**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to treat a resident with a left-hand contracture for 1 of 1 sampled resident reviewed for a range of motion (ROM), Resident #108. The findings included: Review of the facility's policy, titled, Splints and Braces, revised on January 2, 2024, revealed the following: Donn patient splint / brace according to positioning / splinting instructions. Allow the patient to wear a splint / brace per the therapist's recommended wearing schedule and tolerated. Review of the facility's policy, titled, Contracture Management, revised on January 2, 2024, revealed that treatment plans will be geared towards minimizing or possibly alleviating residents noted contractures. Record review revealed Resident #108 was admitted to the facility on [DATE] with diagnoses to include Major Depressive Disorder, repeated Falls, and Dementia. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 02/19/24, revealed a Brief Interview of Mental Status (BIMS) score of 09, indicating mild cognitive impairment. In an observation conducted on 03/18/24 at 10:00 AM, Resident #108 was noted in a chair. Continued observation revealed a splint was located on the side table behind Resident #108's chair. Resident #108's left hand was noted to be contracted. In an observation conducted on 03/18/24 at 1:34 PM, Resident #108 was noted in a chair. Continued observation revealed a splint was located on the side table behind Resident #108's chair. Resident #108's left hand was noted to be contracted. In an observation conducted on 03/18/24 at 2:30 PM, Resident #108 was noted in a chair. Continued observation revealed a splint was located on the side table behind Resident #108's chair. Resident #108's left hand was noted to be contracted. In an observation conducted on 03/19/24 at 9:03 AM, Resident #108 was noted in a chair. Continued observation revealed a splint was located on the side table behind Resident #108's chair. Resident #108's left hand was noted to be contracted. In an observation conducted on 03/19/24 at 12:10 PM, Resident #108 was noted in a chair. Continued observation revealed a splint that was located on the side table behind Resident #108's chair. Resident #108's left hand was noted to be contracted. Review of the Physician's orders showed an order dated 02/16/24 for a left-hand splint after AM [morning] care and off HS [hour of sleep]. Review of the Occupational Therapy Evaluation dated 01/25/24 to 02/23/24 revealed that Resident #108 will tolerate a left-hand orthotic for up to hours to improve skin and joint integrity. An interview was conducted on 03/20/24 at 2:07 PM with Staff E, Occupation Therapist Assistant who stated Resident #108 has a resting hand splint that needs to be placed on the Resident's left hand at AM after morning care and off at PM. She further stated Resident #108 has a left-hand contracture, and the splints will prevent skin breakdown and hygiene. Staff E accompanied the surveyor to Resident #108's room. The surveyor pointed at the resting hand splint at the side table and asked if it needed to be placed on Resident #108, and she said yes. Staff E reported that it is the responsibility of the Certified Nursing Assistants (CNAs) who are taking care of Resident #108 to place the splint on the left hand after morning care. An interview was conducted on 03/20/24 at 2:14 PM, Staff D, Certified Nursing Assistant (CNA), who stated that hand splints are placed on residents by the restorative team and sometimes by the Certified Nursing Assistants. She usually places it on residents after morning care. Staff D was asked if Resident #108 had a hand splint, and she said, I do not know. She was then asked to accompany the surveyor to Resident #108's room. When asked why the left-hand splint was not placed on Resident #108, she said that the restorative staff put it on this morning and must have removed it. An interview was conducted on 03/20/24 at 2:24 PM with Resident #108, who stated the staff has yet to place his left-hand splint on him all week. An interview was conducted on 03/20/24 at 2:50 PM with Staff F, Restorative Certified Nursing Assistant, who stated that she is assigned to some residents on the floor who have orders for hand splints and the designated Certified Nursing Assistant (CNA) assigned for the day. The splints are usually placed after morning care and taken off before she leaves, which is around 3:30 PM to 4:00 PM. She further said that since Resident #108 is on a maintenance program, it is the responsibility of his assigned CNA to place the hand splints on him. When asked if it was placed on Resident #108 this morning, she said that his CNA (Staff D) was assigned to him this morning.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to provide nutritional interventions in a timely manner to prevent further weight loss for 1 of 5 sampled residents reviewed for nutrition, Resident #101. The findings included: Review of the facility policy, titled, Nutrition Assessment, revised in October 2017, revealed the following: Any weight change of 5% or more since the last weight assessment will be verified, and nursing will contact the Dietitian for further evaluation. The Dietitian will review the unit Weight Record by the 15th of the month to follow individual weight trends. Negative trends will be evaluated by the treatment team to determine whether or not the criteria for significant weight change has been met. 5. The threshold for significant unplanned and undesired weight loss will be based on the following criteria where the percentage of body weight loss == (usual weight actual weight) (usual weight) - 100]: a. month 5% weight loss is significant; greater than 5% is severe. b. - 3 months -7.5% weight loss is significant; greater than 7.5% is severe. C. months - 10% weight loss is significant; greater than 10% is severe. Record review documented Resident #101 was admitted to the facility on [DATE] with diagnoses to include Hemiplegia, Dysphagia, and Muscle Weakness. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 02/25/24, documented Resident #101 has a Brief Interview of Mental Status (BIMS) score of 14, indicating cognition was intact. Section B on the MDS revealed Resident #101's speech was unclear. Review of the Physician's orders, which started on 02/26/24 and discontinued on 03/05/24, revealed an order for a med pass (nutritional supplement) of 120 milliliters (ml) three times a day. It further revealed another order for a med pass written on 03/05/24. A phone interview was conducted on 03/18/24 at 4:00 PM, with Resident #101's Fiancé who stated she spoke to the facility's Dietitian a few weeks ago regarding her concerns with Resident #101's continued weight loss. The Dietitian told her she would review updating Resident #101's food preferences but had not heard back from her. In an observation conducted on 03/19/24 at 9:05 AM, Resident #101 was noted in his bed. Staff P, Certified Nursing Assistant (CNA), was noted setting up the breakfast tray for Resident #101 at the bedside. She then proceeded to feed Resident #101 his breakfast meal. The breakfast tray was observed with a regular puree diet and 4 ounces of a mighty shake (nutritional supplement). Continued observation revealed Resident #101 ate 50% of his breakfast tray but did not drink any of the mighty shakes on his tray. In an observation conducted on 03/20/24 at 8:47 AM, Resident #101 was eating his breakfast tray in his room. Staff D, CNA, was sitting near the resident, assisting him with his breakfast tray. The breakfast tray was noted to have a mighty shake (nutritional supplement). Staff D stated that when the resident is done eating, she will document the total amount consumed for the entire meal but will not document the percentage consumed from the nutritional supplement. Review of the Weight Log revealed Resident #101 had dropped from 11/03/24 to 02/07/24 from 148.2 pounds to 136.4 pounds, which was 8.3% severe weight loss in 3 months. Review of a quarterly dietary profile note dated 02/26/24 noted it was written 19 days after Resident #101 had the significant weight loss. In this note, the facility's Dietitian recommended adding an additional nutritional supplement with med pass 120 ml three times a day. The Dietitian noted that Resident #101's Usual Body Weight was 150 pounds, and that Resident #101 had a weight loss of 8% in 2 months. The care plan dated 02/24/24 revealed Resident #101 was at risk for alteration in nutrition. It included Resident #101 will remain free from significant weight loss and to notify the Physician of significant weight changes if noted. Review of the Medication Administration Record (MAR) for March 2024 showed that the med pass nutritional supplement was not documented as given to Resident #101 after 03/05/24. An interview was conducted on 03/20/24 at 3:25 PM with the Dietitian who stated the mighty shakes are placed on the meal trays from the kitchen and that the nurses provide the med pass. The nursing aides will include the percent intake of the resident's meals in their documentation, but it is overall and not specific for the nutritional supplements. When asked how she knows if a resident is drinking any of the nutritional supplements that are placed on the meal tray, she stated that the nursing staff will let her know verbally. The Dietitian reported that she would run the Weight and Vital reports daily to review any severe weight loss triggered for all residents. When asked as to why she only addressed Resident #101 with a severe weight loss of 8.3% 19 days later, she did not know. She stated the electronic system would usually pop up with a significant weight loss when identified but was unsure why it did not for Resident #101. The Dietitian said she placed the order for a med pass on 02/26/24 but was wondering why it was not given after 03/05/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide the correct food consistency for 3 of 3 sampled residents who were on a mechanical soft / chopped, who were observed during dining, Resident #34, Resident #87, and Resident #230. This has the potential to affect 30 residents on a mechanical soft/chopped diet. The census at the time of the survey was 138 residents. The findings included: Review of the facility's diet manual dated 2019, provided by the facility's Dietitian, showed the following foods that were allowed on the mechanical soft diet: canned fruits, cooked or steamed fruit desserts, ripe banana, diced watermelon, diced ripe melon, diced ripe strawberries, and smooth fruit sauces. It further showed that all other fresh fruits were not allowed. Review of the International Dysphagia Diet Standardization Initiative dated 2019, provided by Staff C, Speech Therapist, revealed the following: Level 5 minces and moist diet, to provide fruits served minced or chopped or mashed for level 6 soft bite-sized diet, to provide fruits that are soft enough to be cut into small pieces and not use the white part of an orange. 1a. Record review documented Resident #34 was admitted to the facility on [DATE] with diagnoses to include Dysphagia and Dementia. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview of Mental Status (BIMS) score of 05, indicating severe cognitive impairment. In an observation conducted on 03/18/24 at 1:04 PM, Resident #34 was noted eating her lunch in the Emerald dining room. Closer observation revealed a meal ticket with the following: Regular mechanically altered ground pork. Mechanically altered ground orange twist. Mechanically altered ground black-eyed peas. Closer observation of the meal plate revealed a fresh ½ slice of an orange a quarter of an inch thick. Photographic Evidence Obtained. 1b. Record review documented Resident #87 was admitted to the facility on [DATE] with diagnoses to include Dysphagia and Dementia. The annual MDS assessment dated [DATE] showed a BIMS score of 06, indicating severe cognitive impairment. In an observation conducted on 03/18/24 at 1:04 PM, Resident #87 was noted eating his lunch in the Emerald dining room. Closer observation revealed a meal ticket with the following: regular mechanically altered ground pork, mechanically altered ground orange twist, and mechanically altered ground black-eyed peas. Closer observation of the meal plate revealed a fresh ½ slice of an orange that was a quarter of an inch thick. The mechanically altered ground pork was observed in chunks and not ground. An interview was conducted on 03/19/24 at 3:30 PM with Staff C, Speech Therapist, who stated the facility only has one type of mechanical soft diet. Fresh fruits are not part of a mechanical soft diet but are often used as a garnish. When asked if a mechanical soft / ground diet should have fresh fruit on the plate, she said no. Staff C stated she did not know why the mechanical soft diets on the meal tickets had altered ground noted. An interview was conducted on 03/19/24 at 4:17 AM with the Culinary Service Manager, who stated they have a mechanical soft diet in the facility and that the food provided on this diet is altered ground meat. She further stated they follow the 2019 diet manual and that soft, fresh foods are allowed on mechanical soft diets. 2. Record review documented Resident #230 was admitted to the facility on [DATE], with diagnoses to include Dependence on Renal Dialysis, Peripheral Vascular Disease, and Acquired absence of right leg below knee. On the 02/27/24, the Comprehensive Nursing Evaluation documented a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. On 03/19/24 at 9:20 AM, Resident #230 was observed eating his breakfast during medication administration. Resident #230 was observed with 2 fried eggs on his plate, a slice of toast and a half slice of an orange. Photographic evidence obtained. An observation of his meal ticket revealed the resident was on a renal diet, mechanically altered / ground diet. An interview was conducted with the resident at this time that revealed he was not happy with the breakfast and requested a ham sandwich. He had spoken to Staff O, Licensed Practical Nurse (LPN), and had requested a ham sandwich. Staff O asked Staff G, Certified Nursing Assistant, to bring him a ham sandwich. Shortly after that Staff G came back with a ham sandwich on white bread and the resident began eating it. On 03/19/24 at 3:33 PM, an interview was conducted with Staff C, Speech Therapist. Staff C was asked if fresh fruit, specifically an orange slice, was part of a mechanical soft diet and she stated it was not. On 03/19/24 at 4:09 PM, an interview was conducted with the Registered Dietician (RD) regarding Resident #230's diet order. It was explained to the RD that a ham sandwich was given to the resident and the RD stated that the nurse should have referred the resident to the dietician before giving the ham sandwich since a ham sandwich is not part of a mechanical soft diet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During dining observation of Resident #24 on 03/19/24 at 8:45 AM, the surveyor asked Staff M, CNA, if she performs handwashing to residents who were unable to get up. She stated that she encourages residents to wash their hands and she just completed giving hand wipes to the resident. She further added that she tossed the wipes in the trash bin. When the surveyor requested Staff M to show her where the discarded wipes were, Staff M divulged that she did not wash the hands of the resident or offered him hand wipes today. 4. Resident #83 was observed in the dining hall on 03/19/24 at 12:03 PM. Staff were observed washing their hands before touching the contents of the food cart, but the surveyor did not observe staff encouraging Resident #83 to wash her hands or offer hand sanitizer to her. 5. Resident #381 was observed in his room receiving a snack post dialysis on 03/18/24 at 10:45 AM. There was no bottle of sanitizer or hand wipes observed when snacks were placed on the resident's overbed table. 6. Resident #99 was observed in his room receiving lunch on 03/19/24 at 1:10 PM. The facility failed to provide the resident with hand wipes or hand sanitizer prior to eating his lunch meal. Based on observations, interviews, and record review, the facility failed to maintain a proper sanitizing solution in the central kitchen for 2 of 3 red buckets observed during the initial tour of the kitchen; and failed to offer or encourage hand hygiene prior to dining for 5 of 5 sampled residents observed during dining, Residents #10, #24, #381, #99, and #69. The findings included: 1. The first visit to the central kitchen was conducted on 03/18/24 at 8:50 AM, accompanied by the Culinary Food Manager. The following issues were observed: a. The Culinary Food Manager used a testing strip taken from the (Hydrion quaternary sanitizer test tape) to check the concentration of the solution from the first red bucket. Further observation showed the test strip read 500 ppm (parts per million). This revealed that the concentration solution in the 1st red bucket was too high. In this observation, the Culinary Food Manager stated that the reading of 500 ppm was too high. b. The Culinary Food Manager used a testing strip taken from the (Hydrion quaternary sanitizer test tape) to check the concentration of the solution from the 3rd red bucket. Further observation showed that the test strip read 500 ppm (parts per million). This revealed that the concentration solution in the 3rd red bucket was too high. In this observation, the Culinary Food Manager stated that the reading of 500 ppm was too high. c. The Artic Air commercial refrigerator reach-in had an unidentified container of food that needed to be dated and labeled. d. The walk-in freezer was noted to have debris all around the floor. Photographic Evidence Obtained. e. The dry storage area was noted to have a 6-pound, 10-ounce can of tropical fruit salad can that was dented. 2. Record review documented Resident #10 was admitted to the facility on [DATE] with diagnoses to include Dysphagia, Dementia, and Anxiety Disorder. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #10 has severe cognitive impairment. In an observation conducted on 03/20/24 at 8:42 AM, Staff B, Certified Nursing Assistant, brought the breakfast tray into Resident #10's room and placed it on the side table. Staff B helped Resident #10 to a sitting position and set up the tray in front of the resident. Resident #10 started eating her breakfast food using her fingers. Staff B did not wash or use hand sanitizer to clean Resident #10's hands before she started eating.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide restorative rehabilitation services in a manner that promotes the highest practicable level of functioning for 1 of 5 sampled residents receiving restorative services during dining (Resident #10). The findings included: Review of the facility policy, titled, Restorative Nursing Services,, revised in July 2017, revealed that Residents would receive restorative nursing care as needed to help promote optimal safety and independence. Residents may start on restorative nursing programs upon admission, during stay or when discharged from rehabilitative care. Restorative goals may include: Supporting and assisting the Resident in adjusting or adapting to changing abilities. Maintaining dignity, independence, and self-esteem. Developing and strengthening physiological and psychological resources. Resident #10 was admitted to the facility on [DATE] with diagnoses of Dysphagia, dementia, and anxiety disorder. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident has severe cognitive impairment. Review of the Physician's orders, dated 10/30/23, revealed an order for all food to be served in bowls and beverages in coffee cups with each meal to assist with safe self-feeding. The care plan dated 01/02/24 revealed Resident #10 would participate in the Restorative Nursing Programs: Dining will improve / maintain current self-care abilities related to participation in specified restorative programs as ordered by the next review. Allow adequate time to eat and provide interventions as needed. In an observation conducted on 03/19/24 at 9:00 AM, Resident #10 was noted in her room with Staff B, Certified Nursing Assistant (CNA), standing near Resident #10, feeding her the breakfast meal. Resident #10 attempted to take the spoon from Staff B, who gently pushed Resident #10's hand away. In this observation, Staff B stated that Resident #10 likes to eat independently, but she makes a mess, and it is easier to feed the resident. Staff B continued feeding Resident #10, and at 9:10 AM (10 minutes later) took the breakfast tray out of the room. In an observation conducted on 03/19/24 at 12:15 PM, Resident #10 was noted in the Emerald dining room (Restorative Dining Room) eating her lunch meal with Staff A, Occupational Therapist (OT), sitting near the resident. Resident #10 was observed eating a peanut butter sandwich with no issues. She then picked up a mug/bowl with food inside and used a spoon to scoop the food towards her mouth. In this observation, Staff A stated that Resident #10 can handle a cup and use a spoon for eating, which is why the food is placed in cups and not on plates. She further said that Resident #10 needs supervision, so she sometimes does not pick up the food with her hands and needs reminding. Resident #10 eats in the Restorative dining room on weekdays from Mondays to Fridays. Staff A stated Resident #10 eats breakfasts and dinners in her room. The staff has been educated on the setup and feeding techniques for Resident #10 and said that, hopefully, they are following the same things she is doing with Resident #10 in the restorative dining room. Review of the OT evaluation from 02/8/24 to 03/13/24 showed that Resident #10's Puree food will come in cups. Present cup handle to left hand and give teaspoon to Right hand with voice commend to use her spoon. [Resident #10] is with appropriate self-feeds utilizing her spoon with occasional reminders for use of the spoon. She completes 100% of intake with supervision. In an observation conducted on 03/20/24 at 8:42 AM, Staff B brought the breakfast tray into Resident #10's room and placed it on the side table. Staff B helped Resident #10 to a sitting position and set up the tray in front of the resident. Resident #10 started eating her breakfast food using her fingers. Staff B did not wash or use hand sanitizer to clean Resident #10 hands before she started eating. Continued observation showed Staff B encouraging Resident #10 to use the spoon to eat her meal. After a few minutes, Resident #10 used her fingers to scoop up the food and then started using the spoon to pick up the food. In this observation, Staff B was asked why she fed Resident #10 her entire breakfast meal yesterday and why she let Resident #10 eat independently with cueing today. Staff B said, I like her to be independent, and so I am letting her eat on her own.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observations and records review, the facility failed to ensure that 1 of 2 sampled residents (Resident #102) received an adaptive call light to notify staff of her needs. The findings included: Review of the electronic clinical record revealed that Resident #102 was diagnosed with Cerebral Infarction due to Unspecified Occlusion or Stenosis Of Right Middle Cerebral Artery; Hemiplegia, Unspecified Affecting Left Nondominant Side; and Other Reduced Mobility. On 12/05/22 at 1:21 PM, during an interview with Resident #102, she said that her neck, right elbow, and shoulder were hurting her. She was asked to use her call light to request for assistance. She said that her call light was too far away. Observation conducted during the conversation showed the call light was on the floor on the right side of the resident's bed. Photographic Evidence Obtained. The call light was then placed in the Resident's right hand, and she was asked to press on it. She tried but was unable to press on the balloon to activate the call light. On 12/05/22 at 1:31 PM, the Certified Occupational Therapy assistant (COTA), Employee P, who was present during the interview was asked to have the resident reevaluated for functional ability to use a different call bell. Employee P said that she would report it to the physical therapy (PT) department. Employee P was also asked to reposition the resident and to place a wedge on the resident's right side to ease her discomfort. At 12/05/22 at 1:44 PM, Employee P, assisted by a Certified Nursing Assistant Employee Q, repositioned Resident #102 on the bed. Employee Q, when asked, stated she had bathed the resident at 10:00 AM and had also repositioned her at around 12:00 PM. On 12/07/22 at 2:32 PM, during a follow-up observation in Resident #102's room, it was noted that she did not have another call light that she could use. The balloon call bell was placed under her blanket on her right side. Resident #102 could not reach or use it. At about 2:40 PM on 12/07/22, Employee P (COTA) stated she had reported the call light concern to the PT department and that they were to reevaluate the resident. Employee P stated that she did not know whether the reevaluation was already completed but she would inquire. Review of the Therapy Assessment Notes, dated 12/05/22, revealed a summary of Skills performed with Resident #102 that read: Therapist repositioned patient in bed to ensure proper joint/postural alignment while in bed. Therapist also provided patient with wedge for pressure relief; nursing (NSG) staff informed. Therapist facilitated patient in grasp/release activity with right upper extremity (R UE) to promote functional use of R UE for activity of daily living (ADL) participation. Therapist completed progress report with patient, reviewed progress towards short term/long term (ST/LT) goals, and barriers to progress. Patient in agreement with continued POC. The Therapist also documented that she facilitated patient in left upper extremity (LUE) passive range of motion (PROM) with gentle prolonged stretch in all joints and planes for increased joint mobility, prevention of further contractures, and in preparation for orthotics wear. The Therapist guided patient in RUE [right upper extremity] AROM [Active ROM] in all joints and planes with gentle prolonged stretch in R [right] wrist and hand in preparation for orthotic wear. The PT notes also revealed that Resident #102 received application of R hand grip orthotic with a tolerance of 3 hours secondary to complaints of pain in RUE. Resident #102 complained of chronic generalized pain during the session. The care plan (CP), dated 09/26/22, outlined that Resident #102 was at risk for falls and/or fall related injury due to her weakness, immobility, use of medications, generalized weakness, and limited endurance. She was non ambulatory, used a wheelchair (w/c) as primary mode of locomotion, and received psychotropic meds. Therefore, Resident #102: -Risk of falls would be minimized with staff intervention thru the next review date. -Risk of fall related injuries would be minimized with staff intervention thru the next review date. -Bed would be placed in low position in locked position -The Call bell would be placed in reach when Resident #102 is in the room Staff would: -Keep the bed in low position -Keep call light within reach -PT/OT would screen as indicated. On 12/08/22 at 11:01 AM, the resident was again observed without an adaptive call light. Employee P was reinterviewed and reported that she had informed her supervisor of Resident #102's need for a physical reevaluation for call light usage. During an interview with the Physical Therapy (PT) Director on 12/08/22 at 12:25 PM, he stated that Resident #102 was actively receiving occupational therapy (OT) and PT. He said that he was informed about the resident's need to be reevaluated for a different call light. He indicated that an assessment was not yet done. The PT Director said that he would immediately reevaluate the resident. On 12/08/22 at 1:27 PM, the PT Director reported that they reassessed the resident and determined that she was able to use a different kind of bell. He said that a Desk Bell was subsequently provided to the resident. Failed to provide adaptive call light Resident #282 FTag Initiation 12/07/22 01:00 PM Int w resident #282 during screening on 12/5 and continued interview on 12/6 noted that the resident was alert and interviewable. The resident repeated stated to the surveyor on both interviews that he lies in bed all day. Specifically stated that since admission 2 weeks ago he has remained in bed and wants to get out of bed daily and into the wheelchair. The resident stated he has expressed this to staff but honered his request. 12/7/ - resident stating to surveyor that staff are refusing to utilize the Hoyer lift to aasist from bed to chair. Interview with charge Nurse =E. [NAME] - no doc of refusing transfer to chair Review of clinical record noted: DOA: 11/22/22 DOB: [DATE] Dx: Cerebral Infarction, Hemiplegia & Hemiparesis, Intracranial Hemorrhage, Adult Failure to Thrive, Pro-Cal Malnutrition, Aphasia, Dysphagia, Heart Failure, Malaise, NOtes: 12/6 - Alert & Oriented- denies pain, offered to get ooB and declined many times. 11/29- shower offered - declined still refuses, 11/23- Stated roommate was going to hurt him- supervisor made aware. 11/23 = Roommate was threatening to stabb him w a fork, Roommate was making too much noise, * Request grievance & incident log MD Orders: MD NOtes: 12/5 - restless-agitated, c/o poor sleep , depressed-sad, restless, hostile, insomnia, irritability, 11/27 - Behavioral change, agitated - poor sleep, calling roomate names and had TV on all night , family support, reco melatonin, roomate changed ??? 11/23 Wound_ redness to sacrum , Blanchable - 11/23 - Stabdards of Care - no wounds - redness sacrum , bilateral heels, groin, Pureediet- Nectar Thck ,

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records review, the facility failed to ensure protection of 1 of 1 sampled resident's, Resident # 328, personal property from loss or theft. The findings included: Review of the electronic Census record showed that Resident # 328 was admitted to the facility on [DATE] and discharged from the facility on [DATE]. Review of the Social Service notes, dated [DATE] revealed that the resident's daughter and wife had reported missing a kindle and electric shaver which belonged to the resident. The notes showed that Staff searched the storage room, but the items were not located. A gift card was issued on [DATE] to the family. The Social Worker (SW) noted that the missing items were not on the inventory sheet. On [DATE] at 11:36 AM, Resident #328's family member reported that they made multiple calls to the facility to retrieve Resident #328's personal properties left at the facility subsequent to Resident #328's discharge from the facility. According to Resident #328's relatives, the list of items left behind at the facility included: Various clothing items, a brand-new Kindle, an electric shaver, a portable charger, and a wall cell phone charger, which had been misplaced and were never returned to the family. In an interview with the Social Worker (SW) on [DATE] at 2:46 PM, she said she had documented only the two missing items reported to her. The SW said that none of the items (clothes, chargers) were documented on the inventory sheet. The SW worker also reported that she was informed that Resident #328 had expired. The SW also stated because the resident's belongings were not on the inventory sheet, no one knew exactly what the resident had as personal properties. The SW reported that the family members had called multiple times requesting Resident #328's personal items but they received no positive answers for two months. There was no documentation of the number of times the family member had called. The SW also mentioned that the family members was upset that Resident #328's personal properties were misplaced or lost. Review of Resident #328's care plan (CP) for activities documented that Resident #328 preferred individual in-room activities and communications with wife, family members using personal cell phone. The Inventory list did not reflect that Resident #328 had a cellular phone. Review of the inventory sheet, dated [DATE] documented the resident was admitted to the facility with no belongings. The document was signed by the resident's representative and the facility representative. The form was not updated to at least reflect that the resident had a cell phone.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of policy and procedure, observation, interview and record review, it was determined that the facility failed to provide care and services in accordance with activities of daily living: nail grooming for 1 of 1 sampled resident's observed, Resident #60. The findings included: Review of the facility policy and procedure on 12/07/22 at 2:30 PM, titled, Care of Fingernails/Toenails, provided by the Director of Nursing (DON), revised February 2018, documented, in part: Purpose: The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. Preparation: 1. Review the resident's care plan to assess for any special needs of the resident .General Guidelines: 1. Nail care includes daily cleaning and regular trimming. 2. Proper nail care can aid in the prevention of skin problems around the nail bed .Documentation: The following information should be recorded in the resident's medical record: 1. The date and time that nail care was given. 2. The name of the individual (s) who administered the nail care. 3. The condition of the resident's nails and nail bed 7. The signature and title of the person recording the data. Review of facility licensed nurse or CNA job description on 12/07/22 at 2:45 PM, dated 01/01/15, indicated, in part, that the Purpose of Your Job Position: The primary purpose of you position is to provide each of your assigned residents with routine daily nursing care and services in accordance with the resident's assessment and care plan and any other duties that may be directed by your supervisor Administrative Functions: Record all entries on flow sheets, notes, charts and computer programs in an informative and descriptive manner Personal Nursing Care Functions: Assist residents with nail care (i.e. clipping, trimming, and cleaning the finger or toenails) Resident #60 was admitted to the facility on [DATE] with diagnoses which included Rhabdomyolysis, Parkinson's Disease, Anemia and Hypertension. He had a Brief Interview Mental Status (BIM) score of 13 (cognitively intact). Record review of the Resident #60's personal care plan, initiated 02/21/21 and revised 08/22/22, indicated Focus: Activities of Daily Living (ADL): Resident #60 has a self-care deficit with dressing, grooming, bathing as evidenced by needs assistance with personal care tasks and mobility skills, ADL needs .Interventions: .provide hands on assistance with dressing, grooming, bathing as needed .Goal: .[Resident #60] will have clean, neat appearance daily through the next review date .Resident #60's fingernail care had not been done, on the dates from 12/05/22 through 12/07/22, until after surveyor inquisition / intervention. Further record review of the Minimum Data Set (MDS) sections A, C and G, dated 11/08/22, for Resident #60 Indicated that he required extensive assistance with personal hygiene. During an initial observation conducted on 12/05/22 at 10:05 AM, Resident #60 was observed with long, dirty sharp, unkempt and jagged fingernails on both hands. Photographic Evidence Obtained. On 12/05/22 at 10:12 AM, a brief interview was conducted with Resident #60 in which he was asked if he prefers his fingernails long or if he would like to have his fingernails to be trimmed and cut. The resident replied he remembers telling someone here about trimming his fingernails once but nothing happened. During a second observation conducted on 12/05/22 at 12:55 PM, Resident #60 was still observed with long, dirty sharp, unkempt and jagged fingernails on both hands. During a third observation conducted on 12/06/22 at 11:22 AM, Resident #60 was still observed with long, dirty sharp, unkempt and jagged fingernails on both hands. During a fourth observation conducted on 12/06/22 at 2:52 PM, Resident #60 was still observed with long, dirty sharp, unkempt and jagged fingernails on both hands. During a fifth observational tour conducted on 12/07/22 at 10:41 AM, Resident #60 was still observed with long, dirty sharp, unkempt and jagged fingernails on both hands. Review of the Resident #60's Monthly CNA (Certified Nursing Assistant) ADL (Activities of Daily Living) Flowsheet record, dated 11/24/22 through 12/06/22 revealed that resident's (ADL)s for Personal Hygiene indicated that the Resident #60 had fingernail care provided, when in fact, this was not done. An interview was conducted with the Activities Director (AD) on 12/07/22 at 10:45 AM. The AD stated that her department has been doing fingernail polishing and filing for all the residents in the facility during daily rounds, by either one (1) of her three (3) activities assistants or done by herself. She added that her department is not allowed to cut or clip any of the resident's fingernails and if her staff were to see a resident with long, dirty fingernails that she would alert the nurse of the wing or unit involved and to let them know to follow-up with the resident. The AD said that her department had not provided any nail care services to Resident #60. The Director also acknowledged that Resident #60's fingernails were all long, dirty, sharp, jagged, untrimmed and unkempt. An interview was conducted with Staff A, Certified Nursing Assistant (CNA), on 12/07/22 at 11:37 AM. She stated they had not provided fingernail care to Resident #60, and that it is the responsibility of the CNAs to clean and trim the residents' fingernails. She further acknowledged that Resident #60's fingernails were long, dirty, sharp, jagged, untrimmed and unkempt. An interview was conducted with Staff B, a Licensed Practical Nurse (LPN), on 12/07/22 at 11:41 AM, regarding Resident #60's long, unkempt nails. Staff B also agreed that Resident #60's fingernails were long, dirty, sharp, jagged, untrimmed and unkempt. On 12/07/22 at 11:46 AM, an interview was conducted with Staff E, LPN/Unit Manager (UM) for the North wing, regarding Resident #60's fingernails being long, sharp and untrimmed. She agreed that it is the responsibility of the CNAs to clean and trim the residents nails. She further acknowledged that the resident's fingernails were long and that they should have been cleaned / trimmed / cut. On 12/07/22 at 2:20 PM, an interview was conducted with the (DON) regarding Resident #60's fingernails being long, sharp and untrimmed. She acknowledged that it is the responsibility of the CNAs to clean and trim the resident's nails and the resident's fingernails were long and that they should have been cleaned / trimmed / cut.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations and records review, the facility failed to comprehensively assess 1 of 1 sampled resident (Resident #39) to determine her needs for hearing aids; and failed to promptly identify Resident #39's need for reading glasses and ensure an ophthalmological evaluation was performed timely. The findings included: Review of the electronic clinical record showed Resident #39 was diagnosed with Unspecified Hearing Loss, Unspecified Ear Primary Diagnosis Present on admission of 02/10/22. The resident had diagnoses to include Major Depressive Disorder, Recurrent, In Remission, Unspecified effective 09/15/22. Review of the Physicians' order showed no evidence for hearing aids services. Review of the Minimum Data Set (MDS) dated [DATE] and updated 04/01/22, 09/01/22 and 11/22/22 presented conflicting data in relation to Resident #39's current noticeable visual and hearing deficits. The last updated MDS, dated [DATE], Section B (Hearing) documented that Resident #39 had no hearing aid, in Section B1000 her vision was adequate, and in section B1200, it was documented that she wore no corrective lenses. Review of a Nursing progress notes, dated 11/02/22 at 16:29 PM, documented that Resident #39 was alert, responsive, and hard of hearing. On 12/06/22 at 10:16 AM, while attempting to conduct an interview with Resident #39, it was observed that Resident #39 had serious difficulty understanding what the surveyor was conveying. Even though the surveyor addressed the resident loudly, the resident could not hear what was being said. Resident #39 said that she did not have her hearing aid. Resident #39 said that she partially was deaf in the right ear and totally deaf in the left ear. Review of the care plan (CP), dated 03/15/22, documented it is the Resident's wish to return to the community. The CP revealed that the resident had hearing deficits being hard of hearing (HOH), but there was no indication that the resident wore any assistive device (i.e., hearing aids). The CP updated on 12/02/22 revealed the following: Resident #39 had an alteration in communication ability related to (r/t): (specify) as evidenced by (AEB): is HOH. The plan outline that: o Resident #39 will maintain current level of communication ability thru the next review date. o Resident will respond appropriately to simple, direct communication thru the next review date o Resident will have daily needs met thru staff anticipation thru the next review date. Staff will: o Face resident when speaking and speak in clear, direct tones o Speak in louder tones when in a loud setting o Repeat/rephrase messages as needed if resident misses part of intended message o Speak to resident in simple, direct terms o Ask resident yes/no questions o Allow resident adequate time to respond; provide cues prn resident displays difficulty finding words. o Ask resident to repeat verbalization & validate as needed o Keep call light within reach; respond to communicated needs prn [as needed] o Observe for changes in hearing, speech, communication; notify physician as needed. Review of Social Service notes, dated 04/14/22 at 16:16 PM, showed staff knew that Resident #39 wore a hearing aid, as evidence by the following: social worker assistance and this nurse changed batteries in Hearing aid. Hearing Aid place in right ear, resident state it works very well. Review of the MDS, dated [DATE], showed the resident used the hearing aid in completion of the assessment. The MDS, dated [DATE], did not reflect that Resident #39 wore a hearing aid. The Quarterly MDS, dated [DATE], was completed without evidence of hearing aid. Section B revealed Resident 39 had minimal difficulty hearing. During interview with Resident #39 on 12/07/22 at 11:58 AM, she said that in order to talk to her, one must write the message on a board/paper. Resident #39 said that she was legally blind in the right eye and had poor vision on the left one. She stated that she needed to go to the eye doctor. She added that her hearing aids were misplaced in the facility. She concluded saying that she really needed her hearing aids. Interview with Certified Nursing Assistant / CNA, Staff Q, on 12/07/22 at 12:06 PM reported that she is familiar with Resident #39. Staff Q said with caution, I think she (Resident #39) had a hearing aid. She also said that she was not sure what had happened to the hearing aid. She recalled that Resident #39 had told her that she had a hearing aid. Staff Q ensued and affirmed that she was going to ask the unit manager whether Resident #39 still had the hearing aid. Interview with Staff P, Certified Occupational Therapy Assistant (COTA), on 12/07/22 at 11:57 AM revealed that Resident #39 is hard of hearing, and she was not sure what had happened to her hearing aid. She said the resident used to be in a different room and was recently transferred to her current room. Employee P also stated that I believe the resident's hearing aids are lost. In interview with Staff R, Licensed Practical Nurse (LPN), on 12/07/22 at 12:38 PM, Staff R said that she has been working at this facility a long time. She said that Resident #39 moved to the room a week ago, after she returned from the hospital. The resident used to be in room [ROOM NUMBER] and was transferred to this room on December 1, 2022. Staff R stated that the resident used to have a hearing aid. She said that she is not sure whether the family member has it. When asked whether she had looked for it or reported it, Staff R said that she did not look for it or report it to anyone. Staff R said that she did not know whether Resident #39 had difficulty reading. She said that she did not know the resident had visual impairment. In interview with Unit Manager, Staff E, on 12/07/22 at 12:52 PM, Staff E stated she has been working at this facility since May 2022. She said Resident #39 is alert, oriented, and able to make her needs known and was admitted with a hearing aid. She stated Resident #39 had visual and hearing deficits and she also had difficulty hearing even with the hearing aid. She said that on 12/06/22, they discussed Resident # 39 plan of care and wanted to discuss the matter with the resident's son, but he did not attend the CP meeting. Staff E said that she was not sure when the hearing aid got lost. Staff E stated the resident recently returned to the facility after she went to the hospital on [DATE]. Staff E added that during Resident #39's last Telehealth with her physician, an endocrinologist, on 09/22/22, the resident had her hearing aid on, but the hearing was not working properly. Staff E reported that Resident #39 wore the hearing aid on the right ear. She said that the MDS Coordinator was present during the CP meeting. Staff E also stated she makes her round every morning to ensure that the residents are okay but she was not aware the resident did not have her hearing aid. Staff E stated that she did not discuss the resident's hearing deficit or visual impairment with the Social Worker. Staff E also said during the last telehealth visit, Resident #39's physician had told her that the hearing problem was ongoing for a long time and that the only thing that could resolve the resident's hearing problem would be an implant. Staff E also recalled that one day when she brought the resident's purse to her to look for the batteries for the hearing aid, she noticed the resident was feeling rather than looking in the purse for the battery and at that point, she suspected that the resident had visual impairment. She said that happened in May 2022, when she first met Resident #39. On 12/07/22 at 1:39 PM, Staff S, one of the MDS Coordinators, stated they had a CP meeting on 12/06/22 to discuss the resident's plan of care. She said that the resident's authorized representative (AR) was not present, but she contacted him via phone to discuss the CP. The AR requested that the resident have an eye consult. During an interview with the MDS Coordinator on 12/07/22 at 3:19 PM, she stated that Resident # 39's son brought in the hearing aid for the Resident on March 31, 2022. She said during her last MDS assessment, she asked the resident if she was able to read something and the resident said yes and she was able to. Staff S stated, when I conducted the last assessment, I believe I gave her a menu to read. She also said that she usually carries a book or a magazine during the MDS assessment. Staff S said that she might have given the resident one to read but she was not sure. Review of the 11/19/22 assessment noted that there was no indication that the resident wore hearing aids although it was noted that she did wear one during the assessment in April 2022. Staff S said that she has been able to talk to the resident in louder tone. She said that she will do a change of condition MDS. During a follow-up interview with the MDS Coordinator on 12/08/22 at 9:21 AM, she stated she did go back to the resident and she was able to converse with Resident #39 speaking with a loud tone of voice. She stated that the resident was able to hear what she told her. She also stated an auditory consult was initiated on 12/07/22. The MDS Coordinator stated she found out that the resident does have a Cochlear implant according to hospital records reviewed. She said that she stood very close to the resident when she spoke to her. She also said that she will have the resident vision assessed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, interviews and the facility's policy review, the facility failed to ensure that residents received care and services for the provision of parenteral fluids consistent with professional standards of practice for 1 of 1 sampled resident reviewed for Intravenous Antibiotic (IV) therapy, Resident #178, as evidenced by failure to change the IV Access Line dressing per the facility's policy and the facility's Intravenous (IV) Access Line Maintenance Protocol; failed to administer / infuse IV antibiotic in the pharmacy prescribed timeframe; and failed to have physician orders for IV flushes to maintain the IV-line which were being administered by the nurses. The findings included: 1. Review of the facility's policy, titled, Midline Dressing Changes, revised on April 2016, documented in part, .change midline catheter dressing 24 hours after catheter insertion, every 5- 7 days . Review of the facility's policy titled Intravenous Administration of Fluids and Electrolytes provided by the Director of Nursing (DON), revised on April 2016 documented a physician's order is necessary to give intravenous fluids . Review of Resident #178's clinical record documented an admission to the facility on [DATE] with no readmissions noted on file. The resident's diagnoses included Osteomyelitis (an infection in a bone) Primary Diagnosis, Pyogenic (related to the production of pus) Inflammation of bone, Infection and Inflammatory Reaction due to internal Fixation Device of Spine, Malignant Neoplasm of Vertebral Column, Pseudomonas (Aeruginosa) (Mallei)(Pseudo mallei) (a bacterial Infection), Type 2 Diabetes Mellitus, Neuromuscular Dysfunction of Bladder, Colostomy Status and Arthrodesis Status (the uniting of two bones at a joint). Review of Resident #178's physician orders, dated 11/23/22, documented, Avycaz (an antibiotic) Solution Reconstituted 2.5 (2-0.5) GM (Ceftazidime-Avibactam) Use 2.5 gram intravenously every 8 hours for Pseudomonas (infection) until 01/07/23. Review of the resident clinical record lacked evidence of a physician order for IV flushes before and after IV administration as per facility protocol. Continue review revealed the lack of a physician order for IV dressing changes as per facility protocol. Review of Resident #178's November and December 2022 Medication Administration Record (MAR) and Treatment Administration Record (TAR) lacked documentation of the resident's IV catheter site monitoring or dressing changed. Review of Resident #178's Minimum Data Set (MDS) admission's assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 13, indicating the resident had no severe cognition impairment. The assessment was in progress. Review of Resident #178's care plan, titled, Resident has the potential for complications related to active infection and/or IV ABT (antibiotic), initiated on 11/24/22 documented interventions that included administer antibiotics as ordered; observe for effectiveness, observe IV site . Review of Resident #178's Comprehensive Nursing Evaluation, signed and dated 11/23/22, documented, Resident is not receiving IV medications. The evaluation did not address the resident's IV line, dated 11/20/22, upon on admission. Review of Resident #178's admission Wound and Skin Evaluation dated 11/23/22, lacked documentation of the resident's IV line in place. Review of Resident #178's Daily Skilled Note, dated 11/23/22 and signed on 11/24/22, documented, resident currently has IV-access present, has a PICC [peripherally inserted central catheter] (IV) line on right arm, IV is being utilized for IV medication .IV site intact .administered IV medication as ordered . Review of Resident #178's nurses' note, dated 11/22/22, documented that his medications were verified with the resident's physician. Review of the resident nurses notes, dated 11/25/22, 11/28/22 and 11/29/22, addressed that Resident #178's had an IV line for IV antibiotics. On 12/05/22 at 1:07 PM, an interview was conducted with Resident #178 who stated that he had an infection and was on antibiotics three (3) times a day. Observation revealed an IV line on the resident's right arm, and the IV dressing was dated 11/20/22. The resident stated that he had not declined for the dressing to be changed and replied that they (staff) had not even asked about changing it. Further observation revealed a 250 ml saline bag connected to a bottle of Avycaz with approximated 100 cc of solution left to be infused hanged on an IV pole. The bag was connected to the resident's IV line via a dial flow set at 150 ml per hour. Observation revealed an IV machine at the IV pole. During the interview, Resident #178 stated that the machine was not working, was beeping a lot and they starting to use the dial flow. On 12/06/22 at 8:39 AM, observation revealed Resident #178 in bed and awake. During an interview, the resident stated that the IV antibiotic was hung early this morning, but he did not know the time. On 12/06/22 at 10:05 AM, an interview was conducted with Staff I, Licensed Practical Nurse (LPN) who stated the IV line dressing was to be changed every seven (7) days. Consequently, a side-by-side review of Resident #178's IV dressing was conducted with Staff I, who confirmed that the resident's IV dressing was dated 11/20/22. Staff I stated that the dressing should had been changed before. Staff I added that maybe it was not on the MAR for the dressing to be changed. On 12/06/22 at 10:50 AM, an interview was conducted with the facility's Director of Nursing (DON). The DON stated the facility's Midline (IV) catheter policy was to change the IV dressing every 5-7 day. The DON was apprised that Resident #178 Midline IV dressing was dated 11/20/22. On 12/07/22 at 11:40 AM, an interview was conducted with Staff F, LPN, who stated she checked the Resident #178's IV line dressing on 12/05/22 and it was intact, no redness. Staff F was asked when the IV line dressing was supposed to be changed and stated she was not sure. Staff F stated she did not know the facility's policy and added that she was a new nurse. 2. Review of the facility's protocol, titles, PharmScript Intravenous (IV) Access Line Maintenance Protocol, effective 12/01/18, documented under flush protocols for Midline catheter administer 10 ml (millimeters) of normal saline before and after each IV medication . The protocol documented under site maintenance: transparent dressing changes weekly and as needed. Review of the facility's policy, titled, Intravenous Administration of Fluids and Electrolytes, provided by the Director of Nursing (DON), revised on April 2016, documented, a physician's order is necessary to give intravenous fluids . Review of Resident #178's clinical record documented an admission to the facility on [DATE] with no readmissions noted on file. The resident's diagnoses included Osteomyelitis (an infection in a bone) Primary Diagnosis, Pyogenic (related to the production of pus) Inflammation of bone, Infection and Inflammatory Reaction due to internal Fixation Device of Spine, Malignant Neoplasm of Vertebral Column, Pseudomonas (Aeruginosa) (Mallei)(Pseudo mallei) (a bacterial Infection), Type 2 Diabetes Mellitus, Neuromuscular Dysfunction of Bladder, Colostomy Status and Arthrodesis Status (the uniting of two bones at a joint). Review of Resident #178's Minimum Data Set (MDS) admission's assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 13, indicating that the resident had no severe cognition impairment. The assessment was in progress. Review of Resident #178's care plan, titled, Resident has the potential for complications related to active infection and/or IV ABT (antibiotic), initiated on 11/24/22 included interventions to administer antibiotics as ordered; observe for effectiveness, observe IV site . Review of Resident #178's physician orders, dated 11/23/22, documented, Avycaz (an antibiotic) Solution Reconstituted 2.5 (2-0.5) GM (Ceftazidime-Avibactam) Use 2.5 gram intravenously every 8 hours for Pseudomonas (infection) until 01/07/23. Review of Resident #178's antibiotic label from the pharmacy documented IV- Avycaz .in 250 ml of normal saline, infuse intravenously at 125 ml per hour over 2 hours every 8 hours for Pseudomonas until 01/07/23 . Review of the Resident #178's clinical record lacked evidence of a physician order for IV flushes before and after IV administration as per facility protocol. Review of Resident #178's November and December 2022 Medication Administration Record (MAR) and Treatment Administration Record (TAR) lack documentation of the IV flushes before and after IV antibiotic administration. The resident's MAR dated 12/06/22 documented, Avycaz Solution Reconstituted 2.5 (2-0.5) GM (ceftazidime-Avibactam) Use 2.5 gram intravenously, initialed as administered by Staff R, Licensed Practical Nurse (LPN). On 12/05/22 at 1:07 PM, an interview was conducted with Resident #178 who stated that he had an infection and was on antibiotics three (3) times a day. Further observation revealed a 250 ml saline bag connected to a bottle of Avycaz with approximated 100 cc of solution left to be infused, hung on an IV pole. The bag was connected to the resident's IV line via a dial flow set at 150 ml per hour. Further observation revealed an IV machine at the IV pole. During the interview, Resident #178 stated that the machine was not working, was beeping a lot and they starting to use the dial flow. On 12/06/22 at 8:39 AM, observation revealed Resident #178 in bed and awake. During an interview, the resident stated that the IV antibiotic was hung early this morning and he did not know the time. Review of the IV antibiotic bag pharmacy label documented IV-Avycaz 2-0.5 mg (milligrams) in 250 ml of 0.9% NS (normal saline) .infuse IV at 125 ml per hour over two (2) hours every eight (8) hours . Further review of the resident's IV bag revealed a label dated 12/06/22 and timed at 5:00 AM. At 8:39 AM, the 250 ml IV antibiotic bag had approximately 100 cc of the solution in the bag left to be infused. The IV antibiotic bag was still connected to Resident #178's IV line via a dial flow set to be delivered at 125 ml per hour (photographic evidence). The IV antibiotic solution was dripping three hours after it was connected. On 12/06/22 at 10:05 AM, a side-by-side review of Resident #178's was conducted with Staff I, Licensed Practical Nurse (LPN). The review revealed the resident's IV antibiotic bag was connected to his IV line. The IV antibiotic bag was empty. Staff I confirmed that the resident IV antibiotic bag was dated 12/06/22 and timed at 5:00 AM. Staff I was asked for how long was the IV antibiotic was supposed to be infused and Staff I proceeded to read the pharmacy label and stated, infused over two hours. Staff I stated she was not sure if it was hanged at 5:00 AM. Staff I stated that outgoing nurse did not report any issued or problem with the resident's IV line. Staff I was apprised that around 8:39 AM today (12/06/22) the IV bag had about 100 cc left to be infused. Staff I stated that once the IV was hang, they check on it. Staff I was apprised of the lack of monitoring of Resident #178's IV antibiotic that was hanged at 5:00 AM and was supposed to be infused over two hours and was still had 100 ml left to be infused three hours after connection. Staff I stated that the resident's IV antibiotic scheduled was every eight hours at 6:00 AM, 2:00 PM and 10:00 PM. On 12/06/22 at 10:22 AM, observation revealed Staff I, LPN retrieved a 10 cc normal saline syringe, alcohol pads, entered Resident #178's room, performed handwashing and donned gloves. Staff I wiped the IV port with an alcohol pad then proceeded to flush the resident IV line port. Staff I stated she flushed the line with 5 cc of normal saline solution. On 12/06/22 at 2:01 PM, observation of Resident 178's IV medication administration performed by staff I, LPN was conducted. Staff I retrieved an IV Bag labeled 250 cc of IV Avycaz 2-0.5 mg, labeled to be administered in 2 hours, q 8 hrs (hours) at 125 ml/hr. Staff I primed the IV tubing, wiped the purple IV line port with alcohol pad and then flushed the IV line with 10 cc of saline solution. Staff I stated that the order stands 10 cc of normal saline and not 5 cc like she did before during the disconnection in the morning. On 12/07/22 at 11:40 AM, an interview was conducted with Staff F, LPN who stated that Resident #178's IV pump was not working as per the night shift nurse on 12/05/22, therefore she used the dial flow. Staff F believed that someone was made aware of the machine not working. On 12/07/22 at 3:07 PM, an interview was conducted with the facility's Consultant Pharmacist (CP). The CP was apprised that Resident #178's IV antibiotic was hanged at 5:00 AM on 12/6/22 and that three hours later, at 8:39 AM, there was approximately 100 ml to be infused and the pharmacy label read to be infused over two (2) hours. The CP stated she will speak with the DON. On 12/08/22 at 11:28 AM, an interview was conducted with the DON. The DON was apprised that Resident #178's IV antibiotic was hanged on 12/06/22 at 5:00 AM and continue to drip at 8:39 AM when it was supposed to be infused for two hours (Photographic Evidence Obtained and was presented to DON). The DON stated that the 5:00 AM on the label meant the hanging time. The DON stated that the day shift nurse, Staff I, LPN, told her that the resident was closing his right arm and that the resident did not want to use the pump because it keeps him awake. The DON was asked for other alternative and replied that the IV site could have been changed, explained to the resident the necessity of using the pump so the antibiotic could be infused in a timely manner. The DON stated that in the future the need to use the pump and document why it is not used. The DON stated that she did not see any nurse note related to Resident #178's IV infusion been late, no notification to the physician. The DON was apprised that on 12/06/22 during medication administration observation for Resident #178, Staff I used the pump to infuse the resident IV antibiotic scheduled for 2:00 PM, the antibiotic was infused in two hours with no problems. The DON was asked to arrange a call with the nurse who hanged resident IV on 12/06/22 at 5:00 AM. On 12/8/22 at 11:45 AM, during an interview, the DON stated that it is common practice to flush before and after a medication is given via Midline (IV line). The DON added that the common practice is to flush the IV line with 10 cc (cubic centimeters) of saline solution. The DON was asked where the nurses document the residents' IV flushes administration and stated the flushes are not documented unless, the line was not in use. The DON stated she had never seen a physician order for saline flushes given before and after a medication been given via an IV line and added it was a common practice. The DON was asked how she can ensure that the nurses are flushing the IV line and what amount of cc are the nurses to use. The DON stated it was a common practice to use the 10 cc saline flush syringe and that the nurses did not need a physician order to flush an IV line that was been use for medication administration. On 12/08/22 at 12:14 PM, an interview was conducted with Staff N, LPN who stated that if a resident has an IV line, he will flush the line with 10 cc of saline and check the dressing for signs and symptoms of infection. Staff N was asked if he needed a physician order to flush a resident IV line and stated that he does need a physician order and if he did not see an order, he would be calling the doctor. On 12/08/22 at 12:26 PM, an interview was conducted with Staff G, LPN who stated that she will flush the resident IV line before and after the medication administration with 10 cc of normal saline. Staff G stated that she needed a physician order to do flush the IV line. Staff G stated that if she did not have a physician order, she will call to get one. On 12/08/22 at 12:27 PM, an interview was conducted with Staff B, LPN who stated that he will flush the IV line with normal saline 30 cc before and after medication administration. Staff B stated he did not need to have a physician order for the IV flush and added that it is common practice to flush before and after medication administration. On 12/08/22 at 12:31 PM, an interview was conducted with Staff O, LPN stated he will flush a resident's IV line with normal [NAME] 10 ml before and after the medication administration. Staff O stated that there always a physician's order for flushes and added that he will call the doctor if there is not an order for IV flush. On 12/08/22 at 12:36 PM, an interview was conducted with Staff I, LPN who stated they have to have a physician's order for IV-line flushes. Staff I was apprised that Resident #178 did not have a physician order for IV flushes before and after his IV antibiotic administration. On 12/08/22 12:43 PM, a joint interview was conducted with the DON and the Regional Nurse Consultant (RNC). The DON and the RNC were apprised that nurses' interviews revealed that they need a physician order to do IV line flushes before and after medication administration. The DON was apprised that one nurse stated that he will flush the IV with 30 cc of normal saline. The DON was apprised that one nurse flushed the line with 5 cc of normal saline after IV antibiotic administration. The RNC stated that the facility had to match the Midline (IV line) protocol with the physician orders. The RNC confirmed that the nurse had to have a physician order to flush the IV line. On 12/08/22 at 2:46 PM, a telephone interview was conducted with Staff R, LP, who stated he worked on 12/06/22. Staff R stated he hung Resident #178's IV antibiotic whenever the record (MAR) turned orange (meaning the MAR's computerized screen turned to a color alerting the nurse that he can administer the medication) and did not recall the time connected. Staff R was asked why he did not connect the resident to the IV pump and stated that he was informed the resident's IV pump was not working by the relieving nurse. Staff R added that he checked with another nurse and was told the same thing. Staff R was asked at what rate was the medication to be infused and stated that he did not remember, who stated it was supposed to go at 125 ml per hour but 'don't quote me'. Staff R stated he did not recall how many cc's the IV bag had but there was a small bag and a bigger bag. Staff R stated he flushed the IV line with 10 cc of prefilled saline syringe before and after the IV medication and did not have any problems with the IV site and the IV was dripping when he left about 7:30-7:40 AM. Staff R stated that he passed it over to the incoming nurse that the IV was still dripping. Staff R stated if the bag had 250 ml and it was connected at 125 ml per hour, the infusion should have been finished in two hours. Staff R was apprised that at 8:39 AM, Resident #178's IV antibiotic (connected at 5:00 AM) had approximately 100 ml left to be infused, which was three hours after connection. Staff R did not respond.

Based on review of policy and procedure, interview, and record review, it was determined that the facility failed to ensure that it maintained eighteen (18) months' worth of daily nurse staffing data, as recorded. The findings included: Review of the facility policy and procedure on 12/07/22 at 2:30 PM, titled, Posting Direct Care Daily Staffing Numbers, provided by the Director of Nursing (DON), revised July 2016, documented in part, Policy Statement: Our facility will post, on a daily basis, for each shift, the number of nursing personnel for providing direct care to resident . 8. Records of staffing information for each shift will be kept for a minimum of eighteen (18) months or as required by state law (whichever is greater) . During an interview conducted on 12/05/22 at 12:10 PM with the Staffing Coordinator, she was asked whether or not the facility had maintained the full required 18-month daily nurse staffing data. She stated she had not maintained the full schedule, in either paper or computerized form, dating back from between June 2021 through December 2021. The Staffing Coordinator recognized and acknowledged that there were six (6) months of the daily nurse staffing data that were unaccounted for. She acknowledged they should have been there and maintained for the full eighteen (18) months, but they were not. Record review was conducted of the facility's 18-months daily nurse staffing data provided from January 2022 until December 2022. It was noted that the other six (6) months, prior to January 2022, were missing/not there. A side-by-side record review was conducted with Staffing Coordinator, in which it was noted / indicated that the only daily nurse staffing data that was available and maintained in the facility are dated from January 2022 until December 2022; which was only twelve (12) of the eighteen (18) months requirement. The DON further recognized and acknowledged on 12/06/22 at 9:35 AM that the 18-month daily nurse staffing data should have been maintained, and it was not maintained.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility failed to provide lab services to meet the needs on 1 of 1 sampled resident, Resident #99, reviewed for labs. The findings included: During an environment tour conducted on 12/07/22 at 1:00 PM accompanied with the Corporate Maintenance Director, the specimen refrigerator located in the Soiled Utility Room located in South [NAME] Unit was observed. Further investigation of the refrigerator noted what appeared to be a Urine specimen. A review of the Lab [company name] Sheet that was with specimen collection tube noted it was documented as urine (UA) for Resident #99. Further review of the lab sheet did not document a date that the urine specimen was collected. A review of the specimen tube noted the urine was documented as collected on 12/05/22. The surveyor requested of the Corporate Nurse to investigate why the specimen had not been collected by the lab on 12/05/22. Following the request, the Corporate Nurse submitted documentation and stated the attending physician ordered a one time UA C&S (Urine Analysis-Culture & Sensitivity) for Resident #99 on 12/5/22. The Corporate Nurse stated the facility failed to notify their laboratory vendor [Company Name] of the specimen order and to pick up the specimen for analysis. A call was placed to the attending physician on 12/07/22 and a new ordered was received for a UA C&S. A review of the clinical record of Resident #99 noted: Date of admission: [DATE] Diagnoses: Urinary Tract Infection (09/21/22). Review of Physician Progress notes, dated 12/05/22, confirmed that a Urine UA C&S was ordered on 12/05/22. A 12/07/22 documentation noted the order was not followed for 12/05/22 and a new order was received on 12/07/22. A review of Pharmacy documentation noted the resident was receiving Apixaban 5 mg BID (twice daily) was originally ordered on 10/10/22 for diagnosis of DVT (Deep Vein Thrombosis) Prophylaxes. It was further noted the order documented the medication was put on hold on 12/07/22 through 12/21/22. On 12/08/22, the surveyor was informed by the Corporate Nurse the urine specimen had been picked up by the lab on 12/07/22 but there were no results report as of yet.

Based on observation, interview and record review, it was determined the approved Pureed Diet menu did not meet nutritional needs and was not followed for 14 facility residents with physician ordered Pureed Diets, which included 3 of 3 sampled Residents #28, #88, and #167. The findings included 1. During review of the approved menu for the lunch meal of 12/05/22 and breakfast meal of 12/06/22, the following was noted to be documented: Lunch Meal (12/05/22): 4 ounces Pureed Dinner Roll (pureed diet) 4 ounces Chocolate Pudding (pureed diet) 1 Tsp [teaspoon] Chopped Parsley (garnish) No documentation of an alternate purred vegetable. Breakfast Meal (12/06/22) Slivered [NAME] Onions (garnish). 2. During the observation of the lunch meal in the Main Kitchen on 12/05/22 at 11:30, the following was noted: (a) Observation of the tray line in the main kitchen on 11/05/22 at 11:30 AM noted the Pureed Buttered Dinner Roll had not been prepared and would not be served. Once the surveyor informed the Certified Dietary Manager (CDM) there was a menu omission, an attempt was made to use white bread as the ingredient. The surveyor informed the CDM the freshly prepared buttered dinner was to be utilized for the pureed diet. (b) Observation of the tray line in the main kitchen on 11/05/22 at 11:30 AM noted the Pureed Brownie was prepared and was being served to the pureed diets. The surveyor informed the CDM the approved menu documented Chocolate Pudding for pureed diets. (c) Observation of the tray line in the main kitchen on 12/05/22 at 11:30 AM noted there was not an alternate pureed vegetable prepared for pureed diets. Interview with the CDM noted that an alternate vegetable was documented for all Regular and Therapeutic diets. Addition interview with the Registered Dietitian revealed that an error was made during the development of the Pureed Menu. (d) Observation of the tray line in the main kitchen on 12/05/22 at 11:30 AM noted the Chopped Parsley was not included on the residents' plate. It was also noted there was no pureed garnish included on the approved menu. Interview conducted with the CDM during the meal observation revealed that staff failed to prepare the garnish. Interview with the Registered Dietitian (RD) revealed that an error was made during the preparation of the approved menu for Pureed Diets 3. During the observation of the breakfast meal in the main kitchen on 12/06/22 at 7:00 AM noted the Slivered Onion (garnish) was not included on the residents' food plate. It was also noted that the approved menu did not document a pureed garnish for the breakfast meal. Interview conducted with the CDM during the meal observation revealed that staff failed to prepare the garnish. Interview with the Registered Dietitian revealed that an error was made during the preparation of the approved menu for Pureed Diets. Review of the facility's Diet Census for 12/06/22 noted that there were currently 14 residents with physician ordered Pureed Diet. It was noted that sampled Residents #28, #88 and #167 had physician orders for pureed diet and were included in the 14 facility residents on ordered pureed diets.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility failed to follow physician ordered therapeutic diet for Fluid Restriction for 1 of 5 sampled residents, Resident #281, reviewed for nutrition. The findings included: Review of facility's Policy & Procedures, in part, for Restricting Fluids, noted the following: General Guidelines: < Follow specific instruction (physician order) including fluid intake or restrictions. < Record fluid intake on the intake side of the intake and output record, Record fluid intake in ML's. < When placed on restricted fluid, remove the water pitcher and cup from the room. < Be sure an intake and output record is maintained in the resident's room. During the observation of the lunch meal conducted on 12/05/22 at 1:00 PM, it was noted the meal tray was delivered to the room of Resident #281. Further observation noted the meal tray ticket documented 'Mechanical Soft, Renal. Fluid Restriction 1500 cc (D:720)'. The tray ticket did not have documentation of the type and amount of fluid to be served. It was also noted the resident had a Styrofoam container of water (approximately 300 cc) on the bedside table of which the resident was noted to be drinking from. Observation of the food tray noted the resident was served coffee (6 ounces = 180 cc) and Grape juice (8 ounces =240 cc) for a meal total of 420 cc. Observation of the breakfast meal conducted on 12/06/22 at 7:30 AM again noted the tray served to the room of Resident #281. The resident was noted to be alert but unaware of diet and fluid restriction specifics. It was also noted 8 ounces (240 cc) of unidentified fluid on overbed tray table. Review of the meal tray ticket documented Fluid Restriction: 1500 cc D: 720. Ticket review again noted no specific fluids and amounts to be served on the breakfast tray. Review of the breakfast tray noted the following was served: Coffee (6 ounces = 180cc), milk (8 ounces = 240cc) and apple juice (8 ounces = 240cc) for a meal total of 680cc. Review of the dinner meal ticket for 12/6/22 noted documentation of a Fluid Restriction: 1500cc D: 720. It was also noted that there were no specific fluids and amounts to be served on the dinner tray. A calculation of the resident's meal tickets estimated by the surveyor noted Resident #281 was receiving a minimum of 2040cc of fluids on meal trays per day, which indicated the resident was receiving over 500cc of fluid above the physician order. A review of the clinical record of Resident #281 on 12/7/22 noted the following: Date of admission: [DATE] Diagnoses: ESRD [End Stage Renal Disease] Matrix Documented: In House Dialysis Current Physician Orders: MD Orders: 12/02/22 - Mechanical Soft, Renal Diet 12/2/22 - Fluid Restriction - 1500ml [cc] plus / minus 300 - 720 ml provided by dietary - nursing - day = 300/evening =300, night = 180; total 780. 11/30/22 - Nova Source TID (three times a day) 11/30/22 - House Protein TID- 30 ml. Further review of the record noted the resident's physician ordered Fluid Restriction had not been calculated by meal by Registered Dietitian and the nursing Fluid Allotment had not been calculated by the MDS (Minimum Data Set) Coordinator. It was also noted that an MDS had not been completed due to the resident being admitted less than 14 days. It was noted the resident had a BIMS score of 15, indicating cognition was intact. Review of the December Medication Administration Record (MAR) for the month of December 2022 noted documentation of nursing to provide nursing per day: 30cc day shift, 300cc evening shift, and 180cc night shift, for a total of 780cc. Further review of the MAR noted documentation the resident was receiving fluids via nursing for 2 shifts only (Day & Night). There was no documentation of how much fluid the resident was administered for each shift. Interview with the Registered Dietitian and MDS Coordinator on 12/07/22 revealed the following: a. The facility's Registered Dietitian (RD) confirmed with the surveyor that the 1500cc Fluid Restriction for Resident #281 was not being followed as per physician orders. The RD stated that the resident's fluid restriction has been re-assessed. The RD submitted Dietary Progress notes, dated 12/07/22, that the 720cc of the 1500cc of fluids would include: Breakfast Meal = 240cc (cranberry juice & coffee), Lunch Meal = 240cc ((Cranberry Juice & coffee), Dinner meal = 240cc (cranberry juice & coffee). It also documented the physician's order had been clarified, no bedside water, Novasource Renal 480 cc will not be included in the fluid restriction, and Nursing will provide 780cc fluids for medication pass. The submitted documentation included that the dietary and nursing staff had been in-serviced on Fluid Restrictions. b. The MDS confirmed with the surveyor that the 1500cc Fluid Restriction had not been followed as per physician ordered. The MDS further stated that Nursing was not documenting the 780cc allotment correctly on the MAR and would make appropriate corrections to the MAR, including fluids provided and intake by the resident. The MDS stated the care plan for the fluid restriction has also been updated with the appropriate changes.

Based on observation and interview, it was determined the facility failed to treat 3 of 3 sampled residents, Resident's #95, #105,and #281, and potentially 132 facility residents, with respect and dignity in a manner that promotes enhancement of quality of life that includes providing drinking cups and glasses with meals. The findings included: During the observation of the lunch meal of 12/05/22, breakfast meal of 12/06/22, and lunch meal of 12/06/22, it was observed that all residents who received beverages in disposable cartons, including milk, thickened milk, juice and supplements, did not receive a drinking cup for the cartons' beverages. Specifically, the facility residents were required to drink straight from the disposable cartons. The facility residents were noted to receive 1 - 3 beverages on the meal trays. Interviews conducted with sampled Residents' #95, #105, and #281 at this time voiced their displeasure to be required to drink from disposable cartons. Both residents' #105 and #281 stated they have stopped drinking whole milk and thickened milk due to having difficulty drinking straight from the carton. Interview conducted with the Certified Dietary Manager on 12/06/22 revealed that she was aware that residents should be receiving a drinking cup for all beverages served via carton, however staff failed to include the drinking cups on the residents' meal trays. Documentation review and observation of Resident #95 was noted to receive up to 6 beverage cartons without a drinking cup per day. Documentation review and observation of Resident #105 was noted to receive up to 10 beverages in cartons without a drinking cup per day. Documentation review and observation of Resident #281 was noted to receive up to 6 beverage cartons per day without a drinking cup per day. Review of clinical records noted the following: Resident #95: Minimum Data Set (MDS) of 09/23/22 -Section C: BIMS Score = 14 (Cognitively Intact). Resident 105: MDS of 11/03/22 - Section C: BIMS Score = 13 (Cognitively Intact). Resident #281: MDS of 12/05/22 - Section C: BIMS Score = 15 (Cognitively Intact).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of policy and procedure, it was determined that the facility failed to ensure it secured and locked over-the-counter (OTC) expired and prescription medications for 5 of 5 residents observed during an observational room tour, Resident #80, Resident #77, Resident #68, Resident #230 and Resident #40; failed to ensure it kept its facility emergency crash cart locked and secured; failed to ensure it disposed of an expired stock medication in the South wing Treatment cart; and failed to ensure it secured loose unidentified medication pills for 1 of 6 observed medication carts during the Medication Storage Observation for the North wing medication cart. The findings included: Review of facility policy and procedure on 12/07/22 at 2:30 PM, titled, Storage of Medications, provided by the Director of Nursing (DON), revised date 08/2020, documented in part: Policy: Medications and biologicals are stored safely, securely and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedures: General Guidance .2. Only to licensed nurses personnel, pharmacy personnel, or staff members lawfully authorized to administer medications (such as medication aides) are permitted to access medications. Medication rooms, carts, and medication supplies are locked when they are not attended by persons with authorized access . 8. Outdated, contaminated or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists . 6. The nurse will check the expiration date of each medication before administering it. 7. No expired medication will be administered to a resident. 8. All expired medications will be removed from the active supply and destroyed in accordance with facility policy, regardless of amount remaining. 1. Resident #80 was originally admitted to the facility on [DATE] with diagnoses that included Alcoholic Myopathy, Diabetes Mellitus Type II and Anxiety Disorder. He had a Brief Interview Mental Status (BIM) score of 13, indicating the resident was cognitively intact. During observation conducted on 12/05/22 at 10:51 AM of Resident #80's room, it was noted there was a used tube of prescription Premethrin Cream 5% medication at the resident's bedside which was visible and unsecured on bedside dresser top accessible to other residents, employees and visitors. Photographic evidence obtained. During a brief interview with Resident #80 on 12/05/22 at 10:51 AM, the surveyor inquired of Resident #80 regarding the tube of prescription Premethrin Cream 5% medication on his bedside top who replied that he applies this cream when he has an itchy rash. On 12/05/22 at 2:02 PM, during a second observation, it was again noted there was a used tube of prescription Premethrin Cream 5% medication atop the resident's bedside dresser. On 12/06/22 at 10:36 AM, during a third observation, it was noted there was a used tube of prescription Premethrin Cream 5% medication atop the resident's bedside dresser. On 12/06/22 at 2:18 PM, during a fourth observation, it was noted there was a used tube of prescription Premethrin Cream 5% medication atop the resident's bedside dresser. On 12/07/22 at 10:09 AM, during a fifth observation, it was again noted there was a used tube of prescription Premethrin Cream 5% medication atop the resident's bedside dresser. An interview was conducted on 12/07/22 at 12:40 PM with Resident #80's nurse, Staff F, Licensed Practical Nurse (LPN), regarding the tube of prescription Premethrin Cream 5% medication on Resident #80's bedside dresser top and she acknowledged the tube of prescription Premethrin Cream 5% medication should not have been there. During an interview conducted on 12/07/22 at 12:45 PM with Staff G, LPN / Unit Manager UM, for the North wing, she indicated this resident does not self-administer any of his own medications and neither was he assessed to be able to do. A side-by-side record review of the hard copy chart and the computerized Point-Click-Care (PCC) medical record for Resident #80 was conducted with Staff G, in which it was noted that neither of the records had evidence the resident had any self-assessment completed in order for him to be to administer his own medications. There was no order on the Resident # 80's Medication Administration Record (MAR) for this over-the-counter (OTC) medication to be administered to this resident. The tube of prescription Premethrin Cream 5% medication was not removed from this resident's bedside, until after surveyor inquisition / intervention. 2. Resident #77 was admitted to the facility on [DATE] with diagnoses that included Parkinson's Disease, Diabetes Mellitus Type II, Hypertension, Anxiety Disorder and Peripheral Vascular Disease. She had a Brief Interview Mental Status (BIM) score of 14 (cognitively intact). On 12/05/22 at 11:13 AM, during an observation of Resident #77's room, it was noted there was a used bottle of (OTC) Refresh Optive eyedrops, visibly sitting on the resident's bedside table with an expiration date of 02/22, which was unsecured on bedside dresser top accessible to other residents, employees and visitors. Photographic Evidence Obtained. During a brief interview with Resident #77 on 12/05/22 at 11:13 AM, the surveyor inquired of Resident #77, regarding the bottle of (OTC) Refresh Optive eyedrops on the bedside table, who replied that she uses the eyedrops when she needs them. An interview was conducted on 12/07/22 at 12:53 PM with Resident #77's nurse, Staff F, regarding the bottle of (OTC) Refresh Optive eyedrops observed on Resident #77's bedside table, who acknowledged the medication bottle should not have been there. During an interview conducted on 12/07/22 at 1:05 PM with Staff G, she indicated this resident does not self-administer any of her own medications and neither was she assessed to be able to do so. A side-by-side record review of Resident #77's hard copy chart and the computerized Point-Click-Care (PCC) medical record was conducted with Staff G, which indicated that neither chart had evidence the resident had a self-assessment completed in order for her to be to administer her own medications. 3. Resident #68 was admitted to the facility on [DATE] with diagnoses which included Cutaneous Abscess of Chest Wall, Anemia, Dysphagia, Chronic Kidney Disease and Hypertension. He had a Brief Interview Mental Status (BIM) score of 15, indicating intact cognition. On 12/05/22 at 1:48 PM, during an observational room tour for Resident #68, it was noted there was a used tube of Nystatin cream 100,000 units prescription cream medication visibly sitting on the resident's dresser / bureau with an expiration date of 02/22, which was visible and unsecured on bedside dresser top accessible to other residents, employees and visitors. Photographic Evidence Obtained. During a brief interview with Resident #68 on 12/05/22 at 2:11 PM, the surveyor inquired of Resident #68, regarding the tube of Nystatin cream 100,000 units prescription cream medication bedside dresser table, who replied that he applies this cream for the rash on his bottom [buttocks]. An interview was conducted on 12/07/22 at 11:30 AM with Resident #68's nurse, Staff B, LPN, regarding the tube of Nystatin cream 100,000 units prescription cream medication observed on Resident #68's bedside table. He acknowledged the medication tube should not have been there. During an interview conducted on 12/07/22 at 11:51 AM with Staff E, LPN / Unit Manager (UM), for the North wing, she indicated this resident does not self-administer any of his own medications and was not assessed to be able to do so. A side-by-side record review of Resident #68's hard copy chart and the computerized Point-Click-Care (PCC) medical record was conducted with Staff E, which indicated that neither chart had evidence the resident had any self-assessment completed in order for him to administer his own medications. The tube of Nystatin cream 100,000 units prescription cream was not removed from this resident's bedside, until after surveyor inquisition / intervention. 4. Resident # 230 was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease, Pulmonary Fibrosis, Diabetes Mellitus Type II, Heart Failure, Hypertension and Syncope and Collapse. She had a Brief Interview Mental Status (BIM) score of 13 (cognitively intact). On 12/06/22 at 10:44 AM during an observation of Resident #230's room, it was noted that there was a used container of Blue Super Strength EMU cream located atop her bedside table with an expiration date of 04/2023. Photographic Evidence Obtained. During a brief interview with Resident #230 on 12/06/22 at 10:44 AM, the surveyor inquired of Resident #230 regarding the container of Blue Super Strength EMU cream located atop her bedside table who replied that she asks the staff to apply it to her feet when needed for her painful Neuropathy. During a second observation conducted on 12/06/22 at 2:21 PM, it was noted there was still a used container of Blue Super Strength EMU cream located atop her bedside table with an expiration date of 04/2023. During a third observation conducted 12/07/22 10:10 AM, it was noted there was still a used container of Blue Super Strength EMU cream located atop her bedside table with an expiration date of 04/2023. An interview was conducted on 12/07/22 at 1:15 PM with Resident #230's nurse, Staff F, regarding the container of Blue Super Strength EMU on Resident #230's bedside table, who acknowledged the medication container should not have been there. During an interview conducted on 12/07/22 at 1:20 PM with Staff G, she indicated this resident does not self-administer any of her own medications and was not assessed to be able to do so. A side-by-side record review of Resident #230's hard copy chart nor her computerized Point-Click-Care (PCC) medical record was conducted with Staff G which indicated that neither chart had evidence the resident had any self-assessment completed in order for her to be to administer her own medications. There was no order on the Resident #230's Medication Administration Record (MAR) for this OTC medication to be administered to this resident. The container of Blue Super Strength EMU OTC was not removed from this resident's bedside, until after surveyor inquisition / intervention. 5. During observation in the hallway conducted on 12/05/22 at 2:04 PM, it was noted that the facility's main front lobby Emergency crash equipment cart, containing intravenous (IV) starter kits, a bottle of Normal Saline solution with an expiration date of 10/12/23, a Glucometer machine, Blood Pressure (BP) cuff, Oxygen tubing, IV tubing, catheter kits, sponges and respiratory suction cuts and Trach cuffs and other sterile packaged emergency items, was observed to be unlocked, exposed and accessible to residents, staff and visitors. Photographic Evidence Obtained. 6. During a Medication Storage Observation conducted on 12/07/22 at 1:50 PM with the Director Of Nursing (DON), there was an expired tub of muscle & joint Vanishing gel stock medication, dated 11/22, in the South wing Treatment cart. Photographic Evidence Obtained. 7. During a Medication Storage Observation conducted on 12/07/22 at 2:00 PM with the DON, there were two (2) unidentified white pills, one (1) circular and one (1) oval shaped, located in the second and third drawers on the bottom of the North Medication cart. Photographic Evidence Obtained. On 12/07/22 at 2:20 PM, the DON further acknowledged and recognized that the (OTC) and prescriptions medications found in the resident's rooms, the facility Emergency carts, and the treatment carts, should have all been locked and secured to include no medications left at the residents' bedsides. 8. Review of Resident #40's clinical record documented an admission on [DATE] with no readmissions noted on file. The resident's diagnoses included Anemia, Heart Failure, Diabetes Mellitus, and Urinary Tract Infection (UTI). Review of Resident #40's Minimum Data Set (MDS) admissions assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 11, indicating the resident had moderate cognition impairment. The assessment documented under Functional Status the resident needed extensive assistance from the staff for her activities of daily living (ADLs). Review of Resident #40's December 2022 Treatment Administration Record (TAR) documented a physician order for Cleanse Sacro gluteal daily and as needed with soap and water, pat to dry, apply Zinc Oxide daily and leave open to air. one time a day, order date 11/12/2022. Resident #40 did not have a Self-Medication Administration care plan. Review of Resident #40's physician order did not include an order for Dermovate cream. There was not a physician order to keep medications at the bedside. On 12/05/22 at 12:04 PM, observation revealed Resident #40 in her room, sitting up in a recliner and accompanied by her daughter. Further observation revealed two bottles of Vicks Vapor Rub, a tube of Dermovate 0.05%cream, and a tube of Balmex-zinc oxide 11.35 in a plastic ziplock bag on top of the side table. (Dermovate is a brand of medicine that contains the active ingredient clobetasol propionate. This is a steroid medication which is used in the treatment of eczema and other inflammatory skin conditions like psoriasis. Cream and ointment forms are available and it is a prescription-only medicine). During an interview, the resident stated her daughter brought in the cream because her bottom was hurting and it is better. The resident stated that the Vicks Vapor Rub belongs to her daughter and that she was not using it. On 12/06/22 at 10:45 AM, observation revealed Resident #40 sitting up in the recliner. Further observation revealed the plastic ziplock bag with the Vicks Vapor Rub and the cream noted on top of the side table had been removed from the table. During an interview, the resident was asked about the plastic bag and stated that they probably put them in the drawer. The resident gave the surveyor permission to check the drawer. Observation revealed the zip lock plastic bag with two bottles of Vicks Vapor Rub, a tube of Dermovate 0.05%cream, and a tube of Balmex-zinc oxide 11.35 and Vitamin D ointment in a plastic ziplock bag in the resident's dresser's drawer. Photographic Evidence Obtained. On 12/06/22 at 5:01 PM, a side-by-side review of Resident #40's medications in her dresser's drawer was conducted with Staff, H, LPN. Staff H stated that she did not know if the medication in the ziplock bag came from the facility or not. During the review, Resident #40 stated again in Spanish that the Vicks Vapor Rub was her daughters. Staff H stated that those meds were not supposed to be in the resident's room. Staff H bagged all the medications, removed them form the resident's room and stated she would call her son about it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records review, the facility failed to ensure residents' shower preference was honored and reflective in the care plan that included involvement of residents in the quarterly update of plans of care, for 1 of 1 sampled resident, Resident #7. The findings included: Review of the Comprehensive Person-Centered Care Plans Policy, section 1, stipulated that: The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative must develop and implement a comprehensive, person-centered care plan for each resident. The SWA [Social Worker Assistant] incorrectly updated the Care Plan (CP) without first consulting with Resident #7. Review of Resident #7's Minimum Data Set (MDS) section C, Brief Interview for Mental Status (BIMS) showed that Resident #7 has his full cognitive ability. He obtained a score of 15/15, indicating intact cognition; and Section G0120-Bathing of the MDS dated [DATE] revealed that the resident required one-person physical assistance for bathing. On 09/14/21 at 11:08 AM during an interview with Resident #7, he said that he did not get assistance to shower as often and at the time that he would like. He reported that he complained to everyone about it. Review of the Shower / Bathing schedule revealed that the resident was scheduled to receive showers or bath twice a week. Documentation by staff, in the electronic task completion record, noted that Resident #7 consistently received a bath / shower as scheduled. Review of the activities of daily living (ADL) Care Plan, initiated 03/15/21, outlined that Resident #7 would receive hands-on assistance for bathing. There ws no shower indicated. During an interview with the Director of Nursing (DON) on 09/16/21 at 2:23 PM, she reported that she was not aware that the resident wanted to receive more shower days than were scheduled. She reported that during the care plan meeting with the resident, she told him that the shower schedule was not written in stone; and he may occasionally receive assistance with shower in the morning or in the afternoon. The Corporate Nurse, present during the interview, clarified that the two words shower and bathing are used interchangeably in the MDS and the CP (care plan). Review of the Care Areas Assessment, completed on 03/17/21, revealed the following: Resident #7 is a long-term care resident with the following diagnoses: Peripheral Vascular Disease, Seizure disorders, Arthritis, cataracts, history of nondisplaced fracture of greater trochanter of right Femur, subsequent encounter for closed fracture with routine healing. He is noted to be alert. He requires assistance with his ADL's. He has a history of falls and has interventions in place. He is noted to have clear speech, adequate hearing and vision with the use of glasses. He is at risk for decline due to diagnosis and conditions. Will proceed with care plans and interventions and monitor for changes. Review of the CP, dated 9/9/2021 and updated 09/16/21, after the surveyor's inquiries regarding Resident #7's shower schedule revealed: Resident #7 prefers to deviate from plan of care with treatments: Refusing lab work to be drawn, is capable of understanding risks associated with deviation from plan of care, resident's physician is aware of resident's wishes, and he often refuses showers. During an interview with the Social Worker Assistant (SWA) on 09/16/21 at 5:00 PM, he reported that he has been working at this facility for 6 years. He stated that he updated Resident #7's care plan after he interviewed one of the Certified Nursing Assistants (CNA) who informed him that Resident #7 often refused to shower. Meanwhile, the SWA affirmed that he did not confirm that information with the resident before updating the Care Plan. A follow-up interview with Employee-V on 09/17/21 at 1:14 PM confirmed that Resident #7 refused showers when offered because he would prefer to receive his shower earlier than when offered. Employee-V said that she usually comes to work at 9:00 AM or 10:00 AM. When she comes to work, Resident #7 is usually bathed and dressed at that time; consequently, he often says that he will shower another time. During a follow-up interview conducted with Resident #7 on 09/17/21 at 1:31 PM, he reiterated that when he refused to take a shower it is because the time it is offered is usually too late during the day, and when he is willing to shower, his CNA often told him 'Not now, later, or I will do it the next day'. He said consequently he does not get to shower. He said that they now rectified the problem, they agree for him to receive his showers early in the morning. Review of the updated shower schedule showed that Resident #7 will receive three showers a week, Monday, Wednesday, and Friday.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to maintain a safe, clean, comfortable, and homelike environment in resident rooms, related to Residents #87, #56 and several residents' rooms. The findings included: 1. Review of the record showed that Resident #87 was admitted to the facility on [DATE] with the following diagnoses: Hyperlipidemia, Hypertension, and Type 2 Diabetes Mellitus. Review of Section C of the Quarterly Minimum Data Set (MDS) dated [DATE] documented that Resident #87 had a Brief Interview for Mental Status (BIMS) of 14, which indicated that he was cognitively intact. During an interview conducted on 09/14/21 at 10:34 AM, Resident #87 stated that the bottom two panels on his window have been broken since July. He further stated that he informed maintenance and was told that they were working on it. Resident #87 then reported that he was removed from his room about 1 month ago so that the facility could paint the walls in his room. According to him, they placed him back into his room without finishing painting his walls. Resident #87 then showed the surveyor that the walls had different colors of paint. Resident #87 stated, It doesn't make me feel very important. Review of the record showed that Resident #56 was admitted to the facility on [DATE] with the following diagnoses: Hypertension and Type 2 Diabetes Mellitus. Review of Section C of the Quarterly MDS dated [DATE] documented that Resident #56 had a BIMS of 15, which indicated that she was cognitively intact. 2. During an interview conducted on 09/16/21 at 8:46 AM, Resident #56 informed the surveyor that the footboard of her bed was chipped with large chunks of wood missing from it, exposing the screws underneath. 3. During the environment tour conducted on 09/17/21 at 8:37 AM, accompanied by the Maintenance Director, the following were noted: a. room [ROOM NUMBER]: The wall above the window bed had peeling paint. The wall by the bathroom door was chipped and had peeling paint. b. room [ROOM NUMBER]: The wall by the door had chipped and peeling paint. c. room [ROOM NUMBER]: The door to the room had chipped and peeling paint. d. room [ROOM NUMBER]: The wall by the door had black streaky marks. e. room [ROOM NUMBER]: The wall to the right of the window had chipped and peeling paint. f. room [ROOM NUMBER]: The bottom two panels of the window were broken and detached from the handle that controlled their movement. The wall by the bathroom door had black streaky marks. The wall to the right of the television was missing paint. The wall to the right of the window was observed with spots of different colored paint. g. room [ROOM NUMBER]: The wall to the right of the air conditioning unit had chipped and peeling paint. The air conditioning unit had chipped paint and black streaky marks. The footboard of the window bed had large chunks of wood missing from it, exposing the screws underneath. h. room [ROOM NUMBER]: The wall by the bathroom door had black streaky marks. The wall above the door bed had a gouge in the wooden trim. Following the tour, the Maintenance Director confirmed the findings of the tour and stated that these issues had never been brought to his attention. He stated that a computerized TELS system (maintenance reporting system) was available for staff to report maintenance / environmental issues. He further stated that he relied on the Certified Nursing Assistants and nurses to report issues to him via the TELS system. According to him, all staff were in-serviced on the TELS system and knew that environmental issues (such as those identified during the tour) could be reported to maintenance. The Maintenance Director stated that he mostly received work orders for phones or remotes and has not had any work orders regarding the paint or walls in resident rooms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of policy and procedure, the facility failed to provide care and services in accordance with activities of daily living related to fingernail grooming for 4 of 28 residents, Resident #101, Resident #19, Resident #116 and Resident #55; and failed to provide care and services in accordance with activities of daily living for facial hair trimming / shaving for 2 of 28 residents, Resident #116 and Resident #55. The findings included: Review of facility policy and procedure on 09/17/21 at 1:25 PM, for Activities of Daily Living (ADLs), Supporting Policy provided by the (DON) revised March 2018, indicated that residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support assistance with: a. Hygiene (bathing, dressing, grooming, and oral care); .Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice. The resident's response to interventions will be monitored, evaluated and revised as appropriate. Review of facility policy and procedure on 09/17/21 at 1:36 PM, for Fingernails Care Policy provided by the (DON) revised February 2018, indicated that the purpose of this procedure is to clean the nail bed, to keep nails trimmed, and to prevent infection .The following should be recorded in the resident's medical record: 1. The date and time that nail care was given. 2. The name and title of the individual (s) who administered the nail care . 1. Resident #101, was originally admitted to the facility on [DATE] with diagnoses that included Hemiplegia and Hemiparesis following unspecified Cerebrovascular Disease affecting left non-dominant side, Generalized Muscle Weakness, Dementia, Chronic Kidney Disease, Contracture, Seizures, Vitamin Deficiency, Major Depressive Disorder and Anxiety Disorder. She had a Brief Interview Mental Status (BIM) score of 10 (moderately impaired). On 02/21/21, the computerized care plan documented for Resident #101, indicated that the resident has a self-care deficit with . grooming and needs assistance with personal care tasks .Interventions include: assist with nail shaping, keep nails short and clean. During an initial observation of the resident conducted on 09/14/21 at 10:43 AM, Resident #101 was observed as having long, dirty, sharp, unkempt fingernails on both hands with the fingernail on her left-hand middle finger noted to be turned up. During a brief interview conducted with Resident #101 on 09/14/21 at 10:47 AM, she indicated that she does not like her nails to be this way. She said that the facility used to take care of them. She also added that she recalls mentioning this to one of the staff members before, but she does not know exactly who or when she did so. During a second observation of the resident conducted on 09/14/21 at 1:50 PM, Resident #101 was still observed as having long, dirty, sharp, unkempt fingernails on both hands. During a third observation of the resident conducted on 09/15/21 at 10:56 AM, Resident #101 was still observed as having long, dirty, sharp, unkempt fingernails on both hands. During a fourth observation of the resident conducted on 09/15/21 at 3:40 PM, Resident #101 was still observed as having long, dirty, sharp, unkempt fingernails on both hands. During a fifth observation of the resident conducted on 09/16/21 at 9:30 AM, Resident #101 was still observed as having long, dirty, sharp, unkempt fingernails on both hands. Photographic evidence obtained of Resident #101's long, dirty, sharp, unkempt fingernails. The resident stated at this time, that she even mentioned this to one of the staff members since this surveyor spoke with her earlier this week during the survey, but that still no one had come to trim and clean her fingernails for her. An interview was conducted with Staff C, a certified nursing assistant (CNA), on 09/16/21 at 1:16 PM, in which she acknowledged that Resident #101's fingernails were dirty, sharp and unkempt and should have been kept clean and trimmed. An interview was conducted with Staff D, a Licensed Practical Nurse (LPN), on 09/16/21 at 1:22 PM, in which she also acknowledged that Resident #101's fingernails were dirty, sharp and unkempt and should have been kept clean and trimmed. A side-by-side record review of the computerized Flowsheet schedule for September 2021 with Director of Nursing (DON) indicated that Resident #101 was signed off on Monday 09/14/21 and Tuesday 09/15/21 as having received nail care on the 7AM-3PM shift. Record review on Monday 09/14/21 of the computerized (CNA) Task list indicated that for Resident #101, nail care had been provided to the resident on the 7AM-3PM shift. Further record review of the computerized [NAME] also indicated that nail care had been provided for Resident #101, with a notation to assist with nail shaping, keep nails short and clean. 2. Resident #19 was admitted to the facility on [DATE] with diagnoses that included Dementia, Generalized Muscle Weakness, Diabetes Mellitus Type II, Protein-Calorie Malnutrition, Vitamin Deficiency, Anxiety Disorder and Major Depressive Disorder. She had a Brief Interview Mental Status (BIM) score of 00 (severely impaired). On 05/01/13, the computerized care plan documented for Resident #19, indicated that the resident has a self-care deficit with . grooming and needs assistance with personal care tasks .Intervention: assist with nail shaping .provide hands on assistance with grooming. During an observation of the resident conducted on 09/14/21 at 10:50 AM, Resident #19 was observed to have dirty, unkempt and jagged fingernails on both hands. During a second observation of the resident conducted on 09/14/21 at 1:50 PM, Resident #19 was still observed with dirty, unkempt and jagged fingernails on both hands. During a third observation of the resident conducted on 09/15/21 at 11:09 AM, Resident #19 was still observed with dirty, unkempt and jagged fingernails on both hands. During a fourth observation resident conducted on 09/15/21 at 3:40 PM, Resident #19 was still observed with dirty, unkempt and jagged fingernails on both hands. During a fifth observation of the resident conducted on 09/16/21 at 9:39 AM, Resident #19 was still observed with dirty, unkempt and jagged fingernails on both hands. Photographic evidence obtained of Resident #19's dirty, unkempt and jagged fingernails. An interview was conducted with Staff C, a certified nursing assistant (CNA) on 09/16/21 at 1:16 PM, in which she acknowledged that Resident #19's fingernails were dirty, sharp and unkempt and should have been kept clean and trimmed. An interview was conducted with Staff D, a Licensed Practical Nurse (LPN) on 09/16/21 at 1:22 PM, in which she also acknowledged that Resident #19's fingernails were dirty, sharp and unkempt and should have been kept clean and trimmed. A side-by-side record review of the computerized Flowsheet schedule for September 2021 with Director of Nursing (DON) indicated that Resident #19 was signed off on Monday 09/14/21 and Tuesday 09/15/21 as having received nail care on the 7AM-3PM shift. Record review on Monday 09/14/21 and Tuesday 09/15/21 of the computerized (CNA) Task list indicated that for Resident #19, nail care had been provided to the resident on the 7AM-3PM shift. Further record review of the computerized [NAME] also indicated that nail care had been provided for Resident #19, with a notation to assist with nail shaping, keep nails short and clean. 3. Resident #116 was admitted to the facility on [DATE] with diagnoses which included Cerebral Infarction, Polyneuropathy, Vitamin Deficiency, Contracture left Hand, Major Depressive Disorder and Anxiety Disorder. He had a Brief Interview Mental Status (BIM) score of 15 (cognitively intact). On 02/21/21, the computerized care plan documented for Resident #116, indicated that the resident has a self-care deficit with . grooming and needs assistance with personal care tasks .Interventions include: assist with nail shaping, keep nails short and clean. During an initial observation of the resident conducted on 09/14/21 at 11:03 AM, Resident #116 was noted to have long, sharp, unkempt fingernails on both hands. During a brief interview conducted with Resident #116 on 09/14/21 at 11:03 AM, he stated that he would like to have his fingernails trimmed because he does not like this. He said that when he mentions this to the staff, they tell him that they are too busy and do not have time to do it. During a second observation of the resident conducted on 09/14/21 an 1:48 PM, Resident #116 was still noted to have long, sharp, unkempt fingernails on both hands. During a third observation of the resident conducted on 09/15/21 at 11:06 AM, Resident #116 was still noted to have long, sharp, unkempt fingernails on both hands. During a fourth observation of the resident room on 09/15/21 at 3:43 PM, Resident #116 was still noted to have long, sharp, unkempt fingernails on both hands. During a fifth observation of the resident conducted on 09/16/21 at 9:51 AM, Resident #116 was still noted to have long, sharp, unkempt fingernails on both hands. Photographic evidence obtained of Resident #116's long, sharp, unkempt fingernails. Resident #116 also stated that he even mentioned this to one of the staff members, since this surveyor spoke with him earlier this week, but the resident said that still no one has come to trim and clean his fingernails. An interview was conducted with Staff E, a (CNA) on 09/16/21 at 12:41 PM regarding the resident's long fingernails, and she acknowledged that the fingernails were long and sharp and should have been kept trimmed. An interview was conducted with Staff F, an (LPN) on 09/16/21 at 12:41 PM regarding the resident's long fingernails, and she also acknowledged that the fingernails were long and sharp and should have been kept trimmed. A side-by-side record review of the computerized Flowsheet schedule for September 2021 with Director of Nursing (DON) indicated that Resident #116 was signed off on Monday 09/14/21 and Tuesday 09/15/21 as having received nail care on the 7AM-3PM shift. Record review on Monday 09/14/21, Tuesday 09/15/21 and Wednesday 09/16/21 of the computerized (CNA) Task list indicated that for Resident #116's nail care had been provided to the resident on the 7AM-3PM shift. Further record review of the computerized [NAME] also indicated that nail care had been provided for Resident #116. On 09/15/21, the most recent computerized care plan documented for Resident #116, that the resident has a self-care deficit with .grooming .needs assistance with personal care tasks. Intervention: provide hands on assistance with grooming. There is no mention / notation anywhere in this care plan that indicates that Resident #116 prefers to have long nails. Subsequently, on 09/16/21, the facility provided an altered / updated care plan dated 03/09/21, that now documented for Resident #116, that the resident 'prefers to have long nails', only after surveyor inquisition / intervention. 4. Resident #55 was admitted to the facility on [DATE] with diagnoses which included Cerebral Atherosclerosis and Hypertension. He had a Brief Interview Mental Status (BIM) score of 11 (moderately impaired). On 02/21/21, the computerized care plan documented for Resident #55, indicated that the resident has a self-care deficit with . grooming and needs assistance with personal care tasks .Interventions include: provide hands on assistance with grooming. During an initial observation of the resident conducted on 09/14/21 at 11:08 AM, Resident #55 was observed with dirty, unkempt fingernails. During a second observation of the resident conducted on 09/14/21 at 1:47 PM, Resident #55 was still noted to have dirty, unkempt fingernails. During a third observation of the resident conducted on 09/15/21 at 11:07 AM, Resident #55 was still noted to have dirty, unkempt fingernails. During a fourth observation of the resident room tour conducted on 09/15/21 at 3:45 PM, Resident #55 was still noted to have dirty, unkempt fingernails. During a fifth observation of the resident conducted on 09/16/21 at 9:41 AM, Resident #55 was still noted to have dirty and unkempt fingernails. Photographic evidence obtained of Resident #55's dirty and unkempt fingernails. An interview was conducted with Staff G, a certified nursing assistant (CNA) on 09/16/21 at 1:16 PM, in which she acknowledged that Resident #55's fingernails were dirty and unkempt and should have been kept clean and trimmed. An interview was conducted with Staff D, a Licensed Practical Nurse (LPN) on 09/16/21 at 1:25 PM, in which she also acknowledged that Resident #55's fingernails were dirty and unkempt and should have been kept clean and trimmed. A side-by-side record review of the computerized Flowsheet schedule for September 2021 with Director of Nursing (DON) indicated that Resident #55 was signed off on Monday 09/14/21, Tuesday 09/15/21 and Wednesday 09/16/21 as having received nail care on the 7AM-3PM shift. Record review on Monday 09/14/21, Tuesday 09/15/21 and Wednesday 09/16/21 of the computerized (CNA) Task list indicated that for Resident #55, nail care had been provided to the resident on the 7-3 PM shift. Further record review of the computerized [NAME] also indicated that nail care had been provided for Resident #55. In observation, none of the above four (4) listed resident's fingernails were cleaned and trimmed, until after surveyor intervention. 5. On 02/21/21, the computerized care plan documented for Resident #116, that the resident has a self-care deficit with . grooming and needs assistance with personal care tasks . During an initial observation fo the resident conducted on 09/14/21 at 11:03 AM, Resident #116 was noted to have a full, overgrown beard. During a second observation of the resident conducted on 09/14/21 at 1:48 PM, Resident #116 was still noted to have a full, overgrown beard. During a third observation of the resident conducted on 09/15/21 at 11:06 AM, Resident #116, was still noted to have a full, overgrown beard. During a fourth observation of the resident conducted on 09/15/21 at 3:43 PM, Resident #116 was still noted to have a full, overgrown beard. During a fifth observation of the resident conducted on 09/16/21 at 9:51 AM, Resident #116 was still noted to have a full, overgrown beard. An interview was conducted with Staff E, a (CNA) on 09/16/21 at 12:41 PM regarding the resident's beard, and she acknowledged that the resident's beard was overgrown and should have been kept neatly shaven. An interview was conducted with Staff F, an (LPN) on 09/16/21 at 12:41 PM regarding the resident's beard, and she also acknowledged that the resident's beard was overgrown and should have been kept neatly shaven. A side-by-side record review of the computerized Flowsheet schedule for September 2021 with Director of Nursing (DON) indicated that Resident #116 was signed off on Monday 09/14/21, Tuesday 09/15/21 and Wednesday 09/16/21 as having received personal hygiene to include shaving. Record review on Monday 09/14/21, Tuesday 09/15/21 and Wednesday 09/16/21 of the computerized (CNA) Task list indicated that for Resident #116, that personal hygiene to include shaving, had been provided to the resident. The resident also stated at this time that he even mentioned this to one of the staff members since this surveyor spoke with her earlier this week during the survey, but the resident said that still no one has come to trim his beard. 6. On 02/21/21, the computerized care plan documented for Resident #55, that the resident has a self-care deficit with . grooming and needs assistance with personal care tasks .Interventions include: provide hands on assistance with grooming. During an initial observation of the resident conducted on 09/14/21 at 11:08 AM, Resident #55 was observed with unshaven, scraggly beard/facial hair. During a second observation of the resident conducted on 09/14/21 at 1:47 PM, Resident #55 was still noted to have unshaven, scraggly beard/facial hair. During a third observation of the resident conducted on 09/15/21 at 11:07 AM, Resident #55 was still noted to have shaven, scraggly beard/facial hair. During a fourth observation of the resident conducted on 09/15/21 at 3:45 PM, Resident #55 was still noted to have unshaven, scraggly beard/facial hair. On 09/15/21 at 3:45 PM, Resident #55 was subsequently provided a facial shave, but only after surveyor inquisition. A side-by-side record review of the computerized Flowsheet schedule for September 2021 with Director of Nursing (DON) indicated that Resident #55 was signed off on Monday 09/14/21, Tuesday 09/15/21 and Wednesday 09/16/21, as having received personal hygiene to include shaving. Record review on Monday 09/14/21, Tuesday 09/15/21 and Wednesday 09/16/21 of the computerized (CNA) Task list indicated that for Resident #55, that personal hygiene to include shaving, had been provided to the resident. In observation, the four (4) resident's fingernails had not been cleaned or trimmed and the above two (2) male resident's beard / facial hair had been cut/trimmed, until after surveyor inquisition / intervention. The Director of Nursing (DON) further acknowledged that Resident #19, Resident # 55, Resident #101, and Resident #116, all had fingernails that were either dirty, unkempt, sharp or long and should have been kept clean and trimmed. The (DON) also acknowledged that both Resident #55 and Resident #116 had facial beard hair that was unshaven and unkempt and should have been shaven; this was not done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility's policy titled, Resident Mobility and Range of Motion, revised in July 2017, documented the following: Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in range of motion. Residents with limited mobility will receive appropriate services, equipment, and assistance to maintain or improve mobility. Review of the facility's policy titled, Splints and Braces, revised in December 2020, documented the following: 'Splints and braces are usually fabricated and provided by the Occupational Therapists and/or Physical Therapists to treat temporary conditions of muscle weakness, joint limitations, pain and swelling. On occasion, the splints and braces may be required for long term use to prevent contracture or to stabilize joints. If splint/brace is recommended and therapy services indicated, therapist must obtain physician order. [NAME] patient splint/brace according to positioning/splinting instructions. Allow patient to wear splint/brace per therapist recommended wearing schedule and/or as tolerated.' Review of the record for Resident #4 showed that she was admitted to the facility on [DATE] with the following, in part, diagnoses: Contracture Unspecified Joint, Muscle Wasting and Atrophy, and Quadriplegia. Review of Section C of the Quarterly Minimum Data Set (MDS) dated [DATE] documented that a Brief Interview for Mental Status was not conducted for Resident #4 as she was rarely / never understood. Review of Section O of the Quarterly MDS documented that Resident #4 received Occupational Therapy (OT) from 07/01/21 to 09/03/21. Review of the Care Plan, dated 07/01/21, documented that Resident #4 displayed decreased joint range of motion. Goals were to tolerate bilateral hand and elbow splints for 4-6 hours with good skin integrity to prevent further contractures. Review of the Physician's orders conducted on 09/16/21 at 1:05 PM showed that Resident #4 did not have any orders for hand or elbow splints. During an observation conducted on 09/15/21 at 8:34 AM, Resident #4 was lying awake in bed. Closer observation showed that she had a left hand contracture with no splint. During an observation conducted on 09/15/21 at 10:24 AM, Resident #4 was lying in bed looking at her television. Closer observation showed that she was not wearing a splint on her left hand. During an observation conducted on 09/15/21 at 11:49 AM, Resident #4 was lying awake in bed. Closer observation showed that she was not wearing a splint on her left hand. During an observation conducted on 09/15/21 at 1:51 PM, Resident #4 was lying awake in bed. Closer observation showed that she was not wearing a splint on her left hand. During an observation conducted on 09/16/21 at 8:44 AM: Resident #4 was lying awake in bed. Closer observation showed that she was not wearing a splint on her left hand. During an observation conducted on 09/16/21 at 10:11 AM, Resident #4 was lying awake in bed. Closer observation showed that she was not wearing a splint on her left hand. During an observation conducted on 09/16/21 at 11:35 AM, Resident #4 was lying awake in bed. Closer observation showed that she was not wearing a splint on her left hand. During an interview conducted on 09/16/21 at 1:32 PM, Staff A, Licensed Practical Nurse, stated that he did not know if Resident #4 wore splints. He then reviewed the Physician's orders for Resident #4 with the surveyor and stated that he did not see any orders for splints. Staff A then asked the MDS Director to review the Physician's Orders for Resident #4. The MDS Director reviewed the Physician's orders with the surveyor and stated that she did not see any orders for splints either. She then stated, Residents with splints should have an order unless they are in therapy doing a trial. During an interview conducted on 09/16/21 at 1:43 PM, the Director of Rehab stated that OT was responsible for upper extremity splints and that Physical Therapy was responsible for lower extremity splints. He further stated that residents may need a splint if they develop a contracture and that when a splint is to be issued to a resident, there is always a Physician's order. When asked about orders for splints, the Director of Rehab stated, We talk to the Physician and tell them of what we would advise and the doctor places the order. According to the Director of Rehab, restorative nursing was responsible for donning / doffing splints. He stated that if it was not too complicated, the floor Certified Nursing Assistants (CNAs) and nurses would be responsible for donning / doffing splints. When asked about Resident #4, the Director of Rehab stated that she was discharged from OT on 09/03/21. The Director of Rehab reviewed the OT Discharge summary dated [DATE] and stated that at that time, Resident #4 tolerated her left hand splint for 4.5 hours with no redness. He stated that the Occupational Therapist recommended for Resident #4 to continue to wear her elbow and hand splints. When asked if Resident #4 had current Physician's orders for splints, the Director of Rehab stated that he did not know how to use the computer system and that he needed to ask the Director of Nursing. Review of the Physician's orders conducted on 09/16/21 at 2:09 PM showed that Resident #4 had an order to apply bilateral elbow splint and bilateral resting hand splints after morning care and to doff splints prior to afternoon care. Further review showed that this order was placed on 09/16/21 at 1:51 PM, after the surveyor's interview with the Director of Rehab. This showed that an order for splints was not placed until 13 days after Resident #4 was discharged from OT. During an interview conducted on 09/16/21 at 2:40 PM, Staff B, Restorative CNA, stated that Resident #4 wore an elbow splint for 4 hours per day and wore a hand splint for 2 hours per day. Staff B stated that on 09/15/21, she donned Resident #4's elbow and hand splints at 10:00 AM and removed them around 2:30 PM. She then stated that she donned Resident #4's hand splint today at 12:00 PM. She said, Resident #4 tolerated her elbow and hand splints well. When asked about documentation, Staff B stated that she documented the donning and doffing of splints in PointClickCare (electronic charting system). The surveyor reviewed the CNA Task titled, Restorative nursing program staff will don bilateral elbow and bilateral wrist splints after AM care during daytime and doff before PM care, with Staff B, who stated that this did not look familiar and that she did not conduct any of the documentation in this task. She further stated, Sometimes therapy documents there, maybe they were the ones who did it. Staff B then stated that she charted the donning / doffing of splints elsewhere in PointClickCare and would bring her documentation to review with the surveyor. During a subsequent interview with Staff B on 09/17/21 at 12:10 PM, she provided the surveyor with a printed copy of the CNA task titled, Restorative nursing program staff will don bilateral elbow and bilateral wrist splints after AM care during daytime and doff before PM care. She changed her story and stated that this is where she documented the donning / doffing of splints. Review of the CNA Task titled, Restorative nursing program staff will don bilateral elbow and bilateral wrist splints after AM care during daytime and doff before PM care, showed that the task was marked as completed on 09/15/21 at 12:17 PM, on 09/15/21 at 8:37 PM, on 09/16/21 at 12:26 PM, and on 09/16/21 at 5:39 PM. This showed that the documentation for the donning / doffing of splints did not correlate with the surveyor's observations or with the timeframes Staff B reported as donning / doffing the splints. During a subsequent interview conducted on 09/16/21 at 9:27 AM, the Director of Rehab stated that therapy did not document the donning / doffing of splints under CNA tasks. When asked why an order for splints was placed for Resident #4 on 09/16/21, the Director of Rehab stated, They wanted clarification as to when to use the splints so the order was clarified. When asked why Resident #4 did not have any physician orders for splints prior to 09/16/21, the Director of Rehab stated that he did not know. Based on observation, interview, record review and review of policy and procedure, the facility failed to ensure that it maintained and monitored for proper body positioning and body alignment, at all times, for 2 of 2 sampled residents, Resident #38 and #31; and failed to order and apply splints in a timely manner for 1 of 1 sampled resident reviewed for limited range of motion, Resident #4. The findings included: 1. On 09/17/21 at 1:35 PM, review of facility policy and procedure for Repositioning, provided by the (DON) revised May 2013, indicated that the purpose of this procedure is to provide guidelines for the evaluation of resident repositioning needs, to aid in the development of an individualized care plan for repositioning, to promote comfort for all bed-or-chair bound residents and to prevent skin breakdown, promote circulation and provide pressure relief for residents General Guidelines: 1. Repositioning is a common, effective intervention for preventing skin breakdown, promoting circulation, and providing pressure relief 3. Repositioning is critical for a resident who is immobile or dependent upon staff for repositioning . 1a. Resident #38 was originally admitted to the facility on [DATE] and is medically fragile with a Ventilator and Tracheostomy in place and totally dependent on staff for care, nutrition and hydration. He had a Brief Interview Mental Status (BIMS) of severely impaired cognition. During an initial observation of the resident room tour conducted on 09/14/21 at 1:04 PM, Resident #38, was observed lying on the left side of his body, but on the farthest left end side of his bed, with the left side of his face pressed flush against and directly on top of the left side bed rail with no pillow, cushion or other support in place for his head. During a second observation of the resident conducted on 09/14/21 at 1:57 PM, Resident #38's head and neck were both now observed to have advanced / extended a couple of inches further to the left side with his head and neck being supported only by the resident's 'own power' just beyond the bed rail. Resident #38 was observed to be in this uncomfortable, poor body alignment position for a period of almost one hour, before there was intervention by facility staff. On 09/16/21 at 01:56 PM, an interview was conducted with Staff H, a certified nursing assistant (CNA), who he acknowledged that the resident has a tendency to go over to his left side. He agreed that the resident's left side of his face should not have been pressing into the of his bed rail. On 09/16/21 at 2:02 PM, an interview was conducted with Staff I, a Licensed Practical Nurse (LPN) / Medical Records Director, who he also acknowledged that the resident has a tendency to go over to his left side, but he also agreed that the resident's left side of his face should not have been pressing into the side of his bed rail. On 09/14/21, the facility's computerized task list documented that Resident #38 was total dependence requiring full staff performance. Record review of Resident #38's care plan, dated 06/25/20, revealed that Resident #38 is at risk for further alteration in skin integrity due to decreased mobility / physical limitations .and requires turning and repositioning to promote offloading of pressure. 1b. Resident #31 was admitted to the facility on [DATE] with diagnoses which included Unspecified Fracture of left Femur and of part of neck of right Femur, Generalized Muscle Weakness, Schizophrenia, Dementia, Major Depressive Disorder, Anxiety Disorder and Peripheral Vascular Disease. He had a Brief Interview Mental Status (BIMS) score of 02 (severely impaired). During an initial observation of the resident conducted on 09/15/21 at 10:12 AM, Resident #31 was observed lying in bed on the left side of his back. Resident #31's head was located to the far left-side of the bed with the left side of his face observed pressed (flush) against the left side of his bed rail and his left cheek had a visible reddish-pink area noted. During a second observation of the resident conducted on 09/15/21 at 12:30 PM, Resident #31 was still noted to be lying on the left side of his back with his head located to the far left side of the bed, with the left side of his face still pressed against the left side of his bed rail. The resident was observed to be in this uncomfortable, poor body alignment position for a period of over two (2) hours. Photographic evidence obtained of resident lying in bed with poor body alignment. On 09/16/21 at 01:52 PM, an interview was conducted with Staff J, a (CNA), who she acknowledged that the resident's left side of his face should not have been pressing into his bed rail. On 09/15/21 at 12:40 PM, an interview was conducted with Staff K, an (LPN), who acknowledged that the resident's left side of his face should not have been pressing into his bed rail. On 09/15/21, the facility's computerized task list documented that Resident #31 was total dependence requiring full staff performance. Record review of Resident #31's care plan, dated 01/10/18, revealed that Resident #31 has potential for skin impairment .related to impaired mobility and he requires staff to assist in turning and repositioning to promote offloading of pressure. The Director of Nursing (DON) acknowledged and agreed that the resident's body alignment should be maintained and monitored at all times; this was not done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure residents returned their cigarette lighters to the nursing station after smoking to prevent potential accidents for 1 of 1 sampled resident for smoking review, Resident #79. The findings included: Review of the facility's policy, titled, Safe Smoking revised on 11/01/16, documented, .residents that are smokers may not keep lighters .on their person or in their room unless provided by the nurse to be used during smoking opportunities. Lighters/ignition materials must be maintained at the resident's designated nurses' station or other centralized location . Review of Resident #79's clinical record documented an initial admission to the facility on [DATE] with a readmission on [DATE]. The resident diagnoses included, in part, Chronic Obstructive Pulmonary Disease (COPD), Schizophrenia, Unspecified psychosis, Heart Failure and Diabetes Mellitus. Review of the resident Smoking Evaluation, dated 08/31/21, documented, .resident observation .resident utilizes ashtrays safely and properly (gets ashes into ashtray. Does not cause/allow sparks or tobacco to fall anywhere but into ashtray .maintenance of smoking materials: security. All lighters, matches, lighting materials are kept in a secure location by nursing Review of Resident #79's care plan, titled, Resident has been assessed as able to smoke, initiated on 08/30/21, had an intervention to include maintain smoking materials in designated area . On 09/14/21 at 9:39 AM, observation revealed Resident #79 propelling himself down the hallway in a wheelchair. Observation revealed the resident approached Staff S, Unit Clerk, and asked for three cigarettes. Staff S replied No and gave him two. Staff S stated, 'you have the lighter right?' The resident replied no and continue to wheel himself down the hallway. On 09/17/21 at 9:29 AM, an interview was conducted with Staff O, a Certified Nursing Assistant, who stated that Resident #79 goes to smoke when he wants to go. She stated she did not know the smoking times. On 09/17/21 at 9:35 AM, a joint interview with Staff O and Resident #79 was conducted. Staff O asked the resident if he had a lighter with him and he stated yes. Staff O told the resident that he was not allowed to have it and asked the resident to give it to her and the resident refused. Observation revealed Resident #79 got upset about Staff O asking for his lighter, stating he brought the lighter in from the hospital. The resident voice tone was loud and he did not voluntarily give his lighter to Staff O. On 09/17/21 at 9:39 AM, an interview was conducted with Resident #79. The resident was asked if he was smoking today, and he stated he had no cigarettes. The resident was asked about his lighter and he pulled a red lighter from his pants pocket. He stated that he needed the lighter to light his cigarette when he goes to smoke. On 09/17/21 at 9:41 AM, an interview was conducted with Staff S and was asked about the smoking process when the residents want to smoke. Staff S said, they come to the nurse's station, and she gives them the cigarette and the lighter. Staff S added that the residents are supposed to return the lighter when they come back from smoking. Staff S stated Resident #79 had a smoking schedule and that he goes out to smoke after breakfast about 9:00-9:30 AM and after lunch. Staff S stated Resident #79 was not supposed to have cigarettes or lighter in his room and that they, the nurses, take the lighter away from him. Staff S stated they kept the residents lighter and cigarettes in a locked box at the nurse's station. A side a side review and observation with Staff S of the Rapid Recovery South unit's box with a label that read Lighter's Storage box was conducted. The observation revealed an opened box of cigarettes and no lighters. Staff S stated the opened box was Resident #79 cigarettes. Staff S was asked if Resident #79's lighter should be in the box and stated that the nurse is supposed to ask the resident for his lighter when he comes back from smoking. Staff S was apprised that Resident #79 had a lighter with him in his room. On 09/17/21 at 9:49 AM, an interview was conducted with Staff N, Unit Manager. Staff N stated that the residents are to return their lighter to the nurse's station once they come from smoking. She added that they are not allowed to keep a lighter or cigarettes with them in their room. Staff N was apprised about Resident #79 having a lighter with him in his room and was asked to check with the resident. Staff N stated that the resident knows that he is not have a lighter with him. On 09/17/21 at 10:07 AM, a tour to the facility designated smoking area was conducted. The walking distance to the area from Resident #79's unit was around 260 feet. Resident #79 passed by multiple resident rooms in the south unit, while carrying a lighter and cigarettes. Observation revealed four random residents at the designated smoking area. Observation revealed Staff P, a Restorative Aide, sitting to the far left of the area. An interview was conducted with Staff P who stated she was watching the residents smoking. Further observation revealed ashtrays at the tables where random residents were smoking. Staff P stated the residents get their lighter and cigarettes from the nurse's station. On 09/17/21 at 10:13 AM, continued observation revealed Resident #79 propelled himself in a wheelchair and entered the designated smoking area. The resident parked himself to the far-right side of the area, about 35 feet away from Staff P. Resident #79 was observed lighting a cigarette. Further observation revealed no ashtrays on the table next to the resident. During an interview, the resident was asked where the ashtrays were and he was pointed to the table in the middle of the smoking area, about 10 feet away from him. Observations revealed cigarette ashes on the floor and under his feet. Staff P was asked to come over to Resident #79 and she was asked again about her responsibilities and stated that she watches (them) to make sure they drop the cigarette buds on the ashtray. She asked about Resident #79's ashtray and stated that he was seating at another table. She was apprised that resident did sat at another table and did not have ashtray. Staff P was apprised about ashes and cigarette bud on the floor next to the resident. During an interview, Resident #79 stated he picked butts from the ashtray because he did not have cigarette on yesterday. On 09/17/21 at 10:58 AM, observation revealed the Director of Nursing (DON) in the smoking area by Resident #79 and moved the table closer to the bushes where the cigarette bud and ashes from Resident #79 were. On 09/17/21 at 3:17 PM, a joint interview was conducted with the DON, the Minimum Data Set (MDS) Coordinator and the Regional Nurse. The DON stated that the staff assigned to the designated smoking area are there for hydration and to make sure the residents are keeping social distancing. The DON was apprised about observation during Resident #79 smoking session. The DON stated that the resident was assessed on admission and that it was safe for him to be smoking independently. The MDS coordinator stated that the resident needed to be reassessed for safe smoking. The DON stated that Resident #79 was considered alert and was educated on safety and the facility policy. The DON was apprised that the resident had a lighter in his pocket in his room. She stated the resident was supposed to turn the lighter in and if he did not, they had to educate and reinforce the policy. The DON stated anything can happen, there are safety issues, and he violated the facility policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide appropriate care to prevent future urinary tract infections during perineal / foley care for 1 of 1 sampled resident reviewed for catheter (Foley) care, Residents #115. The findings included: Review of the facility's policy titled Catheter Care, Urinary, revised on 09/2014, documented .The purpose of this procedure is to prevent catheter-associated Urinary Tract Infections .remove gloves .wash and dry hands for a male resident: use a washcloth with warm water and soap and cleanse around the meatus. Cleanse the glands using circular strokes from the meatus outward. Change the position of the washcloth with each cleansing stroke. With a clean washcloth, rinse with warm water using above technique use a clean washcloth .to cleanse and rinse the catheter from insertion site to approximate four inches outward . Review of the facility's policy titled, handwashing/Hand Hygiene revised on 08/2015, documented .use an alcohol-based hand rub containing at least 62% alcohol or alternatively soap and water for the following situations . before moving from a contaminated body site to a clean body site during resident care . after removing gloves . hand hygiene is the final step after removing and disposing of personal protective equipment . Review of Resident #115's clinical record documented an initial admission to the facility on [DATE] with a readmission on [DATE]. The resident's diagnoses included, in part, Urinary Tract Infection, History of Transient Ischemic Attack (TIA) and Cerebral Infarction. Review of the physician orders, dated 09/14/21, documented, Insert/maintain indwelling (foley) catheter diagnosis: Obstructive Uropathy; catheter (Foley) care every shift. On 09/16/21 at 3:52 PM, an interview was conducted with Staff L, a Certified Nursing Assistant. Staff L stated that she empties the resident's Foley drainage bag at the end of her shift and added that his bag is almost empty. On 09/16/21 at 4:00 PM, observation of Foley catheter and perineal care for Resident #115 performed by Staff L was conducted. Staff L stated that after dinner she freshens the resident up and changes his brief, cleans his genital and again every two hours. Observation revealed Staff L with gloves on, retrieved water, placed the basin on the table, repositioned the bed using the bed control, a highly touch surface, removed the privacy sleeve that was covering the catheter drainage bag, placed the drainage bag on top of the bed and removed the resident's pant. Continued observation revealed Staff L removed her left-hand glove and without performing hand hygiene and after performing the multiple tasks, she donned another glove to her left hand. Staff L retrieved a urinal from a plastic bag and a packet of wipes. Observation revealed Staff L continued to wear the same pair of gloves, removed the old brief, retrieved a clean brief and a washcloth. Staff L then proceeded to cleanse the resident penis, the meatus and scrotum with strokes from side to side, top to bottom several times and change the washcloth position once. Staff L then retrieved one disposable wipe and performed multiple cleansing strokes to the penis, meatus, and the perineal area from side to side and top to bottom. Further observation revealed Staff L using the same disposable wipe to clean the catheter (Foley tubing). Staff L removed her gloves and donned new gloves, without performing hand hygiene and then proceeded to cleanse Resident #115's buttocks. Further observation revealed Staff L with gloved hands and after cleaning the residents' buttocks, she repositioned the bed using the bed control, moved the resident phone and retrieved a plastic bag from her pocket. Staff L retrieved a plastic bag from her pocket three times throughout the procedure with soiled gloved hands. An interview was conducted with Staff L who stated she always does the care this way. Staff L confirmed that she used one washcloth and one wipe to perform Resident #79's Foley / perineal care and one to cleanse each buttock. On 09/17/21 at 3:12 PM, a joint interview was conducted with the Director of Nursing, the Corporate Nurse, and the Minimum Data Set (MDS) coordinator. They were apprised of concerns during the Foley care observation for Resident #115.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to conduct nutritional assessments in a timely manner for 4 of 7 residents reviewed for nutrition, Resident #4, Resident #84, Resident #30, Resident #118. The findings included: Review of the facility's policy titled, Weight Assessment and Intervention, revised in September 2008, documented the following: The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. The dietitian will address concerns as needed. 1. Review of the record for Resident #4 showed that she was admitted to the facility on [DATE] with the following diagnoses: Muscle Wasting and Atrophy, Heart Failure, Gastrostomy Status, Type 2 Diabetes Mellitus, and Hypertension. Review of Section C of the Quarterly Minimum Data Set (MDS), dated [DATE], documented that a Brief Interview for Mental Status (BIMS) was not conducted for Resident #4 as she was rarely / never understood. Section K of the Quarterly MDS, dated [DATE], documented that Resident #4 had a height of 59 inches and a weight of 106 pounds (lbs.). Review of the weights documented that Resident #4 weighed 113 lbs. on 06/01/21 and 106 lbs. on 07/06/21. This showed that Resident #4 had a significant weight loss of 6.19% within a 1 month timeframe. Review of the Dietary Progress Note, dated 07/19/21, documented that Resident #4 had a significant weight loss in one month and had a current body weight of 106 lbs. It was documented that Resident #4's blood sugars were consistently greater than 250 milligrams per deciliter and that her unstageable wound to her sacrum continued. It was further documented that her elevated blood sugars may be related to her wound and may be causing weight loss. During an interview conducted on 09/16/21 at 10:18 AM, the Registered Dietitian (RD) stated that she had been working in the facility since the end of March 2021. She stated that all of her notes were documented in PointClickCare (electronic charting system) and that she conducted initial assessments, quarterly assessments, and significant change assessments. The RD reported that residents with weight loss, wounds, tube feeding, dialysis, cancer, or low oral intake would be considered high nutritional risk. According to her, a significant change in weight would be 5% in 1 month, 7.5% in 3 months, or 10% in 6 months. When asked about weights, the RD stated that all weights were documented in PointClickCare and that she conducted an audit on Mondays and Fridays to identify any significant changes in weight. She further stated that restorative aides would meet with her in the morning to let her know if any residents required a re-weigh or if she needed to follow up with any residents on a significant weight change. If a resident experienced a significant weight loss, the RD stated that she would follow up with them immediately, within 24 hours. When asked about Resident #4, the RD stated that she would be considered to be at a high nutritional risk. When asked about the 6.19% significant weight loss from 06/01/21 - 07/06/21, the RD stated that she followed-up on the weight loss on 07/19/21. This showed that the RD did not address the significant weight loss until 13 days after the weight loss was identified. When asked why it took 13 days to address the significant weight loss, the RD stated, I can't tell you for sure. 2. Review of the record for Resident #84 showed that he was re-admitted to the facility on [DATE] with the following diagnoses: Protein-Calorie Malnutrition, Dysphagia, Chronic Kidney Disease Stage 3, Gastrostomy Status, Type 2 Diabetes Mellitus, Muscle Weakness, and Cognitive Communication Deficit. Review of Section C of the Quarterly MDS, dated [DATE], showed that Resident #84 had a BIMS of 08, which indicated that he was moderately cognitively impaired. Section K of the Quarterly MDS dated [DATE] showed that Resident #84 had a height of 69 inches and a weight of 111 lbs. Review of the Care Plan, dated 08/26/21, documented that Resident #84 was at risk for alteration in nutrition and hydration. Interventions included: RD consult as needed. Review of the weights showed that Resident #84 weighed 118.4 lbs. on 02/09/21 and 112.4 lbs. on 03/03/21. This showed that Resident #84 had a significant weight loss of 5.06% within a 1 month timeframe. Review of the Dietary Progress Note, dated 04/08/21, documented that Resident #84 experienced a significant weight loss in one month and had a current body weight of 112.4 lbs. During an interview conducted on 09/16/21 at 10:18 AM, the RD stated that the 5.06% significant weight loss from 02/09/21 - 03/03/21 was assessed on 04/08/21. This showed that the RD did not address the significant weight loss until 36 days after the weight loss was identified. When asked why it took 36 days to address the significant weight loss, the RD stated that she did not know what happened. She further stated, I don't know who the dietitian was at that time. It looks like it was that period of time where I just started. 3. Review of the record for Resident #30 showed that she was admitted to the facility on [DATE] with the following diagnoses: Dementia, Dysphagia, and Hypertension. Review of Section C of the Quarterly MDS, dated [DATE], showed that she had a BIMS of 06, which indicated that she was moderately cognitively impaired. Section K of the Quarterly MDS dated [DATE] showed that she had a height of 58 inches and a weight of 95 lbs. Review of the Care Plan, dated 08/03/21, documented that Resident #30 was at risk for an alteration in nutrition and hydration. Interventions included: RD consult as needed. Review of the weights showed that Resident #30 weighed 93 lbs. on 03/02/21 and 82 lbs. on 07/15/21. This showed that she had a severe weight loss of 11.8% in 4 months. Review of the Weight Change Progress Note, dated 08/03/21, documented that Resident #30 experienced a significant weight loss of 11.5% in about 4 months. It was documented that Resident #30 had a history of refusing to be weighed and that her current weight taken on 07/29/21 was 82.3 lbs. During an interview conducted on 09/16/21 at 10:18 AM, the RD stated that Resident #30 was considered to be at high nutritional risk. She further stated, She is up and around walking so I really have to keep up on her nutrition. When asked about the 11.8% severe weight loss from 03/02/21 - 07/15/21, the RD stated that she followed up on the weight loss on 08/03/21. This showed that the RD did not address the significant weight loss until 19 days after the weight loss was identified. When asked why it took 19 days to address the severe weight loss, the RD stated, Monthly weights get to me by the 10th of the month and then I do my report. I think it was just part of my monthly weight report. When asked, the RD stated that even though the weight came as part of her monthly report, 19 days was not an acceptable timeframe to follow up on a resident with severe weight loss. 4. Review of the record for Resident #118 showed that she was admitted to the facility on [DATE] with the following diagnoses: Protein-Calorie Malnutrition, Gastroesophageal Reflux Disease, Muscle Weakness, Alzheimer's Disease, and Hypothyroidism. Review of Section C of the Quarterly MDS dated [DATE] showed that Resident #118 had a BIMS of 04, which indicated that she was severely cognitively impaired. Review of Section K of the Quarterly MDS, dated [DATE], documented that Resident #118 had a height of 63 inches and a weight of 78 lbs. Review of the Care Plan, dated 09/16/21, documented that Resident #118 was at risk for alteration in nutrition and hydration. Interventions included: RD consult as needed. Review of the weights showed that Resident #118 weighed 110.4 lbs. on 03/04/21 and 103 lbs. on 03/31/21. This showed that she had a significant weight loss of 6.7% in about 1 month. Further review of the weights showed that Resident #118 weighed 86.2 lbs. on 06/01/21 and 79.6 lbs. on 07/08/21. This showed that she had a significant weight loss of 7.65% within a 1 month timeframe. Review of the Nutrition Risk Evaluation, dated 04/12/21, documented that Resident #118 experienced a 6.3% significant weight loss in one month and had a current weight of 103 lbs. The RD documented that Resident #118 appeared malnourished with prominent shoulders and wasting orbital and temporal regions. It was further noted that Resident #118 required maximum assistance with meals and typically left greater than 50% uneaten. Review of the Weight Change Progress Note, dated 08/02/21, documented that Resident #118 experienced a weight loss of 7.6% in one month and had a current weight of 79.6 lbs. It was further documented that Resident #118 was severely underweight. During an interview conducted on 09/16/21 at 10:18 AM, the RD stated that Resident #118 was considered to be at high nutritional risk because she was on hospice. When asked about the 6.7% significant weight loss from 03/04/21 - 03/31/21, the RD stated that she followed up on the weight loss on 04/12/21. This showed that the RD did not address the significant weight loss until 12 days after the weight loss was identified. When asked why it took 12 days to address the significant weight loss, the RD stated, I know it's not a good excuse, but I just started at that time. When asked about the 7.65% significant weight loss from 06/01/21 - 07/08/21, the RD stated that she followed up on the weight loss on 08/02/21. This showed that the RD did not address the significant weight loss until 25 days after the weight loss was identified. When asked why it took 25 days to address the significant weight loss, the RD stated, It was a monthly weight report, I don't know what happened. When asked, the RD stated that even though the weight came as part of her monthly report, 25 days was not an acceptable timeframe to follow up on a resident with significant weight loss.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of policy and procedure, the facility failed to do a post-respiratory lung assessment for 1 of 1 sampled resident observed during Tracheostomy Care and Suctioning, Resident #38. The findings included: Review of facility policy and procedure on 09/16/21 at 2:00 PM for Tracheostomy Care provided by the Director of Nursing (DON), reviewed 04/02/82, indicated Procedure Guidelines .Assessment .Assess resident for respiratory distress .listen to lung sounds with a stethoscope . Resident #38 was originally admitted to the facility on [DATE] and is medically fragile with a Ventilator and Tracheostomy (trach) in place and totally dependent on staff for care, nutrition and hydration. He had a Brief Interview Mental Status (BIMS) of being severely impaired. A tracheostomy care and suctioning observation was conducted on 09/16/21 at 10:20 AM by Staff A, a Licensed Practical Nurse (LPN), assisted by Staff D, an (LPN), for Resident #38. Both nurses were observed washing their hands for 30-45 seconds. The physician's tracheostomy order read as follows: Tracheostomy care as needed and tracheal suctioning every shift. The nurse checked the order and verified the resident's identity. He then prepared his supplies and placed them on the cleaned / covered bedside table after sanitizing his hands. The nurse then checked the resident's pulse rate which was: 72, the resident's oxygen saturation which was 95%, and he then listened to the resident's breath sounds. The nurse then washed his hands 30-45 seconds afterwards, donned a pair of clean gloves and removed the old trach collar dressings and cleaned around the trach area and cleaned it with Peroxide. He then removed the trach collar and applied a another one. He also checked to make sure the collar was not too tight. He then removed his dirty gloves and washed his hands again for 30-45 seconds then donned a pair of gloves and proceeded to remove and clean the resident's inner tracheostomy cannula in a tepid water solution. The nurse then removed his dirty gloves and again washed his hands for 30-45 seconds. There were no signs of acute distress. The nurse then washed his hands for 30-45 seconds and donned a pair of sterile gloves then proceeded to slowly suction the resident's tracheostomy and instilled sterile normal saline to loosen the secretions. Afterwards, the nurse checked Resident #38's oxygen saturation level which was 97% and his heart rate was 89, following the procedure. The resident tolerated it well. It was noted that either of the staff members performing the Tracheostomy care performed a respiratory assessment following the resident's trach care procedure in order to evaluate the current status of the resident's lung sounds. On 09/16/21 at 10:52 AM, an interview was conducted with both Staff A, an (LPN) and with Staff D, an (LPN) and both nurses acknowledged that the resident's lung sounds should have been assessed / evaluated following the procedure. On 09/16/21, the physician's order documented for Tracheostomy care and Tracheal suctioning to be performed as needed. Record review of the resident's care plan for a Tracheostomy revealed that interventions included to perform lung sounds / respiratory assessment as needed. The DON further acknowledged that a post-Tracheostomy care respiratory assessment should have been performed in order to assess the resident's current lung sounds/status; this was not done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of policy and procedure, the facility failed to administer a medication from a properly labeled medication bottle for 1 of 4 sampled resident during medication administration review, Resident #225; failed to ensure medications were properly secured for 1 of 4 sampled resident during medication administration review, Resident #225; and failed to ensure medications were properly secured for 1 of 3 sampled medication cart review in the South wing. The findings included: Review of the facility's policy titled, Storage of Medications, revision date 08/2020, documented, Medications and biologicals are stored safely, securely and properly .all medications dispensed by the pharmacy are stored in the pharmacy container with the pharmacy label . Review of the facility's policy titled, General Guidelines for Medication Administration revision date 08/2020, documented, .at a minimum, the 5 rights-right resident, right drug, right dose, right route and right time- should be applied to all medication administration and reviewed at three steps in the process of preparation: (1) when medication is selected, (2) when the dose is removed from the container, and (3) after the dose is prepared and the medication is put away. Check #1: select the medication, check the label .Check #2: prepare the dose by removing the dose from the container and verifying it against the label and the MAR (Medication Administration Record) .Check #3: complete the preparation of dose and re-verify the label against the MAR .Prior to administration of any medication, the medication and the dosage schedule on the resident's MAR are compared with the medication label . 1. On 09/14/21 at 3:56 PM, medication administration observation for Resident #225 was conducted on the Rapid Recovery Unit (RRU)-South and performed by Staff M, a Registered Nurse. Observation revealed Staff M performed hand hygiene, retrieved a white round bottle from the medication cart top drawer, opened the bottle and poured one tablet into a medication cup. Staff M handed the bottle to the surveyor and stated the medication name was Amiodarone. Observation revealed the white round bottle did not have the facility's contracted pharmacy label with the resident's name, medication name or prescriber directions. The bottle had the pharmaceutical / manufacturer's label on it and it read Amiodarone Hydrochloride 200 mg (milligrams). Continued observation revealed Staff M carried the medication cup and a water cup on one hand and pushed the blood pressure cart with the other hand, entered the room and placed the medication cup on top of the resident's bedside table. Staff M was asked for Resident #225's blood pressure reading and pulse results. She stated that she needed a different machine. Staff M left the resident room, left the medication cup with the medication in it on top of the resident's table unattended for two minutes, walked about 20-30 feet out of the resident's room, returned to the resident's room with another machine, checked the resident's pulse and administered the medications. On 09/15/21 at 3:45 PM, review of the facility's RRU- South medication cart was conducted with Staff U, a Licensed Practical Nurse. The medication cart first drawer had an opened white round bottle with the pharmaceutical / manufacturer's label on and read Amiodarone Hydrochloride 200 mg (milligrams). The bottle still did not have the facility's contracted pharmacy's label with the resident's name, medication name or prescriber directions. During an interview Staff U confirmed that the bottle did not have a pharmacy label, no resident name label on the bottle. He stated that Amiodarone unlabeled medication bottle are not supposed to be in the cart and that they are not supposed to administer that medication without a pharmacy label. On 09/15/21 at 3:49 PM, an interview was conducted with Staff Q, a Licensed Practical Nurse and stated that Resident #225 brought his medications from home. She stated that the medication Amiodarone Hydrochloride 200 mg with no pharmacy label should not be in the medication cart drawer. On 09/15/21 at 4:29 PM, an interview was conducted with Staff N, Unit Manager and confirmed that the white bottle did not have a pharmacy label and that the nurses are not to administer the medication that had no label from the pharmacy. She added that the nurse had to read the name of the resident and the medication name on the bottle and match it up with the MAR (medication administration record). The nurses are to use the pharmacy labeled medications. During the interview, Staff N was asked to contact Staff M. At [NAME] time, Staff N, Unit Manager, also stated that she was informed by Staff M that she had left Resident #225's medications unattended on 09/14/21. Staff N stated resident medications are to be watched and not left at the resident table. On 09/16/21 11:34 AM, a joint interview was conducted with the Director of Nursing (DON) and the facility's Consultant Pharmacist (CP). The DON stated that Resident #225 brought in to the facility three bottles of Amiodarone. She added that the three were all together. The DON showed two white round bottles; one had the resident's home pharmacy and the other had the pharmaceutical / manufacturers label. The DON was apprised that those two bottles, especially the one with the label, was not in the cart and that Staff M did not state that there were other bottles with a label. The DON showed the surveyor the two bottles of Amiodarone, one with a label. The DON stated she thought those two were the only ones. She was informed to check with Staff N. The Consultant Pharmacist stated that the resident's medication bottle should have a pharmacy label, and the nurse should not have been given a medication from a bottle that was not labeled. On 09/17/21 at 4:45 PM, a telephone interview was conducted with Staff M who stated that the white round bottle had a label with the medication name. She was apprised that the bottle did not have the facility's pharmacy label with the resident's name on it. Staff M confirmed she left Resident #225's medications unattended and added that she will do better next time. 2. On 09/15/21 at 2:27 PM, review of the facility's south wing medication cart review was conducted with Staff T, a Licensed Practical Nurse. The review revealed one loose white long pill on the bottom of the third drawer of the cart. Staff T stated she did not know about the loose pill. The facility failed to secure residents' medication on the south wing medication cart.

Based on observations and interviews, the facility failed to maintain food safety requirements with storage, preparation, and distribution in accordance with professional standards for food service safety which included failure to maintain equipment in safe working conditions and failure to maintain sanitary conditions. The findings included: During a tour of the kitchen conducted on 09/14/21 at 8:52 AM, accompanied by the Certified Dietary Manager (CDM), the following were noted: 1. Several small, black flying pests were observed in the dishwashing area. The CDM acknowledged the surveyor's findings and stated that the pests probably came in through the door in the dishwashing area (which was left open for incoming meal carts at the time of the tour). 2. At the request of the surveyor, the chemical concentration of the cleaning cloth bucket located underneath the steamer was tested by the CDM. The result of the chemical testing revealed that the cleaning cloth bucket had a concentration of 400 parts per million (ppm). The CDM acknowledged that the concentration of the cleaning cloth bucket was above the required regulatory concentration of 200 ppm. It was discussed with the CDM that a high chemical concentration of 400 ppm would result in a toxic chemical residue that would remain on the surface of the products being cleaned. 3. At the request of the surveyor, the chemical concentration of the cleaning cloth bucket located underneath the coffee machine was tested by the CDM. The result of the chemical testing revealed that the cleaning cloth bucket had a concentration of 150 ppm. The CDM acknowledged that the concentration of the cleaning cloth bucket was below the required regulatory concentration of 200 ppm. 4. About 20 small, black flying pests were observed in the dry storage area. The CDM acknowledged surveyor's findings and stated that the fruit flies came from the bananas that they had and that there was nothing they could do. 5. In the dry storage area, 3 of 4 lights were out. The CDM stated that maintenance was not informed of this issue. She further stated that she would put in a work order through the TELS system (maintenance reporting system). 6. In the dry storage area, one utensil holder was observed with one dead brown pest. 7. The floor underneath the shelving units in dry storage area was observed with an accumulation of white debris. 8. One, 25 pound bag of yellow cornmeal, and one, 25 pound bag of all-purpose flour, were left open and were not covered or sealed. It was discussed with the CDM that pests could easily enter opened bags of food. 9. The Victory reach-in cooler was observed with a 6-inch tear in the gasket of the door. The CDM stated that maintenance was not aware of this issue. 10. In the reach-in cooler, one container of yellow liquid was not labeled with the name of the product. 11. The floor in walk-in refrigerator was observed with a moderate amount of brown residue. 12. Several small, black flying pests were observed in the emergency food supply storage area.