Based on record review, interviews, and review of the facility's policy titled, Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, the facility failed to ensure allegations of abuse were reported timely to the state agency (SA) for one of three residents (R) (R) (R49) reviewed for abuse out of a total sample of 33. This had the potential to affect resident safety in the facility. Findings include: Review of the facility's policy titled, Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, reviewed 11/15/2024, revealed, The state survey agency and the stated agency for adult protective services should be notified in accordance with state law through established procedures of any allegations of abuse, neglect, exploitation or mistreatment . within 2 hours after the allegation is made if the events upon which the allegation is based involved abuse . Review of R49's Resident Face Sheet tab of the electronic medical record (EMR) revealed R49 was admitted with diagnoses that included schizophrenia, depression, bipolar disorder, and altered mental status. Review of R49's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/7/2025 and located under the RAI [Resident Assessment Instrument] MDS 3.0 Assessment tab of the EMR, revealed R49 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated R49 was cognitively intact. During an interview on 6/10/2025 at 9:29 am, R49 was asked if she had been abused. She stated Yes, verbally. She stated a night nurse was not allowed to come into the room. She stated she reported the incident to the Administrator. She stated the nurse [Certified Nurse Assistant (CNA) 1] came in and asked her if she could change her diaper and told her to get my ass off the phone. Review of the grievance complaint form, dated 2/20/2025 and provided by the facility, revealed R49 stated she felt like CNA1 was being rude to her. The form recorded, . She was rude to me, and I felt like it could be considered abuse . Adm [Administrator] spoke to roommate and she didn't hear staff being mean, just asked her to get off her phone . During an interview on 6/11/2025 at 11:47 am, the Administrator confirmed the grievance revealed it could be considered an allegation of abuse as written on the grievance form from the resident at the time of the incident. She confirmed the allegation was not reported before she initiated an investigation. During an interview on 6/11/2025 at 12:01 pm, the Administrator confirmed the grievance was marked 2/20/2025, and she stated that was when it was reported to her. She acknowledged she did not know the exact date the incident occurred. During an interview on 6/11/2025 at 3:43 pm, the Administrator stated the grievance was originally absent of the date and she just filled in 2/20/2025. She stated she thought the incident occurred back in January 2025 but was unsure of the date. During an interview on 6/12/2025 at 9:00 am, the Administrator confirmed she was the abuse coordinator. At 9:51 am, the Administrator stated the allegation was not reported.

Based on record review, interviews, and review of the facility's policy titled, Investigation of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, the facility failed to ensure allegations of abuse were thoroughly investigated for one of three Residents (R) (R49) reviewed for abuse out of a total sample of 33. This had the potential to affect resident safety at the facility. Findings include: Review of the facility's policy titled, Investigation of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, reviewed 11/15/2024, revealed, The Administrator of the provider is responsible for assuring that an accurate and timely investigation is completed . Documentation of the investigation should include, but not be limited to, the following: Date and time of alleged occurrence. Patient's full name and room number. Names of accused and any witnesses. Names of [facility] partners staff who investigated the allegation. Any physical evidence and description of emotional state of patient. Details of the alleged incident and injury. Signed statements from pertinent parties; Cognitive status of victim and patient who are witnesses; information gathered from the investigation. Action taken by the provider; The conclusions reached by the investigator; Name, address, and phone number of the responsible party and relatives of the victim's; and any other police or ombudsman reports or other documentation related to the investigation. For investigations when the alleged perpetrator is a CNA [Certified Nurse Assistant] or a licensed staff person, the following should also be included in the documentation of the investigation: initial employment application; certification letter; copies of personnel action taken by the provider; if applicable; a current address and phone number; social security number; and professional license number, if applicable . Review of R49's Resident Face Sheet tab of the electronic medical record (EMR) revealed R49 was admitted with diagnoses that included schizophrenia, depression, bipolar disorder, and altered mental status. Review of R49's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/7/2025 and located under the RAI [Resident Assessment Instrument] MDS 3.0 Assessment tab of the EMR, revealed R49 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated R49 was cognitively intact. During an interview on 6/10/2025 at 9:29 am, R49 was asked if she had experienced any abuse. She stated, Yes, verbally. She stated a night nurse was not allowed to come into the room. She stated she reported the incident to the Administrator. She stated the nurse [Certified Nurse Assistant (CNA) 1] came in and asked her if she could change her diaper and told her to get my ass off the phone. She stated there had been no issues since then. She stated she was not told what the resolution was. She stated she was told CNA1 was going to be written up. Review of the grievance complaint form, dated 2/20/2025 and provided by the facility, revealed R49 stated she felt like CNA1 was being rude to her. It was recorded, . She was rude to me, and I felt like it could be considered abuse . Adm [Administrator] spoke to roommate and she didn't hear staff being mean, just asked her to get off her phone . During an interview on 6/11/2025 at 11:47 am, the Administrator confirmed the grievance could be considered abuse as written on the grievance form from the resident at the time of the incident. The Administrator stated she talked to the resident, roommate, and the CNA1. She stated R49's roommate did not confirm the allegation. During an interview on 6/11/2025 at 12:01 pm, the Administrator acknowledged she did not know the exact date the incident occurred. During an interview on 6/11/2025 at 3:43 pm, the Administrator stated the grievance was originally absent of the date and she just filled in 2/20/2025. She stated she thought the incident occurred back in January 2025 but was unsure of the date. During an interview on 6/12/2025 at 9:00 am, the Administrator confirmed she had previously started the investigation into the allegation. She stated she interviewed the resident and roommate at the time. She confirmed she was the abuse coordinator. At 9:51 am, the Administrator confirmed there was no documented evidence that additional interviews were completed. She confirmed the only documentation of the incident was on the grievance form. She stated she had not started the new investigation into the allegation that was reported to SA on 6/10/2025, until this day 6/12/2025.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the Face Sheet, located in the EMR under the Resident Dashboard tab, revealed R73 was admitted on [DATE] with diagnoses including cerebrovascular disease, contracture left elbow, contracture left hand, muscle weakness, and abnormal posture. Review of R73'sannual MDS, located in the EMR under the RAI tab and with an ARD of 2/26/2025, revealed a BIMS score of three out of 15, which indicated R73 was severely cognitively impaired. Review of the June 202025 Physician Orders, located in the EMR under the Active Orders tab, identified an order, dated 11/21/2024, that read, Apply L [left] Elbow orthosis to L Elbow and L Resting Hand orthosis to L wrist/hand daily as tolerated, with skin inspection following removal for edema, redness, pain or skin irritation. Review of the OT - Therapist Progress & Discharge Summary, dated 8/1/2024 and located under the Documents tab in the EMR, noted, RESTORATIVE: Apply L Elbow orthosis to L Elbow and L Resting Hand orthosis to L wrist/hand 4-5 hr (hour) daily as tolerated, with skin inspection following removal for edema, redness, pain or skin irritation. On 6/10/2025 at 9:59 am, R73 was asleep in bed. The resident was not observed to have any splints on either hand. His left hand was observed to be contracted. On 6/10/2025 at 2:48 pm, R73 was observed seated in a Geri chair in the lounge. There was no splint on his contracted left hand. On 6/11/2025 at 12:12 pm, R73 was observed in bed, feeding himself, with his right hand, using a built-up spoon and divided plate. The resident had no splint on his contracted left hand. On 6/12/2025 at 2:35 pm, R73 was observed in the Geri chair, in the lounge. He had no splint on his contracted left hand. On 6/12/2025 at 4:43 pm, R73 was observed seated in the Geri chair. There was no splint on his left contracted hand. In an interview on 6/13/2025 at 8:47 am, CNA4 was asked if R73 was to wear a splint on his left hand due to the contracture. CNA4 stated, I'll be honest, I really don't know, but I can find out. I wasn't told to put a splint on [R73]. In an interview on 6/13/2025 at 8:58 am, the DON was asked to provide access to the Restorative Notes in the EMR in order to view if or when a left-hand splint was applied to R73. The DON stated, There are no restorative notes. He does have order. I don't know if he has a splint. In an interview on 6/13/2025 at 9:00 am, the North Unit Manager/Licensed Practical Nurse (UMLPN) stated, All CNAs are trained in Restorative and are expected to apply splints. On 6/13/2025 at 9:00 am, Certified Medication Aide (CMA3), responsible for administering the medications to R73, said she did not know if (R73) had a splint. On 6/13/2025 at 9:03 am, CNA4 said he found only one splint in the resident's room and was able to put it on without R73 refusing. In an interview on 6/13/2025 at 10:22 am, the Occupational Therapist (OT) stated, The primary therapist is responsible for putting the orders in the system. The OT did not know who was responsible for ensuring the orders are transcribed correctly each month. Based on record review, observation, interview, and review of the facility's policy titled, Restorative Nursing Program, the facility failed to ensure Occupational Therapy (OT) recommendations and Care Plan interventions were followed regarding the placement of splints/braces and failed to ensure physician orders were clear as to how long splints/braces were to be applied for three of five Residents (R) (R5, R54, and R73) reviewed for contractures out of a total sample of 33 residents. This had the potential for the residents to have a decline in range of motion and worsening of contractures. Findings include: Review of the facility's policy titled, Restorative Nursing Program, with a revision date of 11/4/2021, revealed, It is the policy of this healthcare center to provide restorative nursing which actively focuses on achieving and to maintain optimal physical, mental, and psychological functioning and wellbeing of the resident . restorative nursing services are provided by Restorative Nursing Assistants (RNAs), Certified Nursing Assistants (CNAs), and other qualified staff . splint or brace assistance - verbal and physical guidance and direction that teaches the resident how to apply, manipulate, and care for a brace or splint; or a scheduled program of applying and removing a splint or brace . restorative nursing care will be documented in the HER [electronic health record] or paper form . 1. Review of R5's Face Sheet, located in the electronic medical record (EMR) under the Face Sheet tab, revealed the resident was admitted with diagnoses that included cerebral palsy, contractures of the left hand, right hand, right elbow, left elbow, muscle weakness, and profound intellectual disabilities. Review of R5's annual Minimum Data Set (MDS), with an assessment reference date (ARD) of 3/8/2025 and located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) could not be completed and she was noted to be severely impaired in cognition. It was also noted that the resident had range of motion impairment in her upper and lower extremities on both sides. Review of R5's OT [Occupational Therapy] Therapist Progress and Discharge Summary, dated 8/2/2024 and located in the EMR under the Documents tab, revealed the resident's treatment diagnoses were contracture of the right elbow, contracture of the left elbow, contracture of the right hand, and contracture of the left hand. Staff was instructed on splint wear precautions, splint application protocols with four to five hours of wear as tolerated from 7:00 am to 7:00 pm with skin check inspections to potentially prevent further contractures. Staff demonstrated knowledge of discharge instructions. Review of R5's Care Plan, with a reviewed date of 3/5/2025 and located in the EMR under the Care Plan tab, revealed the resident required restorative nursing for splints/braces for upper extremities to maintain current range of motion (ROM) and to prevent further contractures. The goal was that the resident would participate with splint/brace for bilateral hand/wrist/elbow splints daily as tolerated with assistance of one staff from 7:00 am to 7:00 pm. Review of R5's active physician's Orders, located in the EMR under the Orders tab, revealed staff were to apply a left elbow orthosis (splint/brace), hand/wrist splints to joints daily as tolerated with skin inspection following the removal. There was no length of time indicated in the physician's orders for how long the splints should remain on. Review of R5's Certified Nurse Aides (CNAs) Restorative documentation, provided by the facility, revealed there was no documented evidence the resident had the splints/braces applied at all on 6/7/2025, on 6/10/2025 it was documented the splints/braces were applied for a total of 45 minutes, and on 6/11/2025 it was documented the splints/braces were applied for a total of 15 minutes. There was no evidence that the resident refused the splints/braces. During an observation of R5 on 6/10/2025 at 1:45 pm, the resident was in bed and both of her hands and left elbow were contracted. There were no splints/braces observed on the resident. R5 was non-verbal. During an observation of R5 on 6/11/2025 at 1:00 pm, the resident was in bed and no splints/braces were observed on the resident. During an interview and observation on 6/12/2025 at 10:30 am, Certified Nursing Assistant (CNA)3 revealed she was the CNA assigned to the care of R5 and had taken care of her numerous times. She confirmed the resident did not have any splints/braces on and that she had never applied any splints or braces on the resident. 2. Review of R54's Face Sheet, located in the EMR under the Face Sheet tab, revealed the resident was admitted to the facility on [DATE] with diagnoses including severe intellectual disabilities and contracture of the left elbow. Review of R54's quarterly MDS, with an ARD of 5/5/2025 and located in the EMR under the MDS tab, revealed a BIMS score could not be completed and she was severely impaired in cognition. It was noted that the resident had range of motion impairment in her upper and lower extremities on both sides. Review of R54's OT [Occupational Therapy] Therapist Progress and Discharge Summary, dated 8/2/2024 and located in the EMR under the Documents tab, revealed the resident's treatment diagnosis was contracture of the left elbow. Staff was instructed on splint wear precautions, left elbow orthosis (brace/splint) application protocols with four to five hours of wear as tolerated from 7:00 am to 7:00 pm with skin check inspections in order to potentially prevent further contractures. Staff demonstrated knowledge of discharge instructions. Review of R54's Care Plan, with a reviewed date of 5/15/2025 and located in the EMR under the Care Plan tab, revealed the resident required restorative nursing for splints/braces to maintain current range of motion (ROM) and to prevent further contractures to her left upper extremity. Review of R54's current physician's Orders, located in the EMR under the Orders tab revealed staff were to apply a left elbow orthosis to the left elbow joint daily as tolerated with skin inspection following removal for redness, edema, and pain. There was no length of time indicated in the physician's orders for how long the splints should remain on. Review of R54's CNA Restorative documentation, provided by the facility, revealed it was documented on 5/24/2025 that R54's left elbow orthosis was not put on at all, on 5/25/2025 it was documented the resident had on the left elbow orthosis for a total of 15 minutes, on 6/10/2025 it was documented the left elbow orthosis was put on the resident for a total of 45 minutes, and on 6/11/2025 it was documented the left elbow orthosis was put on the resident for a total of 15 minutes. There was no evidence that the resident refused the left orthosis. During an observation on 6/10/2025 at 1:05 pm, R54 was in her geri chair (chair used for residents who have difficulty in sitting upright) in the common area with a contracted left elbow. There was no left elbow orthosis observed on the resident. During an observation on 6/11/2025 at 2:00 pm, R54 was again in her geri chair with no left elbow orthosis on her elbow. During an interview and observation on 6/12/2025 at 10:30 am, CNA3 revealed she was the CNA assigned to the care of R54 and had taken care of her numerous times. She confirmed the resident did not have any splints/braces on and that she had never applied any splints or braces on the resident. During an interview on 6/12/2025 at 1:00 pm, the Director of Nursing (DON) revealed CNAs who were assigned to the care of the resident were to apply splints and braces as ordered and per the Care Plan. She revealed the residents' cares were found in the EMR under the documentation tab so the CNAs knew what cares to provide to each resident. During review of R5 and R54's Restorative documentation with the DON, she confirmed there were many times the application of the splints/braces were not documented as being done at all or for not the recommended time of four to five hours for both residents, or any documentation as to why it was not being done. The DON also confirmed the physician's Orders did not have the recommendations from the OT to have the splints/braces applied for a total of four to five hours a day. During an interview on 6/12/2025 at 4:00 pm, the Physical Therapy Assistant (PTA) confirmed both R5 and R54 were to have the splints/braces on four to five hours a day as tolerated between 7:00 am and 7:00 pm.

Based on interviews, record review, and review of the position description for the Director of Health Services, the facility failed to ensure the Director of Nursing (DON) did not serve as the charge nurse unless the facility had an average daily occupancy of 60 or fewer residents. This failure had the potential to affect 90 of 90 residents. Findings include: Review of the position description for the Director of Health Services, provided by the facility and modified 12/2016, revealed the job purpose: Plans, organizes, develops and directs the overall operation of our Nursing Services Department in accordance with current federal, state, and local regulations . Review of the Daily Nursing Assignment, dated 4/19/2025, revealed the DON was scheduled to work as a nurse from 7:00 pm- 7:00 am for south. Review of the Daily Nursing Assignment, dated 4/20/2025, revealed the DON was scheduled to work as a nurse from 7:00 pm - 11:00 pm for south. Review of the Daily Nursing Assignment, dated 5/4/2025, revealed there was a call off for the nurse on the 7:00 pm - 7:00 am shift for north. The DON was scheduled to cover that shift. Review of the Daily Nursing Assignment, dated 5/21/2025, revealed there was a call off for the nurse on the 7:00 pm - 7:00 am shift for south, and the DON was on the schedule to work 11:00 PM- 5:00 AM. Review of the Daily Nursing Assignment, dated 5/24/2025, revealed a call off for a nurse on the 7:00 am - 7:00 pm shift and was replaced by the DON on south. Review of the Daily Nursing Assignment, dated 5/26/2025, revealed the DON was on the schedule as the nurse from 7:00 pm - 11:00 pm shift for south. Review of the Daily Nursing Assignment, dated 6/2/2025, revealed a call off for the nurse on the 7:00 pm - 7:00 am shift, and the DON was on the schedule to replace the nurse for south. During an interview on 6/11/2025 at 10:21 am, the DON stated Yes, she served as the charge nurse depending on the staff shortage, sometimes twice a week. She stated when she was acting as a charge nurse, she was working on a medication cart. She stated staffing was not good and they were short two nurses for day shift and two nurses for night shift. During an interview on 6/11/2024 at 3:43 pm, the Administrator stated they followed the CMS (Centers for Medicare and Medicaid Services) guidelines for staffing, and she was aware of the staffing shortages. She stated she was not aware of the regulatory requirement for the DON, and there was no policy related to it. During an interview on 6/12/2025 at 3:34 pm, the Administrator stated the occupancy at the facility ranged to 72-91 residents and had not been as low as 60 over the past two years.

Based on observations, staff interviews and review of the facility policy titled, Medication Administration: Guideline, the facility failed to ensure that six residents (R6, R7, R11, R12, R13, R14) of 14 sampled residents' medications were not pre-set on one of four medication carts. Findings included, Review of the facility policy Medication Administration: Guidelines. Policy Statement: Medication are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do only after they have familiarized themselves with the medication. Procedure: 4. Medications are administered at the time they are prepared. Medications are not pre-poured/pre-set/pre-crushed. Only one patient/resident's medications are prepared and administered at a time. During observations on 3/5/2024 at 12:21 pm, on the North Hall far end medication cart were two nurses Licensed Practical Nurse (LPN) AA and LPN BB. When the medication cart drawer was opened, there were several unlabeled plastic cups with medication in them. The medication had been removed from the pharmacy delivery package pouches. During the observation on 3/5/2024 at 12:21 pm, the Licensed Practical Nurse (LPN) AA was asked how she know which medication cups goes with what resident. She revealed that she had put the pills in the cup and placed the pills in the slot with the resident's other medications that was not scheduled. An observation on 3/5/2024 at 12:24 pm observed LPN AA and LPN BB entered the Resident 14 (R14) room with unlabeled plastic cups removed from the medication cart drawer. LPN BB check R14 gastrostomy tube for placement. LPN AA flushed the peg with cold water and then attempted to pour a crush white pill through the tube. The cold water and the white pill caused a blockage in the tubing. After using a declogger in the tubing, the liquid medications were administered through the tubing without any difficulties. An observation on 3/5/2024 at 12:49 pm, observed LPN AA give Resident #6 the pre-set medication from the medication cart. An observation on 3/5/2024 at 12:41 pm, observed LPN AA give Resident 7 the pre-set medication from the medication cart. An observation on 3/5/2024 at 12:45 pm, observed LPN AA give Resident 11 the pre-set medication from the medication cart. An observation on 3/5/2024 at 12:46 pm, observed LPN AA give Resident 12 the pre-set medication from the medication cart. An observation on 3/5/2024 at 12:47 pm observed LPN AA give Resident 13 the pre-set medication from the medication cart. An interview on 3/6/2024 at 4:20 pm, the Director of Health Services (DHS) revealed that nurses should not be pre-setting up medications as this is a safety issue. An interview on 3/6/2024 at 4:38 pm, the Administrator revealed that nurses should never pre-set up medications, as this is a safety hazard.

Based on observation, staff interviews, and resident interview the facility failed to provide privacy by not closing the blinds during incontinence care for one of one resident (Resident (R) 50) reviewed for privacy of 29 sampled residents Findings include: Review of R50's undated Face Sheet located under the Profile tab in the electronic medical record (EMR), indicated R50 was admitted to the facility with diagnoses including but not limited to stroke, hypertension, and diabetes mellitus. Review of the annual Minimum Data Set (MDS) under the MDS Tab in the EMR, with an Assessment Reference Date (ARD) of 7/5/2023 the resident had a Brief Interview Mental Status (BIMS) score of 15 out of 15. This represented R50 was cognitively intact. R50 was also coded as being totally dependent on two staff persons for personal hygiene. During observation on 9/15/2023 at 5:30 AM, a Certified Nurse Aide (CNA)2 was providing incontinence care to R50 in the resident's room while the resident was in the bed. R50 was exposed from the waist down. The resident's window blinds were open to the outside and the room was located on the first floor. During an interview on 9/15/2023 at 6:08 AM, CNA2 stated, When I give the residents care, I pull the privacy curtain and make sure the door is shut. CNA2 was asked if there was anything else that was done before providing care to provide privacy and CNA2 stated, No. During an interview on 9/15/2023 at 9:45 AM, with R50 revealed resident stated, I try to remind them to close the blinds, but I forgot to do that this morning. I don't want anyone to see or look at me like that. During an interview on 9/15/2023 at 10:15 AM the Director of Nursing (DON) was asked what the expectation of a CNA was providing personal care to a resident. DON stated, They are to provide privacy by shutting the resident's door, pulling the privacy curtain and closing the blinds if they are open before they provide any care to the resident. Upon request of the facility's policy on providing privacy during personal hygiene care to a resident. DON replied, The policy doesn't say anything about privacy. It goes over how to perform the care.

Based on record review, staff interviews, resident interviews, and the review of the facility policy titled, Documentation of Skin and Wound Care, the facility failed to provide wound care as ordered by the physician for two of two residents (Resident (R)4 and (R)42) reviewed for wound care of 29 sampled residents. Findings include: Review of the facility's policy titled, Documentation of Skin and Wound Care, dated 7/13/2023 revealed, It is the policy of the Healthcare center to complete documentation that reflects the current resident status as related to skin/wound care . Daily Documentation of Treatments: The wound observation and documentation form for facilities not utilizing an EHR [electronic health record] system or a progress notes for facilities utilizing an EHR system is completed with each dressing change. 1.Review of R4's Face Sheet located in the electronic medical record (EMR), under the Profile tab, revealed R4 was admitted with the diagnoses of diabetes mellitus and end stage renal disease. Review of R4's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/1/2023, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R4 was cognitively intact. During an interview on 9/12/2023 at 3:00 PM, with R4 revealed resident stated, My wound care that is supposed to be done daily wasn't done on Labor Day weekend. It was done on Friday and then it didn't get done again until Monday evening late. I asked for it to be done but everyone kept telling me they would come back. Review of the Orders tab of R4's EMR, revealed the physician had ordered daily dressing changes to the resident's wounds located on the left lateral leg, left lateral ankle, right heel, right lateral leg right lower lateral distal leg, and right lower lateral posterior leg. Order date: 7/17/2023. Review of R4's Medication Administration Record (MAR) located in the Orders tab revealed: -On 9/2/2023 7 AM - 3 PM documentation which revealed, Not Administrated: Other Comment: out of facility. This documentation was noted for the daily dressing changes for wounds located on the left lateral leg, left lateral ankle, right heel, right lateral leg right lower lateral distal leg, and right lower lateral posterior leg; and -On 9/3/2023 7 AM - 3 PM documentation on (R)4's MAR revealed Not Administrated: Other Comment: Tx [Treatment] nurse. This documentation was noted for the daily dressing changes for wounds located on the left lateral leg, left lateral ankle, right heel, right lateral leg right lower lateral distal leg, and right lower lateral posterior leg. During an interview on 9/14/2023 at 4:24 PM with Licensed Practical Nurse (LPN)3 stated, On 9/2/2023 which was a Saturday, the resident was gone out to dialysis, then the next day I thought the treatment nurse was working and she would do it. During an interview on 9/15/2023 at 9:02 AM with LPN1 stated, I don't work on the weekends, so the floor nurse is responsible for doing the dressing changes. If the resident is out to dialysis and won't be back before I leave, then the floor nurse is also responsible for changing these dressings. During an interview on 9/15/2023 at 10:33 AM, the Director of Nursing (DON) stated, The floor nurse are to perform the dressing changes on the weekends because the wound care nurse doesn't work the weekends. They are also to do these dressing changes if the resident comes back from dialysis after the wound care nurse leaves for the day. 2. Review of R42's Face Sheet, located in the Face Sheet tab of the EMR, revealed he was admitted to the facility with diagnoses including dislocation of C4/C5 cervical vertebrae, acquired absence of right leg and left leg above knee, pressure ulcer of right hip, pressure ulcer of left hip, diabetes, anorexia, anemia, and paraplegia. Review of R42's quarterly MDS assessment, located in the RAI tab of the EMR, with an ARD of 8/16/2023, revealed he scored 15 of 15 on the BIMS, indicating intact cognition. He required extensive assistance with bed mobility and had two stage III pressure ulcers. R42 used a pressure-reducing device for his wheelchair and bed and received turning/repositioning assistance and nutrition/hydration approaches for wound healing. Review of R42's Care Plan located in the RAI tab of the EMR, dated 9/12/2023, revealed [R42] has open areas to his left buttocks and right ischium [hip] area. He has a history of pressure ulcer areas to left and right Ischium. Wound areas to left and right ischium often get to the appearance of about to heal and will re-open. He has a history of non- compliance with turning and repositioning, and he does go out frequently and sits for extensive periods while he is out. He does have potential for further skin breakdown r/t [related to] immobility secondary to being [sic] B/L AKA [bilateral above the knee amputations] as well. The pertinent approaches included, encourage [R42] to comply with staff interventions and MD [physician] orders and treatment per MD orders. Review of the Orders tab of R42's EMR revealed the following daily treatment orders for his pressure ulcers: - 8/23/2023: Cleanse left and right ischium with wound cleanser, pat dry, and apply Calcium Alginate with silver cover with 4x4's and border gauze dressing change daily. - 7/19/2023 to 8/23/2023: Cleanse left ischium with wound cleanser pat dry, moisten with acetic acid, slightly pack cover gauze, and border gauze change daily. Review of R42's September 2023 MAR, located in the Reports tab of the EMR revealed the daily right and left ischium wound treatments were not documented as completed on: - 9/5/2023: Not Administered: Other Comment: not signed out by day shift nurse written by the North Unit Manager (NUM). - 9/6/2023: Not Administered: Other Comment: Tx [treatment] nurse did not sign off written by the NUM. Review of R42's August 2023 MAR located in the Reports tab of the EMR revealed the right and left ischium daily wound treatments were not documented as completed on: - 8/29/2023: Not Administered: Other Comment: IV [intravenous] antibiotics completed written by LPN3. Review of R42's July 2023 MAR revealed the right and left ischium daily wound treatments were not documented as completed on: - 7/22/2023: Not Administered: Other Comment: only nurse on floor written by LPN4. In an interview on 9/15/2023 at 8:59 AM, with the NUM revealed she stated on 9/5/2023 and 9/6/2023, the wound treatments were completed, they just had not been signed off by the responsible nurses. She stated was done, but just not signed out. She stated she had followed up with the responsible nurses, but they had not come back to complete their documentation. The NUM stated on 8/29/2023, the nurses documented in error regarding IV discontinuation, as this did not pertain to wound treatment. The NUM stated she was not working on 7/22/2023 and was unsure of the meaning of LPN4's documentation. In an interview on 9/15/2023 at 9:15 AM, with LPN4 revealed she stated on 7/22/2023, she was the only nurse working on the North Hall and had only a Certified Medication Aide (CMA) working with her. LPN4 stated she had passed a report on to the second shift nurse that the treatment was not done, but she could not get to the treatment during her shift because of the tube feedings she had to administer. In an interview on 9/15/2023 at 9:31 AM with DON revealed she stated the floor nurses were responsible for completing wound care when the treatment nurse was not working. She stated if there was only one nurse working on the hall, there were always one or two CMAs working alongside them to pass medications and complete other tasks. The DON stated the facility had sufficient nursing staff to complete all ordered treatments. The DON stated if staff did forget to document provision of a treatment, they only had a 24-hour time frame in the EMR system to go back and document, and so they may not have been able to document after the fact if not caught within the 24-hour period. On 9/15/2023 at 10:13 AM, the DON stated she was not able to find documentation in the 7/22/2023 shift report to indicate the need to complete the treatment was passed on to the second shift nurse.

Based on observations, staff interview, and record review, the facility failed to obtain a physician order for the use of oxygen for one of four residents (Resident (R) 61) reviewed for Oxygen of 29 sampled residents Findings include: Review of R61's undated Face Sheet in the Electronic Medical Record (EMR) revealed R61 was admitted to the facility with diagnoses of dementia and diabetes mellitus. Review of the annual Minimum Data Set (MDS) in the EMR, with an Assessment Reference Date (ARD) of 7/24/2023 coded the resident as having a Brief Interview Mental Status (BIMS) of five out of 15. This represented R61 had severely impaired cognition. Observations were made on 9/11/2023 at 11:00 AM and 9/12/2023 at 9:53 AM of R61 receiving O2 (oxygen) at two L/min (liters per minute) by nasal cannula. Review of R61's Orders under the Orders tab in the electronic medical record (EMR) on 9/12/2023 revealed there were no physician orders for R61 to receive O2 at 2 L/min by nasal cannula. During an interview on 9/12/2023 at 4:00 PM, the Director of Nursing (DON) reviewed the electronic medical record and stated, There is no order for this resident to receive oxygen.

Based on record review, staff interview, and facility document review, the facility failed to obtain written communication from the dialysis center for one of one resident (Resident (R) 4) reviewed for dialysis of 29 sampled residents Findings include: Review of the dialysis contract dated for July 7, 2010 stated . Facility shall be responsible for .the accuracy, timeliness and completeness of all data, reports and any other information .Facility agrees that prompt review and acceptance of any part of the services requiring acceptance is required to ensure compliance with any milestones or other deadlines . Review of R4's undated Face Sheet in the electronic medical record (EMR), revealed R4 was admitted with the diagnoses of diabetes mellitus and end stage renal disease. Review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/1/2023 revealed a Brief Interview for Mental Status (BIMS) score 15 out of 15 indicating R4 was cognitively intact. Review of R4's the Resident Document tab in the EMR, revealed Pre and Post Dialysis documentation. There were only two communication sheets from the dialysis center that were completed from 8/15/2023 through 9/3/2023. During this time period, there were nine visits to the dialysis center. During an interview on 9/13/2023 at 10:09 AM the Director of Nursing (DON) was notified of only two communication sheets received back from dialysis for the dates of 8/15/2023 through 9/3/2023, but during this time, there were nine visits to the dialysis center. The DON stated, It should be the nurse that calls to get the information from the dialysis center or call and get them to send over the information (communication) when they return.

2. Review of R15's Face Sheet tab of the EMR revealed R15 was admitted with diagnoses of coronary artery disease and stroke. Review of R15's quarterly MDS with an ARD of 8/24/2023, revealed a BIMS score of 14 out of 15 indicating R15 was cognitively intact. During an observation on 9/11/2023 at 11:07 AM, R15 had one round, green colored pill in a medicine cup on the over the bed table. R15 stated, I didn't take that one. During an interview on 9/15/2023 at 10:15 AM the DON stated, They know not to leave any medications in the resident's rooms. Based on observations, staff interviews, resident interviews, record review, and review of the facility policies titled, Self-Administration of Medications by Patients/Residents, and Medication Storage in the Healthcare Centers, the facility failed to ensure medications were not stored unattended in resident rooms for two (Resident (R) 46 and R15) of 29 sample residents. This failure had the potential to lead to missed doses of medications or unsafe use of medications for these two residents. Findings include: Review of the facility's policy titled, Self-Administration of Medications by Patients/Residents, dated 12/02/22, revealed Each patient/resident who desires to self-administer medication is permitted to do so if the healthcare center's Licensed Nurse and physician have determined that the practice would be safe for the patient/resident and other patients/residents of the healthcare center . Bedside Storage of Medications is permitted only when it does not present a risk to confused patients/residents who wander into the rooms of, or room with, patients/residents who self-administer. The following conditions are met for bedside storage to occur: The manner of storage prevents access by other patients/residents, . The medications provided to the patient/resident for bedside storage are kept in the package as dispensed by the provider pharmacy, . the electronic health record Medication Administration Record form is printed and maintained at the bedside and is reviewed on each nursing shift, [and the] . attending physician enters an order on the electronic health record for bedside storage . All nurses and aides are required to report to the Charge Nurse on duty any medications found at the bedside not authorized for bedside storage. Review of the facility's policy titled, Medication Storage in the Healthcare Centers, dated 07/28/23, revealed Medications and biologicals are stored safely, securely, and properly following manufacturers recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel and pharmacy personnel . Only licensed nurses and the pharmacy personnel are allowed access to medications . Medication rooms, carts, and medication supplies are locked or attended to by persons with authorized access. 1. Review of R46's Face Sheet tab of the electronic medical record (EMR) revealed she was admitted to the facility with diagnoses including: bipolar disorder, major depressive disorder, and anxiety disorder. Review of R46's quarterly Minimum Data Set (MDS) assessment, located in the RAI [Resident Assessment Instrument] tab of the EMR, with an Assessment Reference Date (ARD) of 8/23/2023, revealed she scored 14 out of 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. The resident was able to make herself understood and understand others. She exhibited frequent verbal behaviors directed toward others and other behaviors not directed toward others. Review of R46's Care Plan located in the RAI tab of the EMR, dated 9/1/2023, revealed Resident has socially inappropriate/disruptive behavioral symptoms as evidenced by: throwing utensils/food, talking/arguing with unseen people and/or unheard stimuli . [R46] has potential for alteration in her moods, behaviors, decision making, [and] cognitive patterns r/t [related to] periods of confusion at times . [R46] requires the assistance of staff with her ADL [activities of daily living] care r/t impaired mobility and confusion at times, she has a hx [history] of right hip fracture, but displays behaviors at times i.e. talking to wall, resistive to care, refusing assistance, verbal rudeness, etc. She can be very difficult to assist at times with her ADL care. Pertinent approaches included: Administer all medications as ordered by MD [physician], . encourage [R46] to comply with staff interventions [and] MD orders, . [and] attempt to educate her on the risk of non-compliance. Review of R46's Self-Administration of Medication assessment, located under the Observation tab of the EMR, dated 8/24/2023, revealed R46 did not want to self-administer medications and had modified independence with decision-making. She was unable to open medication bottles and unable to properly administer medications. R46 was not appropriate to self-administer medications and staff were to give her medications. The assessment documented, She is non-compliant taking her medication. Review of R46's Orders tab of the EMR revealed the following current medication orders: -Levothyroxine (thyroid medication),112 mcg at 6:00 AM. -Metoprolol tartrate (blood pressure medication), 50 milligrams (mg) at 8:00 AM. -Vitamin B-12, 1,000 micrograms (mcg) at 9:00 AM. -Sertraline (anti-depressant medication), 100 mg at 9:00 AM. -Vitamin D3, 2,000 international units at 9:00 AM. -Cetirizine (allergy medication), 10 mg at 9:00 AM. -Oxcarbazepine (seizure medication), 300 mg at 9:00 AM and 7:00 PM. -Atorvastatin (cholesterol medication), 40 mg at 9:00 PM; and -Olanzapine (antipsychotic medication), 7.5 mg at 9:00 PM. During an observation on 9/11/2023 at 11:27 AM in R46's room, R46 was lying awake in bed. There was a medication cup of six pills on the resident's bedside table, right next to her. The resident stated a staff member had left them there that morning, but she was not going to take them. R46 was unable to identify the medications, the time they were brought to her room, or the nurse who left the medications in the resident's room. During a meal observation on 9/11/2023 at 12:55 PM in R46's room, a staff member delivered R46's room tray and placed it on the bedside table, right next to the medication cup with six pills. The staff member did not remove the medications from the resident's room. During a subsequent observation on 9/11/2023 at 3:22 PM in R46's room, the medication cup with six pills was still at the resident's bedside. During an observation on 9/12/2023 at 9:24 AM, a medication cup with one orange pill was on the bedside table, right next to R46 who was lying in bed awake. R46 stated she knew she had a medication cup on her bedside table but was not going to take it. During an observation on 9/15/2023 at 5:57 AM in R46's room, R46 was lying in bed asleep with a medication cup containing two white pills on the bedside table next to her. In a concurrent interview and observation in R46's room on 9/15/2023 at 6:03 AM, Certified Medication Aide (CMA) 1 stated the two pills were R46's evening blood pressure medication and stated, I guess she didn't take them. I'm going to have to remove them. CMA1 then removed and discarded the medications. CMA1 stated R46 was not able to self-administer her medications, but she sometimes asked the CMA to put the medications on the bedside table so she could take them later. CMA1 stated she was trained never to leave medications unattended in a resident's room and to remove medications from a resident's room and reapproach them later if they refused the medications. In an interview on 9/15/2023 at 9:37 AM with the Director of Health Services (DHS), she stated medications should never be left unattended in a resident's room, and expected the staff to reapproach later if a resident refused a medication and document the refusal.

Based on observations, staff interviews, record review, manufacture's guidelines, and review of the facility policy titled, Glucometer Cleaning and Disinfecting, the facility failed to ensure the glucometer (device used to test blood sugar levels in blood specimens) was adequately cleaned and disinfected and infection control principles were followed for three (Resident (R) 60, R31, and R129) of four residents observed for blood sugar checks. In addition, the facility failed to ensure appropriate hand hygiene principles were followed by two Certified Medication Aides (CMAs) (CMA1 and CMA2) during medication administration for R66 and throughout medication administration observations. These failures had the potential to lead to spread of infection, including bloodborne pathogens, between residents. Findings include: Review of the facility's policy titled, Glucometer Cleaning and Disinfecting, dated 06/27/23, revealed, The Glucose Meter must be cleaned and disinfected after each patient use to minimize the risk of transmission of blood-borne pathogens between patients and healthcare professionals. To ensure proper disinfection, it is important to clean the meter prior to disinfecting the meter . 1. Clean and disinfect glucose meter before and after each patient use. 2. Wash hands with soap and water. Put on a pair of single use of [sic] disposable gloves. 3. Inspect for blood, debris, dust, or lint anywhere on the meter. Blood and bodily fluids must be thoroughly cleaned from the surface of the meter. 4. Clean and disinfect the meter by using the EPA approved germicidal/viricidal disinfectant wipes . 5. Ensure the surface of the meter remains wet at room temperature of the contact time listed on the wipe's directions for use. Allow to air dry . NOTE: Single use protective gloves should always be worn during disinfection procedures . Glucose meters used in clinical setting for testing multiple persons must be cleaned and disinfected between patients. Review of R60's Face Sheet, located under the Face Sheet tab of the electronic medical record (EMR) revealed she was admitted to the facility with diagnoses including ovarian cancer, anemia, acute kidney failure, hypertension, gout, and diabetes. Review of R60's EMR revealed no evidence of active infection or presence of bloodborne pathogens. Review of R31's Face Sheet, located under the Face Sheet tab of the EMR revealed he was admitted to the facility with diagnoses including cerebrovascular disease, [NAME] matter disease, heart failure, diabetes, stomach cancer, acute kidney failure, encephalopathy, and seizures. Review of R31's EMR revealed no evidence of active infection or presence of bloodborne pathogens. Review of R129's Face Sheet, located under the Face Sheet tab of the EMR revealed she was admitted to the facility with diagnoses including chronic obstructive pulmonary disease, right lower leg amputation, anemia, schizophrenia, bipolar disorder, and diabetes. Review of R129's EMR revealed no evidence of active infection or presence of bloodborne pathogens. Medication Administration Observation on 9/14/2023 at 11:53 AM revealed CMA2 was observed to carry a glucometer that had been used obtaining a blood sugar from a resident to the medication cart in her bare hands with no gloves on. CMA proceeded to place the used glucometer on the top of the medication cart and cleaned it without using gloves. During an interview on 9/14/2023 at 12:12 PM, CMA2 stated, I should have used gloves to bring it back to the med [medication] cart and to clean it. During an interview on 9/14/2023 at 3:30 PM. The North Unit Manager (NUM) stated, They will take the glucometer in the resident's room to get the blood sugar. They will put their gloves on, get the blood sugar then bring the glucometer back to the medication cart. Place the glucometer on a paper towel and clean the glucometer. Then they will discard the paper towel and remove their gloves and sanitize their hands. Observation on 9/15/2023 at 5:35 AM, CMA1 exited R60's room with a glucometer in her hand and no gloves on. CMA1 stated she had just used the EvenCare G3 glucometer to test R60's blood sugar and was bringing my stuff back to the cart. CMA1 placed the dirty glucometer on top of the medication cart without a barrier, and proceeded to clean the glucometer, without donning gloves, with an alcohol wipe. The glucometer was then placed back on top of the medication cart without a barrier, and without the cart being sanitized. Interview on 9/15/2023 at 5:40 AM, CMA1 stated she used an alcohol wipe to clean the glucometer between residents because it was a quick way to kill germs when going from patient to patient. She stated the same glucometer was used for three residents (R60, R31, and R129), and an alcohol wipe was used to clean it between each resident. She stated she would use the Force2 Disinfectant Wipes to disinfect the glucometer once all three residents' blood sugar tests were done. She stated, I was not trained to do this, but it's something I started doing because with the wipes, you have to wait so long for it to dry and we have to have blood sugars done by a certain time. CMA1 stated she had been trained to use the Force2 Disinfectant Wipes between each resident, but that was not practical because it took too long. The CMA stated, This is a good way to kill the germs between patients. I will do the three blood sugars, clean with alcohol wipes in between each, then use the regular wipe after they are all done. Review of R66's Face Sheet located under the Face Sheet tab of the EMR revealed the resident was admitted to the facility with the diagnoses of heart failure and hypertension. Observation on 9/15/2023 at 5:50 AM, CMA1 was preparing medication for R66. CMA1 picked up a blue capsule in her bare hand and began to open the capsule so that the medication could be given in applesauce. CMA1 picked up the second blue capsule and opened the capsule so that it also could be given in applesauce. During an interview on 9/15/2023 at 10:00 AM, the DON stated, They know they are to wear gloves. Observation on 9/15/2023 at 5:55 AM, CMA1 picked up the same glucometer used for R60 and used it to monitor R31's blood sugar. She exited the resident's room, placed the dirty glucometer on top of the medication cart without a barrier, and again used an alcohol wipe, without first donning gloves, to clean the glucometer, then placed it on top of the medication cart without a barrier and without sanitizing the cart. At 6:02 AM, CMA1 used the same glucometer used for R60 and R31 to test R129's blood sugar. Upon exiting the resident's room, she placed the glucometer on top of the medication cart without a barrier and used a Force2 Disinfecting Wipe to clean and disinfect the glucometer without first donning gloves. She then placed the glucometer back on top of the medication cart without a barrier and without sanitizing the cart. Interview on 9/15/2023 at 8:43 AM, the Infection Preventionist (IP) stated the staff were expected to use a clean paper towel as a barrier on top of the medication cart before placing the glucometer on the cart. She stated staff were expected to use the Force 2 Disinfecting Wipes to clean and disinfect the glucometer after each use following the directions for cleaning, disinfecting, and wet contact time. The IP stated staff were trained to use two different glucometers so while one was being disinfected for the specified wet contact time, the second one could be used on another resident. The IP stated staff should wear gloves both while performing the blood sugar tests and while cleaning and disinfecting the glucometer. The IP stated the Force2 Disinfecting Wipes were determined to be appropriate for glucometer cleaning and disinfection as they were effective against all targeted organisms and bloodborne pathogens. The IP stated she did not do documented audits of staff performing blood glucose testing and cleaning/disinfecting the glucometer; however, she spent a lot of her time on the floor watching hand hygiene and medication administration, which included use of the glucometer. The IP stated these observations were done at least four times per day, but they were not documented. The IP stated training was completed with all CMAs and nurses on cleaning and disinfecting the glucometer on 2/24/2023 and CMA1 was present at the training. Interview on 9/15/2023 at 9:38 AM, the Director of Nursing (DON) stated staff should follow the facility policy and the training provided regarding the appropriate cleaning and disinfection of the glucometer, which included using the Force2 Disinfecting Wipes after each use and using gloves and barrier on the medication cart during cleaning/disinfection. Review of the 2016 EvenCare G3 Blood Glucose System User's Guide revealed, The EvenCare G3 Meter should be cleaned and disinfected between each patient. The meter is validated to withstand a cleaning and disinfection cycle of ten times per day for an average period of three years. The following products have been approved for cleaning and disinfecting the EvenCare G3 Meter: o Dispatch® Hospital Cleaner Disinfectant Towels with Bleach (Environmental Protection Agency (EPA) Registration Number: 56392-8) o Medline Micro-Kill+ (Trademark) Disinfecting, Deodorizing, Cleaning Wipes with Alcohol (EPA Registration Number: 59894-10) o Clorox Healthcare® Bleach Germicidal and Disinfectant Wipes (EPA Registration Number: 67619-12) o Medline Micro-Kill (Trademark) Bleach Germicidal Bleach Wipes (EPA Registration Number: 37549-1) . Other EPA registered wipes may be used for disinfecting the EvenCare G3 system, however, these wipes have not been validated and could affect the performance of your meter . Single-use medical protective gloves should always be worn during disinfection procedures and also by anyone performing blood glucose testing on another person . Glucose meters used in a clinical setting for testing multiple persons must be cleaned and disinfected between patients . Used gloves should be removed and hands washed before proceeding to the next patient.

Based on observations, staff interview, and review of the facility policy titled, Labeling, Dating, and Storage, the facility failed to ensure proper sanitization of ware washing equipment, food was labeled and dated properly, and food was disposed of properly according to professional standards for food service safety. This failure had the potential to affect all 82 residents who consumed food prepared from the facility's kitchen. Findings include: Review of the facility's policy titled, Labeling, Dating, and Storage dated 11/11/2022, revealed Food and beverage items will have an identifying label as well as a received date and opened date, as applicable; for items prepared onsite, a 'use by' date will also be indicated. Observation and interview during the initial kitchen inspection on 8/11/2023 from 9:00 AM to 10:45 AM, with Assistant Director of Food Services (ADFS) present, revealed the following: -The chemical concentration level of Chlorine; Iodine; or Quaternary (QAC) could not be determined because the appropriate chemical strips were not available to evaluate the safe operation of the dish machine and the washing of pots and pans. -Interview with the ADFS during the initial kitchen inspection revealed that periodic testing, at least once per shift, and for the effective contact time according to manufacturer's guidelines, had not been done because their test strips were not good. She said the test strips had previously gotten wet, and they had not obtained additional test strips. Further observation during the initial kitchen inspection, with the ADFS present, revealed food items stored in the refrigerator were not dated, and opened containers of potentially hazardous foods and leftovers were not dated or used within seven days in the refrigerator. The following food items in the cold storage refrigerator were identified as expired: -A large bag of opened grated cheese expired 9/7/2023, -A large, opened container thickened cranberry cocktail expired 8/27/2023, -A large, covered container of prepared cherry preserve expired 9/6/2023, -A large, covered container of prepared pureed brownie expired 9/7/2023, -A large, covered container applesauce expired 9/6/2023, -A case of cottages cheese expired 7/23/2023, -A case of cream cheese spread expired 8/25/2023, and -An opened container of vegetable soup expired 9/7/2023. The following food items in cold storage refrigerator had no open/discard dates: -A large container of opened cool whip, -A large open thick nectar, -An opened ketchup bottle, -A large, opened container of French dressing, -An opened container of water, -A gallon of prepared cool aid, -A large container of opened sliced cheese, -A large, opened container instant pureed bread, -A large, opened carton food thickener, -A Partial used carton of eggs, -AN open container sliced ham, -A large, opened container of pasta, -A large container of cream of chicken soup, -A large container of opened food item with the appearance of mold on top carton of chicken base, -Three packages of crab meat, -A large container of opened potato salad, and -A large container of opened Jell-O fruit mixture. The following food items were labeled with 'open date' but no discard date: -A large jar of pickles open date 9-6-2023, -A large container of Italian dressing open 9/7/2023, -A large container sliced ham lunch meat open date 9/820/23, -A large container lemon pudding open date 9/9/2023, and -A large jar of Picante sauce open 8/9/2023. In addition, a case of whipped topping found in the cold storage refrigerator contained a large label on the outside of the box that read 'keep frozen'.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and policy review titled Advance Directives: Georgia the facility failed to ensure there were no discrepancies between code status and orders related to code status for one of three residents (R58) reviewed for Advanced Directives. Findings include: Review of the facility Advance Directives: Georgia policy, revise [DATE], revealed, this healthcare center recognizes the right of patients/residents to control decisions related to their medical care .A copy of the advance directives shall become a permanent part of the resident's medical record .The healthcare center shall enter in the patient/resident's medical record any change in or termination of the advance directive for health care that becomes known to the healthcare center. Record review of R58's Physician Orders for Life-Sustaining Treatment (POLST) located in the electronic medical record (EMR) under Resident Orders/Advance Directives revealed a signed POLST dated [DATE]. The code status for R58 was Cardiopulmonary Resuscitation (CPR) if the resident had no pulse and was not breathing. This request was also located on the banner heading in the EMR under Face Sheet. Located in the EMR under Resident/Orders was an Order for Do Not Resuscitate (DNR) that was dated [DATE]. Record review of the Minimum Data Set (MDS) annual assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 14 which indicated no cognition impairment. Further review of the MDS assessment revealed no behavioral or mood concerns. Interview on [DATE] at 2:13 p.m. with R58 revealed that he wanted CPR. R58 stated that it had been that way since his admission on [DATE]. During interview on [DATE] at 1:50 p.m. with the Director of Health Services (DHS) it was explained that the DNR order was entered by mistake. DHS explained that R58 had been in the hospital and upon returning, the admitting nurse put in the incorrect order of DNR. The DON stated that staff looked for a resident's code status in the EMR under Face Sheet on the banner which contained the resident's picture, name, and code status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, medical record review, and review of facility policy titled Medication Administration: Enteral Tubes, the facility failed to ensure appropriate care of a gastrostomy (g)-tube during medication administration for one resident of four residents (R27) who were observed during the observation of medication administration. Findings include: The facility's policy, Medication Administration: Enteral Tubes, most recently revised 1/31/20, the healthcare center will provide safe and effective administration of medication via feeding tube only upon Physician Order. Procedure & Key Points: 7. Crush tablets separately into separate cups and dissolve in enough water or other appropriate liquid to dissolve or suspend. Empty capsule contents separately into enough water or appropriate liquid to dissolve or suspend. Dilute liquid medications with 15-20 milliliters (mls) water, using up to 60 mls of water as for oral administration. Medications are never added directly to feeding solution. 8. Flush the tube with 15 milliliters (mls) of water per physician's order. Do not allow air to enter the tube. 9. Remix the medication. Place the first medication into the syringe. After the medication has been given, flush with 5 mls of water or per physician orders then place the next medication into the syringe (then repeat for each medication given). 10. Allow medication to flow down tube via gravity. Give gentle boosts with the plunger (approximately one (1) inch down) if the medication will not flow by gravity. Repeat if necessary. Do not push medications through the tube. R27 was admitted to the facility on [DATE], according to the undated Face Sheet located in the electronic medical record (EMR) under the Diagnoses tab, with diagnoses including but not limited to acute neurologic, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side; aphasia following cerebral infarction; dysphagia, oral phase, following cerebral infarction; secondary hypertension, unspecified; and gastrostomy. According to R27's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/27/21, R27 was cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 7 out of 15 which indicated severe cognitive impairment. R27's Active Orders dated 2/10/22 and located in the EMR under the Orders tab, included the following pertinent orders: Aspirin 325 mg, one tablet per gastric tube once a day for anti-coagulation; Zoloft (sertraline) 25 mg, one tablet per gastric tube once a day for anti-depression; Norvasc (amlodipine) 10 mg tablet, one tablet per gastric tube once a day for high blood pressure; Tradjenta (linagliptin) 5 mg tablet, one tablet once a day per gastric tube for diabetes; Zetia (Ezetimibe) 10 mg tablet, one tablet once a day per gastric tube for high cholesterol, and Ziac (Bisoprolol-hydrochlorothiazide tablet) 2.5-6.25 mg tablets, one tablet per gastric tube for high blood pressure. A crush order was in place for the resident to facilitate administration of the medication through the resident's g-tube, check tube placement prior to medication administration/flushes, and during medication administration times, flush tube with 15 mls water before and after medications and 5 mls with each medication. Licensed Practical Nurse (LPN) 5 was observed administering R27's medications on 2/11/22 at 9:15 a.m. LPN5 individually crushed R27's medications (Aspirin, Zoloft, Norvasc, Tradjenta, Zetia, and Ziac) and placed them into separate medication containers. The crushed medications were not observed to be diluted with water. After LPN5 checked for the placement/patency of the g-tube and flushed the tube with 15 mls water, the crushed non diluted Aspirin medication was placed in the g-tube followed by 5 mls of water, the crushed non diluted medication Zoloft was placed in the g-tube and flushed with 5 mls water, the crushed non-diluted medication Norvasc with placed in the g-tube and flushed with 5mls water. The g-tube was observed to become clogged and LPN5 attempted to milk the tubing to obtain patency. LPN5 then attempted to use a syringe to force the administration of the medication and obtain patency of the g-tube. LPN5 then continued with the administration of the crushed non-diluted medication, Tradjenta into the g-tube and flushed with 5 mls water, Zetia non-diluted administered into the g-tube and flushed with 5 mls water, and Ziac non-diluted administered into the g-tube and flushed with 30 mls water. During an interview with LPN5 on 2/11/22 at 9:30 a.m., following the observation of the medication administration she stated the tubing usually did not become clogged when she administered the dry medication and acknowledged being nervous. During an interview on 2/11/22 at 9:45 a.m. the Director of Health Services (DHS) stated it was her expectation that the crushed medication be diluted with water prior to the administration into the g-tube. The powdered/crushed medication should not be placed directly in the g-tube to prevent clogging of the g-tube.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews, the facility failed to assure medications were locked on the medication cart and inaccessible to unauthorized staff and residents. This failure affected medication carts on one of three wings. Findings include: 1. Observation on 2/8/22 at 11:00 a.m. revealed a medication cart unlocked outside of room [ROOM NUMBER]. The cart was unlocked for five minutes until Licensed Practical Nurse (LPN) 6 returned to the medication cart and locked the cart. Two residents walked up and down the hall while the cart was unlocked. Interview on 2/8/22 at 11:06 a.m. with LPN6 revealed that she had left her medication cart unlocked. LPN6 stated that she did not know why she had left the cart unlocked. 2. On 2/10/22 at 1:22 p.m., an observation was made of a medication cart unlocked outside of room [ROOM NUMBER]. The medication cart was unlocked from 1:00 p.m. until 1:53 p.m. LPN7 was responsible for the medication cart that day. LPN7 left for lunch at 1:00 PM and returned at 1:31PM. The cart was not locked again until 1:53 p.m. by LPN7. Observation of four residents in wheelchairs self-propelling down the hall and three residents walking back and forth by the unlocked medication cart. Observation was made on 2/10/22 at 1:50 p.m. with the Nurse Consultant and she agreed that the medication cart was unlocked and observed residents going by the cart. During an interview on 2/10/22 at 2:00 p.m., when asked why the cart was left unlocked, LPN7 shrugged her shoulders without a verbal response and walked away. Interview with the Assistant Director of Health Services (ADHS) on 2/10/22 at 2:28 p.m. revealed that her expectations were for all nursing to lock the medication cart every time they walk away, even if it is only for a second. The ADHS stated that it should be automatic to lock the cart and follow the right protocol as that is the standard of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, documentation, and review of the policy titled Glucometer Cleaning and Disinfecting the facility failed to protect residents against the potential for blood-borne illness on two of four medication carts on two of four days related to the disinfecting of glucometers as evidenced by not using approved disinfecting wipes, not allowing appropriate dwell time, and failure to use a barrier. The facility also failed to assure that a urinary catheter bag was off the floor for one of five residents (R31) reviewed for catheters. Findings include: 1. Review of the Evencare G3 Glucose Meter that was used by the facility revealed the meter should be cleaned and disinfected between each patient . Use an Environmental Protection Agency (EPA) registered disinfecting wipe . Allow the surface of the meter to remain wet at room temperature for the contact time listed on the wipe's directions for use. Review of the Force 2 Disinfecting Wipes that was used by the facility revealed the following directions To clean and disinfect, wipe hard, non-porous surface with wipe until surface is visibly wet . Allow surface to remain wet for two minutes. Review of the facility Glucometer Cleaning and Disinfecting policy, revised 4/28/21 revealed, ensure that the surface of the meter remains wet at room temperature for the contact time listed on the wipe's directions for use . Allow to air dry. Observation on 2/8/22 at 11:57 a.m. of Licensed Practical Nurse (LPN) 6 who cleaned the glucometer before and after use with an alcohol pad. She did not disinfect the glucometer with an approved disinfecting wipe or use a barrier to lay the glucometer on after cleaning. Interview with LPN 6 on 2/8/22 at 12:12 p.m. revealed that she always cleaned the glucometer with alcohol wipes. When asked if she was to use a disinfecting wipe, she stated that a disinfecting wipe could be used but she did not have any on her cart. LPN6 confirmed the glucometer was shared among residents. 2. Obsevation on 2/10/22 at 11:18 a.m. was made of LPN7 using Force 2 Disinfecting Wipes on the glucometer. The glucometer was wet for less than one minute and did not reach the dwell (time that a disinfectant has to remain visibly moist to work effectively) time of two minutes. A barrier was not used after disinfecting the glucometer and it was placed on top of the medication cart. Interview on 2/10/22 at 11:45 a.m. with LPN7 who confirmed that she used a disinfecting wipe on the glucometer but did not use a barrier. LPN7 did know the correct dwell time of two minutes. 3.Observation of LPN2 on 2/10/22 at 12:02 p.m. revealed that she used a Force 2 Disinfecting Wipe to clean the glucometer. The glucometer was wet for less than one minute and did not reach the dwell time of two minutes. She placed the glucometer on the medication cart without a barrier. Interview on 2/10/22 at 12:15 p.m. with LPN2 who stated that she used a disinfecting wipe to disinfect the glucometer but did not know the dwell time. She thought it was between one and three minutes. After disinfecting, LPN2 put the glucometer on a tissue and covered it with a tissue not allowing it to air dry. Interview with the Assistant Director of Health Services (ADHS) on 2/10/22 at 2:23 p.m. revealed that the expectations were to follow the right protocol. The ADHS reported that staff have been trained on glucose monitor disinfecting and they know the correct procedure to follow, which consisted of using a disinfecting wipe to disinfect the glucometer for 2 minutes then allowing it to air dry. During an interview on 2/10/22 at 2:30 p.m. with the Director of Health Services (DHS) it was revealed that her expectation for disinfecting the glucometer was to clean the meter in between each resident and let air dry for two minutes. DHS confirmed that the glucometers were shared between residents, and this should not have happened. 4. Review of the facility's policy titled, Procedure: Catheter Care, dated 2019, indicated, keep drainage bag below the level of the bladder. The policy did not address infection control related to keeping urinary catheter bags off the floor. During an observation and interview on 2/8/22 at 12:06 p.m. R31 was lying in bed waiting for lunch to be served. At this time, R31's urinary catheter bag was observed on the floor with a large amount of urine in it and was not in a privacy bag. The urinary catheter bag was observed to be hooked to a black cord that belonged to bed control. When asked about the urinary catheter bag, R31 reported that staff empty his catheter bag every shift. R31 denied knowing that his catheter bag was on the floor. (R31 did not voice any concerns related to the catheter bag being in a dignity bag.) During a second observation on 2/8/22 at 12:56 p.m., R31's urinary catheter bag was again observed to be on the floor and could be observed from the hallway. R31 was observed to be in the bed closest to the window. During a third observation on 2/8/22 at 3:00 p.m., R31's urinary catheter was observed from the hallway as being on the floor. Review of R31's Face Sheet found in the electronic medical record (EMR) indicated diagnoses to include cystitis (inflammation of the bladder) without hematuria (blood in the urine), calculus of kidney (kidney stones), retention of urine, and presence of urogenital implants. Review of Physician Orders located in the EMR under the Orders tabs dated 8/10/21 indicated, Supra Pubic Catheter-Indwelling urinary catheter #24 FR [French] 10cc [cubic centimeters] bulb: Dx [diagnosis] Urine Retention. Review of Physician Orders dated 1/4/21 indicated, Change Foley Catheter monthly once a day on the 19th of the month. Review of Physician Orders dated 1/22/21 indicated, Catheter: Change PRN [as needed] per protocol for leakage, dislodgement, obstruction. Review of R31's quarterly Minimum Data Set (MDS) dated [DATE] indicated R31 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating no cognitive impairment. Further review of the MDS indicated R31 had an indwelling catheter in place. Review of an undated Care Plan located in R31's EMR under the RAI [Resident Assessment Instrument] indicated, has a supra pubic catheter .is at risk of UTI [Urinary Tract Infections] secondary to impaired and supra pubic catheter. Approaches included but not limited to attempt to keep catheter bag off floor. During an interview on 2/10/22 at 8:37 a.m., the DHS reported that urinary catheter bags can be hung off the sides of the bed or off of wheelchairs. When the DHS was asked if it would be an acceptable standard of practice to have a residents urinary catheter bag on the floor, the DHS stated, that it would not be acceptable to have the urinary catheter bag on the floor. DHS further explained that the Certified Nursing Assistants (CNAs) should reposition the catheter bag if seen on the floor as they should not be left on the floor. During an observation and interview on 2/10/22 at 8:45 a.m. with the DHS in R31's room., R31's urinary catheter bag was observed to be on the floor. There was a large amount of urine in the catheter bag, and it was observed to be hooked to the black cord that belonged to the bed control. During interview, the DHS stated that the urinary catheter bag does not belong on the floor. During an observation on 2/11/22 at 12:54 p.m., R31's urinary catheter bag was observed to be in a blue privacy bag which was on the floor. During an interview on 2/11/22 at 12:55 p.m., LPN3 it was reported R31 never messes with the urinary catheter tubing or bag. When LPN3 was asked if it would ever be acceptable to have the urinary catheter bag on the floor, LPN3 reported the catheter bag should never be on the floor. During an interview on 2/11/22 at 1:00 p.m., Certified Nursing Assistant (CNA) 2 stated, when she has worked with R31 the catheter bag is supposed to be in a blue bag and hung up off the floor. During an observation and interview on 2/11/22 at 1:05 p.m., LPN3 confirmed R31's urinary catheter bag being on the floor. During an interview on 2/11/22 at 1:15 p.m., when the DON was asked if it would ever be appropriate to have a urinary catheter bag on the floor in a privacy bag. The DON stated if the catheter bag was in a privacy bag, as long as it is below the level of the bladder then it would be ok.