Based on record reviews, staff interviews, and review of the facility's policy titled, Baseline Care Plan, the facility failed to develop a baseline care plan within 48 hours of admission that addressed two medications, (an opioid and a diuretic) for one out of five sampled residents (R ) (R33) selected for unnecessary medications review. This had the potential to cause adverse medical effects for R33 with no known interventions for staff. Findings include: Review of the undated facility's policy titled; Baseline Care Plan under Policy Explanation and Compliance Guidelines revealed, 1. The baseline care plan will: (a.) Be developed within 48 hours of a resident's admission. (b.) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to: i. Initial goals based on admission orders; ii. Physician orders; iii. Dietary orders; iv. Therapy services; v. Social services; vi. PASARR recommendation, if applicable 2.(b.) Interventions shall be initiated that address the resident's current needs including: i. Any health and safety concerns to prevent decline or injury, such as elopement, fall, or pressure injury risk . 3. A supervising nurse shall verify within 48 hours that a baseline care plan has been developed. Review of R33's medical records revealed an admission date of 7/5/2024 with diagnoses that included, chest pain, unspecified, heart failure, unspecified, paroxysmal atrial fibrillation, anemia, unspecified, hypokalemia, chronic kidney disease, stage 4 (severe), muscle weakness (generalized), difficulty in walking, need for assistance with personal care, essential (primary) hypertension, and unspecified diastolic (congestive) heart failure. Review of R33's physician orders revealed, Pain Evaluation Q (every) shift (record numeric value. 0=No Pain. 1-3= Mild Pain. 4-6= Moderate Pain. 7-1-=Severe Pain), with start date of 7/5/2024. Further review of the physician orders revealed, hydrocodone acetaminophen oral tablet 10-325 mg (milligram) with a start date of 7/6/2024, give one tablet by mouth every 12 hours as needed for pain and furosemide oral tablet 20 mg give three tablets by mouth two times a day for daily diuretics; hold for SBP (systolic blood pressure) less than 110 and/or HR (heart rate) less than 60 with a start date of 7/6/2024. Review of R33's baseline care plan dated 7/8/2024 under section 3. Health Conditions and subsection D. Medications revealed, 1. Medications resident is taking provided the option to select the following: a. Psychotropic medications b. PRN Psychotropics c. Diuretics d. Insulin e. Antibiotics f. Anticoagulants g. Opioids (documentation) h. Black Box medications; however, none of the boxes were checked. Interview on 7/18/2024 at 2:20 pm with the Assistant Director of Nursing (ADON) revealed that the nursing staff monitor high risk medications on the MAR (medication administration record). She stated residents who have diuretics ordered are weighed daily on admission and depending on the dose ordered they would continue weekly weights. She stated if a resident were stable, they would complete monthly weights. She stated nursing completes a functional skilled assessment for skilled nursing residents daily. She stated opioid medications are monitored by the nurse practitioner and there was a tool in the EHR (electronic health record) that would trigger to monitor for side effects that was documented on the MAR. She confirmed the care plan should have interventions listed related to the high risk medications that nursing should be able to refer to for guidance. She stated she was not aware of how these items are care planned. Interview on 7/18/2024 at 4:43 pm with the ADON revealed, when a resident admits into the facility, nursing completes their portion of the baseline care plan along with the other different disciplines and try to do them [respective portions of the baseline care plan] within 24 hours. The ADON further revealed typically the DON (Director of Nursing) will check over it to make sure it was correct, if not the DON, the ADON. She stated, if the baseline care plans were not done correctly, that could cause the facility the inability to take care of the residents. She stated, the nurse on the floor would be asked to check for mistakes, make corrections, and make sure the care plans were aligned with the resident's care. Interview on 7/18/2024 at 3:59 pm with the Minimum Data Set (MDS) Licensed Practical Nurse (LPN) revealed, she was responsible for developing care plans after the comprehensive assessments were completed. She stated she was familiar with R33 and stated she had been recently re-admitted to the facility however, she has not been able to get to R33's baseline care plan but would be sure to correct it. She acknowledged and stated, by those (opioid and diuretic) medications not being care planned, could affect R33 because the care plan should address the medications and interventions for staff to provide.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interviews, and review of the facility's policy titled, Comprehensive Care Plans, the facility failed to develop a care plan that included a communication or language preference for one of three sampled residents (R) (R179) whose primary language was not English. This deficiency had the potential to adversely impact the quality of care and quality of life provided to the resident. Findings include: Review of the undated facility's policy titled, Comprehensive Care Plans, under Policy Explanation and Compliance Guidelines revealed the following, Number 3. The comprehensive care plan will describe, at a minimum, the following: (f.) Resident specific interventions that reflect the resident's needs and preferences and align with the resident's cultural identity, as indicated. If the resident is non-English-speaking, the facility will identify how communication will occur with the resident. The care plan will identify the language spoken and tools used to communicate. Number 4. The comprehensive care plan will be prepared by an interdisciplinary team, that includes, but is not limited to: a. The attending physician or non-physician practitioner designee involved in the resident's care, if the physician is unable to participate in the development of the care plan. b. A registered nurse with responsibility for the resident. c. A nurse aide with responsibility for the resident. d. A member of the food and nutrition services staff. e. The resident and the resident's representative, to the extent practicable. f. Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. Examples include, but are not limited to: i. The RAI Coordinator. ii. Activities Director/Staff. iii. Social Services Director/Social Worker. iv. Licensed therapists. v. Family members, surrogate, or others desired by the resident. vi. Administration. vii. Discharge Coordinator. viii. Mental health professional. ix. Chaplain. Review of the electronic medical record (EMR) for R179 revealed, she admitted to the facility with diagnoses to include Covid-19, presence of cardiac pacemaker, hypothyroidism, and generalized muscle weakness. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] for R179 revealed Section A: Identification Information, indicated her preferred language was Korean; Section C: Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderate cognitive impairment; Section D: Mood, a Mood score of zero, indicating no depression and no behaviors and Section GG: Functional Abilities and Goals, which indicated she required setup for eating and moderate to maximum assistance for all other activities of daily living (ADLs). Review of the Care Plan for R179 dated 1/19/2024 revealed there was no focus concern related to communication or language until 7/18/2024 which documented her preferred language as Korean with a goal of being able to make her needs known. Interventions included anticipating her needs, her preference to communicate in Korean, and discussing with her/family concerns regarding communication difficulty. Observation and interview on 7/17/2024 at 1:20 pm with R179 revealed in a response to a greeting in English, she gestured to indicate that she did not speak English. When asked if she spoke Korean, she nodded affirmatively. She was able to understand text communication via Google translator and confirmed that staff took good care of her. During an interview on 7/17/2024 at 3:47 pm with the MDS Licensed Practical Nurse (LPN), she stated she was hired in January 2024 and was the only MDS nurse currently on staff. She stated she was self-taught, mostly through online courses, regarding her knowledge of the MDS process and her duties as the MDS Nurse. She confirmed the most recent MDS assessment included R179's preference for Korean language for communication. During an interview on 7/18/2024 at 10:51 am with Registered Nurse (RN) AA, she stated the staff utilize the translator telephone line when attempting to communicate with a resident who speaks a language that they cannot speak. In addition, she stated staff also use a communication board with symbols to communicate with residents. Finally, she stated the attending nurse can create or update the care plan, but it was usually handled by one or more of the interdisciplinary team (IDT) members. During an interview on 7/18/2024 at 11:04 am with Certified Nursing Assistant (CNA) II, she stated she communicated with residents who do not primarily speak English by facing them when speaking, using the language tools like the translator line, or calling a family member. In addition, she stated several staff members speak different languages and can be called to assist anytime. During an interview on 7/18/2024 at 11:30 am with the Assistant Director of Nursing (ADON), she confirmed communication/language was not part of R179's care plan until today. She stated it would benefit residents and staff if communication was part of the care plan related to potential challenges such as language, cognition, or diagnosis. She stated members of the IDT are mostly responsible for creating and updating the care plan. During an interview on 7/18/2024 at 2:30 pm with the Medical Director, he stated it would be helpful to the staff if communication was a focus concern in the care plan due to language(s) spoken by the resident or other challenges in communication whether cognitive, medical, or cultural.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and review of the facility's policy titled iQIES or Other System Downtime MDS, the facility failed to ensure that required Minimum Data Set (MDS) assessments were transmitted within regulatory guidelines to the Centers for Medicare and Medicaid Services (CMS) Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) System for 31 residents (R) (R89,R55, R56, R8, R62, R7, R33, R85, R3, R19, R86, R84, R16, R31, R91, R15, R25, R72, R75, R88, R81, R90, R77, R38, R45, R20, R92, R78, R50, R278, and R368) out of 44 sampled residents. Findings Include: Review of the undated facility's policy titled iQIES or Other System Downtime MDS, under the Policy section revealed, It is the policy of this facility to transmit MDS data timely so that the facility will not be negatively impacted by iQIES or other system downtimes. Under the Policy Explanation and Compliance Guidelines section revealed, 1. All required MDS assessment files will be transmitted to iQIES using the CMS wide area network within regulatory guidelines: PPS, quarterly, and discharge assessments will be transmitted within 14 days of the completion date in Z0500B. Review of the Resident Assessment Task in the Long-Term Care Survey Process revealed, MDS assessments as being more than 120 days old indicated: R89's Discharge assessment dated [DATE] was coded as 'export ready'. R55's Discharge assessment dated [DATE] was coded 'In Progress'. R56's Discharge assessment dated [DATE] was coded 'In Progress'. R8's Discharge assessment dated [DATE] was coded 'In Progress'. R62's Discharge assessment dated [DATE] was coded 'In Progress'. R7's Discharge assessment dated [DATE] was coded 'In Progress'. R33's Discharge assessment dated [DATE] was coded 'In Progress'. R85's Discharge assessment dated [DATE] was coded 'In Progress'. R3's Discharge assessment dated [DATE] was coded as 'export ready'. R19's Discharge assessment dated [DATE] was coded as 'export ready'. R86's Discharge assessment dated [DATE] was coded 'In Progress'. R84's Discharge assessment dated [DATE] was coded 'In Progress'. R16's Discharge assessment dated [DATE] was coded as 'export ready'. R31's Discharge assessment dated [DATE] was coded 'In Progress'. R91's Discharge assessment dated [DATE] was coded 'In Progress'. R15's Quarterly assessment dated [DATE] was coded as 'In Progress'; Discharge assessment dated [DATE] coded as 'In Progress'. R25's Discharge assessment dated [DATE] was coded as 'export ready'. R72's Discharge assessment dated [DATE] was coded as 'export ready'. R75's Discharge assessment dated [DATE] was coded as 'export ready'. R88's Discharge assessment dated [DATE] was coded 'In Progress'. R81's Discharge assessment dated [DATE] was coded 'In Progress'. R90's Discharge assessment dated [DATE] was coded as 'export ready'. R77's Discharge assessment dated [DATE] was coded 'In Progress'. R38's Discharge assessment dated [DATE] was coded 'In Progress'. R45's Discharge assessment dated [DATE] was coded 'In Progress'. R20's Discharge assessment dated [DATE] was coded 'In Progress'. R92's Discharge assessment dated [DATE] was coded 'In Progress'. R78's Discharge assessment dated [DATE] was coded as 'export ready'. R50's Discharge assessment dated [DATE] was coded 'In Progress'. R278 's admission assessment dated [DATE] was coded 'export ready'. R368 's Discharge assessment dated [DATE] was coded In Progress. During an interview on 7/18/2024 at 8:45 am with the MDS Coordinator revealed the coding was accurate as far as she knew. She stated she was unsure why the 'export ready' assessments had not been submitted. She stated that she was unable to submit them without a Registered Nurse (RN) signature and that the current Director of Nursing (DON) was the RN responsible for signing them and prior to that she had an RN that she worked with, but they let her go. The MDS coordinator confirmed and verified all 31 resident's assessments had not been submitted. During an interview on 7/18/2024 at 11:27 am, the Administrator stated that the DON had been out for 10-12 days, which was longer than they had expected and currently no one was responsible for signing off on the MDS. He stated they had an MDS RN that had led them to believe that she was going to take the job, but she did not take it and therefore they had got behind on the assessments. During an interview on 7/18/2024 at 11:30 am, the Assistant Director of Nursing (ADON) stated the workflow was for the MDS Licensed Practical Nurse (LPN) to complete the MDS assessments and to submit it to the DON for approval, but she was not sure who was responsible for submitting the assessments to CMS. She stated that they had several RN's who had been the MDS nurse, but they had quit or been let go. She stated that the position was currently open and that they were recruiting for the position. During a telephone interview on 7/18/2024 at 1:50 pm, the DON stated she did not set expectations of when the MDS assessments are submitted to CMS. She stated that she was asked by the Administrator to close the MDS assessments because the MDS RN coordinator had left employment at the facility. She stated that the MDS was overseen by the Administrator not the DON. She revealed that the practice of not completing the MDS assessments in time could have a negative consequence financially on the facility and this could have a negative effect on the quality of care provided to the residents. She stated she believed the MDS assessments were submitted late because there had been a lack of a consistent MDS RN coordinator in that department. She stated there had been four MDS RN Coordinator's in the last year, and each time one left, there was a back log of MDS assessments not completed.

Based on observations, staff interviews, and review of the facility's policy titled Food Safety Requirements, the facility failed to ensure food items were properly stored, labeled with expiration dates, and that expired foods were disposed of in a timely manner. The deficient practice had the potential to affect 47 of 49 residents who consumed an oral diet. Findings include: Review of the undated facility's policy titled Food Safety Requirements, under Policy revealed, It is the policy of this facility to procure food from sources approved or considered satisfactory by federal, state, and local authorities. Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety. Under Definitions revealed, Food service safety refers to handling, preparing, and storing food in ways that prevent foodborne illness. Under Policy Explanation and Compliance Guidelines revealed, 1. Food safety practices shall be followed throughout the facility's entire food handling process. This process begins when food is received from the vendor and ends with delivery of the food to the resident. Elements of the process include the following: (b) Storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms 3. Facility staff shall inspect all food, food products, and beverages for safe transport and quality upon delivery/receipt and ensure timely and proper storage. (b) Dry food storage- keep foods/beverages in a clean, dry area off the floor and clear of ceiling sprinklers, sewer/waste disposal pipes, and vents. (c) Refrigerated storage- foods that require refrigeration shall be refrigerated immediately upon receipt or placed in freezer, whichever is applicable. Practices to maintain safe refrigerated storage include .(iv) Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by-date, or frozen (where applicable)/discarded. Observation of the kitchen on 7/16/2024 at 9:00 am revealed a large dented can of corn. Observation of the pantry on 7/16/2024 at 9:05 am revealed the following items which according to the manufacture label should be refrigerated after opening included: a container of (Name) soy sauce (not refrigerated after opening and no open date), a bottle of (Name) squeeze grape jelly 20 oz (ounce) (not refrigerated after opening and no open date), a container of Italian dressing (not refrigerated after opening and no open date), and a container of (Name) barbecue sauce (not refrigerated after opening and no open date). Observation of the kitchen pantry on 7/16/2024 at 9:10 am revealed the following expired foods included: a bag of long grain rice with an expiration date of 2/13/2024 with no open date and seven bags of (Name) marshmallows with an expiration date of 4/16/2024. Observation of the kitchen pantry on 7/16/2024 at 9:20 am revealed the following foods with no label displaying the date after packages had been opened included: mashed potato granules, (Name) long grain wild rice, a container of (Name) baking soda, (Name) corn bread mix- 5 (five) lbs.(pound) bag, two gravy mix bags, one brown gravy mix bag , yellow cake mix -5 lb bag., fudge brownie mix -5 lb bag. spaghetti wrapped in saran wrap, box of (Name) spaghetti (opened, unsealed box and no open date), two bags of breadcrumbs (one bag was not sealed and both bags had no label dates), plain white rice, saltine crackers (opened saltine cracker packages found in box), a container of chopped onions, a bag of lettuce, minced garlic 32 oz., butter found open and unwrapped in box, white American cheese slices in bag, shredded mozzarella in bag, corned beef, a bottle of (Name) grape juice, two quarts of (Name) cranberry juice, unknown meat in bag, and salmon in a bag that was discolored. Observation of the freezer on 7/16/2024 at 9:30 am revealed the following food items with frost bite: (Name) Meat covered in frost with no open date and a bag containing fish covered in frost with no open date. Interview on 7/16/2024 at 9:45 am with [NAME] GG revealed that the Certified Dietary Manager (CDM) was on vacation, and she was unable to confirm who was in charge in her absence. She confirmed and verified that there should be no open containers without a labeled open date on them. She revealed that it was the responsibility of all kitchen staff to label items that were opened. Furthermore, she confirmed that if there are any dented cans, the kitchen staff still use them. She confirmed and verified that the saltine cracker packages should not be opened, and crackers should not be loose inside the box. Interview on 7/16/2024 at 10:30 am with the Administrator revealed that the CDM BB was on vacation and in her absence, he oversaw the kitchen. He stated he did not think dented can should be used. He revealed that staff should be labeling foods as they are opened. Interview on 7/16/2024 at 3:14 pm with the Registered Dietitian Consultant (RD) revealed that she was employed by (Name of Corporation), she stated she usually worked from home and reviewed records to make recommendations related to dietary needs of the residents. She stated recently she had been tasked with monthly observations of the kitchen to determine compliance. She stated in her last walk through the kitchen, she found that the staff had dated opened items with the open dates and the kitchen was clean. She revealed that CDM BB was a working manager and has had a lot of staff turnover. She stated she discovered CDM BB was on vacation this morning when she arrived at the facility. She revealed she did not know who was in charge in the CDM BB absence.

Based on staff interviews and review of the facility's policies titled, Infection Prevention and Control Program and Water Management, the facility failed to develop an effective water management plan which included routine water management activities to prevent the growth and spread of Legionella and other opportunistic waterborne pathogens throughout the facility's water system. The facility's census was 49 residents. Review of the undated facility's policy titled, Infection Prevention and Control under Policy Explanation and Compliance Guidelines revealed the following: Number 17. Water Management, (b): Control measures and testing protocols are in place to address potential hazards associated with the facility's water system. Review of the undated facility's policy titled, Water Management Program under Policy Explanation and Compliance Guidelines revealed the following: Number 8. The water management team shall regularly verify that the water management program is being implemented as designed. Auditing assignments will reflect that individuals will not verify the program activity for which they are responsible. Number 9. The effectiveness of the water management program shall be evaluated no less than annually. Routine infection control surveillance data, water quality data, and rounding data shall be utilized to validate the effectiveness. During an interview on 7/17/2024 at 5:06 pm with the Infection Prevention and Control Nurse (IPCN), she stated the facility had a water management plan with policies and procedures in place to prevent the spread of Legionella. During an interview on 7/18/2024 at 9:03 am with the Administrator, he stated the facility conducted annual testing, but he was not aware of other measures used to prevent the growth and spread of Legionella. During an interview on 7/18/2024 at 9:18 am with the Maintenance Director, he stated he performed daily temperature checks throughout the facility and annual testing for the presence of Legionella in the water system, but he was not aware of any other measures to prevent the growth of water-borne pathogens.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident family interview, Staff interviews, record review, and review of the facility policy titled, Abuse, Neglect and Exploitation, the facility failed to protect the resident's (R) R1 right to be free from sexual abuse by (R5). Specifically, the facility failed to ensure a safe environment for (R1) from (R5) with known behaviors of exposing his penis, masturbating, and inappropriately touching female residents. Findings include: Review of the policy titled Abuse Neglect and Exploitation dated 8/1/2023 indicated under Policy: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. VI. Protection of Resident: The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: B. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; F. Providing emotional support and counseling to the resident during and after the investigation, as needed. 1. Review of the Electronic Medical Record (EMR) for R1 revealed she was admitted to the facility on [DATE] with diagnosis of, but not limited to anemia, unspecified dementia, and osteoporosis. Review of R1's admission 5-day Medicare Minimum Data Set (MDS) 11/7/2023 was in progress. Review of the care plan initiated 11/1/2023 revealed that R1 has an impaired cognitive function related to dementia. Intervention to be implemented communicate with the resident, family, and caregivers regarding residents capabilities and needs. Review of the Facility Incident Report (FRI) dated 11/6/2023 revealed on 11/6/2023 at 3:05 p.m., R5 was observed exposing himself, asking female resident to touch his (R5) penis, and groping R1 chest, by the certified nursing assistant (CNA). 2. Review of the Electronic Medical Record (EMR) for R5 revealed he was admitted to the facility on [DATE] with diagnosis of, but not limited to Alzheimer's disease. Review of R5's admission 5-day Medicare MDS dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was assessed as 8, which indicated moderately impaired. Section D revealed mood none. Section E revealed no behavior exhibited. Cognitive Loss/Dementia triggered as an area of concern on the Care Area Assessment Summary (CAAS). Review of the care plan initiated 10/31/2023 revealed that R5 has a behavior problem related to exposing his genitals to female residents. He will, at times, masturbate in public areas. Intervention to be implemented intervene as necessary to protect the rights and safety of others. An interview on 11/9/2023 at 10:36 am with Certified Nursing Assistant (CNA), CC stated on 11/6/2023 R1 and R5 was sitting across from the nursing station in view of her (CNA). She stated R5 exposed himself to R1 and grabbed her breast. She stated a coworker and herself intervened R5 became upset and stated I want to play with her (R1). The CNA stated R5 has a behavior of exposing his (R5) private parts to other residents and masturbating. An interview on 11/9/2023 at 10:42 am with Social Services Director revealed she did not check on R1 after the incident on 11/6/2023 to see if she was okay or having any anxiety, or fearful. The SSD confirmed that the facility did not have a Long-Term Care Resident Abuse Reporting Act poster. The SSD was asked how a resident or family would report abuse to the SSA. She stated they could tell someone in the facility. She was asked what if the person was uncomfortable with reporting to someone in the facility. She was not sure how the resident/family would report abuse without the phone number to the State Survey Agency (SSA). An interview on 11/9/2023 at 2:00 pm with Family Member of R1 revealed the facility did call her and made her aware of the incident. She stated she was not able to visit R1 on the day of the incident (11/6/2023). She stated the Unit Manager informed her that R1 was okay. She stated she arrived the next day and spoke with the resident, but R1 did not have any awareness of the incident due to her dementia. Further interview also revealed that when she arrived at the facility on the following day, she did look for the posting for the SSA, but she could not locate the posting with a phone number. She stated she did not ask the facility for the number because she wanted to report the incident herself. An interview on 11/14/2023 at 11:56 am with the Director of Nursing (DON) the Administrator (AA) and the onboarding Administrator (DD) was present during the interview. The DON stated a skin assessment or trauma assessment was not completed on R1. The DON stated there was no additional education provided to the staff after the incident. The DON stated moving forward the staff will be reeducated on abuse, to assess the wellbeing of the resident(s), complete skin assessment, and involve the social service department to make sure a trauma assessment is completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and review of the facility policy titled, Compliance with Reporting Allegations of Abuse/Neglect/Exploitation, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act of an allegation of sexual abuse was reported to the State Survey Agency (SSA) within the required time frame for two of eleven residents (R) (R5 and R8). Specifically, the facility failed to report R5 exhibited sexually aggressive behavior, saying sexual things, and exposing his penis to R8. Findings include: Review of the policy titled Compliance with Reporting Allegations of Abuse, Neglect, Exploitation dated 8/1/2023 indicated under Policy: It is the policy of this facility to report all allegations of abuse/neglect/exploitation or mistreatment, are reported immediately to appropriate agencies in accordance with current state and federal regulations within prescribed timeframes. Compliance Guidelines: The purpose is to assure that the facility is doing all that is within its control to prevent occurrences. 4. Identification: The facility will identify events, occurrences, patterns, and trends that may constitute: II Sexual Abuse is the non-consensual sexual contact of any type with a resident. 1. Review of the Electronic Medical Record (EMR) for R5 revealed he was admitted to the facility on [DATE] with diagnosis of, but not limited to Alzheimer's disease. Review of R5's admission 5-day Medicare Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was assessed as 8, which indicated moderately impaired. Section D revealed mood none. Section E revealed no behavior exhibited. Cognitive Loss/Dementia triggered as an area of concern on the Care Area Assessment Summary (CAAS). Review of the care plan initiated 10/31/2023 revealed that R5 has a behavior problem related to exposing his genitals to female residents. He will, at times, masturbate in public areas. Intervention to be implemented intervene as necessary to protect the rights and safety of others. Review of Incident Note dated 10/25/2023 revealed: I was alerted by activity coordinator that the resident rolled his wheelchair up to another female resident unzipped and unbuttoned his pants and asked the resident can you touch my cock. Resident placed at nurses' station where he was observed opening pants and attempting to expose himself. Nurse Practitioner and Director of Nursing made aware. Review of the Nurse Practitioner Psychiatric Diagnostic Evaluation date of service 10/27/2023 seen for psych evaluation and med management for Alzheimer's. The Resident alert and oriented times two. Able to make needs known. The Resident calm, cooperative, and participating with exam. Resident states I'm just playing with my cock; do you want to play with it? proceeded to grope his (R5) penis. The Facility staff made aware. Bizarre behaviors noted. Facility staff reports R5 has been making inappropriate sexual gestures to staff and other patients. No documented new orders. Review of the facility documents and interviews with staff revealed the perpetrator Resident R5 had a history of exposing himself, asking female resident and staff to touch his penis, and masturbating. This was documented in two residents records. 2. Review of the EMR for R8 revealed she was admitted to the facility on [DATE] with diagnoses of, but not limited to chronic obstructive pulmonary disease and emphysema. Review of R8's admission 5-day Medicare MDS dated [DATE] revealed a BIMS was assessed as 14, which indicated cognitively intact. Section D revealed the mood of feeling down, depressed, hopeless. Section E revealed no behavior exhibited. Review of the facility's internal Risk Management Tool provided to the surveyor dated 10/25/2023 revealed: Resident (R8) was sitting in the dining room and was approached by R5 who exposed himself and ask R8 to touch his (R5) private parts. An interview on 11/14/2023 at 11:56 am with Administrator AA stated he is the abuse coordinator for the facility. The Administrator stated he was aware of the incident that took place on 10/25/2023 of R5 exposing himself to the female resident. The Administrator confirmed that the incident was not reported to the SSA. The Administrator stated he did not think the incident should have been reported to the SSA because R5 only exposed himself and did not touch anyone. An interview on 11/17/2023 at 11:03 am with the Activities Assistant BB stated on the day of the incident the residents had just finished lunch and she was in the process of starting an activity (bingo). She stated R5 propelled his wheelchair up to R8. She stated R5 pulled out his private part and ask R8 to touch his (R5) cock. She stated R8 verbalized she was embarrassed and asked the activities assistant not to tell anyone. The Activities Assistant stated R5 had a behavior of unzipping his pants and pulling out his private part, staff would intervene and redirect R5 from the behavior. She stated he would only exhibit this behavior with the female residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure written information on advance directives was provided to two of four residents (R), (R#12 and R#1), reviewed for advance directives. Findings include: Review of a document included in the facility's admission packet titled Acknowledgement and Consents, revealed Resuscitation.The policy of this Healthcare Facility is to initiate Cardiopulmonary Resuscitation (CPR) as a resuscitation procedure to restore breathing and/or heartbeat if I am found to be in Cardiopulmonary arrest, except when my attending physician has documented a valid Do Not Resuscitate (DNR) order on my permanent record. Review of this document revealed no information on what constitutes an advance directive and/or any instructions on how to develop an advance directive. 1. Review of clinical record revealed R#12 was admitted to the facility on [DATE] with a diagnosis of end stage renal disease. Review of R#12's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] indicated a Brief Interview of Mental Status (BIMS) score of 15 out of 15 which revealed R#12 was cognitively intact. Review of R#12's record did not reveal evidence that the resident was provided with information on advance directives. Interview on [DATE] at 9:22 a.m. with the Social Worker (SW), stated her understanding of an advance directive was a resident's wishes and to designate a person to address medical issues when the resident was incapacitated. The SW stated she addresses the advance directives during the resident's care plan meeting on a quarterly basis or if there was a medical crisis. Interview on [DATE] at 9:58 a.m. with the admission Coordinator (AC) stated that she addresses a resident's advance directive verbally and does not provide the resident with anything in writing. Interview on [DATE] at 9:15 a.m., R#12 stated he did not remember receiving information on advance directives. Interview on [DATE] at 2:32 p.m., the Director of Nursing (DON) stated if a resident did not have an advance directive, the process needs to be initiated and the facility needed to modify the admission packet. 2. Review of the clinical record revealed R#1 was admitted on [DATE], with diagnosis of fractures and other multiple traumas, coronary artery disease, dementia, and depression. Review of the admission MDS with an ARD of [DATE] revealed a BIMS score of 12 out of 15, indicating R#1 had moderate cognitive impairment. Review of R#1's care plan dated [DATE], identified a care area to complete/update advanced directives document on file as needed. A review of R#1's medical record, including the social services documents, revealed R#1 did not have an advance directive document nor did it reveal any evidence that he was provided with written advance directive information. Interview on [DATE] at 2:38 p.m., the Social Worker (SW) stated that upon admission she talks to all residents about advance directives and generally tries to document the discussion in the electronic medical record (EMR). The SW acknowledged that she does not provide written information about advance directives, but she provides them with a brochure for attorneys that specialize in elder law.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of the facility policy titled Restraint Free Environment the facility failed to assess one resident (R) (R#141) for the safe use of a medical hand mitten (used to hinder disrupting medical treatment such as pulling out tubes) and/or an arm/hand restraint prior to implementation, failed to ensure there were physician orders to apply and remove restraint. In addition, the facility failed to obtain consent for the use of the restraint and failed to re-evaluate the continued use of the restraint. Findings include: Review of a facility policy titled Restraint Free Environment, dated 5/22/22, indicated It is the policy of this facility that physical restraints may be used in emergency care situations for brief periods to permit medically necessary treatment that has been ordered by a practitioner unless the resident has previously made a valid refusal of the treatment in question. A physician's order alone is not sufficient to warrant the use of a physical restraint. The facility is responsible for the appropriateness of the determination to use a restraint. Before a resident is restrained, the facility will determine the presence of a specific medical symptom that would require the use of restraints, and determine; a. How the use of restraints would treat the medical symptom. b. The length of time the restraint is anticipated to be used to treat the medical symptom, who will apply the restraint and the time and frequency that the restraint will be released. c. The type of direct monitoring and supervision that will be provided during use of the restraint. d. How the resident will request staff assistance and how his/her needs will be met while the restraint is in place. e. How to assist the resident in attaining or maintaining his or her highest practicable level of physical and psychosocial well-being. Medical symptoms warranting the use of restraints should be documented in the resident's medical record. The care plan should be updated accordingly to include the development and implementation of interventions to address effectiveness of the restraint in treating the medical symptom and any risks related to the use of the restraint. Review of the clinical record revealed R#141 was admitted to the facility on [DATE], with a diagnosis of cerebral vascular accident (CVA-stroke) with right sided hemiparesis (paralysis). Review of the admission Assessment revealed no evidence of a hand mitten restraint or other interventions used prior to initiating the restraint. Review of R#141's care plan dated 5/15/22, indicated R#141 required total care for all Activities of Daily Living (ADL) due to history of CVA and hemiparesis on her right side. The care plan did not address the use of restraints. Review of R#141's Clinical Physician Orders for the month of May 2022, did not include evidence of an order for the use of a mitten restraint. Review of R#141's Treatment Administration Record (TAR), for the month of May 2022 did not reveal evidence of the use mitten restraint. Review of the Progress Notes, dated 5/9/22 through 5/23/22 revealed no documentation concerning R#141 pulling at the percutaneous endoscopic gastrostomy (PEG) tube. Review of R#141's Progress Notes, dated 5/17/22 through 5/23/22 did not identify evidence of the use of mitten restraint or assess the use of the mitten restraint to R#141's left hand. Observation on 5/22/22 at 11:00 a.m., R#141 was observed to have a mitten on her left hand, attached at the wrist. R#141 was observed to be non-verbal and was moving the left hand with the mitten back and forth on the grab bar. Observation and concurrent interview on 5/22/22 at 2:30 p.m., family member of R#141 was observed sitting beside the bed, holding R#141's hand. Family member of R#141 stated, I always take the mitten off when I am here and put it on before I leave. I guess it is to keep her from pulling out her tube. Observation on 5/23/22 at 9:19 a.m., R#141 was resting in bed with the mitten in place to left hand. R#141 was observed rubbing and tapping her left arm against the quarter side rail. Observation on 5/23/22 at 11:30 a.m., R#141 was observed to have a mitten on the left hand. During an observation and concurrent interview on 5/24/22 at 11:25 a.m., Registered Nurse (RN) DD was asked how long R#141 has had a mitten on her left hand (unaffected by a previous stroke). RN DD stated that she did not know. RN DD also stated the mitten was to prevent the resident from pulling out her tube. RN DD was asked how the resident would ring her call bell. She replied, That is a good question, she couldn't. RN DD removed the mitten because it was dirty and placed the call bell in R#141's hand. During an interview on 5/25/22 at 1:00 p.m., the Director of Nursing (DON) stated she was not aware that any type of restraint was in use in the facility. The DON stated, We are a restraint free facility.

Based on interview, record review, and review of the facility policy titled Abuse, Neglect, and Exploitation, the facility failed to implement the facility abuse policy by failing to ensure the references for the Administrator were checked prior to employment. Findings include: Review of the facility policy titled Abuse, Neglect and Exploitation, dated 9/28/21, indicated . The components of the facility's abuse prohibition plan are discussed herein. Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property.Background, reference, and credentials' checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants . Review of the employee file for the Administrator indicated the date of hire was 6/29/20. The Administrator's employee file did not include evidence that a reference check for employment was completed prior to employment. During an interview on 5/24/22 at 2:48 p.m., Human Resources confirmed there were no employment reference checks completed for the Administrator. Human Resources stated there was a previous Human Resource employee who did not complete references on employees and identified this when she completed an audit on the employee files.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of the facility policy titled, Abuse, Neglect, and Exploitation, the facility failed to ensure a thorough investigation was completed for an injury of unknown origin for one of three residents (R) R#1, reviewed for accidents. Findings include: Review of the facility's policy titled Abuse, Neglect and Exploitation, revised on 9/28/21, directs Possible indicators of abuse include . Physical injury of a resident, of unknown source . An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur . written procedures for the investigation include . identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. Review of the clinical record revealed R#1 was admitted on [DATE] with diagnoses of fractures and other multiple traumas, coronary artery disease, dementia, and depression. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/15/22 revealed a Brief Interview Mental Status (BIMS) score of 12 out of 15, indicating R#1 had moderate cognitive impairment. Review of the care plan dated 5/13/22 revealed R#1 was identified as a fall risk related to falls with injury prior to admission to the facility. On 5/15/22 R#1 had a fall without injury with interventions to use a fall mat, non-skid footwear, and to monitor/document /report pain, bruises, change in mental status, with new onset of confusion, sleepiness, inability to maintain posture, and agitation. Review of a nursing Progress Note, dated 5/20/22, revealed R#1 had a new hematoma on his head, and he could not explain how he got the injury. Review of an Incident Report, dated 5/20/22 revealed Staff was rendering ADL care and observed bleeding from back of R#1's head; however, R#1 did not have the ability to communicate what happened. R#1 sustained a medium sized hematoma on the back of his head near the top on his right side with a scratch mark extending downward and sustained an unwitnessed injury. Predisposing factors documented that R#1 was confused, drowsy, incontinent, impaired memory, weakness, recent illness, gait imbalance and indicated R#1 ambulates without assistance. The conclusion of the Incident Report was that R#1 had an unwitnessed fall. However, the Incident Report did not include a thorough investigation, which as per the facility policy included . identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. During an interview on 5/25/22 at 11:15 a.m., Registered Nurse (RN) BB, acknowledged that she is responsible to track and review incident reports for occurrences in the facility, and stated that she determined R#1 had an unwitnessed fall based on what the reporting nurse documented. RN BB acknowledged that for an injury of unknown origin, the facility usually interviews staff and determines a conclusion of the occurrence based on comprehensive staff interviews; however, the staff interviews were not conducted for R#1's injury that occurred on 5/20/22. During an interview on 5/25/22 at 11:50 a.m., the Administrator stated that he did not know about R#1's hematoma and stated if it was an injury of unknown origin it should have been investigated. During an interview on 5/25/22 at 1:46 p.m., the Director of Nursing (DON) acknowledged that she was not aware of R#1's injury of unknown origin. The DON stated that the injury of unknown origin should have been investigated further and that RN BB was currently following up. The DON acknowledged that this was a delayed investigation that should have started at the time of the occurrence.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interviews, and review of the facility policy titled, Fall Prevention Program, the facility failed to ensure one resident (R) (R#29) of three residents reviewed for accident hazards, identified potential risk factors to prevent further falls. Findings include: Review of facility policy titled Fall Prevention Program, dated 5/22/22, indicated . Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls . The facility utilizes a standardized risk assessment for determining a resident's fall risk . The risk assessment categorizes residents according to low, moderate, or high risk . For program identification purposes, the facility utilizes high risk and low/moderate risk, using the scoring method designated on the risk assessment . Upon admission, the nurse will complete a fall risk assessment along with the admission assessment to determine the resident's level of fall risk . Low/Moderate Risk. Complete a fall risk assessment every 90 days and as indicated when the resident's condition changes . When any resident experiences a fall, the facility will . Assess the resident . Complete a post-fall assessment . Notify physician and family . Review the resident's care plan and update as indicated . Document all assessments and actions . Review of the clinical record revealed R#29 was admitted to the facility on [DATE], with a diagnosis of encephalopathy. Review of the facility document titled History & Physical, dated 4/21/22 indicated R#29 was able to ambulate with a walker and sustained head trauma prior to his admission into the facility. Review of R#29's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/26/22 indicated a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which revealed moderate cognitively impaired. This assessment also indicated that R#29 required extensive assistance of one staff member for bed mobility and transfers. This MDS assessment revealed R#29 had a fall, in the past month, prior to his admission to the facility. Review of R#29's care plan revealed no evidence that R#29 had a fall care plan with interventions developed for R#29's risk for falls (falls prior to admission to facility). Review of R#29's Progress Note dated 5/3/22, indicated R#29 sustained an unwitnessed fall. R#29 was found on the floor next to his bed. Per review of progress notes, R#29 sustained no injuries. Review of R#29's Post Fall Assessment dated 5/3/22, revealed R#29 attempted to ambulate unassisted and had an unwitnessed fall. There were no injuries noted. There was no evidence in the post fall assessment that facility staff reviewed R#29's care plan or updated new interventions. Review of R#29's Progress Note dated 5/7/22, indicated R#29 sustained an unwitnessed fall. The progress notes revealed R#29 stated he was walking prior to the fall. The progress notes inaccurately indicated R#29 did not have prior history of falls and indicated the resident did not sustain injuries. Review of R#29's Post Fall Assessment dated 5/7/22 revealed R#29 stated he fell to his knees while using his walker. There was no indication in the post fall assessment that facility staff reviewed R#29's care plan or updated new interventions. Review of R#29's care plan revealed that there was no evidence that a care plan with interventions to prevent falls was developed after R#29 had two falls in the facility. Review of a facility document referred to as a Kardex (a care plan for the Certified Nursing Assistants (CNA) to reference) for R#29 indicated the staff were to encourage the resident to use his call light and to place his bed in the lowest position. During an interview on 5/25/22 at 2:00 p.m., with the MDS Coordinator and Director of Nursing (DON), the DON stated the nursing progress notes identify interventions after a fall. The DON stated the care plan would then be reviewed after a resident sustained a fall. The DON and the MDS Coordinator confirmed there were no fall interventions developed in R#29's care plan related to the two falls R#29 sustained in the facility. Cross Refer F656

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and review of facility policies, the facility failed to assess nutritional status after a significant weight loss and failed to notify the physician of the weight loss for one resident (R) (R#29), of three residents reviewed for nutrition. Findings include: Review of the facility policy titled Nutritional Management, dated 11/19/21, indicated . The facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition . A systematic approach is used to optimize each resident's nutritional status . Identifying and assessing each resident's nutritional status and risk factors . Evaluating/analyzing the assessment information . Developing and consistently implementing pertinent approaches . Monitoring the effectiveness of interventions and revising them as necessary . Review of the facility policy titled Weight Monitoring, dated 11/19/21, indicated . Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicated otherwise . Weight can be a useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended loss over a period of time) may indicate a nutritional problem . Newly admitted residents-monitor weight weekly for 4 weeks . Weight Analysis: The newly recorded resident weight should be compared to the previous recorded weight. A significant change in weight is defines as . 5 % change in weight in 1 month (30 days) . Documentation . The physician should be informed of a significant change in weight and may order nutritional interventions . The physician should be encouraged to document the diagnosis or clinical conditions that may be contributing to weight loss . Meal consumption information should be recorded and may be referenced by the interdisciplinary care team as needed . Review of the clinical record revealed R#29 was admitted to the facility on [DATE] with diagnoses of encephalopathy, dementia, Alzheimer's disease, hypotension, hypertension, and prostatic hyperplasia without lower urinary tract symptoms. Review of R#29's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/26/22 indicated a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which revealed moderate cognitive impaired. The MDS assessment indicated R#29 required supervision with cueing and oversight for eating. Review of lab results for R#29, dated 4/13/22 revealed an albumin (protein indicator of malnutrition or other diseases) level of 3.1 which was indicated as low. The document provided a range of normal values from 3.4 to 5.0 grams per deciliter (g/dL). Review of R#29's Weights indicated the following weights taken for R#29: On 4/21/22 the resident weighed 135.2 pounds; on 4/27/22 the resident weighed 137.0 pounds; no weekly weight was taken on 5/4/22; and on 5/11/22 the resident weighed 129.8 pounds. This represented a 5.26 percent weight loss from 4/21/22 until 5/11/22. Review of R#29's physician's orders (PO) dated 4/27/22 indicated R#29 was to have weekly weights. During an interview on 5/25/22 at 10:38 a.m., the Registered Dietician (RD) stated she goes to the facility on a weekly basis and participates in a Patient at Risk Meeting. The RD stated when a resident is first admitted , the staff were to do weekly weights. The RD stated she runs a weekly report on resident's weights. She further stated the report will show only those residents who have sustained a 5 percent, 7.5 percent, or a 10 percent weight loss. The RD stated she was not sure who would notify the physician of the significant weight loss. The RD confirmed there was not a weekly weight for 5/4/22 and confirmed there were no re-weighs completed. During an interview on 5/25/22 at 2:07 p.m., the MDS Coordinator and the Director of Nursing (DON) confirmed there was no nutritional assessment following R#29's weight loss. The DON confirmed there was no weekly weight obtained week of 5/4/22.

Based on record review, staff interview, and review of the Facility Assessment, the facility failed to conduct and document a comprehensive facility-wide assessment to evaluate the characteristics of the resident population, community resources, and risks and failed to develop a plan to address these factors and deploy their resources in the most effective manner to maintain safety and security for all facility residents. The census was 44. Findings include: Review of the Facility Assessment revealed the purpose is to determine what resources are necessary to care for the residents competently during day-to-day operations and emergencies. Review of the Facility Assessment revealed it was not completed in its entirety and was not signed by the Administrator or approved by the Quality Assurance (QA) Committee. Further review revealed the Facility Assessment failed to address the following pertinent characteristics affecting day-to-day operations: 1. The specialized training and competencies of the staff who work in the facility, such as a certified wound care professional, infection control preventionist and/or other clinical specialties/services routinely provided for the residents. 2. Staff access to electronic medical records. 3. Information on physical equipment needed to provide care and services for the residents who reside in the facility, such as vehicles to provide transportation for residents to and from medical appointments and care equipment such as mechanical lifts to transfer residents from their beds to wheelchairs and Personal Protective Equipment (PPE). Interview on 5/25/21 at 3:27 p.m.with the Administrator reported he had no other facility assessment and confirmed there was no specific resident information tied to the assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Review of the clinical record revealed R#141 was admitted to the facility on [DATE], with a diagnosis of cerebral vascular accident (CVA-stroke) with right sided hemiparesis (paralysis). Review of R#141's comprehensive care plan dated 5/15/22 (six days after admission), indicated R#141 was dependent on staff for all emotional, intellectual, physical, and social needs related to non-verbal status and physical dependence. The care plan indicated R#141 required total care for all Activities of Daily Living (ADL-such as bathing, eating, dressing, toilet use) due to history of CVA and hemiparesis on her right side. There was no evidence that a baseline care plan was developed. Interview on 5/23/22 at 11:12 a.m. with the DON and Registered Nurse (RN) BB a copy of the baseline care plan for R#141 was requested. RN BB verified that there was no baseline care plan for R#141. 4. Review of the clinical record revealed R#193 was admitted to the facility on [DATE] with a diagnosis of abnormal weight loss, stroke, atrial fibrillation, heart failure, and pneumonia. Review of R#193's clinical record revealed no evidence that R#193's representative was provided with the baseline care plan. Interview on 5/25/22 at 1:36 p.m., the Social Worker (SW) stated any staff member could initiate the baseline care plan and that the baseline care plan was to occur within 48 hours. Interview on 5/25/22 at 1:43 p.m., both the Director of Nursing (DON) and the Minimum Data Set (MDS) Coordinator were present. Both the DON and the MDS Coordinator reviewed the EMR for R#193 and confirmed the resident's representative was not provided with a copy of the baseline care plan. Based on record review, interviews, and review of the facility policy titled, Baseline Care Plan, the facility failed to develop a baseline care plan for five of five residents (R) (R#242, R#1, R#40, R#193, and R#141), out of 20 sample residents Findings include: Review of the facility's policy titled Baseline Care Plan dated 1/1/21 revealed The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care .1. The baseline care plan will: a. Be developed within 48 hours of a resident's admission. b. Include the minimum healthcare information necessary to properly care for a resident . A written summary of the baseline care plan shall be provided to the resident and representative in a language that the resident/representative can understand. The summary shall include, at a minimum, the following: a. The initial goals of the resident. b. A summary of the resident's medications and dietary instructions. c. Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. 1. Review of the clinical record revealed R#242 was admitted on [DATE] with diagnoses of cancer, atrial fibrillation, hypertension, malnutrition, and depression. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview Mental Status (BIMS) score of 10 out of 15, indicating R#242 had moderate cognitive impairment. Review of R#242's care plan revealed no evidence that a base line care plan was developed. During an interview on 5/24/22 at 9:37 a.m., family member of R#242 stated that he was in the facility for a care plan meeting scheduled for 10:00 a.m. and acknowledged that the facility had not previously provided a written summary of R#242's care plan to the family or resident; this was confirmed by R#242. 2. Review of the clinical record revealed R#1 was re-admitted to the facility on [DATE] with fractures and other multiple traumas, coronary artery disease, dementia, and depression. Review of the admission MDS with an ARD of 5/15/22 revealed a BIMS score of 12 out of 15, indicating R#1 had moderate cognitive impairment. Review of Care Plan Meeting Notes revealed there was no evidence of a care plan note for the 5/12/22 readmission date. 3. Review of the clinical record revealed R#40 was admitted on [DATE] with diagnoses of fractures and other multiple traumas, anemia, hip fracture, and thyroid disorder. Review of the admission MDS with an ARD of 5/9/22 revealed a BIMS score of five out of 15 indicating R#40 had severe cognitive impairment. Review of Care Plan Meeting Notes revealed a baseline care plan meeting was documented on 5/16/22, 10 days after admission to the facility. During an interview on 5/25/22 at 2:11 p.m., the MDS Coordinator, (MDSC) acknowledged that R#242, R#1, and R#40 had baseline care plans that were developed late. The MDSC acknowledged that the only paperwork she provides to residents and their families is a medication list and not their entire baseline care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Observation on 5/22/22 at 11:00 a.m., R#141 was observed to have a hand mitten on her left hand, attached at the wrist. R#141 was observed to be non-verbal and was moving the left hand back and forth on the grab bar. Review of R#141's admission Record, revealed that R#141 was admitted to the facility on [DATE], with a diagnosis of cerebral vascular accident (CVA-stroke) with right sided hemiparesis (paralysis). Review of R#141's care plan dated 5/15/22, indicated R#141 was dependent on staff for all emotional, intellectual, physical, and social needs related to non-verbal status and physical dependence. The care plan indicated R#141 required total care for all Activities of Daily Living (ADL) due to history of CVA and hemiparesis on her right side. There was no evidence that the use of a restraint mitten to R#141's left hand was identified or addressed on the care plan. During an interview on 5/25/22 at 1:00 p.m. the Director of Nursing (DON) verified the restraint was not included in the care plan it [the restraint] was not to be used in this facility. It must have come from the hospital because we don't have restraints here. Based on record review, observation, interviews, review of the Resident Assessment Instrument (RAI), and review of the facility policy titled, Comprehensive Care Plan the facility failed to develop and implement a person-centered comprehensive plan of care with measurable goals and timeframe's to meet resident needs for five of 20 residents (R) (R#29, R#12, R#40, R#1, and R#141) reviewed for care planning. Findings include: Review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, dated 10/19, indicated, . Care Area Assessment (CAA) Process. This process is designed to assist the assessor to systematically interpret the information recorded on the MDS . The CAA process helps the clinician to focus on key issues identified during the assessment process so that decisions as to whether and how to intervene can be explored with the resident . Specific components of the CAA process include: - Care Area Triggers (CATs) are specific resident responses for one or a combination of MDS elements. The triggers identify residents who have or are at risk for developing specific functional problems and require further assessment . The MDS does not constitute a comprehensive assessment. Rather, it is a preliminary assessment to identify potential resident problems, strengths, and preferences. Care Areas are triggered by MDS item responses that indicate the need for additional assessment based on problem identification, known as triggered care areas, which form a critical link between the MDS and decisions about care planning . Review of a facility policy titled Comprehensive Care Plan, dated 1/1/21, indicated . It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment . The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record . 1. Review of the clinical record revealed R#29 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease. Review of R#29's admission MDS with an Assessment Reference Date (ARD) of 4/26/22 indicated a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which revealed R#29 was moderately cognitively impaired. This MDS assessment indicated R#29 required extensive assistance of one staff member for bed mobility and transfers. The MDS assessment also indicated R#29 had a fall, in the past month, prior to his admission to the facility. Review of the CAA indicated R#29 triggered for falls and directed the staff to develop a care plan. Review of R#29's care plan revealed no evidence that a care plan was developed to address resident's risk for falls. Interview on 5/25/22 at 2:09 p.m., the MDS Coordinator confirmed she was the staff member who completes the MDS and then develops a care plan. The MDS Coordinator stated if a care area has been triggered in the MDS then a care plan was developed. The MDS Coordinator confirmed R#29 did not have a care plan for falls even though the resident triggered for falls in the CAA. 2. Review of the clinical record revealed R#12 was admitted to the facility on [DATE] with a diagnosis of end stage kidney disease. Review of R#12's admission MDS with an ARD of 3/28/22 indicated a BIMS score of 15 out of 15 which revealed R#12 was cognitively intact. Review of the CAA indicated R#12 triggered for nutrition and directed the staff to develop a care plan. Review of R#12's care plan revealed that there was no evidence that a care plan was developed to address resident's nutritional risk. During an interview on 5/25/22 at 2:09 p.m. the MDS Coordinator confirmed R#12 had no care plan that addressed the resident was at high risk for nutrition. She also stated that if an area was triggered under the CAA, she would have developed a care plan. 3. Review of the clinical record revealed R#40 was admitted on [DATE] with diagnoses of fractures and other multiple traumas, anemia, hip fracture, and thyroid disorder. Review of the admission MDS with an ARD date of 5/9/22 revealed a BIMS score of five out of 15, indicating R#40 had severe cognitive impairment. Review of the admission History and Physical dated 5/6/22 revealed R#40 had urinary retention with an indwelling Foley catheter with plans to follow urology instructions for removal of the catheter based on how well the patient does. Review of physician orders (PO) revealed an order dated 5/8/22 to change the Foley Catheter every 30 days and as needed. Review of R#40's care plan revealed there was no evidence that a care plan was developed for the Foley Catheter. 4. Review of the clinical record revealed R#1 was admitted on [DATE] with fractures and other multiple traumas, coronary artery disease, dementia, and depression. Review of the admission MDS with an ARD of 5/15/22 revealed a BIMS score of 12 out of 15, indicating R#1 had moderate cognitive impairment. Review of R#1's Discharge Documentation, dated 5/12/22 revealed R#1's discharge diagnosis was a fall with a fracture of the fifth metacarpal (finger joint) bone of the left hand and a hematoma (pooling of blood) of the hip with hip pain and plans for administration of Tylenol (pain medication) for mild pain and Hydrocodone-Acetaminophen (narcotic pain medication) for moderate pain. R#1 was scheduled for follow-up with an orthopedist in one week with directions to wean the narcotic pain medication as tolerated. Review of PO dated 5/12/22 directed performance of a pain evaluation every shift (record numeric value. 0=No Pain. 1-3= Mild Pain. 4-6=Moderate Pain. 7-10=Severe Pain . Acetaminophen Tablet Give 650 mg by mouth every 6 hours as needed for MILD PAIN . Hydrocodone-Acetaminophen Tablet 5-325 MG Give 1 tablet by mouth every 6 hours as needed for moderate pain. Review of R#1's care plan revealed no evidence that a care plan was developed for pain. During a concurrent record review and interview on 5/25/22 at 2:11 p.m., the MDS Coordinator (MDSC) acknowledged that R#1 did not have a care plan for pain and his admission records, comorbidities, and orders for pain medication should have prompted a care plan for pain.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review clinical record revealed R#13 was admitted to the facility on [DATE]. Diagnosis include Enterocolitis due to recurrent Clostridium difficile (C-diff). Review of R#13's PO revealed dated 11/15/21 R#13 was placed on Transmission Based Precautions for C-Diff with no stop date. Observation on 5/23/22 at 10:05 a.m., Licensed Practical Nurse (LPN) EE entered R#13's room to administer medications wearing gloves and facemask but no gown. Interview on 5/23/22 at 10:10 a.m. with LPN EE stated she was not sure why R#13 was on Isolation Precautions on 5/22/22 but not on 5/23/22. She stated that he had probably finished his antibiotics and had a specimen collected a couple days ago. LPN EE was unable to verify if R#13 continued to have diarrhea which is a symptom of C.diff. Interview on 5/23/22 at 10:30 a.m. with CNA II stated she had given R#13 a shower earlier on 5/23/22 and he had an episode of diarrhea before and after the shower. When asked if she wore a gown, CNA II replied, no, he is not on isolation anymore. Interview on 5/23/22 at 10:40 a.m. with Certified Registered Nurse Practitioner (CRNP) HH stated that R#13 has had multiple episodes of C-Diff since admission and has been on and off isolation. She then verified that as of 5/23/22, R#13 remained on isolation. Based on observations, record review, interviews, review of the facility policies, and review of Centers for Disease Control and Prevention (CDC) guidance, the facility failed to implement effective infection control program to prevent the spread of infections. Specifically, the facility failed to follow isolation procedures for three residents (R) (R#193, R#191, and R#1) who were under droplet and contact precautions for COVID-19 and failed to ensure R#13 was under contact precautions for potential Clostridium difficile (C. diff) infection. Findings include: Review of CDC guidance, dated 2/22/22, indicated . HCP [Health Care Professional] caring for residents with suspected or confirmed SARS-CoV-2 infection should use full PPE (gowns, gloves, eye protection, and a NIOSH-approved N95 or equivalent or higher-level respirator) . https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html. Review of a policy provided by the facility titled Isolation Precautions, dated 11/26/21, indicated . It is our policy to take appropriate precautions, including isolation, to prevent transmission of infectious agents. This policy specifies the different types of precautions, including when and how isolation should be used with a resident . Contact . are measures that are intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the resident or the resident's environment . Droplet . refers to actions designed to reduce/prevent the transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions . Facility staff will apply Transmission-Based Precautions, in addition to standard precautions, to resident who are known or suspected to be infected or colonized with infectious agents requiring additional controls to prevent infection. The facility will use standard approaches, as defined by the CDC for transmission-based precautions: airborne, contact, and droplet precautions . The category of transmission-based precautions will determine the type of personal protective equipment (PPE) to be used . The category of and duration of transmission-based precautions will depend on the infectious agent or organism involved . Transmission-based precautions will be maintained in accordance with physician orders for as long as necessary to prevent transmission of infection. Further review of the policy revealed a table which indicated that standard precautions included the use of gloves for touching body fluids, secretion, body fluids, and non-intact skin, gown for procedures when exposure to blood/body fluids, secretions, and excretions is anticipated, and mask, eye protection and/or face shield during procedures and patient care activities likely to generate sprays or sprays of blood, body fluids, secretions, especially suctioning endotracheal intubation, Contact precautions directed the use of gown and gloves, and droplet precautions directed the use of a gown, gloves, and mask. Review of the facility's policy titled Hand Hygiene, dated 11/26/21, revealed that staff should perform hand hygiene after contact with contaminated objects . before and after handling clean and soiled dressing, linens . the use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after using gloves. Review of facility's policy, dated 11/26/21, titled Infection Control revealed 3. Contact Precautions a. intended to prevent transmission of infection agents . c. Healthcare personnel caring for residents on contact precautions wear a gown and gloves for all interactions that may involve contact with resident . 1. During an observation on 5/23/22 at 8:55 a.m., R#193 had three posters on the outside of the room door, facing the hallway. One poster was titled Droplet & Contact Precautions. The second and third poster showed directions donning and doffing personal protective equipment (PPE). Observation on 5/23/22 at 9:18 a.m., Certified Nursing Assistant (CNA) AA was observed in the room of R#193. CNA AA was observed wearing a surgical mask, not an N95 facemask, and no gown and/or eye protection while in the room of R#193. On the outside of the room was a plastic three drawer container which held gowns, N95 masks, and gloves. Interview on 5/23/22 at 9:28 a.m. with CNA AA stated R#193 was no longer on isolation. CNA AA stated she did not know why the PPE container and posters were still available on the outside of R#193's room. Review of the Orders, revealed that R#193 was on isolation precautions on 5/23/22. Observation on 5/23/22 at 9:44 a.m., Registered Nurse (RN) BB entered the room of R#191. RN BB was observed wearing a surgical facemask. The door leading to R#191's room had three posters on it. One poster was titled Droplet & Contact Precautions. The second and third poster showed directions on donning and doffing PPE. On 5/23/22 at 9:48 a.m., RN BB exited R#191's room and then entered R#193's room. RN BB did not have full PPE on before entering R#191 or R#193's rooms. Interview on 5/23/22 at 9:53 a.m. with RN BB confirmed she had a surgical mask on and stated she should have donned a gown and eye protection prior to enter the residents' rooms. Interview on 5/23/22 at 1:05 p.m., the Medical Director (MD) stated he has made the decision to be more restrictive than what CDC recommends and place fully vaccinated residents under quarantine. The Medical Director stated his expectation for staff before they enter a droplet/contact precaution room was to be 100 percent compliant with donning full PPE. 2. Review of the admission Record, revealed R#1 was admitted on [DATE]. Review of R#1's physician orders (PO) dated 5/12/22, revealed Droplet Precautions x 10 days every shift for 10 Days and review of the Medication Administration Record (MAR) revealed the droplet precautions were schedule for completion on the end of the day shift, 3:00 p.m., on 5/22/22. Observation on 5/22/22 at 10:59 a.m. revealed outside R#1's room there were signs for Contact & Droplet Precaution and CDC signs for how to properly don and doff PPE. Continued observation on 5/22/22 revealed R#1 was taken to the therapy room without a mask by Physical Therapist (PT) VV who was only wearing a surgical mask and no gown or gloves. Continued observation revealed PT VV worked with R#1 for a half-hour and transported R#1 back to his room, without a gown or gloves. Interview on 5/22/22 at 11:34 a.m. with PT VV stated that R#1 has been on quarantine for more than 10 days, so he knew that he did not need to wear PPE. During an additional observation on 5/22/22 at 11:00 a.m., Housekeeper (HK) TT entered R#1's room that had signs posted on the door for Contact & Droplet Precaution and CDC signs for how to properly don and doff PPE. HK TT entered R#1's room without wearing a gown or goggles and was only wearing a surgical mask. HK TT emptied the soiled laundry bin which contained used PPE gowns and placed the bag of soiled linens in a covered linen cart in the hall without changing gloves. HK TT was about to enter another resident room without changing gloves at 5/22/22 at 11:02 a.m. when he was stopped for an interview. Interview on 5/22/22 at 11:02 a.m. HK TT acknowledged that he is supposed to wear full PPE in R#1's room; however, HK TT stated that R#1 was not in the room, and he did not have any resident contact, so he did not put on full PPE. In addition, HK TT acknowledged that he is supposed to change gloves and wash his hands or use alcohol-based hand rub (ABHR) between rooms; however, after the interview HK TT entered another resident room to empty a laundry bin without changing gloves and washing his hands or using ABHR. Interview on 5/23/22 at 1:05 p.m., the MD acknowledged that the facility has never changed their policy for new admission quarantine since the pandemic, despite the changing CDC guidance for quarantine of new admissions and there is a mandatory 10-day observation period that includes the use of full PPE. The MD also stated that he expected 100% compliance with all staff for this policy. Interview on 5/24/22 at 10:04 a.m., the Director of Nursing (DON), also the acting Infection Preventionist (IP), stated that staff are expected to follow the infection control precautions posted outside a resident's room and that handwashing and changing of gloves is expected between all resident contact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, policy review, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to offer three of five residents (R) (R#11, R#26, and R#241) reviewed for influenza/pneumonia vaccinations. Specifically, the facility failed to offer R#11, R#26, and R#241 and/or their representative the opportunity to be vaccinated with Pneumococcal 15-valent Conjugate Vaccine (PCV15) or Prevnar 20 (PCV20) in accordance with nationally recognized standards. In addition, the facility's pneumococcal vaccination data was not updated to reflect current CDC guidelines dated 1/27/22. Findings include: Review of the CDC guidance titled Use of 15-Valent Pneumococcal Conjugate Vaccine Among U.S. Adults: Updated Recommendations of the Advisory Committee on Immunization Practices - United States, 2022 dated 1/27/22 revealed Adults aged 65 years who have not previously received a pneumococcal conjugate vaccine or whose previous vaccination history is unknown should receive a pneumococcal conjugate vaccine (either PCV20 or PCV15). If PCV15 is used, this should be followed by a dose of PPSV23 . Adults with previous PPSV23 only. Adults who have only received PPSV23 may receive a PCV (either PCV20 or PCV15) 1 year after their last PPSV23 dose. When PCV15 is used in those with history of PPSV23 receipt, it need not be followed by another dose of PPSV23 . Adults with previous PCV13 . These adults should complete the previously recommended PPSV23 series. Review of the facility's policy titled Pneumococcal Vaccine (Series,) dated 11/23/21, revealed Each resident will be assessed for pneumococcal vaccination upon admission . Additional efforts to obtain information shall be documented, including efforts to determine date of immunization or type of vaccine received . Prior to offering the pneumococcal immunization, each resident or the resident's representative will receive education regarding the benefits and potential side effects of the immunization . The individual receiving the immunization, or the resident's representative will be provided with a copy of CDC's current vaccine information statement relative to that vaccine . A consent form shall be signed prior to the immunization and filed in the individual's medical record . The type of pneumococcal vaccine (PCV13, PPSV23/PPSV) offered will depend upon the recipient's age and susceptibility to pneumonia, in accordance with current CDC guidelines and recommendations. The summary of the guidance for administration on pneumococcal vaccination was based on the documented reference of the use of the 8/07/20 CDC guidance for pneumococcal vaccination and the policy was not updated to provide the updated CDC guidance issues on 1/27/22. 1. Review of clinical record revealed R#11 was greater than [AGE] years old and was admitted to the facility on [DATE]. Review of consent and education for the pneumococcal polysaccharide vaccine dated 3/22/22, revealed R#11's Health Care Proxy (HCP) received education and consented to the administration of pneumococcal vaccine. Review of R#11's electronic medical record (EMR) revealed there were no physician orders for the administration of pneumococcal vaccination. Review of R#11's Immunization, revealed there was no documentation that R#11 received a pneumococcal vaccination in accordance with CDC recommendations and per the consent of the HCP. 2. Review of the clinical record revealed R#26, was greater than [AGE] years old and was admitted to the facility on [DATE]. Review of R#26's EMR revealed there were no physician orders for the administration pneumococcal vaccination. Review of R#26's Immunization record revealed R#26 refused the pneumococcal vaccine; however, there was no documentation in the medical record that R#26 and/or responsible party received education and signed for consent or refusal of the pneumococcal vaccination. 4. Review of clinical record revealed R#241 was greater than [AGE] years old and was admitted to the facility on [DATE]. Review of R#241's EMR revealed there were no physician orders for the administration of pneumococcal vaccination and there was no documentation in the medical record that R#241 and/or responsible party received education and signed for consent or refusal of the pneumococcal vaccination Review of R#241's Immunization record revealed no evidence that R#241 had received the pneumococcal vaccine. Interview on 5/25/22 05:38 p.m. with the Director of Nursing (DON), also serving as the facility's Infection Preventionist (IP), acknowledged that the facility's documentation of pneumococcal vaccinations in the EMR was not always accurate and/or lacked relevant information about pneumococcal vaccination. During the interview the DON provided additional historical information for R#11 and R#26 from GRITS (Georgia Registry of Immunization Transactions) not contained in the EMR; however, the information did not reveal the specific pneumococcal vaccination and the series was not administered in accordance with CDC guidelines for R#11 and R#26. The DON acknowledged that she was not aware of new CDC guidance for pneumococcal vaccination until she was questioned about it the day before and said she relied on the Assistant Director of Nursing (ADON), who served as the IP and was on leave, to monitor the residents' vaccinations to ensure that they were up to date. The DON acknowledged that she could not provide any documentation that R#26 and R#241 received education regarding the pneumococcal vaccination(s).

Based on record review, interview, and policy review, the facility failed to ensure that the staff COVID-19 vaccination rate was 100%, and that the facility's COVID-19 Vaccination Policy for staff was in accordance with Centers for Medicare and Medicaid Services (CMS) guidelines. The census was 44. Findings include: Review of CMS QSO- 22-07-All-Revised revised on 4/5/22 revealed, . the regulations and guidance described in this attachment apply to all states. Implementation of this guidance will occur according to the timeframe's and parameters identified in either QSO-22-07-ALL-Revised effective 12/28/21, QSO-22-09-ALL- Revised effective 1/14/22, or QSO-22-11-ALL-Revised effective 1/20/22, . Long Term Care and Skilled Nursing Facility Attachment A . The facility must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine §483.80(i)(3)(i): Requires the facility to have a process for ensuring all staff (as defined above) have received at least a single-dose, or the first dose of a multi-dose COVID-19 vaccine series, or have a pending, or have been granted a qualifying exemption, or identified as having a delay as recommended by the Centers for Disease Control (CDC), prior to providing any care, treatment, or other services for the facility and/or its residents. During an entrance conference on 5/22/22 10:38 a.m., the Administrator was asked to provide all COVID-19 policies and procedures, including policies for staff COVID-19 vaccination; no policy for staff COVID-19 vaccination was provided during the survey. Review of the facility's COVID-19 policies did not include: Definition that the facility would meet the 100 % vaccination rate for COVID-19 as required by CMS, nor define how it would educate staff or what steps to take for staff who had exemptions for COVID vaccination. A process for ensuring the implementation of additional precautions, intended to mitigate the transmission, and spread of COVID-19, for all staff who were not fully vaccinated for COVID-19. A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained booster doses as recommended by the CDC. A process for ensuring that all documentation which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws; or for further ensuring that such documentation contains all information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications and a statement by the authenticating practitioner recommending that the staff member be exempted from the facility's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; a process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and Contingency plans for staff who are not fully vaccinated for COVID-19. Interview on 5/25/22 at 8:38 a.m., with the Director of Nursing (DON) acknowledged that she could not provide a policy for staff COVID-19 vaccination and stated that she relied on the Assistant Director of Nursing (ADON), who was currently on leave, to review and organize the COVID-19 policies to ensure the facility complies with CMS and CDC guidelines. Review of a document titled Entrance Conference Worksheet, dated 4/22, indicated the facility will provide, as part of the recertification survey, a . List of contract companies that provide services to the facility/residents. Identify the name of the contract company; whether the company provides direct care or non-direct care; how often services are provided (e.g., daily, weekly); the approximate number of contract staff provided by the company; and information on how the facility ensures contractor staff are compliant with the vaccination requirement . Interview conducted during the entrance conference on 5/22/22 at 10:30 a.m., the Administrator was asked to produce a list of contractors which would identify what services were provided the residents of the facility. An email request dated 5/24/22, a request of contractors was made to the Administrator. A list of the contractors was not provided to the survey team prior to exit. Review of an e-mail dated 5/23/22 for staff Covid Testing provided by the DON for documentation of the status for active staff COVID-19 vaccinations revealed that two staff declined the vaccination, one staff had a waived status, three staff were partially vaccinated without a complete primary vaccination series, and four staff had no information submitted. In addition, the facility's Covid Testing Log did not identify if medical and non-medical exemptions were pending or granted. Thus 75/85 staff had an approved vaccination status who were working in the facility which equated to an 88.2% vaccination status. Review of the facility's staff COVID-19 Vaccination Consent Forms revealed on 9/24/21, Certified Nursing Assistant (CNA) OO declined the COVID vaccination, on 9/29/21 Registered Nurse DD declined the COVID-19 vaccination, and on 5/25/22 Licensed Practical Nurse (LPN) JJ declined the COVID-19 vaccination. LPN JJ, whose COVID-19 vaccination was waived on the facility's log, also had on file a personal provider visit note dated 9/15/21 that did not contain documentation of the reason for a medical exemption that was signed and dated by a licensed practitioner. During an interview on 5/24/22 at 9:21 a.m. LPN JJ stated that she was not vaccinated for COVID-19 and that she has not been required to fill out an exemption form for medical or non-medical reasons. During the interview, despite inquiry, she did not disclose her reason for lack of a COVID-19 vaccination. Review of CDC COVID-19 Vaccination Record Cards confirmed that LPN JJ, CNA MM, and CNA LL were partially vaccinated and did not complete their primary vaccination series for COVID-19. Interview 5/24/22 at 9:46 a.m., CNA LL confirmed that she only had one COVID-19 vaccination and had not completed the primary COVID-19 vaccination series for personal reasons. CNA LL acknowledged that facility staff have not required her to fill out a medical or non-medical exemption form and/or implemented any education/attempts to have her complete the primary COVID-19 vaccination series. Interview on 5/25/22 at 8:38 a.m., the DON confirmed that LPN JJ's paperwork did not support a medical exemption, and that she could not identify that any further efforts were taken on the part of the facility to educate and obtain COVID-19 vaccinations and or medical or non-medical exemptions for RN DD, LPN JJ, LPN KK, CNA LL, CNA MM, CAN OO, LPN PP, Housekeeper QQ, Contract Staff RR, and LPN SS. The DON stated that she relied on the Assistant Director of Nursing (ADON), who was currently on leave, to have processes and procedures in place to ensure the facility had achieved the required staff vaccination status.

Based on interviews, review of facility documentation, and policy review titled Quality Assurance Performance Improvement, the facility failed to ensure policies and procedures were implemented to address the facility's Quality Assessment and Performance Improvement (QAPI) plan and program, in which data was gathered, analyzed, developed, implemented, and re-evaluated to address adverse events related to potential deficient practice. This had the potential to affect all 44 residents residing in the facility at the time of the survey. Findings include: Review of the facility policy titled Quality Assurance Performance Improvement, dated 7/10/20, indicated . It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life . The QAPI program will be ongoing, comprehensive, and will address the full range of care and services provided by the facility . At a minimum, the QAPI will . Address all systems of care and management practices . Include clinical care, quality of life, and resident choice . Utilize the best available evidence to define and measure indicators of quality and facility goals that reflect processes of care and facility operations that have been shown to be predictive of desired outcomes for residents of a Skilled Nursing Facility . Further review of the QAPI program revealed no identification or tracking for the following deficient practices identified during the survey: There was no evaluation of general nursing issues and corrective action taken. There was no evaluation of an infection control program. There was no evaluation of an antibiotic stewardship program. There was no evaluation for exemptions for the COVID vaccines. There was no evaluation for development and implementation of care plans. There was no evaluation for pneumococcal vaccine guidelines. There was no evaluation of advance directives. There was no evaluation of potential restraints. During an interview on 5/25/22 at 4:16 p.m., the Administrator stated he did not have data to show how the facility tracks and trends potential deficient practice. The Administrator stated there have been very few issues that require a performance improvement plan (PIP) since the facility was newer.M

Based on record review, interviews, and review of facility policy titled Quality Assurance and Performance Improvement (QAPI), the facility failed to ensure that the Quality Assessment and Assurance (QAA) committee met at least quarterly. The census was 44. Findings include: Review of the facility policy titled Quality Assurance & Performance Improvement (QAPI), dated 7/20/20, indicated . Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects under the QAPI program, are necessary. Review of documents titled QAPI Sign In Sheet, for the year 2021, indicated the facility held QAPI meetings on a monthly basis. The last QAPI meeting was held on 12/30/21. There was no additional information provided to show the facility held a quarterly QAPI meeting for the month of March 2022. During an interview on 5/25/22 at 4:16 p.m., the Administrator confirmed the March 2022 quarterly QAPI meeting was not held. The Administrator stated he just forgot to hold this meeting.

Based on record review, interview, and review of the Centers for Medicare and Medicaid Services (CMS) policy, the facility failed to ensure that all residents and/or their representatives were informed by 5:00 p.m. the next calendar day following the occurrence of a single resident or staff confirmed COVID-19 positive infection, received cumulative updates, and informed of mitigating actions taken by the facility to prevent or reduce the risk of transmission. The census was 44. Findings include: Review of CMS QSO-20-29-NH, dated 5/6/20, indicated, Facilities must .Inform residents, their representatives, and families of those residing in facilities by 5:00 p.m. the next calendar day following the occurrence of either a single confirmed infection of COVID-19, or three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other.Include information on mitigating actions implemented to prevent or reduce the risk of transmission, including if normal operations of the facility will be altered; and . Include any cumulative updates . During the entrance conference interview on 5/22/22 10:38 a.m., the Administrator stated that the facility had not had any COVID positive staff or residents in the past four weeks and acknowledged that he is responsible to inform the residents and responsible parties about the COVID-19 status in the facility, which he does by e-mail. The Administrator stated that he keeps a log to track the communications. During the entrance conference the policy for resident and staff notification of COVID-19 incidence in the facility was requested; however, none was provided during the duration of the survey. Line Listings of positive staff and residents was also requested during the entrance conference; however, none were provided. Interview on 5/24/22 at 10:04 a.m., the Director of Nursing (DON) acknowledged the facility was notified that Licensed Practical Nurse (LPN) NN tested positive for COVID 19 on 5/18/22. The DON stated that after working the night of 5/17/22, LPN NN performed a self-administered COVID-19 rapid test at home, tested positive, immediately went for a PCR COVID-19 test that was also positive. A line listing of COVID-19 positive residents and staff was requested again; however, none was provided. Review of the information provided in e-mails sent to resident, families, and friends for notification of COVID-19 occurrences in the facility revealed that communication for the COVID-19 positive result for LPN NN was not sent until 5/24/22. Interview on 5/23/22 at 1:19 p.m., the Medical Director acknowledged that the facility should follow CMS and CDC (Centers for Disease Control and Prevention) guidelines for their COVID-19 policies and procedures. Interview on 5/25/22 at 3:18 p.m., the Administrator acknowledged late notification of LPN NN's COVID positive test results to residents and families and upon questioning he did not provide an explanation for the late notification.