Based on staff interviews, record review, and review of the facility policy titled, Abuse Prohibition, the facility failed to protect residents from sexual abuse by another resident by not reporting to the State Survey Agency (SSA) within the required timeframe for one resident (R) (R85) reviewed for abuse and neglect. The deficient practice had the potential of future unreported abuse.Findings include:Review of the facility policy titled Abuse Prohibition review date 4/7/2025 revealed under Policy: It is the intent of this center to actively preserve each patient's right to be free from mistreatment, neglect, abuse or misappropriation of patient property. We believe that each patient has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. The purpose of these identified procedures is to assure that we are doing all that is withing our control to create a standard of intolerance and to prevent any occurrences of any form of mistreatment, neglect, abuse or misappropriation of any patient and, or their property. The procedures herein establish standards of practice for protection of patients and for identification and prevention of abuse. Under Identification of coverage and responsibility: Any person observing abuse, neglect, or exploitation as previously defined, should immediately report it to the Administrator or the direct supervisor (i.e. Charge Nurse, Director of Nursing, Departmental Leaders) present at the time of the incident.Review of the Five-Day follow-up dated 4/28/2025 summarized the details of the incident:Certified Medication Aide (CMA) JJ approached Administrator during a resident care meeting and states she observed male resident inappropriately touch R85 several months ago. CMA JJ stated she doesn't remember exactly when, but she told the nurse who said they would report. CMA JJ could not remember who she told about incident. She heard R85 giggling and turned to see male resident reaching across and grabbing R85's breast. CMA JJ told male resident to stop immediately and moved R85 away. Further review revealed that CMA JJ received 1:1 (one to one) education regarding immediately reporting to the Administrator as Abuse Coordinator.Interview with the Administrator on 9/11/2025 at 10:00 am revealed that CMA JJ was no longer employed by the facility. The incident took place before the current Administrator accepted their position. The Administrator confirmed that staff received regular in-services related to abuse and abuse reporting.

Based on observations, staff interviews and review of the facility's policy titled, Infection Prevention Plan, the facility failed to ensure proper infection control procedures were followed for four residents (R) (R5, R11, R1 and R78), creating cross-contamination. This failure had the potential to contribute to the transmission of infectious diseases among residents and staff. Findings include:Review of the facility's policy titled, Infection Prevention Plan, dated 12/27/2024 revealed, under Scope Prevention of Infections - Policies, procedures, and aseptic practices are followed by personnel when performing procedures and disinfecting equipment.Observation on 9/10/2025 at 8:25 am, Certified Medication Aide (CMA) AA was performing a medication pass for R5 in Dining Room Three. CMA AA was observed with a paper towel placed on the medication cart as a barrier. She proceeded to administer medications to R11 and then R1 without changing the barrier, creating cross contamination. Interview on 9/10/25 at 9:00am with CMA AA, confirmed she used a barrier on her medication cart and did not change it between residents. CMA AA confirmed it should have been changed between residents. Observation and subsequent interview on 9/10/25 at 8:44 am revealed CMA BB administering medications to R78 with a paper towel taped to the medication cart surface as a barrier. CMA BB completed the medication pass for R78 and proceeded to the next room without changing the barrier, creating cross contamination. CMA BB confirmed the barrier was not changed between residents. Interview on 9/10/2025 at 9:26 am with the Director of Nursing (DON) confirmed the nursing staff were expected to change barriers between residents during medication administration to prevent cross contamination.

Based on interviews, record review, and review of the facility's policy titled, Abuse Prohibition--Reporting and Investigating, the facility failed to complete a thorough investigation for two of two sampled Residents (R) (R48 and R82) reviewed for abuse. Specifically, there was no evidence the facility interviewed R48 the victim, other staff, or residents regarding the allegations of potential sexual abuse as a part of the facility's investigations. Findings include: Review of the facility's policy titled, Abuse Prohibition--Reporting and Investigating dated 12/29/2023 under the section titled, Guidelines indicated . Interviews will be conducted of pertinent parties. Written signed statements from any involved parties will be obtained if possible or a witnessed, signed interview would be an appropriate alternative. Information regarding the event will be gathered from the suspect, person making the accusations, patient involved, reliable patients who may have witnessed the incident, and any other persons who may have witnessed the incident, and any other persons who may have credible, pertinent information . All investigative information will be kept on file in a secured location. All information gathered is confidential in nature . Review of an undated document provided by the facility titled, Face Sheet indicated R82 was admitted with a diagnosis of dementia. Review of a document provided by the facility titled, admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/26/2024, indicated R82 had a Brief Interview for Mental Status (BIMS) score of three out of 15 indicating severely impaired cognition. The assessment indicated the resident wandered and was ambulatory. Review of a document provided by the facility titled Face Sheet indicated R48 was admitted with a diagnosis of Parkinson's disease. Review of a document provided by the facility titled, admission MDS, with an ARD of 1/25/2024, indicated R48 had a BIMS score of 15 out of 15 which revealed the resident was cognitively intact. The assessment indicated the resident had no behaviors such as hallucinations or delusions. The assessment indicated the resident used a wheelchair and required substantial to maximum assistance from staff for activities of daily living. Review of a file provided by the facility (referred to as the facility's investigation of a 3/6/2024 incident), dated 3/14/2024, indicated R82 was observed to kiss R48 on the cheek. To determine consent and competency of R48, the facility completed another BIMS and the resident scored a six out of 15, which revealed severe cognitive impairment. Both R48 and R82 were separated. According to the facility's investigation, R82 attempted to enter the room of R48 and was redirected. The investigation indicated R48 was transferred to the opposite side of the building. The facility could not substantiate abuse. There was no evidence the facility interviewed other staff regarding the allegations of potential sexual abuse. In addition, there was no evidence R48, the victim, was interviewed as part of the facility's investigation. Review of a file provided by the facility (referred to as the facility's investigation of a 3/18/2024 incident) dated 3/26/2024 indicated a staff member was attending to R48, while she was in a wheelchair and out in the hallway. The investigation revealed R82 leaned over R48 and kissed her cheek. Staff immediately removed R82 from R48. According to the facility's investigation, R82 was upset he could not pursue a relationship with R48. R82 was sent to a local hospital for a psychiatric evaluation and returned back to the facility three days later. Facility-wide training with staff occurred and the facility implemented 15-minute checks for R82. The investigation revealed R48 was to be monitored by the staff. The facility could not substantiate abuse. There was no evidence the facility interviewed other staff regarding this allegation of potential sexual abuse. In addition, there was no evidence R48, the victim, was interviewed as part of the facility's investigations. The facility also failed to ensure residents were interviewed as part of the facility's investigation. Review of R82's and R48's clinical records revealed there were no staff witness statements documented for the incidents dated 3/6/2024 and on 3/18/2024. During an interview on 4/2/2024 at 5:29 pm, the Administrator stated she did not collect a statement from R48 since the resident had a low Brief Interview for Mental Status (BIMS) score. The Administrator stated the staff who witnessed the two incidents between R48 and R82, were in the clinical records.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to complete and electronically transmit a Discharge Minimum Data Set (MDS) assessment to CMS's (Centers for Medicare and Medicaid Services) Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system for two of two residents (R) (R35 and R80) reviewed for discharge to home. Findings include: Review of the RAI Manual, dated 10/1/2019, indicated, There are three types of discharges: two are OBRA [Omnibus Budget Reconciliation Act] required-return anticipated and return not anticipated; the third is Medicare required-Part A PPS [Prospective Payment System] Discharge. A Discharge assessment is required with all three types of discharges . Any of the following situations warrant a Discharge assessment . Resident is discharged from the facility to a private residence . Discharge Assessment - return not anticipated. 1. Review of an undated document provided by the facility titled, Face Sheet indicated R35 was admitted to the facility on [DATE] and was discharged home on [DATE]. Review of a document provided by the facility titled, Nursing Home Part A PPS Discharge MDS with an assessment reference date (ARD) of 12/20/2023, indicated R35 ended Medicare skilled nursing care. There was no evidence of a discharge assessment completed which would indicate R35 was discharged from the facility to home and would not return to the facility. 2. Review of an undated document provided by the facility titled, Face Sheet indicated R80 was admitted to the facility on [DATE] and was discharged home on [DATE]. Review of a document provided by the facility titled, Nursing Home Part A PPS Discharge MDS, with an ARD of 11/26/2023, indicated R80 ended Medicare skilled nursing care. There was no evidence of a discharge assessment completed which would indicate R80 was discharged to home and would not return to the facility. During an interview on 4/3/2024 at 2:55 pm, the MDS Coordinator confirmed R35 and R80 should have had an OBRA discharge MDS assessment to indicate the two residents were discharged and not returning to the facility. During an interview on 4/4/2024 at 8:53 am, the Administrator and Director of Nursing stated it was their expectation that all mandatory MDS assessments be completed and transmitted per RAI requirements.

Based on interviews, record review, and review of facility's policy titled, Patient's Plan of Care, the facility failed to update a Care Plan for one Resident (R) (R31) when a pacemaker monitoring device was provided to the facility and failed to ensure one (R1) was invited to participate in the quarterly care plan meeting. These failures had the potential for R31 not to receive necessary care and services for a pacemaker monitoring device and R1 not to be involved in decisions affecting care in the facility. The sample size was 41 residents. Findings include: Review of the facility policy titled, Patient's Plan of Care, dated 12/29/2023, revealed The patient's care plan should be reviewed . and revised based on changing goals, preferences, and needs of the patient and in response to current interventions. The comprehensive care plan should also be updated as ongoing clinical assessments identify changes. The policy also documented, The center will provide the patient and/or patient's representative with advance notice of care planning conferences to enable patient/patient representative participation at a time the patient/patient representative is available to participate, in person or via phone call/video conferencing . 1. Review of R31's undated Face Sheet, located in the electronic medical record (EMR) under the Face Sheet' tab, revealed R31 was admitted with diagnoses including sick sinus syndrome, left bundle branch block, and presence of a cardiac pacemaker. Review of R31's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/28/2024 and located in the MDS tab of the EMR, revealed a Brief Interview of Mental Status (BIMS) score of 99, which indicated severe cognitive impairment. R31's diagnoses included heart failure and hypertension. Review of the Care Plan tab in the EMR under the focus area for anticoagulant related to left bundle branch block, sick sinus syndrome and pacemaker, included interventions initiated on 2/16/2024 for administering medications and watch for signs of bleeding. The Care Plan lacked interventions about the device to monitor the pacemaker. During an observation on 4/2/2024 at 9:15 am in R31's room, on a table located against the wall opposite the bed a device was plugged into the wall. The label on the device listed the (Name of the remote management system). There was a phone number for assistance label on top of monitoring device, plugged into wall socket and green light on in the bottom right corner of the device. During an interview on 4/4/2024 at 10:05 am, Licensed Practical Nurse (LPN)2, who was providing care for R31, stated she did not know what the device did or anything about the purpose of the device located in R31's room and confirmed the resident's Care Plan lacked documentation of the device. During an interview on 4/4/2024 at 12:34 pm, Registered Nurse (RN)1 verbalized the Care Plan for R31 should have been updated when the device was brought into the facility and staff should have occasionally confirmed the signal was being sent to the cardiologist office. During an interview on 4/4/2024 at 1:30 pm, the Assistant Director of Nursing (ADON) explained the device was brought to the facility after a cardiology appointment by FM2, it was a remote monitor, and the only requirement was to be plugged into the wall. The ADON confirmed the remote monitoring device for the pacemaker should have been updated on R31's Care Plan when it was brought into the facility. During an interview on 4/4/2024 at 1:18 pm, the Director of Nursing (DON) confirmed information about the monitoring device was not included on R31's Care Plan, and once the monitoring device came into the facility it should have been added to the Care Plan. 2. Review of a document provided by the facility titled, Face Sheet indicated R1 was admitted to the facility with a diagnosis of a traumatic head injury. Review of a document provided by the facility titled, Care Plan, dated 8/31/2020, indicated R1 had short- and long-term memory problems. Review of a document provided by the facility titled, Care Plan Conference, dated 10/24/2023, indicated the family member of R1 was invited to participate in his care conference and did not attend. The document failed to indicate if R1 was invited to participate in his quarterly care conference. Review of a document provided by the facility titled, quarterly Minimum Data Set (MDS), with an Assessment Reference Date of 12/20/2023, indicated R1 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 indicated led the resident was moderately cognitively impaired. Review of a document provided by the facility titled, Care Plan Conference dated 1/23/2024 indicated the family of R1 was invited to participate in his care conference and did not attend. The document failed to indicate if R1 was invited to participate in his quarterly care conference. During an interview on 4/2/2024 at 9:18 am, R1 stated he did not get invited to his quarterly care conferences. During an interview on 4/3/2024 at 1:11 pm, the Social Services Director (SSD) stated the MDS Coordinator would send out invitations to the residents' representatives on a quarterly basis and would always invite the residents. The SSD did not invite the resident to attend the Care Plan Conference. During an interview on 4/3/2024 at 2:14 pm, the MDS Coordinator stated all the resident representatives were sent invitations. The MDS Coordinator stated the SSD would invite the residents to their quarterly care plan meetings. The MDS Coordinator did not invite the resident to attend the Care Plan Conference. During an interview on 4/4/2024 at 4:52 pm, the Director of Nursing (DON) stated her expectation was for the residents and their family members to be invited to quarterly care conferences and the facility does send out invitations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review, and review of the facility's policy titled, Using A Portable Lifting Machine, the facility failed to ensure a mechanical lift sling was inspected for damage and defects after laundering for one out of five residents (R) (R13) reviewed for falls. The deficient practice caused R13 to fall from a mechanical lift sling because of a broken strap while being transferred from his motorized wheelchair to the bed. Findings include: Review of the facility's policy titled, Using A Portable Lifting Machine, dated 12/29/2023, provided by the facility, revealed, Various manual and/or electric mechanical lifts may be used by this center. Manufacturer recommendations for use should be followed. Review of the manufacturer guidelines titled, Liko (Trademark) Soft Original High Back Sling, Mod. 26 Instructions for Use, dated 12/11/2013, provided by the facility, revealed Care and Maintenance of Liko Slings . Check the Sling after Washing. All points are inspected with regard to wear and damage Fabric, Straps, Seams, Suspension loops, Buckles (where applicable) . Do not use damaged slings. Protocol for periodic inspection can be used as guidance as to which parts are extra important to check for each sling model. Slings in polyester fabric have a longer lifetime than slings in net polyester. The handles on certain slings are intended for steering. Too heavy a load on the handles can result in the sling breaking. Review of R13's undated Face Sheet located in the electronic medical record (EMR) under the Face Sheet tab revealed R13 was admitted to the facility on [DATE] with diagnoses of cerebral palsy (CP) and morbid obesity. Review of R13's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/17/2023 located in the EMR under the MDS tab, revealed R13 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The assessment indicated R13's functional status as being dependent on staff for transfers, and he used a motorized wheelchair. Review of R13's Care Plan, dated 10/6/2023, located in the EMR under the Care Plan tab, indicated R13 fell on [DATE] with an intervention on 10/2/2023 of 911 call [sic], MD [physician] notified, Sent to ER [emergency room], Neuro [neurological] check and an intervention on 10/6/2023 of Slings evaluated and blue sling appropriate for use. Review of R13's Nursing Progress Notes, dated 10/2/2023, located in the EMR under the Progress Notes tab, indicated 0305 [3:05 AM]-Staff was putting resident to bed when strap on lift seat [sling] broke and resident fell to floor with legs still in lift seat. Back was lying across leg of lift with head on floor. Lift lowered and sling removed. Resident rolled off leg of lift onto floor. Pillow under head, No Loc [loss of consciousness]. Resident c/o [complained of] pain to back. Able to MAEW [move all extremities well]. 0359 [3:59 AM] 911 notified. 0401 [4:01 AM]-Dr [doctor] and on call notified 0402 [4:02 AM]-Neuro check WNL [within normal limits]. 0410 [4:10 AM]-EMS [emergency medical services] here. Awaiting additional personel [sic]. 0430 [4:30 AM]-Resident to [hospital] via stretcher. 0431 [4:31] AM-Report called to RN [registered nurse] at [hospital]. During an interview on 4/2/2024 at 11:01 am, R13 stated on 10/2/2023, three-night shift staff--two Certified Nursing Aides (CNAs) and one RN--were in the process of transferring him from the motorized wheelchair to his bed when the upper right strap of the sling ripped and broke. His head fell to the floor, but his legs stayed in the sling. R13 also stated he had pain in his neck and back, he was sent to the hospital, and he had no injuries. During an interview on 4/2/2024 at 3:06 pm, the Administrator stated R13 fell from the mechanical lift when the right upper strap broke when three staff were moving him from the wheelchair to the bed on 10/2/2023. The Administrator also stated R13 was sent to the hospital because he complained of pain but did not suffer any injuries. The Administrator indicated the cause of the broken sling could not be determined; however, the investigation revealed the laundry staff did not document that mechanical lift slings were inspected for defects or damage prior to putting them back in circulation on the floor prior to R13's fall. The Administrator confirmed no other incidents had occurred before or after R13's fall but she removed those slings and ordered new slings for all the residents. During an interview on 4/2/2024 at 3:17 pm, the Housekeeping Supervisor stated the laundry staff washed and hung the mechanical lift slings to dry then sent them to floor or stored them in storage bins but did not check them for damage or defects or document it until after R13's fall on 10/2/2023. The Housekeeping Supervisor also stated laundry staff now inspect every sling after they were laundered, and they documented the inspection on the Mechanical Lift Inspection Log. During an interview on 4/3/2024 at 11:54 am, Laundry Aide 1 stated that after the mechanical lift slings were laundered, they were inspected for damage, and they documented it on the sling log, but that process did not begin until after R13's incident last year. Laundry Aide 1 also stated if the slings were damaged, they removed the sling and gave it to the Housekeeping Supervisor.

Based on observation, interview, and record review, the facility failed to ensure staff were informed or educated about the remote cardiac monitor's purpose for one of one Resident (R) (R 31) with a pacemaker monitor. The deficient practice had the potential to place R31 at risk of not receiving necessary care and monitoring for cardiac instability. Findings include: Review of the Facility Assessment, dated 3/6/2024, revealed Education is conducted on our L.E.A.D. platform which is assigned monthly by (Name of Company) and on an as needed basis for individuals and groups. L.E.A.D. assignments are conducted based on QAPI processes and annual education requirements for regulatory purposes. Other training needs are addressed through On-boarding and orientation-Annua/Skills Fair (completed in May 2023), Safety Boot Camp, Webinars, Staff Meetings, Huddles and (Name of Company). Notifications. (Name of Company) consultants conduct education during site visits and via Zoom meetings. Outside education is offered through GHCA, AHCA, Healthcare Coalitions and (Name of Company) training and meetings off-site. The Facility Assessment did not identify cardiac pacemaker monitoring equipment or staff training needed for use of the device. Review of the undated Face Sheet, located in the electronic medical record (EMR) under the Face Sheet tab, revealed R31 was admitted with diagnoses including sick sinus syndrome, left bundle branch block, and presence of a cardiac pacemaker. Review of R31's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/28/2024 and located in the EMR under the MDS tab, revealed a Brief Interview of Mental Status (BIMS) score of 99, which indicated severe cognitive impairment. R31's diagnoses included heart failure and hypertension. Review of the Care Plan tab in the EMR under the focus area for anticoagulant related to left bundle branch block, sick sinus syndrome and pacemaker, included interventions initiated on 2/16/2024 for administering medications and watch for signs of bleeding and lacked interventions about the device to monitor the pacemaker. During an observation on 4/2/2024 at 9:15 am, in R31's room, on a table located against the wall opposite the bed a device was plugged into the wall. The label on the device was (Name of the remote management system). There was a phone number for assistance label on top of monitoring device, plugged into wall socket and green light on in the bottom right corner of the device. During an interview on 4/2/2024 at 9:59 am, R31's Family Member (FM)1 explained the device was a monitor that sent information about the heart rhythm and pacemaker to the cardiologist's office for evaluation. During an interview on 4/4/2024 at 10:05 am, Licensed Practical Nurse (LPN)2, who was providing care for R31, stated she did not know what the device did or anything about the purpose of the device located in R31's room. During an interview on 4/4/2024 at 1:30 pm, the Assistant Director of Nursing (ADON) explained the device was brought to the facility after a cardiology appointment, it was a remote monitor, and the only requirement was to be plugged into the wall. During an interview on 4/5/2024 at 1:55 pm, R31's FM2 explained during the visit with the cardiologist and R31 in December 2023, the device was provided to monitor the pacemaker due to the battery being very low (implanted in 2016). The cardiologist's office would notify the facility if there were issues with the battery or cardiac rhythm. FM2 brought the device to the facility to monitor R31's cardiac stability. During an interview on 4/5/2024 at 9:17 am, Licensed Practical Nurse (LPN)3 confirmed FM2 brought the device into the facility to monitor the pacemaker of R31 to set up for monitoring. LPN3 plugged in the device and called the customer service number to set up the monitor. The responsibility of the facility was to be sure the device was plugged in, green light on in the bottom right corner, and placed in the resident room. LPN3 stated since the device was already set up, she did not communicate information about the device to any other staff. During an interview on 4/5/2024 at 12:23 pm, the Director of Nursing (DON) verbalized staff development and training was performed as a group project involving the DON, ADON, supervisors, and other staff as needed. The DON confirmed no education was provided for the device in R31's room for monitoring the cardiac health of the resident when the device was brought into the facility, but training should have been done to ensure all staff could provide the necessary care for the monitor.

Based on observation, interview, record review, and review of the facility's policy titled, Standard Patient Room Cleaning, the facility failed to ensure prevention of spread of infection by using foam protectors in disrepair over bed rails that created an uncleanable surface for four of four Residents (R) (R19, R22, R10, and R13) reviewed for side rail use. This deficient practice had the potential for the foam covers on the side rails to harbor bacteria and spread infection to the residents. Findings include: Review of the facility's policy titled, Standard Patient Room Cleaning, dated January 2024, revealed 5. DISINFECT: . b. Patient zone: Using the same microfiber cloth and enhanced disinfectant, clean and disinfect surfaces in the patient's zone (i.e., over bed table, bed rails, bedside table, phone, call light cord). 1. Review of R22's undated Face Sheet, located in the electronic medical record (EMR) under the Face Sheet tab, revealed R22 was admitted with diagnoses including rheumatoid arthritis and chronic pain syndrome. Review of the Care Plan tab in R22's EMR revealed an intervention initiated 7/14/2023 to apply side rails to the bed. The Care Plan lacked documentation of reason indicating a need to pad the side rails. During an observation on 4/2/2024 at 1:56 pm in R22's room, bilateral 1/4 side rails attached to the upper frame of the resident's bed were covered with a gray foam padding and secured with duct tape. During an interview on 4/3/2024 at 3:31 pm, the Director of Nursing (DON) expressed a lack of understanding of the concern for the uncleanable surface of the foam on the side rails, stating it was just their germs. During an observation on 4/4/2024 at 2:19 pm, the foam padding on the R22's bed rails was cracked and peeling, exposing porous areas of the foam. During an interview on 4/4/2024 at 11:21 am, in R22's room, R22 verbalized they did not know the reason for the foam padding on the rails on the bed and the foam had been in place since the admission in June 2023. During an interview on 4/4/2024 at 12:48 pm, the Maintenance Director explained a work request was placed in the TELS (building maintenance documentation system) system to pad the resident's bed rails. He acquired the foam from Ace Hardware (same foam used to apply insulation to the outside of pipes), cut it to size, and secured it with tape to the bed rails. During an interview on 4/5/2024 at 11:10 am, the Infection Preventionist (IP) confirmed the foam was not cleanable due to the porous texture and residents or staff could infect or reinfect themselves during contact with the foam due to reservoirs for bacteria in the texture of the foam. 2. Review of R19's Face Sheet, located in the EMR under the Face Sheet tab, revealed R19 was admitted with diagnoses including Alzheimer's disease and unspecified lack of coordination. Review of the Care Plan tab in R19's EMR revealed an intervention initiated 2/5/2023 to apply side rails to the bed. The Care Plan lacked documentation of reason indicating a need to pad the side rails. During an observation on 4/2/2024 at 1:56 pm in R19's room, bilateral side rails attached to the upper frame of the resident's bed were covered with a gray foam and secured with black tape. During an observation on 4/4/2024 at 2:19 pm, the foam padding on R19's bed rails was cracked, pitted, and part peeled off exposing porous areas of foam. During an interview on 4/4/2024 at 12:48 pm, the Maintenance Director explained a work request was placed in the TELS system to pad the resident's bed rails. He acquired the foam from Ace Hardware (same foam used to apply insulation to the outside of pipes), cut it to size, and secured it with tape to the bed rails. During an interview on 4/5/2024 at 11:10 am, the IP confirmed the foam was not cleanable due to the porous texture and residents or staff could infect or reinfect themselves during contact with the foam due to reservoirs for bacteria in the texture of the foam. 3. Review of R10's undated Face Sheet located in the EMR under the Face Sheet tab revealed R10 was admitted with diagnoses of amnesia and difficulty walking. Review of R10's Care Plan, revised 4/4/2024, located in the EMR under the Care Plan tab, indicated a problem of Skin breakdown: at risk for/actual and an intervention to Continue padded rails related to history of bruising. Observations in R10's room on 4/2/2024 at 9:36 am and 4/4/2024 at 9:22 am revealed R10 lying in bed with two side rails elevated at the top of the bed with gray foam covering the top of the side rail, secured with gray tape. During an interview on 4/4/2024 at 12:48 pm, the Maintenance Director revealed the nurses submitted a work order for the foam padding for the side rails, which he ordered and picked up from (Name of Store) Hardware, then secured it to the side rails with duct tape. During an interview on 4/5/2024 at 11:10 am, the IP confirmed the foam was not cleanable due to the porous texture and residents or staff could infect or reinfect themselves during contact with the foam due to reservoirs for bacteria in the texture of the foam. 4. Review of R12's undated Face Sheet, located in the EMR under the Face Sheet tab, revealed R12 was admitted with diagnoses that included dementia and transient cerebral ischemic attack (stroke). Review of R12's Care Plan, revised 4/4/2024 and located in the EMR under the Care Plan tab, revealed a problem of Skin breakdown: at risk for/actual and an intervention to Continue padded side rail on left per patient preference. Observations in R12's room on 4/2/2024 at 11:35 am and 4/3/2024 at 8:39 am revealed R12 was lying in bed with two side rails raised at the top of the bed with a dark gray foam covering the top of the left side rail, secured with black tape at the top and bottom of the rail. During an interview on 4/3/2024 at 8:39 am, R12 stated she did not know when or why the foam was applied to the side rail. During an interview on 4/4/2024 at 12:30 pm, Registered Nurse (RN) 1 stated the foam was applied to the bed rails to prevent skin tears or bruises on the resident's arms due to her fragile skin. During an interview on 4/4/2024 at 12:48 pm, the Maintenance Director revealed the nurses submitted a work order for the foam padding for the side rails which he ordered and picked up from (Name of Store) Hardware, then secured it to the side rails with duct tape. During an interview on 4/5/2024 at 11:10 am, the IP confirmed the foam was not cleanable due to the porous texture and residents or staff could infect or reinfect themselves during contact with the foam due to reservoirs for bacteria in the texture of the foam.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, policy review, interviews, and Rule 410-10-.02 Standards of Practice for Licensed Practical Nurses, the facility failed to maintain professional nursing standards of quality as evidenced by two Licensed Practical Nurses (LPN), administered insulin to R#18, using another resident's insulin pen on two different occasions. The sample size was 33. Findings include: Review of the policy titled, Pharmacy Services: Insulin Administration, copyright 2022, revealed policy guideline - nursing should double-check all insulin therapy before administering. Administration as follows: Patient name and drug order is checked and double-checked. Insulin pen: Never share insulin pens between patients. Review of the Georgia Rule 410-10-.02 - Standards of Practice for Licensed Practical Nurses revealed that: The practice of licensed practical nursing means the provision of care for compensation, under the supervision of a physician practicing medicine, a dentist practicing dentistry, a podiatrist practicing podiatry, or a registered nurse practicing nursing in accordance with applicable provisions of law. Such care shall relate to the promotion of health, the prevention of illness and injury, and the restoration and maintenance of physical and mental health through acts authorized by the board, which shall include, but not be limited to the following: (a) Participating in patient assessment activities and the planning, implementation, and evaluation of the delivery of health care services and other specialized tasks when appropriately educated and consistent with board rules and regulations. (b) Providing direct personal patient observation, care, and assistance in hospitals, clinics, nursing homes, or emergency treatment facilities, or other health care facilities in areas of practice including, but not limited to coronary care, intensive care, emergency treatment, surgical care and recovery, obstetrics, pediatrics, outpatient services, dialysis, specialty labs, home health care, or other such areas of practice. (c) Performing comfort and safety measures. (d) Administering treatments and medications by various routes. Review of the Novolog Pen Manufacturer package insert, provided by the consultant pharmacist revised 10/2021 revealed; WARNINGS AND PRECAUTIONS - Never share a NOVOLOG® Flex Pen® or a NOVOLOG® FlexTouch®, PenFill® cartridge or PenFill® cartridge device between patients, even if the needle is changed. Review of the clinical record revealed R#18 was admitted to the facility on [DATE] with diagnoses including but not limited to cerebral palsy, glaucoma, essential (primary) hypertension, and hyperglyceridemia. Review of R#18's quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview Mental Status (BIMS) score of 15, indicating no cognitive impairment. Section G revealed resident requires total dependence for ADLs. Section N indicated the use of insulin injections. Review of the care plan initiated on 12/16/2022, revealed resident had a care area problem of Diabetes Mellitus related to type 2 diabetes and hyperglyceridemia. Resident chooses to not take ordered insulin at times. Interventions to care include accu-checks as ordered, administer insulin and/or oral hypoglycemics as ordered, provide education on blood glucose management, respect residents decision not to take insulin or accu-checks and eat foods of his choice. Review of the February 2023 Physician Orders revealed an orders for reduced concentrated sweets diet, Victoza 0.6 milligrams (mg) subcutaneous pen injector 0.6 mg one time daily, Lantus Solostar U-100 Insulin 100 unit/milliliters (ml) pen 56 units subcutaneous one time per day, Lantus Solostar U-100 Insulin 100 unit/ml 68 units subcutaneous one time per day, Novolog U-100 Insulin aspart 100 unit/ml solution 20 units subcutaneous three times per day, Novolog U-100 Insulin aspart 100 unit/ml subcutaneous solution per Sliding Scale before meals and at bedtime VIAL ONLY NO FLEX PEN. Review of Medication Error Report dated 9/19/2022 indicated nurse pulled insulin from patient slot on cart. Patient hs two he receives and both insulin I slot side by side. Nurse spoke to patient about the insulin before administration of missing cap. Nurse than {sic} proceeded to administrate {sic} insulin by sliding scale. Immediately after injection resident states that only one of his insulins are in pen not both. Nurse noted that the fast-acting insulin belong to another resident that was in R#18 slot. Review of a Nurse's Note dated 9/19/2022 at 8:34 p.m. notated as Medication Error revealed R#18 had blood sugar check and results was for 6 units sliding scale coverage. LPN BB pulled all residents eye drops, medication, and insulins from his room slot on cart. LPN BB noted that flex pen for fast acting did not have a cover on it. LPN BB asked R#18 if he knew why his cover was missing off the pen. R#18 verbalized he was not sure. LPN BB informed resident that it was ok that cover just helps protect pen. LPN BB clicked the units of insulin for sliding scale at 26 units and administered to resident as he indicated to his right abdomen. Nurse disguarding {sic} the needle, and R#18 asked which insulin he took first, LPN BB stated his fast acting and resident stating that his fast acting was not a pen but a vial. Nurse checked the flex pen and noted that another resident's flex pen Novolin R was in R#18's slot. Nurse informed resident of the error and explained to resident that his vial was not in his slot but they both are fast acting insulin and there were not any contradicting issues of him receiving the Novolin R verse his Novolog. LPN BB explained to resident no cross contamination was at risk either since all needle tips are changed with each flex pen use and the needle is designed to prevent any back flow. LPN BB contacted physician to report the medication error. Further review of the medical record revealed a second Medication Error Report dated 2/8/2023 indicating Novolog given from another patients pen, not vial as ordered (validated it was a new pen of Novolog that was used). Nurse states she did not see residents' vial and saw the pen, so gave Novolog from pen-did not think it was a med error. Review of Nurse's Note dated 2/8/2023 at 12:46 p.m. indicated R#18 came to Administrator office and said the agency nurse gave him insulin from a pen at 6:00 a.m.-Physician notified-new orders received-follow-up with resident and reassured him he is safe. Interview on 2/14/2023 at 2:47 p.m. R#18 revealed that he was injected with the wrong insulin pen on two separate occasions. He stated the first time it happened was in September last year, and again this month (February). He stated the first incident the nurse placed his and another resident's insulin pen in the wrong place in the medication cart. The nurse picked it up and administered it to him without checking the name. Resident stated he was worried about cross contamination and requested a blood test to make sure he was not infected. He stated this happened a second time this month (February 2023) when an Agency nurse, who was unfamiliar with the medication cart, administered his morning insulin with an insulin pen. He stated he was trying to tell her to wait he doesn't get an insulin pen in the morning, that his morning insulin was in a vial, but before he could tell her she had already injected him with the insulin pen. He stated that the nurse informed him that the insulin was similar and there was not a chance of him getting a bloodborne pathogen. He stated the nurse told him she would file a report, since he was concerned about it. Resident stated that he followed up with the Administrator, and she told him that she was sorry that this happened again, and she would do training with the staff to make sure that it does not continue to happen. Resident stated the facility did training the first time it happened, yet it happened again, and this should not keep happening to him. Interview on 2/15/2023 at 1:10 p.m., the consultant pharmacist revealed that the facility did not make him aware of the medication errors with the insulin. He further stated that insulin pens should not be shared between residents. During further interview, he stated that he is not sure if there is a risk of any infections or blood borne pathogens with sharing insulin pens. Interview on 2/15/2023 at 2:38 p.m., the Medical Director revealed that he was notified of the medication errors involving the mix up of the insulin pens. He stated that if the same needles were not shared, there is little concern. Telephone interview on 2/15/2023 at 7:01 p.m., LPN BB revealed she works at the facility as needed (PRN) basis. She stated that she worked with R#18 prior to the incident with the insulin and was aware that she had to administer two different types of insulin based on his physician orders. She stated resident takes short acting and long-acting insulin. She stated she was talking with the resident about his medications as she was preparing the medications for administration. She stated that she pulled what she thought was his short acting insulin pen from his slotted medications in the med cart and administered the insulin to resident. She stated immediately as she administered the insulin, resident stated hey wait, what are you giving me, my short acting insulin is not a pen it is in a vial. LPN stated she looked at the insulin pen at this time and it did not have a label with resident's name. She further stated that the insulin pens come from the pharmacy in a bag with a label, and also a label on the cap. She stated the pen did not have a cap. She attested to not looking at the insulin closely enough before administering it to the resident. LPN BB stated that she should not have administered the medication if it did not have his name on it. She further stated that after auditing the medication cart, she found residents insulin vial in another resident's medication drawer and the nurse on the previous shift had not properly stored the insulins. Interview on 2/16/2023 at 9:13 a.m., DON revealed that nurses should have limited distractions when administering medications. She stated she contributes the medication errors to nurses being distracted during the medication pass. She stated that she had performed random medication rounds with the nurses and the certified medication aides (CMAs) and did not identify any issues. Interview on 2/16/2023 at 12:11 p.m., the Regional Nurse Consultant (RNC) revealed that she was aware of the February 2023 insulin administration error. She stated she advised the facility to find the root cause of the error and come up with a plan to keep things like this from happening. Interview on 2/16/2023 at 1:02 p.m., the Administrator revealed the new hire orientation has been revamped to ensure that the core competencies are completed prior to staff being able to work with residents independently. Review facility's education records revealed that licensed nurses and certified medication aides were re-educated on insulin administration and the 5 Rights of Medication Administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility failed to follow Physician Orders for one resident (R) (R#24) related to sliding scale insulin order to notify the physician for blood sugars greater than 401. The sample size was 33. Findings Include: Review of the clinical record revealed resident was admitted to the facility on [DATE] with diagnoses including congested heart failure (CHF), chronic obstruction pulmonary disease (COPD), acute respiratory failure, diabetes mellitus, and restless leg syndrome. The resident's most recent quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of nine out of 15, which indicated moderate cognitive impairment. Section N revealed resident received insulin injections seven days during the look back period. Review of the care plan dated 2/1/2023 revealed resident has diagnosis of diabetes mellitus with persistent elevation in fingerstick blood sugars (FSBS). Interventions to care include administer insulin and/or oral hypoglycemics as ordered and notify Physician as indicated. Review of the February Physician Orders revealed an order dated 8/24/2022 for Novolog Flex-pen 100 unit/milliliter (ml) sliding scale subcutaneous before meals: 0-59 = 0 units (call MD); 60-119 = 0 units; 120-150 = 0 units; 151-200 = 3 units; 201-250 = 5 units; 251-300 = 7 units; 301-350 = 9 units; 351-400 = 11 units; 401 or greater = 11 units (call MD). Review of the January 2023 Medication Administration Record (MAR) revealed on 1/26/2023 at 11:00 a.m., FSBS was 420 milligrams/deciliter (mg/dL) and on 1/30/2023 at 11:00 a.m., FSBS was 441 mg/dL. Review of the electronic medical record (EMR) revealed no evidence that the physician was notified of FSBS over 400 mg/dL, as ordered. Interview on 2/16/2023 at 1:58 p.m., the Director of Nursing verified there was no evidence in the EMR that physician was informed about elevated FSBS on 1/26/2034 and 1/30/2023. She stated it was an oversight, and reported that she had done an in-service on 2/3/2023 for the nurses and certified medication aides (CMAs) related to following physician orders for elevated blood sugars. Cross Refer F656

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the clinical record revealed R#70 was re-admitted to the facility on [DATE] with diagnoses of venous thrombosis, depression, aphasia, gastroesophageal reflux disease (GERD), apraxia, spastic hemiplegia affecting right dominant side, muscle weakness, history of falling, and unsteadiness of feet. Review of the quarterly MDS dated [DATE] revealed a BIMS score of 10, indicating moderate cognitive impairment. Section G revealed resident required one-person physical assistance for ADLs and had limitations in range of motion (ROM) of her upper and lower extremities. Review of the care plan dated 2/2/2023 revealed the resident had limited mobility related to weakness and spastic hemiplegia affecting right side. Interventions to care include assist with ADLs as needed and refer to therapy as indicated. Review of the list of residents on Restorative Nursing services revealed R#70 had start date for Restorative Nursing on 11/10/2023 for ROM to upper/lower body and walking. The last documented date of service provided was 1/2/2023. Interview on 2/13/2023 at 11:53 a.m. with resident and her husband revealed she was admitted to the facility after a stroke and came here for therapy. Her husband stated that she is no longer on therapy services and that the staff does not walk with her or perform any exercises. He stated that the only exercises she gets now is when her husband walk with her with the walker. Interview on 2/14/2023 at 10:17 a.m. with R#70 with spouse at bedside, revealed she is not getting therapy. Her husband stated she is right-handed and her whole right side has weakness. He stated she needs some speech therapy. Interview on 2/16/2023 at 12:08 p.m. the Rehabilitation Director revealed they set up restorative program for all residents once they discharge from therapy, unless they refuse. She stated R#70 restorative plan is for ambulation 300 feet with weight bearing as tolerated with a hemi-walker, upper body range of motion, and lower body is active ROM for both legs. Based on observations, record review, resident and staff interviews, the facility failed to implement restorative nursing care for three residents (R) (R#35, R#43, R#70) as recommended post discharge from inpatient Rehabilitation Services. The sample size was 33 residents. Findings include: 1. Review of the clinical record revealed R#35 was admitted to the facility on [DATE] with diagnoses including cerebral vascular accident (CVA) with left hemiplegia, gastroesophageal reflux disease (GERD), and major depressive disorder. Review of the annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive deficit. Section G revealed resident was total dependent of two-persons for all activities of daily living (ADLs). She had functional limitations of upper and lower extremities on one side. Review of the care plan dated 1/1/2023 revealed the resident had limited mobility related hemiplegia and limited range of motion (ROM) to right side. Interventions to care include assist with ADL's as needed and refer to therapy as indicated, and see Restorative Plan. Review of the Physical Therapy Summary and Occupational Therapy Summary with service dates 11/9/2022 through 11/29/2022 revealed R#35 had met her maximum potential with a discharge disposition to Skilled Nursing Facility-Restorative Program. Restorative care to include ROM, transfers with Stand Aid, and exercise. Review of the list of residents on Restorative Nursing services revealed R#35 had start date for Restorative Nursing on 11/30/2022 for ROM to upper/lower body and transfers, but no evidence or documentation that Restorative Nursing services were provided. Interview on 2/16/2023 at 1:10 p.m., the Rehab Director stated R#35 reached her maximum potential and was discharged from therapy with referral to restorative nursing services. She stated R#35 was non-ambulatory but could stand with assistance. 2. Review of the clinical record revealed R#43 was admitted to the facility on [DATE] with diagnoses to include sacral pressure ulcer, difficulty in walking, generalized muscle weakness, unsteadiness on feet, need for assistance with personal care, and nicotine dependence. Review of the admission MDS dated [DATE] revealed a BIMS score of 11, indicating mild cognitive impairment. Section G revealed resident required total dependence for all ADLs. He had functional limitations of upper extremities on both sides. Review of the care plan dated 1/19/2023 revealed the resident had limited mobility related to limited ROM to the shoulders bilaterally. Interventions to care include assist with ADL's as needed and refer to therapy as indicated. Review of the Physical Therapy Summary and Occupational Therapy Summary with service dates 1/5/2023 through 2/6/2023 revealed R#43 had met his maximum potential with a discharge disposition to Skilled Nursing Facility-Restorative Program. Restorative care to include ROM, ambulation, and exercise. Review of the list of residents on Restorative Nursing services revealed R#43 had start date for Restorative Nursing on 2/7/2023 for ROM to upper/lower body and walking, but no evidence or documentation that Restorative Nursing services were provided. Interview with the Rehab Director on 2/15/2023 at 1:10 p.m., stated R#43 was on caseload but had met maximum potential. She stated she referred him to Restorative Nursing for ROM to bilateral lower extremities and transfers with stand aid. Interview on 2/15/2023 at 11:00 a.m., the Director of Nursing (DON) stated the Restorative Nursing Program was in the process of being restarted and provided a list of residents who should be receiving Restorative Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, interviews, and review of the facility policy titled Fall Management, the facility failed to assure the safety of one resident (R#19) with a history of falls, by not placing resident in bed when she was asleep and leaning forward in wheelchair. The sample size is 33. Findings include: Review of the policy titled Fall Management reviewed 12/4/2021, indicates each patient is assisted in attaining/maintaining his or her highest practicable level of function by providing the patient adequate supervision, assistive devices and/or functional programs as appropriate to minimize the risks for falls. If a fall occurs, the interdisciplinary team conducts an evaluation to ensure appropriate measures are in place to minimize the risk of future falls. Review of the clinical record revealed resident was admitted to the facility on [DATE] with diagnoses of but not limited to Parkinson's Disease, difficulty in walking, muscle weakness (generalized), need for assistance with personal care, osteoarthritis of knee, cramp and spasm, age-related osteoporosis without current pathological fracture. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. Section G indicated resident was total dependent of two-persons for transfers and limited assistance with walking. She had limitations in range of motion - Upper and Lower extremities - Impairment on both sides. Mobility Devices include wheelchair and walker. Balance During Transitions and Walking - Not steady only able to stabilize with human assistance. Review of the care plan updated 2/14/2023 indicated resident is a fall risk related to difficulty in walking, generalized muscle weakness, unsteadiness on feet and unsteady gait. The interventions listed includes assess contributing factors related to fall history, place patient in open area for maximum observation, place back to bed, and non-skid strips to both sides of bed. Review of the Progress Note dated 2/13/2023 at 10:00 a.m. that revealed Observed resident on floor in room. Resident stated she fell back asleep after I gave her morning meds and fell out of wheelchair. Noticed she had a cut approximately 1 cm long to top of head and she said she bumped it on her bedside table when she tried to get up. Small amount of blood washed out of hair and cut is no longer bleeding. Physician notified and advised to do neuro checks and keep an eye on the cut. Resident moved all extremities and assisted back into wheelchair. RP-son notified. Observation on 2/13/2023 at 12:30 p.m. revealed resident sitting in a wheelchair in the dining room eating lunch. Resident is moving the wheelchair back and forth while eating. The wheelchair's wheels are not locked. Observation on 2/14/2023 at 10:32 a.m. revealed resident out of bed to wheelchair in her room at the end of the hall. Resident has a walker positioned in front of her. Observation on 2/14/2023 at 12:11 p.m. revealed resident in her room at the end of the hall, sitting in her wheelchair. She was asleep and leaning forward in her wheelchair. During this observation, Housekeeper DD exited the room, looked at surveyor and stated, she is snoozing and has been since I have been in there cleaning. Housekeeper DD proceeded up the hall to clean other rooms on the hall. Observation on 2/14/2023 at 12:17 p.m., Licensed Practical Nurse (LPN) AA walked past R#19's room, looked in as she passed by, but did not enter the room. Observation on 2/14/2023 at 12:28 p.m. LPN AA entered residents' room, awakened her, asked if she was alright, and then administered her medications. LPN AA asked resident if she wanted to lay down, resident stated I don't care. LPN AA left the room. At this time surveyor asked LPN AA if she felt resident was safe sleeping in the wheelchair. LPA AA further stated that she is not sure why resident was left in the room at the end of the hall. She revealed that R#19 should not be left unattended in her room asleep in the wheelchair, because she is a high-risk for falls. She stated resident had a fell yesterday (2/13/2023). Interview on 2/14/2023 at 12:29 p.m. CNA CC revealed she saw resident at approximately 11:45 a.m. sitting in her room in the wheelchair sleepy and nodding off. CNA CC stated that she did not ask resident if she wanted to lie down for a nap or attempt to assist her to another area to be monitored because it just did not dawn on her to do that. CNA CC further stated that she is aware that resident is a high-risk for falls because her name is on the list that she has. Interview on 2/14/2023 at 12:55 p.m. with Director of Nursing Services (DNS) revealed her expectation is that if a resident with a history of falls is in a wheelchair asleep, that the staff should assist the resident to bed. She further stated residents that are high risk for falls be placed in a frequently observed area such as the nurse's station or dining room, to be monitored.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the policy titled Skilled Inpatient Services: Use of Oxygen Therapy reviewed 12/4/2021, revealed that guidelines for use is that physician order for oxygen should be obtained and include the flow rate or percentage ordered; indicate if use should be continuous or as needed; method of oxygen delivery via nasal cannula, mask, etc. The care plan should reflect resident specific needs for oxygen as ordered. Review of the policy titled Skilled Inpatient Services-Patients Plan of Care dated 12/4/2021, revealed each resident will have a person-centered comprehensive care plan developed and implemented to meet the residents preferences and goals, and to address the residents medical, physical, mental, and psychosocial needs. Review of the clinical record revealed R#51 was admitted to the facility on [DATE] with diagnoses including bipolar disorder, cerebral infarction, congested heart failure (CHF), COPD, and dementia. Review of the quarterly MDS dated [DATE], documented a BIMS score of 15, indicating no cognitive impairment. Review of the February Physician Orders revealed an order dated 3/27/2022 for oxygen via N/C at two lpm nasally every second shift. Review of care plan dated 12/31/2022, revealed resident has respiratory difficulties and risk for further decline related to COPD, respiratory failure, and history of bronchitis. Interventions to care include administer medications and treatments as ordered and oxygen at two liters as ordered. Review of the February 2023 electronic medication record (EMR) revealed staff were documenting every shift that oxygen was set at two liters via N/C. Observation on 2/13/2023 at 11:16 a.m., resident in bed with oxygen in use via N/C, and flow rate was set on one lpm. Observation on 2/14/2023 at 10:30 a.m. and 4:24 p.m., resident lying in bed with oxygen in use at one lpm, via N/C. Observation on 2/15/2023 at 11:35 a.m., resident lying in bed with oxygen at one lpm, via N/C. Observation and interview on 2/15/2023 at 12:05 p.m. with Licensed Practical Nurse (LPN) SS, verified the oxygen flow rate was set on one liter. She stated to surveyor is he ordered for two liters? Interview on 2/16/2023 at 11:45 a.m. revealed that nurses should be signing on the EMR after they have confirmed the oxygen rate is set as ordered. Based on observations, resident and staff interviews, and review of facility polices, the facility failed to ensure respiratory care was provided in accordance with standards of nursing practice for two of 13 residents (R) receiving oxygen therapy. Specifically, the facility failed to change the oxygen nasal cannula for R#37 and failed to administer oxygen at prescribed flow rate for R#51. Findings include: Review of the facility policy titled, Skilled Inpatient Services: Use of Oxygen Therapy reviewed 12/4/2021, revealed the intent is to ensure that patients maintain optimal oxygenation via the proper oxygen device and concentration when appropriate and medically indicated. The nasal cannula should be changed every month and as needed. 1. Review of the clinical record revealed R#37 was admitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, and obstructive sleep apnea (OSA). Review of the admission Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. Review of the February Physician Orders revealed an order dated 1/12/2023 for oxygen via N/C at three lpm nasally every eight hours. Observation and interview on 2/13/2023 at 11:50 a.m. R#37 revealed the oxygen nasal cannula (N/C) was undated. The oxygen concentrator was set at three liters per minute (lpm) with the humidification bottle half full and undated. The resident stated the nasal cannula was the same one he came from the hospital with. Observations/interviews on 2/14/2023 at 10:43 a.m. and 2/15/2023 at 2:20 p.m., revealed N/C remained undated and resident stated no-one has changed the nasal cannula. Interview on 2/15/2023 at 8:52 a.m. Certified Nursing Assistant (CNA) GG stated he had been a CNA for over 32 years. He stated he usually works on the 100 Unit but was also responsible for changing out and/or cleaning the respiratory supplies throughout the facility, including changing out the oxygen nasal cannulas monthly. During further interview regarding R#37 report of using the same nasal cannula that he came from the hospital with, CNA GG replied that he did not know the resident was on oxygen. He stated it was an oversight. He further stated he assumed the responsibility for the respiratory supplies on 2/2/2023 and he now has access to residents receiving respiratory therapy, to track when supplies need to be changed. Interview on 2/16/2023 at 9:46 a.m., R#37 stated a man changed his nasal cannula last night and it felt much better.

Based on resident and staff interviews and review of facility policy titled Orientation, Training, and Competency, the facility failed to ensure staff was competent related to maintaining resident Bilevel Positive Airway Pressure (BiPAP) units used in the facility. The census was 75. Findings include: Review of the facility policy titled, Orientation, Training, and Competency reviewed 12/30/2022 revealed the intent of this center to establish an orientation plan, training schedule, and a defined set of competencies to promote well-trained associates for the position. Guideline: Competencies should be based on the center assessment Associates should complete competencies based on job duties and needs Education/training is provided routinely/covering various topics A record of learning for each associate will be maintained Organizational support may provide additional trainings through meetings, phone calls, emails, and webinars Review of CPAP [Continuous Positive Airway Pressure] Cleaning Instructions-How to properly clean your CPAP machine at https://comprehensivesleepcare.com/cpap-cleaning-instructions/ and CPAP Cleaning Instructions at www.mercyhme.com revealed the humidifier chamber should be washed in soapy water, rinsed well, and allowed to air dry. Interview on 2/15/2023 at 8:52 a.m. Certified Nursing Assistant (CNA) GG stated he had been a CNA for over 32 years. He stated he usually worked the 3-11 and 11-7 shifts as double shifts on 12-day stretches then off for two days. He stated he usually works on the 100 Unit but was also responsible for changing out and cleaning the respiratory supplies throughout the facility as follows: 1. Weekly (Wednesday nights): wash out the PAP humidifier chamber with soap and water and dries it with a dry wipe. He stated that's the way he's always done it. 2. Every three months: change out PAP humidifier chambers. He stated he recently found out he could order replacement PAP humidifier chambers. During continued interview, he stated he did not receive any formal inservice training for these responsibilities but relied on his experience as a CNA and verbal recommendations from the Corporate Respiratory Therapy Consultant (CRTC). Interview on 2/16/2023 at 4:45 p.m., the Administrator stated she was unaware that CNA GG did not receive inservice training from the Respiratory Consultant.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff interviews, and review of the facility policy titled Skilled Inpatient Services - ADL Plan of care, the facility failed to follow the care plan for eight residents (R) (R#26, R#35, R#43, R#7, R#23, R#27) related to activities of daily living (ADL), R#19 related to falls, and R#24 related to elevated finger stick blood sugar levels. The sample size was 33. Findings include: Review of policy titled Skilled Inpatient Services ADL Plan of Care reviewed on 12/4/2021 revealed the intent is to develop and communicate patient needs for assistance with ADLs. The policy stated ADLs are assessed on admission for each resident, addressed on the baseline care plan, and communicated to the staff. Nursing is responsible for development of care plan and communication of level of assistance residents require. 1. Review of the clinical record revealed R#26 was admitted to the facility on [DATE] with diagnoses of but not limited to fracture of right femur, blindness, anxiety disorder, major depressive disorder, need for assistance with personal care, muscle weakness, diabetes mellites type 2. The resident's annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was 15, which indicated no cognitive impairment. Review of the care plan updated 2/7/2023 revealed resident has limited mobility related to need for assistance with functional activities of daily living (ADLs). Interview on 2/14/2023 at 2:45 p.m. with CNA MM revealed all residents have a care plan which the CNA's can access to review and obtain the residents functional ability and the assistance level they require. She revealed she makes rounds every two hours and provides incontinent care to residents when needed during rounds. Interview on 2/14/2023 at 3:11 p.m. with CNA NN revealed the residents care plan indicates the level of assistance each resident needs with ADL's. She revealed CNA's make rounds every two hours and all residents who are incontinent are checked during these rounds and perineal care is provided as needed. 4. Review of the clinical record revealed R#27 was admitted to the facility with diagnoses that include but not limited to Alzheimer's Disease, Diseases of gallbladder, recurrent major depressive disorder, hypothyroidism, dysphagia, morbid obesity, chronic viral hepatitis C, and hypertension (HTN). Review of the quarterly MDS 1/1/2023 revealed a BIMS score of 99, which indicates severe cognitive impairment. Review of the Care Plan updated 1/17/2023 revealed the resident has self-care deficit related to the needed for assistance with personal care, needs assistance to clean teeth or dentures, and needs assistance with toileting hygiene. Observation on 2/14/2023 at 10:20 a.m. notification at the head of resident's bed posted by the family as a reminder for the staff to brush resident's teeth and offer fluids. Surveyor unable to locate a toothbrush in residents' room or bathroom. When asked if her teeth had been brushed today, resident shook her head no. Interview on 2/14/2023 at 2:46 p.m. and 2/15/2023 at 10:08 a.m., R#27 denied that staff had provided oral hygiene for her. Interview on 2/15/2023 at 10:09 a.m. CNA EE stated that she did not brush resident's teeth before or after breakfast. She stated that she is aware of the signage indicating residents' teeth needed to be brushed but stated she has never brushed her teeth. 5. Review of the clinical record revealed R#23 was admitted to the facility on [DATE] with diagnoses that include but not limited to systolic (congestive) heart failure, bradycardia, atherosclerotic heart disease of native coronary artery without angina pectoris, chronic obstructive pulmonary disease (COPD), difficulty in walking, need for assistance with personal care, dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the quarterly MDS Quarterly dated 1/11/2023 revealed a BIMS score of five, which indicates severe cognitive impairment. Review of the Care Plan updated 1/27/2023 revealed the resident has self-care deficit related to the needed for assistance with personal care, needs assistance to clean teeth or dentures, and needs assistance with toileting hygiene. Observation on 2/13/2023 at 12:03 p.m. revealed resident was observed with facial hair that was unkempt and not shaved. There was tobacco spit/juice on his facial hair. He had tobacco crumbs and spit juice on his shirt and pants. Resident's fingernails had a dark substance underneath. Observation on 2/14/2023 at 10:08 a.m. and 2:26 p.m. resident observed to be unkempt with long facial hair with tobacco spit and juice in his facial hair. Resident has a large amount of an unknown white substance on his shirt and pants, fingernails remain dirty, hair is disheveled. Observation and interview on 2/15/2023 at 9:51 a.m. R#23 continued to have long facial hair and dirty fingernails. Resident stated he has not been shaved this week or last week. Interview on 2/15/2023 at 10:03 a.m., CNA EE stated R#23 is self-sufficient, but she provides incontinent care for him. CNA EE confirmed that she had not offered R#23 a bath, shave, or to have his fingernails cleaned today. 6. Review of the clinical record revealed R#27 was admitted to the facility with diagnoses that include but not limited to Alzheimer's Disease, Diseases of gallbladder, recurrent major depressive disorder, hypothyroidism, dysphagia, morbid obesity, chronic viral hepatitis C, and hypertension (HTN). Review of the quarterly MDS 1/1/2023 revealed a BIMS score of 99, which indicates severe cognitive impairment. Review of the Care Plan updated 1/17/2023 revealed the resident has self-care deficit related to the needed for assistance with personal care, needs assistance to clean teeth or dentures, and needs assistance with toileting hygiene. Observation on 2/14/2023 at 10:20 a.m. notification at the head of resident's bed posted by the family as a reminder for the staff to brush resident's teeth and offer fluids. Surveyor unable to locate a toothbrush in residents' room or bathroom. When asked if her teeth had been brushed today, resident shook her head no. Interview on 2/14/2023 at 2:46 p.m. and 2/15/2023 at 10:08 a.m., R#27 denied that staff had provided oral hygiene for her. Interview on 2/15/2023 at 10:09 a.m. CNA EE stated that she did not brush resident's teeth before or after breakfast. She stated that she is aware of the signage indicating residents' teeth needed to be brushed but stated she has never brushed her teeth. 7. Review of the clinical record revealed R#19 was admitted to the facility on [DATE] with diagnoses of but not limited to Parkinson's Disease, difficulty in walking, muscle weakness (generalized), need for assistance with personal care, osteoarthritis of knee, cramp and spasm, age-related osteoporosis without current pathological fracture. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. Review of the care plan updated 2/14/2023 indicated resident is a fall risk related to difficulty in walking, generalized muscle weakness, unsteadiness on feet and unsteady gait. The interventions listed includes assess contributing factors related to fall history, place patient in open area for maximum observation, place back to bed, and non-skid strips to both sides of bed. Observation on 2/14/2023 at 10:32 a.m. revealed resident out of bed to wheelchair in her room at the end of the hall. Resident has a walker positioned in front of her. Observation on 2/14/2023 at 12:11 p.m. revealed resident in her room at the end of the hall, sitting in her wheelchair. She was asleep and leaning forward in her wheelchair. Interview on 2/14/2023 at 12:29 p.m. CNA CC revealed she saw resident at approximately 11:45 a.m. sitting in her room in the wheelchair sleepy and nodding off. CNA CC stated that she did not ask resident if she wanted to lie down for a nap or attempt to assist her to another area to be monitored because it just did not dawn on her to do that. CNA CC further stated that she is aware that resident is a high-risk for falls because her name is on the list that she has. Interview on 2/14/2023 at 12:55 p.m. with Director of Nursing Services (DNS) revealed her expectation is that if a resident with a history of falls is in a wheelchair asleep, that the staff should assist the resident to bed. She further stated residents that are high risk for falls be placed in a frequently observed area such as the nurse's station or dining room, to be monitored. 8. Review of the clinical record revealed R#24 was admitted to the facility on [DATE] with diagnoses including congested heart failure (CHF), chronic obstruction pulmonary disease (COPD), acute respiratory failure, diabetes mellitus, and restless leg syndrome. The resident's most recent quarterly Minimum Data Set (MDS) dated [DATE] revealed a BIMS score of nine out of 15, which indicated moderate cognitive impairment. Review of the care plan dated 2/1/2023 revealed resident has diagnosis of diabetes mellitus with persistent elevation in fingerstick blood sugars (FSBS). Interventions to care include administer insulin and/or oral hypoglycemics as ordered and notify Physician as indicated. Interview on 2/16/2023 at 1:58 p.m., the DON verified there was no evidence in the EMR that physician was informed about elevated FSBS on 1/26/2034 and 1/30/2023. Interview on 2/16/2023 at 3:30 p.m. with the DON revealed CNA's can access residents care plan to determine the level of assistance required for each resident. The expectation is that the CNA follow the care plan and provide care for each resident as directed by the care plan. 2. Review of the clinical record revealed R#35 was admitted to the facility on [DATE] with diagnoses to include cerebral vascular accident (CVA) with left hemiplegia, gastroesophageal reflux disease (GERD), and major depressive disorder. Review of the annual MDS dated [DATE] revealed a BIMS score of 15, indicating no cognitive impairment. Review of the Care Plan updated 1/1/2023 revealed the resident has self-care deficit related to the need for assistance with personal care, needs assistance to clean teeth or dentures, and needs assistance with toileting hygiene. Observation/interview on 2/15/2023 at 11:03 a.m., R#35., she stated she did not receive a shower yesterday. Observation/interview with R#35 on 2/16/23 at 3:55 p.m., she stated she had not received a shower this week, although she did get a bed bath yesterday. Interview on 2/15/2023 at 10:00 a.m., LPN JJ stated staff should be making rounds every two hours and as needed to provide care and service. 3. Review of the clinical record revealed R#43 was re-admitted to the facility on [DATE] with diagnoses to include sacral pressure ulcer, difficulty in walking, generalized muscle weakness, unsteadiness on feet, and need for assistance with personal care. Review of the admission MDS dated [DATE], revealed a BIMS of 11, indicating mild cognitive impairment. Review of the care plan dated 2/5/2023 revealed the resident has a self-care deficit related to a need for assistance with personal care and needs assistance with toileting hygiene. Interview on 2/15/2023 at 10:40 a.m., LPN II stated staff should make resident rounds every two hours and as needed and answer call lights as soon as possible. Interview on 2/15/2023 at 1:40 p.m., CNA HH stated staff should make resident rounds every two hours and as needed to provide a check and change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, and review of the policy titled Skilled Inpatient Services -ADL Plan of Care, the facility failed to provide activities of daily living (ADL) care for six residents (R) (R#26, R#35, R#43, R#23, R#27, R#7). The sample size was 33. Findings included. Review of the policy titled Skilled Inpatient Services -ADL Plan of Care dated 12/4/2021, indicated the intent is to develop and communicate patient needs for assistance with ADLs. Guideline: Nursing develops the patient's ADL care plan and will communicate the level of assistance required for the patient. 1. Review of the clinical record revealed R#26 was admitted to the facility on [DATE] with diagnoses of but not limited to fracture of right femur, blindness, anxiety disorder, major depressive disorder, need for assistance with personal care, muscle weakness, diabetes mellites type 2. The resident's annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was 15, which indicated no cognitive impairment. Section G revealed that the resident was assessed for extensive to total dependance with one to two-person assistance required for activities of daily living (ADL). Section F indicated it was very important for resident to choose between a tub bath, shower, bed bath, or sponge bath. Review of the care plan updated 2/7/2023 revealed resident has limited mobility related to need for assistance with functional activities of daily living (ADLs). Interventions to care include assist with ADLs as needed and provide level of assistance to promote safety. Review of grievances filed by resident on 8/9/2202 revealed resident stated he did not receive a bed bath as scheduled; and on 2/6/2023 resident stated staff was rushing to complete his bed bath. Review of the grievances revealed resident was satisfied with the outcome of each grievance. Review of Facility Reported Incident dated 11/3/2022 indicated resident stated he is being neglected by staff by not responding to the call-light and not taking care of him at night in a timely manner. Facility investigation revealed interviews from staff assigned to care for resident and other residents. There is no documentation regarding the outcome of the facilities investigation into this complaint of neglect. Review of the weekly shower schedule provided by the Director of Nursing (DON) revealed R#26 was bathed one time the week of 1/23/2023, none the week of 1/30/2023, one time the week of 2/6/2023, and as of 2/15/2023 no baths were recorded for the week of 2/12-2/18/2023. Interview on 2/14/2023 at 2:52 p.m. with Licensed Practical Nurse (LPN) JJ stated if a resident is requesting care, the CNA assigned to that resident is notified of residents need. During further interview, LPN JJ stated if the assigned CNA is unable to attend to the resident, then the person who answered the call light would tend to the resident's request/needs. Interview on 2/14/2023 at 2:45 p.m. with CNA MM revealed she makes rounds every two hours and provides incontinent care to residents when needed during rounds. She stated R#26 receives his baths on Monday's and Fridays. During further interview, she stated she was unaware of a bath log or where to locate documentation of baths. Interview on 2/14/2023 at 3:11 p.m. with CNA NN revealed CNA's make rounds every two hours and all residents who are incontinent are checked during these rounds and perineal care is provided as needed. During further interview she stated there is a bath schedule posted at the nursing desk. She stated all baths and care given should be documented in the EMR. Interview on 2/14/2023 at 4:17 p.m. with CNA/CMA CC revealed there is a shower sheet kept in the shower room, but she was unsure if anyone documents on it. She stated they obtain a vital sign sheet and as they complete baths, they mark it on this sheet and at the end of shift they place this sheet under the DON's office door. Interview on 2/15/2023 at 3:30 p.m. with the DON revealed there is no documentation in the EMR for R#26 receiving a bath. She stated she is aware that the CNA's are not documenting care provided and has been providing education to them regarding documenting the care provided to residents. During further interview, she stated if residents refuse their bath, they should be documenting the refusal, and the resident should be care planned for refusal of care. She stated her expectation is that when care is given, the CNA should chart care in the EMR. 6. Review of clinical record revealed R#7 was admitted to the facility on [DATE] with diagnoses that include but are not limited to absence epileptic syndrome, moderate intellectual disabilities, schizoaffective disorder, depressive, type 2 diabetes mellitus, and muscle weakness. Review of the quarterly MDS 11/18/2022 revealed a BIMS score of five, which indicates severe cognitive impairment. Section G revealed resident is total dependent on two-persons ADL care. Section F indicated it was very important for resident to choose between a tub bath, shower, bed bath, or sponge bath. Review of the Care Plan updated 12/2/2022 revealed the resident has self-care deficit related to the needed for assistance with personal care, needs assistance to clean teeth or dentures, and needs assistance with toileting hygiene. Interventions to care include encourage resident to participate in ADLs and praise accomplishments, give as many choices as possible about care, assist with ADLs as needed, break tasks down into manageable segments, and refer to ADL POC for levels of assistance needed. Observation on 2/13/2023 at 11:10 a.m. revealed resident was in the bed, with eyes open and head of bed up. Her fingernails were dirty with brown substance and her gown was dirty. Observation on 2/14/2023 at 10:28 a.m. revealed resident in the bed, gown is still dirty, and fingernails are still dirty. Observation on 2/14/2023 at 4:22 p.m. residents' gown was still dirty, fingernails were dirty with dark substance and fingers dirty with Cheetos cheese powder. Observation on 2/15/2023 at 11:31 a.m., Resident's gown was clean, but her fingernails were still dirty. Interview on 2/15/2023 at 12:15 p.m., CNA TT verified R#7's fingernails were dirty. She stated resident got a bed bath this morning. She stated that she should have soaked her fingernails to clean and trim them. Interview on 2/15/2023 at 4:11 p.m. DON revealed that nail care, mouth care, and shaving are activities of daily living and should be completed during baths and/or showers. She also stated the CNAs should be completing shower sheets to indicate the care provided. During further interview, she indicated if residents room number is crossed out on the shower sheet, it means the bath or shower was completed, it the room number is circled, it was refused by the resident, and if the room number was left alone, nothing was not done at all. 4. Review of the clinical record revealed R#23 was admitted to the facility on [DATE] with diagnoses that include but not limited to systolic (congestive) heart failure, bradycardia, atherosclerotic heart disease of native coronary artery without angina pectoris, chronic obstructive pulmonary disease (COPD), difficulty in walking, need for assistance with personal care, dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the quarterly MDS Quarterly dated 1/11/2023 revealed a BIMS score of five, which indicates severe cognitive impairment. Section G revealed resident is total dependent of two-persons for bathing and personal hygiene. Section F was incomplete for preferences for care. Review of the Care Plan updated 1/27/2023 revealed the resident has self-care deficit related to the needed for assistance with personal care, needs assistance to clean teeth or dentures, and needs assistance with toileting hygiene. Interventions to care include assist with ADLs as needed, assist with oral hygiene after meals and as needed, assist with showers/baths, and refer to ADL POC for levels of assistance needed. Review of the Unit Three Weekly Shower Schedules dated 1/23/2023 through 2/12/2023 revealed R#23 was scheduled for showers twice weekly on Tuesday and Friday, with Sunday as the make-up day, to double check nails and trim. The shower schedules documented he received a bed bath on 2/6/2023. There were no refusals documented. Review of the ADL documentation in the EMR revealed one documented bath on 1/19/2023. The DON confirmed there was no other documentation for showers/baths. Review of nurse's progress notes from 1/1/2023 through 2/15/2023 revealed no documentation regarding refusal of ADL care or baths/showers. Observation on 2/13/2023 at 12:03 p.m. revealed resident sitting in his wheelchair watching television. He was observed with facial hair that was unkempt and not shaved. There was tobacco spit/juice on his facial hair. He also had tobacco crumbs and spit juice on his shirt and pants. Resident's fingernails had a dark substance underneath. Observation on 2/14/2023 at 10:08 a.m. and 2:26 p.m. resident observed out of bed sitting in the wheelchair. Resident observed to be unkempt with long facial hair with tobacco spit and juice in his facial hair. Resident has a large amount of an unknown white substance on his shirt and pants, fingernails remain dirty, hair is disheveled. Observation and interview on 2/15/2023 at 9:51 a.m. R#23 continued to have long facial hair and dirty fingernails. Resident stated he has not been shaved this week or last week. He stated that he likes to be bathed in the bed but has not had a bath because they don't do anything to help him. During further interview, resident stated that his fingernails are cleaned when he gets his bath but stated he has not had a bath in a while. Interview on 2/15/2023 at 10:03 a.m., CNA EE stated R#23 is self-sufficient, but she provides incontinent care for him. She stated resident was already out of bed when she arrives for her shift. She stated she had not looked at the shower sheet to see if R#23 needed to be showered, shaved, or his fingernails cleaned, but she provided incontinent care. CNA EE stated resident refuses care at times, and when he does, she asks a second time, if he continues to refuse, she reports the refusal to the nurse. CNA EE confirmed that she had not offered R#23 a bath, shave, or to have his fingernails cleaned today. Interview on 2/15/2023 at 9:47 a.m., the ADON after reviewing this week's bath/shower sheets, confirmed that CNAs have not documented shower or bed baths done for this week. She stated that she and Director of Nursing (DON) are responsible for checking the shower sheets for compliance. During further interview, she stated she has not had the opportunity to check the sheets this week. Interview on 2/15/2023 at 10:27 a.m. with LPN JJ, revealed he has worked on the 300 hall all week. He stated the CNAs had not reported refusal of care for R#23 for this week. He further stated that if a R#23 refuses care, he will talk to him and encourages resident to comply, and stated he usually he does. During further interview, LPN JJ stated that if a resident refuses care, it is documented in the nurse's progress notes. Observation and interview on 2/15/2023 at 10:36 a.m., DON verified that R#23 hair had not been combed, his fingernails were not clean, and he had not been shaved. She stated that resident sometimes refuses care, but it should be documented by the CNAs and the Nurses. During further interview, she stated R#23 dips tobacco and that has caused his hygiene issues, but stated the staff should be offering to clean him up. R#23 agreed to receive a bed bath and shave at this time. The DON concluded that the implemented process for ADL care and showers is not working and will have to be revised. 5. Review of the clinical record revealed R#27 was admitted to the facility with diagnoses that include but not limited to Alzheimer's Disease, Diseases of gallbladder, recurrent major depressive disorder, hypothyroidism, dysphagia, morbid obesity, chronic viral hepatitis C, and hypertension (HTN). Review of the quarterly MDS 1/1/2023 revealed a BIMS score of 99, which indicates severe cognitive impairment. Section G revealed resident is total dependent on two-persons ADL care. Section F was incomplete for preferences for care. Review of the Care Plan updated 1/17/2023 revealed the resident has self-care deficit related to the needed for assistance with personal care, needs assistance to clean teeth or dentures, and needs assistance with toileting hygiene. Interventions to care include assist with ADLs as needed and refer to ADL POC for levels of assistance needed. Review of the EMR ADL documentation revealed there is not a specific area where mouth care is documented. Observation on 2/14/2023 at 10:20 a.m. notification at the head of resident's bed posted by the family as a reminder for the staff to brush resident's teeth and offer fluids. Surveyor unable to locate a toothbrush in residents' room or bathroom. When asked if her teeth had been brushed today, resident shook her head no. Interview on 2/13/2023 at 1:26 p.m. resident's daughter stated the staff does not brush her mother's teeth. She stated that she posted signs in the resident's room to remind staff to brush her mother's teeth and they still do not brush her teeth. During further interview, daughter stated resident had two teeth removed for lack of oral care by the facility. Interview on 2/14/2023 at 2:46 p.m. and 2/15/2023 at 10:08 a.m., R#27 denied that staff had provided oral hygiene for her. Interview on 2/15/2023 at 10:09 a.m. CNA EE stated that she has provided feeding assistance, incontinent care and obtained vital signs for R#27 today. CNA EE stated did not brush resident's teeth before or after breakfast. She stated that she is aware of the signage indicating residents' teeth needed to be brushed but stated she has never brushed her teeth. At this time, CNA EE searched residents' room for a toothbrush and located an unused toothbrush and verified the toothbrush was new and has never been used. The CNA verified that R#27 had not refused mouth care, and stated she has never offered to brush her teeth for her. Interview on 2/15/2023 at 1:35 p.m., Social worker (SW) revealed that she is responsible for the Dental Services at the facility. She stated that the residents receive dental services through [provider], and revealed they visited the facility on 1/17/2023. She stated that R#27 was seen at that time and will be seen at the next scheduled visit for extractions. The SW stated the CNAs working on the floor are responsible for making sure resident's teeth are brushed and this is a part of their ADL care. Interview on 2/15/2023 at 10:29 a.m., DON revealed that she was not aware that resident was not receiving oral hygiene and that R#27 should have her teeth brushed in the mornings and after each meal. Telephone interview on 12/16/2023 at 10:09 a.m. Hospice Aide (HA) FF stated that R#27 has been on her caseload since 2021. She stated that she provides care R#27 two-three times per week. During further interview, HA FF stated she uses lemon glycerin swabs to clean residents' mouth when needed, but stated she has never brushed her teeth. 2. Review of the clinical record revealed R#35 was admitted to the facility on [DATE] with diagnoses to include cerebral vascular accident (CVA) with left hemiplegia, gastroesophageal reflux disease (GERD), and major depressive disorder. Review of the annual MDS dated [DATE] revealed a BIMS score of 15, indicating no cognitive impairment. Section G revealed she required total care of two-persons for all activities of daily living (ADLs). Section F indicated it was very important for resident to choose between a tub bath, shower, bed bath, or sponge bath. Review of the Care Plan updated 1/1/2023 revealed the resident has self-care deficit related to the need for assistance with personal care, needs assistance to clean teeth or dentures, and needs assistance with toileting hygiene. Interventions to care include assist with ADLs as needed, refer to ADL POC for levels of assistance needed. Review of the Unit Three Weekly Shower Schedules dated 1/23/2023 through 2/12/2023 revealed R#35 was scheduled for showers twice weekly on Tuesday and Friday. The shower schedules documented she received showers on 1/24/2023, 2/6/2023, and 2/9/2023. There were no refusals documented. Observation/interview on 2/13/2023 at 11:35 a.m. R#35 in her room, stated she has had to wait for toileting and ADL care from one to one and half hours. Observation/interview on 2/14/2023 at 11:19 a.m., R#35 stated she had one shower last week, but stated they had not been consistent, and she did not receive bed baths. Observation/interview on 2/15/2023 at 11:03 a.m., R#35., she stated she did not receive a shower yesterday. Observation/interview on 2/16/23 at 3:55 p.m., R#35 stated she had not received a shower this week, although she did get a bed bath yesterday. Interview on 2/13/2023 at 1:35 p.m., CNA VV and CNA WW stated residents were scheduled for showers twice a week. Further interview revealed they had not given any showers so far today. They stated they should report all refusals or omissions to the nurse. Interview on 2/15/2023 at 10:00 a.m., LPN JJ stated staff should be making rounds every two hours and as needed to provide care and service. He stated showers should be given twice a week and as needed. He stated staff should report refusals to the nurse who should check the resident and confirm the refusal and try to talk the resident into accepting care. During further interview, he stated no one reported to him that R#35 refused a shower or that the shower was omitted. 3. Review of the clinical record revealed R#43 was re-admitted to the facility on [DATE] with diagnoses to include sacral pressure ulcer, difficulty in walking, generalized muscle weakness, unsteadiness on feet, and need for assistance with personal care. Review of the admission MDS dated [DATE], revealed a BIMS of 11, indicating mild cognitive impairment. Section G revealed resident was total dependence of two-persons for all ADLs. Section F indicated it was very important for resident to choose between a tub bath, shower, bed bath, or sponge bath. Review of the care plan dated 2/5/2023 revealed the resident has a self-care deficit related to a need for assistance with personal care and needs assistance with toileting hygiene. Interventions to care include assist with ADLs as needed and see ADL POC for assistance levels. Review of the Unit One Weekly Shower Schedules dated 1/23/2023 through 2/12/2023 revealed R#43 was scheduled for showers twice weekly on Wednesday and Saturday. The shower schedules revealed he had not received any showers and there were no refusals documented. Interview on 2/14/2023 at 2:20 p.m., R#43 revealed he could not remember the last time he had a shower. Interview on 2/15/2023 at 10:25 a.m., R#43 stated he still had not had a shower. Interview on 2/15/2023 at 10:40 a.m., LPN II stated staff should make resident rounds every two hours and as needed and answer call lights as soon as possible. She stated showers are scheduled twice a week. She stated if a resident refused a shower, the staff should report it to the nurse and document on the shower sheet. Interview on 2/15/2023 at 1:40 p.m., CNA HH stated staff should make resident rounds every two hours and as needed to provide a check and change. She stated she tries to give her residents bed baths daily and tries to get her residents their scheduled showers if time and staffing permit. Interview on 2/15/2023 at 9:47 a.m., Assistant Director of Nursing (ADON) reviewed the Weekly Shower Schedules beginning 1/23/2023 through 2/12/2023. She stated staff document showers performed by crossing out the room number, refusals with a circle around the room number, and leaving the room number undisturbed if the shower was omitted. During further interview, she stated she and the DON are responsible for checking the shower sheets for compliance because they recognized either a lack of showers performed and/or a lack of documentation. She concluded that they had not had the opportunity to check the shower sheets for this week.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, and review of facility policies, the facility failed to implement an effective Infection Control Program to prevent the spread of infections by not ensuring staff practiced infection control standards during wound care for two residents (R) (R#43 and R#71) and by not storing respiratory supplies properly for one resident (R#18). The census was 75. 1. Review of the policy titled Skilled Nursing Services Wound Care revised 10/11/2022 revealed the intent is to provide guidelines for clean technique in providing wound care. Start with a clean surface and a clean tray, using approved cleanser and observing appropriate wet times. Cover the tray with an impervious barrier. Prepare the supplies on the tray with the barrier. Upon entering room, place tray on a clean surface. If the resident is soiled, wound care should not be completed until the resident is clean. Review of the clinical record revealed R#43 was re-admitted to the facility on [DATE] with diagnoses to include sacral pressure ulcer, difficulty in walking, generalized muscle weakness, unsteadiness on feet, and need for assistance with personal care. Review of the admission MDS dated [DATE], revealed a BIMS of 11, indicating mild cognitive impairment. Section G revealed resident was total dependence of two-persons for all ADLs. Section M revealed four stage two pressure ulcers. Review of the resident's care plan reviewed 1/19/2023 revealed resident is at risk for skin breakdown, stage three pressure ulcer to sacral region. Interventions to care include referral for wound care and treatment/dressings as ordered. Observation on 2/14/2023 at 10:52 a.m. wound care with Treatment Nurse/Registered Nurse (RN) KK assisted by Licensed Practical Nurse (LPN) WW for R#43, revealed RN KK prepared a tray with a barrier, gathered supplies, and placed them on the tray, knocked on resident's door explained the procedure and obtained permission to proceed. The RN KK set up wound care tray on residents' bedside table. He did not remove any items from the bedside table and did not clean the bedside table before placing the tray onto the bedside table. He placed the tray on the bedside table next to residents' 20-ounce soda. He proceeded with dressing change. Hand hygiene was performed, and gloves donned, and doffed appropriately throughout the procedure. Wound treatment completed per orders, removed gloves, and performed hand hygiene. He donned clean gloves, removed, and secured trash bag, and placed new trash bag in trash can. Interview on 2/14/2023 at 11:00 a.m., RN KK confirmed he did not clean the bedside table prior to placing the wound care tray on it, and stated he should have removed residents belongings from the bedside table prior to starting the dressing change. At this time, LPN WW verified and confirmed that the bedside table was not cleansed, and residents' soda and other belongings were not removed from the bedside table prior to the dressing change. During further interview, both nurse's acknowledged the bedside table should have been cleaned and residents' personal items should have been removed, and a barrier applied to the table prior to placing dressing supplies on the table. Interview on 2/16/2023 at 1:00 p.m., the Director of Nursing (DON) revealed the wound care nurse should prepare the surface in which they plan to use to set their supplies on. This includes removing of items from the table, clean surface, use a covered tray which they bring the supplies into the room on, and place covered tray onto a clean work area. 2. Review of the clinical record revealed R#71 was admitted to the facility on [DATE] with diagnoses including fracture of left femur, difficulty in walking, muscle weakness, unsteadiness on feet, need for assistance with personal care, and Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 99, indicating severe cognitive impairment. Section G revealed she was totally dependent on staff for all care. Section M revealed one stage three pressure ulcer. Review of the resident's care plan reviewed 12/29/2022 revealed resident is at risk for skin breakdown, stage three pressure ulcer to sacral region. Interventions to care include referral for wound care and treatment/dressings as ordered. Observation on 2/14/2023 at 12:39 p.m. wound care with RN KK, prepared bedside table with facility approved wipes prior to procedure, then applied a barrier to the table. RN KK performed hand hygiene and obtained supplies needed for dressing change and placed on a tray with a barrier cover. He entered residents' room and placed tray of supplies with barrier on bedside table. He performed hand hygiene, donned gloves, and assessed resident for pain. RN KK removed soiled dressing and resident began displaying nonverbal cues of pain. He stopped treatment to reassess resident for pain. He determined the resident could not tolerate further treatment at this time. It was noted during the removal of the soiled dressing, that resident had dark green soft bowel movement. RN KK reapplied residents depends without performing peri-care or applying a dressing or covering the sacral wound. RN KK communicated to surveyor that next dose of pain medication could be given at 5:00 p.m. at which time he would finish dressing change. Interview on 2/14/2023 at 1:15 p.m. RN KK stated he was concerned about whether it was appropriate to leave the sacral wound uncovered when replacing the brief, when resident was in pain and unable to tolerate the dressing change. Observation on 2/14/2023 at 1:30 p.m., DON and RN KK returned to R#71's room to verify that dressing was not applied to the resident's sacral wound with stool in the depend. Peri-care was performed, and RN KK assessed resident's pain level, and wound care was provided appropriately. Interview on 2/14/2023 at 1:36 p.m., the DON stated her expectation when residents are having pain is the dressing change should be stopped, and stated the wound should not be left uncovered, or covered with a depend. She stated she expects peri-care be done and then reattempt to perform wound care. 3. Review of the clinical record revealed R#18 was admitted to the facility on [DATE] with diagnoses including but not limited to cerebral palsy, pulmonary embolism with acute cor pulmonale, obstructive sleep apnea (OSA), retention of urine, glaucoma, essential (primary) hypertension, hyperglyceridemia, major depressive disorder, and Hyperlipidemia. Review of quarterly MDS dated [DATE], revealed a BIMS score of 15, indicating no cognitive impairment. Section G was coded total dependence for ADLs. Section O indicated the use of BIPAP. Review of the care plan initiated on 12/16/2022, revealed resident had respiratory difficulties/risk for further decline related to BIPAP and diagnosis of other pulmonary embolism with acute cor pulmonale and obstructive sleep apnea. Approaches to care include BIPAP as ordered. Review of February Physician Orders (PO) revealed an order dated 2/28/2022 for BiPAP at bedtime IPAP 24---EPAP 14---RR 16. Observation on 2/14/2023 at 2:21 p.m. and 2/15/2023 at 1:41 p.m. revealed R#18's BIPAP mask lying his bed unbagged, uncovered, and exposed to the environment. Interview on 2/14/2023 at 2:45 p.m., R#18 stated he wears the BIPAP at night and stated his mask or tubing has not been cleaned in the last three months, since the respiratory therapist left. Resident stated that the staff does not clean the tubing or the mask of his BIPAP regularly. He stated that the mask is supposed to be washed at least weekly with soap and water but stated they don't ever do it. Interview on 2/15/2023 at 1:46 p.m., LPN II stated the CNAs are responsible for assisting residents with removal and storage of BIPAP mask. She confirmed that BIPAP masks should be kept in a bag when not in use. LPN II verified R#18's BIPAP mask to be lying on the bed, unbagged, uncovered, and exposed to the environment. Interview on 2/15/2023 at 1:52 p.m., CNA HH revealed that she assisted R#18 out of bed around 10:00 a.m. this morning. She stated that she placed that BIPAP mask on the bed, while she was assisting resident with ADLs. During further interview, she stated there is someone assigned to wash the mask and she does not have to deal with the BIPAP mask that much. She stated, Honestly I only clean the BIPAP mask if resident asks me to do so, for instance if it falls on the floor. CNA HH stated that she does not store the mask when it is not in use. Interview on 2/15/2023 at 2:00 p.m., DON revealed that the respiratory consultant comes to the facility every three months and changes the filters and checks the tubing of the BIPAP for wear and tear. During further interview, she stated that CNAs change and clean the tubing every Wednesday night and revealed the BIPAP mask should be stored in a bag when not in use.

Based on observations, record review and staff interviews, the facility failed to ensure that all items on the kitchen tray line, specially ground pork, were held at the appropriate temperature to prevent food born illness which effected 20 residents who received ground meats. Findings include: Review of policies entitled, Food Preparation and Distribution, updated February 2019 revealed that a temperature monitoring log will be maintained throughout meal service hot foods will be held at greater or equal to 135 degrees Farenheit (F), cold foods will be held at less or equal to 41 degrees F, while frequently monitoring temperatures during meal service, if any temperature is determined to be out of ranger, corrective action will take place (hot items will be pulled from the tray line and re-heated until an internal temperature of 165 degree F for 15 seconds is reached; cold items will be pulled from the tray line and placed into an ice bath, cooler, freezer, or blast chiller until 41 degrees or lower is reached; and items will be re-checked and proper temperature verified before beginning to serve. Observation and interview of the main kitchen tray line temperature taken by Food Service Aide (FSA) AA with the facilities calibrated thermometer on 1/23/20 between 6:24 p.m. through 6:39 p.m., revealed that the ground pork had a temperature of 130 degrees F. Interview with FSA AA at this time revealed that he was unsure how many ground pork have been served so far. An interview with Dietary Manager on 1/24/20 at 12:51 p.m. revealed the facility has in-services monthly, and she expects that staff identify when temps are not correct and pull food and not serve any food at a temperature that is too low or too high.