**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, and interview, the facility failed to encode and transmit a discharge Minimum Data Set (MDS) assessment for 1 of 2 sampled discharged residents. Resident #11. The findings included: Review of the policy titled Transfer From Distinct Part to Non-Certified Household / Neighborhood revised 10/2024 documented in part, Procedure: . 6. The MDS Coordinator shall complete the appropriate Minimum data Set (MDS) assessment. Upon entering the facility on 10/21/24, the Administrator informed the survey team that although they had five active households (resident units), only one household (Biscayne) was certified while the other four were non-certified and licensed only. The Administrator explained they did not accept residents from outside of their community and did not accept Medicaid. The Administrator stated the decertification process happened in two stages, but was completed by 11/20/23. Review of the record revealed Resident #11 was admitted to the facility on [DATE], into the certified Biscayne household. Further review of the census record revealed the resident was moved to a licensed only household, Key West, on 07/13/24. This move indicated Resident #11 no longer lived in a certified facility, which needed to be reflected in the MDS (certification) assessment. Review of the MDS assessments lacked any MDS discharge assessment for the resident's move out of the certified household as of 07/13/24. During an interview on 10/22/24 at 2:52 PM, the MDS Coordinator was asked her MDS process for a resident who moved out of the Biscayne household. The MDS Coordinator explained she would complete (encode) and transmit a discharge MDS assessment with the resident's return not anticipated. During a side-by-side review of the record, the MDS Coordinator confirmed she failed to complete and transmit the discharge MDS assessment for Resident #11.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review and interview, the facility failed to ensure a discharge summary, to include a recapitulation of the residents stay, for 1 of 2 sampled residents, Resident #3. The findings included: Review of the policy titled Transfer and Discharge Rights, revised 10/2024, documented, in part, Documentation of Transfer or discharge: . 4. Information provided to the receiving community/provider should include the following: . Discharge Summary. The discharge packet provided by the Administrator included a form titled, Discharge Assessment & Summary. Upon entering the facility on 10/21/24, the Administrator informed the survey team that although they had five active households (resident units), only one household (Biscayne) was certified while the other four were non-certified and licensed only. The Administrator explained they did not accept residents from outside of their community and did not accept Medicaid. The Administrator stated the decertification process happened in two stages, but was completed by 11/20/23. Review of the record revealed Resident #3 was admitted to the Biscayne household on 09/25/24, and then moved to the [NAME] Villa household on 10/17/24, a non-certified and licensed only household. Review of the Minimum Data Set (MDS) assessments revealed a discharge Minimum Data Set (MDS) assessment, with return not anticipated, was completed on 10/17/24. A progress note written by Staff B, Registered Nurse (RN), on 10/17/24 at 10:47 AM documented Resident #3 was safely moved to the [NAME] Villa unit. Further review of the record lacked a discharge assessment and summary, but revealed a Room Change Notification indicating Resident #3 was moving from the skilled services bed on Biscayne to [NAME] Villa. During an interview on 10/24/24 at 11:45 AM, when asked the process when one of the residents in the Biscayne household was discharged out to one of the other households in the facility, Staff B, RN, explained she completes a functional assessment, gives verbal report to the accepting nurse, and it is treated like a room change. When asked if she completes a discharge summary, the RN stated she does not, but stated that would make sense since the resident would be moving out of the certified household into a non-certified household, similar to when they are discharged back to their apartment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews, and review of facility policies and procedures, the facility failed to cook raw unpasteurized eggs in a manner to destroy all viable Salmonella species bacteria, a virulent foodborne pathogen (disease-causing microorganism) that could cause food borne illness for 3 of 3 sampled residents, Residents #11, #334 and #335. Residents #11, #334 and #335 were over [AGE] years of age and were immunocompromised. Residents #11, #334 and #335 preferred undercooked eggs (over easy) for breakfast and were served unpasteurized shell eggs (that have not been specifically treated to destroy all viable Salmonella species bacteria). The findings included: The facility's policy, titled, Egg Preparation, most recently updated 02/2017, documented, in part, the following: Policy: when preparing eggs separately or as part of a recipe, only commercial Grade A or pasteurized egg products may be used. When preparing eggs to order only pasteurized eggs may be used. No raw eggs will be served. Procedure: 1. Examine all fresh eggs discarding any that are cracked or damaged. 2. Grade A raw egg may only be used in recipes where the egg will be cooked (i.e. pudding, cakes, quiche, etc. 3. Grade A raw eggs prepared separately must be cooked to at least 140 degrees for three minutes or 145 degrees for 15 seconds. This will yield a product in which the egg whites are completely set and the yolks are congealed. 4. All poached, over easy and other non-fully cooked egg menu items need to be prepared with pasteurized shell eggs. The facility's policy, titled, Cooked Egg Policy, most recently updated 04/2023, documented, in part, the following: To strive to protect residents from the potential for food-borne illness, all residents will be served eggs that have been cooked to the recommended internal temperature according to the Food and Drug Administration. Procedure: 1. All residents will be served eggs that have been cooked to the recommended internal temperature of 145F, based on federal guidelines. 2. Pasteurized eggs will be used for preparations that will not meet the internal temperature of 145F, such as over-easy or poached eggs. The facility's menus that the residents fill out for their choices for breakfast offered Eggs Made to Order: Scrambled / Over Easy / Fried every day for breakfast. 1. Resident #11, who was over the age of 65 years, was admitted to the facility on [DATE] with diagnoses that included: Post Polio syndrome, Personal History of COVID 19 (Coronavirus Disease 2019), Carcinoma (cancer) of skin, scalp and neck, Major depressive disorder, Acute embolism (blockage in a blood vessel due to a blood clot or other foreign matter that gets stuck while traveling through the bloodstream) and thrombosis (the formation or presence of a blood clot within a blood vessel which can block or limit blood flow) of right lower extremity, Atherosclerotic heart disease of the native coronary artery (hardening of the arteries due to gradual plaque buildup) without angina pectoris (chest pain or pressure), Hypertension, Paroxysmal Atrial Fibrillation (an irregular and often very rapid heart rhythm), Hyperlipidemia (high blood cholesterol), Atherosclerosis (a buildup of fats, cholesterol and other substances in and on the artery wall that causes arteries to narrow blocking blood flow), Anemia, Malignant Neoplasm (cancer) of the pancreas, Diaphragmatic Hernia, Disorders of Plasma protein Metabolism (inherited metabolic disorders that involve malfunction of metabolism of proteins in the blood), and Gastroesophageal Reflux Disease (GERD). Review of physician orders revealed Resident #11 had orders that included: Pantoprazole Sodium Tablet Delayed Release 40 MG - for GERD. Review of the Annual Minimum Data Set (MDS) assessment documented Resident #11 had a Brief Interview for Mental Status (BIMS) score of 15 of 15, indicating the resident was cognitively intact. 2. Resident #334, who was over the age of 65 years, was admitted to the facility on [DATE] with diagnoses that included: Congestive heart failure (a progressive heart disease that affects pumping action of the heart muscles, which can cause fatigue and shortness of breath upon exertion and fluid retention), Hypertension, Diabetes Mellitus, Alzheimer's disease, Non Alzheimer's dementia, Depression, Deep vein thrombosis of right lower extremity, Multinodular goiter (a condition where the thyroid gland is enlarged due to multiple lumps that can grow on more than one part of the gland), Atrial fibrillation, Rheumatoid Arthritis (a chronic inflammatory disease that affects the joints that results in painful joints, swelling and stiffness in the joint), and Osteoarthritis (degenerative joint disease). Review of the quarterly MDS assessment, dated 06/08/23, documented Resident #334 had a BIMS score of 15 of 15, indicating the resident was cognitively intact. 3. Resident #335, who was over the age of 65 years, was admitted to the facility on [DATE] with diagnoses that included: Hypertension, Idiopathic peripheral autonomic Neuropathy (a condition in which the nerves located outside of the brain and spinal cord are damaged causing weakness, numbness, and pain), history of COVID 19 (Coronavirus Disease 2019), Macular degeneration (a vision impairment resulting from deterioration of the central part of retina), Atrial fibrillation, Constipation, Arthritis, Osteoporosis, and Chronic Kidney Disease Stage 3 (moderate kidney damaged and notable loss of function, but they still work well enough without dialysis or a kidney transplant). Review of the quarterly MDS, dated [DATE], documented Resident #335 had a BIMS score of 15 of 15, indicating the resident was cognitively intact. The initial kitchen tour was conducted on 07/31/23 at 8:51 AM, accompanied by the Executive Chef. During an observation in the walk-in cooler, it was noted that there was one full unopened case of unpasteurized shell eggs and a half of a case of unpasteurized shell eggs. It was also noted that there were no pasteurized shell eggs in the walk-in cooler. When the Executive Chef was asked how many staff cook eggs to order (e.g., over easy, sunny side up), the Executive Chef replied that the facility cooked eggs to order for the residents in the individual kitchens on the units without measuring the final cooking temperature of 145°F for 15 seconds for unpasteurized eggs. During a tour of the Biscayne Unit on 07/31/23 at 9:10 AM, it was noted that there were approximately 2.5 dozen unpasteurized shell eggs in the reach-in refrigerator, and no pasteurized shell eggs. During an interview with Staff A, Line Cook, when asked about cooking eggs to order, the Line [NAME] stated that she cooks eggs to residents' order for breakfast without measuring the final cooking temperature of 145°F for 15 seconds for pasteurized eggs. The line cook stated that none of the residents requested the eggs to be undercooked (e.g., sunny side up, over easy eggs) for breakfast on this day. When asked by the surveyor, Staff A was not aware of the risks of foodborne illness associated with residents consuming undercooked unpasteurized shell eggs. During a tour of the Key [NAME] Unit, on 07/31/23 at 9:55 AM, it was noted that there were no eggs in the reach-in refrigerator. During an interview with Staff B, Cook, when asked about cooking eggs to order for the residents, the [NAME] stated that he cooks eggs to order for breakfast, including breakfast that morning. The [NAME] stated that the eggs were removed from the reach-in cooler after it was identified by the surveyor that the eggs were not pasteurized. The [NAME] stated that he cooked an over easy egg without measuring the final cooking temperature of 145°F for 15 seconds for unpasteurized eggs for one resident on the unit, Resident #11, and that the rest of the residents had scrambled eggs made from pasteurized liquid eggs. When asked by the surveyor, Staff B was not aware of the risks of foodborne illness associated with residents consuming undercooked unpasteurized eggs. During an interview, on 07/31/23 at 12:04 PM, with Staff C, Dietary Aide on the Sweetwater Unit, when asked about residents ordering undercooked eggs, the Dietary Aide replied, none today, they only had three resident that asked for eggs. The Dietary Aide further stated the residents received scrambled eggs made from the pasteurized liquid eggs and that she cooks eggs to order when requested by residents. The staff were cooking the unpasteurized eggs without measuring the final cooking temperature of 145°F for 15 seconds. When asked by the surveyor, Staff C was not aware of the risks of foodborne illness associated with residents consuming undercooked unpasteurized eggs. During an interview with Resident #11, on 07/31/23 at 1:51 PM, when asked about the breakfast served this morning, Resident #11 replied, I had one over easy egg, with hash browns and a slice of bacon. Resident #11 further stated that he has one over easy egg several times a week. During an interview, on 07/31/23 at 5:22 PM, with a Sales Representative from [NAME] Wholesale Fruit and Produce, the food vendor that the facility purchases their eggs from, the Sales Representative confirmed that the vendor did not have pasteurized shell eggs to sell and had never had them. During an interview, on 08/01/23 at 7:11 AM, with Staff D, Dietary Aide, when asked about residents that ask for and receive undercooked eggs, Staff D replied, 3 or 4 (residents). Staff D further stated that she prepared eggs to order based on residents' preferences. When asked, Staff D was not aware of the risks of foodborne illness associated with residents consuming undercooked unpasteurized eggs. During the interview, on 08/01/23 at 7:37 AM, with the Registered Dietitian (RD), the RD stated that she was not aware that the facility was using undercooked, unpasteurized eggs, I assumed they were all pasteurized. During an interview, on 08/01/23 at 7:37 AM, with the Executive Chef and the Culinary Services Director, when asked about ordering and receiving shell eggs, the Executive Chef stated he had been ordering the unpasteurized shell eggs from [NAME] Wholesale Fruit and Produce vendor for the previous 5.5 months and that he had not ordered or received eggs from any other vendor. The Executive Chef stated that he ordered the eggs as he felt that the eggs that he was ordering were more natural and healthier. The Executive Chef stated that he was not aware that the eggs were unpasteurized. During a review of the website from Jack [NAME] Wholesale Fruit and Produce (where the facility buys eggs from) revealed that there were no pasteurized shell eggs that could be ordered from the supplier. During an interview, on 08/01/23 at 9:24 AM, with Staff E, Certified Nursing Assistant (CNA), when asked about residents being served undercooked eggs, Staff E stated that Resident #335 requests and receives over easy eggs once or twice a week. When asked Staff E stated that she was not aware of the risks of foodborne illness associated with residents' consuming undercooked unpasteurized shell eggs. During an interview, on 08/01/23 at 9:37 AM, with Resident #335, she confirmed that she ordered and received undercooked and unpasteurized shell eggs regularly. During an interview, on 08/01/23 at 1:12 PM, with Resident #334, when asked of her preferences for eggs, Resident #334 stated that she requested over easy eggs regularly for the 5.5 months that she had been in the facility. Resident #334 further stated that she has over easy eggs Monday, Wednesday and Friday, but I don't eat the yolks. Review of the invoices for the Jack [NAME] Wholesale Fruit and Produce vendor revealed the unpasteurized eggs were ordered on 02/03/23 and to be delivered on 02/03/23 to the facility. During an interview, on 08/01/23 at approximately 4:30 PM, the Administrator was told that the Agency had a concern related to the facility serving undercooked unpasteurized eggs. The Administrator stated she was not aware the facility was serving undercooked unpasteurized shell eggs prior to the concern being brought to her attention. During an interview, on 08/02/23 at 12:30 PM, with the Infection Preventionist, the Infection Preventionist stated that there had been no reports of residents with signs or symptoms of Salmonella illness. She confirmed she was not aware of the residents being served undercooked unpasteurized eggs. During an interview, on 08/03/23 at approximately 9:00 AM, with the Medical Director by telephone, the Medical Director stated that he had been made aware of the concern by the Administrator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to treat 1 of 17 sampled resident who reside in the [NAME] Villa neighborhood in a dignified manner, Resident #57, who was served all meals on Styrofoam or paper disposable dinnerware with plastic utensil, while all other residents were served on traditional dinnerware with regular utensils. The findings included: On 03/28/22 at 8:36 AM, Resident #57 ambulated into the dining room with his rolling walker and sat down at a table. Resident #57 was served his breakfast meal on disposable dinnerware with plastic utensils. The [NAME] Villa neighborhood housed 17 residents as of 03/28/22, and residents came and went from the dining room as desired. There would be five to seven residents in the dining room for the breakfast meal, and later determined there were up to nine or ten residents in the dining room for the lunch and dinner meals. Other residents were served in their rooms. The kitchen area was maintained, and food served by dietary staff, although all nursing staff was also trained to assist. On 03/28/22 at 8:51 AM, Staff D, a private home health aide was standing in the [NAME] Villa dining room watching the residents. When asked why Resident #57 was eating on disposable dinnerware, Staff D, the private aide stated, because he likes to [NAME] into his plate . you'll see what I mean. On 03/28/22 at 12:12 PM, Resident #57 was observed eating lunch in the [NAME] Villa dining room. His meal was served on the disposable dinnerware. On 03/30/22 at 8:49 AM, Resident #57 had just finished eating breakfast, which was again served on disposable dinnerware with plastic utensils, except for the cereal, which was in a regular bowl (photographic evidence obtained). Resident #57 ambulated back to his room. When asked why he was eating on paper plates, Resident #57 stated he did not know. Resident #57 was very hard of hearing, had some trouble expressing his thoughts, and conversation was difficult. He was able to explain his food was soft because of a swallowing problem. When asked if he wanted regular plates and silverware, Resident #57 stated, Guess I'll leave it up to them and shrugged his shoulders. Resident #57 was again observed on 03/30/22 at 12:30 PM with the disposable dinnerware and when done, stated he wanted to go back to his apartment. Resident #57 was observed during this meal and all previous meals with the disposable dinnerware on paper napkins. At no time was Resident #57 observed hacking up mucus or spitting. During an interview on 03/30/22 at 12:31 PM, when asked why Resident #57 was eating on disposable dinnerware, Staff F, a Certified Nursing Assistant (CNA) stated, because he spits in his plate. When asked if they appropriately clean and disinfect the plates, the CNA stated, I guess the kitchen staff don't like it (referring to the resident's behavior) or something. On 03/30/22 at 12:50 PM, when asked why Resident #57 was served his meal on disposable dinnerware, Staff G, a Dietary Aide, explained it was a doctor's order because he spits in his plate and hacks up mucus. When asked if the dishes are cleaned and sanitized after use, the Dietary Aide stated they were. When asked if a regular plate could be cleaned and disinfected for Resident #57, the Dietary Aide stated it could be. The Dietary Aide then stated, To be honest with you, I have small kids and we can't wear gloves in the dining room, and I can't pick up his plate when he spits in it. When asked if she could pick up his plate, put it in the dish washer, and then wash her hands, she said yes, she could, but still would not want to pick up his plate. The Dietary Aide again stated it was a doctor's order. When asked how the doctor's order was initiated or why it was brought to the doctor's attention for an order, the Dietary Aide stated, I think he saw it himself. Review of the record revealed Resident #57 was admitted to the facility on [DATE], to the [NAME] Villa neighborhood. Review of the current Minimum Data Set (MDS) assessment dated [DATE] lacked any score for mental status. This same MDS documented Resident #57 could eat independently after being set up. Review of the physician's orders documented on 11/26/21 that paper products were to be used for meals. This same order was written on 12/26/21 with the resident's most current re-admission to the facility. Review of the care plan initiated on 11/25/21 documented the continued need for a mechanically altered diet. One of the interventions documented by the Registered Dietician was Please provide me with disposable products for all meals. Review of the behavior monitoring completed by the CNAs in the tasks section of the electronic medical record lacked any documented spitting behavior in the past 30 days. During an interview on 03/30/22 at 2:55 PM, Staff I, a Licensed Practical Nurse (LPN), was asked about the order for the paper products for Resident #57. Staff I, the LPN, stated she thought it was brought up by dietary during the COVID-19 pandemic, because he has a lot of mucus all the time. When asked if there was a functional need for the use of paper products for Resident #57, the LPN again stated, I think it is a dietary thing. During an interview on 03/30/22 at 3:04 PM, the Director of Culinary services was asked why Resident #57 was served on disposable dinnerware, while everyone else was being served on traditional dinnerware. The Director of Culinary services stated it happened when he first got here, as he was hacking up mucus and spitting it on his plates and into his cups. The Director of Culinary services stated some of the CNAs and dietary aides mentioned it. The Director of Culinary stated, We use universal precautions, and then we had COVID, and our medical director said it was ok to use paper products for Resident #57. The Director of Culinary services agreed they do disinfect the plates and glasses, and further stated, Staff were saying they would not touch it. It wasn't a decision I made alone. It was a team decision. When asked about glove use, the Director of Culinary services explained that gloves are not to be worn while serving food as it's a dignity issue. The Director of Culinary services stated, but after meals while cleaning up it's fine to wear gloves. The Director of Culinary services stated staff could wear glove during a meal if there was a need to clean something up. The Director of Culinary services stated she had educated staff on universal precautions. When asked if she specifically educated them related to Resident #57 and his behaviors, the Director of Culinary services did not believe she had. During an interview on 03/30/22 at 3:33 PM, the Registered Dietician was asked about the care plan related to paper plate use for Resident #57. The Registered Dietician stated there was a physician order for the paper products, so I put it in the care plan. The Registered Dietician stated at the time he was spitting up and vomiting. When asked if she was part of the decision to use paper products, she stated she does not recall being part of the conversation, and she just knows he has the issue with spitting up. When asked if there was a functional reason for the paper products, the Registered Dietician stated there was not, but she just had an order, so she care planned it. The Registered Dietician stated she understood the concern with the use of paper products and dignity. On 03/30/22 at 4:30 PM, Resident #57 ambulated to the [NAME] Villa dining room for dinner. Resident #57 was provided a regular spoon, but disposable dinnerware set on paper napkins. At this meal, residents in the dining room were served a hand scooped frozen dessert in a scalloped glass bowl, while Resident #57 was noted with a frozen dessert in a cardboard container. Resident #57 was observed during this entire meal, and at no time was Resident #57 observed hacking up mucus or spitting. On 03/30/22 at 4:35 PM, Staff N, the MDS Coordinator provided the November 2021 care plan meeting for Resident #57. Review of this meeting lacked any documentation related to the use of paper products. When asked for documented evidence of the team decision to provide paper products to Resident #57, the MDS coordinator stated, There is an order. When told the Director of Culinary services stated it was a team decision, the MDS Coordinator referred to the Director of Nursing. On 03/30/22 at 4:57 PM, the MDS Coordinator returned to the surveyor and stated, What I'm finding out is the decision was made between the previous Nutritional Care Coordinator and Staff I, the LPN, and an order was obtained, but I can't find any notes to show that. During an interview on 03/31/22 at approximately 3:30 PM, the Social Worker agreed holding a conversation with Resident #57 was extremely difficult related to his hearing problem, even with the provided headset (amplifier devise). The Social Worker stated she attempted to re-assess his mental status, and his Brief Interview for Mental Status (BIMS) score was 1, on a 0 to 15 score, indicating cognitive impairment. The Social Worker explained that after the first question, Resident #57 stated, why bother referring to asking the questions. The Social Worker stated Resident #57 was cognitively impaired, and that his only activity was walking in the hallway, walking to and from the dining room, and eating.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to provide showers, per request and schedule, for 1 of 1 sampled resident reviewed for choices, Resident #41. The findings included: During an interview on 03/28/2022 at 9:32 AM, with Resident #41, she stated had not had a shower in two weeks. A review of Resident #41's records revealed Resident #41 was admitted on [DATE] with a diagnosis which included Fibromyalgia, Dementia Without Behavioral Disturbances, Hypertension, History of Falling, Rheumatoid Arthritis, Hypothyroidism, Paroxysmal Atrial Fibrillation, Chronic Pain Syndrome, Neuritis, Osteoporosis, Muscle Weakness, Abnormalities of Gait & Mobility, Lack of Coordination, and Anemia. Review of the Significant change MDS (Minimum Data Set) for wound healing, dated 03/16/22, revealed the resident had a Brief Interview Mental Status (BIMS) of 12, which indicated her cognition is mildly impaired. Her functional status for bathing documented total dependence with one person assist. Review of Resident #41's care plan documented the resident has an ADL (Activity of Daily Living) self-care performance deficit related to Dementia, weakness, confusion, impaired vision and hearing. The documented interventions included the resident required total dependence by 1 staff with bathing and showering, as necessary, and to give a sponge bath when a full bath or shower cannot be tolerated. Resident #41's CNA (Certified Nursing Assistant) Task sheet for showers documented Resident #41's bathing preference days are Wednesdays and Saturdays on the 3:00 PM-11:00 PM shift. The CNAs were documenting bathing in two areas, the task sheet in the computer and a paper document in a binder for bathing. Further review of both documents revealed the following: January 2022: Received showers 0 of 5 on scheduled days and 3 on nonscheduled days. 01/17/22, 7 AM-3PM shift (Monday): Shower documented in computer. 01/24/22, 7AM-3PM shift (Monday): Shower documented in computer. 01/31/22, 7AM-3PM shift (Monday): Shower documented in computer and in a binder. February 2022: Received 1 of 8 showers on scheduled days and 1 bed bath on nonscheduled day 02/07/22, 7AM-3PM shift (Monday): Bed Bath 02/09/22 7AM-3PM shift (Wednesday): Shower March 2022: Received 2 of 9 showers on scheduled days and 1 shower on nonscheduled days. 03/05/22, 7AM-3PM shift (Saturday): shower 03/06/22, 7AM-3PM shift (Sunday): Shower 03/30/22, 2:03PM (Wednesday): Shower During an interview on 03/30/22 at 1:53 PM with Staff M, CNA (Certified Nursing Assistant), she stated, I have worked in this facility 28 years, 25 years as a CNA. Staff M was asked how the shower schedule works for the residents. She responded, They have shower days listed and can have a shower any days they want. The aides will log the showers in the computer. The tab under bathing has boxes for a shower, sponge bath, etc. We will then click the box, and it documents for that day what that resident had. If they dirty themselves after a bowel movement, I will sponge bathe them. I would document that under bathing. I gave Resident #41 a shower this morning, because she asked for one. During an interview with Resident #41 on 03/30/22 at 2:50 PM, the resident was asked if she had a shower today. She stated, Oh yes, it felt so good! My hair was itching so bad. She stated she had not been getting showers prior to this morning. She stated she has never refused a shower, but she believes maybe one time she asked to have it the next day, but she never got it. She stated she would prefer to have her showers on the 7AM-3PM shift because the aides in the afternoon don't seem to want to give her one. Review of a Progress Note from the Director of Nursing (DON), dated 03/30//22 at 2:58 PM, documented, I went to speak with resident. I asked her when she would prefer her shower. She stated that she would prefer to keep her showers on Wednesday and Saturday, but she would like to change the time from afternoon shifts to day shifts. I asked her if there were any other days that she would like to have a shower or bath and she replied, 'No, two days is plenty, I am inactive.' I let her know that if she should change her mind that we could change her bathing schedule at any time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to ensure accurate assessments and implementation of wanderguard for 2 of 4 sampled residents, Residents #41 and #61; and failed to document evidence showing that a thorough fall investigation was completed for 1 of 3 sampled residents with falls, Resident #45. The findings included: Review of the policy, titled, Elopement/Wandering Risk Assessment, revised 03/2021, documented, Purpose: to strive to identify residents who are at risk for wandering and potential elopement and provide a safe environment while maintaining their highest practicable level of physical, mental, and psychosocial well-being. Procedure: 1. Residents are assessed upon admission to determine their risk for wandering or elopement and a wander guard bracelet is applied for the initial 72-hour assessment period. The resident will be reassessed as follows: Upon admission; after 72 hours of admission; Within one month of admission; Quarterly; With any new behaviors related to exit seeking activities. 3. Wander guard bracelets are to be worn by residents exhibiting signs of any of the above behaviors or on being assessed at risk to wander or elope. 12. Bracelets are not to be removed except for replacement, upon transfer from the monitored unit, or when the resident's medical condition renders them no longer to be an elopement risk (i.e., bed/chair bound). 1. Record Review of Resident #41 documented an admission to the facility on [DATE] with diagnoses to include Fibromyalgia, Dementia Without Behavioral Disturbances, Hypertension, History of Falling, Rheumatoid Arthritis, Hypothyroidism, Paroxysmal Atrial Fibrillation, Chronic Pain Syndrome, Neuritis, Osteoporosis, Muscle Weakness, Abnormalities of Gait & Mobility, Lack of Coordination, and Anemia. Review of her Significant change MDS (Minimum Data Set) for wound healing, dated 03/16/22, revealed the resident had a BIMS (Brief Interview Mental Status) of 12, which means her cognition is mildly impaired. The MDS also documented that Resident #41 has a wander elopement alarm used daily. Review of the Physician Orders, dated 01/15/22, documented an order for a 'Wander Guard ID#42, expires 08/27/22', and to check for placement and function Q shift (every shift). A review of the resident's care plan documented a risk to wander with interventions in place that included a room that is located away from entrances / exits, a wander alert device during the first 72 hours after admission or readmission, and a wander alert device to be checked for function, placement and expiration regularly. She also had a care plan documenting having impaired cognitive function or impaired thought processes related to dementia with behaviors and on psychotropic medication. Review of the most recent Wander Assessment/Risk scale, dated 02/06/22, documented a score of 6, indicating the resident is at risk for wandering. Observations and an interview on 03/30/22 at 2:38 PM with Resident #41 revealed the resident sitting in her recliner in her room. She was asked if she wears a bracelet / wander guard that is on her. She stated, I am supposed to wear it but it's too big, it's hanging on my wheelchair. She was asked if she uses her wheelchair to get around the facility, and she advised the surveyor that she used to use it more, but she now uses her walker to get around. The wander guard was observed hanging from the handle of her wheelchair. On 03/31/2022 at 8:45 AM, Resident #41 was observed in the hallway using her walker going back to her room after breakfast. The surveyor did not see the wander guard on her but observed it again hanging on wheelchair. Photographic evidence obtained. During an interview on 03/31/22 at 9:20 AM with Staff N, MDS Coordinator, she was asked if Resident #41 is at risk for wandering / elopement. She reviewed the resident's care plan and said, She has a Care Plan for risk to wander and her MDS documents she has a wander guard. During an interview on 03/31/22 at 9:44 AM with DON (Director of Nursing), the DON stated, This resident doesn't usually go outside the household. The wander guard should be on her ankle or wrist. If she doesn't ambulate, it might be put on her wheelchair. The Wander risk assessments are completed quarterly. When residents are first admitted , all residents will be placed with a wander guard for three days. During an interview on 03/31/22 at 9:54 AM with Staff M, CNA (Certified Nursing Assistant), she acknowledged Resident #41 has a Wander guard that is on her wheelchair or walker. During an interview on 03/31/22 at 10:20 AM with Staff C, RN (Registered Nurse), she acknowledged that Resident #41 has a Wander guard, and it is sometimes on her wrist, ankle or sometimes on the device the resident uses. She uses both [walker and wheelchair]. We test the wander guard every shift when we go in. She stated that if the resident changes mobility devices, she does not move it over. We check to see if it is on the resident or mobile device. 2. Review of the record revealed Resident #45 was admitted to the facility on [DATE], with a re-admission on [DATE] after a two-day hospital stay. Review of the current Minimum Data Set (MDS) assessment dated [DATE], documented Resident #45 had a Brief Interview for Mental Status (BIMS) score of 04, on a 0 to 15 scale, indicating the resident was cognitively impaired. This MDS indicated Resident #45 had had a fall with a fracture. During an interview on 03/29/22 at 3:41 PM, when asked how she fell and hurt her leg, Resident #45 could not recall. Resident #45 uncovered her right leg and showed the surveyor her now healed incision, extending from her outer right hip to her knee. Review of a progress notes dated 01/17/22 at 2:41 PM by Staff I, a Licensed Practical Nurse (LPN), documented, Resident called on team room phone (a room used by staff for charting and meetings) from room number and this writer answered. Resident stated, I was trying to call my cousin and I am sitting on the ground in my room and my leg hurts. This writer immediately went to resident's room and she is sitting on the floor on bottom in front of window. Lights in room were turned off by resident she stated because they were too bright. Call light was not initiated. C/O [complained of] 8/10 RLE [right lower extremity] pain. Vitals all WNL [within normal limits]. Foley [urinary drainage device] intact. RLE [right lower extremity] visibly swollen with no noted redness. 2 person assist with transfer to w/c [wheelchair] with difficulty. Resident grimacing and holding right thigh. This note further documented the physician, Director of Nursing (DON), and family were notified, and Resident #45 was sent to the emergency room (ER). A subsequent progress note, dated 01/17/22 at 11:27 PM, revealed Resident #45 was admitted to the hospital with a right femur (leg) spiral fracture and needed surgery. Review of the current care plan, initiated on 12/25/19, documented that Resident #45 was at risk for falls. Interventions in place prior to the fall included having personal items including her phone within reach. During an interview on 03/31/22 at 8:42 AM, when asked about Resident #45's fall with subsequent fractured hip, Staff F, the resident's usual Certified Nursing Assistant (CNA), stated she was not at the facility that day, but she heard her phone was out of reach and the resident got up to get her phone and fell and broke her hip. During an interview on 03/31/22 at 11:09 AM, Staff I-LPN who took the phone call from Resident #45 on the day of the fall, was asked what happened. Staff I recalled receiving the phone call from Resident #45. The LPN stated she was shocked and ran into her room. Staff I stated she found Resident #45 on the floor and her phone was next to her. Staff I stated she tends to get up and furniture-walk in her room, and refuses to wear a leg bag for the Foley. When asked if she asked Resident #45 what happened, Staff I stated Resident #45 said she got up out of her wheelchair and was walking. Staff I could not recall what the resident said she was doing. During an interview on 03/31/22 at 12:37 PM, Staff H, the CNA who was assigned to the resident on the day of the fall, stated she doesn't recall exactly what happened when Resident #45 sustained the fall with subsequent fracture, but remembers Resident #45 was on the floor. Staff H stated, We didn't move her at first, because she was hurting real bad . sharp pain and fidgeting. When asked if she recalls anyone asking the resident what she was doing, Staff H stated, We asked her . I think she said she was trying to get around to the phone to the other side of the bed. We found her at the foot of the bed. I never knew (name of Resident #45) to walk. She always wheeled herself with her feet and would take herself to the bathroom. That day was the only time I knew of her to try to walk. When asked if management spoke with her after the event as part of the investigation, or if she wrote any type of statement. During an interview on 03/31/22 at 12:51 PM, Staff B, a Registered Nurse (RN), explained that Staff I-LPN, asked her to assess Resident #45 after the fall, as another set of eyes. When asked if Resident #45 said what she was trying to do, Staff B, the RN stated Resident #45 said she was trying to do something . something about a phone but did not recall exactly. When asked if management spoke with her after the incident about what happened, Staff B, the RN stated, No. During a subsequent interview on 03/31/22 at 1:00 PM, when asked what was Resident #45's usual mobility routine prior to the fall, Staff F-CNA, stated Resident #45 would never get up and try and walk. Staff F explained she would leave the Foley bag hanging on the side of the bed next to the bathroom because the resident would self-transfer from the bed to her wheelchair and go to the bathroom by herself. Staff F stated Resident #45 did get occasional calls from her family. When asked if she asked the resident upon her return to the facility what she was trying to do, Staff F stated Resident #45 could not remember but later said the resident said something about the phone. The DON was asked to locate and provide documented evidence of a review of the 01/17/22 fall sustained by Resident #45. The DON provided a summary of the fall. During an interview on 03/31/22 at approximately 12:00 PM, the DON was asked if there was any other documented evidence that she spoke with staff about the fall to determine the cause of the fall. The DON stated she does not write down every interview she completes. When asked if spoke with staff to try to determine what the resident was doing at the time of the fall, the DON again stated she did, but did not have any documented evidence of this. 3. During observations throughout the survey, Resident #61 was noted to independently self-propel in her wheelchair throughout the [NAME] Villa neighborhood. On 03/28/22 at 10:52 AM, Resident #61 was observed at the end of the hallway, trying to get into the room of Resident #39, who was not happy and closed the door on Resident #61. Review of the record revealed Resident #61 was admitted to the facility on [DATE]. Review of the Wandering Risk Scale assessments revealed the last completed assessment was on 01/13/21. The electronic medical records (EMR) had two additional incomplete Wandering Risk Scale assessments dated 11/18/21 and 02/06/22. The record lacked any further wandering risk assessments. Review of the Behavior Symptoms documented in the tasks portion of the EMR revealed Resident #61 exhibited wandering behaviors on 5 of the 30 days, all within the past 10 days, and mainly documented by Staff F, the resident's usual CNA. During an interview on 03/30/22 at 11:25 AM, Staff I, a Licensed Practical Nurse (LPN) stated Resident #61 has not been exit seeking nor has she eloped, but she will wander into other resident rooms. When asked about the Wandering Risk Assessments, Staff I explained they are done quarterly and with any event. When asked how she knows when it is due to be done, the LPN stated it will show up red on the EMR. During a side-by-side review of the record at this time, Staff I agreed the last two wandering risk assessments were incomplete and the last completed assessment was dated 01/13/21. When told Resident #61 was observed on Monday 03/28/22 trying to get into the room of Resident #39, the LPN stated, Oh boy, I hope (name of Resident #39) wasn't there as she would not be happy. Staff I was told Resident #39 was at the door, was not happy, and closed it on Resident #61. During an interview on 03/30/22 at 11:56 AM, Staff F-CNA, stated she documented wandering for Resident #61 in the EMR because the resident goes in and out of other resident rooms and has been known to take items from other residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and policy review, the facility failed to ensure proper care and services for 1 of 1 sampled resident, Resident #25, who was being fed by enteral means, as evidenced by nursing staff provided more fluids than were assessed by the Registered Dietician and ordered by the physician, which had the potential for fluid overload; failed to follow orders for recording intake and output; and failed to ensure an ordered laboratory draw was completed for Resident #25, who was primarily fed via enteral means (via tube) but could also take fluids orally. The findings included: Review of the policy, titled, Tube Feedings & Medication Administration, revised 06/2018, documented, Procedure: 1. Check the physician's order for the tube feed and ensure that it includes: . d. Amount of water to flush per shift. Bolus Feeding: . 5. Flush the tube with 30 - 60 ml of water, or amount otherwise ordered by physician, after nourishment is introduced. Documentation: . 3. Record intake and output in the intake and output section of the electronic record or if the electronic record is not available in the Intake and Output Record. Review of the record revealed Resident #25 was admitted to the facility on [DATE], with a re-admission date of 04/01/21. Review of the current Minimum Data Set (MDS) assessment documented Resident #25 received 51% or more of her daily nutrition via a tube feeding. The MDS documented Resident #25 had a BIMS score of 12, indicating the resident had some cognitive impairment. Review of the current orders related to Resident #25's nutritional and fluid needs revealed the following: 04/06/21, Regular diet, Regular texture, Thin/Regular consistency Dietary liberties for special occasions. Serve only per resident's request. 04/01/21, Ensure Plus four times a day for enteral feeding. Administer 1 can via bolus and record % consumed. 04/01/21, Flush G-tube (specific type of feeding tube) with 50 ml of warm water before meals and with 50 ml of warm water after meals. Also, flush G-tube with 50 ml of warm water at bedtime for maintenance. (Note this would total 450 ml of water via the tube in a 24-hour period.) 04/01/21, Document total intake via G-tube on log sheet in Treatment Administration Record (TAR) binder. Includes flushes & Ensure. 04/30/21, Give 120 ml fluid of choice twice daily by mouth for hydration and record % consumed. 02/07/22, Basic Metabolic Panel (BMP) (Routine) laboratory draw. Review of the most current progress note by the RD, dated 03/08/22, documented Resident #25 had orders for enteral nutrition: Ensure Plus . which provides 948 ml fluid daily. Flush with 50 ml water before meals, after meals, in the evening for maintenance (400 ml). Provides a total of 1298 ml/water daily. She has orders for 120 cc. H2O BID (twice daily), consumes 100% most days. (Note the calculation of 400 ml for the water flush should be 450 ml, with the provision of fluids via tube at 1398 ml of water daily.) The documented resident fluid need was calculated at 1360 ml/day, as per this progress note. During an observation on 03/29/22 at 10:39 AM, Staff J, a Registered Nurse (RN) provided the ordered Ensure Plus via bolus (administering the nutrition via gravity) to Resident #25. Before the RN gave the Ensure Plus, she flushed the feeding tube with 120 ml (milliliters) of water. After the Ensure Plus, the RN provided another 120 ml of water. The amount of water was verbally confirmed by Staff J. During an observation on 03/29/22 at 12:01 PM, Staff J-RN provided medications crushed in applesauce for Resident #25. During this medication administration, Staff J explained Resident #25 received her nutrition via the tube, but she can and does take her pills by mouth. Resident #25 was offered and accepted a drink of water after the administration of the pills. A large water jug was noted at her bedside. On 03/29/22 at 2:12 PM, Staff J-RN was observed in the room of Resident #25. She was just capping off the resident's tube and stated she had just finished. Two empty water cups were noted at the bedside, just as had been used with the earlier administration. Staff J confirmed she had just provided the Ensure Plus bolus, with 120 ml of water both before and after administration. During an interview on 03/29/22 at 2:18 PM, Staff J-RN confirmed she was giving 120 ml water before and after each meal instead of the ordered 50 ml. The RN confirmed the order for the 120 ml of fluid twice daily is to be offered and given by mouth. Staff J explained she was giving the extra fluid with the Ensure Plus bolus feed because she had the 120 ml twice daily order for fluids by mouth, and the resident refuses it. When asked why this wasn't communicated to the RD (Registered Dietician) or physician to have the order changed, the RN did not have any answer. Staff J agreed that by giving the 120 ml of water before and after each feeding, Resident #25 would be receiving 960 ml of water each day, instead of the ordered 450 ml of fluid. When asked why she gives more fluids than ordered, Staff J stated, just for the hydration . she gets the dry lips. When asked about an intake and output record in the TAR (Treatment Administration Record) binder as ordered, Staff J found the record, which contained some documentation daily, but not consistently on each shift. Staff J stated she does not document on that record. During an interview on 03/29/22 at 2:34 PM, the RD explained Resident #25 refuses to eat anything by mouth as it grosses her out and even the thought of food makes her upset. The RD stated prior to her admission to the facility, her husband was feeding her via a tube at home. When asked about her fluid and hydration status, the RD stated Resident #25 is getting her fluid needs met through the tube with the formula and water flushes. The RD stated Resident #25 is also encouraged to drink water with medications, which she believes the nurses document on the MAR. The RD stated Resident #25 will accept water to drink by mouth. When asked about the purpose of the intake and output record in the TAR order, the RD was unsure, stating she reviews the intake on the Medication Administration Record (MAR). The RD was told of the observation of the provision of 120 ml of water before and after each meal by Staff J, the RN, and the RD stated she would be concerned about the extra fluid administration and the possibility of a fluid overload. The RD suggested we look at the current laboratory values to determine the resident's fluid status. The RD was shown the order for the BMP on 02/07/22 and was asked to locate and provide the results. The RD was unable to locate the results. During an interview on 03/29/22 at 3:02 PM, Staff K, the day shift CNA (Certified Nursing Assistant), stated she does not encourage Resident #25 to drink fluids by mouth, but explained Resident #25 will sometimes ask for water to drink and the CNA will provide it. At this same time, Staff L, the evening CNA, was noted passing out fresh water to all of the residents. Staff L stated she provides water for Resident #25 and encourages her to drink it. Staff L stated Resident #25 is supposed to drink 120 ml during the shift. Staff L stated she records the resident's intake in the computer. Review of the CNA documentation in the computer for the past 30 days (02/28/22 through 03/29/22) revealed the following: Resident #25 drank fluids 6 times during the breakfast meal, ranging from 60 ml to 360 ml time. Resident #25 drank fluids 5 times during the midday meal, ranging from 40 ml to 350 ml at a time. Resident #25 drank fluids 12 times during the evening meal, ranging from 60 ml to 120 ml at a time. The medical record for Resident #25 had documented fluid intake in three different locations to include on the MAR (Medication Administration Record), the intake and output paper record in the TAR binder, and the CNAs documentation. During a subsequent interview on 03/29/22 at 3:19 PM, Staff J-RN, explained any order for laboratory draws get put into the computer, the night shift prints out the requisition for the labs to be drawn, and then a laboratory staff will come the next morning to draw the sample. When asked to locate and provide the ordered BMP (Basic Metabolic Panel) labs for Resident #25 on 02/07/22, Staff J was unable to find it. The RN also looked for a subsequent progress note as to why the order was not completed and could not find any documentation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure proper labeling and storage of medications, as evidenced by failure to secure medication cabinets for 3 of 19 sampled residents, Residents #66, #16, and #57; failure to store medications properly for 1 of 3 inspected medication carts (loose medications); and failure to accurately label medications for 1 of 6 sampled residents, Resident #44. The findings included: 1a. Clinical record review revealed Resident #66 was initially admitted to the facility on [DATE] with a re-admission on [DATE]. The annual (modification) minimum data set (MDS) assessment reference date 01/27/22, revealed, Resident #66 had a brief interview for mental status score of 03 indicating Resident #66 was cognitively impaired. This MDS documented Resident #66 exhibited behaviors that included: pacing, and rummaging. The care plan, with revision date 02/03/22, recorded Resident #66 had impaired cognitive function or impaired thought processes related to dementia. A progress note dated 03/24/22 at 11:28 PM, documented Resident #66 had increased confusion, agitation, grunting, and pacing. On 03/28/22 at 8:41 AM, an observation was made in Resident #66's room, in the Bueno Vista unit, of the medication cabinet located towards the left side of the room. The medication cabinet was observed to be left unlocked and unattended with 3 bottles of medications (meds) sitting inside of it that included Losartan, Metoprolol, and Multaq. There was another resident's name written on these bottles of the medications, but this resident no longer lives in the facility. Resident #66, who was currently residing in this room, was observed with confusion, pacing, and wandering between her room and the Bueno Vista unit. She was self-ambulatory using a rolling walker. On 03/28/22 at 1:42 PM, the medication cabinet located in Resident #66's room remained unlocked with the 3 bottles of meds inside the cabinet. During that time the attending nurse, Staff B, a registered nurse (RN), was made aware of the finding. Staff B and the surveyor went into the resident's room. Staff B noted the medication cabinet was unlocked. Staff B stated, Those medications shouldn't be in the cabinet, as [the resident's name written on the bottle of the medications] had passed away. During this time Resident #66 was observed out of bed, wandering around in the room using a rolling walker, and was noted with confusion. 1b. Clinical record review revealed Resident #16 was admitted to the facility on [DATE]. The annual MDS assessment reference date 03/26/22, documented a Brief Interview for Mental Status (BIMS) score of 11, indicating Resident #16 was moderately cognitively impaired. Additionally, there was a progress note, dated 03/30/22 at 1:53 PM, that documented, 'Resident #16 was alert with forgetfulness. He uses a wheelchair for mobility. He was able to self-propel upon household.' On 03/29/22 at 9:41 AM, an observation was conducted in the resident's room, located at the Key [NAME] unit. It was revealed that the medication cabinet towards the right side of the room was observed to be left unlocked and unattended. There was a Tresiba insulin pen in the cabinet. During this time, the surveyor had informed Staff C-RN that the medication cabinet was left unlocked. Staff C stated, The cabinet was supposed to be locked. Resident #16, who resided in this room, was observed self-propelling using wheelchair. Photographic evidence obtained. On 03/29/22 at 10:00 AM, the Assistant Director of Nursing (ADON) was made aware of the concerns regarding medication cabinets left unlocked in the rooms of Resident #66 and Resident #16. Photographic evidence was shown to the ADON. On 03/29/22 at 10:05 AM, the Director of Nursing (DON) was also made aware of the findings. Photographic evidence was shown to the DON. 1c. During an observation on 03/28/22 at 02:08 PM in Resident #57's room, the bottom right cabinet door of the bedside medication cabinet for Resident #57, was observed to be unlocked. This cabinet contained at least two tubes of Hydrocortisone cream, extra batteries, four containers of inhalers and at least one tube of Ketoconazole cream. Resident #57 was observed independently ambulating with his rolling walker to and from his room numerous times, passing by the medication cabinet. Resident #57 was cognitively impaired with a Brief Interview for Mental Status score of 01, on a 0 to 15 scale, as per the Social Worker assessment of 03/29/22, indicating severe cognitive impairment. The roommate, Resident #91, was also observed self-propelling in his wheelchair, in and out of his room which passes by the medication cabinets, throughout the survey week. Resident #91 had a BIMS score of 06, indicating he was severely cognitively impaired as well. 2. On 03/31/22 at 11:58 AM, the Bueno Vista medication cart was audited and observed. There were two unidentified pills noted in a plastic medicine cup, unlabeled, in the top drawer of the medication cart. The attending nurse, Staff E, a license practical nurse (LPN), stated she did not put the medication there; she thought it was from the night shift. Staff E stated, The medications should not have been stored in a medicine cup, unlabeled. 3. During an observation of the [NAME] Villa medication cart on 03/31/22 at 9:42 AM, a random narcotic count was conducted with Staff I-LPN. Resident #44 had a Individual Patient Narcotic Record for Tramadol that had 53 tablet left. The label for this medication documented, 03/23/22 Tramadol-Acetaminophen Tablet 37.5-325 mg (milligrams), take one tablet by mouth at bedtime and one tablet daily as needed for pain. The corresponding bubble pack label, with the 53 tablets, documented the same information. Review of the current orders included the following two orders: 01/26/21, Tramadol-Acetaminophen Tablet 37.5-325 MG Give 1 tablet by mouth at bedtime for moderate pain and give 1 tablet by mouth one time only for routine pain for 1 day. 01/26/22, Tramadol-Acetaminophen Tablet 37.5-325 MG Give 1 tablet by mouth every 6 hours as needed for moderate pain not to exceed 3,000 grams in 24 hrs. During an interview on 03/31/22 at 10:34 AM, Staff I-LPN agreed with the confusion and lack of consistent labeling. Staff I phoned the pharmacy to determine the order on their records. Review of their order documented a third set of directions as follows: 10/07/21, Tramadol-Acetaminophen 37.5 - 325 mg take one tablet by mouth at bedtime and one tablet daily as needed for pain. During a subsequent interview on 03/31/22 at 11:07 AM, Staff I explained that the physician for Resident #44 would usually have his office staff call in a new prescription for narcotics directly into the pharmacy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and CDC (Center for Disease Control) recommended guidance, the facility failed to implement their new resident admission policy related to Covid-19 and CDC guidance for 1 of 1 sampled resident, Resident #292; and failed to consistently screen staff upon arrival at the [NAME] and when entering the nursing home. The findings included: Review of the undated Infection Control Policy, for new resident admissions, provided by the Infection Control Preventionist (ICP) on 03/30/22, revealed: all not fully vaccinated residents returning or newly admitted . from a hospital stay / or outing 24 hours or greater will be rapid tested immediately upon arrival and will be admitted /readmitted to a private room if available on droplet-based isolation or to a semi-private shared with a resident on the same droplet-based isolation precautions for 14 days and will be rapid tested every other day for 14 days. Review of the CDC guidance for Newly admitted or readmitted Residents at the CDC website, https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, updated February 2, 2022, documented: In general, all residents who are not up to date with all recommended COVID-19 vaccine doses and are new admissions and readmissions should be placed in quarantine, even if they have a negative test upon admission, and should be tested as described in the testing section above; COVID-19 vaccination should also be offered. Facilities located in counties with low community transmission might elect to use a risk-based approach for determining which of these residents require quarantine upon admission. Decisions should be based on whether the resident had close contact with someone with SARS-CoV-2 infection while outside the facility and if there was consistent adherence to IPC practices in healthcare settings, during transportation, or in the community prior to admission. Residents . who are not up to date with all recommended COVID-19 vaccine doses: These residents should generally be restricted to their rooms, even if testing is negative, and cared for by HCP using an N95 or higher-level respirator, eye protection (goggles or a face shield that covers the front and sides of the face), gloves and gown. They should not participate in group activities. Residents who are not up to date with all recommended COVID-19 vaccine doses and who have had close contact with someone with SARS-CoV-2 infection should be placed in quarantine after their exposure, even if viral testing is negative. HCP caring for them should use full PPE (gowns, gloves, eye protection, and N95 or higher-level respirator). Residents can be removed from Transmission-Based Precautions after day 10 following the exposure (day 0) if they do not develop symptoms. Although the residual risk of infection is low, healthcare providers could consider testing for SARS-CoV-2 within 48 hours before the time of planned discontinuation of Transmission-Based Precautions. Residents can be removed from Transmission-Based Precautions after day 7 following the exposure (day 0) if a viral test is negative for SARS-CoV-2 and they do not develop symptoms. The specimen should be collected and tested within 48 hours before the time of planned discontinuation of Transmission-Based Precautions. 1. On 03/30/22 at 9:45AM, an isolation cart was observed outside of the room of Resident #292. There was no signage on the door, and the social worker was noted in the room within 6 feet of Resident #292, who was standing up with her walker. The door to Resident #292's room was open. When the social worker left the room, she was asked what the isolation cart was for. The social worker stated, I don't know. You would have to ask the nurse. On 03/30/22 at 9:55 AM, an interview was conducted with Staff I, the attending nurse, a Licensed Practical Nurse (LPN). When asked what the isolation cart outside of Resident #292's room was for, Staff I stated, the DON told me to put it there because Resident #292 was a new admission, so she needed to be on isolation. When asked about signage for the door, Staff I stated, I am looking for a droplet precautions sign now. Staff I confirmed Resident #292 was admitted over the weekend on 03/26/22. When asked if that was something that should have been done upon admission, Staff I was unsure. When asked if Resident #292 was vaccinated, Staff I stated, I think so. On 03/30/22 at approximately 10:20 AM, Staff I informed the surveyor that she was just informed from Independent Living (IL) that Resident #292 was not vaccinated. On 03/30/22 at 11:42 AM, an interview was held with the Infection Control Preventionist (ICP). When asked whether Resident #292 was vaccinated, the ICP revealed that the facility was unaware of Resident #292's vaccination status until Monday 03/28/22, when the facility obtained Resident #292's records from IL. The ICP further added that Resident #292 was admitted during the weekend on 03/26/22, the IP was not there but the admitting nurse should have asked Resident #292 about her vaccination status as she was alert and oriented, so she (the nurse) could determine the infection control process. The ICP voiced that when she came in Monday morning (03/28/22), she sent an email to Resident #292's nurse at the IL to obtain information regarding the resident's vaccination status. The ICP voiced the nursing home also has access to the IL computer system for immunization record. On 03/30/22 at 11:52 AM, an interview was held with Staff A, a LPN, and when asked about the process and protocols for new admissions relating to infection control status post hospitalization, Staff A revealed the protocol for new admissions was to ask residents about their vaccination status if able; if they are unvaccinated, they are to be place on isolation precaution right away; if residents were unable to convey their vaccination status, the staff were to contact the resident family or the IL nurse. On 03/30/22 at 4:23 PM, Resident #292 was observed walking from her room to the door of the outdoor patio without a face mask, to the double doors of the neighborhood, and then over to the surveyor who was in the dining room. Resident #292 voluntarily stated, They are re-evaluating my Covid status because I can't get the vaccine and they just discovered that today. When asked if she was on isolation, Resident #292 stated, they haven't said anything to me about that. When asked about a face mask, Resident #292 stated, I have one, it's in my room, they haven't said anything to me. 2. During the infection control review process, the Infection Control Preventionist / Assistant Director of Nursing (ICP/ADON) revealed there was a staff who tested positive for Covid-19 on 02/12/22, Staff O, a Certified Nursing Assistant (CNA). A request of one week of screening reports for Staff O was made for days that she worked, prior to the positive result. The ADON provided the screening records. Review of the screening records revealed they were incomplete, with no temperature and no answers to the surveillance questions. The ICP stated that visitors and staff were to be screened at the [NAME] and at the nursing home and are to ask the surveillance questions and take temperatures. The screening records were as follows: The screening record dated 02/08/22 with check in time of 6:47 AM for Staff O, recorded no temperature and no answers to the surveillance questions. The surveillance questions were as follows: 'signs and symptoms, have you been exposed to anyone with a positive COVID-19 diagnosis? Have you been tested for COVID-19? Have you returned from any of the following (travel) withing 14 days?' There were no answers in the record for any of these questions. The record documented Staff O was allowed to work. The screening record dated 02/09/22 with check in time 6:44 AM for Staff O, recorded no temperature and no answer to the same surveillance questions. The record documented Staff O was allowed to work. The screening record dated 02/10/22 with check in time 6:51 AM for Staff O, recorded no temperature and no answer to the same surveillance questions. The record documented Staff O was allowed to work. The screening record dated 02/11/22 with check in time 6:47 AM for Staff O, recorded no temperature and no answer to the same surveillance questions. The record documented Staff O was allowed to work. The screening record dated 02/12/22 with check in time 6:33 AM for Staff O, recorded no temperature and no answer to the same surveillance questions. The record documented Staff O was allowed to work. The ADON who is also the ICP reviewed the screening records and agreed with the findings. Staff O was unavailable for interview by the surveyor. The ICP stated that Staff O had no signs and symptoms and tested positive after residents she cared for had tested positive.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review and interview, the facility failed to ensure screening for the pneumococcal immunization for 3 of 5 sampled residents, Residents #8, #9, and #14. The findings included: The policy, titled, Influenza and Pneumococcal Education and Consent for Residents, documented to strive to inform and educate the residents in WillowBrooke Court (WBC) of the legislative requirement for: offering the influenza and the pneumococcal immunization. Documenting offering, education, administration or refusal of the influenza and pneumococcal immunization. The procedure included: upon admission, the licensed nurse will notify the resident, family and/or responsible party of the legislative requirements that each resident be advised to receive immunization against influenza and pneumonia. 1. Clinical record revealed Resident #8 was admitted to the facility on [DATE]. It was revealed Resident #8 had advance directive of health care surrogate (HCS). During the infection control review process, it was revealed Resident# 8 had not been screened for the pneumococcal immunization / vaccination. There was no evidence of a pneumococcal vaccination screen in the records. During a side-by-side review of Resident #8's record with the infection control preventionist (ICP), she agreed with the finding. 2. Record review revealed Resident #9 was admitted to the facility on [DATE], she had advance directive of HCS. Clinical record review was conducted for Resident # 9, there was no evidence of a screen for the pneumococcal immunization in the record. During a side-by-side review of Resident #9's record with the ICP, she agreed with the finding. 3. Clinical record review for Resident#14 revealed that Resident #14 was screened for the pnuemonoccal immunization in 02/26/20 but refused to receive the pneumococcal vaccine. There was no evidence of a pneumococcal immunization re-screen in 2021. The ICP said Resident #14 should have been re-screened in 2021.