APRN will discuss changes that are needed to the treatments. He said prior to APRN leaving the facility for the day she always prints out her reports that can include changes to treatments. He was asked if he reads the reports he stated yes and confirmed that he will make the changes in the TAR. Staff H stated I didn't go with the APRN on 09/01/2022. The DON went with her that week On 09/08/2022 at 09:15 a.m. an interview was conducted with the Wound APRN and confirmed she sees Resident #10 every week. She confirmed she had changed the resident wound orders last week from every three days to daily. She said it was due to the amount of drainage the wounds were producing. And due to the delay in wound progression. The APRN confirmed at that time it is her expectation her orders are followed. Review of policy Wound Treatment Management dated 8/25/22 Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physicians orders. Policy Explanation and Compliance Guidelines: 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type if dressing, and frequency of dressing changes. Based on observations, record review and interview, the facility failed to ensure 1.) skin condition was accurately assessed and documented for one resident (#27) of three residents reviewed; and 2.) wound care was provided as per Physician's orders for one resident (#10) of three residents reviewed. Findings included: 1. Review of Resident #27's record revealed he was admitted to the facility on [DATE] has diagnosis that includes: Parkinson's disease, cognitive communication deficit, Major depressive disorder, and shortness of breath. Review of the skilled nursing note dated 9/1/22 indicated the resident is oriented to person and has impaired decision making ability. Observations of Resident #27 on 09/06/22 at 11:06 AM revealed the resident lying on his bed with his right tennis shoe on and his left tennis shoe off. The residents left foot was noted to be red with abrasions, and had no socks on. Observations on 09/06/22 at 11:50 AM of Resident #27 revealed him seated in the dining room for his midday meal. The resident was noted to be wearing his tennis shoes with no socks to cushion his feet. Observations on 09/06/22 at 12:38 PM revealed the resident lying on his bed. It was noted at this time the resident had bare feet and black wounds were noted to the toe area on bilateral feet, with his toenails long and not manicured. Skilled nursing note dated 9/6/22 indicated that the resident has no current skin impairments. Skilled nursing note dated 9/5/22 indicated that the resident has no current skin impairments. Skilled nursing note dated 9/4/22 indicated that the resident has no current skin impairments. Skilled nursing note dated 9/3/22 indicated that the resident has no current skin impairments. Skilled nursing note dated 9/2/22 indicated Rash to trunk and thighs, no mention of feet skin impairments. Skilled nursing note dated 9/1/22 indicated Rash to trunk and thighs, no mention of feet skin impairments. Interview on 09/07/22 at 11:36 AM with the Director of Nursing (DON) revealed the resident's skin check dated 9/2/22 revealed the resident had Rash to Trunk, redness to left heel, bruising on dorsal left foot. He reported nurses notes should indicate what is actually present, and that the expectation is for staff to provide foot care. Interview on 09/07/22 at 12:48 PM with the Social Service Director revealed she sets up podiatry services, but did not know if Resident #27 had been seen by the podiatrist. Review of the physician order dated 8/19/22 revealed the following: Weekly Skin evaluation FRIDAY on 7-3 Shift -Complete weekly check in [electronic medical record] evaluations. every day shift every Fri for monitoring **Report all new positive findings to the treatment nurse Immediately** RECORD IN SKIN: HEAD TO TOE ASSMNT Review of the Head to Toe Weekly Skin Checks dated 8/26/22 revealed the following: Resident has existing skin impairment, Resident nails cleaned and trimmed, Existing Bruise Existing rash-Right toe(s) - Pressure: Length = .6cm, Width =, Other (specify): dorsal left foot: Bruising: Width = , Right elbow - Other (specify): scab: Width =, Left elbow - Other (specify): scab: Width =, Right heel - Other (specify): redness: Width =, Left heel - Other (specify): redness: Width =, - Other (specify): BUE TRUNK BACK THIGH: - Rash: Width =, Review of the Head to Toe Weekly Skin Checks dated 9/2/22 revealed the following: Resident has existing skin impairment-Resident nails cleaned and trimmed-Existing Bruise Existing rash-Right toe(s) - Pressure: Length = .6cm, Width =, - Other (specify): dorsal left foot: - Bruising: Width =, Left heel - Other (specify): redness: Width =, - Other (specify): BUE TRUNK BACK THIGH: - Rash: Width =, Resolved Bruise, Skin impairment resolved on Review of the Head to Toe Weekly Skin Checks dated 9/7/22 revealed the following: Resident has existing skin impairment, Resident nails cleaned and trimmed, Existing rash discoloration and eschar-Right toe(s) - Other (specify): eschar: Length = .8cm, Width = .6, Depth = 0, - Stage Unstageable, - Other (specify): dorsal left foot: - Other (specify): redness: Width =, Left toe(s) - Other (specify): discoloration: Width =, Right toe(s) - Other (specify): discoloration: Width =, Left toe(s) - Other (specify): discoloration: Width =, Left heel - Other (specify): callus: Width =, - Other (specify): BUE TRUNK BACK THIGH: - Rash: Width =, Interview on 09/07/22 at 03:18 PM with the Regional Director of Risk Management and the DON revealed an Assessment done by a nurse today 9/7/22 should be accurate and reflect both of the residents feet. They confirmed that there was no documentation in the record that would indicate the the physician had been notified of the residents wounds. They reported that assessments should be accurate and reflect the actual condition of the residents skin. Review of the facility policy titled Provision of Physician Ordered Services dated 8/25/22 revealed the following: The purpose of this policy is to provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality. Professional Standards of Quality means that care and services are provided according to accepted standards of clinical practice. Standards may apply to care provided by a particular clinical discipline or in a specific clinical situation or setting.

Based on interview, and record review, the facility failed to ensure communication and coordination with an external service were conducted on days of treatment for one (#32) out of three residents who receive hemodialysis. Findings Included: On 09/06/22 at 10:05 a.m. Resident #32 call light was on she stated, I going to dialysis pretty soon and I'm waiting for the nurse to apply cream to my site. The resident said she was at the facility for short term therapy services and was hoping to return home some. Medical record review for Resident #32 revealed admission to the facility a month prior. Diagnosis information read dependence on renal dialysis, acquired absence of kidney, and end stage renal disease. On 09/07/22 at 11:30 a.m. an interview was conducted with Staff Member N, Licensed Practical Nurse, who said the normal process when a resident has a dialysis appointment the nurse is to perform the pre-dialysis assessment. After the resident returns a post dialysis assessment is completed, and the dialysis center communication form is completed and reviewed for any changes or new orders. On 09/07/2022 at 11:55 a.m. the Regional Director of Risk Management was asked where the communication forms were located for Resident #32 outside dialysis services. She stated, we have a difficult time getting communication forms from dialysis center. Review of Resident #32 Pre/Post Dialysis forms and the Dialysis Communication Form form from 08/04/2022 to 09/06/2022 revealed the following omissions of either pre-dialysis, post-dialysis or the outside Dialysis Communication Form on 08/04, 08/06, 08/13, 08/18, 08/20, 08/23, 08/25, 08/27/2022, 08/30, 09/01, 09/03, and 09/06/2022, indicating a lack of communication between the two entities. Review of Care Plan with a focus on Renal failure with dialysis. The goal: Resident will be free of complications at dialysis access site thru next review. The Interventions included: review Dialysis communication form(s). Review of policy tilted Hemodialysis dated 08//20/2022 Policy This facility will provide the necessary care and treatment, consistent with professional standards of practice. Purpose: Ongoing communication and collaboration with the dialysis facility regarding dialysis care ands services. Definitions: End stage Renal Disease - the stage of renal impairment that appears irreversible and permeant and requires a regular course of dialysis or kidney transplantation to maintain life. Dialysis- A process by which dissolved substances are removed from a patient's body by diffusion from one fluid compartment to another across a semipermeable membrane. The two types that are currently common are hemodialysis (HD) and peritoneal dialysis (PD). Review of the Nursing Facility Dialysis Agreement that did not contain a date C. Communication Nursing facility shall reasonably cooperate with center.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to ensure a paid caregiver for one (Resident#30) of 18 sampled residents had specific competencies and skill sets necessary to care for the Resident#30 care needs. Findings included: During an observation of Resident#30 on 9/6/22 at 2:49 p.m. a private paid caregiver (Staff C) was observed providing care. An immediate interview with private sitter who was providing perineal care to Resident#30 was conducted. She reported she has been his private paid caregiver for the last three years. She was asked if she is here everyday and reported that she is here from 7:30 a.m. to 3:30 p.m. Monday through Friday. She said Resident#30 has an additional private caregiver here on the weekends until Sunday afternoon when his wife arrives. During the interview she was asked if the resident was incontinent, as she was observed putting on a brief to the resident. She confirmed that she places a brief on the resident while he is in bed and demonstrated the brief. She also confirmed that Resident#30 has a catheter and she empties the catheter bag. The medical record review for Resident #30 revealed he was admitted to the facility on [DATE] with a readmission date of 8/23/22 with multiple diagnosis but not limited to pulmonary embolism, cerebral infarction, dysphagia, muscle wasting and atrophy, pressure ulcer and urinary tract infection. Resident#30 had an indwelling catheter, and was not interviewable due to poor cognition. A review of Resident#30 plan of care dated 7/12/2022 for skin impairment indicates: The resident has potential/actual impairment to skin integrity r/t (related to) fragile skin. Left posterior hip, sacrum, open area to penis, bilateral heel boggy. Intervention: Date initiated 8/24/22-Do not use briefs while in bed. Use a bed pad under resident while in bed/chair unless resident having loose stools. On 09/08/22 at 1:40 PM an interview with Certified Nursing Assistant (CNA) staff member (A) reported she only provides care to the resident after the sitter leaves. Today CNA staff member (B) assisted the resident with a bath. CNA (A) stated she has been at the facility for 2 weeks, and this was her first time working with Resident #30. On 09/08/22 1:19 P.M. an interview with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) was conducted. The DON confirmed there was no education provided to her and they would start education as soon as possible. He was asked if she had any credentials, and said he was unsure. During the interview the NHA reported she was unaware that Resident#30 had a caregiver in his room. A continued review of the medical record revealed only one note documenting the paid caregiver's presence, dated 8/23/2022. A facility policy on private caregivers/sitters was requested; the DON reported the facility did not have a policy.

Based on observation, interview, and policy review, the facility failed to maintain drugs and biologicals in a safe and secure manner in one (A) out of two medication carts. Findings Included: On 09/06/22 at 09:03 a.m. upon entrance to the facility lobby multiple residents were observed sitting in their wheelchairs. Staff and family members were also observed walking through the area to enter adjoining units. An unlocked medication cart was observed positioned next to one of the residents. Upon closer observation a soufflé cup sat on top of the cart that contained multiple different colored capsules and tablets. The cart top also contained a blister card facing the lobby entrance revealing a resident name. There were no licensed staff members in the immediate vicinity (photographic evidence obtained). Approximately three minutes later the Nursing Home Administrator (NHA) was observed walking down the hallway toward the facility lobby. Upon approaching, the NHA reached past the surveyor and locked the medication cart. She then reached forward with her right hand to the cart were the souffle cup sat with multiple pills. The NHA indicated at that time she did not know which nurse was responsible for the cart. She stated, I will be looking into it. On 09/06/22 at 10:00 a.m. an interview was conducted with Staff Member H, Licensed Practical Nurse, he confirmed he had left his medication cart unlocked, with medications on top of the cart. Review of policy Medication Storage dated 8/25/22 Policy: It is the policy of this facility to ensure all medication housed on our premises will be stored in the pharmacy and or medication rooms according to manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Policy Explanation and Compliance Guidelines 1. General Guidelines: a. all drugs and biological's will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperate controls. c. during a medication pass medication must be under the direct observation of the person administering medications or locked in the medication storage area/cart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to make attempts to ensure hospice services were appropriately coordinated related to effective communication and consistent delivery of services was maintained for one (#27) of two residents sampled for hospice services. Findings included, 1. Review of the agreement between the facility and the hospice vendor dated September 1, 2021 revealed the following: 2.1 Hospice Plan of Care-Hospice will furnish to facility a copy of the most recent Hospice Plan of Care specific to each patient provided Hospice services (including Respite Care Services, Inpatient Services and Purchased Hospice Services) under this agreement. The Hospice Plan of Care shall reflect the participation of Hospice, Facility, and Hospice Patient and Hospice Patient's family to the extent possible, and must specifically identify which provider or party is responsible for performing the respective functions that have been agreed upon and included in the Hospice Plan of Care. 3.1 Facility Plan of Care. Facility will develop a Facility Plan of Care to coordinate with the Hospice Plan of Care for each Hospice Patient. Review of Resident #27's record revealed he was admitted to the facility on [DATE] has diagnosis that includes: Parkinson's disease, cognitive communication deficit, Major depressive disorder, and shortness of breath. The review of the skilled nursing note dated 9/1/22 indicated that the resident is oriented to person and has impaired decision making ability. Review of the resident's record revealed the resident's payer source changed on 8/19/22 to hospice. Continued review of the record revealed no documentation in the record from the hospice vendor Review of the residents care plan dated 8/22/22 indicated that the resident chooses to have death with dignity, advanced directive established. Resident is hospice. Interview on 09/07/22 at 10:52 AM with Staff D Licensed Practical Nurse (LPN) revealed there is no hospice book, and the hospice staff start their documentation in the facility and then finish at their office; they send them to the facility electronically and then they are scanned into the residents record. Interview on 09/07/22 at 11:36 AM with the Director of Nursing (DON), revealed all residents on hospice should have an physician's order for hospice services, and the hospice plan of care (POC), and the hospice notes should be in documents section of the resident record. He reported he could not determine when hospice was last in the building to see Resident #27, and was unable to verbalize what disciplines the resident receives from the hospice vendor, He reported all this information would be in the hospice care plan. He confirmed there was no physician orders for hospice, no hospice plan of care from the hospice vendor and no hospice notes from the hospice vendor. Interview on 09/07/22 at 12:27 PM with the Resident Assessment Coordinator revealed the hospice care plan in place does not mirror the hospice care plan from the hospice vendor as she has never seen a hospice care plan from the hospice vendor. She reported she did not know she was supposed to mirror the hospice vendors care plan to ensure continuity of care. Interview on 09/07/22 at 12:48 PM with the Social Service Director, revealed she was not sure who is supposed to ensure that hospice documentation is in the building. She reported she sets up and runs care plan meetings, but does not do anything related to continuity of care with hospice. Interview on 09/09/22 at 08:54 AM with the Hospice Nurse, Registered Nurse, (RN), revealed the resident started on hospice services on 8/19/22. She reported she shares info with the facility and talks to the nurse. She reported she will normally will call and collaborate with the facility and that the communication is word of mouth with nursing and CNAs (certified nursing assistants). The Hospice nurse reported she provides the written notes and plan of care to the facility and visits this resident weekly, and the aide comes in one time a week as of last week. Continued interview with the Hospice nurse at this time revealed this facility did not get a plan of care for this resident until this week.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure respiratory care and services were provided according to professional standards of practice for three (#19, 28, 146) out of four residents sampled. Findings Included: 1. On 09/06/22 at 12:33 p.m. Resident #19 was observed sitting in her wheelchair in her bedroom, and smiled when approached. Resident #19 stated I can't leave my room as she pointed to her nose that contained oxygen tubing. The tubing was attached to concentrator, which was turned on and registered at 2 liters. The tubing reflected the date 08/24/2022. Additionally on the bedside table a small volume nebulizer machine was observed with the tubing and mask dated 08/24/2020. The nebulizer aerosol mask was lying on top of a gait belt and not stored in a clean manner (photographic evidence obtained). On 09/07/22 at 11: 00 a.m. Resident #19 was observed sitting up in her wheelchair with nasal cannula in place and attached to the concentrator running at 2 liters. On 09/08/2022 at 2:34 p.m. resident #19 lying in bed sleeping with oxygen running at 2 liters per nasal cannula. Medical record review revealed Resident #19 Physician orders for small volume nebulizer 3 ml Ipratropium-Albuterol solution 0.5-2.5 mg (3) MG (milligram)/3ML (milliliter) via neb (nebulizer) every (Q)12 hours (H) dated 8/15/2022 for pneumonia (PNA) supplementary, and Oxygen at 2L (liters) via nasal cannula to maintain a sat (saturation) above 90 as needed related to chronic obstructive pulmonary disease start date 08/14/2022. Review of the medication administration record did not reflect the use of the oxygen on 09/06/2022, 09/07/2022 nor on 09/09/2022. Further review of the Vitals Summary reflected the use of oxygen on 09/02/2022, 09/03/2022, 09/04/2022, 09/05/2022, 09/07/2022 and 09/08/2022. Review of the treatment administration record did not contain orders to change oxygen tubing nor nebulizer equipment weekly. On 09/08/2022 at 4:00 p.m. an interview was conducted with the Director of Nursing, who confirmed if an as needed order (PRN) is being used it should be documented. 2. On 09/06/22 at 12:41 p.m. Resident #28 bedroom revealed a small volume nebulizer machine with oxygen tubing attached that was dated 08/24/2020. The tubing was attached to an aerosol mask that was not stored in a clean nor sanitary manner. Medical record review contained physician orders for Albuterol Sulfate Nebulization Solution 1.25 MG/3ML 1 applicator inhale orally one time a day for COVID/Pneumonia (PNA) start Date 07/12/2022. Review of the treatment administration record (TAR) read to change nebulizer mask and tubing every week by respiratory therapist (RT) every day shift every Tue for Infection control Start date 10/13/2020. The TAR revealed documentation on 09/06/2022 that the nebulizer mask and tubing were changed yet photographic evidence does not depict. 3. On 09/06/22 at 12:19 p.m. random observation revealed Resident # 146 oxygen tubing stored on the floor. Upon closer observation the tubing did not contain a date. On 09/08/2022 at 4:00 p.m. an interview was conducted with the Director of Nursing, who confirmed oxygen tubing should not be stored on the floor. 4. Review of Resident #27's record revealed that he was admitted to the facility on [DATE] has diagnosis that includes: Parkinson's disease, cognitive communication deficit, Major depressive disorder, and shortness of breath. The review of the skilled nursing note dated 9/1/22 indicated that the resident is oriented to person and has impaired decision making ability. Observations of the resident on 09/06/22 at 11:06 AM revealed that a oxygen concentrator was at the residents bedside. The concentrator was not running and the oxygen tubing was note to be dated 8/24/22. Observations of the resident on 09/06/22 at 11:50 AM revealed that a oxygen (O2) concentrator was at the residents bedside. The concentrator was not running and the oxygen tubing was note to be dated 8/24/22. Observations of the resident on 09/06/22 at 12:38 PM revealed that a oxygen concentrator was at the residents bedside. The concentrator was not running and the oxygen tubing was note to be dated 8/24/22. Observations of the resident on 9/7/22 at 8:41 AM revealed the resident lying on his bed, with the O2 concentrator not running and the tubing bagged, The resident was noted with no O2 on. observations of the labeled tubing still indicated a date of 8/24/22. Observations of the resident on 09/07/22 at 10:31 AM revealed that a oxygen concentrator was at the residents bedside. The concentrator was not running and the oxygen tubing was note to be dated 8/24/22. Observations of the resident on 09/07/22 at 11:28 AM revealed that a oxygen concentrator was at the residents bedside. The concentrator was not running and the oxygen tubing was note to be dated 8/24/22. Review of the residents current physician orders revealed an order dated 8/19/22 which indicated the following: O2 at 2liter/min via nasal cannula continuous for sob/comfort-every shift related to SHORTNESS OF BREATH Review of the September treatment administration record (TAR) revealed that the resident was administered O2 on all 3 shifts for 9/6/22 Review of the residents care plan dated 8/22/22 revealed the following: The resident has oxygen therapy r/t Ineffective gas exchange, with interventions that included Give medications as ordered by physician. Monitor/document side effects and effectiveness. If the resident is allowed to eat, oxygen still must be given to the resident but in a different manner (e.g., changing from mask to a nasal cannula). Return resident to usual oxygen delivery method after the meal. Review of the skilled nursing noted for the month of September revealed the following: Skilled nursing note dated 9/6/22 indicates N/A for respiratory. Skilled nursing note dated 9/5/22 indicates N/A for respiratory. Skilled nursing note dated 9/4/22 indicates N/A for respiratory. Skilled nursing note dated 9/3/22 indicates N/A for respiratory. Skilled nursing note dated 9/2/22 indicates N/A for respiratory. Skilled nursing note dated 9/1/22 indicates N/A for respiratory. Interview on 09/07/22 at 11:29 AM with Staff D, Licensed Practical Nurse (LPN) revealed that there is no documentation in the TAR yet for her residents because she has not yet started her treatments. Interview on 09/07/22 at 11:36 AM with the DON, confirmed that he did not see an order for changing O2 tubing but in the absence of an order the tubing should be changed weekly. the DON confirmed that current tubing for Resident #27 is more than a week old per the existing labeled tape. (Photographic evidence obtained) The DON confirmed that based on the physician order the resident should be getting O2 continuously which means at all time. He reported that the expectation is to follow the doctors orders for O2 use. Review of the facility policy titled Oxygen Administration dated 8/25/22 revealed the following: b. Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. Review of the facility policy titled Provision of Physician Ordered Services dated 8/25/22 revealed the following: The purpose of this policy is to provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality. Professional Standards of Quality means that care and services are provided according to accepted standards of clinical practice. Standards may apply to care provided by a particular clinical discipline or in a specific clinical situation or setting.

Based on observations, record reviews, and interviews, the facility failed to ensure the medication error rate was less than 5.00%. Thirty-one medication administration opportunities were observed, and seven errors were identified for five (#8, 6, 24, 30 and 9) of six residents observed. These errors constituted a 22.58% medication error rate Findings Included: 1. On 09/08/2022 at 9:15 a.m. medication observed task was conducted alongside Staff Member D, Licensed Practical Nurse (LPN) as she prepared medications for Resident #8. She confirmed the medications that were prepared was all that was due at that time except the Medrol dose pack. She said it was not available to be given. She stated when the order was put in the medication administration record it was not transcribed accurately. Staff L confirmed the order was dated on 09/07/2022 and the order still needed to be clarified before it could be administered. 2. On 09/08/2022 at 9:41 a.m. Staff D prepared the following medications for Resident #6 Ibuprofen tablet 200 mg (milligrams) three tablets, carbidopa-levodopa 25 -100 mg, apixaban 5 mg, glipizide 5 mg two tablets, metformin HCL tablet 500 mg, nuplazid capsule 34 mg, oxybutynin chloride tablet 5 mg, lorazepam tablet 0.5 mg, and one multivitamin tablet. Resident #8 was observed sitting up in his bed with the over bedside table positioned in front of him. The table contained a toothbrush, toothpaste, water, and a basin. The resident was receptive with the observation and accepted his medications. Medication reconciliation revealed Physician orders for glipizide tablet 5 mg give 2 tablets by mouth in the morning related to TYPE 2 Diabetes Mellitus before breakfast dated 08/30/2022, and multivitamin with minerals tablet give 1 tablet by mouth one time a day dated 08/05/2022. 3. On 09/08/2022 at 10:08 a.m. an observation was conducted with Staff Member I, Registered Nurse (RN) as she prepared the following medications for Resident #24. Zinc tablet 50 mg, vitamin D tablet 25 mcg (micrograms), aspirin tablet 325 mg, vitamin C tablet 500 mg, cranberry 425 mg one tablet, methenamine Hippurate tablet 1 gr (gram), tamsulosin HCL capsule 0.4 mg, amlodipine 10 mg, and valsartan 40 mg. Medication reconciliation revealed zinc tablet 25 mg give 1 tablet by mouth one time a day dated 07/30/2022, and cranberry tablet 400 mg give 2 tablet by mouth one time a day for vitamin supplement dated 07/20/2022. 4. On 09/08/2022 at 11:53 p.m. Staff Member I was observed as she prepared insulin for Resident #30 at his bedside. The flex pen read Novolog 70/30 flex pen Staff I turned the dose selector to 2 units; the pen was held down and pressed the injector button. The pen was then turned the dose selector to 4 units and administered the insulin into his right upper extremity. 5. On 09/08/2022 at 12:05 p.m. Staff member D, was observed as she prepared Humalog an insulin pen for Resident #7 the pen dose selector was dialed to 2 units. The pen was held sideways as she pressed the injector pen. When asked she stated it's not perfectly straight as she selected 16 units. The insulin was administered into Resident #7 left upper abdomen. On 09/08/2022 at 1:00 p.m. an interview was conducted with the Director of Nursing (DON); he confirmed medication should be administered as ordered. Review of policy titled Medication Administration dated 8/25/2022 Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do in this stated, as ordered by the Physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines: 11. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name medication name, form, dose, route, and time. Examples guidelines for Medication Administration (unless otherwise ordered by physician), this list is not all-inclusive. Medications requiring administration on an empty stomach: Glipizide. Accessed on 09/09/2022 at: https://pi.lilly.com/ca/basaglar-ca-ifu-kp.pdf Priming your Pen Prime before each injection. Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. Step 5: To prime your Pen, turn the Dose Knob to select 2 units. Step 6: Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. Step 7: Continue holding your Pen with Needle pointing up. Push the Dose Knob in until it stops, and 0 is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. You should see insulin at the tip of the Needle. - If you do not see insulin, repeat the priming steps, but not more than 4 times. If you still do not see insulin, change the Needle and repeat the priming steps.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure adequate supervision measures were in place to prevent falls for two (Resident #28 and Resident #188) out of five sampled residents. Findings Included: 1. During the entrance conference conducted on 05/24/21 with the facility Administrator (NHA) and the facility Director of Nursing (DON), it was reported that Resident #188 was under transmission-based isolation precautions because she was a new admission to the facility. During the initial tour of the facility on 05/24/21, the resident's door was observed closed, and it was observed to be always closed throughout the survey period (05/24/21-05/27/21). Record review revealed that Resident #188 had been admitted to the facility on [DATE] following a hip fracture with surgical repair. Other diagnoses included Parkinson's disease and dementia. The MDS revealed a Brief Interview of Mental Status (BIMS) score of 6 which meant that the resident had moderate cognitive impairment. The MDS revealed that the resident required extensive assist for transfers and had a history of falls with injury. The care plan revealed a focus area for toilet use with interventions including check and change program initiated 05/19/21. The care plan revealed a focus area for at risk for falls with interventions including family provides private sitter 10 - 4 p.m. daily; offer and assist with toileting schedules to meet any continence needs. Review of Certified Nursing Assistant (CNA) task list revealed, check and change every two hours. An observation was conducted on 05/24/21 at 11:37 a.m. in Resident #188's room. There was a visitor in the room who identified herself as the resident's caregiver and family member; she reported she was hired by the family to sit with the resident most days at the facility. The resident was observed in bed with her call light in reach. She reported that she often had to wait long periods for the call light to be answered, sometimes as long as 30 minutes. Her caregiver confirmed this report. Multiple call light observations were conducted for Resident #188 during the survey: on 5/24/21 light was on at 12:08 p.m. and answered nine minutes later at 12:17 p.m.; on 5/25/21 the light was on at 12:45 p.m. and was answered at 12:49 p.m.; on 5/25/21 the light was on at 2:34 p.m. and answered at 2:40 p.m.; on 5/26/21 the light was on at 10:12 a.m., multiple staff were observed passing by in the hallway without answering, the light was answered at 10:19 a.m.; on 05/26/21 the light was on at 2:00 p.m., there was housekeeper on the hall, at 2:06 p.m. and 2:08 p.m. staff walked by the door without answering, at 2:11 p.m. the resident's private caregiver was observed donning PPE outside the door, at 2:12 p.m. the DON was observed standing in the hallway talking to the caregiver, at 2:15 the private caregiver entered the room, the light remained on, at 2:18 p.m. a CNA was observed entering the room. During the call light observation beginning at 10:12 a.m. on 05/26/21, Staff B, Licensed Practical Nurse (LPN) and Staff C, Minimum Data Set (MDS) Coordinator were observed donning Personal Protective Equipment (PPE) outside of the room and Staff B entered the room at 10:19 a.m. (seven minutes had passed). Staff B said that the door could not be opened without first donning all required PPE according to facility policy. She was observed entering the room without the required eye protection and said that was because it's an emergency .the resident is on the floor. An interview was conducted with Staff B and Staff C on 05/26/21 at 12:47 p.m. Staff B reported that she had known that Resident #188 was on the floor before arriving to the room because the receptionist had told her. Staff B said that the receptionist had received a call from the resident's daughter informing her that the resident had fallen in her room while on the phone with her. Staff C said, I didn't know what happened, but I saw [Staff B] take off and so I thought, I'm a nurse, I might as well go .you know how it is. Staff B reported that when she entered the resident's room, she found her on her buttocks on the floor, the resident told her she was reaching for her television remote and denied pain or injury. Staff B completed a head-to-toe assessment with no findings of injury or concern. Staff C reported that the resident was confused and forgetful and said the resident did not tell us why the call light was on .I don't know if she even knew it was on. Both confirmed that at the time of Res. #188's fall her private sitter was not there; she was alone in the room. Staff B reported that she followed facility post-fall protocol including initiating neuro checks and notifying the resident's physician and family. Staff C reported that the resident had not fallen in the facility before, had been assessed upon admission to be at risk for falls, and interventions established at admission included low bed with side mats, staff to peek in every so often, and staff to check and change every two hours. Staff C said, If BIMS less than 9 I try to put them on a check and change. Staff C reported that the resident's family wanted the private caregiver with her at the facility because she had her at home, and said, as far as I know she's paid to be here by the family. Staff C confirmed that the private caregiver was only allowed to sit, not allowed to provide any hands-on care to resident in the facility. Call lights were still required to be answered by facility staff. An interview was conducted with the DON and Staff C on 05/26/21 at 2:15 p.m. They confirmed that the private sitter was something the family wanted in place, her schedule was Monday to Thursday generally between hours of 10:00 a.m. to 4:00 p.m., did not come Friday-Sunday, and functioned only as a sitter where in facility, paid by family, and had not been requested by the facility. The DON reported that there was no facility policy that the resident's door could not be opened to check on her without staff fully donning PPE and that there was no policy that mandated the door had to remain closed. The DON reported that there was no specific time standard for answering call lights, that the expectation was timely, and that she would consider answering a light within 6-8 minutes as reasonable. The DON confirmed that a wait of 15 minutes was a long time. The DON confirmed there was no facility policy regarding expectations for answering call lights and that no specific training was provided to facility staff on expectations. The DON followed up at 5/26/21 at 4:30 p.m. to report that she had initiated education with the staff on call light response based on the previous conversation regarding Res. #188. An interview was conducted with the DON on 05/27/21 at 9:53 a.m. She revealed that post-fall interventions put in place for Resident #188 included 15-minute checks by nurse or CNA during times that private sitter was not there. 2. Resident #28's hall was observed on 05/26/21 at 11:52 a.m.; no staff were observed on the hall. At 11:57 a.m. another resident across the hall from Res. #28's room called out that she needed to use the bathroom. At 12:28 p.m. Resident #28 was observed attempting to get out of bed, Staff A, CNA, was observed walking away down the hallway and was informed. By the time Staff A arrived at the room the resident had rolled out of bed and was on the mat on the floor next to the bed. Staff A assisted her into a side-lying position and called for a nurse. At 12:31 the facility Assistant Director of Nursing (ADON) arrived, and at 12:32 the resident's nurse arrived and began assessing the resident. Staff A was interviewed on 05/26/21 at 12:39 p.m. She said, she (Resident #188) does this all the time .has happened two or three times since she's been here when I've been working .she's very confused, doesn't use call light. Staff A confirmed that when she entered the room the resident was on all-fours and her head was under the bed frame. She said she didn't know if the resident hit her head. Staff A said, we keep the door open and check on her when we pass .lunch is hectic. At 12:42 the ADON exited the resident's room, confirmed head to toe assessment revealed no injury and said, this has happened before. Record review revealed that Resident #28 was admitted to the facility on [DATE] following a right hip fracture with surgical repair. Other diagnoses included history of falling, seizures, and dementia. The most recent completed MDS dated [DATE] revealed a BIMS score of 2 which meant that the resident had severe cognitive impairment. The MDS revealed that the resident required extensive assist from two persons for transfers and had a history of falls with injury. The care plan revealed a focus area for fall risk that included the following interventions: keep resident near concierge desk for high fall risk, poor safety awareness; right side of bed placed against the wall for safety; scoop mattress to prevent falls. Progress notes revealed the following: 05/16/21: Activities assistant notified nurse of resident found on floor on top of side mats . 05/25/21: Resident attempted to stand up from wheelchair alone x 3 despite offering fluids, food and toileting stated, 'I want to get on the floor.' Close monitoring in progress. 05/26/21: Around 12:30 while in nursing round upon entering to room observed resident lying on floor mat next to bed positioned on right side of body, stated 'I was trying to get up . Review of the facility incident log revealed entries for Resident #28 of alleged fall on 05/16/21 and 05/19/21. An interview was conducted with the DON on 05/27/21 at 9:15 a.m. She confirmed that the resident had been assessed to be at risk for falls upon admission and that the following preventive measures had been put in place at that time: bed against the wall (family request); bed in lowest position; floor mat when in bed, call light in reach, check on her every two hours. The DON said that checking on residents every two hours was a facility standard and was not something that got documented. She confirmed that the fall on 05/26/21 was the resident's third fall since her admission to the facility. The DON reported the first fall was on 05/16/21 at 2:00 p.m., she got out of bed and was found sitting on the mat .could not say what she was doing .no injury .initiated scoop mattress as customized intervention. She reported that the second fall occurred on 05/19/21 at 2:20 p.m. when the resident again attempted to climb out of the bed and was found on the floor on her right hip. The DON reported that the resident's daughter had not wanted her sent out, so a mobile x-ray was completed of her right hip and revealed no injury. The intervention put in place at that time was to place the resident in front of the concierge desk between care, meals, and therapy sessions so she could be supervised. The DON reported that the following had been put in place following the fall on 05/26/21: staff instructed not to leave Resident #28 alone in her room; 15-minute checks would be started today by nurses and CNAs; next step will probably be one on one in the daytime. The DON confirmed that it was facility responsibility to keep resident safe and that they could provide one on one if needed. Review of facility policy titled, Accidents/Incidents effective 02/29/16 revealed the following within the policy statement, It is the community's policy to provide an environment that is free from hazards over which the community has control. The intent of this policy is that the community identifies each resident at risk for accidents and/or falls, and adequately plans care and implements procedures to prevent accidents . Action steps outlined in the policy included, .In the event an accident or incident occurs the Licensed Nurse: .g. Initiates measure to prevent a re-occurrence, including validating that each resident receives adequate supervision and assistance to prevent accidents .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure one Resident #31 received indwelling catheter care to reduce the potential for infection by storing and reusing used catheter bags observed with urine in a plastic bag hanging from the safety rail in the bathroom for 2 of 4 days of 5 residents with urinary catheters. Findings Included: During an interview with Resident #31 on 5/24/21 at 11:40 a.m. she stated she was new to using an indwelling catheter and gets a leg bag that is removed and placed in the bathroom until the next day whey the same bag is put back on while she is out of bed. The resident was observed wearing a drain bag laying in bed and said she was waiting for a shower to go to therapy. Resident #31 was observed on 5/24/21 at 11:48 a.m. going to the shower room with a leg bag on for her shower. Photographic evidence obtained of catheter bags in the the bathroom. During an interview on 5/24/21 at 3:10 p.m. with Staff member A, CNA she confirmed she changed Resident #31 from the urinary bed bag to the leg bag. Staff member A, CNA confirmed the bed bag is removed from the resident and goes in the trash bag which is tied to safety rail. Staff member A, CNA confirmed the urine bag is emptied when changed out and does not clean out the bag. Staff member A, stated she does clean the tube with alcohol sometimes. During observation and confirmation of the urine bags hanging in the bathroom Staff member A, CNA confirmed on 5/24/21 at 3:16 p.m two leg bags and one drain bag containing dark yellow brown urine in each bag. Staff member A, CNA also stated one leg bag did not have the cap attached to the bag. During an interview on 5/24/21 at 3:17 p.m with Staff member B, LPN, she stated it was facility protocol to remove the urine bags and place them in a plastic bag in the bathroom as long as the bags were emptied and checked for tears or spills prior to use. Observation of two leg bags with urine hanging in the bathroom on 5/25/21 at 10:21 a.m. Photographic evidence obtained. During an interview on 5/25/21 at 10:45 a.m. the Assistant Director of Nursing (ADON) stated the facility does reuse the catheter bags but does not have a policy on reuse of the catheter bag or how to clean and store the bag. She stated the facility uses nurses discretion and the physician order that stated to change the bags weekly. The ADON confirmed three used catheter drainage bags with urine were in two plastic bags. One leg bag, dated 5/19/21 and two leg bags, dated 5/12/21. The ADON confirmed the bed bag that was on the resident was dated 5/20/21. The ADON stated the aides should be rinsing out the catheter bags prior to placing them in the plastic bag and they should be used for one week. The ADON disposed of the three bags and said she would start an inservice. During an interview with the Director of Nursing (DON) on 5/25/21 at 12:15 p.m. she was asked to provide the instructions for use on the drain bag and bed bag. The ADON brought in a document typed by the DON on 5/25/21 at 12:20 p.m. signed by the DON titled: Instructions for usage of Foley catheter bags: it is the practice of [NAME] Gardens of [NAME] certified nursing assistants can rinse the Foley catheter leg bag or the large drainage bag with soap and water and store in plastic bag labeled with the resident room number and date in the bathroom for up to seven days, unless bag is leaking, then bag will be discarded and notification to the nurse will be made. Signed by the DON Resident #31 was admitted on [DATE], diagnoses included neuromuscular dysfunction of bladder, urinary tract infection. Review of the medical certification for medicaid long-term care services and patient transfer form (3008) revealed the resident had urinary retention due to Vancomycin-resistant enterococcus (VRE) urinary tract infection (UTI). Review of the physician orders revealed: Change catheter drainage bag every Wednesday 11 to 7 shift every night shift every Wednesday dated 5/1/21. Review of care plan revealed a focus area of indwelling catheter. Goal to show no signs or symptoms of urinary infection through review date, initiated on 5/1/21. Interventions to change catheter as ordered by physician, initiated on 5/1/21. During an interview with the Advanced Registered Nurse Practitioner (ARNP) on 5/26/21 at 1:13 p.m. she stated she was told the staff emptied the urine bags before hanging them in the bathroom in a plastic bag and she would expect the bags to be emptied and rinsed prior to reusing them. During an interview on 5/26/21 at 12:45 p.m. the DON stated the facility had a template order to change the leg and drain bag once a week. The DON stated her expectation would be to rinse leg or drain bag with water and soap. The DON confirmed she never contacted the company or looked on the company website to find a cleaning protocol to verify the bags could be reused. The DON stated the facility does not have a policy on how to clean or store the urine bags. The DON confirmed the facility has 5 residents that use the catheter bags and stated the staff were instructed to dispose of all drainage bags earlier today. A phone call to the catheter bag manufacturer on 5/25/21 at 1:48 p.m. revealed the leg and drain bag can be reused as long as they are cleaned according to the instructions for use. The manufacturer emailed the instructions for use indicating Cleaning your drain and leg bag: mix cleaning solution: either 2 parts of vinegar and 3 parts water or 1 tablespoon of chlorine bleach and 1/2 cup of water. Step 1. Empty the bag of urine, and then close the drainage spout. 2. Place tubing under the faucet, putting warm water into the bag. 3. Swish it around for 10 seconds, and then empty it through the drainage spout. Close the spout. 4. Pour cleaning solution into the bag. Put the protective cap on the connector. 5. Swish solution around for 30 seconds, and then let it sit in the bag for 20 minutes. Empty through the drainage spout. 6. Keep spout open and pointed down. Hang the bag to dry until switching bags again. 7. Remember to close the spout when attaching it to the catheter. Review of the the facility Foley catheter care skills checklist, dated 2017, 9 pages, revealed: 12. Fill the bag with cleaning agent. 2 parts vinegar and 3 parts water or 1 part bleach to 10 parts water. 13. Swish the cleaning agent around to get hard to reach areas. 14. Allow the cleaning agent to remain in the bag 20 to 30 minutes. 15. Drain the cleaning agent by opening the drainage spout/clamp. 16. Rinse the bag with tap water. 17. Hang the bag to drain and dry. 18. Remove your gloves and wash your hands. 19. Clean bags daily and use new bags at least every 30 days.