Based on observation and interview, the facility failed to treat one of 2 residents sampled Resident (R)292 with respect and dignity by staff not responding in a timely manner to R292's request for assistance with food replacement. This deficient practice has the potential to affect all residents in the facility. Findings include: During breakfast meal observation on 04/02/25 at 08:52 AM, inside R292's room, R292 asked the Certified Nurse Aide (CNA)3 to replace toasted bread with a freshly toasted bread for her breakfast. On 04/02/25 at 10:20 AM, observed Activities Assistant (AA) brought in freshly toasted bread inside R292's room, one hour and 20 minutes after R292 requested for a replacement. Conducted an interview with Food Service Director (FSD) on 04/02/25 at 10:32 AM, FSD confirmed an hour and 20 minutes was too long for the toasted bread replacement to be delivered, and was not done in a timely manner.

Based on record review, staff interview, and review of policy, the facility failed to report an allegation of abuse for one Resident (R)27, out of one resident reviewed, to other officials including Adult Protective Services (APS). As a result of this deficiency, the facility did not allow further review of the abuse allegation by APS. Findings include: Review of Facility Reported Incident (FRI), allegation of abuse for R27 stated that the facility did not contact APS for the incident. During staff interview on 04/02/25 at 01:30 PM, Administrator acknowledged that this allegation of abuse was not reported to APS. Administrator said they were not aware of the obligation to report all cases to APS and will make the change going forward. Review of policy on Abuse, Inservice Training read Policy; the facility will maintain an effective training program for all staff, which includes, at a minimum, training on abuse, neglect, exploitation, misappropriation of resident property and dementia management, that is appropriate and effective, as determined by staff need and the facility assessment . Staff, includes for the purposes of the training guidance, all facility staff (direct and indirect care and auxiliary functions), contractors and volunteers. Procedure; staff orientation and training . Facility procedures and Federal and State requirements for reporting abuse, neglect, exploitation and misappropriation of resident property, including injuries of unknown sources, timeframes for reporting and to whom staff and others must report their knowledge related to any alleged violation without fear of retaliation .

Based on interview and record review the facility failed to ensure the assessment accurately reflected the resident's status for one resident (Resident (R)42) sampled. As a result of this deficient practice, there is the potential for more than minimal physical harm to the resident. Findings include: (Cross Reference to F692: Nutrition Status Maintenance) On 03/31/25 at 11:10 AM, conducted a review of R42's Electronic Health Record (EHR). Review of the resident's vitals documented on 02/08/25, the resident weighed 154 pounds (lbs). On 03/07/25 and 03/09/25, R42 weighed 143.2 lbs, which is a -7.01 % loss in one month. Review of R42's progress notes did not contain documentation addressing the resident's significant weight loss of more than 5% in a month. Reviewed the resident's most recent quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/27/25, Section K. Swallowing and Nutritional Status K0300. Weight Loss documented No or Unknown to a loss of 5% or more in the last month, indicating R42 did not have a significant weight change. On 04/02/25 at 12:12 PM, conducted a concurrent review of R42's EHR and interview with Dietician (D)1. D1 reviewed R42's weights on 02/08/25, 03/07/25, and 03/09/25, then confirmed R42 did lose more than 5% in one month. D1 confirmed he/she did was not aware that R42's weight loss was significant. D1 reviewed R42's quarterly MDS with an ARD of 03/27/25, Section K. and confirmed the MDS should have coded R42 for a weight loss of 5% or more, but did not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prevent the development of pressure ulcers for one of three residents (Resident (R)294) sampled for pressure ulcers. Staff failed to report R294's refusal to be turned every two hours which delayed the implementation of new interventions to prevent the development of a new pressure ulcer. As a result of this deficient practice, R294 developed a Stage 2 pressure ulcer to her coccyx area and has the potential to affect other residents who are high risk for developing pressure ulcers. Findings include: Cross-reference to F726. (Competent Nursing Staff) R294 is an [AGE] year-old female who was admitted to the facility on [DATE] for short-term rehabilitation services. Diagnoses included but not limited to muscle weakness, unspecified protein-calorie malnutrition, and depression. During an interview with her Family Member (FM) at the bedside on 03/31/25 at 12:40 PM, FM stated that R294 had no skin problem or pressure ulcer prior to her admission. FM explained that R294 is now complaining of pain to her coccyx. FM stated that she visits every day and stays in the facility for up to six hours, and did not observe the staff repositioning R294 every two hours. FM stated most of the time R294 refuses to be moved. On 04/02/25 at 10:29 AM, review of R294's Electronic Health Record (EHR) was conducted. Care Plan Report dated 03/19/25, stated R294 was . at risk for break in skin integrity . Skin assessment upon admission done on 03/19/25 documented skin condition as, . coccyx - brown discoloration . admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/21/25, Section M, documented R294 is at risk of developing pressure ulcers/injuries. R294's Braden Scale assessment with a completion date of 03/26/25, noted a score of 12, which identified R294 as high risk for developing pressure ulcer and mobility as Very Limited. Physical Therapy treatment encounter notes for 03/25/25 to 04/01/25, documented the resident's resistance to care. On 03/26/25, . Resistive to sitting edge of bed . Documentation for 03/27/25 stated . Attempted to have the patient stand but she was combative . Documentation for both 03/28/25 and 03/29/25 stated . exhibits heightened anxiety w/ activity . Documentation for 04/01/25 stated . She was agreeable for therapist to assist with mobility but then would resist movement or want to return to bed. On 04/03/25 at 10:00 AM, conducted an interview with Certified Nurse Aide (CNA)9. Asked how often CNA9 assist R294 with repositioning, she said, We try to reposition resident every two hours, but she always refuses to be moved or repositioned. When asked what should staff do if R294 refuses to be turned, CNA9 stated that she is supposed to report to the nurse. Then asked CNA9 if R294's refusal to be repositioned was reported to the nurse. CNA9 confirmed the resident's refusals was not reported until the open area was noticed on R294'c coccyx on 03/31/25, which is 12 days after the resident was admitted . Conducted a concurrent interview and record review with the Director of Nursing (DON) on 04/03/25 at 10:17 AM in her office. DON confirmed there was no documentation about resident being repositioned every two hours or the resident's refusals. DON confirmed that CNAs should have repositioned the resident every two hours but did not. Review of the facility's policy and procedure manual on 04/03/25, titled Skin Integrity & Pressure Ulcer/Injury Prevention and Management stated, . 3. A skin assessment/inspection should be performed weekly by a licensed nurse . a. Skin observations . Any changes or open areas are reported to the Nurse . a. reposition at least every 2-4 hours .

Based on interview and record review, the facility failed to maintain acceptable parameters of nutritional status for one resident (Resident (R)42) sampled. As a result of this deficient practice, there is the potential for more than minimal physical harm to the resident. Findings include: (Cross reference to F641 Accuracy of Assessment) On 03/31/25 at 11:10 AM, conducted a review of R42's Electronic Health Record (EHR). Review of the resident's vitals documented on 02/08/25, the resident weighed 154 lbs. On 03/07/2025 and 03/09/25, R42 weighed 143.2 pounds which is a -7.01 % loss. Review of R42's progress notes did not contain documentation addressing the resident's significant weight loss of more than 5% in a month. Review the resident's most recent quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/27/25, Section K. Swallowing and Nutritional Status K0300. Weight Loss documented No or Unknown to a loss of 5% or more in the last month. On 04/02/25 at 12:12 PM, conducted a concurrent review of R42's EHR and interview with the Dietician (D)1. D1 reviewed R42's weights on 02/08/25, 03/07/25, and 03/09/25 then confirmed R42 lost more than 5% in one month. D1 stated he/she was aware that R42 was losing weight, but did not identify the weight loss as being more than 5% in one month. D1 reported adding supplemental nutrition to R42's meals and confirmed he/she may have given the resident more calories and monitored the resident more closely had he/she identified R42 loss more than 5% in one month.

2) On 04/02/25 at 07:57 AM, observed RN7 during medication administration. RN7 asked R246 what her pain level was. R246 said, Six out of 10. RN7 opened the computer on the cart, logged R246's pain level and checked the medication to be given. RN7 then prepared Hydrocodone-Acetaminophen (opioid pain medication) 10-325 mg (milligrams) tablet and administered it to R246. After giving the medication, RN7 documented on the computer. Review of R246's Electronic Health Record (EHR) was conducted. The following orders for pain were noted: Hydrocodone-Acetaminophen Oral Tablet 10-325 mg every 6 hours as needed for severe pain and Hydrocodone-Acetaminophen Oral Tablet 5-325 mg every 6 hours as needed for moderate pain. On 04/02/25 at 10:11 AM, a concurrent interview and record review was conducted with RN7 just outside R246's room. Asked RN7 what numeric pain level is considered severe. RN7 said, Seven to 10 is considered severe. Asked RN7 if the pain medication dose given to R246 earlier in the morning was correct. RN7 checked in the computer and said R246 should have been given Hydrocodone-Acetaminophen 5-325 mg since her pain level was only at six and considered moderate. On 04/02/25 at 10:20 AM, an interview with Unit Manager (UM)3 was conducted at the nurse's station. UM3 confirmed that a pain level of six out of ten is considered moderate. Based on interviews and record review, the facility failed to provide competent nursing services for two residents (Resident (R)249 and R246) in the sample. Staff did not report to the Registered Nurse (RN) when R249 refused to be repositioned and R246 was given a higher dose of pain medication for the pain level reported by the resident. As a result of the deficient practice, the two residents were placed at risk for avoidable injuries and adverse health conditions. Findings include: Cross-reference to F686. (Treatment to Prevent/Heal Pressure Ulcers) 1) Reviewed of R294's Electronic Health Record (EHR), Task records performed from 03/19/25 through 04/02/25 for bed mobility, noted check marks indicating the resident was repositioned every two hours three times a day. On 04/01/25, the task was checked only twice and there was no documentation in the progress notes of R294 refusing to be repositioned every two hours. On 04/03/25 at 10:00 AM, conducted an interview with Certified Nurse Aide (CNA)9. When asked how often CNA9 assist R294 with repositioning, she said, We try to reposition resident every two hours, but she always refuses to be moved or repositioned. CNA9 also stated that she is supposed to report to the nurse when the residents refuse care, but did not report anything to the nurses until she noticed the open area on R294's coccyx on 03/31/25, 12 days after the resident was admitted . Conducted an interview with the Director of Nursing (DON) on 04/03/25 at 10:17 AM, in her office. Asked if CNAs should report the resident's refusal to be turned or repositioned, DON confirmed it should be reported to the nurses.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals are stored in a locked compartment for one of six medication carts. Proper storage of medications is necessary to promote safe administration practices and to decrease the risk for diversion of residents' medications. Findings include: On 04/02/25 at 08:02 AM, observed Registered Nurse (RN)7 as she was administering medications. RN7 walked to the medication cart to log into the computer to check the orders. After checking the orders, RN7 took the medications from the other cart that was being used by RN5 and brought it to her cart. RN7 then prepared the medications and placed the blister packs back in RN5's cart. As RN7 walked to the resident's room, observed the medication cart was not locked, and three other staff members were walking around the hallway. After giving the medications to the resident, RN7 went back to the cart, signed off on the medications on the computer and walked back to the other section of the unit. The medication cart remained unlocked. On 04/02/25 at 10:11 AM, shared observation of the cart not being locked and left unattended with RN7. RN7 said she did not notice it since she did not open the cart, only used it to prepare the medications and document on the computer. RN7 added that the cart was being used by two other RNs helping to pass medications for day shift. On 04/02/25 at 10:20 AM, an interview was conducted with Unit Manager (UM)3 at the nurse's station. Shared observation of the unlocked medication cart with UM3. UM3 confirmed that medication carts should always be locked and secured when not in use. A review of the facility policy titled, Medication Storage stated, . Medication rooms, cabinets and medication supplies should remain locked when not in use or attended to by persons with authorized access.

Based on interview and record review, the facility failed to provide food that accommodates the food allergies for one of the two residents in the sample. Resident (R)294 is allergic to eggs and was served eggs for breakfast more than once. As a result of this deficient practice, residents are at risk for more than minimal physical harm. Findings include: During breakfast meal observation on 04/02/25 at 08:52 AM, inside R294's room, Family Member (FM) reported on two separate occasions (03/202025 and 03/29/2025), R249 was served breakfast with scrambled eggs. FM stated that she notified the Food Service Director (FSD) about the incidents and R249's food allergy included eggs. Reviewed R294's Electronic Health Record (EHR) on 04/02/25. R294's clinical resident profile included list of allergies, created on 03/19/25, documented, Allergies: Aspirin, metronidazole, Eggs . Nutrition Assessment, dated 03/20/25 at 04:47 PM, also identified eggs as a food allergy. Conducted an interview with the FSD on 04/02/25 at 10:32 AM, FSD verified R294's food allergies included eggs, but the resident was served eggs on 03/20/25 and 03/29/25. The FSD said it should not have been given to resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview and record review, the facility failed to maintain a functioning clock for one Resident (R)143 out of three residents sampled. As a result of this deficiency, R143 did not know the time of day when referring to that non-functioning clock. Findings include: Review of Electronic Health Record (EHR) showed R143 was admitted on [DATE] with diagnosis including Stroke, Aphasia (language disorder that affects the ability to communicate), Urinary Tract Infection. During observation of R143's room on 04/01/25 at 10:30 AM, a wall clock showed the time as 08:25 and was not functioning. Observation of R143's room wall clock on 04/02/25 at 08:45 AM showed the same time 08:25 as previously mentioned and still not functioning. Resident interview on 04/02/25 at 08:50 AM, R143 said he wished the wall clock worked because it was located on the wall right in front of him. R143 said he told the staff about the clock not working a day ago. Staff interview on 04/03/25 at 09:15 AM, Unit Manager (UM)1 acknowledged that the clock was not functioning and said they will have someone come and fix it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to identify, support, and honor one Resident's (Resident 32) preference to be informed of a time range that rehabilitation therapy services would occur. As a result of this deficient practice, R32 did not have her needs met and was placed at risk of not attaining her highest practicable well-being. This deficient practice has the potential to affect all the residents at the facility receiving therapy services. Findings include: Resident (R)32 is a [AGE] year-old female admitted to the facility on [DATE] for short-term rehabilitation therapy (therapy) following a fall with resulting fractures. R32's admitting diagnoses include, but are not limited to, fractures of her hip and pelvis with surgical intervention, hypertension (high blood pressure), anxiety, insomnia, constipation, and urinary retention. Review of R32's Minimum Data Set (MDS) admission Assessment with an Assessment Reference Date (ARD) of 03/11/24 noted that R32 was evaluated as having a score of 14 out of 15 for her Brief Interview for Mental Status exam, reflecting a determination of cognitively intact. On 04/24/24 at 11:07 AM, an interview was done with R32 at her bedside. R32 complained that she never knows when therapy will be. She thought she was supposed to have therapy in the morning, but it had not occurred yet. R32 stated that she does not like waiting the whole day. She likes to prepare herself for therapy and wants the ability to plan her day. R32 explained that her grandson wanted to visit in the afternoon, and she did not want to cut the visit short because of therapy. R32 stated that she had asked the therapists repeatedly to give her a time range of when they would visit, but they have not honored her request. On 04/25/24 at 09:05 AM, observed a therapy slip (piece of paper) at R32's bedside indicating that she was scheduled for physical (PT), occupational (OT), and speech therapy (ST). R32 stated that she gets the therapy slips every morning that let her know what type of therapy was scheduled for the day, but I don't know when [what time of day], that's bad! R32 complained again that she would like to know a time range of when therapy would occur, especially when there were multiple types of therapy scheduled for the day. R32 explained that in addition to being able to plan her day with regards to visits and activities, she would like to be able to request pain medications prior to PT, now that she was doing more. It would be nice to be able to do that [pre-medicate]. On 04/25/24 at 02:31 PM, an interview was done with the Director of Rehab [rehabilitation] (DOR) in the Conference Room. The DOR explained that the therapy schedules are printed the afternoon or evening before and provided to the nursing staff. The night shift nursing staff then make the therapy slips for the following day. When asked about R32 specifically, DOR agreed that she was aware that R32 preferred a set routine regarding the schedule and confirmed that the therapy staff do not schedule residents for specific times or time blocks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4) R7 is an [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of, but not limited, to vascular dementia. During R7's stay she was hospitalized twice on 03/04/24 and 03/21/24. On 04/25/24 at 10:56 AM, review of R7's electronic health record (EHR) found no copy of her AHCD. The EHR included a progress note documenting on 01/25/24, Resident has a Hawaii Advanced Health Care Directive/Power of Attorney, she [daughter] will provide copy once found. Copy of Power of Attorney (POA) documentation was not found in the EHR. No further follow-up was found. On 04/26/24 at 09:43 AM, an interview with Social Worker (SW) was done. SW confirmed the facility does not have a copy of R7's AHCD or POA and did not follow-up with R7's daughter to receive a copy. Review of the facility's policy and procedure Advanced Directives and Advance Care Planning under resident transfers, .If the resident leaves the facility temporarily (e.g., ER visit, hospital stay, or diagnostic procedure), a copy of the advance directive is sent with the resident .Each time the resident is admitted to the facility, quarterly, and when a change in condition is noted in the resident condition, the facility should review the advance directive and advance care planning information. Based on record review and interview the facility failed to follow-up and ensure residents were informed of their right to develop an advance health care directive (AHCD); or periodically reassessed in his/her decision-making capacity to do such according to State Law, for four of ten residents sampled (Resident (R) 2, R16. R40 and R7). As a result of this deficient practice, the residents were placed at risk of not having their wishes honored for future health care decisions, should they become incapacitated. Findings include: 1) On 04/24/24 at 09:55 AM during record review of R2's Electronic Health Record (EHR), R2's advanced health care directive was not found. R2 is a [AGE] year-old resident who was admitted to the facility on [DATE]. Review of R2's Care Plan (CP) found she has a Focus identified as DISCHARGE PLAN: Resident's Name wishes to discharge home after therapy is completed. Code Status: DNR (Do Not Resuscitate), Comfort measures only, No artificial nutrition by tube. Advanced Directives: Resident's Name (R2) has a completed POA (Power of Attorney) which first representative as daughter's name (daughter) and secondary representative as son's name (son). This problem was initiated on 02/21/23 and revised on 03/23/23. Review of R2's last quarterly Minimum Data Set (MDS) dated [DATE] found she had a Brief Interview for Mental Status (BIMS) with a score of 15 out of 15 identifying her as cognitively intact. On 04/25/24 at 04:10 PM met with and interviewed Social Worker (SW) who provided a copy of R2's POA and found it was for financial powers. SW confirmed the POA is for finances only. SW also provided a copy of the Declaration of Authority to Act As A Surrogate form. The front page of this facility form was filled out and the back was left blank. The back part of this form is filled out by the physician which identifies the resident as not having capacity to make their own healthcare decisions. SW explained facility uses the Declaration of Authority to Act As A Surrogate form internally for residents to fill out with resident identifying who will make healthcare decisions for them if they cannot. SW stated residents either cannot afford or refuse to do the AHCD when it is offered instead choose to use the Declaration of Authority to Act As A Surrogate form. R2 is cognizant and has not been identified by her physician as being incapacitated. Requested SW to provide documentation she met with R2 to discuss AHCD as a follow up. On 04/26/24 at 09:42 AM interviewed SW who was unable to provide any documentation of follow up regarding a meeting to discuss R2's options for AHCD. 2) On 04/23/24 at 03:03 PM reviewed R16's hard medical record for AHCD and none was found. On 04/24/24 at 10:05 AM during record review of R16's EHR R16's AHCD was not found. R16 is a [AGE] year old resident who was admitted to the facility on [DATE]. Review of R16's CP found he had a Focus identified as DISCHARGE PLAN: Mr. Resident's Last Name wishes to remain in the facility as ICF level. Code Status: Full Code which included the following: Advanced Directives: Mr. Resident's Last Name reported resident's Aunt's first name, Aunty, has copy of AHCD and she is listed as the first agent. KPO surrogate formed [sic.] completed by R16's Aunt's name (Aunty). This problem was initiated on 12/19/2022 and revised on 01/23/2024. Review of R16's last quarterly MDS dated [DATE] found he had a BIMS with a score of 15 out of 15 identifying him as cognitively intact. On 04/25/24 at 04:24 PM interviewed SW, who had provided a copy of R16's AHCD. Review of R16's AHCD found it was not filled out completely, was not signed by two witnesses or notarized when he signed it on 7/10/19. SW confirmed R16's AHCD was not fully filled out and she stated she would ask R16's Aunt for a copy of his AHCD if she has a copy that is fully filled out as she is the person named as his decision maker for healthcare. On 04/26/24 at 09:44 AM interviewed SW who stated she met with R16's Aunt on 04/25/24. R16's Aunt did not have a fully filled out copy of R16's AHCD. SW stated she provided a blank copy of the AHCD and R16's Aunt was receptive to have two witnesses come to the facility to sign the document when the resident fills out this form. 3) On 04/24/24 at 10:30 AM reviewed R40's EHR and hard medical record for AHCD and none was found. R40 is an [AGE] year old resident admitted to the facility on [DATE]. Review of R40's EHR found his diagnosis includes, but is not limited to, vascular dementia, unspecified severity, with agitation. Review of R40's last quarterly MDS dated [DATE] found he had a BIMS with a score of 00 out of 15 identifying him with severe impairment. On 04/26/24 at 09:30 AM met with and interviewed SW who was able to provide a copy of R40's POA which is only for financial. SW confirmed R40 did not have an AHCD. Reviewed copy of Declaration of Authority to Act As A Surrogate form which the front is only completed, back of the form, which the physician would fill out to state resident does not have capacity, is not filled out. SW confirmed R40's copy of Declaration of Authority to Act As A Surrogate form was not fully filled out with the back of the form left blank. SW confirmed there is no documentation the physician was asked to fill out the form.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a clean, comfortable and homelike environment, as evidenced by uncomfortable temperatures in Resident (R) 283's and R284's room(s), and splatters on the kitchen ceiling. In addition, the facility failed to exercise reasonable care for the protection of one resident's clothing from loss, as evidenced by Resident (R)32's complaint that so many of her clothing pieces were not returned to her from laundry that she now had her family doing her laundry. This deficient practice has the potential to affect all the residents at the facility. Findings include: 1) On 04/23/24 at 09:39 AM, made observation of R283 and R284 in their room. R283 was observed to have at least four blankets covering her with a blanket covering her head. R284 was observed sleeping covered with two blankets up to her neck. The blow of the cold air conditioner could be felt when entering the room. The thermostat read 71 degrees Fahrenheit (F). On 04/23/24 at 12:43 PM, observation and interview with R283 and R284 was done in their room. Observed the air conditioner to be off. R283 reported she seems to be always cold, especially at night and early morning. It gets so cold she covers her face and uses multiple blankets. During the day, currently, it is usually comfortable. R284 concurred the room gets very cold during the night and in the early morning. On 04/24/24 at 11:03 AM, made observation of R283 and R284's room. R283 was not in her room, but R284 was sleeping with two blankets covering her from neck to toes. The blow of the cold air conditioner could be felt when entering the room. The thermostat read 71 degrees F. On 04/25/24 at 08:42 AM, observation and interview with R283 and R284 was done in their room. Observed the air conditioner to be off. R283 reported she believes a staff member turns on the air conditioner when providing assistance to them because it is too hot for the staff member, but then does not turn it off, making the room very cold at times. R284 reported she does not mind having the air conditioner on but wants it at a comfortable temperature and not blasting cold air. R284 stated 76 degrees would probably be more comfortable. On 04/25/24 at 01:46 PM, an interview with Certified Nursing Aide (CNA) 31 was done. CNA31 stated R283 and R284's will report the room is cold to her and had noticed R283 blankets covered all the way to her head. On 04/25/24 at 01:48 PM, an interview with Registered Nurse (RN) 12 was done. RN12 reported R283 and R284 will complain if the temperature is too cold and had to turn it down for them yesterday. RN12 noticed R283 wears a lot of blankets. Review of the facility's policy and procedure Resident Rights reviewed on 09/25/23, The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safety. 2) On 04/23/24 at 08:06 AM, during the initial observation of the facility's kitchen with Food Service Director (FSD), observed multiple, various sized light brown splatters, some as big as a quarter, on the ceiling around the speaker in the kitchen. Inquired with FSD what the splatters were, FSD reported he did not know but called someone to clean it this morning. On 04/25/24 at 11:51 AM, a second observation of the kitchen was done. Observed the splatters from the ceiling to be cleaned. Inquired with a dietary staff member, how long had the splatters been there. The dietary staff member stated, a couple of months and someone had been called to help clean the splatters after this surveyor pointed it out on 04/23/24. Inquired with Registered Dietician (RD) 1, the kitchen cleaning schedule, concurrently observed the cleaning schedule on the bulletin board with weeks not completely signed off. The cleaning schedule did not include cleaning the ceiling, inquired with RD1 if maintenance is responsible for cleaning the ceilings if there are food splatters, RD1 reported it would be dietary staff. Review of the facility's policy and procedure Cleaning Schedule reviewed on 04/25/23, The Director of Food and Nutrition Services develops a cleaning schedule, with assistance from the Registered Dietician, to ensure that the Food and Nutrition Services department remains clean and sanitary at all times. 3) Resident (R)32 is a [AGE] year-old female admitted to the facility on [DATE] for short-term rehabilitation therapy (therapy) following a fall with resulting fractures. R32's admitting diagnoses include, but are not limited to, fractures of her hip and pelvis with surgical intervention, hypertension (high blood pressure), anxiety, insomnia, constipation, and urinary retention. Review of R32's Minimum Data Set (MDS) admission Assessment with an Assessment Reference Date (ARD) of 03/11/24 noted that R32 was evaluated as having a score of 14 out of 15 for her Brief Interview for Mental Status exam, reflecting a determination of cognitively intact. On 04/24/24 at 10:57 AM, and interview was done with R32 at her bedside. R32 stated that when she was first admitted , the facility would wash her clothes for her. She quickly realized that several articles of clothing were not returned to her. When she reported it to facility staff, she was told that she or a family member could go to the laundry room and look through the missing clothes kept there. R32 stated that her daughter had gone to look a couple times but never found her missing items, so now her daughter takes all her clothes home to wash. On 04/26/24 at 01:22 PM, an interview was done with the Housekeeping Director (HD) in the laundry room. HD explained that residents are instructed to label their own clothing. Sometimes the facility staff may assist residents with labeling their clothes. When asked to show a sample of a properly labeled clothing item, HD provided Surveyor with a woman's top that had the resident's name written in faded black ink on the inside behind the neck area. HD confirmed they recommend using a black permanent marker for labeling. When asked about the process, HD reported that if clothes are 'unlabeled [with a name]', they are placed with the 'missing laundry.' HD explained that missing laundry is placed on a large metal cart, both hanging and folded, of clothing and linen, kept in the back of the laundry room. HD stated that the items stay on the cart for 3 months, then if unclaimed, they are donated to the facility. HD further explained that when a resident says they have missing laundry, laundry staff check the missing laundry cart for the missing items. If the missing items are not on the cart, they let the resident know and invite the resident or family to come in and look for themselves. HD reported that he does not keep track of or log which residents were missing laundry, or what their missing items were. On 04/26/24 at 02:45 PM, an interview was done with the Social Worker (SW) in the Conference Room. When asked about what process is followed when a resident reports missing laundry, SW explained that usually it is a Certified Nurse Aide (CNA) that gets report of missing laundry. The CNA then would notify nursing staff and the unit managers (UMs), and they would look for the missing items. If not located, the Director of Nursing (DON) or UM would notify SW. SW stated she would then investigate the missing item(s) and document the incident on a blue comment card. If it is appropriate to replace the missing items, SW would be responsible for that. SW stated she could not recall being notified that R32 was missing laundry and confirmed that she did not fill out nor did she see a blue comment card for her. A review of the facility policy and procedure, Closet Search - Lost and Unmarked Clothing, last revised 09/24/21, revealed the following: 1. A concern and comment form [blue comment card] should be completed, as appropriate, and turned into the Environmental Services Director [HD] or Social Services [SW] . 2. Using the description given for the lost article of clothing, the Laundry Department will go to each room and search through every closet. Of note is HD seemed unaware of a closet search and only described checking the missing laundry cart when interviewed by the Surveyor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) R7 was transferred and admitted to the hospital twice on 03/04/24 to 03/06/24 and 03/21/24 to 03/25/24 with diagnosis of stroke. A review of R7's Electronic Health Record (EHR) found no documentation that a written notification for transfer to the hospital was provided to R7 or her representative for both hospitalizations. On 04/26/24 at 10:47 AM, an interview with Administrator was done. Administrator reported the facility did not give written notification for transfer/discharge to R7 or her representatives and to the State Long-Term Care Ombudsman for both hospitalizations. 3) R29 was discharged home on [DATE] due to Notice of Medicare Non-Coverage effective 04/18/24. A review of R29's EHR found no documentation that a written notification for discharge was provided to R29 or his representative. On 04/26/24 at 10:47 AM, an interview with Administrator was done. Administrator reported the facility did not give written notification for discharge to R29 or his representatives and to the State Long-Term Care Ombudsman. Based on interviews and record reviews, the facility failed to ensure written notification of discharge was provided to the resident or resident representative as soon as practicable before transferred or discharged and send a copy of that notice to a representative of the Office of the State Long-Term Care Ombudsman for three Residents ((R)25, R7, and R29) sampled. Findings include: 1) Conducted a review of R25's EHR on 04/23/24 at 10:28 AM which documented R25 was transferred and admitted to an acute hospital, twice, on 01/01/24 to 02/21/24 and 02/24/24 to 03/05/24. Review of the R25's EHR did not contain documentation of a written notification. Requested the Administrator provide documentation of the written notification to R25's resident representative and the Office of the State Long-Term Care Ombudsman for both times R25 was transferred to an acute hospital. On 04/25/24 at 04:15 PM, the Administrator provided an email which documented an email was sent to R25's resident representative on 02/26/24, two days after the resident was discharged to an acute hospital. Administrator confirmed no written notification was sent to R25's resident representative when R25 was discharged to an acute hospital on [DATE] and no notice was provided to the Office of the State Long-Term Care Ombudsman for both discharges.

Based on interview and record review, the facility failed to ensure written notification of the facility's bed hold policy was provided to one of four residents sampled (Resident (R) 7) and their representative. Findings include: R7 was transferred and admitted to the hospital twice on 03/04/24 to 03/06/24 and 03/21/24 to 03/25/24 with diagnosis of stroke. A review of R7's Electronic Health Record (EHR) found no documentation that a written notification regarding the facility's bed hold policy was provided to R7 or her representative for hospitalization from 03/21/24 to 03/25/24. On 04/26/24 at 10:47 AM, an interview with Administrator was done. Administrator reported the facility did not give written notification regarding the facility's bed hold policy to R7 or her representative for hospitalization from 03/21/24 to 03/25/24. Review of the facility's policy and procedure Bed-Hold Policy reviewed on 08/09/23, documented The Bed-hold policy should be given upon admission, upon transfer of a resident to the hospital (if in an emergency within 24 hours), or the resident goes on therapeutic leave of absence. The facility will provide written information to the resident or resident representative the nursing facility policy on bed-hold periods and the residents return to the facility to ensure that residents are made aware of a facility's bed-hold and reserve bed payment policy before and upon transfer to a hospital or when taking a therapeutic leave of absence from the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that the Discharge Assessment for Resident (R)80 accurately reflected the resident's discharge status. Findings include: Record review done on 04/25/24 at 02:59 PM noted Resident (R)80 was admitted to the facility on [DATE] and discharged to home on [DATE]. Review of Minimum Data Set (MDS) Discharge Assessment with an Assessment Reference Date (ARD) of 02/17/24 noted R80 was incorrectly documented as discharged to Short-Term General Hospital (acute hospitals, IPPS [inpatient prospective payment system]). On 04/26/24 at 10:31 AM, an interview was done with MDS Coordinator (MDSC)3 in her office. MDSC3 confirmed that R80's Discharge Assessment had been incorrectly documented and transmitted. MDSC3 stated that R80 had been discharged home with home health services.

Based on observations, interviews, and record review, the facility failed to ensure a comprehensive person-centered care plan was implemented for one resident (Resident 6) sampled. Resident (R)6 is totally dependent on staff for all care, was observed lying in bed with no activities implemented. As a result of this deficient practice, dependent residents are at risk of a lack of sensory stimulation. Findings include: On 04/24/24 at 03:03 PM, conducted a review of R6's EHR which documented R6 was admitted to the facility with diagnosis of an intracranial hemorrhage, convulsions, quadriplegia, aphasia (loss of the ability to understand or express speech related to brain damage), with bilateral stiffness and contractures of the shoulders, hands, and knees. Review of R6's most recent annual Minimum Data Set (MDS) with an Assessment Reference Date of 03/14/24, Section GG. Functional Abilities and Goal, documented R6 has impairment of the upper and lower extremities and is dependent on staff for all care. Review of R6's activities care plan documented R6 is dependent on staff for meeting emotional, intellectual, physical, and social needs related to cognitive deficits and physical limitations. Review of R6's Interventions/Task documented an intervention to Encourage leisure interests such as listening to bedside radio, watching TV and visiting with family was added to the activities care plan on 04/14/23 and was the most recent revision. However, R6 is unable to move or express himself verbally or otherwise, so the resident is reliant on staff to turn on the radio and/or television. Review of R6's activity progress notes through 2024-2023 remain mostly unchanged and appeared to be almost template-like, with the main task rearranged in the order it is mentioned. Observation was made of R6 lying in bed, in the resident's assigned room, without any music, television, or other form of entertainment on 04/23/24 at 08:39 AM, 09:10 AM, 09:45 AM,10:03 AM, 10:55 AM 11:40 AM, 12:03 PM; 04/24/24 at 09: 13 AM, 10:00 AM, 12:12 PM, and 01:57 PM; and 04/25/24 at 08:44 AM and 10:32 AM. On 04/26/24 at 10:50 AM, conducted an interview with an anonymous staff (AS)2. AS2 confirmed R6 is dependent on staff to turn on the radio or television and if staff is unable to turn it on because they are busy, or if they forget, then R6 is lying in bed with no form of stimulation for most of the day. AS2 reported being busy with other residents on 04/23/24 and confirmed the radio or television was not on unless the resident's roommate was in the room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure a resident's medical record was accurate for one resident (R)6 sampled. R6's hard medical record chart located in the nursing station contained a Physician Orders for Life Sustaining Treatment (POLST) which documented in the event of a medical emergency, R6 should receive cardiopulmonary resuscitation. However, a POLST located in the unit's POLST binder contained a POLST which documented R6 as Do Not Attempt Resuscitation (DNAR). Findings include: On [DATE] at 10:08 AM, conducted a review of R6's electronic health record (EHR). Review of R6's physician's orders documented an order to Do Not Attempt Resuscitate- Full Treatment (ordered on [DATE]). Review of an acute hospital's hospitalist discharge summary ([DATE]) documented .Given patient's multiple medical comorbidities, discussed that if an event were to occur where the patient (R6) would need to need CPR, prognosis would be poor. [Family Member (FM)1] in agreement, patient to be DNAR, okay with emergency protocols . Review of the acute hospital's pulmonary/critical care history and physical ([DATE]) documented R6's code status, FULL SUPPORT patient has POLST done 10 years ago expressing DNR preference and [FM] wanted to honor this but after talking with patient's (R6) [FM2], FM1 changed to full code . On the afternoon of [DATE], requested with Social Worker (SW) for R6's AHCD. On [DATE], SW provided R6's POLST and surrogate decision maker documentation. Review of the POLST provided documented R6's code status is DNR-Full Treatment. At 12:04 PM, conducted a review of R6's POLST, located in the resident's hard chart in the nursing station, with SW and Social Worker Assistant (SWA)1, which documented R6 should receive CPR and the marked DNAR box had a strike through it with error [illegible initial] per [FM1], witnessed conversation w(with)/MD (Medical Doctor). SW and SWA1 could not identify the who had initialed the strike through the DNAR box. On the counter located above resident's hard chart was a unit binder labelled POLST. Review of R6's POLST in the unit POLST binder documented R6 was DNAR, and this form was not altered. Inquired with SW and SWA1 as to why there were two different POLST for R6 and which POLST was valid. SW and SWA1 could not provide an immediate answer and needed time to investigate the situation. Compared both POLST forms and SW confirmed it is the same forms, however, the original POLST form was altered when R6's code status was changed to receive CPR. At 02:59 PM, SW confirmed R6's hard chart contained the wrong POLST and if there are any changes made to a resident's POLST, a new POLST should be completed instead of revising the original document.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standard of practice, the comprehensive person-centered care plan, and the resident's choices, for 5 of 21 Residents (R32, R231, R22, R2, and R47) sampled. As a result of this deficient practice, the residents were placed at an increased risk for avoidable declines and/or injuries. This deficient practice has the potential to affect all the residents at the facility. Findings include: 1) Resident (R)32 is a [AGE] year-old female admitted to the facility on [DATE] for short-term rehabilitation (rehab) following a fall with resulting fractures. R32's admitting diagnoses include, but are not limited to, fractures of her hip and pelvis with surgical intervention, hypertension (high blood pressure), anxiety, insomnia, constipation, and urinary retention. Review of R32's Minimum Data Set (MDS) admission Assessment with an Assessment Reference Date (ARD) of 03/11/24 noted that R32 was evaluated as having a score of 14 out of 15 for her Brief Interview for Mental Status (BIMS) exam, reflecting a determination of cognitively intact. On 04/24/24 at 11:02 AM, an interview was done with R32 at her bedside. R32 complained that sometimes no bowel movement for 5 days, they do nothing, then all of a sudden they come in 3 times a day. When asked to elaborate, R32 explained that she has had a problem with constipation since before admission, and regularly takes medication at home for it. Since she got here, she has had days go by with no bowel movement, has experienced and complained of abdominal discomfort, but felt like the staff doesn't really pay attention to that. R32 stated that once she had 5 days of constipation and not much was done. A review of R32's electronic health record (EHR), specifically her bowel movement log, revealed that there was no bowel movement documented from 04/07/24 to 04/13/24 at 05:17 PM, a period of more than 6 days. A review of her physician orders noted the following: Bisacodyl (a laxative) Suppository 10 milligrams (mg) as needed for constipation if no results from Lactulose. Lactulose (a laxative) 30 milliliters (ml) as needed for constipation if no bowel movement for 3 days. Polyethylene Glycol (a laxative) Powder 17 grams once a day for constipation. Senna Plus (a laxative plus stool softener) 8.6-50 mg two times a day for constipation. Tap water enema 240 ml rectally as needed for constipation if Lactulose and suppository are ineffective. A review of R32's Medication Administration Record (MAR) for April notes the as needed Lactulose was given once on 04/10/24 and twice on 04/12/24. All 3 doses were marked as ineffective [in resulting in a bowel movement]. Also noted was that there were no Bisacodyl suppositories or Tap Water enemas administered in the month of April. On 04/26/24 at 12:08 PM, an interview was done at the Nurses' Station with Unit Care Coordinator (UCC)3 regarding R32. UCC3 agreed that given her opioid pain medication, admitting diagnosis of constipation, and that she was not ambulating very much, constipation should be expected and monitored for. During a concurrent review of R32's bowel movement log, UCC3 expressed surprise that R32 had gone 6 days with no bowel movement in April. UCC3 agreed that either a Bisacodyl suppository should have been administered on 04/10/24 after the Lactulose had been marked as ineffective, or there should be documentation as to why it was not administered. After a review of the MAR and nurse progress notes, UCC3 confirmed there was no indication/documentation that the constipation the Lactulose had been given for three times in April, had been treated and managed as it should have been. A review of the facility's Bowel Protocol policy and procedure, last revised 09/12/23 revealed the following: The facility in coordination with the resident's attending practitioner will implement standing orders to address a lack of bowel movement. 2) R231 is a [AGE] year-old female admitted to the facility on [DATE] for short-term rehab. Review of her EHR noted she was admitted with lower leg edema (when the tissues or blood vessels in your legs hold more fluid than they should) at a level of +4 (the most severe type of edema), as determined by the Nurse Practitioner (NP)1 at her admission assessment. On 04/23/24 at 09:44 AM, an interview was done with R231 at her bedside. R231 stated she had been at the facility for 2 weeks. Observed R231 with a cast to her lower right leg and moderate to severe swelling visible to both feet. R231 was sitting up in bed with the head of the bed at an 80-degree angle, with both lower legs extending straight out from her hips in approximately a 90-degree angle, resting on the bed. When asked about elevating her lower legs because of the swelling, R231 pointed to one flattened pillow at the foot of her bed and stated that was all she was given to elevate her lower legs and that just doesn't cut it, so she hadn't bothered putting it under her legs. On 04/23/24 at 03:52 PM, observed R231 sitting outside in the sun in a wheelchair with no footrests. When asked about the footrests so that she might elevate her feet while sitting, R231 stated she (facility staff) took them back to the room. R231's left ankle was still visibly swollen along with her right foot and toes. On 04/24/24 at 08:23 AM, a review of R231's EHR noted that despite being admitted with edema, numerous nurse progress notes documenting edema to both lower legs, and being sent out to the emergency room on [DATE] for increased edema, there was neither a care plan initiated for the edema, nor were there active provider orders to address the edema such as to keep her lower legs elevated, monitor and document level of edema, or apply compression stocking(s). On 04/26/24 at 11:04 AM, an interview was done with the Director of Nursing (DON) in the Conference Room. The DON agreed there should have been a care plan initiated for R231's lower leg swelling, especially considering that the facility did identify the swelling as a problem. The DON explained that when she spoke to staff, they told her they always encouraged R231 to elevate her legs, however she confirmed that the documentation did not reflect that. The DON also agreed that the nursing staff should have been consistently monitoring and documenting the amount of swelling instead of only documenting its presence. A review of Patient Education: Edema (swelling) (Beyond the Basics), by [NAME] H [NAME], MD, found at https://www.uptodate.com/contents/edema-swelling-beyond-the-basics/print, and current through August 2023, revealed the following: Leg, ankle, and foot edema can be improved by elevating the legs above heart level for 30 minutes three or four times per day. 5) On 04/23/24 at 08:32 AM, smelled a strong urine odor as this surveyor approached the entrance to R47's room. While at the doorway, observed R47 had a covered catheter bag hanging from the bedframe (on the side closest to the doorway) and the catheter tubing was visibly cloudy. After entering the R47's room, the strong urine odor intensified, observed R47 sitting upright in bed, doing a nebulizer breathing treatment. Made a closer observation of R47's catheter tubing which revealed the entire catheter tubing was cloud with multicolored (white, gray, brown, and reddish) sediment the entire length of the visible catheter tubing. Inquired with R47 about the strong urine smell and the resident confirmed the urine odor was strong and stated, I think it's coming from the catheter. R47 confirmed all meals are eaten in the room and the smell is always there, I just got used to it, but maybe my visitors might not want to stay as long with that smell. R47 confirmed the Foley catheter is for long-term use because the resident has difficulty breathing, especially when having to lay flat when changed due to incontinence. R47 looked at the tube and stated, It's dirty (catheter tubing), they haven't changed it in awhile. On 04/24/23 at 11:08 AM, observed the hospice nurse (HS)1 in R47's room finishing up a physical assessment of the resident. R47's catheter bag and tubing remained unchanged, and the strong urine odor was still present. On 04/24/24 at 02:13 PM, conducted a review of R47's EHR which documented the resident was admitted to the facility on [DATE] and started receiving hospice services on 04/12/24 with diagnosis which include end stage COPD, abnormal weight loss, and a lung mass with the life expectancy of less than six (6) months if disease progresses as expected. Review of R47's most recent quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/02/24, Section C. Cognitive Patterns, Brief Interview for Mental Status (BIMS) score was 15, indicating the resident's cognition is intact and is a reliable source of information. Section H. Bladder and Bowel, documented R47 has an indwelling catheter. Review of the physician's orders documented an order for Indwelling catheter to straight drainage size 18 Fr (French) bulb: 10 cc. Change for leakage or obstruction every day shift starting on the 20th and ending on the 20th every month for Foley care (ordered on 06/22/23 and started on 07/20/23). Other orders related to providing care for R47's Foley catheter included, change for leakage or obstruction, catheter care with warm water and soap, flush with 100cc of sterile water for increased sediment/low urine output, and implementation of enhanced barrier precautions for the resident's Foley catheter. Review of R47's March 2024 and April 2024, Medication Administration Record (MAR) documented on 03/19/24 and 04/20/24 the indwelling catheter was changed. On 04/25/24 at 02:00 PM, conducted a concurrent interview and record review of R47's EHR with Registered Nurse Unit Care Coordinator (UCC)2. Inquired with UCC2 when R47's Foley catheter bag and tubing was last changed. UCC2 reviewed the April 2024 MAR and confirmed nursing staff documented the Foley catheter bag and tubing was changed on 04/20/24. UCC2 stated according to the orders the Foley catheter is not changed unless it is obstructed or leaking and there is an order to flush with sterile water for sediment. At 02:08 PM, UCC2 and this surveyor went to look at R47's Foley catheter bag and tubing. Prior to entering the room, inquired about the strong urine odor coming from and in the resident's room. After investigating the dirty linen bins in the hallway and the soiled laundry room, UCC2 concluded the urine smell was coming from the catheter bag privacy cover. UCC2 stated the privacy bags are not routinely changed and if the clamp is not sealed tightly or there is residual urine in the tubing when it is placed back into the privacy bag, the inside of the privacy bag could be soiled with urine. UCC2 confirmed the strong urine odor in R47's room was not a homelike environment for R47, especially because the resident eats all meals in bed and rarely leaves the room. UCC2 inspected the Foley catheter tubing and confirmed the tubing had a lot of sediment, so much sediment that it could potentially have a negative outcome for the resident and needed to be changed immediately. Then UCC2 pulled the catheter bag out of the privacy cover and the bag was labeled, Change foley set 3/19/24. UCC2 confirmed during review of the April 2024 MAR, staff documented the catheter was changed on 04/20/24. Also, R47 showed us the sticky pad (used to adhere secure a portion catheter tubing to the resident's leg to minimize damage to the resident's urinary structures which are in contact with the catheter) on the resident's left thigh was starting to peel off of the resident's leg. UCC2 confirmed the R47 could potentially be harmed if the catheter tubing was to be forcefully pulled on. UCC2 followed-up with staff who documented (on the April 2024 MAR) the Foley catheter was changed on 04/20/24 and this surveyor was informed, the responsible staff did not change the Foley bag and tubing because there was no obstruction or leakage, and the MAR was marked as done to indicate the Foley catheter was inspected for obstruction and leakage. UCC2 confirmed staff signing off on the MAR indicated the Foley catheter system was changed. UCC2 also confirmed R47's physician orders only addressed changing the Foley catheter for obstruction and leakage but did not include clinical indications, such as visible sediment in the catheter tubing. The facility contacted the nurse practitioner and got a new physician's order which included changing the Foley catheter for clinical indication. Review of the facility's policy and procedure, Indwelling Urinary Catheter (Foley) Management (last reviewed on 08/24/23) and the Center for Disease (CDC) guideline for the prevention of Catheter-Associated Urinary Tract Infections (CAUTI), III. Proper techniques for Urinary maintenance, documented, .it is suggested to change catheter and drainage bags based on clinical indication. However, literature review on the National Institutes of Health (NIH) indicated the long-term use (one month or more) of indwelling catheters should also include the manufacturer's recommendations, which may include recommended changes every 30-days. 3) On 04/23/24 at 01:38 PM interviewed R22 who is a [AGE] year old resident admitted to the facility on [DATE]. Inquired if R22 ever has constipation or diarrhea and she stated she has had diarrhea, sometimes it takes her two times for her to use the toilet to empty her bowels. On 04/24/24 Record Review (RR) of R22's last quarterly Minimum Data Set (MDS) dated [DATE] found she had a Brief Interview for Mental Status (BIMS) with a score of 15 out of 15 identifying her as cognitively intact. During RR of R22's last quarterly MDS dated [DATE], found she is continent (uses the toilet) of bowel and bladder and rated 02 = Substantial/maximal assistance - Helper does MORE THAN HALF the effort for toilet transfer, making R22 dependent upon staff to assist her onto the toilet. R22's diagnoses include, but are not limited to, constipation, unspecified, history of falling, and heart failure unspecified. During RR of R22's EHR found the resident had the following physician's ordered medication to help prevent constipation: polyethylene glycol 3350 powder give 17 gram by mouth one time a day for constipation with breakfast. Dissolve in 8 oz of liquid. Hold for loose stools ordered on 08/11/23 and Senna-Docusate Sodium Oral tablet 8.6 - 50 mg (Sennosides-Docusate Sodium) give 1 tablet by mouth one time a day for Constipation hold for loose stools ordered on 11/08/23. Both medications were given every day from 04/01/24 - 04/24/24. Review of R22's documented bowel movements (BM's) found she had four loose BM's on 03/31/24 at 11:03 AM, 04/02/24 at 10:02 AM, 04/14/24 at 03:37 PM, and 04/23/24 at 06:27 PM. On 04/25/24 at 08:34 AM observed medication pass by Licensed Practical Nurse (LPN) 5 to R22. LPN5 gave R22 her Senna-Docusate Sodium Oral tablet 8.6 - 50 mg tablet and polyethylene glycol 3350 powder 17 gram that was dissolved in water. At this time LPN5 did not ask R22 if she had any loose stools and was not observed reviewing R22's EHR for documentation of her last BM. On 04/25/24 09:07 AM interviewed LPN5 and asked if she would ask the resident if she had loose stools before giving medication that states hold for loose stools. LPN5 said no that R22 knows her medications and would tell her if she had a loose stool and that R22 is very vocal. LPN5 stated the CNA's (Certified Nurse Assistants) report if the residents have loose stools to her. 4) On 04/24/24 at 09:46 AM interviewed R2 who is a [AGE] year old resident who was admitted to the facility on [DATE]. Inquired if she has a history of constipation or diarrhea. R2 stated sometimes she has diarrhea and has told staff she does not want to take the Miralax (brand name for polyethylene glycol 3350 powder) but the staff give it with her medications. On 04/24/24 RR of R2's last quarterly MDS dated [DATE] found she had a BIMS with a score of 15 out of 15 identifying her as cognitively intact. Review of R2's functional abilities, under section GG of the MDS, found she was rated 01 for toileting hygiene which means she is dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. R2's EHR found her diagnoses include, but are not limited to, constipation, unspecified, unspecified glaucoma, history of falling and muscle weakness (generalized). During RR of R2's EHR found the resident had the following physician's ordered medication to help prevent constipation: polyethylene glycol 3350 powder (polyethylene glycol 3350 (bulk)) give 17 gram by mouth two times a day for Constipation HOLD for loose stools ordered on 02/13/24 and senna oral tablet 8.6 MG (Sennosides) give 1 tablet by mouth in the evening for Constipation; HOLD for loose stools ordered on 08/25/23. On 04/26/24 at 10:43 AM Review of R2's documentation of BM's found from 04/01/24 - 04/25/24 she had 33 loose stools and 7 putty like BM's. During this time reviewed R2 did not have any formed bowel movements. A review of her medications found she received 42 of 51 doses of polyethylene glycol 3350 from 04/01/24 -04/25/24 with 9 doses held and not given. Review of R2's Senna oral tablet given in the evening found R2 received 23 of 25 doses with only 2 doses held and not given. On 04/15/24 R2 received 2 doses of polyethylene glycol 3350 powder and a dose of senna and had four documented loose stools that day at 05:55 AM, 09:41 AM, 11:41 AM and 07:05 PM. R2 also received the 2 doses of polyethylene glycol 3350 powder and a dose of senna the next day. R2 had loose stools 21 days out of 25 days reviewed from 04/01/24 -04/25/24. 04/26/24 at 10:54 AM interviewed Registered Nurse Unit Care Coordinator (UCC) 2 and reviewed R2's documented BM's with her. UCC2 confirmed R2's documented BM's showed R2 had loose stools documented for almost all of April 2024. Inquired if she would ask R2 if she had a loose BM prior to giving medication that states hold for loose BM and UCC2 confirmed she would ask the patient, assess if she had a loose stool before giving these medications. On 04/26/24 at 11:17 AM interviewed DON. Reviewed R2's BM's for April 2024 and she confirmed the resident should not have been given the medications (polyethylene glycol 3350 powder and senna oral tablet) because of the documented loose stools. On 04/26/24 at 01:35 PM interviewed UCC2. Inquired what would happen to the resident if R2 continued to have loose stools and UCC2 stated the resident could experience dehydration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) On 04/23/24 at 11:51 AM, during a tray line observation in the kitchen, observed an unsampled resident's order form with ordered diet, dislikes, likes, and preferences indicated on the form. The form included the preference service sandwiches on hot plate. Observed the sandwich on the resident's tray not on a hot plate. Registered Dietician (RD) 1 was observed to check the order form twice prior to announcing the cart was ready to go on the unit at 12:15 PM. After RD1 announced the cart was ready to go, inquired with RD1 if the resident's plate was on a hot plate and if it was her preference, both RD1 and FSD reviewed the order form and FSD announced to dietary staff at the tray line that they did not put the sandwich on a hot plate. Based on observation, interview, and record review, the facility failed to support and honor the food preferences of one resident (R) in the sample, and one unsampled resident. This deficient practice has the potential to impact all the residents at the facility with food preferences. Findings include: 1) Resident (R)33 is an [AGE] year-old female admitted to the facility on [DATE] for short-term rehabilitation therapy (rehab) following a left hip fracture. R33's admitting diagnoses include, but are not limited to, congestive heart failure, hypertension (high blood pressure), and chronic obstructive pulmonary disease (COPD). Review of R33's Minimum Data Set (MDS) initial 5-day assessment with an Assessment Reference Date (ARD) of 04/01/24 noted that R33 was evaluated as having a score of 13 out of 15 for her Brief Interview for Mental Status (BIMS) exam, reflecting a determination of cognitively intact. On 04/23/24 at 11:25 AM, an interview was done with R33 at her bedside. When asked about unintended weight loss, R33 stated [I] think I lost 6 - 8 pounds since getting here. R33 explained that sometimes she cannot eat the food she is given because the texture is off-putting. R33 stated that for example, she gets oatmeal and mush [a hot porridge] for breakfast a lot, and she will not eat it. R33 stated she has told staff 4-5 times that she doesn't eat oatmeal/mush and has asked that they stop giving it to her, but she still gets it. A review of R33's electronic health record (EHR) revealed her measured weight on admission was 186.4 pounds. Her last measured weight taken on 04/22/2024 was 180.6 pounds, reflecting a 5.8 pound or 3.11% weight loss in less than a month. On 04/25/24 at 08:27 AM, concurrent interview and observation was done with R33 at her bedside. R33 stated there was mush on her breakfast tray, I told them no put mush, they still give me. Observation of R33's meal ticket sitting on her breakfast tray noted that on the left side of the ticket, under Allergies/Dislikes, CEREAL was bolded and at the top of the list. On the right side of the ticket, under Preferences, NO CEREAL was bolded and the second item on the list. On 04/25/24 at 04:04 PM, an interview was done with the Food Service Director (FSD) in his office. FSD confirmed that he was aware that R33 does not like cereal. When asked what cereal means with regards to facility meals, FSD answered that cereal could mean either oatmeal or a hot porridge. FSD stated that he checked the meal tickets himself as the trays were being made that morning and confirmed that R33 should not be receiving oatmeal or hot porridge on her tray. On 04/26/24 at 08:52 AM, conducted a second interview with FSD in his office. FSD explained that with regards to R33's meal ticket, because cereal was listed on the ticket in two places (under Dislikes and Preferences), it shows that it was already a problem of not honoring that preference. Ideally, it should just be there one time, but when there are complaints of it not being followed, he adds it to the ticket in two spots to increase the chance of it being seen. FSD stated he has now added the no cereal preference to R33's meal ticket in a third spot.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure appropriate protective and preventive measures to prevent the transmission of communicable diseases and infections. This is evidenced by the facility failing to ensure staff followed transmission-based precautions (TBP) by wearing the proper personal protective equipment (PPE) and performing the proper form of hand hygiene at all appropriate times while caring for Resident (R)33. In addition, the facility failed to assure staff performed hand hygiene between glove changes while performing perineal care (cleaning genital and anus area) for R131. These deficient practices have the potential to affect all residents in the facility, as well as all healthcare personnel, and visitors at the facility. Findings include: 1) Resident (R)33 is an [AGE] year-old female admitted to the facility on [DATE] for short-term rehabilitation therapy (rehab) following a left hip fracture. R33's admitting diagnoses include, but are not limited to, congestive heart failure, hypertension (high blood pressure), and chronic obstructive pulmonary disease (COPD). On 04/21/23 R33 was placed on contact enteric precautions for a symptomatic and confirmed clostridium difficile infection (C-diff a highly transmissible bacterial infection that can cause diarrhea and an inflammation of the colon). On 04/23/24 at 09:24 AM, observed a contact enteric precautions sign posted outside R33's room door. The sign provided the following instructions: Everyone Must: Clean hands with sanitizer when entering room and wash with SOAP AND WATER upon leaving the room. Doctors and Staff Must: Gown and glove at door. Use patient dedicated or disposable equipment. Clean and disinfect shared equipment. On 04/23/24 at 12:30 PM, observed Registered Nurse (RN)1 deliver lunch tray to R33 as she took in her noon-time medications. Observed R33's lunch was not in disposable containers and was carried in on a non-disposable tray. On 04/23/24 at 02:48 PM, observed Certified Nurse Aide (CNA)3 doff her PPE at the doorway prior to exiting R33's room, however she did not wash her hands, and instead used alcohol-based hand rub (ABHR) to clean her hands after she exited. Surveyor stopped CNA3 and asked her what type of hand hygiene should be performed before exiting R33's room. CNA3 apologized and stated she should have washed her hands with soap and water. On 04/24/24 at 11:17 AM, observed RN21 administer medications to R33 in her room, doff his PPE at the doorway prior to exit, then walk out of the room with no hand hygiene at all. Surveyor immediately stopped RN21 and insisted he return to R33's room to wash his hands. RN21 acknowledged the importance of proper hand hygiene due to R33's level of TBP, apologized, and returned to the room to wash his hands. On 04/25/24 at 09:20 AM, informed CNA31 that R33 had requested ice and explained that due to her TBP, her water pitcher could not be carried out of her room, so the ice had to be carried in separately. At 09:23 AM, observed CNA31 carry R33's water pitcher out of her room, take it to the nourishment room to fill it with ice, then return to R33's room with the same pitcher. As she re-entered R33's room, R33 did not don a gown, only a pair of gloves. Observed R33 deliver the water pitcher filled with ice, then pick up R33's non-disposable breakfast tray from her bedside table and exit the room without performing any type of hand hygiene. CNA31 carried the breakfast tray across the hall and discarded all the disposable containers that were on the tray into the trash can. At 09:26 AM, interviewed CNA31 in the hall outside of R33's room as she held the now empty non-disposable breakfast tray. Inquired what PPE should be worn when entering R33's room. CNA31 answered that because R33 had C-diff, she only needed to don a gown when she was toileting her. Asked about hand hygiene, CNA31 admitted that she did not wash her hands and would do it right away. At 09:28 AM, followed CNA31 from our interview in the hall, down the hallway to the kitchen where she returned R33's non-disposable breakfast tray. CNA31 still had not washed her hands and observed her touching door handles and doors along the way. On 04/25/24 at 10:08 AM, an interview was done with the Infection Preventionist (IP) in her office. IP confirmed that staff should be donning gown and gloves when entering R33's room for any reason and should always be washing their hands with soap and water prior to exiting. IP agreed that CNA31 should not have carried R33's water pitcher out of the room and should have instead carried the ice in. IP also explained that R33's meals should be delivered in disposable containers on a disposable tray, however for transport from the kitchen to the room, the entire tray was placed on a non-disposable tray. IP reported that staff should know to leave the non-disposable tray on the transport cart and only take the disposable meal items into the room. A review of the facility's policy and procedure, Clostridium (Clostridioides) Difficile (CDI), last revised 06/20/23, revealed the following: 2. A resident diagnosed with CDI should be placed in a single room on Contact Precautions. 7. Meal trays should be bagged prior to removal from the room . 8. Healthcare personnel caring for patients on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. 9. Actively promote adherence to hand hygiene among healthcare personnel, patients, and visitors in patient care areas affected by C-diff. a.Wash hands with non-antimicrobial soap and water or with antimicrobial soap and water if contact with spores (e.g., C. difficile .) is likely to have occurred.2) On 04/23/24 at 12:38 PM overheard a nurse request Certified Nursing Assistant (CNA) 24 help change R131's adult brief. CNA24 went to R131's room and told resident she will help her right after she assists another resident. CNA24 went to help deliver a resident's lunch tray and open it up for him. CNA24 performed hand hygiene by using the hand sanitizer. On 04/23/24 at 12:42 PM CNA24 returned to R131's room and was observed putting on gown, gloves and mask for Enhanced Barrier Precautions (EBP) with this resident. At this time interviewed CNA24 and asked why R131 had EBP and she stated R131 has EBP for open wounds. On 04/23/24 at 12:46 PM observed CNA24 provide perineal care and adult brief change for R131. CNA24 gathered her supplies. During the interaction CNA24 asked resident if it was ok to lower her back and raise her bed. Curtains were drawn for privacy. During perineal care CNA24 was observed taking off a glove and then putting on a new one, no hand hygiene was performed. On 04/23/24 at 12:58 PM interviewed Registered Nurse (RN) Unit Care Coordinator (UCC) 2 and inquired if staff are to perform hand hygiene between glove change and she confirmed staff are expected to do hand hygiene once they take off gloves and throw them away. On 04/23/24 at 01:01 PM interviewed CNA24 who confirmed she is supposed to use hand sanitizer after she takes her glove off, before putting on a new glove.

Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety. Findings include: On 04/23/24 at 08:06 AM, during the initial tour of the facility's kitchen with Food Service Director (FSD), inquired with FSD if the facility labels food items when the arrive at the facility, FSD reported they label food items when they arrive and when they open them. Observed in the small prep-refrigerator, juice refills of apple juice, orange juice, cranberry juice, and passion orange guava juice for a juice dispenser without a label when the juice arrived. Inquired if the juice had a use-by date, FSD was not able to locate the date on the juice refills. Further observed three boxes of fudge brownie mix, with no use-by-date or date when the facility received the items. Review of the facility's policy and procedure, Food Safety revised on 04/26/23 documented The First In, First Out (FIFO) method is used in food storage or according to state regulations .Food is labeled with the date received if not already indicated on the item.

Based on observations and interviews, the facility failed to ensure the resident's right to self-determination through support of a resident's choice was facilitated for one of seven (Resident (R)189) residents sampled. R189 had previously selected to have miso soup with lunch and did not receive the item. As a result of this deficient practice, there is the potential for psychosocial harm. Finding include: On 05/02/23 at 12:49 PM, conducted an observation of Resident (R)189 during lunch. Review of R189's lunch ticket located on the resident's tray, documented R189 had circled and selected to have miso soup with lunch. Observation of the food items on the resident's tray revealed there was no miso soup. Inquired with R189 about the missing miso soup. R189 confirmed the circled miso soup on his/her lunch ticket indicated that the resident wanted it for lunch, but the item was not on his/her lunch tray. The resident stated that staff did not check or notice the miso soup was not his/her lunch tray. R189 stated I usually have soup with all of my meals at home, so I was really looking forward to it for lunch, it's comfort food for me, plus it helps me to warm up. That's why I picked it on my lunch ticket, it's important to me and helps me to feel good. There have been other times when I chose something for my meal and did not get the food. 05/04/23 at 1:15 PM, conducted an interview with R189 regarding the resident's lunch preferences. R189 stated he/she did not receive any soup on 05/02/23 and did not receive a bun as requested with lunch today (05/04/23). Inquired if the resident informed staff of the missing food items from his/her tray. R189 stated that he/she did not want to be a burden or cause any issues for staff and did not feel comfortable reporting the missing food items even though it was important to him/her. R189 explained that it was part of her cultural background to not complain or speak out about things. On 05/04/23 at 11:05 AM, conducted a review of R189's Electronic Health Record (EHR). Review of R189's admission Minimum Data Set (MED with an Assessment Reference Date (ARD) of 04/12/23, Section F, documented it was very important for the resident to have snacks between meals. Section C, Cognition, the resident scored a 13 on the Brief Interview for Mental Status (BIMS), indicating the resident is cognitively intact and able to make decisions. On 05/04/23 at 03:12 PM, conducted an interview with the Food Service Director (FSD) at the nursing station. Inquired with FSD regarding the facility process of checking the resident's meal trays to ensure the residents receive their preference of food. FSD explained that there are several checks of the resident's trays in the kitchen prior to going out to the unit and floor staff (CNA and Nurses) should also check the resident's trays when it is delivered to the resident. FSD stated that there is a choice card (is done daily) and will override any dislikes the resident had previously reported. Informed FSD of this surveyor's observation of R189's miso soup missing from the resident's lunch tray and of the missing bun reported by the resident today. FSD replied, residents were given his direct telephone line and can call to report any issue with the kitchen. Informed FSD of R189's cultural background and the impact of his/her cultural background that prevents the resident from speaking out. FSD responded, there are new staff in the kitchen and the kitchen will do a better job of ensuring the residents receive the food items they selected.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review (RR), the facility failed to provide written transfer/discharge notice upon hospitalization for one of three (Resident(R)88) residents sampled. Findings include: (Cross-Reference to F625 - Notice of Bed Hold Policy and Return) On 05/04/23 at 02:20 PM, conducted RR of R88's electronic health record (EHR) of hospitalization. Nursing progress notes documented R88 transferred to hospital on [DATE], but review of EHR progress notes, miscellaneous documentation, and social services notes, did not find documentation of facility providing written notice of transfer or discharge to R88 or resident's representative. On 05/04/23 at 04:16 PM, conducted an interview and concurrent RR with Administrator. The Administrator stated following R88's transfer to the hospital on [DATE], the facility informed the resident's representative by telephone but did not provide written notice of R88's transfer or discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** (Cross-Reference to F623 - Notice Requirements Before Transfer/ Discharge) 2) On 05/04/23 at 02:20 PM, conducted RR of R88's electronic health record (EHR) of hospitalization. Nursing progress notes documented R88 transferred to hospital on [DATE], but review of EHR progress notes, miscellaneous documentation, and social services notes, did not find documentation of facility providing written notice of bed-hold policy to R88 or resident's representative. On 05/04/23 at 04:16 PM, conducted an interview and concurrent RR with Administrator. The Administrator stated following R88's transfer to the hospital on [DATE], the facility informed the resident's representative by telephone but did not provide written notice of facility's bed-hold policy. Based on record review, staff interview and review of policy, the facility failed to provide written notice of bed-hold policy for two Residents (R): 1) R139 of four residents sampled, 2) R88. As a result of this deficiency, there was potential for miscommunication. Findings include: 1) Review of the Electronic Health Record indicated that R139 was transferred to the hospital on [DATE] for a fall, hip fracture. Further review did not show any written notice of bed-hold policy to the resident and/or representative. During staff interview on 05/05/23 at 09:20 AM, Admissions Assistant (Admit1) acknowledged that the facility did not provide written notification of bed-hold policy to R139 and/or representative. Admit1 also said that the facility recently started a new process to provide written notification of bed-hold policy to resident and/or representative. Review of facility policy on Discharge Process and Bed Holds read the following: Bed-hold, holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization. 483.15(d)(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (d)(1) of this section. Bed-hold policies will be provided and explained to the resident or responsible party upon admission and explained to the patient before each temporary absence. Before the resident transfers to a hospital or the resident goes on therapeutic leave, the facility will provide written information to the resident or responsible party that specifies: the duration of the state bed-hold policy, if any during which the resident is permitted to return and resume residence in the nursing facility, the reserve bed payment policy in the state plan, if any, the facility policies regarding bed-hold, in cases of emergency transfer, notice at the time of transfer means that the family, surrogate, or responsible party are provided with written notification within 24 hours of the transfer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review (RR), the facility failed to develop and implement a baseline care plan to provide effective and person-centered care of the resident that meets professional standards of quality care for one Resident (R)340. Findings include: (Cross-Reference to F697 - Pain Management) On 05/02/23 at 10:15 AM, interviewed R340. R340 underwent right knee surgery and was admitted to the facility on [DATE]. Observation of R340 confirmed swelling to the right knee and right lower leg. Regarding pain, R340 stated that staff have been providing pain medication every 4-6 hours based on resident's reported pain level but resident prefers to minimize opioid use and has been attempting to decrease amount of opioid medication taken. R340 denied being advised by care provider or facility staff of non-pharmacological or non-opioid interventions for treating pain or edema. On 05/04/23 at 10:42 AM, RR of R340's medical orders in resident's electronic health record (EHR) documented: Attempt non-med interventions prior to administering PRN pain medications: 1. Rest, 2. Reposition, 3. Diversional activity, 4. Warm/cold pack, Do not arouse from sleep. Do not exceed 3,000 mg Acetaminophen in a 24 hour period from all sources. -Order Date- 04/29/2023; Acetaminophen Tablet 325 MG, Give 2 tablet by mouth every 4 hours as needed for pain, Acetaminophen NTE 3G/24 hours-Order Date-04/29/2023; Percocet Oral Tablet 5-325 MG (Oxycodone w/ Acetaminophen), Give 1 tablet by mouth every 4 hours as needed for moderate (score 5-7), -Order Date-04/29/2023. On 05/04/23 at 12:00 PM, conducted concurrent staff interview and RR with Nurse Manager (NM)2 regarding R340 care plan for swelling and pain management. NM2 confirmed that R340's care plan did not identify non-pharmacological interventions for swelling or pain nor did the care plan include attempting non-opioid analgesic medications for pain control prior to using opioid analgesics as ordered. RR of resident's Medication Administration Record (MAR) documented that facility staff had not administered acetaminophen prior to opioid medication per physician's orders. NM2 stated that the resident's care plan should document non-pharmacological interventions for pain as well as using non-opioid medications prior to opioids.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Cross Reference to F757 (Drug Regimen is Free from Unnecessary Drugs). Facility failed to monitor for side effects of antidepressant. R4 is an [AGE] year-old resident admitted on [DATE]. Diagnoses include diabetes (high blood sugar), congestive heart failure (condition where the heart is not able to pump blood efficiently), cancer to inner cheek and depression. Review of electronic health record (EHR) under Orders revealed that R4 was on duloxetine HCL (antidepressant medication) 30 mg (milligrams) once a day for depression. Common side effects for this medication include blurred vision, feeling dizzy, difficulty sleeping, dry mouth, headache, constipation and nausea or vomiting. Review of care plan updated on 03/24/23 documented that R4 uses antidepressant medication and interventions include Administer ANTIDEPRESSANT medication as ordered by physician. Observe for side effects and effectiveness Q-SHIFT (every shift). Review of medication administration record (MAR) revealed that the licensed staff documented monitoring for signs and symptoms of hypoglycemia (low blood sugar) and bleeding since R4 was also taking insulin (medication to lower blood sugar) and warfarin (medication that prevents blood from clotting). Surveyor was not able to find where the licensed staff documented their observations for the side effects of antidepressant. On 05/05/23 at 10:37 AM, concurrent interview and records review conducted with the Nurse Manager (NM) 1 by the nurse's station. Asked NM1 if the staff monitored R4 for side effects of the antidepressant. NM1 replied that they do, and it is documented in the MAR. NM1 then opened R4's MAR on the computer but was not able to find any documentation for the monitoring. Asked NM1 if the licensed staff would document their observations anywhere else in the EHR, she replied No. NM1 then looked in the Orders tab and stated that since there was no order to monitor for the side effects of antidepressant, it would not show up it in the MAR. NM1 stated that there should be an order and she will input one in the EHR. Review of EHR under Orders on 05/05/23 at 01:23 PM, revealed that monitoring for side effects of the antidepressant initiated on 05/05/23. Based on interviews and record review, the facility failed to ensure comprehensive person-centered care plans were developed/implemented for two residents (Resident (R)191 and R4) sampled. R191 wandered unsupervised out of the facility on 04/15/23 and the facility did not develop a care plan until 05/02/23. Review of monitoring sheets documented staff did not implement 30-minute checks of R191 for wandering behavior in accordance with the resident's interventions listed on the care plan. R4 was not being monitored for side effects of prescribed psychotropic (drugs affecting behavior, mood, thoughts, or perception) medications. This deficient practice has the potential to affect all residents with wandering behavior or those psychotropic medications and has the potential to result in harm. Findings Include: (Cross reference to F689 Accident Hazard) 1) R191 was admitted to the facility on [DATE] with diagnosis that include congestive heart failure, hemiplegia and hemiparesis following a cerebral infarction affecting the dominant right side, pneumonitis due to inhalation of food and vomit, glaucoma, atrial fibrillation, and memory deficit following cerebrovascular disease. On 05/03/23 at 1:07 PM, conducted a review of R191 Electronic Health Record (EHR). Review of R191's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/13/23, Section C. Brief Interview for Mental Status (BIMS) score was 5 indicating the resident has severe cognitive impairment. Review of progress notes documented R191 had episodes of getting out of bed without activating the call light (04/10/23 at 07:35 AM). A progress note on 04/15/23 at 2:24 PM documented, Received update from unit manager that resident was found by another staff in parking lot in wheelchair. Resident immediately brought inside, in no distress, no changes in condition, baseline mentation AxOx1, confused and forgetful. Brought back inside into room to use bathroom and then back into bed. Resident location checks started every 30 minutes. Resident stayed in bed, ate lunch in bed, only got out of bed to work with therapy and brought back into bed after. Current staff and oncoming staff aware. Review of R191's care plan documented a care area for elopement due to disoriented to place, impaired safety awareness, and resident wandering aimlessly was not developed until 17 days (on 05/02/23) after the resident eloped/wandered from the facility without staff being aware that the resident was missing. On 05/05/23 at 11:05 AM, conducted an interview with the Director of Nursing (DON) regarding R191's elopement and care plan. Inquired with DON regarding the 15-day delay in the developing an elopement/wandering care plan for R191. DON confirmed a care plan with person centered interventions should have been developed sooner than 15 days to ensure the resident's safety but was not. Reviewed interventions for R191's potential for eloping, and it documented an intervention for frequent monitoring (every 30 minutes). Requested to view the documentation of the 30-minute checks. At 11:55 AM, went with DON to the unit nursing station to review the monitoring sheet. The Unit Care Coordinator (UCC) informed us that R191's 30-minute monitoring checks sheet was located on a medication cart. Reviewed of the 30-minute monitoring sheet with the DON, which documented staff had not complete the monitoring for 05/05/23 from 07:00 AM to 10:30 AM. DON confirmed the 30-minute monitoring should have been completed but was not most likely due to staff having to abruptly leave.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure adequate supervision to prevent an elopement for a resident (Resident (R)191) with wandering behavior. R191 exited the facility unsupervised and without staff's knowledge and only became aware of the resident's absences after another resident alerted staff. As a result of this deficient practice, there was the potential for serious harm to the resident. Findings include: (Cross reference to F656 Develop/Implement a Comprehensive Care Plan) R191 was admitted to the facility on [DATE] with diagnosis that include congestive heart failure, hemiplegia and hemiparesis following a cerebral infarction affecting the dominant right side, pneumonitis due to inhalation of food and vomit, glaucoma, atrial fibrillation, and memory deficit following cerebrovascular disease. On 05/03/23 at 1:07 PM, conducted a review of R191 Electronic Health Record (EHR). A progress notes on 04/15/23 at 2:24 PM documented, Received update from unit manager that resident was found by another staff in parking lot in wheelchair. Resident immediately brought inside, in no distress, no changes in condition, baseline mentation AxOx1, confused and forgetful. Brought back inside into room to use bathroom and then back into bed. Resident location checks started every 30 minutes. Resident stayed in bed, ate lunch in bed, only got out of bed to work with therapy and brought back into bed after. Current staff and oncoming staff aware. Review of R191's care plan documented a care area for elopement due to disoriented to place, impaired safety awareness, and resident wandering aimlessly was not developed until 17 days (on 05/02/23) after the resident eloped/wandered from the facility without staff being aware that the resident was missing. Further review of progress notes documented on 04/10/23 at 07:35 AM (5 days prior to eloping) R191 had episodes of getting out of bed without activating the call light and staff was aware of the resident's impulsivity and cognitive deficits. Review of R191's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/13/23, Section C. Brief Interview for Mental Status (BIMS) score was 5 indicating the resident has severe cognitive impairment On 05/05/23 at 11:05 AM, conducted a concurrent record review and interview with the Director of Nursing (DON) regarding R191's elopement. Reviewed the progress note written on Sunday, 04/15/23 at 02:24 PM (previously mentioned) and asked DON for more information/details of the event. DON stated staff was in the parking lot coming into the building, spotted R191, and brought the resident back into the facility without incident. Regarding the location where staff saw R191, DON stated that the resident was approximately 5-10 feet away from the entrance to the facility's entrance gate, within the area of the roundabout. DON emphasized that the resident had wandered from the facility looking for a bathroom. Review of R191's EHR with the DON and confirmed an elopement assessment was not completed after the incident, no staff interviews were conducted, no root cause analysis was conducted to determine how the resident was able to leave the facility and prevent other elopement attempts, and a care plan was not developed until 05/02/23 (17 days after the incident). DON stated further inquiry into the incident was not done because R191 did not leave the facility with the intent to leave, which would have been worse, but wandered from the facility looking for a bathroom. This surveyor queried the DON if there is a greater chance of injury or the potential for injury for a resident with impaired cognition due to a lack of awareness of their abilities and inability to make safe decisions. Discussed with the DON the foot traffic of homeless residents that frequently pass through the facility grounds and shared two surveyors had observed a homeless female approximately 20 feet from the entrance of the facility talking to herself, putting her hands down her pants, and appeared to have a bowel moment on the facility's sidewalk. The surveyors were able to view this incident through the windows of the conference room in the administrative office building. The DON stated that the resident was found by staff not that far from the entrance. Inquired which staff had found the resident and DON stated she was unsure of which staff it was exactly but that it was one of the front receptionists. Inquired if R191's representative had been notified of the resident's elopement and the DON could not verify if the family notified. On 05/05/23 at 12:05 PM, conducted an interview with Receptionist (RP)45 regarding R191's elopement. RP45 stated that he/she found the resident in the parking lot to the right (after exiting). RP45 confirmed that R191 was not found 5-10 feet from the entrance to the facility by staff, but another resident who was sitting out front alerted RP45 that he thought he recognized another resident, and he/she was heading toward the parking lot. RP45 took this surveyor out into the parking lot and showed this surveyor exactly where R191 was. RP45 stated that he/she called the resident and R191 began to wheel the wheelchair faster in an attempt to go away saying, I'm looking for the bathroom. RP45 confirmed that R191 appeared confused and was not aware of his/her own abilities and was not in a safe situation. RP45 confirmed staff did not identify R191 in the parking lot but was alerted by another resident and no other staff was involved in returning the resident to the facility. On 05/05/23 at 12:15 PM, conducted an interview with R191's Resident Representative (RR)3 via telephone. During the interview, RR3 confirmed that she was not aware that R191 had eloped from the facility and had not been notified of any of the details of the event or what the facility has done to ensure the resident's safety. On 05/05/23 at 01:15 PM, reviewed the facility's policy and procedure, Area of Focus: Elopement (last reviewed 11/23/2022), documented the interdisciplinary team (IDT) will review unsafe wandering and/or elopement risk indicators and revised the resident's care plan, a specific system will be implemented to notify staff the exit doors have been opened: -Documented and routine testing of door alarms -Documented and routine testing of staff's response to alarms -Monitoring practices when door alarms are disabled or during instances of higher traffic -Monitoring practices for exits that are not visible to staff but readily accessible to residents. Also, family members will receive education on the resident's unsafe wandering and elopement management care plan and provided an opportunity for feedback and with any unsafe wandering or elopement event the resident will be assessed for indicators utilizing the Elopement Risk Evaluation UDA in PCC (Point Click Care).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews (RR), the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two of two (Resident (R)71 and R340) residents sampled. Findings include: (Cross-Reference to F655 - Baseline Care Plan) 1) On 05/02/23 at 10:15 AM, interviewed R340. R340 underwent right knee surgery and was admitted to the facility on [DATE]. Observation of R340 confirmed swelling to the right knee and right lower leg. Regarding pain, R340 stated that staff have been providing pain medication every 4-6 hours based on resident's reported pain level but resident prefers to minimize opioid use and has been attempting to decrease amount of opioid medication taken. R340 denied being advised by care provider or facility staff of non-pharmacological or non-opioid interventions for treating pain or edema. On 05/04/23 at 10:42 AM, RR of R340's medical orders in resident's electronic health record (EHR) documented: Attempt non-med interventions prior to administering PRN pain medications: 1. Rest, 2. Reposition, 3. Diversional activity, 4. Warm/cold pack, Do not arouse from sleep. Do not exceed 3,000 mg Acetaminophen in a 24 hour period from all sources. -Order Date- 04/29/2023; Acetaminophen Tablet 325 MG, Give 2 tablet by mouth every 4 hours as needed for pain, Acetaminophen NTE 3G/24 hours-Order Date-04/29/2023; Percocet Oral Tablet 5-325 MG (Oxycodone w/ Acetaminophen), Give 1 tablet by mouth every 4 hours as needed for moderate (score 5-7), -Order Date-04/29/2023. On 05/04/23 at 12:00 PM, conducted concurrent staff interview and RR with Nurse Manager (NM)2 regarding R340 care plan for swelling and pain management. NM2 confirmed that R340's care plan did not identify non-pharmacological interventions for swelling or pain nor did the care plan include attempting non-opioid analgesic medications for pain control prior to using opioid analgesics as ordered. RR of resident's Medication Administration Record (MAR) documented that facility staff had not administered acetaminophen prior to opioid medication per physician's orders. NM2 stated that the resident's care plan should document non-pharmacological interventions for pain as well as using non-opioid medications prior to opioids. 2) On 05/03/23 at 10:51 AM, interviewed R71. R71 confirmed receiving pain medication to control pain and expressed a preference to minimize opioid medication use. R71 stated that facility staff had not offered non-pharmacological or non-opioid therapies for pain. On 05/04/23 at 10:59 AM, conducted RR of R71's care plan in resident's electronic health record (EHR) which documented the following non-pharmacological and non-opioid interventions for resident's pain: Attempt non-med interventions prior to administering PRN pain medications: 1. Rest, 2. Reposition, 3. Warm/Cold pack, 4. Diversional activities. Do not arouse from sleep. Do not exceed 3,000 mg Acetaminophen in a 24-hour period from all sources. Date Initiated: 03/13/2023. On 05/04/23 at 12:10 PM, conducted a concurrent staff interview and RR with NM2 of R71's care plan. NM2 confirmed that R71's care plan identified non-pharmacological interventions and use of non-opioid medications for pain control prior to using opioid analgesics as ordered by the resident's physician. RR of resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR) documented that facility staff did not implement non-pharmacological interventions nor had acetaminophen been administered prior to opioid analgesics per care plan and provider's orders. NM2 stated that non-pharmacological interventions as well as non-opioid medications should have been used to treat resident's pain in accordance with the care plan, physician's orders, and resident preference.

Based on observations, interviews, and record reviews (RR), the facility failed to provide or arrange for the provision of physician services 24-hours a day, in case of emergency for one of two residents (Resident (R)342) sampled. As a result of this deficient practice, the facility failed to adequately assess a resident for a potentially contagious condition. Findings include: (Cross-Reference to F880 - Infection Prevention and Control) On 05/02/23 at 09:46 AM, observed R342. No enhanced-barrier precautions (EBP) or other transmission-based precautions (TBP) sign was posted at resident's room. R342 had diffuse red rash covering both legs and was being evaluated by resident's Advance Practice Registered Nurse (APRN)1. Upon completing the evaluation, APRN1 stated that the resident was the one who identified the rash to her, and this was the first time APRN1 was informed of R342's condition. On 05/02/23 at 01:09 PM, interviewed R342. R342 stated that she identified the rash to the nurse last week. On 05/04/23 at 12:32 PM, conducted a RR of R342's Electronic Health Record (EHR). Resident progress notes showed that nursing staff documented redness to resident's bilateral legs and feet on 04/30/23 at 02:11 PM. Registered Nurse (RN)2 documented applying Miconazole to feet as well as calling and leaving message for R342's medical provider. Progress notes did not document implementation of TBP or other intervention at that time. Rash was not documented on 05/01/23 progress notes. On 05/04/23 at 03:19 PM, conducted a concurrent RR and staff interview with Nurse Manager (NM)2. NM2 stated that on 04/30/23 when R342 identified the rash to RN2, RN2 attempted to contact R342's medical provider per provider's medical group protocol rather than facility policy or procedure. When asked how long facility staff will wait if they receive no response before calling the provider again, NM2 stated that after making the initial phone call, staff waited for the provider to come on the provider's usual day to visit facility residents and that the rash was not really bothering R342. When asked how facility staff determine whether a new rash is a sign of an infectious or contagious condition, NM2 stated, We kind of just go off the nurse's assessment. NM2 confirmed that it is beyond nursing scope of practice to diagnose whether a rash is infectious or contagious. On 05/05/23 at 02:25 PM, interviewed Medical Director. When asked about the time frame he would expect for a resident's treating provider to respond to a message concerning a new, undiagnosed rash, he stated, Within half an hour to an hour. When asked what nursing staff should have done to address a new rash, the Medical Director stated that staff should have attempted to contact the resident's provider again and if there was no response, staff should have attempted to contact him.

Based on record review and staff interview, facility failed to provide adequate monitoring for one of the residents (R) sampled. R4 was not being monitored for side effects of prescribed psychotropic (drug effecting behavior, mood, thoughts or perception) medication. As a result of this deficient practice, there is a potential for negative impact on R4's quality of life. This deficient practice has the potential to affect all residents on psychotropic medications. Findings Include: Cross reference to F656 (Develop/Implement Comprehensive Care Plan). Facility failed to implement intervention to monitor resident for side effects of antidepressant. Review of electronic health record (EHR) revealed that R4 was prescribed duloxetine HCL (antidepressant medication) 30 mg (milligrams) once a day for depression. Common side effects for the medication include blurred vision, feeling dizzy, difficulty sleeping, dry mouth, headache, constipation and nausea or vomiting. Surveyor was not able to locate documentation in the EHR if the staff were monitoring R4 for side effects of the antidepressant. Concurrent record review and interview with the nurse manager (NM) 1 on 05/05/23 at 10:37 AM revealed that there was no order inputted into the EHR to monitor R4 for side effects of the antidepressant. NM1 stated that since there was no order, it would not show in the medication administration record (MAR) to monitor R4 for side effects of the antidepressant. NM1 stated that all monitoring is documented in the MAR.

Based on observation, staff interview, record review, and review of equipment service manual, the facility failed to ensure routine maintenance cleaning of the cabinet filter, based on the manufacturer's recommendation, for one out of three oxygen concentrators reviewed. This deficient practice put Resident (R) 44 at risk for the development and transmission of communicable diseases and infections. Findings include: During resident observation, on 05/03/23 at 09:00 AM, R44 was receiving oxygen via a Perfecto2 V Oxygen Concentrator. The cabinet filter of that oxygen concentrator appeared to have dirt and/or dust on the cabinet filter. A review of Electronic Health Record showed that R44 was admitted with a diagnosis of Dementia, Stroke, Hypertension, Atrial Fibrillation, Hypothyroidism, Hyperlipidemia, Anxiety, Encephalopathy, Palliative Care. R44 had a doctor's order to use oxygen as needed for shortness of breath. During staff query on 05/03/23 at 10:30 AM, Director of Nursing (DON) acknowledged that the cabinet filter was dirty and that there was no routine maintenance cleaning. DON immediately had the cabinet filter cleaned and said that they would coordinate with hospice for future routine maintenance cleaning. A review of the Service manual for the Perfecto2 V Oxygen Concentrator, Section 6 - Preventive Maintenance revealed the following: Cleaning the cabinet filter. There is one cabinet filter located on the back of the cabinet. 1. Remove the filter and clean at least once a week depending on environmental conditions. Note: Environmental conditions that may require more frequent cleaning of the filters include but are not limited to; high dust, air pollutants, etc. 2. Clean the cabinet filter with a vacuum cleaner or wash in warm soapy water and rinse thoroughly. 3. Dry the filter thoroughly before reinstallation.

Based on observations, interviews, and record review, the facility failed to ensure a resident (Resident (R)50) received a therapeutic diet as prescribed. As a result of this deficiency, R50 could have experienced harm due to aspiration had this surveyor not intervened prior to staff administering water that was not nectar thickened. Findings include: On 05/03/23 at 11:14 AM, this surveyor was seated outside of R50's room. R50 was coughing and one of the resident's visitors (V)1 approached this surveyor and requested a cup of water for the resident. V1 was encouraged to activate R50's call light as no staff were visible in the hallway. V1 activated the call light and Licensed Nurse (LN)22 answered the call light at 11:17 AM and was informed that R50 was coughing and needed some water. At 11:22 AM, LN22 approached R50's room with a cup of water and proceeded to don Personal Protective Equipment (PPEs) and this surveyor observed the water in the cup did not appear to be nectar thickened and stopped LN22 from giving R50 the water. Had this surveyor not intervened at this time, R50 could have potentially aspirated the fluid and result in harm to the resident. Inquired with LN22 if the water in the cup was nectar thickened. LN22 stated the water was poured from a carton of nectar thickened water located on the medication cart. This surveyor requested that LN22 observe the viscosity of the water in the cup and confirm if it appears to be nectar thickened. LN22 examined and moved around the water in the cup and concluded the consistency was not nectar thickened. Requested LN22 to show this surveyor the box of nectar thickened water that he/she poured from. LN22 showed this surveyor an opened carton of SYSCO Imperial Thickened Lemon-Flavored Water (46 fluid ounces (oz.)) which felt approximately 1/3 full. Further inspection of the carton documented the manufacturer's expiration date was 03/19/23 and staff had written 05/01 (at) 01:00 (01:00 AM) which LN22 verified was when the carton was opened. Directions on the carton documented, Refrigerate prior to serving. Shake well before using. Twist cap to open then pour and serve. After opening, may be kept up to 7 days under refrigeration. Storage and handling: Store at room temperature. Do not freeze. Serve chilled. A medical food for the dietary management of dysphagia (swallowing problems). For use under medical supervision. LN22 confirmed the 46 oz. carton of thickened water usually remains on top of the medication cart and is not refrigerated after opening. Unit Care Coordinator (UCC)2 came to the medication cart and inquired if the consistency of the water in the carton was nectar thickened consistency. UCC2 confirmed that the water was thinner than nectar thickened. LN22 and this surveyor inspected the unit stock refrigerator and found one carton of expired thickened water in the unit stock refrigerator. UCC2 confirmed the carton should have been disposed of but was stored in the refrigerator for future use. On 05/03/23 at 11:34 AM, this surveyor went to the other unit to and inspected all cartons of SYSCO Imperial Thickened Lemon-Flavored Water (46 fluid ounces (oz.) in the unit stock refrigerator with LN35. The cartons were not expired and were stored appropriately in the refrigerator. LN35 to pour some of the thickened water into a cup and observed it to be thicker than previously observed from the expired unrefrigerated carton. At 11:45 AM, informed the Director of Nursing (DON) this surveyor's observation of the expired/unrefrigerated nectar thickened water not observed to be nectar thickened and the notable difference in the viscosity of the unexpired/refrigerated thickened water. DON later inquired with the manufacturer and confirmed the 46 oz. cartons of SYSCO Imperial Thickened Lemon-Flavored Water should be refrigerated after opening and served chilled. On 05/04/23 11:36 AM, conducted a review of R50's Electronic Health Records (EHR). Review of R50's physician orders documented the resident was ordered to receive nectar consistency for liquids on 04/20/23 at 09:30 AM.

Based on observations and staff interview, the facility failed ensure that all foods were stored in a closed container and provide a clean area to prepared food. As a result of this deficient practice, there is an increased potential for a food-borne illness that could affect all residents, staff and visitors that the facility kitchen serves meals to. Findings Include: 1) On 05/02/23 at 08:02 AM, initial tour and observation was done in the kitchen with the Food Services Director (FSD). Observed an uncovered plastic container filled with a white powdered substance by the juice dispenser. Next to the container was a clear plastic cover that was of the same size. Asked FSD what the clear cover was for, he said it was for the uncovered container next to it that was filled with the powdered thickener they use to thicken liquids. FSD then proceeded to cover the open container of powdered thickener. Interview with FSD conducted on 05/04/23 at 09:34 AM in his office. Asked FSD if the container of powdered thickener observed on 05/02/23 was supposed to be covered. FSD stated that all containers are supposed to be covered immediately after use to prevent contamination. 2) On 05/02/23 at 08:22 AM, observed a stand-up fan directed at an area the FSD identified as the food preparation area. Noted both front and back areas to be covered in dust. Observed a bigger fan that was lower to the floor close to the dishwashing area without any dust on it. On 05/04/23 at 09:34 AM, concurrent observation and interview conducted with the FSD in the kitchen area. Showed FSD the fan that was directed at the area the staff were preparing food. Asked FSD who is tasked with cleaning the fans in the kitchen area and how often do they perform this. The FSD responded the kitchen staff clean them weekly. FSD confirmed that the fan is dusty and proceeded to turn it off and removed the cover and blades. He then stated that he will clean the cover and the blades and tell the kitchen staff not to point it directly towards the area where food is prepared to prevent the food from being contaminated with dust.

Based on observations, interviews with staff, and review of the facility's infection control policy, procedures, and protocols 1) the facility failed to ensure appropriate protective and preventive measures for COVID-19 and other communicable diseases and infections were implemented, 2) the facility failed to ensure measure to prevent the spread and transmission of communicable diseases were followed. Facility staff did not perform hand hygiene between glove use and did not disinfect shared equipment after use. This deficient practice has the potential to affect all residents, staff and visitors at the facility. Findings include: (Cross-Reference to F713 Availability of Physicians for Emergency Care) 1) On 05/02/23 at 09:18 AM, observed Resident(R)37 with an indwelling urinary catheter. No Enhanced Barrier Precaution (EBP) or other transmission-based precautions (TBP) sign was posted at the door of the room and appropriate EBP/TBP personal protective equipment (PPE) supplies were not located outside of R37's room. 2) On 05/02/23 at 09:46 AM, observed R342. No enhanced-barrier precautions or other transmission-based precautions (TBP) sign was posted at resident's room. R342 had diffuse red rash covering both legs and was being evaluated by resident's Advance Practice Registered Nurse (APRN)1. Upon completing the evaluation, APRN1 stated that the resident was the one who identified the rash, and this was the first time APRN1 was informed of R342's condition. 3) On 05/02/23 at 10:45 AM, observed APRN1 evaluating R339's wound to left foot. EBP sign was posted with appropriate PPE outside R339's doorway. APRN1 was masked with face shield but not gowned with a glove on right hand only. While evaluating R339's wound, APRN1 removed R339's sock from the affected foot with an ungloved left hand to visually assess R339's wound. 4) On 05/02/23 at 12:19 PM, observed Registered Nurse (RN)1 flushing R341's peripherally inserted central catheter (PICC) line. No EBP or TBP sign was posted at resident's room and no PPE was located outside of room. 5) On 05/03/23 at 08:56 AM, observed Certified Nursing Assistant (CNA)47 changing linens in resident's room. EBP sign was posted with PPE supplies located outside resident's doorway. CNA47 was wearing mask and gloves but was not gowned at this time. 6) On 05/04/23 at 03:19 PM, conducted concurrent RR and staff interview with Nurse Manager (NM)2. NM2 stated that on 04/30/2023 when R342 identified the rash to the RN, the RN attempted to contact R342's medical provider per provider's medical group protocol rather than facility policy or procedure. When asked how long facility staff will wait if they receive no response before calling the provider again, NM2 stated that after making the initial phone call, staff waited for the provider to come on the provider's usual day to visit facility residents and that the rash was not really bothering R342. When asked how facility staff determine whether a new rash is a sign of an infectious or contagious condition, NM2 stated, We kind of just go off the nurse's assessment. NM2 confirmed that it is beyond nursing scope of practice to diagnose whether a rash is infectious or contagious. 7) On 05/05/23 at 09:38 AM, conducted RR and concurrent staff interview with Infection Preventionist (IP) and Assistant Director of Nursing (ADON). IP stated that EBP is implemented for residents that either have known multi-drug resistant organism (MDRO) colonization or any resident with an indwelling medical device or chronic wound (regardless of MDRO colonization or infection status). The IP confirmed that R37 and R341's rooms should have had EBP signs posted with PPE available outside of their rooms based on their medical conditions. IP also confirmed that R339's medical provider should have been gowned and wearing gloves on both hands when entering R339's room to assess a chronic wound. The IP confirmed that RN1 should have been gowned when conducting direct care to R341's PICC and that CNA47 also should have been gowned when changing linens of a resident identified for EBP. The IP and ADON stated that R342's rash could have been a sign of a potentially contagious condition and EBP or TBP should have been implemented to prevent potential spread to other residents until the resident's condition was diagnosed by a medical provider. 8) On 05/02/23 at 09:10 AM, observed Certified Nursing Assistant (CNA) 22 as she finished providing care for resident (R) 56. CNA22 walked to the trash bin close to the door and removed her gown and gloves. She then took two gloves from the box by the door and donned them without performing hand hygiene, grabbed the used linens on R56's bed, and placed them in the used linen receptacle. CNA22 then removed her gloves and performed hand hygiene. 9) On 05/02/23 at 12:45 PM, observed CNA22 and CNA29 as they repositioned R68 in his bed. After performing the task, CNA22 removed her gloves, performed hand hygiene, and exited the room. CNA29 also removed her gloves, took the towel that was on the foot of R68's bed, exited the room and placed the towel in the used linen receptacle. CNA29 then entered R25's room, donned new gloves and repositioned R25 as she was leaning slightly to her left while sitting up in her bed. CNA29 then removed her gloves, exited the room and walked over to R13's room. 2 other staff members were in the room and had the mechanical lift next to R13 as she sat on her wheelchair. CNA29 donned new gloves and proceeded into the room to assist in transferring R13 back to her bed. CNA29 was not observed performing hand hygiene between glove changes. 10) On 05/02/23 at 01:47 PM, observed Licensed Practical Nurse (LPN) 3 as she was checking the blood pressure of R239. After obtaining R239's blood pressure reading, LPN3 removed her gloves, performed hand hygiene, walked to the medication cart, and placed the blood pressure equipment on top of the medication cart without disinfecting it. LPN3 then documented the blood pressure reading and prepared her medications. On 05/05/23 at 11:09 AM, interview was conducted with the Infection Preventionist (IP), and the above observations were mentioned. IP confirmed that staff were supposed to perform hand hygiene after removal of gloves and all shared equipment are supposed to be wiped with disinfecting wipes after each use. IP also stated that she will be doing weekly infection control audits.