**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review, and resident and staff interviews, it was determine the facility failed to ensure residents were assessed to determined if they were safe to self-administer medication. This was true for 2 of 2 residents (#5 and #7) reviewed for self-administration of medication. This failure created the potential for adverse outcomes if Resident #5 and #7 self-administered their inhaler inappropriately. Findings include: The facility's Self-Administration of Medications policy and procedure, released 11/28/17 documented the resident may self-administer drugs if the interdisciplinary team has determined that this practice is safe. Qualified nursing staff administers drugs until the determination is made. 1. Resident #5 was admitted to the facility on [DATE], with multiple diagnoses including chronic pulmonary disease (COPD - a progressive lung disease characterized by increasing breathlessness.) A physician's order, dated 3/11/25 documented Resident #5 was to receive one inhalation of Advair Diskus powder Breath Activated 100-50 mcg (micrograms)/dose (a steroid and bronchodilator combination medicine that is used to prevent flare-ups of COPD), inhale orally every 12 hours for shortness of breath. The order included an instruction for the resident to rinse her mouth with water and spit in cup after use. On 4/2/25 at 9:10 AM, during Medication Pass observation, Medication Assistant Certified (MAC) #1 administered Resident #5's oral medications. When the MAC was about to give the Advair Diskus to Resident #5, Resident #5 stated she already used the inhaler. On 4/2/25 at 9:20 AM, MAC #1 stated he forgot that Resident #5 had the inhaler at her bedside. On 4/2/25 at 9:47 AM, the Nurse Manager #1 reviewed Resident #5's record and stated Resident #5 was not assessed to self-administer her Advair Diskus. 2. Resident #7 was admitted to the facility on [DATE], with multiple diagnoses including COPD. A physician's order, documented Resident #7 was to receive Albuterol Sulfate HFA (90 Base) mcg/act Aerosol solution, two puff inhale orally every four hours as needed for asthma. On 3/31/25 at 3:39 PM, Resident #7 was in his room sitting on his recliner. An inhaler was observed on top of his overbed table. Resident #7 stated he was using the inhaler two times a day. On 3/31/25 at 3:43 PM, LPN #1 and the surveyor went to Resident #7's room. LPN #1 took the inhaler and reviewed Resident #7's physician's order. LPN #1 stated the physician's order did not state Resident #7 could keep the inhaler in his room. On 3/31/25 at 6:13 PM, the CNO reviewed Resident #7's record and stated Resident #7 did not have an assessment to self-administer his inhaler. The CNO stated Resident #7 should have been assessed first prior to having his inhaler at his bedside.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review, and resident and staff interview, it was determined the facility failed to promote and facilitate a resident's ability to make food choices. This was true for 1 of 16 residents (Resident #24) reviewed for accommodation of food choices. This deficient practice placed Resident # 24 at risk for decreased sense of wellbeing and self-worth, and frustration when her food preferences were not accommodated. Findings include: The facility's Resident Rights policy dated, 10/15/22 documented residents will be cared for in a manner and in an environment that promotes maintenance or enhancement of each resident's quality of life. Resident #24 was admitted to the facility on [DATE] with multiple diagnoses, including macular degeneration (a chronic eye disease that affects the macula, the central part of the retina responsible for sharp, central vision- meaning one cannot see right in front of them) and nutritional deficiency (this occurs when the body doesn't get enough of a specific nutrient, leading to various health problems, and can be caused by poor diet, malabsorption, or increased needs.) An admission MDS assessment, dated 3/12/25 documented Resident #24 was cognitively intact and had impaired vision - sees large print, but not regular print in newspapers/ books. A care plan dated 3/8/25, documented, resident was to be provided feeding/dining assistance as needed. On 4/1/25 at 10:41 AM, when asked if resident #24 was given choices about her food, she stated no. When asked if she was provided a menu with meal choices, she stated yes, but it did her no good because she was blind and could not read it. Resident #24 stated she has been served eggs every morning since admission and has informed the CNA's several times she would like an alternative but still gets served eggs every day. When asked if resident #24 has been offered any assistance in filling out her menu, she stated no one has offered to help her. There was no documentation in Resident #24's medical record she was asked about her diet preferences. On 4/02/25 at 9:20 AM, the facility's Registered Dietician, stated she was unaware of Resident #24's meal choices was not assessed. On 4/02/25 at 10:07 AM, the CNO stated the facility's process for residents to make meal choices are as follows: -Dining provides menu option cards once a week for residents to choose meals. -Residents, family member, or staff can assist with filling out the menu choices. -The expectation is that the resident would circle the main dish or alternate choice, if no choice is circled then the assumption would be that they want the main dish. On 4/02/25 at 10:26 AM, the Dietary Manager stated he keeps all resident's menu choices for the whole week and if no menu returned to the kitchen the staff should go check with residents to see what their choices are. The Kitchen Manager could not locate resident #24's menu choices for this week and he stated he did not know why it was not addressed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, review of facility's Grievances, and staff interview, it was determined the facility failed to ensure residents grievances were thoroughly investigated for 1 of 1 resident (Resident #77) whose grievance was reviewed. This failure created the potential for Resident #77 to be subjected for ongoing abuse without detection and intervention. Findings include: The facility's Identification and Investigation of Abuse, Neglect, Misappropriation, and Injuries of Unknown Origin policy and procedure, revised 8/1/23 documented the facility has processes in place to assist in preventing abuse, neglect, misappropriation of resident property and exploitation. The policy documented residents, the accused and all witnesses would be interviewed. If there are no witnesses, consider interviewing all employees on the shift or the unit as appropriate as well as other residents on the unit. Upon the conclusion of the investigation, prepare a summary report of the findings and conclusions. Resident #77 was admitted to the facility on [DATE] with multiple diagnoses including chronic pulmonary disease (COPD - a progressive lung disease characterized by increasing breathlessness) and congestive heart failure (weakness of the heart leading to a buildup of fluid in the body). A Grievance Report, dated 11/27/24 documented Resident #77's representative filed a grievance report to the facility documenting Resident #77 had cash in his wallet and it was missing. Resident #77 and his representative were unable to identify how much money was missing. A comprehensive search was completed to locate the money. No money was found. The report also documented other residents were interviewed and none of the residents reported missing items. Resident #77's representative was asked if they would like the opportunity to speak to a police officer, they said yes. The police came and conducted their interviews. The Grievance report did not include staff interviews, the police report, and the facility's conclusion of the investigation. On 4/1/25 at 1:49 PM, the CEO stated he did not have a copy of the police report. On 4/3/25 at 8:43 AM, the CNO with the CEO present stated Resident #77 was aware he had money in his wallet, but he did not know how much it was. The CNO stated Resident #77 had many friends visiting him in the facility, and sometimes he goes out with them. When asked why none of the staff were interviewed, the CNO stated the staff were interviewed, but she did not document the interviews. When asked what the conclusion of their investigation was, the CEO stated he thought Resident #77 was potentially spending the money with his friends. When asked about the police report, the CNO stated the police officer told them they were unable to determined how much money was missing. The CNO stated Resident #77 did not want to pursue on the investigation of his missing money. A Police report, dated 12/30/24, obtained by the facility on 4/3/25 documented the CNO and Resident #77 were informed that It was unlikely we would find out where the money went due to the amount of people that come and go from the room coupled with no cameras.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and interview, it was determined the facility failed to ensure information was provided to the receiving hospital for 1 of 2 residents (Resident #13) reviewed for transfers. This deficient practice had the potential to cause harm if residents were not treated in a timely manner due to lack of information. Findings include: The facility's Transfer and Discharge policy and procedure, released 11/18/24 documented during an emergent transfers of a resident to an acute care, the following information are provided to the receiving provider: - Contact information of the practitioner who was responsible for the care of the resident. - Resident representative information, including contact information. - Advance directive information. - Special instructions and/or precautions for ongoing care, as appropriate, which must include, if applicable, but are not limited to: treatment and devices such oxygen, implants, intravenous, tubes/catheters, precautions such as isolation or contact, and other risk factors such as risk for falls, bleeding, aspiration precautions and pressure ulcer injury. - Resident's comprehensive care plans. - List of resident's medications, relevant laboratory and diagnostic test, diagnoses and allergies. Resident #13 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including diabetes and heart disease. A nursing note, dated 3/17/24 at 3:21 PM documented Resident #13 was showing signs of increased anxiety and complained of his chest feeling heavy and can't catch his breath. The provider was notified and requested for CBC (Complete Blood Count), BMP (Basic Metabolic Panel), D Dimer (test for blood clotting), and chest x-ray. A nursing note, dated 3/17/24 at 5:14 PM documented Resident #13's x-ray showed mild congestion and an elevated D Dimer result. An order was received to send Resident #13 to the emergency room. Resident #13's record did not include documentation information was provided to the hospital to ensure a safe and effective transition of care. On 4/1/25 at 3:35 PM, the CNO stated the facility would send the face sheet, medications list, code status, and pertinent laboratory results and diagnostics. The CNO stated she was unable to find documentation of what was sent with Resident #13 when he went to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure staff rinsed and stored the nebulizer mouthpiece appropriately after each use. This was true for 5 of 5 residents (#7, #13, #15, #78, and #80). This failure placed residents at risk of respiratory infection due to growth of pathogens (organism that cause illnesses) in the respiratory equipment. Findings include: An article from American Heart Association website, accessed on 4/9/25 at https://www.lung.org, titled ABCs of Using a Nebulizer documented the following: - After each treatment, disassemble and wash the nebulizer parts in warm soapy water or in the dishwasher. - Rinse and let the pieces air dry and store in clean dry place. - Once a week soak them in a vinegar solution for 30 to 60 minutes to disinfect them. - The tubing and compressor for a jet nebulizer should never be put into water. They can be wiped with a damp soapy towel or disinfectant wipe if they get soiled. 1. Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including chronic pulmonary disease (COPD - a progressive lung disease characterized by increasing breathlessness). A physician's order, dated 12/3/24 documented Resident #7 was to receive Olodaterol HCL (Hydrochloride) Inhalation Aerosol Solution 2.5 mcg(microgram)/actuation. On 3/31/25 at 2:39 PM, Resident #7's nebulizer mouthpiece was observed on top of his nebulizer machine. On 3/31/25 at 5:10 PM, LPN #1 and the surveyor went to Resident #7's room. LPN #1 stated the nebulizer mouthpiece should be rinsed, air dried and placed inside a plastic bag. 2. Resident #13 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including acute respiratory failure with hypoxia (low levels of oxygen in the body tissue). A physician's order, dated 3/20/25 documented Resident #13 was to receive Ipratropium-Albuterol Solution 0.5-2.5 mg/ml (milligram per milliliter), three ml inhale orally every four hours as needed for shortness of breath. On 3/31/25 at 5:15 PM, Resident #13's nebulizer mouthpiece was observed on top of his bedside table next to his nebulizer machine. On 3/31/25 at 5:17 PM, LPN #1 and the surveyor went to Resident #13's room. LPN #1 stated the nebulizer mouthpiece should be rinsed, air dried and placed inside a plastic bag. 3. Resident #15 was admitted to the facility on [DATE], with multiple diagnoses including emphysema (a lung disease that causes shortness of breath due to damage to the air sacs [alveoli] in the lungs). A physician's order, dated 2/14/25 documented Resident #15 was to receive Ipratropium-Albuterol Solution 0.5-2.5 mg/ml (milligram per milliliter), three ml inhale orally every six hours as needed for shortness of breath. On 3/31/25 at 5:20 PM, LPN #1 and the surveyor observed Resident #15's nebulizer mouthpiece on top of his bedside table. LPN #1 stated the nebulizer mouthpiece should be rinsed, air dried and placed inside a plastic bag. 4. Resident #78 was admitted to the facility on [DATE], with multiple diagnoses including chronic pulmonary disease (COPD) A physician's order, dated 3/25/25 documented Resident #78 was to receive Ipratropium-Albuterol Solution 0.5-2.5 mg/ml (milligram per milliliter), three ml inhale orally via nebulizer before meals and at bedtime for shortness of breath. On 3/31/25 at 4:35 PM, Resident #78's nebulizer mouthpiece was observed on top of his bedside table next to the nebulizer machine. Resident #78 stated he used the nebulizer three times a day. On 3/31/25 at 5:23 PM, LPN #1 and the surveyor went to Resident #78's room. LPN #1 stated Resident #78's nebulizer mouthpiece should be rinsed, air dried and placed inside a plastic bag. 5. Resident #80 was admitted to the facility on [DATE], with multiple diagnoses including hypertension and diabetes. A physician's order, dated 4/2/25 documented Resident #80 was to receive Duoneb Solution 0.5-2.5 mg/3 ml, three milliliters inhale orally via nebulizer every six hours as needed for shortness of breath/cough. On 4/2/25 at 8:41 AM, RN #1 prepared Resident #80's Duoneb Solution, turned on the nebulizer machine, and handed the mouthpiece to Resident #80. Resident #80 took the nebulizer mouthpiece and started to inhale the medication. On 4/2/25 at 9:30 AM, Resident #80 was inside her bathroom being assisted by CNA #1 and CNA #2. Resident #80's nebulizer mouthpiece was observed inside the plastic bag on top of her bedside table. When asked about the nebulizer mouthpiece, CNA #1 stated the mouthpiece was empty and she placed it inside the plastic bag, and turned off the nebulizer machine. On 4/2/25 at 11:45 AM, the Nurse Manager #1 stated the nebulizer mouthpiece should be rinsed after each use and placed inside a plastic bag. On 4/2/25 at 12:17 PM, the Infection Preventionist (IP) stated the nebulizer mouthpiece should be rinsed, air dried and placed inside a plastic bag after each use.

Based on observation, record review, resident interview, test tray evaluation, and staff interview, it was determined the facility failed to ensure palatable food was served. This affected 5 of 16 residents (#2, #14, #16, #17, and #127) who were reviewed for dietary concerns. This failed practice created the potential to negatively affect residents' nutritional status and psychosocial well-being. Findings include: The facility's Food Preparation policy dated 8/1/23, documented food is prepared by methods that conserve nutritive value, flavor, and appearance. The following resident interviews were conducted: On 3/31/24 at 4:04 PM, Resident #14 said the food is terrible, as if it came from a box like hamburger helper, no taste, the chicken has no flavor and sometimes food is too salty. On 3/31/25 at 4:15 PM, Resident #16 said food is not palatable and his daughter has started taking him home on Sundays to feed him good food. On 3/31/25 at 4:29 PM, Resident #2 said the food had bland taste and food that should be hot is sometimes served cold even though she eats in dining room. On 4/1/25 at 9:00 AM, Resident #17 said the food tastes good, but it looks terrible. She stated if she were to place it in front of her husband, he would vomit. On 4/1/25 at 10:10 AM, Resident #127 said the food tastes good and is well seasoned, but the appearance is lacking and resembles dog poop. On 4/2/25 at 12:38 PM, a lunch meal test tray was evaluated by two surveyors, a CNA and the CEO. The main dish of meat and pasta had an inner temperature of 149-degrees Fahrenheit. The toasted French bread had in inner temperature of 108.7-degrees Fahrenheit and was determined to be cold and hard. The broccoli had an inner temperature of 135.3-degrees Fahrenheit and was determined to be mushy, dark muddy green color, and did not taste palatable. The CEO confirmed the broccoli looked mushy and not palatable. The chocolate pie had an inner temperature of 51.0-degrees Fahrenheit and had good flavor but tasted a bit too warm for a cold pie and was melting, and did not look palatable. On 12/3/25 at 12:00 PM, the Kitchen Manager stated he did not recall ever getting any grievances regarding food temperatures and palatability. He stated he thought the broccoli had become mushy and unpalatable because he had used frozen instead of fresh and due to the time in the heating table.

Based on observation, interview, policy review, and review of the Idaho Food Code, the facility failed to appropriately store, label, and serve foods. This deficient practice had the potential to affect all 27 residents who received meals from the facility kitchen served in the dining room and resident rooms. This placed residents at risk for potential contamination and use of spoiled foods, and adverse health outcomes, including food-borne illnesses. Findings include: Review of the Idaho Food Code, revised February 2021, stated 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking . refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. The facility's Food and Supply Storage policy dated 11/28/17, documented under Policy for Labeling and rotating food supply: 1. For products that are opened and not completely used or prepared at the facility and stored, the product should be labeled as to its contents and use-by dates. On 3/31/25 at 2:00 PM, during the initial kitchen tour with cook #1 the following was observed in: a. walk-in freezer - the inside of the walk-in freezer, the left corner just inside the door was observed with thick layers of ice along the food racks. The boxes stacked along that side of the shelf were observed to have sparkling ice crystals covering the outside and inside of these boxes. Ceiling was observed to have ice buildup in small round cone shapes. - a container of jam with a use-by date of 3/8 - an opened and unlabeled bag of blueberries - an opened and unlabeled bag of dinner bread - a bag of crinkle cut carrots opened to the air, not sealed correctly and not dated when opened - a large bag of tater tots opened to the air, not sealed correctly and not dated when opened - a large bag of breaded chicken patties opened to the air, not sealed correctly and not dated when opened b. walk-in refrigerator - two opened and plastic wrapped stacks of sliced yellow cheese with use by date of 3/27 - four small containers of single serve salad dressing with use by date of 3/28 - a large bag of broccoli opened to the air, not sealed correctly and not dated when opened - a large container of mayonnaise opened and undated - a large container of ranch dressing opened and undated - a container of milk opened and undated On 3/31/25 at 2:10 PM, [NAME] #1 stated they sometimes don't write the dates on opened packages when they know they will be used that day. On 4/2/25 at 9:30 AM, during a second trip to the kitchen with the Kitchen Manager, a box of opened undated bag of diced potatoes with crystallized freezer burn was observed in the walk in freezer. Kitchen manager confirmed food should be labeled and sealed after opening and the potatoes looked freezer burned. He stated that he believes that the door to this freezer doesn't get closed all the way sometimes resulting in thawing and refreezing of foods located by the door.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, grievance review, and resident and staff interview, the facility failed to ensure grievance concerns and/or complaints were thoroughly investigated and resolved to the satisfaction of the complainant without fear of reprisal. This was true for 2 of 4 residents (#7 and #143 ) whose grievances were reviewed. This deficiency had the potential for harm should residents experience a loss of self-worth and psychosocial distress. Findings include: The facility's Complaint and Grievances policy, dated 11/28/17, documented An individual has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC [Long Term Care] facility stay. The facility should make prompt efforts by the facility to resolve grievances the resident may have. 1. Resident #7 was admitted on [DATE] and readmitted on [DATE] with multiple diagnoses including syncope (fainting most often occurs when blood pressure is too low) and systemic lupus erythematosus (an autoimmune disease in which the immune system attacks its own tissues, causing widespread inflammation and tissue damage in the affected organs). An MDS assessment, dated 2/8/24, documented Resident #7 was cognitively intact. The facility's Grievance Log did not include a grievance submitted by Resident #7 on 3/24/24. Review of LPN #2's personnel file included a grievance from Resident #7, dated 3/25/24. The grievance documented the following from Resident #7: This morning after breakfast [LPN #2] came in with what she said were my pills. I started to dump them in my mouth. I looked at them as I was about to put them in my mouth. I told her they were not my pills. She took them back and said she just wanted to see if I was awake. She walked out and got mine. I could have been poisoned. [CNA #4] walked in as she was saying that. I was a bit shocked! I don't think I have ever given her reason to resent me. I must remind her of someone she does not like. Please read above. I am thankful I actually recognized they were not my meds [medications]. I could have been poisoned. [LPN #2] never apologized or showed any concern. Sunday 3/24/23 at around 9 AM. The grievance did not include a summary of the incident from leadership. The section on the grievance form for resolution and corrective actions taken by the facility was blank and the signature line for the Executive Director was blank. During an interview on 4/30/24 at 12:33 PM, the Social Services (SS) representative explained the grievance process. She stated once the grievance form was initially completed, the concern was presented at the facility's morning stand up meeting, and then a review with the resident was conducted to get more information and clarify their concerns were documented on the form. The SS stated the concern was then summarized and assigned to a manager for follow-up and outlined who to do what on the back of the form. During an interview on 5/1/24 at 5:04 PM, the CNO and the Human Resources Director found the incomplete grievance form in the personnel file for LPN #2. The CNO and Human Resources Director stated they saw the form and did not follow up on the grievance documented by Resident #7. The SS representative stated she had not seen the form from Resident #7 dated 3/24/24 and it was not followed up on. She stated Resident #7 was not interviewed for more information or clarity about the incident and no resolution was identified. 2. Resident #143 was admitted to the facility on [DATE], with multiple diagnoses including post-surgical care following a spinal fusion, Diabetes Mellitus, Sjogren's Syndrome (autoimmune disease affecting the functioning of the glands that produces tears and salvia), Major Depressive Disorders and Post Traumatic Stress Disorder (PTSD). An admission MDS assessment, dated 11/20/23, documented Resident #143 was cognitively intact and able to make her own decisions. Review of the facility's grievance log for December 2023 documented Resident #143 filed a grievance/complaint on 12/8/23 concerning the way LPN #2 spoke to her regarding her pain medication. Resident #143 documented on 12/8/23 at 3:45 AM that LPN #2 approached her about the amount and frequency of pain medication Resident #143 was receiving. Resident #143 documented LPN #2 stated there were other pain medications and other pain-relieving options available to her. Resident #141 documented on 12/8/23 at 8:37 AM that LPN #4 also approached her about the frequent use of pain medication. The 12/8/23 grievance form documented the Unit Manager, CNO, and CEO were notified of the incident on 12/12/23. The CNO summarized the incident as inappropriate conversations with Resident #143 regarding narcotic use by two different nurses in her room. The grievance documented the CNO determined this was not abuse. The CNO documented the grievance/complaint was resolved on 12/12/23. The grievance documented resolution consisted of staff education on appropriate and non-appropriate conversations with residents. The CNO documented Resident #143 was satisfied with the resolution. However, the form did not include Resident #143's signature confirming she was satisfied with the resolution. The form also did not include the signature of the CEO indicating the investigation was complete. During an interview on 4/30/24 at 10:06 AM, Resident #143 stated LPN #2 made a comment about her frequent use of narcotic medications for pain. Resident #143 stated LPN #2 mentioned using other medications and techniques to relieve her pain. Resident #143 stated LPN #4 later entered the room talking about Resident #143's use of narcotics. Resident #143 stated she felt the nurses were talking behind her back. Resident #143 also stated the way both nurses approached her about the pain medication, hurt her to the core. Resident #143 stated the nurses' behavior made her reluctant to request pain medication. Resident #143 also stated LPN #4 wanted her to change the grievance/complaint that she had completed. Resident #143 said she requested to see the Unit Manager or the SS representative. Resident #143 further stated the nurses' behavior toward her was abusive at the time. Resident #143 stated since that time the issue had been resolved. She stated after the grievance/complaint was filed, LPN #2 was moved to a different unit and LPN #4's agency contract was not renewed. During an interview on 4/30/24 at 5:20 PM, the CEO stated the incident between Resident #143, LPN #2, and LPN #4 was investigated. The CEO stated at the time, he did not feel the incident rose to the level of abuse. The CEO stated Resident #143 may have misunderstood what the nurses were trying to tell her. The CEO stated the Nurse Practitioner had planned to have a conversation with the resident about decreasing the amount of pain medication. The CEO felt this should have been documented in Resident #143's chart by Social Services. The CEO agreed that SS should have followed-up with Resident #143 on the resolution of the incident and documented it in her chart. The CEO reviewed the grievance form and stated ideally Resident #143 should have signed the form indicating acceptance of resolution and the form was missing the CEO signature which meant the form was incomplete.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the State Agency's Long Term Care Reporting Portal, record review, grievance report review, and resident and staff interview, it was determined the facility failed to ensure allegations of resident abuse were reported to the State Survey Agency within 2 to 24 hours. This affected 1 of 3 residents (Resident #7) who were reviewed for abuse. This failure created the potential for residents to be subjected to ongoing abuse without detection and protective measures implemented by the facility. Findings include: The facility's policy, titled Abuse, revised 8/1/23, documented: Allegations of verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, and neglect of the resident as well as mistreatment, injuries of unknown source, exploitation, deprivation of goods and services by staff, and misappropriation of resident property are reported to the CEO immediately and the state agency . a. Within 2 hours if there was alleged abuse or serious bodily injury as a result of an event. b. Within 24 hours if the event that caused the injury did not involve abuse or did not result in serious bodily injury. Resident #7 was admitted on [DATE] and readmitted on [DATE], with multiple diagnoses including syncope (fainting most often occurs when blood pressure is too low) and systemic lupus erythematosus (an autoimmune disease in which the immune system attacks its own tissues, causing widespread inflammation and tissue damage in the affected organs). An admission MDS assessment, dated 2/8/24, documented Resident #7 was cognitively intact. During an interview on 4/29/24 at 2:42 PM, Resident #7 stated LPN #2 seemed to be rude to her. Resident #7 stated she was worried about retaliation from LPN #2 and not being able to return to the facility if needed in the future. Resident #7 said LPN #2 was a little vengeful meaning hateful. Resident #7 said she could not trust LPN #2. A facility grievance form, dated 3/10/24, initiated by Resident #7, documented the following on a grievance form: Date of occurrence- Ongoing, I feel bad [LPN #2] thinks that I am sleeping every time she comes in, not true! I feel if she had been wanting to help me that my incision would not have burst. I told her last Monday that it was hot, swollen, and discolored, she said it was fine and I felt if I hesitated to make an issue of this, I would have a problem. She said it was okay, but it wasn't, and it burst dressing on Wednesday. I have a bad immune system and wanted antibiotics. I feel that if something is not her idea that it doesn't ___ [sic]. Very rude and dismissive, asked me for details. I can't write with my right hand. She is a bully. The resolution and/or corrective action taken section documented Facility MD [Medical Doctor] following up with concerns, ortho [orthopedic physician] also notified and provided treatment orders-Resident concerns with [LPN #2] being dismissive-Education and resources provided on effective communication. [LPN #2] to not provide non-emergency cares, CNO had a conversation with [LPN #2]. The grievance form was signed at the bottom by the CEO. A facility grievance form, dated 3/24/24, initiated by Resident #7, documented the following: This morning after breakfast [LPN #2] came in with what she said were my pills. I started to dump them in my mouth. I looked at them as I was about to put them in my mouth. I told her they were not my pills. She took them back and said she just wanted to see if I was awake. She walked out and got mine. I could have been poisoned. [CNA) #4] walked in as she was saying that. I was a bit shocked! I don't think I have ever given her reason to resent me. I must remind her of someone she does not like. Please read above. I am thankful I actually recognized they were not my meds. I could have been poisoned. [LPN #2] never apologized or showed any concern. Sunday 3/24/23 at around 9 AM. The form did not include documentation for the summary of the incident by the department head. The section for resolution and corrective actions taken was blank and the signature line for the Executive Director was blank. Review of the State Agency's Long Term Care Reporting Portal did not include a report by the facility to the State Agency within 2 hours of Resident #7's allegation of verbal abuse by LPN #2. During an interview on 4/30/24 at 1:14 PM, the CEO stated there was an investigation of the grievance for Resident #7, dated 3/10/24 and the conclusion was education and counseling by the CNO and did not identify that abuse should have been investigated. During an interview on 04/30/24 at 1:25 PM, the CEO stated the investigation of the grievance dated 3/10/24, should have been conducted to rule out abuse and was not investigated for abuse. The CEO said he was unaware of the grievance documented by Resident #7 on 3/24/24 and if aware of the grievance, would have functioned as outlined in the facility abuse policy and investigated for abuse. During an interview on 05/01/24 at 5:04 PM, in reference to the 3/24/24 grievance, the CEO confirmed the language in the form completed by Resident #7 was abusive by LPN #2 and should have been investigated as abuse and confirmed it was not investigated as abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, the facility failed to ensure abuse allegations documented on grievance forms were recognized, reported, and investigated for 1 of 3 residents (Resident #7) reviewed for abuse. This failure created the potential for residents to be subjected to ongoing abuse without detection and protective measures implemented by the facility. Findings include: The facility's policy, titled Abuse, revised 8/1/23, documented The facility respects the resident right to be free from abuse . Prohibitions on abuse including and not limited to verbal . prohibitions apply to . facility staff. The facility's policy, titled Identification and Investigation of Abuse, Neglect, Misappropriation, and Injuries of Unknown Origin Identification of Incidents and Occurrences that may Constitute or Contribute to Abuse and Neglect, revised 8/1/23, documented Review reports of grievances, complaints, and allegations of abuse, neglect, injuries of unknown injury, and misappropriation for patterns or isolated incidents of unexplained functional regression, or other evidence of physical, verbal, sexual or psychological abuse or punishment posing a serious and immediate threat to individuals. Resident #7 was admitted on [DATE] and readmitted on [DATE], with multiple diagnoses including syncope (fainting most often occurs when blood pressure is too low) and systemic lupus erythematosus (an autoimmune disease in which the immune system attacks its own tissues, causing widespread inflammation and tissue damage in the affected organs). An admission MDS assessment, dated 2/8/24, documented Resident #7 was cognitively intact. During an interview on 4/29/24 at 2:42 PM, Resident #7 stated LPN #2 seemed to be rude to her. Resident #7 stated she was worried about retaliation from LPN #2 and not being able to return to the facility if needed in the future. Resident #7 said LPN #2 was a little vengeful meaning hateful. Resident #7 said she could not trust LPN #2. A facility grievance form, dated 3/10/24, initiated by Resident #7, documented the following on a grievance form: Date of occurrence- Ongoing, I feel bad [LPN #2] thinks that I am sleeping every time she comes in, not true! I feel if she had been wanting to help me that my incision would not have burst. I told her last Monday that it was hot, swollen, and discolored, she said it was fine and I felt if I hesitated to make an issue of this, I would have a problem. She said it was okay, but it wasn't, and it burst dressing on Wednesday. I have a bad immune system and wanted antibiotics. I feel that if something is not her idea that it doesn't ___ [sic]. Very rude and dismissive, asked me for details. I can't write with my right hand. She is a bully. The resolution and/or corrective action taken section documented Facility MD [Medical Doctor] following up with concerns, ortho [orthopedic physician] also notified and provided treatment orders-Resident concerns with [LPN #2] being dismissive-Education and resources provided on effective communication. [LPN #2] to not provide non-emergency cares, CNO had a conversation with [LPN #2]. The grievance form was signed at the bottom by the CEO. A facility grievance form, dated 3/24/24, initiated by Resident #7, documented the following: This morning after breakfast [LPN #2] came in with what she said were my pills. I started to dump them in my mouth. I looked at them as I was about to put them in my mouth. I told her they were not my pills. She took them back and said she just wanted to see if I was awake. She walked out and got mine. I could have been poisoned. [CNA) #4] walked in as she was saying that. I was a bit shocked! I don't think I have ever given her reason to resent me. I must remind her of someone she does not like. Please read above. I am thankful I actually recognized they were not my meds. I could have been poisoned. [LPN #2] never apologized or showed any concern. Sunday 3/24/23 at around 9 AM. The form did not include documentation for the summary of the incident by the department head. The section for resolution and corrective actions taken was blank and the signature line for the Executive Director was blank. During an interview on 4/30/24 at 1:14 PM, the CEO stated there was an investigation of the grievance for Resident #7, dated 3/10/24 and the conclusion was education and counseling by the CNO and did not identify that abuse should have been investigated. During an interview on 04/30/24 at 1:25 PM, the CEO stated the investigation of the grievance dated 3/10/24, should have been conducted to rule out abuse and was not investigated for abuse. The CEO said he was unaware of the grievance documented by Resident #7 on 3/24/24 and if aware of the grievance, would have functioned as outlined in the facility abuse policy and investigated for abuse. During an interview on 05/01/24 at 5:04 PM, in reference to the 3/24/24 grievance, the CEO confirmed the language in the form completed by Resident #7 was abusive by LPN #2 and should have been investigated as abuse and confirmed it was not investigated as abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, it was determined the facility failed to ensure a transfer notice was provided in writing to a resident, their representative, and the Office of the State Long-Term Care Ombudsman prior to transfer. This was true for 1 of 1 residents (Resident #30) reviewed for transfers. The deficient practice created the potential for psychosocial distress if residents and their representatives were not made aware of or able to exercise their rights related to transfer from the facility. Findings include: The facility's policy, Transfer and Discharge, revised 10/15/22, documented If the facility determines a resident who was transferred with an expectation of returning to the facility . The written notice of transfer/discharge includes: 1) Reason for transfer/discharge, 2) Effective date of transfer/discharge, 3) Location to which the resident is transferred/discharged , 4) Statement that the resident has the right to appeal the action to the state. Resident #30 was admitted to the facility on [DATE], with multiple diagnoses including post-surgical care for a total joint replacement. A progress note, dated 3/21/24 at 10:39 AM, documented Resident #30 had an order to send her to the hospital for a cardiac evaluation due to epigastric pain and positive troponin level (protein that's found in the cells of the heart muscle and when elevated in the bloodstream can indicate heart damage), and she was being transported to the hospital at that time. Resident #30's record did not include documentation of notification in writing of transfer to the hospital. During an interview on 5/3/24 at 11:50 AM, the Social Services (SS) representative stated the facility was not sending discharge/transfer notices to residents and/or their representative for facility-initiated transfers to the hospital for a higher level of care. The SS said the ombudsman was notified when a resident was discharged from the facility, but not if the resident was sent to the hospital. During an interview on 5/3/24 at 12:52 PM, the CRN stated notices should be sent for residents discharged to the hospital including notification to the ombudsman. She stated the facility was not following the policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, it was determined the facility failed to ensure a bed hold notice was provided to a resident or their representative upon transfer to the hospital. This was true for 1 of 1 resident (Resident #30) reviewed for transfers. This deficient practice created the potential for harm if residents were not informed of their right to return to their former bed/room at the facility within a specified time. Findings include: The facility's policy, Transfer and Discharge, revised 10/15/22, documented At the time of transfer/discharge, the resident and a family member or legal representative are given a written notice of the bed-hold policy that specifies the duration of the bed-hold and readmission criteria after the bed-hold period ends . Resident #30 was admitted to the facility on [DATE], with multiple diagnoses including post-surgical care for a total joint replacement. A progress note, dated 3/21/24 at 10:39 AM, documented Resident #30 had an order to send her to the hospital for a cardiac evaluation due to epigastric pain and positive troponin level (protein that's found in the cells of the heart muscle and when elevated in the bloodstream can indicate heart damage), and she was being transported to the hospital at that time. Resident #30's record did not include documentation of notification in writing a bed hold notice was provided to her or her representative upon transfer to the hospital. During an interview on 5/3/24 at 11:50 AM, the Social Services (SS) representative stated the facility was not sending bed hold notices to residents and/or their representative for facility-initiated transfers to the hospital. During an interview on 5/3/24 at 12:08 PM, the Resident Care Manager (RCM) said the bed hold notices were not sent out and a process was needed to be revisited for implementation. During an interview on 5/3/24 at 12:52 PM, the CRN stated bed hold notices should be sent for anyone discharged to the hospital and the facility was not following the policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #26 was admitted to the facility on [DATE], with multiple diagnoses including End Stage Renal Failure. An admission physician order, dated 4/11/24, documented Resident #26 was to receive dialysis every evening on Monday, Wednesday, and Friday for End Stage Renal Disease. Resident #26's Baseline Care Plan, dated 4/12/24, did not include baseline care development for her dialysis. During an interview on 5/2/24 at 2:05 PM, LPN #1 reviewed the process for Resident #26 for dialysis and confirmed the 48-hour care plan did not include dialysis care. During an interview on 5/2/24 at 3:32 PM, the CNO and the CRN reviewed the 48-hour care plan for Resident #26 and confirmed there was no focus or plan of care for dialysis and said there should have been a plan of care for dialysis in place upon admission. Based on record review, policy review, and staff interview, it was determined the facility failed to ensure a baseline care plan was developed within 48 hours of resident's admission. This was true for 2 of 12 residents (#26 and #84) reviewed for baseline care plans. This failure created the potential for harm if the care plan failed to provide direction for care. Findings include: The facility's Care Plans policy, revised 10/15/22, documented the baseline care was developed within 48 hours of admission to address the immediate needs of the resident until a comprehensive care plan could be developed. The baseline care plans were required to address at a minimum, physician orders, dietary orders, therapy orders, social services; initial goals based on admission orders and desired outcomes. 1. Resident #84 was admitted to the facility on [DATE], with multiple diagnoses including End Stage Renal Disease (ESRD), Hypertension (elevated blood pressure), Sepsis (infection in blood stream), Methicillin Resistant Staphylococcus Aureus (MRSA) Infection, and Type 2 Diabetes Mellitus. A physician admission order, dated 4/23/24, documented Resident #84 was to receive hemodialysis on Monday, Wednesday, and Friday at 11:00 AM. Resident #84's Baseline Care Plan, initiated 4/24/24, did not include baseline care development for his dialysis. During an interview on 5/3/24 at 5:35 PM, the MDS Coordinator reviewed the baseline care plan for Resident #84 initiated during the admissions process by nursing and completed within 48 hours of the resident's admission to the facility. The MDS Coordinator stated the baseline care plan should have included the dialysis treatment and interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, it was determined the facility failed to ensure comprehensive resident-centered care plans were developed and implemented. This was true for 1 of 12 residents (Resident # 26) whose care plans were reviewed. This failure placed Resident #26 at risk of negative outcomes if services were not provided or provided incorrectly due to lack of information in the care plan. Findings include: The facility's Care Plan policy, revised 10/15/22, documented The facility develops and implements a comprehensive person-centered care plan for each resident, consistent with the resident rights and includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs identified in the comprehensive assessment. Resident #26 was admitted to the facility on [DATE] with multiple diagnoses including End Stage Renal Failure with Dialysis. An admission MDS assessment, dated 4/14/24, documented Resident #26 was cognitively intact and required special treatment for dialysis. A physician's order, dated 4/11/24, documented Resident #26 was to be transported for her dialysis to the hospital on Monday, Wednesday, and Friday at 12:00 PM. The order documented staff were to send her lunch and cushion in her wheelchair with her. The order further documented staff were to validate the Dialysis Communication Record was returned from the hospital, and if it was not returned, call the hospital, and make a progress note. The order stated if the Dialysis Communication Record was returned, to transcribe orders as indicated and to note and time the order transcription. Resident #26's care plan did not include a focus care area for her dialysis. During an interview on 5/2/24 at 2:05 PM, LPN #1 reviewed the process for Resident #26 for dialysis and confirmed the care plan did not include dialysis care. During an interview on 5/2/24 at 3:32 PM, the CNO and the CRN reviewed the comprehensive care plan for Resident #26 and confirmed there was no focus or plan of care for dialysis and there should have been a plan of care for dialysis in place upon completion of the comprehensive care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, protocol review, and resident and staff interview, the facility failed to ensure physician orders for bowel care were followed for a resident. This was true for 1 of 1 resident (Resident #7) reviewed for bowel care. This deficient practice placed Resident #7 at risk for constipation or bowel obstruction. Findings include: The facility's protocol for Bowel Care, updated 1/27/11, documented the following process: 1. After 9 pm, the medication/charge nurse for each unit was responsible for reviewing the resident Certified Nursing Assistant (CNA) flowsheet records for bowel regularity. When a resident has not had a documented BM (bowel movement) in the last 48 hours the nurse was responsible to ensure the physicians orders provide coverage for the bowel regime and then follow the directives. 2. Bowel Regime: a. Follow specific physician orders for residents that require an increase in frequency over protocol. b. If resident is 48-hours without a BM documented, administer 30cc [by mouth] Milk of Magnesia (MOM) as per medical doctor (MD) orders. c. If resident is 72-hours without a BM documented, administer l5mg [by rectum] Dulcolax suppository as per MD orders. d. If no BM documented by the following morning, administer fleets enema [by rectum] as per MD order. e. If no BM within 2 hours, phone MD for additional orders. Resident #7 was admitted on [DATE] and readmitted on [DATE], with multiple diagnoses including syncope (fainting most often occurs when blood pressure is too low) and systemic lupus erythematosus (an autoimmune disease in which the immune system attacks its own tissues, causing widespread inflammation and tissue damage in the affected organs). An admission MDS assessment, dated 2/8/24, documented Resident #7 was cognitively intact. A physician order, dated 2/2/24, documented the following bowel care for Resident #7: - Milk of Magnesia (MOM - medication used to relieve constipation) 1200 mg/15 ml by mouth as needed for no bowel movement for 2 days. If no results in 24 hours, see Dulcolax suppository order. - Dulcolax suppository (stool softener) 10 mg rectally as needed for bowel care. Administer if no results from the MOM. If no results in 24 hours, see Fleets enema order. - Fleets enema 7-10 gm/118ml - 1 unit rectally as need for bowel care if no results from MOM and subsequent Dulcolax suppository. Complete bowel assessment and notify MD if no results. During an interview on 4/30/24 at 2:42 PM with Resident #7, LPN #3 came into the room and Resident #7 said, I have not had a BM [bowel movement] for more than three days. During an interview on 5/1/24 at 2:55 PM, Resident #7 explained last Wednesday [4/24/24] was the last time she had a BM and was telling someone every day. She stated she had MiraLAX (stool softener) on Saturday and every day since. Resident #7 stated she was not offered Milk of Magnesia, had a lot of gas, and finally started having BMs today. Resident #7's TAR for bowel function, documented she had a BM on 4/24/24 and no BM on 4/25/24, 4/26/24, 4/27/24, 4/28/24, 4/29/24, and 4/30/24 (6 days). Resident #7 MAR for April 2024, did not include documentation of administration of MOM. A Dulcolax 10 mg suppository was administered on 4/30/24 at 11:27 AM, 6 days after her last BM. During an interview on 5/3/24 at 8:41 AM, the CRN stated the bowel protocol was reviewed and compared to Resident #7's record. Resident #7's record was reviewed for the bowel function task, the physician orders, and the MAR for April 2024. The CRN stated the physician orders were not followed and the bowel protocol was not followed and should have been implemented when Resident #7 reported not having a BM on 4/26/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, observation, and staff interview, it was determined the facility failed to ensure to keep accurate and complete clinical records for each resident. This was true for 1 of 12 residents (Resident #7) whose records were reviewed. This deficient practice created the potential for harm if inappropriate care and/or treatment was provided. Findings include: The facility's policy, Documentation of Resident Health Status Needs and Services, revised 10/15/22, documented The medical record must contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress, including his/her response to treatments and/or services, and changes in his/her condition, plan of care goals, objectives and/or interventions .factual .and accurate. The facility's policy, Oral Medication Administration, revised 1/1/18, documented After medication administration document in the electronic MAR the dose of the medication, route of administration, date, and exact time administered with your initials. Any assessments required prior to administration should be included in the documentation. Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including syncope (fainting most often occurs when blood pressure is too low) and systemic lupus erythematosus (an autoimmune disease in which the immune system attacks its own tissues, causing widespread inflammation and tissue damage in the affected organs). An admission MDS assessment, dated 2/8/24, documented Resident #7 was cognitively intact. On 4/29/24 at 2:42 PM, Resident #7 stated LPN #2 was assigned to her room and did not come into the room. She stated when medications were administered, a different nurse brought the pills into the room for administration. Resident #7's MAR, dated 4/28/24, documented medications were administered by LPN #2. During an interview on 4/30/24 at 12:15 PM, RN #1 stated Resident #7 and LPN #2 had issues between them and Resident #7 requested LPN #2 not come into her room. RN #1 stated LPN #2 requested RN #1 to assist in medication administration on 4/28/24. RN #1 stated LPN #2 prepared the medications to be administered, gave the pills to RN #1, who took the medications into the room and administered them to Resident #7. RN #1 stated LPN #2 documented the medications as given in the MAR which documented LPN #2's initials in the administration box. RN #1 stated giving the pills prepared by LPN #1 was not following procedure which included to have one nurse document the administration of a medication and a different nurse do the actual administration of medications. During an interview on 5/2/24 at 10:54 AM, the CNO and the CRN stated the staff was to follow the medication administration policy and the nurse who documented the medication as given should have been the same nurse who administered the medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, the facility failed to ensure a licensed pharmacist reviewed each residents' medications at least monthly, and the physician/prescriber addressed the medications irregularities identified by the pharmacist. This was true for 2 of 5 residents (#3 and #17) whose medications were reviewed. These deficient practices created the potential for harm if residents' medications were administered without a clinical rationale. Findings include: The facility's policy, Pharmacy Consultation, dated 11/28/17, documented the Pharmacy Consultant would conduct monthly medication regimen review (MRR) for each resident in the facility. The review should address any side effects of medication; allergic reactions to antibiotic therapy; significant medication interactions; if prescribed medication was consistent with the resident's condition; whether the physician and staff have documented progress towards or maintenance of goals for medication therapy; whether the physician and staff have noted and acted upon possible medication related causes of recent or persistent changes in the resident's condition such as worsening of an existing problem or the emergence of new signs or symptoms. The policy also stated the CNO, and the facility physician would respond to recommendations made by the Pharmacy Consultant. 1. a. Resident #3 was admitted to the facility on [DATE], with multiple diagnoses including Alzheimer's Disease. Physician Orders for the month of May 2024, documented Resident #3 was to receive Lexapro (antidepressant used to treat mood disorders) 20 mg daily and Zyprexa (used to treat Dementia) 2.5 mg daily. The order stated Resident #3 was to be monitored every shift for behaviors and side effects of the medications. Resident #3's record did not include documentation a Drug Regimen Review was completed by the Pharmacy Consultant. b. Resident #17 was admitted to the facility on [DATE], with multiple diagnoses including a craniotomy for a puncture wound to the head, major depressive disorder, and anxiety disorder. Physician Orders for the month of May 2024, documented Resident #17 was to receive Baclofen 10 mg daily (for bladder spasms), Diclofenac Gel 1% 2 gm (topical gel for pain), Doxepin 50 mg daily (for sleep), Eliquis 10 mg daily (anticoagulant for Deep Vein Thrombosis), Enoxaparin 40 mg subcutaneous injection (prevent Deep Vein Thrombosis), Gabapentin 100 mg daily (used to treat seizures and pain), Lexapro 20 mg daily (for depression), Melatonin 5 mg (treat insomnia), and Tramadol 50 mg (opioid for pain) every four hours as needed for pain. Resident #17's record did not include documentation a Drug Regimen Review was completed by the Pharmacy Consultant. The MMRs for the months of March 2024 and April 2024, did not include documentation of medication reviews for Resident #3 and Resident #17. The MMRs that included recommendations from the Pharmacy Consultant did not include reviews were completed by the physician. During an interview on 5/3/24 at 8:41 AM, the CRN stated the Pharmacy Consultant was notified of new admissions especially those residents receiving psychoactive medications. The CRN stated the Pharmacy Consultant would complete an Interim Drug Regimen Review remotely within 24 hours of the resident's admission. The review was faxed to the CNO to review with the facility physician. The CRN stated the Pharmacy Consultant conducted monthly Medication Regimen Reviews with recommendations. The CRN stated these reviews/recommendations were given to the CNO to review with the facility physician. The CRN also stated the facility did not have a system in place to ensure the physician reviewed the recommendations made by the Pharmacy Consultant. During a telephone interview on 5/3/24 at 11:34 AM, the Clinical Pharmacist stated the facility notified the pharmacist when a new resident arrived. He stated the Pharmacist would perform a remote evaluation (called Interim Medication Review) for those residents that were on psychotropic medications. The Clinical Pharmacist also stated another pharmacist was responsible for reviewing all the residents in the facility monthly. He stated that the Pharmacist would make the necessary recommendations; and this information was sent to the CNO. The Clinical Pharmacist further stated the Pharmacist that completed the MRRs for January, February, March, and April was unaware there was a new CNO and sent the reviews to the wrong CNO.

Based on record review, policy review, observation, and staff interview, the facility failed to ensure that 5 of 13 diabetic residents ( #8, #15, #18, #26, and #85) with insulin medications kits located in their rooms were locked; 1 of 2 medication carts were locked; and daily medication refrigerator temperatures were documented. These deficient practices created the potential for harm if residents and unauthorized personnel accessed medications and they became missing or were administered incorrectly, needles were improperly used, or residents received medications with decreased efficacy from not being stored at the correct temperature. Findings include: The facility's policy, Medication Management, revised 10/15/22, directed the staff to ensure Medications and biologicals are stored appropriately according to the manufacturer's guidelines and to prevent unauthorized access. Unlocked medication/treatment carts are always under the nurse control. 1. The following diabetic kits were not securely stored: - On 4/29/24 at 1:10 PM, an unlocked green diabetic kit containing insulin injector pens, needles, glucometer, alcohol wipes, and cotton balls were observed in Resident #85's room. - On 5/1/24 at 12:21 PM, unlocked green diabetic kits containing insulin injector pens, needles, glucometers, alcohol wipes, and cotton balls were observed in Resident #8, Resident #15, Resident #18, and Resident #26's rooms. During an interview on 5/1/24 at 11:10 AM, RN #1 stated all the diabetic residents had a green diabetic kit that contained a glucometer, strips, needles, the residents' prescribed insulin pens, cotton balls, and alcohol wipes. RN #1 stated these kits were to be locked and maintained in the residents' rooms. RN #1 stated the keys to the insulin kit were maintained on the medication cart key rings. During an interview on 5/2/24 at 11:31 AM, LPN #1 stated the green diabetic kits were unlocked and contained glucometer, strips, alcohol wipes and cotton balls, and the residents prescribed insulin pens. However, it was identified there was a problem in locking the kits. During an interview on 5/2/24 at 1:58 PM, the CRN stated that green diabetic insulin kits were maintained in the resident's room. The CRN stated the kits were to be always locked. The CRN stated the facility did not have a policy for diabetic kits in the resident's rooms. The CRN also stated it was identified there was a problem with securely locking kits in the residents' rooms, so it was decided to remove all sharps (needles) from the kits thereby ensuring residents safety. 2. On 4/30/24 at 9:44 AM, the medication cart on Hall Two was observed unlocked in front of Resident #83's room. Residents and staff members were passing by the unsecured medication cart. During an interview on 4/30/24 at 9:58 AM, RN #1 stated the medication cart was left unlocked and was out of line of sight. RN #1 stated he was in a hurry to administer Resident #83's medication and forgot to lock the cart. During an interview on 4/30/24 at 4:10 PM, the CNO stated it was an expectation for the medication cart to always be locked when the nurse was not at the cart. 3. During inspection of the central medication room on 5/1/24 at 3:00 PM, the temperatures for the medication refrigerator were inconsistently documented. Review of the temperature logs for medication room refrigerator documented the following: for the month of December 2023 temperatures were recorded 9 days out of 31 days. For the month of January 2024 temperatures were recorded 12 days out of 31 days. For the month of February 2024 temperatures were recorded 11 days out of 29 days. For the month of March 2024 temperatures were recorded 10 days out of 31 days. For the month of April 2024 temperatures were recorded 15 days out of 30 days. During an interview on 5/1/24 at 4:47 PM, the CRN stated the night nurses were responsible for the daily checking and documenting the temperatures for the medication refrigerator. The CRN stated the nurses must record the date and time the temperature was taken. The CRN stated the nurse must also record the ambient/room temperature and then the actual temperature of the medication refrigerator. The CRN further stated no medications were stored in the freezer, so the nurse did not record temperatures for the freezer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, policy review, and staff interview, it was determined the facility failed to ensure infection control prevention practices were maintained to provide a safe and sanitary environment. This was true for 9 of 9 residents (#2, #5, #26, #81, #83, #84, #133, #135, and #137) observed for enhanced barrier precautions. These failures had the potential to impact all residents in the facility by placing them at risk for cross contamination and infection. Findings include: The CDC Website for Long-Term Care Facilities - Frequently Asked Questions about Enhanced Barrier Precautions in Nursing Homes, dated 4/2/24, and accessed on 5/16/24, states: - Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). - Enhanced Barrier Precautions expand the use of gown and gloves beyond anticipated blood and body fluid exposures. They focus on use of gown and gloves during high-contact resident care activities that have been demonstrated to result in transfer of MDROs to hands and clothing of healthcare personnel, even if blood and body fluid exposure is not anticipated. Enhanced Barrier Precautions are recommended for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). Standard Precautions still apply while using Enhanced Barrier Precautions. For example, if splashes and sprays are anticipated during the high-contact care activity, face protection should be used in addition to the gown and gloves. The facility's policy, Enhanced Barrier Precautions (Based upon Resident Risk), revised 4/2/24, states Enhanced Barrier Precautions (EBP) are recommended for use in resident rooms when residents have any of the following conditions, but do not require contact precautions: a, Open chronic wounds (not shorter lasting wounds such as skin breaks or skin tears with a Band-Aid) requiring dressing change. Chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcer, unhealed surgical wounds, and venous stasis ulcers. b. indwelling medical devices, central line, urinary catheter, feeding tube, . A peripheral intravenous line (not a peripherally inserted central catheter [PICC]) is not considered an indwelling medical device. c. Colonization with an [multi-drug resistant organism] (MDRO). Procedure included . Post the appropriate precaution signage outside the resident room. One side may say See Nurse with the backside stating specific directives for resident privacy protection. The following residents were observed not being provided enhanced barrier precautions (EBP) as ordered and/or who met the criteria for EBP. a. Resident #133 was admitted to the facility on [DATE], with a multiple diagnoses including Type 2 Diabetes with a Foot Ulcer. A physician order, dated 4/23/24, documented staff were to administer peripherally inserted central catheter (PICC - a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the heart) dressing changes weekly and as needed one time a day every Sunday. The order also stated staff were to provide wound care to Resident #133's right foot diabetic ulcer as follows: cleanse with normal saline, pat dry, apply Hydrofera (type of dressing) to the wound bed, and wrap with Kerlix (gauze dressing), an ace wrap, and tape. The order stated to change dressings daily and as needed. Resident #133's Care Plan documented Enhanced barrier precautions to reduce the risk of MDRO transmission related to history of methicillin-resistant Staphylococcus aureus (MRSA), initiated on 4/23/24. On 4/30/24 at 12:58 PM, there was no sign observed on Resident #133's door to see the nurse before entering the room and no personal protective equipment (PPE) was available in or near the Resident #133's room. b. Resident #139 was admitted to the facility on [DATE], with multiple diagnoses including Acute Cystitis with Hematuria (infection of the urinary tract with presence of blood). A physician order, dated 4/23/24, documented staff were to change Resident #139's indwelling urinary catheter bag and tubing (urine is drained through a tube inserted into the bladder and connected to a collection bag) on admission and every 30 days for urinary catheter maintenance. On 4/30/24 at 9:24 AM, there was no sign observed on Resident #139's door to see the nurse before entering the room and no personal protective equipment (PPE) was available in or near the Resident #139's room. c. Resident #26 was admitted to the facility on [DATE], with a multiple diagnoses including End Stage Renal Failure. A physician order, dated 4/11/24, documented Resident #26 was to be placed in Enhanced barrier precautions for wound treatment and dialysis. Gown and gloves required for high-contact patient care dressing, bathing, transferring, incontinence or toileting care, dressing, changing linens, or device or wound care. A gown and gloves are not required when not performing high-contact care. Resident may leave room. On 4/30/24 at 9:43 AM, there was no sign observed on Resident #26's door to see the nurse before entering the room and no personal protective equipment (PPE) was available in or near the Resident #26's room. d. Resident #135 was admitted to the facility on [DATE], with a multiple diagnoses including MRSA Infection. A physician order, dated 4/11/24, documented staff were to provide wound care for Resident #135 to the right and left gluteal cleft (deep groove lying between the two buttocks) pressure ulcers. The order directed staff to cleanse the wound with normal saline, pat dry, apply protective ointment daily, and cover with a foam dressing on every day shift until resolved. Resident #135's Care Plan documented, was to be placed in Enhanced barrier precautions to reduce the risk of MDRO transmission related to history of MRSA, initiated on 4/22/24. On 4/29/24 at 1:20 PM, there was no sign observed on Resident #135's door to see the nurse before entering the room and no personal protective equipment (PPE) was available in or near the Resident #135's room. e. Resident #84 was admitted to the facility on [DATE], with multiple diagnoses including MRSA Infection and End Stage Renal Disease. A physician order, dated 4/11/24, documented Resident #84 wad to be placed in Enhanced barrier precautions for wound treatment and dialysis. Gown and gloves were required for high-contact patient care dressing, bathing, transferring, incontinence or toileting care, dressing, changing linens, or device or wound care. A gown and gloves are not required when not performing high-contact care. Resident may leave room. On 4/29/24 at 1:25 PM, there was no sign observed on Resident #84's door to see the nurse before entering the room and no personal protective equipment (PPE) was available in or near the Resident #84's room. f. Resident #81 was admitted to the facility on [DATE], with multiple diagnoses including infection and inflammatory reaction due to an internal right hip prosthesis. A physician order, dated 4/23/24, documented staff were to change Resident #81's PICC line dressing weekly and as needed one time a day every Sunday. Resident #81's Care Plan documented Resident #81 was to be placed in Enhanced barrier precautions to reduce the risk of MDRO transmission related to surgical incision, initiated on 4/23/24. On 5/1/24 at 11:25 AM, there was no sign observed on Resident #81's door to see the nurse before entering the room and no personal protective equipment (PPE) was available in or near the Resident #81's room. g. Resident #5 was admitted to the facility on [DATE] and readmitted [DATE], with multiple diagnoses including Acute Bronchitis due to Respiratory Syncytial Virus. A physician order, dated 3/23/24, documented Resident #5 was to be placed in Enhanced barrier precautions for wound treatment. Gown and gloves were required for high-contact patient care dressing, bathing, transferring, incontinence or toileting care, dressing, changing linens, or device or wound care. A gown and gloves are not required when not performing high-contact care. Resident may leave room. On 5/1/24 at 11:08 AM, there was no sign observed on Resident #5's door to see the nurse before entering the room and no personal protective equipment (PPE) was available in or near the Resident #5's room. h. Resident #2 was admitted to the facility on [DATE] and readmitted [DATE], with multiple diagnoses including Chronic Multifocal Osteomyelitis (a disease that causes pain and damage in bones due to inflammation). A physician order, dated 2/13/24, documented Resident #2 was to be placed in Enhanced barrier precautions for wound treatment. The gown and gloves were required for high-contact patient care dressing, bathing, transferring, incontinence or toileting care, dressing, changing linens, or device or wound care. A gown and gloves are not required when not performing high-contact care. Resident may leave room. On 5/1/24 at 11:04 AM, there was no sign observed on Resident #2's door to see the nurse before entering the room and no personal protective equipment (PPE) was available in or near the Resident #2's room. i. Resident #83 was admitted to the facility on [DATE] with multiple diagnoses including Type 2 Diabetes Mellitus with a Foot Ulcer. A physician order, dated 3/23/24, documented Resident #83 was to be placed in Enhanced barrier precautions for PICC line. The gown and gloves were required for high-contact patient care dressing, bathing, transferring, incontinence or toileting care, dressing, changing linens, or device or wound care. A gown and gloves are not required when not performing high-contact care. Resident may leave room. On 4/30/24 at 10:01 AM, there was no sign observed on Resident #83's door to see the nurse before entering the room and no personal protective equipment (PPE) was available in or near the Resident #83's room. During an interview on 5/2/24 at 9:09 AM, LPN #1 stated there were no residents on hallway one that were on isolation precautions or enhanced barrier precautions. Resident #133, Resident #139, Resident #27, Resident #26, Resident#135 were located on hallway one. During an interview on 5/2/24 at 10:43 AM, RN #1 [who worked on hallway two] stated he was not sure what EBP meant; then RN #1 stated EBP was used on residents with wounds and the supplies needed when doing wound care, PPE (gown, mask, and gloves) were located in the supply room. RN #1 stated it was something new and was not sure what EBP involved, was not sure if CNAs should wear PPE. RN #1 was unable to identify which residents on hallway two were on EBP. RN #1 confirmed he did not have training on the EBP policy. Resident #84, Resident #81, Resident #5, Resident #2, and Resident #83 were located on hallway two. During an interview on 5/2/24 at 10:07 AM, the Infection Preventionist (IP) stated orders were placed in resident's electrtonic medical record (EMR) depending on criteria of EBP, the EBP be in the header for each resident in their EMR. The IP then confirmed residents who should have been on EBP did not have information listed for EBP on the header in the EMR. The IP stated there were no signs on the doors for residents who met the criteria for EBP, and no PPE supplies were located in or near the resident rooms for use. During an interview on 5/2/24 at 10:54 AM, the CNO and the CRN stated the staff was to initiate EBP for residents who met the criteria outlined in the procedure. They stated for direct resident care of a wound, dressing change of a PICC line, or care of a wound, PPE supplies should be located in or near the resident room. The CRN stated the signs were not located on the door, the PPE supplies were not in or near the resident rooms and staff were not aware of the updated transmission-based precautions policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, it was determined the facility failed to ensure newly admitted residents were provided education for pneumococcal vaccines prior to refusing the vaccine. This was true for 5 of 5 residents (#2, #7, #14, #15, and #16) reviewed for pneumococcal immunizations. This failure created the potential for harm should residents contract Pneumococcal pneumonia and experience illness from pneumonia. Findings include: The facility's policy for their Pneumococcal Program, revised 5/31/23, stated Educate residents or resident advocate about the pneumococcal vaccination, the benefits, potential side effects and general safety of receiving the vaccine. Provide a copy of the VIS [Vaccination Information sheet] statement. The following residents did not receive education prior to refusing the pneumococcal vaccine. a. Resident #14 was admitted to the facility on [DATE]. A Vaccine Information Acknowledgement, dated 2/14/24, documented Resident #14 checked the box I do not wish to take (blank line filled in with word any) vaccine at this time and the boxes for information about the pneumococcal vaccine to be provided to the resident (Vaccine Information Sheet), were not checked. b. Resident #7's was admitted to the facility on [DATE] and readmitted on [DATE]. A Vaccine Information Acknowledgement, dated 2/2/24, documented Resident #7 checked the box I do not wish to take (blank line filled in with word any) vaccine at this time and the boxes for information about the pneumococcal vaccine to be provided to the resident (Vaccine Information Sheet), were not checked. c. Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE]. A Vaccine Information Acknowledgement, dated 2/2/24, documented Resident #2 checked the box I do not wish to take (blank line filled in with word any) vaccine at this time and the boxes for information about the pneumococcal vaccine to be provided to the resident (Vaccine Information Sheet), were not checked. d. Resident #15 was admitted to the facility on [DATE] and readmitted on [DATE]. A Vaccine Information Acknowledgement, dated 2/2/24, documented Resident #15 checked the box I do not wish to take (blank line filled in with word any) vaccine at this time and the boxes for information about the pneumococcal vaccine to be provided to the resident (Vaccine Information Sheet), were not checked. e. Resident #16 was admitted to the facility on [DATE]. A Vaccine Information Acknowledgement, dated 3/15/24, documented Resident #16 checked the box I do not wish to take (blank line filled in with word any) vaccine at this time and the boxes for information about the pneumococcal vaccine to be provided to the resident (Vaccine Information Sheet), were not checked. During an interview on 5/1/24 at 1:10 PM, the Infection Preventionist (IP) stated the process was to review the Vaccine Information Acknowledgement form at admission if the resident desired the pneumococcal vaccine and if they wanted th vaccine, then it would be provided. The IP confirmed the Vaccine Information Sheet was not provided to the residents during the admission process when the Vaccine Information Acknowledgement form was signed to provide the vaccine or not. During an interview on 5/2/24 at 10:59 AM, the CNO and the CRN stated the Vaccination Information Sheet was not provided during the admission process prior to the signing of the Vaccine Information Acknowledgement form and the Vaccination Information Sheet should have been provided to the residents prior to signing the form.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, it was determined the facility failed to ensure discharge plans were developed for residents. This was true for 1 of 1 resident (Resident #7) reviewed for discharge planning. This failure created the potential for harm if the resident's various discharge needs were not met. Findings include: The facility's discharge policy, dated 2/21/18, documented the discharge plan of care was developed to assist a resident to adjust to their new living environment by providing continuity of care. This policy was not followed. Resident #7 was admitted to the facility on [DATE], for post-operative care following surgical repair of a fracture of the top of her left femur (thigh bone). Additional diagnoses included congestive heart failure and diabetes. Resident #7's baseline care plan, dated 6/22/19, documented discharge plans were for her to return home alone. A physician progress note, dated 7/1/19, documented Resident #7 fell in her home in late May, 2019 and was later diagnosed with a left femur fracture. The progress note documented Resident #7 described the reason for the fall as a syncopal episode (fainting or passing out). The progress note further documented over the weekend Resident #7 reported to nursing staff she had chest pain and shortness of breath and was transported to the hospital for evaluation. The progress note stated the hospital evaluation ruled out cardiac (heart) and pulmonary (lung) pathology, but identified she was quite anemic and required a blood transfusion. A progress note, dated 7/20/19 at 10:29 PM, documented Resident #7 complained she could not catch her breath and had chest and low back pain. Medications administered were not effective. The note documented emergency services were called and Resident #7 was transported to the hospital via ambulance. A progress note, dated 7/21/19 at 1:33 AM, documented Resident #7 was admitted to the hospital with a diagnosis of CHF exacerbation. A progress noted, dated 7/22/19 at 2:45 PM, documented Resident #7 returned to the facility. A physician order, dated 7/23/19, documented Resident #7 was discharged to her home with services from a home health agency on 7/23/19. Resident #7's record did not include documentation a discharge plan was completed. There was not a plan addressing Resident #7's episodes of shortness of breath when she was alone in her home. On 10/18/19 at 8:37 AM and 9:08 AM, the DON said Resident #7 was discharged from the facility with home health. The DON said there was not a discharge plan in her record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, it was determined the facility failed to ensure residents were involved in the post-discharge plan of care. This was true for 1 of 1 resident (Resident #7) reviewed for discharge planning. This failure created the potential for residents to be discharged without plans in place to effectively meet their post-discharge needs. Findings include: The facility's discharge policy, dated 2/21/18, documented a post-discharge plan of care would be developed with the participation of the resident and their family and would be provided a copy. This policy was not followed. Resident #7 was admitted to the facility on [DATE], for post-operative care following surgical repair of a fracture of the top of her left femur (thigh bone). Additional diagnoses included congestive heart failure and diabetes. Resident #7's baseline care plan, dated 6/22/19, documented discharge plans were for her to return home alone. A physician progress note, dated 7/1/19, documented Resident #7 fell in her home in late May, 2019 and was later diagnosed with a left femur fracture. The progress note documented Resident #7 described the reason for the fall as a syncopal episode (fainting or passing out). The progress note further documented over the weekend Resident #7 reported to nursing staff she had chest pain and shortness of breath and was transported to the hospital for evaluation. The progress note stated the hospital evaluation ruled out cardiac (heart) and pulmonary (lung) pathology, but identified she was quite anemic and required a blood transfusion. A progress note, dated 7/20/19 at 10:29 PM, documented Resident #7 complained she could not catch her breath and had chest and low back pain. Medications administered were not effective. The note documented emergency services were called and Resident #7 was transported to the hospital via ambulance. A progress note, dated 7/21/19 at 1:33 AM, documented Resident #7 was admitted to the hospital with a diagnosis of CHF exacerbation. A progress noted, dated 7/22/19 at 2:45 PM, documented Resident #7 returned to the facility. A physician order, dated 7/23/19, documented Resident #7 was discharged to her home with services from a home health agency on 7/23/19. Resident #7's record did not include documentation she was involved in the post-discharge plan of care, to ensure her needs were met after returning home. On 10/18/19 at 8:37 AM and 9:08 AM, the DON said Resident #7 was discharged from the facility with home health. The DON said Resident #7's record did not include documentation of her involvement in the discharge planning process.

Based on observation and staff interview, it was determined the facility failed to ensure medications were properly labeled and stored for 1 of 5 residents (Resident #161) observed for medication administration. This deficient practice placed residents at risk for receiving the wrong medication and experiencing an adverse event. Findings include: On 10/17/19 at 7:33 AM, during a medication administration observation, LPN #1 pulled medications that were held in three small paper cups out of the top drawer of the medication cart and administered the medication to Resident #161. LPN #1 said he tried to administer the medications earlier, but Resident #161 was not ready. The paper cups were not labeled with Resident #161's name, the date, or the time. On 10/17/19 at 8:20 AM, LPN #1 said he could not recall how he was trained regarding labeling of medications when they were returned to the medication cart. On 10/17/19 at 8:49 AM and on 10/18/19 at 8:12 AM, the DON said nursing staff were trained on medication administration during orientation and when an issue arose. She said the paper cups containing medication were to be labeled if they were put back into the medication cart for any reason, and were only held for a short period of time. She said the facility did not have a policy that specifically addressed returning a paper cup full of pills to a medication cart. She said the medication administration policy instructed the nurse to offer the medication three times and then dispose of the medication. The DON said the policy did not address labeling the cup. The DON said she expected the cup to be labeled before it was returned to the medication cart for storage.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review, Activity Calendar review, and resident and staff interview, it was determined the facility failed to ensure there was an ongoing activity program to meet the individual and social needs for 1 of 1 resident (Resident #162) reviewed for activities and had the potential to affect all other 25 residents in the facility. This failure created the potential for residents to experience boredom and lacked meaningful engagement throughout their stay. Findings include: The facility's Activity policy, dated 1/3/18, documented the facility provided an ongoing program of resident activities to meet the interests and physical, mental and psychosocial well-being of each resident and scheduled activities were posted. This policy was not followed. The facility's October 2019 Activity Calendar documented the following activities and times: * Mondays - Wii Game of Choice at 10:00 AM and Bingo at 2:15 PM * Tuesdays - Cornhole (Game) at 10:00 AM and Root Beer Floats at 2:15 PM * Wednesday - Trivia at 10:00 AM and Bingo at 2:15 PM * Thursday - Wii Games at 10:00 AM and Nail Care at 2:15 PM, except 10/31/19 10:00 AM Costume Contest and 5:00 PM Trick or Treat * Friday - Outdoor Games or Board Games at 10:00 AM, Ice Cream Social at 2:15: PM, and Walks at 2:30 PM * Saturday and Sunday - Movies at 2:15 PM Resident #162 was admitted to the facility on [DATE], with multiple diagnoses including a stroke and dementia. Resident #162's admission activity assessment, dated 10/14/19, documented she liked cards, games, walking outside, music, and watching TV. The assessment documented she had no interest in watching movies. Resident #162's Activity Participation record from 10/11/19 to 10/16/19, documented she attended one ice cream social, one root beer float activity, attended bingo once, and refused movies twice. On 10/15/19 at 3:54 PM, Resident #162 was sitting on a couch in the lobby, near the fireplace and not engaged in an activity. A minute later, she stood up and walked down the hallway toward her room. At 4:40 PM, Resident #162 was back on the couch in the lobby and not engaged in an activity. She said, There really isn't anything to do. It's boring here. She said she was not aware of what activities there were for her to do and said she liked to play games. On 10/15/19 at 4:48 PM, near Resident #162's room there was an electronic display board with the activity calendar in the hallway. The activity calendar display showed there was going to be cornhole at 10:00 AM and root beer floats at 2:15 PM. The display also showed the activities for the following day were trivia at 10:00 AM and bingo at 2:30 PM. The display did not tell residents where the activities were to take place. On 10/16/19 from 9:40 AM to 10:10 AM, during observations it was noted the activity display board showed trivia as an activity at 10:00 AM. There were no staff members observed offering residents to attend the trivia activity, including Resident #162. At 10:03 AM, there was no trivia game observed occurring in the facility as an activity in the lobby, the dining room, or the therapy room. On 10/16/19 at 10:10 AM, Resident #162 was in the recliner in her room with the TV off. She said she liked games and would be interested in a trivia game. She said no one had offered her to attend a trivia activity that day. She said there was a woman who sat with her on the couch in the lobby with her that morning for a few minutes and she said she liked that. Resident #162 said she was not sure what activities were available and no one had offered her a schedule of activities. On 10/16/19 at 2:34 PM, the activity display board showed bingo as an activity at 2:30 PM. There were no staff members observed offering residents to attend the bingo activity. There was no bingo activity observed occurring in the facility as an activity in the lobby, the dining room, or the therapy room. Resident #162 was observed spending time in her room or on the couch in the lobby. She was not observed engaging in activities she enjoyed according to her activity assessment. Examples include: * On 10/16/19 from 8:15 AM to 8:30 AM, Resident #162 finished eating breakfast in the dining room and a staff member walked with her from the dining room, into the lobby area and the staff member assisted Resident #162 onto the couch. A minute later the Director of Rehabilitation (DOR) sat next to her and began talking with her. At 8:30 AM, the DOR told Resident #162 that she had to go and left the resident on the couch. * On 10/16/19 from 8:32 AM to 8:34 AM, Resident #162 got up from the couch and walked down to her room. At 8:34 AM, Resident #162 came out of her room with her TV remote in her hand and asked the DON to help her turn on the TV. * On 10/16/19 from 9:03 AM to 9:35 AM, Resident #162 was in the therapy room participating in therapy. At 9:35 AM, a therapist walked with Resident #162 back to her room. * On 10/16/19 from 9:40 AM to 10:10 AM, Resident #162 was in the recliner in her room with the TV on. At 9:54 AM, her eyes were closed, and the TV was still on. * On 10/16/19 at 10:36 AM and 11:04 AM, Resident #162 was on the couch in the lobby and was observed leafing through a magazine or sitting and not engaging in an activity. * On 10/16/19 at 11:26 AM, Resident #162 was on the couch in the lobby and not engaged in an activity. CNA #1 (Certified Nursing Assistant) informed her lunch was in a half hour. CNA #1 said, The fireplace feels pretty good, huh? CNA #1 then walked away from Resident #162. * On 10/16/19 at 2:39 PM, Resident #162 had completed her therapy and OT #1 walked out of the therapy room with her. OT #1 asked Resident #162 if she had any plans for the rest of the day and Resident #162 responded she was not sure. OT #1 did not suggest bingo which was scheduled as an activity for 2:30 PM that day. They walked back to her room and OT #1 situated her in the recliner. On 10/16/19 at 2:44 PM and 4:36 PM, OT #1 said Resident #162 had some memory issues and needed some direction. OT #1 said Resident #162 usually spent time on the couch in the lobby or in her room. OT #1 said she was unaware that bingo was on the calendar for 2:30 PM that day and said she normally found out about the activities from the scrolling board or from the Activity Assistant (AA). On 10/16/19 at 2:58 PM, OT #2 was in the therapy room and said bingo was held in the therapy room and ice cream socials were held in the lobby. OT #2 said there were no activities and no scheduled activities in the therapy room that day. On 10/16/19 at 3:57 PM, CNA #2 said Resident #162 was restless sometimes and staff would take her down to the lobby couch and turn the fireplace on. CNA #2 said staff read the activity display board to find out what activities were scheduled and asked residents if they wanted to attend the activities. On 10/16/19 at 4:12 PM, the AA said he conducted the majority of the activities on the weekdays, unless he had to drive one of the facility's transportation vans, like he did that morning. He said he was one of the back-up van drivers and therapy staff conducted the activities when he was pulled from activities to drive. He said he was unaware the trivia activity did not occur as scheduled that morning and said he conducted the bingo activity later than the scheduled posted time and Resident #162 attended. He said bingo was held in the therapy room and root beer floats and ice cream socials started in the lobby and then he went room to room offering the floats and ice cream. The AA said if an activity was changed or postponed, he placed that information on a cork board with an easel in the lobby outside of the therapy room. He said he had not put up the cork board and had not posted any changes for that day. He said since the facility was a short-stay rehabilitation facility there was a lack of interest and participation in activities by most of the residents. The AA said residents were verbally informed upon admission where the activities were held. He said residents were not given activity calendars because they were posted on the electronic display boards. He said there were no activities scheduled in the evenings. On 10/17/19 at 8:25 AM, the Activity Director (AD) said she was off work the previous day and was not aware the trivia activity did not occur or that bingo was delayed. The AD said she expected staff to conduct scheduled activities as planned and within a reasonable time frame. She said if there was a change in an activity, she expected staff to post that information on the cork board and to make an announcement on the overhead speaker system. She said Resident #162 wandered a lot and said there was not a specific plan to address her activity needs. The AD said staff had been walking and talking with Resident #162, but staff had not documented those interactions in her activity participation record. The AD said Resident #162's representative had informed her that Resident #162 was not much of a TV watcher. She said there were no activities scheduled in the evenings. She said evenings were a time for residents to do individual activities like using the games that were in the library.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure infection prevention practices were implemented and followed during medication administration and blood glucose testing. This was true for 3 of 5 residents (#1, #156, and #161) whose medication administrations were observed. This deficient practice placed residents and staff at risk for infection due to potential cross contamination and exposure to needle sticks or blood. Findings include: The facility's undated Glucometer Disinfection policy and procedure, documented, after completing patient's blood testing and prior to leaving the patient's room, thoroughly clean and disinfect the machine by wiping all surfaces with an approved disinfecting wipe (Bleach wipe). This policy was not followed. According to the Centers for Disease Control and Prevention (CDC) website, accessed 10/31/19, if blood glucose meters are shared the device should be cleaned and disinfected after every use, per the manufacturer's instructions, to prevent carry-over of blood and infectious agents. The CDC website also stated Do not carry supplies and medications in pockets. On 10/17/19 at 7:15 AM, during an observation of Resident #156's blood glucose monitoring, LPN #1 placed the glucose test strips, the lancet, and the glucose meter into the pocket of his scrub top. To perform the glucose monitoring assessment, he pulled the items from his pocket and after completion of the assessment he put the bottle of glucose test strips, the lancet, and the glucose meter back into the same pocket prior to cleaning the items. LPN #1 returned to the medication cart and pulled the items out of his pocket, disposed of the lancet, and wiped the testing strips bottle and glucose meter with an approved cleanser wipe. On 10/17/19 at 7:37 AM, during an observation of Resident #161's blood glucose monitoring, LPN #1 placed the glucose test strips, the lancet, and the glucose meter into the pocket of his scrub top. To perform the glucose monitoring assessment, he pulled the items from his pocket and handed them to Resident #161 to perform the test herself. After completion of the assessment, LPN #1 put the bottle of glucose test strips, the lancet, and the glucose meter back into his scrub top pocket, prior to cleaning the items. LPN #1 returned to the medication cart and pulled the items out of his pocket, disposed of the lancet, and wiped the test strips bottle and glucose meter and allowed it to dry per protocol. LPN #1 then prepared 2 insulin pens to be used to administer 42 units of Lantus U-100 (2 pens were necessary as the original pen did not contain enough product to reach the needed 42 Units). He then prepared a syringe of 3 Units of Humalog (insulin). LPN #1 then placed the 2 pens and the syringe into his scrub top pocket. After reaching Resident #161's room at 7:51 AM, LPN #1 pulled the 2 insulin pens and the insulin syringe out of his pocket and used them to administer the ordered insulin to Resident #161. After the administration of the insulin, LPN #1 placed the 2 insulin pens and the syringe into his scrub top pocket and returned to the medication cart. At the cart LPN #1 disposed of the syringe, the sharps from the pens, and the exhausted insulin pen, and placed the remaining pen in a plastic bag and then in the drawer of the medication cart. On 10/17/19 at 8:10 AM, during an observation of Resident #1's medication administration, LPN #1 placed a Vigflex container (a type of intravenous medication delivery system), which held an antibiotic solution into his scrub top pocket. Upon reaching Resident #1's room he then pulled the system from his pocket and administered the medication. On 10/17/19 at 8:20 AM, LPN #1 said that everywhere he had worked they just put things in their pockets. When asked how he had been trained at the current facility, LPN #1 did not respond. On 10/17/19 at 8:40 AM, the DON said training for infection control was conducted during employee orientation and said audits were conducted on an annual basis. She said if an issue with infection control was identified then training would be conducted at that time. The DON said the testing and antibiotic delivery system should not have been placed in the pockets of the scrub top. On 10/17/19 at 9:10 AM, the Clinical Care Coordinator said the glucose meters should be cleaned immediately after checking a blood sugar and before leaving a room.