**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review, and review of the facility's policy titled Medication Administration: Insulin Injections, the facility failed to ensure care and services were provided in accordance with accepted professional standards for two of 19 Residents (R) (R34 and R57) receiving insulin pens. Specifically, the facility failed to sanitize the insulin pen before attaching a new needle prior to use for R34 and by not properly administering the insulin pen for R57. Findings include: Review of the facility's policy titled Medication Administration: Insulin Injections, dated 7/18/2024 under the Policy section revealed, For insulin Pens: 1. Remove the cover from the pen and swab with an alcohol swab. Screw on a new needle and remove cap 6. Count to 10and remove the pen. Review of the manufacturer's instruction guide for using the Tresiba FlexTouch insulin pen revealed, Insert the needle into the thigh . Press and hold the dose button. After the dose counter reaches 0, slowly count to 6. Please note that if the needle is removed before the 6-second count is completed after the dose counter returns to 0, your dose may be up to 20% too low.' 1. Review of R34's clinical records revealed, a diagnosis that included but not limited to Type 2 diabetes mellitus without complications. Review of R34's Medication Administration Record (MAR) revealed, [Name] (insulin lispro) insulin pen; 100 unit/ml (milliliter); amount to administer per sliding scale, before meals and at bedtime with start date of 4/4/2024 and [Name] (insulin glargine) insulin pen; 100 unit/ml (3 ml); amount to administer 7 units subcutaneous twice a day with start date of 10/28/2024. During a medication pass on 3/19/2025 at 8:00 am, Licensed Practical Nurse (LPN) AA was observed preparing an insulin pen. LPN AA removed the cover and attached a needle without swabbing the pen with an alcohol swab before inserting the new needle prior to use for R34. In an interview on 3/19/2025 at 8:10 am with LPN AA following the insulin administration, she confirmed that she did not swab the pen but should have done it. 2. Review of R57's clinical records revealed, a diagnosis that included but not limited to Type 2 diabetes mellitus with other specified complications. Review of R57's MAR revealed, [Name] U-100 Insulin (insulin aspart u-100) insulin pen; 100 unit/mL (3 mL); amount to administer: per sliding scale with start date of 10/11/2024 and [Name] U-200 (insulin degludec) insulin pen; 200 unit/mL (3 mL); amount to administer: 10 units; subcutaneous with start date of 10/11/2024. During a medication pass on 3/19/2025 at 8:39 am, LPN BB was observed administering insulin to R57. The LPN prepared the insulin pen without issue and injected the prescribed 7 units of medication; however, she withdrew the syringe immediately without waiting the recommended 10 seconds before removal. During an interview on 3/19/2025, at 11:15 am, LPN BB was asked whether the pen should be held against the skin for six to 10 seconds when administering insulin pens. She was uncertain and revealed, that she typically listens for a click and counts one to two seconds before removing the pen. However, she confirmed that she did remove the pen immediately. She also confirmed that she failed to hold the pen in place for six to 10 seconds which could lead to insulin leakage, potentially resulting in the resident receiving less than the prescribed dose. During an interview on 3/19/2025 at 9:24 am with the Director of Nursing (DON) revealed, that the correct procedure for using insulin pens include cleaning the top of the pen, attaching the needle, priming with 2 units of insulin, cleaning the skin, injecting the medication, and holding the needle in place for 10 seconds. The DON revealed, this process was reviewed during annual competency checkoffs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review, and review of the facility- provided documents titled Packaged Terminal Air Conditioner (PTAC) Preventative Maintenance Guide and Heating Ventilation, and Air Conditioning (HVAC): Clean Air Filters details the following steps, the facility failed to maintain a clean, sanitary, and comfortable environment as evidenced by dirty PTAC filters for 42 out of 42 residents' rooms on three Halls (Hall A, Hall B and Hall C) and the C Hall Dayroom. This deficient practice had the potential to compromise the health and safety of all 60 residents and staff by increasing the risk of respiratory and allergy symptoms due to inadequate air filtration and reduced fresh air circulation. Findings include: Review of the undated facility- provided document titled PTAC Preventative Maintenance Guide under the Three-Monthly PTAC Air Cleaning Tasks section revealed, 1. Air Filter .Clean the filter with a vacuum or running water .2. Vent Screen .Clean or replace the vent screen .3. Front [NAME] Remove the front grille and clean it with a dampened cloth . Review of the undated facility- provided document titled HVAC: Clean Air Filters details the following steps, revealed, 6. At a minimum, air filters are to be replaced or thoroughly cleaned depending on the type of filter every three months. 7. Clean evaporated coils if lint build up is present. Observations on 3/18/2025 between 9:00 am and 1:00 pm of the facility's air filters in residents' rooms revealed, that rooms on Halls A (15 out of 15 rooms), B (16 out of 16 rooms), and C (11 out of 11 rooms), as well as the C Hall dayroom, had heavily soiled air filters with a thick accumulation of dust, dirt, and debris. Originally white, the air filters appeared dark gray due to trapped contaminants. When lifted for inspection, they released visible dust clouds and were clogged with a dense layer of grime. During an interview with Housekeepers II and Housekeeper JJ on 3/19/2025 at 9:35 am, they revealed that they do not clean the air filters. However, they do clean the grills, wiping them daily when they clean the rooms. During an interview with the Director of Housekeeping on 3/19/ 2025, at 9:40 am, she confirmed during a facility tour that maintenance was responsible for cleaning the air filters. During an interview with the Maintenance Director on 3/19/2025, at 9:30 am, he stated that air filters were cleaned every three months, and maintenance staff clean the grills on the air filter covers as needed. He provided logbook documentation confirming that air filters were replaced every three months, with the most recent recorded change on 1/20/2025. Additionally, he stated that he cleaned the air filters on 3/18/2025, after being notified. During an interview with the Infection Preventionist (IP) on 3/20/2025 at 10:12 am, she stated that she expects the air filters to be clean and that maintenance was responsible for checking them. During an interview with the Director of Nursing (DON) and the Administrator on 3/20/2025 at 10:14 am, it was revealed that there was no specific policy on environmental maintenance. They stated that they follow a three-month schedule, as the system alerts them when the air filters need to be cleaned. They confirmed that the air filters were due for cleaning soon and noted that they would naturally become filthy as the cleaning time approached. The policy on environmental maintenance, specifically regarding air filter cleaning, was requested but not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of the facility policy titled, Care Plans, the facility failed to develop a baseline care plan within 48 hours of admission for one of one Resident (R) 63 reviewed for baseline care plans. The deficient practice increased the potential for R63 to not receive effective and person-centered care according to her needs. Findings include: Review of the facility's policy titled, Care Plans dated [DATE] revealed, It is the policy of the health care center for each patient/resident to have a person- centered baseline care plan . Procedure: New admission Baseline Plan of Care, 1. Upon a new admission, a baseline will be developed by the admitting nurse in conjunction with other IDT [Interdisciplinary Team], the patient/ resident and/or patient/ resident representative. The baseline care plan should be initiated in 24 hours and will be completed and implemented within 48 hours of admission . Review of R63's Face Sheet, date unknown, located under the Face Sheet tab in the electronic medical record (EMR), revealed R63 was admitted to the facility on [DATE] with diagnoses including atherosclerotic heart disease, non-rheumatic aortic valve disorder, and myocardial infarction. R63 expired in the facility on [DATE]. Review of R63's Progress Notes, dated [DATE] located under the Progress Notes tab in the EMR, revealed R63 was admitted on respite care. Review of R63's Care Plan, located under the Care Plan tab in the EMR, revealed there was no baseline care plan for R63. During an interview on [DATE] at 4:15 pm, the Minimum Data Set Coordinator (MDSC) was asked who completes the baseline care plan and when the baseline care plan should be completed. The MDS Coordinator stated, The admitting nurse should do the baseline care plan and it should be completed within 48 hours. During an interview on [DATE] at 4:37 pm, the Director of Nursing (DON) was asked who completed the baseline care plan and when the baseline care plan should be completed. The DON stated, I do all the baseline care plans for new admissions. There was not one done for her because she was on respite. The DON was asked for a policy that states the facility did not have to do a baseline care plan for residents admitted for respite. The DON stated, I can't find one.

Based on record review, staff and resident interviews, and review of the facility policy titled, Physician Orders, the facility failed to ensure physician orders were in place for two of 23 Residents (R) 45 and R64. The deficient practice placed residents at risk to not receive needed care and services in accordance with professional standards of practice. Findings include: Review of the facility's policy titled, Physician Orders with a revised date of 9/15/2017, revealed, Policy Statement: Physician orders must be complete and legible when written by the physician, physician extender or transcribed by the licensed professional. Procedure: Written Orders: 1. A physician order for medication or treatment must include the following information: o Patient/resident's name. o Healthcare center name and wing. o Room number. o Allergies. o Date and time of order. o Name of medication. o Strength of medication where indicated. o Dosage. o Route of administration. o Frequency of administration. o Quantity or duration (length) of therapy. If not specified by the prescriber on a new order, the duration is limited by the pharmacy automatic stop order policy if applicable. o Diagnosis or condition for which medication is prescribed. 2. The order must be signed and dated by the physician. 1. Review of R45's Face Sheet undated, located under Face Sheet tab in the electronic medical record (EMR), revealed R45 diagnoses included end stage renal disease, cerebral infarction, and dependence on renal dialysis. Review of R45's significant change Minimum Data Set (MDS) assessment, located under the MDS tab in the EMR and with an Assessment Reference Date (ARD) of 10/6/2023, revealed Section C-Cognitive Patterns: A Brief Interview for Mental Status (BIMS) score of 10 out of 15, indicating R45 was moderately cognitively impaired; Section O- Special Treatments and Programs: indicated the resident was receiving dialysis. During an interview on 10/4/2023 at 9:30 am, R45 was asked how often he goes to dialysis. R63 stated, I only go on Mondays and Fridays. Review of the physician orders located under the Orders tab in the EMR, revealed no order was written for R45's dialysis treatment. During an interview on 10/4/2023 at 4:43 pm, Licensed Practical Nurse (LPN) Charge Nurse1 was asked if she could locate the physician's order for R45's dialysis. After reviewing the physician orders, LPN Charge Nurse1 stated. There is no order. During an interview on 10/5/2023 at 10:20 am, the Director of Nursing (DON) was asked about physician orders for resident receiving care. The DON stated, The admitting nurse or nurse manager will place the orders in the system. Each resident should have orders when they come into the facility and as treatments or medications change. Yes, there should be an order [for dialysis]. 2. Review of R64'Face Sheet undated, located under Face Sheet tab in the EMR, revealed diagnoses including epilepsy, acquired absence of left toes, and acute osteomyelitis of the left ankle. Review of R63's admission MDS assessment, located under the MDS tab in the EMR with an ARD of 7/25/2023, revealed Section C-Cognitive Patterns: a BIMS score of 12 out of 15, indicating R64 was moderately cognitively impaired. Review of the Progress Notes, located under the Progress Notes tab in the EMR, indicated the resident returned from an appointment on 7/27/2023 at 1:04 pm, indicating the physician from the vascular unit was discharging him home. There was no paperwork accompanying R63 from the physician's office. Review of R64's physician orders located under the orders tab in the EMR, revealed there was no order for discharge to home. During an interview on 10/5/2023 at 3:45 pm, the Social Service Director (SSD) was asked about an order because she wrote the discharge summary. The SSD stated that they did have an order. The SSD returned with an order that was received on 10/5/2023 from the Medical Director. During an interview on 10/5/2023 4:40 pm, the DON was asked about a physician's order for discharge. The DON stated. There should be an order discharging the resident home. [The SSD] states there was an order, but it is not in the system.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of the RAI 3.0 User's Manual Version 1.18.11, and the Resident Assessment Instrument (RAI) User's Manual, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded for five out of 23 Residents (R) 36, R18, R31, R33, and R58. This failure had the potential for the residents not to receive the necessary care and services related to the inaccurate data reflective of the residents status at the time of the assessment. Findings include: Review of the RAI 3.0 User's Manual Version 1.18.11, dated 10/1/2023, revealed . Chapter 2: Assessments for the RAI . 03. Significant Change in Status Assessment (SCSA) (A0310A = 04) . A SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home . Chapter 3: MDS Items . O0110: Special Treatments, Procedures, and Programs . O0110K1, Hospice care, code residents identified as being in a hospice program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related conditions . Review of the Resident Assessment Instrument (RAI) Manual, dated 10/1/2019, indicated, . It is important to note here that information obtained should cover the same observation period as specified by the Minimum Data Set (MDS) items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT (Interdisciplinary Team) completing the assessment . 1. Review of R36's Face Sheet, located in the electronic medical record (EMR) under the Face Sheet tab, revealed diagnoses that included encephalopathy and unspecified severe protein-calorie malnutrition. Review of R36's Physician's Orders, dated 8/28/2023, located under the Orders tab in the EMR, indicated an order to admit to hospice services. Comfort measures only. D/C [discontinue] all labs. Please notify hospice prior to transfers, X-rays etc. Review of R36's Care Plan, dated 6/27/2023, located under the Care Planning tab in the EMR, revealed the problem of Terminal Care readmitted to facility from hospital on 6/19/2023 to the services of hospice. Review of R36's SCSA MDS, with an Assessment Reference Date (ARD) of 6/26/2023, Section-O: Special Treatments and Programs indicated under O0110K1, Hospice Care while a Resident was not coded. During an interview on 10/5/2023 at 8:50 am, the MDS Coordinator stated R36 went on hospice after returning from the hospital on 6/19/2023. The MDS Coordinator confirmed she completed the SCSA MDS for R36 on 6/26/2023 and did not code the resident was in a hospice program while in the facility but should have coded it. The MDS Coordinator stated the Clinical Reimbursement Consultants completed random audits on the MDS assessments; however, an audit was not performed on the SCSA MDS. The MDS Coordinator indicated she used the RAI Manual to code MDS assessments and reviewed progress notes, physician orders, hospital discharge summaries, and other documentation to code the MDS assessments. 2. Review of R18's admission Record, located in the EMR under the Profile tab, indicated the resident was admitted to the facility on [DATE] with diagnoses including anxiety disorder. Review of R18's Care Plan, updated 6/6/2022 and located in the EMR under the Care Plan tab, included psychotropic drug use related to diagnosis of anxiety. Review of R18's Physician Orders, located in the EMR under the Orders tab, included Buspar (an antianxiety medication) 15 milligram (mg) tablet by mouth twice daily starting on 10/20/2022. Review of R18's quarterly MDS with an ARD of 9/8/2023 located in the EMR under MDS tab, indicated the resident had not received antianxiety medications in the previous seven day look back period. 3. Review of R31's admission Record, located in the EMR under the Profile tab, indicated the resident was admitted to the facility on [DATE] with diagnoses including anxiety disorder. Review of R31's Care Plan, updated 10/7/2021 and located in the EMR under the Care Plan tab, included psychotropic drug use related to diagnosis of anxiety. Review of R31's Physician Orders, located in the EMR under the Orders tab, included Buspar 10mg tablet by mouth three times daily starting on 9/28/2021 and lorazepam (an antianxiety medication) 0.5mg by mouth at bedtime starting on 6/13/2023. Review of R31's quarterly MDS, with an ARD of 9/25/2023 and located in the EMR under MDS tab, indicated the resident had not received antianxiety medications in the previous seven day look back period. 4. Review of R33's admission Record, located in the EMR under the Profile tab, indicated the resident was admitted to the facility on [DATE] with diagnoses including anxiety disorder. Review of R33's Care Plan, updated 6/4/2019 and located in the EMR under the Care Plan tab, included psychotropic drug use related to diagnosis of anxiety. Review of R33's Physician Orders, located in the EMR under the Orders tab, included Buspar 5mg tablet by mouth once daily starting on 3/8/2021. Review of R33's quarterly MDS, with an ARD of 8/15/2023 and located in the EMR under MDS tab, indicated the resident had not received antianxiety medications in the previous seven day look back period. 5. Review of R58's admission Record, located in the EMR under the Profile tab, indicated the resident was admitted to the facility on [DATE] with diagnoses including heart failure, atrial fibrillation, and anxiety disorder. Review of R58's Care Plan, updated 4/13/2023 and located in the EMR under the Care Plan tab, included treatment of anxiety disorder. Review of R58's Physician Orders, located in the EMR under the Orders tab, included lorazepam 0.5mg tablet by mouth as needed every four hours starting on 7/26/2023 and lorazepam 1mg tablet by mouth at bedtime starting on 6/24/2023. Review of R58's quarterly MDS, with an ARD of 8/24/2023 and located in the EMR under MDS tab, indicated the resident had not received antianxiety medications or anticoagulants in the previous seven day look back period. During an interview on 10/5/2023 at 4:16 pm, the Minimum Data Set Coordinator (MDSC) confirmed that R18, R31, R33, and R58's MDS assessments were coded incorrectly for the use of antianxiety medications.

Based on record reviews, staff and resident interviews, and review of the facility policy titled, Care Plans, the facility failed to conduct quarterly care plan conferences in a timely manner for 12 out of 23 Residents (R) 19, R39, R3, R14, R26, R37, R5, R6, R18, R31, R33, and R58. This failure had the potential for staff, residents, and resident representatives (RP) not to be informed of the care and treatment to meet the resident's needs in a timely manner. Findings include: Review of the facility's policy titled Care Plans, revised 7/27/2023, revealed . 7. During all care plan meetings other than admission Comprehensive Care Plan that was conducted during a Post admission Care Conference: Review each problem, goal and approach . Care plan meetings should be documented using the multidisciplinary care conference user defined assessment as evidence that the care conference has taken place and occurred with the multidisciplinary team, the resident and resident representative [RP] . Care plan meetings including IDT [interdisciplinary team], resident, and resident representative attendance should be documented in care conference notes . 1. Review of R19's Face Sheet, located in the Electronic Medical Record (EMR) under the Face Sheet tab, revealed diagnoses that included encephalopathy (damage or disease that affects the brain), and cerebral infarction (stroke). Review of R19's Minimum Data Set (MDS) assessments, located in the EMR under the MDS 3.0 Assessments tab, revealed the following assessments were completed: Significant Change in Status (SCSA) on 3/27/2023, Quarterly on 5/18/2023, Quarterly on 6/9/2023, and Quarterly on 9/6/2023. Review of R19's Care Plan Conference, dated 8/18/2022, located in the EMR under the Care Plan tab, revealed, . care conference held with IDT. RP invited and declined. Review of R19's Care Plan Conference, dated 2/22/2023, located in the EMR under the Care Plan tab, revealed . care conference held with IDT and RP. Review of R19's Care Plan Conference, dated 5/4/2023, located in the EMR under the Care Plan tab, revealed . care conference held with IDT. RP declined the invitation. Review of R19's Care Plan Conference, located under the Care Plan tab in the EMR revealed there was no documentation that indicated R19 had care plan conferences held with the (SCSA) assessment on 3/27/2023, Quarterly assessment on 5/18/2023, Quarterly assessment on 6/9/2023, and Quarterly assessment on 9/6/2023. 2. Review of R39's Face Sheet, located in the EMR under the Face Sheet tab, revealed a diagnosis of dementia. Review of R39's MDS assessments, located in the EMR under the MDS 3.0 Assessments tab, revealed the following completed assessments: Quarterly on 5/19/2023 and Annual on 7/21/2023. Review of R39's Care Plan Conference, dated 6/23/2022, located in the EMR under the Care Plan tab, revealed . care conference held with RP and IDT. Review of R39's Care Plan Conference, dated 3/23/2023, provided by the facility, revealed . care conference held in room with IDT and daughter. Review of R39's Care Plan Conference, dated 9/21/2023, located in the EMR under the Care Plan tab, revealed . care conference held with IDT and RP cancelled attendance at the meeting. Review of R3's Care Plan Conference, located under the Care Plan tab in the EMR revealed there was no documentation that indicated R39 had care plan conferences held with the Quarterly assessment on 5/19/2023 and Annual assessment on 7/21/2023. 3. During an interview on 10/2/2023 at 11:41 am, R3 was asked if he was invited to care plan conferences. R3 laughed and said, Those don't happen. Review of R3's Face Sheet undated, located under Face Sheet tab in the EMR, revealed diagnoses that included hypotension, embolism thrombosis, and anxiety. Review of R3's annual MDS assessment, located under the MDS tab in the EMR with an ARD of 7/17/2023, revealed Section C-Cognitive Patterns: a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating R3 was cognitively intact. Review of R3's Care Plan Conference, located under the Care Plan tab in the EMR, indicated no care plan conference meetings before 3/9/2023. 4. During an interview on 10/2/2023 at 10:20 am, R14 was asked if he was invited to care plan conferences. R14 stated, I don't know anything about care plan conferences. Review of R14's Face Sheet undated, located under Face Sheet tab in the EMR, revealed diagnoses that included chronic obstructive pulmonary disease (COPD), cerebrovascular disease, and dementia. Review of R14's annual MDS assessment, located under the MDS tab in the EMR and with an ARD of 7/26/2023, Section C-Cognitive Patterns: a BIMS score of 12 out of 15, indicating R14 was cognitively intact. Review of R14's Care Plan Conference, located under the Care Plan tab in the EMR, indicated a meeting was held in August 2022 and the next meeting was in February 2023. No care plan conference meeting was held in November 2022. 5. Review of R26's undated Face Sheet, located under Face Sheet tab in the EMR, revealed diagnoses that included metabolic encephalopathy, diabetes mellitus, and asthma. Review of R26's quarterly MDS assessment, located under the MDS tab in the EMR with an ARD of 9/11/2023, revealed Section C-Cognitive Patterns: a BIMS score of 6 out of 15 indicating R26 was severely cognitively impaired. Review of R26's Care Plan Conference, located under the Care Plan tab in the EMR, indicated a meeting was held in July 2022 and the next meeting was in January 2023. No care plan conference meeting was held in October 2022. 6. Review of R37's undated Face Sheet, located under Face Sheet tab in EMR, revealed diagnoses of encephalopathy, COPD, and dementia. Review of R37's quarterly MDS assessment, located under the MDS tab in the EMR with an ARD of 9/14/2023, revealed Section C-Cognitive Patterns: a BIMS score of 11 out of 15, indicating R37 was moderately cognitively impaired. Review of R37's Care Plan Conference, located under the Care Plan tab in the EMR, indicated a meeting was held in June 2022 and the next meeting was in July 2023. No care plan conference meeting was held in September 2022, December 2022, or March 2023. 7. Review of R5's Care Conference tab, located in the EMR under the Care Plan tab, indicated R5 had care conferences on 1/20/2022, 4/20/2022, 8/4/2022, and 5/18/2023. No documentation was available indicating R5 had care plan conferences during 10/2022-11/2022 or 1/2023-2/2023. Review of R5's Care Plan Conference Guidelines, provided by the facility, indicated R5 had a care plan conference on 8/17/2023. During an interview on 10/2/2023 at 10:35 am, R5 stated she was not sure when her last care plan conference was. 8. Review of R6's Care Conference tab, located in the EMR under the Care Plan tab, indicated R6 had care plan conferences on 8/24/2022. No documentation was available indicating R6 had care plan conferences 11/2022, 2/2023, 5/2023, or 8/2023. Review of R6's Care Plan Conference Guidelines, provided by the facility, indicated R6 had a care plan conference on 3/09/2023 and 6/22/2023. During an interview on 10/2/2023 at 10:43 am, R6 did not answer when asked about care plan conferences. 9.Review of R18's Care Conference tab, located in the EMR under the Care Plan tab, indicated R18 had care conferences on 4/14/2022, 7/28/2022, 1/26/2023, 3/29/2023, and 9/7/2023. No documentation was available indicating R18 had a care plan conference in 10/2022. Review of R18's Care Plan Conference Guidelines, provided by the facility indicated R18 had a care plan conference on 7/13/2023. During an interview on 10/02/2023 at 3:35 pm, R18 stated he was not aware of any care plan conferences being held. 10. Review of R31's Care Conference tab, located in the EMR under the Care Plan tab, indicated R31 had a care plan conference on 4/27/2023. No documentation was available indicating R31 had any care plan conferences in 2022 through 4/27/2023. Review of R31's Care Plan Conference Guidelines, provided by the facility, indicated R31 had a care plan conference on 7/27/2023. During an interview on 10/2/2023 at 11:14 am, R31 stated the facility used to have care plan conferences but she was not sure when the last one was. 11. Review of R33's Care Conference tab, located in the EMR under the Care Plan tab, indicated R33 had care plan conferences on 6/2/2022, 1/05/2023, 3/30/2023, and 9/7/2023. No documentation was available indicating R33 had any care plan conferences 9/2022 or 12/2022. Review of R33's Care Plan Conference Guidelines, provided by the facility, indicated R33 had a care plan conference on 6/22/2023. R33 was not interviewable. 12. Review of R58's Care Plan Conference Guidelines, provided by the facility, indicated R58 had a care conference on 6/29/2023 and 8/24/2023. No documentation was available indicating R58 had any care plan conferences upon admission. R58 was not interviewable. During an interview on 10/03/2023 at 1:35 pm, the MDS Coordinator (MDSC) stated that care plan conferences should be conducted quarterly with the IDT, RP, and resident. The MDSC stated their system generated a care plan conference list based on the completed MDS assessment; however, the care plan conferences were not always in line with the MDS assessments. The MDSC acknowledged that meetings were held but they were written on paper and not entered in the system. The MDSC confirmed that some of the care plan conferences were not held on a quarterly basis. During an interview on 10/3/2023 at 2:12 pm, MDSC was asked who sets up the meetings and invites the residents. The MDSC stated, We have had meetings all along, but they were not documented into the computer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interview, record review, and facility policy titled, Bed Rails, the facility failed to obtain physician orders for the medical symptoms being treated by using bed rails, attempt to use appropriate alternatives prior to installing a side or bed rail, assess the resident for risk of entrapment from bed rails prior to installation, review the risks and benefits of bed rails with the resident or resident representative, and obtain informed consent prior to installation for 14 of 23 Residents (R) 19, R29, R36, R39, R14, R37, R55, R5, R6, R18, R31, R33, R56, and R57 reviewed for accident hazards. These failures had the potential to increase the risk of entrapment resulting in injuries. Findings include: Review of the facility's policy titled Bed Rails, revised 2/01/2018, revealed Policy Statement: It is the policy of the facility and its affiliated healthcare centers (collectively, the Organization) that healthcare center patients (including those referred to as residents) should be free from the use of bed rails, except where the use of bed rails has been appropriately determined to be medically necessary in accordance with this policy or in instances where the use of bed rails has been specifically requested by the patient or the patient's representative. As further described in this policy, prior to using bed rails, the risks of doing so for a particular patient should be evaluated by appropriate staff of the healthcare center (as described herein) and discussed with the patient and/or the patient's representative . Procedure: Bed rails should not be used unless they are determined to be medically necessary or specifically requested by a patient or a patient's representative. Bed rails may be used to enable a patient to turn independently. When installed or used for this purpose, bed rails are considered to be an enabler. 3. Prior to installing or using beds rails on a patient's bed, the patient should be assessed by the admitting nursing and/or the inter-disciplinary team (IDT) to determine whether the use of bed rails would constitute an enabler or a restraint for the patient. All factors of a patient's functional ability should be taken into consideration when making this determination. The admitting nurse and/or IDT will also determine whether the use of bed rails is necessary for the patient's care, regardless of whether the use of bed rails would constitute an enabler or a restraint. When it has been determined by the admitting nurse and/or IDT that bed rails are medically necessary for a patient's care (or are specifically requested by a patient or the patient's representative). The following procedures should be followed prior to their use: 1. The patient and/or the patient's representative should be educated on the proper use of bed rails as well as the risks of using bed rails, which should include, but not be limited to, the risk of entrapment. 2. The nurse should complete the Initial/Annual Observation for Physical Device Form in determining whether the bed rails should be considered an enabler or a restraint for the patient . 1. Review of R19's Face Sheet, located in the Electronic Medical Record (EMR) under the Face Sheet tab, revealed diagnoses that included encephalopathy (damage or disease that affects the brain), and cerebral infarction (stroke). Review of R19's quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 9/06/2023, located in the EMR under the MDS 3.0 Assessments tab, revealed Section C-Cognitive Patterns: a Brief Interview for Mental Status (BIMS) score of 99 which indicated the resident could not be interviewed and was moderately impaired in decision making; Section G-Functional Status: indicated R19 required extensive assistance of one person with bed mobility, dressing, and personal hygiene; total assistance of two persons with transfers; and total dependence of one person with eating, toilet use, and bathing. Review of R19's Physician's Orders, dated 12/20/2022, located in the EMR under the Orders tab, revealed an order for 1/4 siderails topside up x [times] 2 [two] to assist with bed mobility PRN [as needed]. Review of R19's Care Plan, dated 4/19/2020, located in the EMR under the Care Planning tab, revealed under the problems of ADL functional status/Rehabilitation Potential and Falls was an intervention to raise upper ¼ side rails x 2 to assist with bed mobility as indicated. Review of R19's Restraint-Adaptive Equipment Use Assessment, dated 6/6/2023, located in the EMR under the Observations tab, revealed the assessment was completed after R19's readmission from the hospital. Under the Observation Details, Adaptive Equipment, yes was marked under the question Is adaptive equipment in use? and ¼ side rails was entered after the question If so, what is the physician's order? Include device, reason for use, and duration. However, there was no admission or additional annual assessments completed on bed rails. Additionally, there was no signed consent for the bed rails located in the EMR. Observations on 10/2/2023 at 11:15 am, 10/3/2023 at 5:00 pm, and 10/4/2023 at 9:44 am revealed R19 was lying in the bed with 1/4 length size siderails up on both sides of the head of the bed. During an interview on 10/4/2023 at 3:26 pm, the Licensed Practical Nurse (LPN) Charge Nurse 2 confirmed R19 had ¼ side rails on the bed and used the side rails for turning and repositioning in bed. During an interview on 10/4/2023 at 4:32 pm, Certified Nursing Assistant (CNA) 1 confirmed R19 had ¼ side rails, could use the side rails to turn and reposition in the bed, could not lower the side rails, and needed extensive assistance with activities of daily living (ADLs). 2. Review of R29's Face Sheet, located in the EMR under the Face Sheet tab, revealed the resident was admitted to the facility on [DATE] with a diagnosis of encephalopathy. Review of R29's quarterly MDS Assessment with an ARD of 9/14/2023, located in the EMR under the MDS 3.0 Assessments tab, revealed Section C-Cognitive Patterns: a BIMS score of six out of 15 indicated the resident was cognitively impaired; Section G-Functional Status: indicated R29 required extensive assistance of one person with transfers, dressing and personal hygiene; limited assistance of one person with bed mobility; supervision and setup only for eating; and total dependence of one person with toilet use and bathing. Review of R29's Physician's Orders, located in the EMR under the Orders tab, revealed there were no orders for side rails. Review of R29's Care Plan, located in the EMR under the Care Planning tab, revealed there was no care plan or interventions regarding bed rails. Review of R29's Restraint-Adaptive Equipment Use Assessment, dated 5/13/2023, located in the EMR under the Observations tab, revealed the assessment was completed quarterly. Under the Observation Details, Adaptive Equipment, yes was marked under the question Is adaptive equipment in use? and ¼ side rails was entered after the question If so, what is the physician's order? Include device, reason for use, and duration. However, there was no admission or additional annual assessments completed on bed rails. Additionally, there was no signed consent for the bed rails located in the EMR. Observations on 10/4/2023 at 3:52 pm revealed R29 was lying in the bed with 1/4 length size siderails up on both sides of the head of the bed. During an interview on 10/4/2023 at 3:25 pm, LPN Charge Nurse 2 confirmed R29 had two ¼ side rails on the bed, could not lower them, and used them for turning and repositioning when in the bed. During an interview on 10/4/2023 at 4:30 pm, CNA1 confirmed R29 had ¼ side rails on the bed, and she could hold onto them for rolling from side to side during care. CNA1 stated that R29 needed extensive assistance with transfers, dressing and personal hygiene. 3. Review of R36's Face Sheet, located in the EMR under the Face Sheet tab, revealed the resident was admitted to the facility on [DATE] with diagnoses that included encephalopathy (damage or disease that affects the brain), and chronic obstructive pulmonary disease (COPD). Review of R36's significant change in status MDS Assessment with an ARD of 6/26/2023, located in the EMR under the MDS 3.0 Assessments tab, revealed Section C-Cognitive Patterns: a BIMS score of 13 out of 15 which indicated R36 was cognitively intact; Section G-Functional Status: indicated R36 required extensive assistance of one person with bed mobility, dressing, eating, toilet use, and personal hygiene. Review of R36's Physician's Orders, dated 11/7/2019, located in the EMR under the Orders tab, revealed an order for 1/4 side rails up x [times] 2 [two] to assist with bed mobility and positioning; Special Instructions: Ensure side rails are up when resident is in bed. Review of R36's Care Plan, located in the EMR under the Care Planning tab, revealed there was no care plan or interventions regarding bed rails. Review of R36's Restraint-Adaptive Equipment Use Assessment, dated 6/19/2023, located in the EMR under the Observations tab, revealed the assessment was completed after R36's readmission from the hospital. Under the Observation Details, Adaptive Equipment, yes was marked under the question Is adaptive equipment in use? and ¼ side rails was entered after the question If so, what is the physician's order? Include device, reason for use, and duration. However, there was no admission or additional annual assessments completed on bed rails. Additionally, there was no signed consent for the bed rails located in the EMR. Observations on 10/3/2023 at 12:11 pm, 10/4/2023 at 9:46 am, and 10/4/2023 at 4:57 pm revealed R36 was lying in the bed with 1/4 length size siderails up on both sides of the head of the bed. During an interview on 10/3/2023 at 12:13 pm, R36 stated she could not lower the bed rails, the rails were already on the bed when she was admitted to the facility, she did not remember if she was told about the risks and benefits of them, and she used them for pulling up in the bed. During an interview on 10/4/2023 at 3:10 pm, LPN Charge Nurse 2 confirmed R36 required maximum assistance with ADLs, had bed rails, could not lower them, and used them for turning and repositioning while in the bed. 4. Review of R39's Face Sheet, located in the EMR under the Face Sheet tab, revealed the resident was admitted to the facility on [DATE] with a diagnosis of dementia. Review of R39's annual MDS Assessment with an ARD of 7/21/2023, located in the EMR under the MDS 3.0 Assessments tab, revealed Section C-Cognitive Patterns: a BIMS score of 99 which indicated the resident could not be interviewed and was moderately impaired in decision making; Section G-Functional Status: indicated R39 required extensive assistance of one person with bed mobility; total dependence with two persons for transfers; total assistance of one person for dressing, toilet use, personal hygiene, and bathing; and supervision with eating. Review of R39's Physician's Orders, dated 8/19/2022, located in the EMR under the Orders tab, revealed an order for 1/4 side rails up x [times] 2 [two] to assist with bed mobility to aid with transfers as needed. Review of R39's Care Plan, located in the EMR under the Care Planning tab, revealed there was no care plan or interventions regarding bed rails. Review of R39's Restraint-Adaptive Equipment Use Assessment, dated 7/13/2023, located in the EMR under the Observations tab, revealed the assessment was the annual review. Under the Observation Details, Adaptive Equipment, yes was marked under the question Is adaptive equipment in use? and ¼ side rails was entered after the question If so, what is the physician's order? Include device, reason for use, and duration. However, there was no admission or additional annual assessments completed on bed rails. Additionally, there was no signed consent for the bed rails located in the EMR. Observations on 10/2/2023 at 10:12 am, 10/3/2023 at 10:30 am, 10/4/2023 at 9:40 am and 4:11 pm revealed R39 was lying in the bed with 1/4 length size siderails raised on both sides of the head of the bed. During an interview on 10/4/2023 at 3:34 pm, LPN Unit Manager 1 confirmed R39 had ¼ side rails on the bed, could use the side rails to get up but could not lower the side rails. LPN Unit Manager 1 stated the admitting nurse was responsible for completing the initial assessment that included a question about side rails and entering the order for the side rails; however, annual side rail assessments were not completed. LPN Unit Manager 1 also stated that consents for bed rails were not completed. LPN Unit Manager 1 indicated the bed rails were not removed from the bed after a resident was discharged from the facility and the Maintenance Director completed monthly bed and bed rails inspections. During an interview on 10/4/2023 at 4:18 pm, CNA3 confirmed R39 had ¼ side rails on the bed, could use them to get up out of the bed, could not lower the side rails, and required total care with ADLs. 5. Review of R14's undated Face Sheet, located under Face Sheet tab in the EMR, revealed R68 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), cerebrovascular disease, and dementia. Review of R14's Physician Orders, located under the Orders tab in the EMR, revealed an order, dated 5/5/2019, for ¼ top sides rails to assist with mobility. Review of R14's annual MDS assessment, located under the MDS tab in the EMR and with an ARD of 7/26/2023, revealed Section C-Cognitive Patterns: a BIMS score of 12 out of 15, indicated R14 was mildly cognitively impaired; Section G-Functional Status: indicated R14 extensive assistance for bed mobility, transfers, dressing, and personal hygiene. Review of R14's Assessments, located under the Observation tab in the EMR, revealed no assessment for bed rails. Review of R14's records revealed no consent for the bed rails was in the EMR. During an observation on 10/2/2023 at 10:20 am, R14 was observed to have ¼ rails on the bed. During an interview on 10/4/2023 at 2:33 pm, CNA2 was asked if the bed rails were used for R14. CNA2 stated, He is blind and will grab on the rails to assist with moving in the bed. During an interview on 10/420/23 at 4:19 pm, LPN Charge Nurse 1 was asked if the R14 needed the side rails and when should assessments be completed. LPN Charge Nurse1 stated, The resident does use the side rails to turn from side to side. Assessments should be completed on admission. 6. Review of R37's undated Face Sheet, located under Face Sheet tab in EMR, revealed R68 was admitted to the facility on [DATE] with diagnoses of encephalopathy, COPD, and dementia. Review of R37's Physician Orders, located under the Orders tab in the EMR, revealed an order, dated 7/26/2021 for ¼ top side rails for turning and repositioning. Review of R37's quarterly MDS assessment, located under the MDS tab in the EMR and with an ARD of 9/14/2023, revealed Section C-Cognitive Patterns: a BIMS score of 11 out of 15, which indicated R37 was cognitively impaired; Section G-Functional Status: indicated R37 required limited assistance for bed mobility and transfers and extensive assistance for dressing, toilet use, and personal hygiene. Review of R37's records revealed no consent for the bed rails was in the EMR. During an observation on 10/2/2023 at 11:00 am, R37 was in bed with ¼ side rails. During an interview on 10/4/2023 at 2:39 pm, CNA2 was asked if R37 used the bed rails. CNA2 stated, He does use the bed rails for repositioning. 7. Review of R55's undated Face Sheet, located under Face Sheet tab in EMR, revealed R68 was admitted to the facility on [DATE] with diagnoses of diabetes mellitus, congestive heart failure, and absence of right leg below knee. Review of R55's Physician's Orders, located under the Orders tab in the EMR, revealed an order, dated 10/26/2021, for ¼ top side rails turning and repositioning. Review of R55's Assessments, located under the Observation tab in the EMR, revealed an assessment dated [DATE] for bed rails. Review of R55's quarterly MDS assessment, located under the MDS tab in the EMR and with an ARD of 8/14/2023, revealed Section C-Cognitive Patterns: a BIMS score of 15 out of 15, which indicated R55 was cognitively intact; Section G-Functional Status: indicated R55 required supervision for bed mobility, transfer, dressing, toilet use and personal hygiene. Review of R55's records revealed no consent for the bed rails was in the EMR. During an observation on 10/2/2023 at 11:15 am, R55 was sitting in the wheelchair at bed side with ¼ side rails. R55 stated he does use them because of the amputation to his right leg. During an interview on 10/4/2023 at 2:39 pm, CNA2 was asked if R55 used the bed rails. CNA2 stated, He does for himself. During an interview on 10/4/2023 at 4:41 pm, LPN Charge Nurse1 was asked if the bed rails were needed for R55. LPN Charge Nurse1 stated, Yes. He uses them for positioning. 8. Review of R5's admission Record, located in the EMR under the Profile tab, indicated the resident was admitted to the facility on [DATE]. Review of R5's Care Plan, updated 7/20/2023 and located in the EMR under the Care Plan tab, revealed no care plan or interventions related to the use of siderails. Review of R5's Physician Orders, located in the EMR under the Orders tab and dated 9/21/2021, revealed an order for half rails. Review of R5's Restraint-Adaptive Equipment Use, located in the EMR under the Observations tab and dated 6/13/2023, indicated R5 used quarter siderails for turning and repositioning. Review of R5's records located in the EMR revealed there was no consent for the use of siderails. During an observation on 10/2/2023 at 10:35 am, R5's bed was observed to have ¼ rails on each side. 9. Review R6's admission Record, located in the EMR under the Profile tab, indicated the resident was admitted to the facility on [DATE]. Review of R6's Care Plan, updated 8/24/2023 and located in the EMR under the Care Plan tab, revealed no care plan or interventions related to the use of siderails. Review of R6's Physician Orders, located in the EMR under the Orders tab, revealed an order for half rails dated 8/23/2022. Review of R6's Restraint-Adaptive Equipment Use, located in the EMR under the Observations tab and dated 8/17/2023, indicated R6 used quarter siderails for turning and repositioning. Review of R6's records located in the EMR revealed no consent for the use of siderails. 10. Review R18's admission Record, located in the EMR under the Profile tab, indicated the resident was admitted to the facility on [DATE]. Review of R18's Care Plan, updated 6/6/2022 and located in the EMR under the Care Plan tab, revealed no care plan or interventions related to the use of siderails. Review of R18's Physician Orders, located in the EMR under the Orders tab, revealed no order for siderails. Review of R18's Observations, located in the EMR, revealed no assessment for the use of Restraint-Adaptive Equipment Use. Review of R18's records, located in the EMR, revealed no consent for the use of siderails. During an observation on 10/2/2023 at 10:17 am, R18's bed was observed to have ¼ rails on each side. 11. Review R31's admission Record, located in the EMR under the Profile tab, indicated the resident was admitted to the facility on [DATE]. Review of R31's Care Plan, updated 2/18/2022 and located in the EMR under the Care Plan tab, included R31's use of quarter rails. Review of R31's Physician Orders, located in the EMR under the Orders tab, included an order for half rails dated 6/1/2021. Review of R31's Restraint-Adaptive Equipment Use, located in the EMR under the Observations tab and dated 4/19/2023, indicated R31 used quarter siderails for turning and repositioning. Review of R31's documents, located in the EMR, revealed no consent for the use of siderails. During an observation and interview on 10/3/2023 at 5:07 pm, R31's bed was observed to have ¼ rails on each side. R31 stated she was able to raise and lower the rails. 12. Review R33's admission Record, located in the EMR under the Profile tab, indicated the resident was admitted to the facility on [DATE]. Review of R33's Care Plan, updated 2/13/2022 and located in the EMR under the Care Plan tab, included R33's use of quarter rails. Review of R33's Physician Orders, located in the EMR under the Orders tab, revealed an order for quarter rails dated 4/13/2019. Review of R33's Restraint-Adaptive Equipment Use, located in the EMR under the Observations tab and dated 4/15/2023, indicated R33 used quarter siderails for turning and repositioning. Review of R33's records, located in the EMR, revealed no consent for the use of siderails. During an observation on 10/3/2023 at 10:41 am, R33's bed was observed to have ¼ side rails bilaterally. 13. Review R56's admission Record, located in the EMR under the Profile tab, indicated the resident was admitted to the facility on [DATE]. Review of R56's Care Plan, updated 9/4/2023 and located in the EMR under the Care Plan tab, revealed no care plan or interventions related to the use of siderails. Review of R56's Physician Orders, located in the EMR under the Orders tab, revealed no order for the use of siderails. Review of R56's Observations, located in the EMR, revealed no assessment for the use of Restraint-Adaptive Equipment Use. Review of R56's records, located in the EMR, revealed no consent for the use of siderails. During an observation on 10/2/2023 at 4:52 pm, R56's bed was observed to have bilateral side rails. 14. Review of R57's admission Record, located in the EMR under the Profile tab, indicated the resident was admitted to the facility on [DATE]. Review of R57's Care Plan, dated 9/21/2023 and located in the EMR under the Care Plan tab, revealed no care plan or interventions related to the use of siderails. Review of R57's Physician Orders, located in the EMR under the Orders tab, included an order for half rails dated 9/14/2023. Review of R57's Observations, located in the EMR, revealed no assessment for the use of Restraint-Adaptive Equipment Use. Review of R57's records, located in the EMR, revealed no consent for the use of siderails. During an observation and interview on 10/3/2023 at 6:00 pm, R57's bed was observed to have bilateral side rails that were lowered. R57 stated she could raise and lower the side rails. During an interview on 10/4/2023 at 12:24 pm, the Administrator stated that the bed rails consents were completed on admission by the social worker, and the admitting nurses completed the side rail assessments and obtained orders for the side rails. The Administrator confirmed the bed rail consents were not completed for the residents until 10/04/2023 because they could not find them. During an interview on 10/4/2023 at 1:16 pm, the Director of Nursing (DON) stated the admitting nurse completed the side rail assessment to determine if the side rail would benefit the resident with positioning, and then risks and benefits would be explained, and a side rail consent would be completed by the resident/representative. The DON confirmed that she found out today that the nursing department had not completed some of the required admission and annual assessments and had not obtained consents for the bed rails. During an interview on 10/4/2023 at 1:36 pm, the DON was asked about bed rail assessments and consents. The DON stated, The assessment is done on admission and consents should be done also. Consents have been competed as of today. The DON was shown in the facility policy where the assessment should be done annually also. The DON stated, I did not know that. During an interview on 10/4/2023 at 3:03 pm, LPN Charge Nurse 2 was asked if the bed rails were necessary. LPN Charge Nurse 2 stated, The bed rails are used to assist the residents in turning and positioning. There should be an assessment at the time of admission by the admitting nurse and someone else gets the consents. During an interview on 10/5/2023 at 8:59 am, the MDS Coordinator stated if a resident had side rails for the medical reason of mobility, then the intervention did not need to be care planned. The MDS Coordinator also stated bed rails were care planned when the bed rails were a restraint.

Based on observation, interview, and review of the facility policy titled, Infection Prevention- Hand Hygiene, the facility failed to ensure the stove hood was maintained in good condition, adhere to hand hygiene practices when handling food and to ensure food was handled in a manner to prevent the potential spread of food borne illness for 58 or 61 residents that were provided meals from the kitchen. Findings include: Review of the facility's policy titled, Infection Prevention- Hand Hygiene, dated, 3/8/2019 revealed, Policy Statement: . partners will improve hand hygiene practices and reduce health care infections.Procedures. Indications Requiring Hand Wash, 1. Before handling food. 1. Observation on 10/2/2023 at 8:54 am revealed the hood above the stove was covered with rust including the vents. Interview on 10/2/2023 at 9:00 am with the Dietary Manager (DM) stated, The company was out in August and the hood had to be replaced. We are waiting on a quote. During this time, the DM was asked to provide a policy and any paperwork that they facility was waiting on a quote. The DM did not provide any records as requested prior to exit on 10/5/2023 at 7:30 pm. 2. Observations on 10/4/2023 of the noon meal preparation and service revealed the following: a. At 11:59 am, the [NAME] was observed wearing gloves and touched the handles of the fryer baskets as the sweet potato fries were being prepared. The [NAME] went over to the steam table and began to pull plates out for the meal service. The Cook's gloved hands touched the surface of the plates where the food would be placed. At 12:02 pm, the [NAME] began to serve food and touched the hamburger buns with the same gloved hands. At 12:05 pm, the [NAME] moved over to the oven, pulled out a pan, and then returned to the steam table where she helped serve food and touched the hamburger buns. The [NAME] did not change her gloves or sanitize her hands. b. At 12:02 pm, the Assistant Dietary Manager (ADM) was observed washing her hands and donning gloves. The ADM then went throughout the kitchen touching drawer handles on the plastic bins, pulled out serving utensils, and placed them on the steam table. The ADM began to serve food, touching the hamburger buns without changing her gloves or sanitizing her hands. At 12:25 pm, the ADM left the serving line, collected a Styrofoam container, went back to the serving line, touched the hamburger bun, and placed it in the container. c. At 12:14 pm, Dietary Aide (DA) 2 was observed touching his mask and continued to set up trays, put drinks on the trays and lids on the plates without changing his gloves or sanitizing his hands. During an interview on 10/4/2023 at 12:25 pm, the ADM was asked if it was appropriate to go through the kitchen wearing gloves collecting the utensils and touching the drawers with the same gloves that she served and touched the food. The ADM stated she did not do that. The ADM was asked if it was appropriate to leave the line and get the Styrofoam container and return to the line without changing gloves. The ADM stated she did not recall doing that. During an interview on 10/5/2023 at 12:27 pm, the DM was asked what her expectation was of staff's hand hygiene practices when gathering utensils, touching the handles of fryer, drawers and staff touching their mask. The DM stated, Staff should wash hands and change gloves when moving to a new task. The DM stated, Gloves should have been changed out, hands washed, and new gloves put on with each new task. The DM stated, Staff should not be touching their mask. If they do, then they should wash their hands before doing anything else.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and review of the facility policies titled, Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings and Infection Prevention and Control Plan the facility failed to have a documented water management program that included measures to prevent the growth of opportunistic water-borne pathogens and how to monitor for them. This had the potential to affect 61 of 61 residents that resided at the facility. Findings include: Review of the facility's policy titled, Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings, dated 6/5/2017 revealed, . Your building may need a water management program to reduce the risk for Legionnaires' disease associated with your building water system and devices. This water management program should identify areas or devices in your building where Legionella might grow or spread to people so that you can reduce that risk . The bottom line is that you need to: Identify building water systems for which Legionella control measures are needed . assess how much risk the hazardous conditions in those water systems pose . apply control measures to reduce the hazardous conditions, whenever possible, to prevent Legionella growth and spread . make sure the program is running as designed and is effective . Review of the facility's policy titled, Infection Prevention and Control Plan, revised 6/23/2023 revealed, . The Infection Prevention and Control Plan outlines the framework by which all [NAME] Health facilities will assess, implement, and evaluate an active, effective, comprehensive facility-wide Infection Prevention and Control program . Program Objectives . Monitoring and evaluation of the environment, (e.g., environmental control, waste management, water management, . ), to identify potential reservoirs of epidemiologically important microorganisms, investigate outbreaks or to facilitate education opportunities for the staff . Review of the Direct Supply TELS (building management system) indicated water management testing was done monthly with no information provided regarding the type of testing or if it included Legionella. Drinking water fountains were prompted for monthly cleaning. Observation on 10/3/2023 at 5:15 pm revealed a drinking water fountain capped off on the A hall with a red cover over the fountain spicket. During an interview on 10/5/2023 at 5:40 pm, the Maintenance Director was asked about testing the facility's water supply for Legionella. The Maintenance Director did not know what Legionella was or where it grew but stated that the facility had a company that performed routine testing. The Maintenance Director provided a flow diagram but did not know which areas of the diagram should be checked for Legionella. The Maintenance Director then provided results for chlorine water testing and was not aware that chlorine testing did not include Legionella water levels. Additionally, he confirmed that he was not flushing, monitoring, or disinfecting water systems that could harbor Legionella. There was no system in place for monitoring faucets, sinks/showers, or water fountains that were not in use. The Maintenance Director confirmed that drinking water fountains were included in the TELS task list to be cleaned monthly but had not been done in the past year of his employment because the fountains had not been in use.

Based on observations, interviews, review of job descriptions, and review of the policy titled Infection Control- Housekeeping, the facility failed to ensure that it was maintained in a safe, clean, and comfortable home-like environment in ten of 16 resident rooms (rooms A2, A4, A5, A6, A7, A8, A9, A10, A11, A12) including dirty and stained privacy curtains, chipped paint on walls, and air conditioner vents with dust and debris. The facility census was 57. Findings include: Review of the policy titled Infection Control- Housekeeping revised 1/15/16 indicated it is the policy of this facility to ensure housekeeping services will be performed on a routine and consistent bases to ensure an orderly, sanitary, and comfortable environment. Procedure: Frictional Cleaning - Thorough scrubbing will be used for all environmental surfaces that are being cleaned in patient/resident care areas. A deep cleaning will be performed for each patient/resident room monthly and as needed. Routine cleaning of Horizontal Surfaces: In patient/resident care area cleaning of non-carpeted floors and other horizontal surfaces will be performed daily and more frequently of spillage or visible soiling occurs. Review of position description for Maintenance Director revealed Key Responsibilities 3. Establishes and conducts scheduled maintenance throughout physical plant and for all equipment. Observation on 8/20/22 at 9:31 a.m. of room A-2 privacy curtain between bed A and bed B noted to have large brown stain at the top of curtain by the netting. Observation on 8/20/22 at 9:34 a.m. of room A-4 privacy curtain for bed A noted to have brown stains throughout curtain. Observation on 8/20/22 at 9:35 a.m. of room A-5 privacy curtain for bed B with large brown stain noted on lower part by the hem and outer edges. Also, the air conditioner vent noted to be dusty, with food debris inside vent. Observation on 8/20/22 at 9:36 a.m. of room A-6 privacy curtain for bed A and bed B both have brown stains noted and visible dirt on the outer hem, the air conditioner vent was dusty, and the wall between the two beds had dirty brown stain. Observation on 8/20/22 at 9:39 a.m. of room A-7, the bathroom door has missing paint, brown stains on the wall by bed A, paint missing off the wall B bed by window. Observation on 8/20/22 at 9:41 a.m. of room A-8 privacy curtain stained. Observation on 8/20/22 at 9:42 a.m. of room A-9 paint scraped off wall behind bed A, privacy curtain noted to have brown stain outer edge of curtain. Observation on 8/20/22 at 9:43 a.m. of room A-10 paint missing off wall behind bed under light. Observation on 8/20/22 at 9:45 a.m. of room A-11 privacy curtain brown stains outer edge, paint peeling off bathroom door. Observation on 8/20/22 at 9:46 a.m. of room A-12 privacy curtain bed B noted with brown stains middle of the curtain. Interview on 8/21/22 at 10:05 a.m. with Housekeeper AA, revealed that when cleaning the residents' rooms, she deep cleans every day. She stated she starts with pulling the trash and then dusting everything in the room and the bathroom is the last thing that is cleaned in the room with a disinfectant. During further interview, she revealed that maintenance is responsible for ensuring that the residents air conditioner vents are cleaned and for changing the resident's privacy curtain when they are soiled and need repair. Environmental rounds conducted on 8/21/22 at 10:21 a.m. with Administrator, Environmental Services Director, and Maintenance Director where all concerns identified during the survey were confirmed by administrative staff. Interview on 8/21/22 at 10:42 a.m. with Environmental Services Director revealed that deep cleans are conducted weekly and are scheduled through Building Engines. During the deep clean process, he stated the floor techs will go into the residents' room to be cleaned and remove all the furniture. The housekeeper will then start cleaning the room by first high dusting and then dusting everything on the lower level of the room. The bathroom is the last thing that is cleaned which is cleaned with Peroxide cleaning mixture that has a dwell time of 3 minutes. During further interview, he stated the privacy curtains are part of the deep cleaning regimen which includes inspecting curtains for stains and replacing as needed. He revealed that the Maintenance Director is responsible for ensuring that the residents air conditioner vents are cleaned monthly. Interview on 8/21/22 at 10:51 a.m. with Maintenance Director stated his department is responsible for ensuring that the residents air conditioner vents are cleaned monthly. Further interview revealed that he had started cleaning the AC vents and have only completed C hall thus far. He stated he would continue painting and touching up the rooms that need repair. Interview on 8/21/22 at 11:06 a.m. with Administrator revealed that new privacy curtains will be ordered for the residents to replace the old worn ones, and those that have stains and spots on them will be removed and replaced. The expectation is for the resident always live in clean and homelike environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, and policy review, the facility failed to ensure quality of care and services in accordance with professional standards related to not following physician orders for antibiotic use for one of one resident (R) (R#35) with recurring urinary tract infections (UTI's). The sample size was 26. Findings include: Review of the policy titled Medication Administration: General Guidelines revised 4/10/19, revealed medications are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so. This policy applies to all licensed nursing staff in a healthcare center serviced by [name] Pharmacy. Procedure 10. After medication administration for facilities utilizing electronic [medication administration record] MAR, the patient/resident's e-MAR is electronically signed off. Procedure 13. If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time, for facilities utilizing the e-MAR system, the NOT ADMINISTERED button will be utilized with the appropriate reason for not administering medication at scheduled time. If more than two consecutive doses of a vital medication are withheld or refused, the physician is notified. Review of the clinical record for R#35's revealed resident was originally admitted to the facility on [DATE] with diagnoses including sepsis, infection and inflammatory reaction due to indwelling urethral catheter, severe sepsis without septic shock, urinary tract infection (UTI), kidney failure, fever, and wound to right buttock. She had a hospitalization and was readmitted to the facility on [DATE] with diagnoses of sepsis and UTI. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was coded as 13 indicating resident is cognitively intact. Section H revealed resident had an indwelling urinary catheter. Section N revealed antibiotics were administered 6 out of 7 days during look back period. Section O revealed intravenous medications were administered. Review of the lab report for urine culture and sensitivity dated 7/15/22 indicated greater (>) 100,000 colony count Pseudomonas Aeruginosa. Handwritten on the bottom of the lab report was an order for Cipro 500 milligram (mg) twice daily by mouth for 10 days. Review of the lab report for urine culture and sensitivity dated 8/1/22 indicated > than 100,000 colony count of ESBL Producer Klebsiella Pneumoniae. Handwritten on the lab report was an order for amikacin 150mg intramuscularly (IM) times (x's) nine. Review of care plan for R#35, initiated on 8/1/2022, revealed resident requires [intravenous] IV antibiotics due to diagnosis of UTI. Interventions include administer antibiotics as ordered, assess for complications of IV, flushes as ordered, monitor IV site for swelling, dressing changes to IV site as ordered. Problem was resolved on 8/20/22. Review of July 2022 Physician Orders (PO) revealed an order dated 7/15/22 for cipro (a medication used to treat infections) 500 milligrams (mg) by mouth every 12 hours for ten days at 9:00 a.m. and 9:00 p.m. Review of Medication Administration Record (MAR) for month of July 2022, revealed the medication cipro 500 mg was not administered on 7/19/22 at 9:00 a.m. or 9:00 p.m. and 7/20/22 at 9:00 p.m. Medication was documented as not available on 7/19/22 at 9:00 p.m., but no documented reason for 7/19/22 at 9:00 a.m. or 7/20/22 at 9:00 p.m. Review of August 2022 Physician Orders (PO) revealed an order dated 8/9/22 for amikacin (a medication used to treat infections) 150 mg intramuscularly (IM) for five days at 9:00 a.m. and 9:00 p.m. Review of MAR for month of August 2022, revealed the medication amikacin 150 mg was not administered on 8/9/22 at 9:00 p.m., 8/11/22 at 9:00 p.m. or 8/13/22 at 9:00 p.m. The medication was documented as not available. Interview on 8/21/22 at 9:09 a.m. with R#35, she stated that she has had several UTI's while at the facility and has been treated for them. She stated that she is unsure if she received all the prescribed doses for the medications. During continued interview, she stated, I take what they give me. Interview on 8/21/22 at 9:43 a.m. with the Director of Nursing (DON) and Registered Nurse (RN) AA, after reviewing the July 2022 and August 2022 MAR's, both verified that there is missing documentation for the prescribed antibiotics for 7/1/22, 7/15/22, 8/9/22, 8/11/22 and 8/13/22. Interview on 8/21/22 at 10:26 a.m. with Senior Nurse Consultant (SNC), DON and RN AA, revealed the SNC stated the asterisk (*) next to nurse initials on the MAR indicated that there is a note into the entry; a parenthesis () around the nurse initials indicates a note that medication was not given.