**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a resident's dignity when a staff member is feeding a resident (R4) seated in a wheelchair in a total sample of 5 residents (R1, R2, R3, R4 and R5) reviewed for improper nursing care.Findings include:On 8/25/2025 at 11:54 AM, R4 observed sitting in R4's wheelchair positioned in front of a table in the dining room with lunch meal tray in front of R4, and R4's lunch meal consists of a mechanical soft texture meal.On 8/25/2025 at 12:05 PM, V3 (Licensed Practical Nurse, LPN) observed walking up to the side of R4, who remains seated in R4's wheelchair at the dining room table and stands next to R4. While in a standing position over R4, V3 picks up spoon and begins to feed R4 mechanical soft food from the tray. V3, while standing, continues to feed R4 over 10 spoons of food from R4's tray.R4's admission Record documents, in part, diagnoses of dementia, dysphagia, convulsions, epilepsy, chronic obstructive pulmonary disease, type 2 diabetes mellitus, cardiomegaly, hypertensive heart disease with heart failure, paroxysmal atrial fibrillation, atherosclerotic heart diseases of native coronary artery without angina pectoris, pneumonia, abnormalities of gait and mobility, lack of coordination, personal history of other malignant neoplasm of skin, sleep apnea, major depressive disorder, hearing loss, obstructive sleep apnea, primary osteoarthritis, and hyperlipidemia.R4's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview for Mental Status (BIMS) score of 3 which indicates that R4 has severe cognitive impairment. R4's Swallowing/Nutritional Status shows that R4 is on a mechanically altered diet (required change in texture of food or liquids) and therapeutic diet (low salt, diabetic, low cholesterol).On 8/27/2025 at 9:25 AM, V2 (Director of Nursing, DON) stated that all nurses and CNAs (Certified Nursing Assistants) are trained when they are feeding a resident, they must sit in front of the resident, at the same eye level as the resident. V2 stated that not standing above a resident while feeding is a resident's right of dignity and respect. Also, V2 stated that the nurse feeding a resident with the face-to-face approach allows for the nurse to check the resident for swallowing or choking concerns while the resident is chewing and swallowing.R4's Care Plan (date initiated 11/23/2022, revision on 11/16/2023) documents, in part, a focus of R4 having a swallowing problem of dysphagia as evidenced coughing or choking during meals and difficulty with thin liquids secondary to baseline dementia and history of aspiration pneumonia. R4's interventions include for all staff to be informed of R4's special dietary and safety needs; eat with supervision only; and monitor/document/report as needed signs of symptoms of dysphagia such as pocketing, choking, coughing, or drooling.R4's Order Summary Report documents, in part, a physician order (dated 7/29/2025) of mechanical soft texture, nectar thick liquids consistency, and consistent carbohydrate diet with supervision for small bites.Facility policy titled Dignity and dated 4/23/2018 documents, in part, Guidelines: The facility shall promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality . Staff shall carry out activities in a manner which assists the resident to maintain and enhance his/her self-esteem and self-worth. Maintaining a resident's dignity should include but is not limited to the following: . Promoting resident independence and dignity while dining, such as avoiding: . Staff standing over residents while assisting them to eat.Facility policy titled Resident Rights and dated 1/4/2019 documents, in part, Purpose: To promote the exercise of rights for each resident, including any who face barriers (such as communication problems, hearing problems and cognition limits) in the exercise of these rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the call light was within reach for 1 resident (R63) and ensure the call light was working properly for 1 resident (R229) out of 49 residents reviewed for call lights. Findings include: On 01/13/2025 at 11:00am observed R63 lying on her right side in the bed, alert and oriented. Surveyor asked R63 Where is your call light cord/button located? R63 stated, It is somewhere in the bed with me. On 01/13/2025 at 11:02am observed R63's call light cord hanging off the left side of R63's bed towards the floor. On 01/13/2025 at 11:05am surveyor asked V6(CNA/Certified Nursing Assistant) to come into R63's room. V6 was asked, Where is R63's call light string? V6 stated R63's call light cord is located on the left side of the bed hanging towards the floor. V6 stated the call light should be attached to the resident and within close reach of the resident. On 01/13/2025 at 11:06am surveyor observed V6(CNA/Certified Nursing Assistant) move the call light cord from hanging off the left side of the bed and place the call light cord on the bed close to R63's right hand. On 1/13/2025 at 12:28pm V5(RN/Registered Nurse) stated the call light should be within reach of the patient. V5 stated the purpose of the call light is so that the patient will be able to request assistance from the certified nursing assistant or the nurse and let us know that they need help. On 1/15/2025 at 10:43am V2(DON/Director of Nursing) stated the purpose of the call light is to make staff aware of the resident's needs. V2 stated the call light should be placed within reach of the resident. R63's diagnosis includes, but are not limited to, dysphagia, oropharyngeal phase, multiple sclerosis, acute respiratory failure with hypoxia, paraplegia, unspecified, other acute osteomyelitis, left ankle and foot, and arthritis due to other bacteria, left ankle and foot. R63 has a Brief Interview for Mental Status (BIMS) dated 11/08/2024 which documents that R63 has a BIMS score of 12, indicating R63's cognition is moderately impaired. R63's care plan documents in part, Focus: I am at risk for falls r/t (related to) paraplegia. Goal: I will not sustain serious injury through the review date. Intervention: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Received the facility's policy titled Call Light via email from V1(Administrator) on 1/15/2025. Call light policy dated 11/28/2012 with a revision date of 2/2/18. Call light policy documents in part, 1. All residents that have the ability to use a call light shall have the nurse call light system available at all times and within easy accessibility to the resident at the bedside or other reasonable location . 6. Call bell system defects will be reported promptly to the Maintenance Department for servicing. Check room frequently until system is repaired. Reviewed the Certified Nursing Assistant job description with a creation date of 05/02/2017, which documents in part, The Certified Nursing Assistant (CNA) is responsible for providing resident care and support in all activities of daily living and ensure the health, welfare and safety of all residents. On 1/13/25 at 10:25am, this surveyor observed R229's call light on. On 1/13/25 at 11:01am, this surveyor observed R229's call light still on. On 1/13/25 at 11:02am, this surveyor notified V3 (Registered Nurse/RN) and V3 said, (R229's) call light is broken. They're aware and working on fixing it. When asked what interventions and alternatives are in place for R229 due to the call light being broken, V3 replied, Whenever I pass the room I just pop in there and see if she (R229) needs anything. When asked the importance of the call light, V3 replied, So they (residents) can get help from us (staff). On 1/13/25 at 12:43pm, this surveyor observed R229's call light still on. On 1/14/25 at 11:22am, R229 said, I need some help. I need the call light so the nurse can help me get up and help me with the bathroom. R229's face sheet documents, in part, diagnosis that include but are not limited to abnormal posture; age-related osteoporosis without current pathological fracture; difficulty in walking; and history of falling. R229's Minimum Data Set (MDS), dated [DATE], documents, in part, a brief interview of mental status (BIMS) score of 12 which indicates R229's cognition is moderately impaired. R229's Care Plan, date 1/6/25, documents, in part (R229) have an ADL (activities of daily living) self-care/mobility performance (functional abilities) deficit that may fluctuate with activity throughout the day r/t (related to) confusion and weakness. (R229) have lupus with interventions, dated 12/30/24, that document, in part, Encourage the resident to use bell to call for assistance. R229's Care Plan, date 1/6/25, documents, in part (R229) am at risk for falls r/t previous fall with fracture in Dec (December) prior to admission. On 1/14/2025 at 12:28pm, V19 (Maintenance Director) said that R229's call light cord was wrapped around R229's bedrail and when staff put the bed rail down, not only did the bed rail pull the cord but it also pulls the call light out of the wall. On 1/14/25 at 1:01pm, V2 (Director of Nursing/DON) said, If a resident's call light is not working then we're supposed to give them (the residents) one of those . you know . those doorman hand bells. I'll (V2) get her (R229) one. When asked the importance of the call light, V2 replied, So the residents can get assistance. Facility policy titled, Call Light, revised date 2/2/18, documents, in part, 1. All residents that have the ability to use a call light shall have the nurse call light system available at all times and within easy accessibility to the resident at the bedside or other reasonable accessible location . 5. Hand bells will be provided for alert dependent residents when positioned out of reach of permanent call light when needed . Facility job description titled, Registered Nurse/RN, dated 5/2/17, documents, in part, The RN is responsible for providing direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, to ensure that the highest degree of quality care is maintained at all times . ensure that nursing services and activities can be adequately maintained to meet the needs of the residents. Facility job description titled, Maintenance Director, dated 5/2/17, documents, in part, The primary purpose of the Maintenance Director is to plan, organize, develop, and direct the overall operation of the Maintenance Department in accordance with current federal, state and local guidelines, standards, and regulations that governing our facility, to assure that our facility is maintained in a safe and comfortable manner . Ensure that supplies, equipment, etc., are maintained to provide a safe and comfortable environment . Make periodic rounds to check equipment and to assure that necessary equipment is available and working properly.

Based on observation, interview and record review, the facility failed to ensure that residents have a clean, home like environment by providing clean linen for 2 residents (R1 and R54) and clean, home like room for 1 resident (R1). This failure affected 2 residents (R1 and R54), reviewed for resident's rights to enjoy a clean, comfortable, homelike environment, in a total sample of 49 residents. Findings include: On 1/13/25 at 10:27am, surveyor observed R1 lying in bed, on her back, with 2 areas of a brown substance on R1's bottom sheet of her bed. Also observed was multiple areas of a tan/beige substance on R1's floor and bed side dresser. When asked about the brown substance and tan/beige substance, R1 replied, I know the stuff on the floor and dresser is what they (staff) give me through my tube (tube feeding). I don't know what the brown stuff is. It's probable poo. They (staff) never clean in here. They (staff) don't care. Makes me wonder how their own houses look. R1's Face Sheet, documents medical diagnosis that include but are not limited to other abnormalities of gait and mobility; cerebral infarction; dislocation of internal left hip prosthesis; hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side; need for assistance with personal care; dysphagia, oropharyngeal phase; gastro-esophageal reflux disease without esophagitis; gastrostomy status; and dysphagia following cerebral infarction. R1's BIMS (Brief Interview for Mental Status) Summary Score: 10, dated 10/11/24, suggests moderate cognitive impairment. R1's Care plan, revised date 5/22/24, documents, in part, (R1) has an ADL (activities of daily living) self-care/mobility performance (functional abilities) deficit that may fluctuate with activity throughout the day r/t (related to) Activity Intolerance, Fatigue, Limited Mobility, abnormal gait, Dysphagia, weakness, CVA (cerebral vascular accident) with residual hemiplegia, with interventions that document, in part, (R1) receive nutrition per tube feedings or parenteral feeding; Shower/Bathe self: (R1) take a shower/bath/bath at sink/bed bath my usual performance is dependent. R1's Care Plan, revised date 11/27/24, documents, in part, (R1) requires tube feeding GT (gastrostomy tube) r/t (related to) gastrostomy status secondary to cva (cerebral vascular accident) W/(with) dysphagia . On 1/13/25 at 10:53am, surveyor observed R54 sitting on the side of his bed, in and adult brief, with 3 areas of a brown substance on his bottom linen of his bed. When asked about the brown substance, R54 replied, If something looks like shit and smells like shit it's probably shit. The nurse knows about it (brown substance). She (nurse) said she'll be back. I don't know how long ago she said that she would be back. R54's Face Sheet, documents medical diagnosis that include but are not limited to need for assistance with personal care; history of falling; difficulty in walking; and other abnormalities of gait and mobility. R54's BIMS (Brief Interview for Mental Status) Summary Score: 14, dated 12/02/24, suggests R54 is cognitively intact. R54's Care Plan, revised date 12/04/24, documents, in part, (R54) have an ADL (activities of Dily living) self-care/mobility performance (functional abilities) deficit that may fluctuate with activity throughout the day r/t (related to) Right intertrochanteric femoral fracture, with interventions Toilet hygiene-My usual performance is substantial/maximal assistance. On 1/13/25 at 11:02am, while surveyor and V3 (Registered Nurse/RN) were in R1's room, V3 said that the tan/beige substance on the floor and dresser is dried tube feeding. V3 stated, I'm not sure why that wasn't cleaned up. I didn't spill it. I'll call and get it cleaned. When asked about the brown substance on R1's bottom sheet on R1's bed, V3 replied, It's probably chocolate. Yes, they (residents) should have clean linen. After leaving R1's room surveyor asked V3 if V3 could come to R54's room to inquire about the brown substance in R54's linen and V3 replied, Oh, the CNA (certified nursing assistant) is going to change that. I'll make sure R54 has his (R54) linens changed. On 1/14/25 at 1:01pm, V2 (Director of Nursing/DON) said that all resident's should have clean rooms and linen. V2 said that cleanliness is key to prevent infection and promote recovery. Facility policy titled, Housekeeping Guidelines, undated, documents, in part, To provide guidelines to maintain a safe and sanitary environment for residents, facility staff and visitors . Housekeeping personnel shall clean rooms which are occupied by residents diagnosed with infectious diseases, using precautionary measures, at the completion of the assignment. Facility policy titled, Pressure Ulcer Prevention, revised date 1/15/18, documents, in part, 3. Change bed linen per schedule and whenever soiled with urine, feces, or other material. Facility policy titled, Resident Rights, reviewed date 1/04/19, documents, in part, Purpose: To promote the exercise of rights for each resident, including any who face barriers (such as communication problems, hearing problems and cognition limits) in the exercise of these rights. A resident, even though determined to be incompetent, should be able to assert these rights based on his or her degree of capability.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to conduct care plan conferences that allow the residents to participate in the development and implementation of their plan of care and failed to develop a comprehensive care plan within the required time frame. This failure affects 2 residents (R19, R328) in a sample of 49. Findings include: 1. Record review of R19's admission record documents in part R19 has the following diagnoses including, but not limited to: spinal stenosis, chronic obstructive pulmonary disease, unspecified dementia without behavioral disturbance, major depressive disorder, and epilepsy. Record review of R19's Minimum Data Set (dated 12/5/2024) documents in part a Brief Interview of Mental Status Summary Score of 13, indicating that R19 is cognitively intact. On 1/13/2025 at 11:32 AM, R19 denied that R19 is invited to care plan meetings or invited to participate the R19's plan of care. R19 stated that if there was a meeting that discussed R19's plan of care, R19 would want to attend. Record review of R19's progress notes documents in part that R19 had a care plan meeting on 3/13/2024. No further documentation of care plan meetings for R19 or invitations to participate in R19's plan of care were provided during the survey. 2. Record review of R328's admission record documents in part R328 has the following diagnoses including, but not limited to: osteomyelitis, sepsis, paraplegia, neuromuscular dysfunction of bladder, and colitis. Record review of R328's SS (Social Services) Lookback Summary dated 12/20/2024, documents in part that R328 has a Brief Interview of Mental Status (BIMS) summary score of 15, indicating that R328 is cognitively intact. On 1/13/2025 at 11:37 AM, R328 stated that R328 has never attended a care plan meeting or has been invited to participate in developing R328's care plan. R328 affirmed that R328 would want to be involved with developing R328's plan of care. R328 stated, maybe I would be able to make better decisions about my care if I were able to have one of those meetings. I should be going home next week, but now I am not. That meeting would be a good place to discuss what's going to happen when I discharge, right? Record review of R328's electronic health record does not document that R328 has had any care plan conferences or been invited to participate in the development of R328's plan of care. Surveyor requested documentation of care plan conferences for R328, and no evidence was received during the survey. Record review of R328's comprehensive MDS dated [DATE] does not document a signature in section Z0500 Signature of RN Assessment Coordinator Verifying Completion. Additionally, no signatures are noted for V0200B Signature of RN Coordinator for CAA Process and Date Signed and V0200 C Signature of Person Completing Care Plan Decision and Date Signed. In section V, the MDS indicates that a care area assessment was triggered for nutritional status and was not addressed. Sections A, GG, H, I, J, K, L, M, N, O, P, S and V are incomplete. This review indicates that the MDS and care planning process is incomplete. On 1/15/2025 at 1:06 PM V27 (Regional Director of Clinical Reimbursement) reviewed R328's MDS dated [DATE] and confirmed that the assessment was late. V27 stated that the assessment should have been completed by 12/30/2024 in accordance with the resident assessment instrument (RAI) guidelines. V27 explained that the reason why the assessment was late was because the prior MDS nurse quit around that time, but the facility had secured a company to complete the MDS remotely. V27 stated that V27 is not a registered nurse, so V27 is unable to act as the registered nurse assessment coordinator on behalf of the facility. V27 stated that the primary purpose of the MDS is to identify resident conditions and needs. On 1/15/2025 at 1:50 PM, V2 (Director of Nursing) affirmed that the facility does not have a nurse that is the registered nurse assessment coordinator and is actively hiring for that position. V2 stated that the MDS drives the resident's plan of care. V2 stated that all residents should be getting a care plan meeting quarterly. V2 affirmed that residents have the right to participate in the development and implementation of their plan of care. Record review of CMS' Resident Assessment Instrument (10/2024), Chapter 5: Submission and Correction of the MDS Assessments documents in part, .For the admission assessment, the MDS Completion Date (Z0500B) must be no later than 13 days after the Entry Date (A1600). - For the admission assessment, the Care Area Assessment (CAA) Completion Date (V0200B2) must be no later more than 13 days after the Entry Date (A1600). For the Annual assessment, the CAA Completion Date (V0200B2) must be no later than 14 days after the ARD (A2300) . Record review of facility policy titled, Comprehensive Care Plan (Revised 11/17/17) documents in part, .Purpose: To develop a comprehensive care plan that directs the care team and incorporates the resident's goals, preferences, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment . A comprehensive care plan must be-Developed within 7 days after completion of the comprehensive assessment. Prepared by an interdisciplinary team, that includes but is not limited to-- .To the extent practicable, the participation of the resident and the resident's representative(s). An explanation should be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan .Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. The CAAs provide a link between the MDS and care planning. The care plan should be revised on an ongoing basis to reflect changes in the resident and the care that the resident is receiving. The resident and/or resident representative shall be invited to review the plan of care with the interdisciplinary team either in person, via telephone or video conference (if available) at least quarterly .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete and submit a comprehensive assessment within the required timeframes. This failure has the potential to affect 1 resident (R328) in a sample of 49. Findings include: Record review of R328's admission tracking minimum data set (MDS) documents in part an assessment reference date of 12/17/2024. Record review of R328's comprehensive MDS dated [DATE] documents that Sections A, GG, H, I, J, K, L, M, N, O, P, S and V of the MDS are incomplete. The MDS does not document a signature in section Z0500 Signature of RN Assessment Coordinator Verifying Completion. Additionally, no signatures are noted for V0200B Signature of RN Coordinator for CAA Process and Date Signed and V0200C Signature of Person Completing Care Plan Decision and Date Signed. This indicates that the MDS is incomplete. On 1/15/2025 at 1:06 PM V27 (Regional Director of Clinical Reimbursement) reviewed R328's MDS dated [DATE] and confirmed that the assessment was late. V27 stated that the assessment should have been completed by 12/30/2024 in accordance with the resident assessment instrument (RAI) guidelines. V27 explained that the reason why the assessment was late was because the prior MDS nurse quit around that time, but the facility had secured a company to complete the MDS remotely. V27 stated that V27 is not a registered nurse, so V27 is unable to act as the registered nurse assessment coordinator on behalf of the facility. V27 stated that the primary purpose of the MDS is to identify resident conditions and needs. On 1/15/2025 at 1:50 PM, V2 (Director of Nursing) affirmed that the facility does not have a nurse that is the registered nurse assessment coordinator and is actively hiring for that position. V2 stated that the MDS drives the resident's plan of care. Record review of CMS' Resident Assessment Instrument (10/2024), Chapter 5: Submission and Correction of the MDS Assessments documents in part, .For the admission assessment, the MDS Completion Date (Z0500B) must be no later than 13 days after the Entry Date (A1600). - For the admission assessment, the Care Area Assessment (CAA) Completion Date (V0200B2) must be no later more than 13 days after the Entry Date (A1600). For the Annual assessment, the CAA Completion Date (V0200B2) must be no later than 14 days after the ARD (A2300) .

Based on observation, interview, and record review, the facility failed to ensure that 2 residents (R1 and R54) who depend on staff assistance for ADL (Activities of Daily Living) care and grooming receive nail care and 1 resident (R1) receive hair care. This affects 2 residents (R1 and R54) in the sample of 49 residents reviewed for accommodation of needs. Findings include: On 1/13/25 at 10:27am, R1 said, My fingernails and hair aren't any better. My hair is all matted. This surveyor observed R1 with long, discolored fingernails on both hands and brown substances underneath the nail beds and R1's hair appeared tangled, tousled, and unkempt. R1 stated, I've asked the nurses to cut my nails and fix my hair but look . I'm a mess. I doubt my hair can even be unmatted. R1's Face Sheet, documents medical diagnosis that include but are not limited to type 2 diabetes mellitus; other abnormalities of gait and mobility; cerebral infarction; dislocation of internal left hip prosthesis; hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side; need for assistance with personal care; dysphagia, oropharyngeal phase; gastro-esophageal reflux disease without esophagitis; gastrostomy status; and dysphagia following cerebral infarction. R1's BIMS (Brief Interview for Mental Status) Summary Score: 10, dated 10/11/24, suggests moderate cognitive impairment. R1's Care plan, revised date 5/22/24, documents, in part, (R1) has an ADL (activities of daily living) self-care/mobility performance (functional abilities) deficit that may fluctuate with activity throughout the day r/t (related to) Activity Intolerance, Fatigue, Limited Mobility, abnormal gait, Dysphagia, weakness, CVA (cerebral vascular accident) with residual hemiplegia, with interventions that document, in part, Toilet hygiene-My usual performance is Dependent; Shower/Bathe self: (R1) take a shower/bath/bath at sink/bed bath my usual performance is dependent. On 1/13/25 at 10:53am, surveyor observed R54 sitting on the side of his bed, in and adult brief, unshaven, with long fingernails on both hands and brown substances under the first, second and third fingernails on right hand. When asked about R54's fingernails, R54 responded that he would like them to cut and would also like help shaving. When asked if R54 has notified staff about his nails and wanting a shave, R54 said that he has asked a few times, but they (staff) are always busy. R54's Face Sheet, documents medical diagnosis that include but are not limited to need for assistance with personal care; history of falling; difficulty in walking; and other abnormalities of gait and mobility. R54's BIMS (Brief Interview for Mental Status) Summary Score: 14, dated 12/02/24, suggests R54 is cognitively intact. R54's Care Plan, revised date 12/04/24, documents, in part, (R54) have an ADL (activities of Dily living) self-care/mobility performance (functional abilities) deficit that may fluctuate with activity throughout the day r/t (related to) Right intertrochanteric femoral fracture, with interventions Shower/Bathe self: I take a shower/bath/bath at sink/bed bath my usual performance is dependent. Toilet hygiene-My usual performance is substantial/maximal assistance. On 1/13/25 at 11:02am, while surveyor and V3 (Registered Nurse/RN) were in R1's room, V3 said, She (R1) needs her nails trimmed and hair brushed. It (nails trimmed and hair brushed) should have been done wither her last bathing. On 1/14/25 at 1:01pm, V2 (Director of Nursing/DON) said that there's a schedule for the resident's for bathing. V2 stated that staff look at the resident's nails during bathing and trim as needed. V2 said that long nails can cause self-inflicted injuries. Facility policy titled, Activities of Daily Living (ADLs), undated, documents, in part, Bathing: Washing and drying the body (excluding back and shampooing hair), including full body sponge bath, planning the task, and gathering supplies, and transfer into and out of tub/shower. Grooming: Maintaining personal hygiene, including planning the task and gathering supplies, combing and/or styling hair, face, and hands, brushing teeth, shaving, or applying makeup, oral hygiene, self-manicure (safety awareness with nail care), and/or application of deodorant or powder. Facility policy titled, Nail Care, revised date 1/25/18, 1. Observe condition of resident nails during each time of bathing. Note cleanliness, length uneven edges, hypertrophied nails . 4. After bathing, use orange stick, and clean debris from around and under finger and toenails. 5. Trim toenails carefully in a straight fashion and fingernails in an oval fashion avoiding tissue after bathing or when needed. Be sure nails are soft before trimming. Additional soaking in warm soapy water may be necessary to soften nails . 10. Document provision of care and pertinent observations. Facility policy titled, Resident Rights, reviewed date 1/04/19, documents, in part, Purpose: To promote the exercise of rights for each resident, including any who face barriers (such as communication problems, hearing problems and cognition limits) in the exercise of these rights. A resident, even though determined to be incompetent, should be able to assert these rights based on his or her degree of capability.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure dressings were changed daily (as per physician order) for one resident (R24) with pressure ulcers, who is also at risk for further pressure ulcers; and failed to have the low air loss mattress at the correct weight settings for one resident (R54) with pressure ulcers, who is also at risk for further pressure ulcers. This failure has the potential to affect two residents (R24 and R54), reviewed for pressure ulcer prevention interventions, in a total sample of 49 residents. Findings include: On 1/13/25 at 10:53am, surveyor observed R54 sitting on the side of his bed, on a LAL (low air loss) mattress, with the LAL mattress weight setting set at greater than 350 pounds. When asked if R54 has any pressure wounds, R54 replied, I have one on my butt, I'm not sure when it's supposed to be changed. Every day, I think. When asked how much R54 weighs, R54 replied, I think about 150. I think I'm losing weight though. When asked if R54's mattress was comfortable, R54 replied, My mattress at home is more comfortable. This one is too firm. R54's face sheet documents, in part, diagnosis that include but are not limited to need for assistance with personal care; displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing; and history of falling. R54's Minimum Data Set (MDS), dated [DATE], documents, in part, a brief interview of mental status (BIMS) score of 14 which indicates R54 is cognitively intact. R54's Minimum Data Set (MDS), dated [DATE], Skin Conditions (section M) documents, documents, in part, . Is this resident at risk of developing pressure ulcers/injuries? YES . Does this resident have one or more unhealed pressure ulcers/injuries? YES .Number of these Stage 3 pressure ulcers that were present upon admission/entry or reentry 1 . B. Pressure reducing device for bed YES . E. Pressure ulcer/injury care . that R54's Skin and Ulcer/Injury Treatments include a pressure reducing device for bed. R54's admission Note, dated 11/30/2024, documents, in part, 1410 received a 77 yr. old male from (hospital) via stretcher . The writer . then proceeded to perform a head-to-toe-assessment . pressure injury on back and coccyx. R54's Braden Observation, dated 11/30/24, documents, in part, a Braden score of 17 which indicates that R54 is at risk for developing a pressure ulcer. R54's progress note, dated time of service 1/9/25 at 6:00am, documents, in part, Integumentary (Hair, Skin) Wound #1 status is Open. The date acquired was: 11/30/2024. The wound has been in treatment 4 weeks. The wound is currently classified as a Category/Stage IV wound with etiology of Pressure Ulcer and is located on the Coccyx. The wound measures 4.5cm length x 6cm width x 1.5cmdepth; 21.206cm^2 area and 31.809cm^3 volume. There is muscle and Fat Layer (Subcutaneous Tissue) exposed. There is a medium amount of serosanguineous drainage noted. There is medium (34-66%) granulation within the wound bed. There is a medium (34-66%) amount of necrotic tissue within the wound bed including Adherent Slough and Necrosis of Muscle. The peri wound skin appearance had no abnormalities noted for texture. The peri wound skin appearance had no abnormalities noted for moisture. The peri wound skin appearance had no abnormalities noted for color. Wound #2 status is Open. The date acquired was: 11/30/2024. The wound has been in treatment 4 weeks. The wound is currently classified as a Category/Stage III wound with etiology of Pressure Ulcer and is located on the Midline Back. The wound measures 5cm length x 11.5cm width x0.1cm depth; 45.16cm^2 area and 4.516cm^3 volume. The wound is limited to skin breakdown. There is a none (sic) present amount of drainage noted. There is no granulation within the wound bed. There is a small (1-33%) amount of necrotic tissue within the wound bed including Adherent Slough. The peri wound skin appearance had no abnormalities noted for texture. The peri wound skin appearance had no abnormalities noted for moisture. The peri wound skin appearance had no abnormalities noted for color. R54's Care Plan, revision date 12/04/24, documents, in part, (R54) require assistance with bed mobility r/t (related to) Right intertrochanteric femoral fracture, with interventions, revision date12/02/24, documents, in part, (R54) will reposition self in bed from sitting to lying and lying to sitting with partial/moderate assistance. R54's Care Plan, revision date 12/06/24, documents, in part, (R54) has pressure ulcer to the coccyx and mid back. R54's Weight Summary Sheet, dated 1/01/2025 at 3:07pm, documents, in a part, a weight of 139.2lbs. R54's Order Summary Report, dated 1/14/25, documents, in part, Coccyx: Cleanse with NSS (normal saline solution), pat dry, apply Santyl and Dakins and cover with foam dressing. one time a day for wound care . Mid Lateral back: cleanse with NSS, pat dry, apply Silvadene and cover with foam dressing. one time a day every Mon, Wed, Fri for wound care .please keep pressure off of bilateral heels, float heels with pillow or use heel boots . On 1/13/25 at 11:02am, V3 (Registered Nurse/RN) said, I'm don't know a lot about the wound mattresses. I can get the DON (Director of Nursing) to help you. On 1/15/25 at 1:49pm, V2 (Infection Preventionist/Director of Nursing/DON) said, The LAL (low air loss) mattresses should only have a flat sheet or a brief. If there's more than that the mattress may not do what it's supposed to do. The weight setting for the mattress should be set at the resident's weight or else it defeats the purpose of the low air loss mattress. If it's (LAL mattress) not set at the resident's weight it can prevent healing or cause more pressure ulcers. In Center for Medicare and Medicaid Services article, dated 4/7/22 and titled Pressure Reducing Support Surfaces - Group 2 - Policy Article, documents, in part, that styles of Group 2 powered pressure reducing mattress (alternating pressure, low air loss, or powered flotation without low air loss) which is characterized by all of the following: an air pump or blower which provides either sequential inflation and deflation of the air cells or a low interface pressure throughout the mattress, and inflated cell height of the air cells through which air is being circulated is 5 inches or greater, and height of the air chambers, proximity of the air chambers to one another, frequency of air cycling (for alternating pressure mattresses), and air pressure provide adequate beneficiary lift, reduce pressure and prevent bottoming out, and a surface designed to reduce friction and shear, and can be placed directly on a hospital bed frame. Facility presented document titled, . Low Air Loss Mattress System with Foam Base Manual, dated 2014, documents, in part, mattress are intended to help reduce the incidence of pressure ulcers while optimizing patient comfort . 9. Turn the Pressure Adjust Knob to set a comfortable pressure level using the weight scale as a guide. Facility policy titled, Pressure Ulcer Prevention, revised date 1/15/18, documents, in part, Purpose: To prevent and treat pressure sores/ pressure injury. 3. Change bed linen per schedule and whenever soiled with urine, feces, or other material. 9 . Specialty mattresses such as low air loss, alternating pressure, etc. may be used as determined clinically appropriate. Specialty mattresses are typically used for residents who have multiple Stage 2 wounds or one or more Stage 3 or Stage 4 wounds. Facility policy titled, Resident Rights, reviewed date 1/04/19, documents, in part, Purpose: To promote the exercise of rights for each resident, including any who face barriers (such as communication problems, hearing problems and cognition limits) in the exercise of these rights. A resident, even though determined to be incompetent, should be able to assert these rights based on his or her degree of capability. On 01/13/25 at 10:35 AM, observed foam dressing to R24's left and right hips dated 1/8/2025. V3 (Registered Nurse) stated that R24 has a wound care order to change the foam dressings to R24's bilateral hips twice a day. V3 (RN) verified the date of 1/8/2025 written on R24's right and left foam dressings. R24 was observed with red and purple blanchable erythema wound appearances the size of a half dollar or larger to R24's bilateral hips. Wound care consult conducted by V28 (Registered Nurse- Wound Care Nurse) dated 12/11/2024 verifies 3 wounds, documents the following: R24's Wound Care Consult Note on 12/11/2024 written by V28, Wound Care Nurse documents: 1. Pressure Injury to Right Hip Deep Tissue Injury Pink; Red; Blanchable Erythema; Intact 2. Pressure Injury to Left Hip Deep Tissue Injury Pink; Red; Blanchable Erythema; Intact 3. Pressure Injury Ankle Right; Outer Deep Tissue Injury Pink; Red; Intact; Purple; Non-Blanchable Erythema R24's Treatment Administration Record documents a physician's order for wound care to R24's right and left hips that reads Bilateral hips-Foam dressing every night shift for pressure injury -Start Date- 12/13/2024 2300. Treatment Administration Record has documented signatures that wound care dressing changes were performed 1/8/2024 to 1/13/24. R24's Physicians Order Sheet (POS) contains an order dated 12/13/2024 which documents: for wound care dressing to Bilateral Hips-Foam dressing every night shift for pressure injury. On 1/15/2025 at 3:35 pm, V21 RNC (Regional Nursing Consultant) stated that R24 does not have pressure wounds. On 1/15/2025 at 3:39 pm V21 RNC returned to conference room where surveyors were present and stated that R24 has scar tissue from previous pressure injuries and his dressing is just for comfort. Requested wound care measurements and weekly assessment from 12/11/2024 but none was provided. Per face sheet R24's medical diagnosis includes other abnormalities of gait and mobility; difficulty in walking; unsteadiness on feet; infection and inflammatory reaction due to indwelling; urethral catheter, subsequent encounter; dysphagia, oropharyngeal phase; other disorders of phosphorus metabolism; other lack of coordination; hyperkalemia; acute kidney failure; obstructive and reflux uropathy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 01/13/25 at 11:23am R57 observed with electric space heater at bedside. R57 stated that the facility was aware of her having the space heater. R57 stated that the facility has been having heating issues and R57 uses the heater to stay warm. R57's Minimum Data Set (MDS) dated [DATE] has a Brief Interview for Mental Status (BIMS) score of 15 which indicates that R57's cognition is intact. On 01/15/25 at 1:51pm V2 (Director of Nursing/DON) stated that residents should not have space heaters but because of the climate, the facility allowed the residents to have space heaters. V2 stated that the facility just had repairs done to the boilers. V2 stated that space heaters are a fire hazards and that someone could die in a fire. On 01/15/25 a 2:13pm V19 (Maintenance Director) stated that the facility shouldn't have space heaters in resident rooms and that space heaters are a safety hazard. On 010/14/25 at 1:38pm V1 (Administrator) stated that he was unable to locate the facility's policy on safety and hazards regarding space heaters. Based on interview and record review, the facility failed to ensure that oxygen cylinders were secured and that personal heaters were not in use. This failure has the potential to affect all 87 residents that reside within the facility. Findings include: Record review of facility census documents in part that 87 residents reside in facility. Record review of R3's admission record documents in part that R3 has the following diagnoses including but not limited to: chronic obstructive pulmonary disease, pulmonary fibrosis, depression, anxiety and dependence on supplemental oxygen. Record review of R3's Minimum Data Set (dated 11/04/2024) documents in part a Brief Interview of Mental Status score of 15, indicating that R3 is cognitively intact. On 1/13/2025 at 11:02 AM, observed an oxygen cylinder freestanding, unsecured next to R3's bed. R3 stated that the oxygen cylinder used to be in a holder, but the facility took the holder away a couple of months ago. On 1/13/2025 at 11:32 AM, V10 (Agency Licensed Practical Nurse) observed the oxygen cylinder in the room. V10 stated that oxygen cylinders should be secured to a holder to prevent the tank from tipping over. V10 affirmed that oxygen cylinders are combustible and removed the cylinder from R3's room. On 1/15/2024 at 1:50 PM, V2 (Director of Nursing) stated that the facility secures oxygen tanks in a holder. V2 stated that oxygen cylinders need to be secured because oxygen cylinders are a fire hazard. Facility policy titled Oxygen Safety and Training Policy reviewed 11/2024, documents in part, .7. Compressed gas cylinders shall be stored in an upright position with the valve end up, the valve cap in place and the cylinder chained to the wall or otherwise secured. This protects the vulnerable cylinder valve and prevents the cylinder from falling and becoming a dangerous projectile.

Based on observations, interviews, and record reviews, the facility failed to ensure a tube feeding syringe was changed daily on 1 resident (R1). These failures have the potential to affect 1 resident (R1) reviewed for tube feeding management in the total sample of 49 residents. Findings include: On 1/13/25 at 10:27am, surveyor observed R1's tube feeing syringe with an open date of 1/9/25. When asked if R1 noticed staff changing the tube feeding syringe recently, R1 replied, Doubt it. I can't even get my hair washed or brushed. Look, my hair is all matted. R1's Face Sheet, documents medical diagnosis that include but are not limited to dysphagia, oropharyngeal phase; gastro-esophageal reflux disease without esophagitis; gastrostomy status; and dysphagia following cerebral infarction. R1's BIMS (Brief Interview for Mental Status) Summary Score: 10, dated 10/11/24, suggests moderate cognitive impairment. R1's Care Plan, revised date 11/27/24, documents, in part, (R1) requires tube feeding GT (gastrostomy tube) r/t (related to) gastrostomy status secondary to CVA (cerebral vascular accident) W/(with) dysphagia . R1's Order Summary Report,, dated 1/14/25, documents, in part, Enteral Feed Order one time a day (Tube feeding) @ 70mL/hr (hour) x 14 hours. On 1/13/25 at 11:02am, V3 (Registered Nurse/RN) said, Tube feeding syringes should be changed every 5 days, but I (V3) change them every other day. On 1/14/25, surveyor observed R1's tube feeing syringe, again, with an open date of 1/9/25. On 1/15/25 at 1:49pm, V2 (Director of Nursing/DON/Infection Preventionist) said, (Tube Feeding) syringes are to be changed every 24 hours. When asked the purpose of changing tube feeding syringes every 24 hours, V2 replied, Infection. Not changing can cause an infection. Facility policy titled, Gastrostomy Tube- Feeding and Care, revised date 8/3/20, documents, in part, 13. Feeding tube syringes and irrigation containers are to be changed every 24 hours. Facility policy titled, Resident Rights, reviewed date 1/04/19, documents, in part, Purpose: To promote the exercise of rights for each resident, including any who face barriers (such as communication problems, hearing problems and cognition limits) in the exercise of these rights. A resident, even though determined to be incompetent, should be able to assert these rights based on his or her degree of capability.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility staff failed to secure in a bag the oxygen tubing and nasal cannula when not in use for one resident (R21) and failed to properly date the oxygen tubing, humidifier bottle, and nebulizer tubing for one resident (R11). Findings include: R21's diagnosis includes, but are not limited to, chronic obstructive pulmonary disease with (acute) exacerbation, chronic respiratory failure with hypoxia, muscle weakness (generalized), unspecified dementia, unspecified severity, with other behavioral disturbance, chronic systolic (congestive) heart failure, hypertensive heart disease with heart failure, and atherosclerotic heart disease of native coronary artery without angina pectoris. R21 has a Brief Interview for Mental Status (BIMS) dated 11/13/2024 which documents that R21 has a BIMS score of 07, indicating R21's cognition is severely impaired. R21's Physician Order Summary Report dated 01/14/2025 documents, in part, Continuous oxygen at 2-3 LPM (liters per minute) via nasal cannula. On 01/13/2025 at 2:00pm observed R21's oxygen tubing and nasal cannula hanging on the oxygen concentrator machine, not contained in a bag. On 01/13/2025 at 2:15pm V11(LPN/Licensed Practical Nurse) stated the oxygen tubing and nasal cannula should be put up, covered up. V11 stated the tubing should not be hanging over the machine. V11 stated the purpose of having the tubing covered is to prevent germs from getting on the tubing. On 1/15/2025 at 10:43am V2 (DON/Director of Nursing) stated when the nasal cannula and oxygen tubing are not in use by the resident the tubing should be placed in a plastic bag. V2 stated placing the tubing in the plastic bag prevents issues with infection control. On 01/13/25 at 11:37am R11 observed receiving nebulizer treatment. No date observed on R11's nebulizer treatment face mask, oxygen tubing or humidifier bottle. On 01/13/25 at 11:43am V10 (Licensed Practical Nurse/LPN) stated that she did not see a date on R11's oxygen tubing, humidifier bottle, or nebulizer treatment. On 01/15/25 at 1:51pm V2 (Director of Nursing/DON) stated that oxygen tubing is changed every seven days and as needed and should be dated. V2 stated that oxygen tubing is changed for infection control reasons. R11's diagnoses include but are not limited to chronic diastolic congestive heart failure, hypertensive heart disease with heart failure, cardiomegaly, type 2 diabetes mellitus without complications, major depressive disorder, generalized anxiety. R11's Minimum Data Set (MDS) dated [DATE] has a Brief Interview for Mental Status (BIMS) score of 15, which indicated R11's cognition is intact. R11's active order dated 09/25/22 documents in part, Oxygen nasal cannula at 2 liters per minute as needed to keep oxygen saturation above ninety two percent. R11's active order dated 09/25/22 documents in part, Nebulizer every four hours as needed for shortness of breath. R11's care plan dated 09/27/24 documents in part, R11 is at risk for cardiac distress related to multiple cardiac conditions affecting functions diagnosis with the following chronic diastolic CHF (congestive heart failure) .Apply oxygen at two liters as needed through nasal canula to keep oxygen saturation above 92 percent. Facility's policy dated 01/07/19 titled Oxygen and Respiratory Equipment - Changing/Cleaning documents in part, Purpose: 1. To provide guideline to employees for changing all disposable respiratory supplies. 2. To ensure the safety of residents by providing maintenance of all disposable respiratory supplies. 3. To minimize the risk of infection transmission .Procedure: 1. Hand Held Nebulizer and mask .The handheld nebulizer should be changed weekly and PRN (as needed) .2. Nasal cannula .a. Nasal cannulas are to be changed once a week and PRN .4. Oxygen Humidifiers. a. Oxygen humidifiers should be changed weekly or as needed and will be dated when changed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure there were sufficient staff to meet the resident's needs. This failure caused R328 to not have an intravenous antibiotic administered; failed to have an intravenous antibiotic administered timely; failed to have R328's comprehensive assessment completed timely; failed to have R328's plan of care to be developed within the required timeframe. This failure affects 1 (R328) resident in a sample of 49. Findings include: Record review of the facility's staffing schedule/assignment for 1/13/2025 documents in part that an agency nurse was supposed to begin at 9:30 AM. The staffing records do not indicate the agency nursing staff's names or titles (registered nurse vs licensed practical nurse). Record review of R328's admission record documents in part R328 has the following diagnoses including, but not limited to: osteomyelitis, sepsis, paraplegia, neuromuscular dysfunction of bladder, and colitis. Record review of R328's Brief Interview of Mental Status (BIMS) assessment dated [DATE], documents in part that R328 has a BIMS summary score of 15, indicating that R328 is cognitively intact. Record review of R328's medication administration record documents in part that R328 has active orders for Ampicillin 12 g in 0.9% normal saline Use 12 gram intravenously one time a day for sepsis until 01/20/2025 23:59 ampicillin 12g in 0.9% NSS 500ml daily in continuous pump, and Vancomycin HCl Intravenous Solution 1500 MG/300ML (Vancomycin HCl) Use 1500 mg intravenously every 8 hours for Osteomyelitis until 01/20/2025 23:00. Additionally, the record documents that Vancomycin should be administered at 01:00 AM, 9:00 AM and 5:00 PM. On 1/13/2025 at 11:37 AM, observed R328 sitting upright in a wheelchair with a double lumen peripherally inserted central catheter (PICC) line to R328's right upper arm. An IV (intravenous) pole with a bag containing approximately 500 milliliters (mL) labeled Ampicillin 12 grams in 500 mL of 0.9% sodium chloride (normal saline) was observed to the right of R328 with the IV line disconnected from R328. The directions on the bag of Ampicillin stated, infuse intravenously at 41.7 ml/hr (hour) over 24 hours. R328 stated that the medication on the IV pole was antibiotics and explained that R328 has multiple pressure ulcers that became infected, causing R328 to become septic and needing nursing home level of care. R328 stated that R328 does not get prescribed antibiotics regularly because the facility does not have enough nursing staff to run R328's IV medication. R328 stated that R328 feels that R328's wounds have had delayed healing because R328 does not get antibiotics regularly. R328 stated, the staff here are good, they just don't have enough of them. They (the staff) are too stretched thin, overworked and underpaid. On 1/13/2025 at 11:50 AM, V2 (Director of Nursing) entered the room and observed the ampicillin not connected or being administered to R328. V2 affirmed that the ampicillin should be running and the ampicillin gets stopped when (R328) gets vancomycin. When V2 was asked why the ampicillin wasn't running V2 stated, we had some staffing issues this morning and a nurse called off. V2 explained that the ampicillin and vancomycin were being given for R328's osteomyelitis and V2 would check the medication administration record and administer the ampicillin. V2 left the room without administering the ampicillin. On 1/14/2024, documentation of the working schedule that reflects the nurse call-in was requested. This was not provided prior to the exit of the survey. On 1/14/2025 at 1:37 PM, V14 (Regional [NAME] President of Operations) reviewed the facility assessment and affirmed that the staffing needs are not broken down by unit. V14 stated that the facility has identified that there are staffing needs for nurses, an MDS nurse, a wound care nurse and an assistant director of nursing. V14 stated that the facility does have a formal contingency plan to ensure resident needs are met should there be a staffing crisis. V14 explained that the plan is only if there is a large number of staff unable to work (beginning with 75% of the workforce), not if there is a call in. V14 stated after a call-in, other staff/agency would be called in to cover the shift. Record review of R328's comprehensive MDS dated [DATE] does not document a signature in section Z0500 Signature of RN Assessment Coordinator Verifying Completion. Additionally, no signatures are noted for V0200B Signature of RN Coordinator for CAA Process and Date Signed and V0200 C Signature of Person Completing Care Plan Decision and Date Signed. In section V, the MDS indicates that a care area assessment was triggered for nutritional status and was not addressed. Sections A, GG, H, I, J, K, L, M, N, O, P, S and V are incomplete. This review indicates that the MDS and care planning process is incomplete. On 1/15/2025 at 1:06 PM V27 (Regional Director of Clinical Reimbursement) reviewed R328's MDS dated [DATE] and confirmed that the assessment was late. V27 stated that the assessment should have been completed by 12/30/2024 in accordance with the resident assessment instrument (RAI) guidelines. V27 explained that the reason why the assessment was late was because the prior MDS nurse quit around that time, but the facility had secured a company to complete the MDS remotely. V27 stated that V27 is not a registered nurse, so V27 is unable to act as the registered nurse assessment coordinator on behalf of the facility. V27 stated that the primary purpose of the MDS is to identify resident conditions and needs. On 1/15/2025 at 1:50 PM, V2 (Director of Nursing) affirmed that the facility does not have a nurse that is the registered nurse assessment coordinator and is actively hiring for that position. V2 stated that the MDS drives the resident's plan of care. V2 stated that the facility has active positions for registered and licensed practical nurses, a wound care nurse and an MDS nurse. V2 affirmed that V2 is the only nurse in a supervisory role for the facility. V2 stated that if a facility does not have enough staff, the residents may not be delivered the care they need. Facility policy titled, Staffing undated, documents in part, .Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment . Record review of facility assessment (reviewed 10/23/2024) staffing plan documents in part that on average, 5 licensed nurses are needed on every shift, on average 11 certified nursing assistants are needed on day shift and evening shift, and Other department heads, quality assurance nurse, ancillary staff in maintenance, housekeeping, dietary, laundry, etc. Customize to the staffing of your facility 1 Director of Nursing, 1 Night weekend supervisor, 1 MDS coordinators, 1 Restorative Nurse. The facility assessment also indicates that the facility has 2 specialty units, a memory care unit and a short stay unit. The facility assessment does not indicate the following: the average daily census, the amount of nursing and ancillary staff needed per unit per shift. The facility assessment documents that this was reviewed with V1 (Administrator). The facility assessment also does not identify that the facility needs a wound care nurse or an assistant director of nursing and does not list any recruitment/retention strategies being used by the facility.

Based on observation, interview, and record review, the facility failed to administer medications per physician's order for 2 residents (R63 and R379.) The Facility had 2 medication errors out of 25 opportunities resulting in an 8% medication error rate. Findings include: On 1/14/2025 at 9:12 am, observed V2 (Director of Nursing-DON), administer prefilled syringe Enoxaparin Sodium 30 mg/0.3 ml injection to R63's Left Thigh instead of the 20 mg/0.2 ml dosage per physician's order. V2 did not discard 0.1 ml before administering Enoxaparin Sodium injection and administered Enoxaparin 30mg/0.3 ml to Left Thigh. On 1/14/2025 at 1:54 pm, V2 (DON), stated that she believes R63's medication dosage for Enoxaparin Sodium is 30mg or 20mg and that she administered 30 mg of the medication. V2 was asked if she discarded 0.1 ml before administering Enoxaparin Sodium and V2 stated No, I don't think so. V2 stated that administering more than the prescribed dosage of the medication can cause excessive bleeding. V2 stated that when a medication error occurs it must be reported to the DON and Physician and an incident report is written. R63's Physician Order Sheet (POS) documents an order dated 12/13/2024: Enoxaparin Sodium Injection Solution Prefilled Syringe 30MG/0.3ML (Enoxaparin Sodium) Inject 20 mg subcutaneously one time a day for anticoagulant dispose 0.1 ml and administer 20 mg. On 1/14/2025 at 9:26 am, observed V3 (Registered Nurse-RN) preparing 1 tablet of Acetaminophen 500 mg to be administered to R379. V3 (RN) showed a house stock of Acetaminophen 500 mg tablets and stated that R379's order is actually 325 mg of Acetaminophen for pain. V3 administered 325 mg 1 tab by mouth to R379. On 1/14/2025 at 1:41 pm, V3 (RN) stated R379 has an order for Acetaminophen 325 mg. V3 provided R379's POS which excludes an order for Acetaminophen 325mg. V3 (RN) stated that R379 had an order for Acetaminophen yesterday, so he was just following the order from yesterday. V3 stated that all orders for Acetaminophen had been discontinued and there were no standing orders for Acetaminophen at the time of administration of the medication to R379. Facility presented a policy titled Medication Administration General Guidelines undated which documents: FIVE RIGHTS - Right resident, right drug, right dose, right route and right time, are applied for each medication being administered. A triple check of these 5 Rights is recommended at three steps in the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication put away. a) Check #1: Select the Medication - label, container and contents are checked for integrity, and compared against the medication administration record (MAR) by reviewing the 5 Rights. b) Check #2: Prepare the dose - the dose is removed from the container and verified against the label and the MAR by reviewing the 5 Rights. c) Check #3: Complete the preparation of the dose and re-verify the label against the MAR (Medication Administration Record) by reviewing the 5 Rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that residents were free of serious medication errors. This failure affects 1 resident (R328) in a sample of 49. Findings include: Record review of R328's admission record documents in part R328 has the following diagnoses including, but not limited to: osteomyelitis, sepsis, paraplegia, neuromuscular dysfunction of bladder, and colitis. Record review of R328's Brief Interview of Mental Status (BIMS) assessment dated [DATE], documents in part that R328 has a BIMS summary score of 15, indicating that R328 is cognitively intact. Record review of R328's medication administration record documents in part that R328 has active orders for Ampicillin 12 g in 0.9% normal saline Use 12 gram intravenously one time a day for sepsis until 01/20/2025 23:59 ampicillin 12g in 0.9% NSS 500ml daily in continuous pump, and Vancomycin HCl Intravenous Solution 1500 MG/300ML (Vancomycin HCl) Use 1500 mg intravenously every 8 hours for Osteomyelitis until 01/20/2025 23:00. Additionally, the record documents that Vancomycin should be administered at 01:00 AM, 9:00 AM and 5:00 PM. On 1/13/2025 at 11:37 AM, observed R328 sitting upright in a wheelchair with a double lumen peripherally inserted central catheter (PICC) line to R328's right upper arm. An IV (intravenous) pole with a bag containing approximately 500 milliliters (mL) labeled Ampicillin 12 grams in 500 mL of 0.9% sodium chloride (normal saline) was observed to the right of R328 with the IV line disconnected from R328. The directions on the bag of Ampicillin stated, infuse intravenously at 41.7 ml/hr (hour) over 24 hours. R328 stated that the medication on the IV pole was antibiotics and explained that R328 has multiple pressure ulcers that became infected, causing R328 to become septic and needing nursing home level of care. R328 stated that R328 does not get prescribed antibiotics regularly because the facility does not have enough nursing staff to run R328's IV medication. R328 stated that R328 feels that R328's wounds have had delayed healing because R328 does not get antibiotics regularly. On 1/13/2025 at 11:50 AM, V2 (Director of Nursing) entered the room and observed the ampicillin not connected or being administered to R328. V2 affirmed that the ampicillin should be running and the ampicillin gets stopped when (R328) gets vancomycin. When V2 was asked why the ampicillin wasn't running V2 stated, we had some staffing issues this morning and a nurse called off. V2 explained that the ampicillin and vancomycin were being given for R328's osteomyelitis and would check the medication administration record and administer the ampicillin. V2 left the room without administering the ampicillin. On 1/13/2025 at 12:30 AM, V2 entered R328's room and flushed both lumens of R328's PICC line with 10 mL of normal saline (indicating patency to both lumen). V2 began administering vancomycin 1500 mg mg/400 mL through R328's PICC line (administered 3 hours late). V2 affirmed that once the vancomycin was completed, that V2 would connect R328 to the ampicillin and continue the infusion. V2 left the room without infusing the ampicillin. On 1/13/2025 2:50 PM, observed V10 (Agency Licensed Practical Nurse) in R328's room and the bag of ampicillin at 500 mL. V10 stated that R328's Vancomycin IV had been completed and V10 was going to find a registered nurse to administer the ampicillin. V10 was unaware if the ampicillin was supposed to be continuously infusing. On 1/14/2025 at 12:10 PM, observed R328 lying in bed. A 500 mL bag (with 500 mL of fluid) labeled ampicillin 12 g was noted on R328's IV pole and not connected to R328. R328 stated that R328 had not been administered the ampicillin on 1/14/2025. On 1/15/2025 at 11:09 AM, observed R328 lying in bed. A 500 mL bag (with 500 mL of fluid) labeled ampicillin 12 g was noted on R328's IV pole and not connected to R328. An IV bag labeled for vancomycin with an unidentifiable amount of liquid (small amount) was affixed to the IV pole and infusing to R328's PICC line. R328's infusion pump was heard alarming. R328 stated that the ampicillin was disconnected while the vancomycin was running. On 1/15/2026 at 1:06 PM, V22 (Registered Pharmacist) stated that V22 had reviewed the physician's orders for R328. V22 stated that Ampicillin can be administered continuously over 24 hours for the indication of osteomyelitis/sepsis. V22 stated, As ordered, (R328's) ampicillin should be continuously infusing over 24 hours. Ampicillin and Vancomycin are compatible and can be ran through the same PICC line as long as (R328) has multiple lumens. The facility should not be stopping the ampicillin to administer the vancomycin. If medications are not given, or not given on time, a general adverse effect could be delayed healing, microbial resistance, or persistent infection. Facility policy titled Medication Administration General Guidelines (undated) documents in part, .Medications are administered as prescribed in accordance with good nursing principles and practices . 6. FIVE RIGHTS - Right resident, right drug, right dose, right route and right time are applied for each medication being administered . Medications are administered within 1 hour before or after scheduled time, except before, with or after meal orders which are administered based on mealtimes .

Based on observation, interview, and record review the facility failed to ensure two licensed personnel conducted a physical inventory of controlled substances at each change of shift. This failure has the potential to affect 8 residents who are prescribed controlled substances from the 3rd floor medication cart and 6 residents who are prescribed controlled substances from the 4th floor medication cart. Findings include: On 01/14/2025 at 12:10 pm, review of the 3rd Floor medication cart with V15 (RN/Registered Nurse) surveyor observed the controlled substances count verification form for January 2025. The Nurse's Initials Off box was left blank for January 10, 2025 (night shift). The Nurse's Initials On box was left blank for January 13, 2025 (day shift). The Nurse's Initials Off box was left blank for January 13, 2025 (evening shift). On 01/14/2025 at 12:40pm, review of the 4th Floor medication cart with V11(LPN/Licensed Practical Nurse) surveyor observed the controlled substances count verification form for January 2025. The Nurse's Initials Off box was left blank for January 04, 2025 (day shift). The blank spaces on the facility's-controlled substances count verification form indicate the controlled substances were not reconciled at the end and beginning of the shift on the specified days. On 01/14/2025 at 12:15pm V15 (RN/Registered Nurse) stated when the nurse comes on the shift, this nurse counts the number of controlled substances in the medication packs and initials the controlled substances count verification form. V15 stated the nurse going off shift also verifies the count of the controlled substances in the medication packs and initials the controlled substances count verification form indicating the count of controlled substances is correct. On 1/15/2025 at 10:43am V2 (DON/Director of Nursing) stated the controlled substances count verification sheet is used by the nurses to keep track of the narcotics. V2 stated the nurse coming onto the shift is to count the narcotics with the nurse leaving the shift. V2 stated the nurse beginning the shift signs in the nurse initials on box and the nurse ending the shift signs in the nurse initials off box. V2 stated it is my expectation that the nurses are initialing the controlled substances count verification sheets to indicate that the count is correct. Received the facility's undated policy titled Counting Controlled Substances and responding to errors in a controlled substance count via email from V1(Administrator) on 1/15/2025, which documents in part, General Guidelines: Always participate in the counting of controlled substances at the beginning and ending of your shift. On 01/15/2025 reviewed the facility's Registered Nurse job description dated 05/02/2017 which documents in part, underneath Essential Duties and Responsibilities: Perform routine charting duties as required & in accordance with established charting & documentation policies & procedures. On 01/15/2025 reviewed the facility's Licensed Practical Nurse job description dated 05/02/2017 which documents in part, underneath Essential Duties and Responsibilities: Perform routine charting duties as required & in accordance with established charting & documentation policies & procedures.

Based on observation, interview and record review the facility failed to ensure: three medication carts out of the three medication carts reviewed were free of loose tablets, insulin pens that were dated with an open date and the temperature was properly logged for two of the three medication storage refrigerators reviewed. This deficient practice has the potential to affect 24 residents on the fourth floor, 23 residents on the third floor and 11 residents on the 2nd Floor [NAME] (East Wing) who receive medications from the medication carts and units. Findings include: On 01/14/ 2025 at 11:37am inspected the 3rd Floor medication cart with V15 (RN/Registered Nurse). The following was observed: V15 pulled 5 loose white tablets, 3 loose yellow tablets, and 1 loose white capsule from the second drawer of the 3rd floor medication cart. On 01/14/2025 at 12:24pm inspected the 4th Floor medication cart with V11 (LPN/Licensed Practical Nurse). The following was observed: V11 pulled 1 loose pale pink tablet, 2 loose orange tablets, 20 loose white tablets, 2 loose green tablets, 5 loose pink tablets, and 1 loose gray tablet from the second drawer of the 4th floor medication cart. On 01/14/2025 at 1:23pm inspected the 2nd Floor [NAME] East Wing medication cart with V16 (LPN/Licensed Practical Nurse). The following was observed: V16 pulled 5 loose white tablets, 1 loose orange tablet, and 1 loose green tablet from the second drawer of the 2nd floor [NAME] East wing medication cart. On 01/14/ 2025 at 11:37am inspected the 3rd Floor medication cart with V15 (RN/Registered Nurse). The following was observed: two insulin pens with no date documented indicating when the insulin pen was opened. Each insulin pen was inside a plastic bag with a label on the bag, the label documented in part, High Alert Refrigerate until opened, once opened store at room temperature for 28 days. Date opened________. Observed no date on the plastic bag containing the insulin pen or the pen itself. On 01/14/2025 at 11:40am inspected the 3rd floor medication storage refrigerator with V15(RN/Registered Nurse). The following was observed: the 3rd floor unit medicine refrigerator temperature log was missing documentation of a temperature for the following dates 1/6/25, 1/7/25, 1/8/25, 1/9/25, and 1/10/25. On 01/14/2025 at 12:30pm inspected the 4th floor medication storage refrigerator with V11(LPN/Licensed Practical Nurse). The following was observed: the 4th floor unit medicine refrigerator temperature log was missing documentation of a temperature for the following dates 1/1/25, 1/8/25, 1/8/25, and 1/11/25. On 01/14/2025 at 1:30pm V16 (LPN/Licensed Practical Nurse) stated the nurse on each shift is responsible for cleaning the medication cart. On 1/14/2025 at 12:31pm V11 (LPN/Licensed Practical Nurse) stated the nurse is responsible for obtaining and documenting a temperature for the medication storage refrigerator in the nurse's station. On 1/15/2025 at 10:43am V2 (DON/Director of Nursing) stated the nurses are responsible for checking the temperature in the refrigerators used to store medications. V2 stated the temperature is usually checked by the overnight nurse. V2 stated the temperatures in the refrigerators used to store medications should be checked once a day. V2 stated it is my expectation that the nurses document a temperature on the temperature log once the temperature in the refrigerator is checked. V2 stated the purpose of maintaining a proper temperature is because certain medications need to be at a certain temperature. V2 stated the nurses are responsible for cleaning the medication carts. V2 stated the medication carts are to be cleaned as needed. V2 stated there should not be any loose tablets in the bottom of the drawers of the medication cart. V2 stated the insulin pens are to be dated when the pen is opened. V2 stated the date the pen was opened can be placed on the pen itself or on the bag the insulin pen was contained in. On 1/15/2025 reviewed facility's undated policy titled Storage of Medications which documents in part, Underneath Procedures 8. Medication storage areas are kept clean, well-lit, and free of clutter and extreme temperatures and humidity. Underneath Temperature 3. Medications requiring refrigeration are kept in a refrigerator at temperatures between 2 degrees Celsius and 8 degrees Celsius with a thermometer to allow temperature monitoring. 5. The facility should maintain a temperature log in the storage area to record temperature at least once a day. Underneath Expiration Dating 5. When the original seal of manufacturer's container or vial is initially broken, the container or vial will be dated. a) The nurse shall place a date opened sticker on the medication and enter the date opened.

On 1/13/2025 at 11:51am surveyor observed R74's personal refrigerator without a temperature log for January 2025; partially completed temperature log was for December 2024 was displayed. Surveyor also observed the thermostat sitting on top of the refrigerator inside of inside of the refrigerator. On 1/13/2025 at 11:57am surveyor observed R56's personal refrigerator with a partially completed temperature log for December 2024; there was no temperature log for January 2025. There was an unopened carton of 2% milk dated 1/02/2025 in the refrigerator. On 1/13/2025 at 12:10am V8 (Certified Nursing Assistant) said, Oh no, that (referring to the unopened 2% milk carton on the door inside of the refrigerator) says 1/2/2025 and is expired. I will throw that out. V8 stated R56's son is responsible for documenting the date on the log and I don't see a date but it's for the month of December 2024. On 1/13/2025 at 12:28pm V5 (Registered Nurse) stated the nurses and CNAs are supposed to update the refrigerator log, daily, on the third shift and we (nursing staff) are responsible for changing the log and documenting the temperature from the refrigerator. V5 stated the thermostat should be inside of the fridge to regulate the temperature and make sure the refrigerator is functioning and we are to make sure there is no expired food. On 1/13/2025 at 12:37pm surveyor observed R49's personal refrigerator with no temperature log at all, but the refrigerator was stocked with a container of french onion dip and Pepsi. On 1/13/2025 R49 stated she did not know there was supposed to be a refrigerator log. On 1/15/2025 at about 10:15am V4 (Registered Nurse) stated that the nurse's and CNAs on the third shift are responsible for maintaining the resident's personal refrigerator log, but other shift nurses and CNA's help also. On 1/15/2025 at 1:55pm V2 (Director of Nursing) stated housekeeping staff is responsible for checking and maintaining resident's personal refrigerator. On 1/15/2025 at 2:33pm V19 (Housekeeping Director) stated my staff is responsible for cleaning the resident's personal refrigerators only and does not maintain temperature logs. V19 stated the nurses are responsible to maintain the temperature logs. Undated policy titled Food Brought in By Family or Visitors Personal Refrigerators documents, in part, personal refrigerator temperatures are maintained at 41 degrees Fahrenheit or below and perishable foods are discarded on the sixth day after preparation/opening or on the expiration date. Undated policy titled Older Adults and Food Safety policy documents, in part, keep it safe, use a refrigerator/freezer thermometer to check temperatures. Based on observation, interview and record review, the facility failed to properly log refrigerator temperatures for resident's personal refrigerators for 6 residents (R11, R42, R49, R56, R57 and R74). This failure has the potential to affect all 6 residents reviewed for safety of personal food items, in a total sample size of 49 residents reviewed. Findings include: On 01/13/25 at 11:23am R57's refrigerator observed with no temperature log and no thermometer inside R57's refrigerator. On 01/13/25 at 11:32am R11's refrigerator observed with refrigerator log dated 05/2024 with missing check dates. R11 had no additional refrigerator logs for any date beyond 05/2024 including 01/2025. On 01/13/25 at 11:37 R42's refrigerator observed with refrigerator log dated June with missing check dates. R11 had no additional refrigerator logs for any date beyond June including 01/2025. On 01/13/25 at 11:43am V10 (Licensed Practical Nurse/LPN) stated that R11, R42 and R57 did not have refrigerator temperature logs for January 2025. On 01/15/25 at 1:51pm V2 (Director of Nursing/DON) stated that resident refrigerator temperature logs should be checked daily and that the inside of the refrigerator should be cleaned every three days. V2 stated that if the resident's refrigerators are not checked, then food could spoil, and a resident could get food poisoning. Facility's policy dated 06/2016 titled Compact Refrigerator-Resident Rooms, documents in part, Purpose: The facility will ensure that all refrigerators in resident rooms meet the appropriate safety and infection control pursuant to State and Federal regulations .Procedure: 1. Every refrigerator must have a thermometer for ancillary services to monitor proper fridge temps daily .5. Housekeeping will clean the interior and exterior of the refrigerator on a daily basis and annotate it on the log sheet .7. Housekeeping supervisor will spot check on a daily basis for thermometers, cleanliness and dates on food .8. Supervisor will check all refrigerators on a weekly basis and annotate inspection on a log sheet.

Based on interview and record review, the facility failed to follow policies and procedures for immunization of residents against pneumococcal disease in accordance with national standards of practice. The facility failed to vaccinate eligible residents with the pneumococcal vaccine. The facility failed to document the refusal and/or the benefits and side effects in the resident's electronic medical records. This deficient practice affected 3 residents (R1, R17 and R74) reviewed for pneumococcal immunizations in a total sample size of 49 residents. Findings include: Review of records for R1, R17 and R74 from admission date to 1/14/25 and there were no findings of documentation of pneumococcal vaccine offering or education of the vaccine. Review of physician orders for R1, R17 and R74 from admission to 1/14/25 show no orders of pneumococcal vaccination. Immunization records for R1, R17 and R74 have no current pneumococcal vaccination listed. On 1/15/25 at 1:27pm, V21 (Regional Nurse Consultant) said that the facility hasn't had a pneumococcal vaccine clinic. Only Influenza vaccines have been administered. On 1/15/25 at 1:49pm, V2 (Infection Preventionist/Director of Nursing/DON) was unable to produce a list of residents that the facility had given the pneumococcal and COVID-19 vaccines to. V2 said, I do not have any documentation that (R1, R17 and R74) received or declined the pneumococcal or COVID-19 vaccine. Facility haven't had pneumonia or COVID-19 clinics since I've been here. They've (pneumonia and COVID-19 clinics) been booked. I've been here since April (April 2024). Pneumonia and COVID-19 vaccines are important to prevent infection and a facility breakout. V2 stated that the COVID-19 and pneumococcal vaccines should be offered on admission, if eligible, and the resident has the right to decline. V2 stated that if the resident declines the vaccine, the refusal should be documented in the EMR (electronic medical record) as well. When asked if vaccination education should be provided to the resident prior to offering the COVID-19 and pneumococcal vaccines, V2 replied, Yes. Facility's policy titled, Influenza and Pneumococcal Immunizations, revised date 4/21/2022, documents, in part, To minimize the risk of resident's acquiring, transmitting, or experiencing complications from influenza and pneumococcal pneumonia. The facility shall provide pertinent information about the significant risks and benefits of vaccines to residents (or resident's legal representative) . Before offering the pneumococcal immunization, each resident or the resident's representative will be provided education regarding the benefits and potential side effects of the immunization. The resident's medical record includes documentation that indicates, at a minimum, the following: The resident either received or did not receive the pneumococcal immunization due to medical contraindications or refusal. Facility policy titled, Resident Rights, reviewed date 1/04/19, documents, in part, Purpose: To promote the exercise of rights for each resident, including any who face barriers (such as communication problems, hearing problems and cognition limits) in the exercise of these rights. A resident, even though determined to be incompetent, should be able to assert these rights based on his or her degree of capability.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to develop and implement a resident council that allows residents to meet regularly to discuss facility policies and procedures, care, treatment and quality of life. This failure affected four residents (R8, R37, R51 and R74) out of a total sample size of 49 and has the potential to affect all 87 residents residing in the facility. Findings include: R8's Minimum Data Set (MDS) dated [DATE] has a Brief Interview for Mental Status (BIMS) score of 9, which indicates that R8's cognition is moderately impaired. R37's MDS dated [DATE] has a BIMS score of 15, which indicated R37's cognition is intact. R51's MDS dated [DATE] has a BIMS score of 15, which indicates R51's cognition is intact. R74's MDS dated [DATE] has a BIMS score of 14, which indicates R74s cognition is intact. On 01/15/25 at 10:30am surveyor attended resident council meeting with 2 residents (R8 and R51) who were able to verbally answer questions and respond appropriately. 8 residents in attendance were nonverbal and inattentive. On 01/15/25 at 10:37am R51 stated that she had not been informed of or attended a resident council meeting before that day. R51 stated that she had not been informed of resident council meetings when she was a resident on a different floor. R51 stated that on the morning of 01/15/25 V24 (Activity Director) had asked R51 twice to be the Resident Council President. R51 stated that she accepted the offer the second time she was asked and was then brought to the resident council meeting. On 01/15/25 at 10:40am R8 stated that she had not been informed of previous resident council meetings. On 01/15/24 at 11:25am R74 stated that no one in the facility had ever mentioned to her anything about a meeting for residents and had not been invited to the resident council meeting held on 01/15/25 at 10:30am. On 01/15/25 at 11:30am R37 stated that he used to attend resident council meetings when the meetings were run by social service. R37 stated that he has not heard anything about the facility having resident council meetings in a long time. R37 stated that he would like to attend the resident council meetings to listen to what other residents have to say and to see what is going on in the facility. R37 stated that if he was given the option to attend the resident council meeting, he would say a few words. On 01/15/25 at 11:43am V24 (Activity Director) stated that she asked R51 on the morning of 01/15/25 to be the resident council president. V24 stated that she is aware that the residents are supposed to vote for the resident council president. V24 stated that the resident council meeting held on 01/15/25 was the first resident council meeting that was hosted and organized by her. V24 stated that before 01/15/25, all resident council meetings were done by V28 (Social Services). On 01/15/25 at 11:58am V18 (Human Resource Director) stated that V28's employment with the facility ended on 11/14/24. On 01/15/25 at 1:51pm V2 (Director of Nursing/DON) stated that the facility's old ownership required the social service department to organize and assist the residents with resident council meetings. V2 stated that when the facility changed ownership in 03/2024, resident council was given the responsibility of organizing and hosting resident council meetings. V2 stated that it is important for residents to have resident council meetings to allow residents to voice their concerns. V2 stated that the Activity Director is responsible for informing the residents about the resident council meetings. On 01/15/25 at 12:00pm V17 (Social Service Director/SSD) stated that the social service department does not host the resident council meetings. V17 stated that they have always been ran by the activity department. Facility's policy dated 09/2015 titled Resident Council Policy documents in part, Purpose: To establish guidelines for assisting residents with the development and facilitation of a Resident Council in order to voice concerns, make recommendations, and participate in resolution of concerns .Responsibility: 1. The facility will provide residents with an appropriate meeting place and privacy will be afforded during meetings .2. The Resident Council is to be formed by all residents who wish to participate on a voluntary basis .3. The Activity Director will be responsible to coordinate the establishment of the Resident Council and be available to render assistance as needed. Council format, procedures and agenda will be developed by the council members with the assistance of the activity director .4. The council shall determine the leadership structure if any and/or officers in accordance with the by-laws. These persons shall preside at the meetings of the council, assisted by the Activity Director .5. All Resident Council meetings shall be open to participation by all residents and their invited guests .6. New residents will be informed of the Resident Council by the Activity Director .9. The Council will also be encouraged to discuss and offer suggestions about facility policies and procedures affecting residents' care treatment, and quality of life. Facility's policy dated 01/04/19 titled Resident Rights documents in part, Purpose: To promote the exercise of rights for each resident, including any who face barriers in the exercise of these rights. A resident, even though determined to be incompetent, should be able to assert these rights based on his or her degree of capability .Guidelines: .Exercise his or her rights .Be informed about what rights and responsibilities he or she has.

Based on observation, interview and record review, the facility failed to ensure that agency staff received sufficient competency prior to starting the scheduled shift and failed to ensure a system is in place to ensure agency staff are competent in the facility's policies and procedures. This failure has the potential to affect all 87 residents that reside within the facility. Findings include: Record review of facility census documents in part that 87 residents reside within the facility. On 1/13/2024 at 11:28 AM, V10 (Agency Licensed Practical Nurse) was observed unable to access the electronic health record. V10 stated that V10 works for an agency but has picked up shifts in the past. V10 stated that V10 picked up today and was having issues accessing the electronic health record, so V10 was unable to administer medications. V10 stated that V10 needed to start R358's IV medication and had a bag of vancomycin in V10's hands. V10 was unsure if it was within V10's scope of practice as a licensed practical nurse to access and administer IV medications through a peripherally inserted central catheter (PICC) line. V10 stated that V10 did not receive any training, orientation or competency checks from the facility including but not limited to, abuse, skills training, emergency preparedness. V10 affirmed that V10 has worked on multiple units when V10 has picked up shifts at the facility, usually on night shift. V10 could not give the code to disengage the alarm to the stairwell or elevators. On 1/14/2024 at 11:18 AM, surveyor requested all documentation of V10 and V12 (Agency Registered Nurse) orientation and training documents. These documents were not received by the end of the survey. On 1/14/2025 at 1:37 PM, V14 (Regional [NAME] President of Operations) stated that when agency staff pick up shifts at the facility, they are given a verbal orientation of the unit and report. V14 stated that there is not a formal orientation process or competency process that agency staff are given. V14 affirmed that there is no documentation that agency staff are oriented or checked for competency prior to working on the units. V14 stated, this (agency staff orientation and competencies) process is something we need to evaluate for the facility. On 1/15/2025 at 1:50 PM, V2 (Director of Nursing) affirmed that the facility has no documentation of agency staff competency or formal system to ensure agency staff are trained to meet the resident's needs. V2 stated that if agency staff are not trained or competent, they may not provide care at a level that the residents need. Facility policy titled, Staffing undated, documents in part, .Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment . The facility assessment (reviewed 10/23/2024) identifies in part that staff need the following competencies to meet the resident's needs, including but not limited to: communication, resident rights, abuse/neglect/exploitation, infection control, antibiotic stewardship, person-centered care, identification of changes in condition, cultural competency, first aid/cardiopulmonary resuscitation, pressure ulcer prevention/treatment, fall prevention and interventions, emergency preparedness, and QAPI.

Based on interview and record review, the facility failed to ensure the facility's facility assessment was developed with input from the resident's family members; failed to identify staffing needs per unit within the facility; failed to update the facility assessment as new needs arise; and failed to list average daily census. These failures have the potential to affect all 87 residents that reside within the facility. Findings include: Record review of facility census documents in part that 87 residents reside in facility. Record review of facility assessment (reviewed 10/23/2024) staffing plan documents in part that on average, 5 licensed nurses are needed on every shift, on average 11 certified nursing assistants are needed on day shift and evening shift, and Other (department heads, quality assurance nurse, ancillary staff in maintenance, housekeeping, dietary, laundry, etc. Customize to the staffing of your facility 1 Director of Nursing, 1 Night weekend supervisor, 1 MDS coordinators, 1 Restorative Nurse. The facility assessment also indicates that the facility has 2 specialty units, a memory care unit and a short stay unit. The facility assessment does not indicate the following: the average daily census, the amount of nursing and ancillary staff needed per unit per shift, any input from resident family members in the development of the facility assessment, a specific member from the facility's governing body (Aperion Care Corporate Compliance). The facility assessment documents that this was reviewed with V1 (Administrator). The facility assessment also does not identify that the facility needs a wound care nurse or an assistant director of nursing. On 1/14/2025 at 1:30 PM, V1 stated that the regional team (V14, Regional Director of Operations and V21, Regional Nurse Consultant) would be able to better answer questions about the facility assessment. On 1/14/2025 at 1:37 PM, V14 stated that V14 participates in the development of the facility's assessment. V14 stated that the resident's family members were not involved in development of the facility assessment and was unsure if that was a requirement. V14 reviewed the facility assessment and affirmed that the staffing needs are not broken down by unit. V14 stated that the facility has identified and is currently hiring for an assistant director of nursing and a wound care nurse. Record review of facility assessment tool (undated) documents in part, .The purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Use this assessment to make decisions about your direct care staff needs as well as your capabilities to provide services to the residents in your facility. Using a competency-based approach focuses on ensuring that each resident is provided care that allows the resident to maintain or attain their highest practicable physical, mental, and psychosocial well-being .Guidelines for Conducting the Assessment .1 . Facilities are encouraged to seek input from residents, their representatives(s), or families, and consider that information when formulating their assessment .3. The facility must update this assessment annually or whenever there is/the facility plans for any change that would require modification to any part of this assessment .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to properly don PPE (personal protective equipment) upon entering the room of one resident (R71) on isolation precautions, failed to provide waste bins to properly dispose of PPE for 3 residents (R49, R52 and R65) on isolation precautions, and failed to monitor the measures the facility has in place to prevent the growth of Legionella and other opportunistic waterborne pathogens in the facility's water systems. These failures have the potential to affect all 87 residents residing in the facility reviewed for preventing the spread of microorganisms in the facility when reviewed for infection control. Findings include: Facility census, dated 1/13/25, documents 87 active residents. Facility's policy titled, Infection Prevention and Control Program, has a revised date 11/28/17 and the Reviewed/ Approved by: section is blank. R71 has a diagnosis of but not limited to Displaced Intertrochanteric Fracture of Left Femur, Subsequent Encounter for Closed Fracture with Routine Healing, Encounter for Other Orthopedic Aftercare, Abnormal Posture, Pressure Ulcer of Left Heel, Unstageable. R71's Brief Interview of Mental Status score is 13 whioch indicates R13 is cognitive. R71 is on Enhanced Barrier Precautions. R71's Order Summary Report with active orders as of 1/15/2025 documents, in part, Enhanced Barrier Precautions related to wounds. R49 has a diagnosis of but not limited to Acute Metabolic Acidosis, Cor Pulmonale, Influenza due to Identified Novel Influenza A Virus and Plasma-Protein Metabolism. R49's Order Summary Report with active orders as of 1/15/2025 documents, in part, Contact and Droplet Precautions due to Influenza A Positive (1/4/025). On 1/13/2025 at 11:58am surveyor observed an Enhanced Barrier Precaution sign on R71's door, but there was no PPE (Personal Protective Equipment) bin outside of the room. Surveyor also observed that there was no separate garbage specifically to doff PPE. On 1/13/2025 at 12:03pm surveyor observer Droplet and Contact Precautions signs on R49's door but there was no PPE bin outside of the room. On 1/13/2025 at 12:28pm V5 (Registered Nurse) stated the PPE is located in the container, attached to the wall, by the nurse's station and stated staff are not to walk down the halls with PPE on outside of the room. On 1/13/2025 at 12:37pm surveyor observed that R49 had no PPE disposal bin inside of her room. On 1/14/2025 at 11:55am surveyor observed V2 (DON) and V13 (Wound Care tech/CNA) donning PPE inside of R71's room. V2 asked V13 did she bring a gown in for her too? On 1/15/2025 at 1:55pm V2 stated PPE should be donned prior to entering a resident's room because the area is considered a clean space. On 1/16/2025 at 11:01am via email V2 stated the adverse effects that can result from donning PPE inside of the resident's room before providing care is the transfer of pathogens (MDRO) which will increase the risk of infection and the purpose of enhanced barrier precautions is to reduce the transmission of (MDRO) to high-risk residents. On 1/15/25 at 1:49pm, when asked when the facility's Infection Prevention and Control Program, was last reviewed, V2 (Infection Preventionist/Director of Nursing/DON) replied, I'm not sure. I'll have to check. V2 never provided the date when the facility's Infection Prevention and Control Program was last reviewed. Email from V14 (Regional [NAME] President of Operations), dated 1/15/25 at 5:37pm, documents, in part, We do not have any recent testing. Please find our water system management - legionella . Attached was the facility's policy titled, Water Management Program for Prevention of Legionella Growth, revision date 5/17/24. Facility policy titled, Water Management Program for Prevention of Legionella Growth, revision date 5/17/24, documents, in part, Purpose: To identify and reduce the risk of Legionella growth and spread. Definition: Legionella is found naturally in [NAME] environments, like lakes and streams, but generally the low amounts in [NAME] do not lead to disease. Legionella can become a health problem in building water systems . Preventative maintenance will be performed as applicable: The following will be verified and documented at least once weekly: Thermostat indicating the temperature of water entering the circulating system at the mixing valve is 120F or above. Weekly sanitizing of medical devices such as CPAP. Email from V1 (Administrator), dated 1/16/25 at 11:23am, documents, in part, 1. Weekly thermostat readings indicating the temperature of water entering the circulating system at the mixing valve, we do not have a log for this. 2. Weekly sanitizing of medical devices such as CPAP. We do not have a log for this. On 1/15/25 at 3:53pm, when asked for the documentation regarding the facility's water management program for Legionella, V1 (Administrator) replied, I don't think the water supply has been tested for it (Legionella). It (water supply) should be tested yearly. It (Legionella) is a deadly disease. Residents can get sick and die. On 1/15/25 at 1:49pm, V2 (Infection Preventionist/Director of Nursing/DON) said, There should be bins in the rooms for residents on isolation so the staff can throw out the PPE (personal protective equipment) after use. I ordered them, but you guys are here before the order came in. It prevents infection from spreading. Facility's policy titled, Infection Prevention and Control Program, revised date 11/28/17, To comply with a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement . 1. The facility has established an Infection Control Program which addresses all phases of the organization's operation to reduce or prevent the risks of nosocomial infections in residents and health care workers . 5. All infection control policies and procedures will be reviewed annually by the Quality Assurance Committee and revised as needed. Department Heads are responsible for assuring personnel are made aware of all revisions to respective policies and procedures . Scholarly article from CDC (Center for Disease Control and Prevention) titled, Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings A PRACTICAL GUIDE TO IMPLEMENTING INDUSTRY STANDARD, dated June 24, 2021, documents, in part, Factors that might make testing for Legionella more important include: being a healthcare facility that provides inpatient services to people who are at increased risk for Legionnaires' disease . Patients with severe pneumonia, in particular those requiring intensive care . Immunocompromised patients with pneumonia . Patients at risk for Legionnaires' disease with healthcare-associated pneumonia (pneumonia with onset ?48 hours after admission) https://www.cdc.gov/control-legionella/media/pdfs/toolkit.pdf Facility policy titled, Enhanced Barrier Precautions, revised date 5/7/24, documents, in part, To reduce risk of transmitting multidrug-resistant organisms (MDRO) and targeted MDRO when contact precautions do not apply for residents identified as higher risk. Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. The facility should ensure PPE and alcohol-based hand rub are readily accessible to staff. Discretion may be used in the placement of supplies which may include placement near or outside the resident's room. Facility policy titled, Infection Precaution Guidelines, revised date 5/15/23, documents, in part, It is the policy of this facility to, when necessary, prevent the transmission of infections within the facility through the use of Isolation Precautions. Facility policy titled, Resident Rights, reviewed date 1/04/19, documents, in part, Purpose: To promote the exercise of rights for each resident, including any who face barriers (such as communication problems, hearing problems and cognition limits) in the exercise of these rights. A resident, even though determined to be incompetent, should be able to assert these rights based on his or her degree of capability. On 1/13/2025 at 10:13 AM, surveyor observed Enhanced Barrier Precautions sign on R52 ' s door. On 1/13/2025 at 10:15 AM, observed R52's room without garbage cans to dispose of Proper Personal Equipment when exiting a positive COVID-19 resident's room. On 1/13/2025 at 10:21 AM, V3 (Registered Nurse) stated that the staff disposes the Personal Protective Equipment in the garbage can down the hall and that PPE from a positive COVID-19 patient is disposed of before we leave the resident's room. V3 stated that improper disposal of PPE can result in an outbreak of COVID-19. On 1/15/2025 at 2:39 pm, V2 (DON) provided a document dated 11/17/17 titled Medical Waste Disposal. V2 state that the facility only has a policy for medical waste and does not have a policy for disposal of COVID-19 medical waste that uses red bags. Per face sheet R52's active medical diagnosis includes COVID-19. On 01/13/2025 at 10:28 AM, surveyor observed Enhanced Barrier Precautions sign on R65 ' s door. On 1/13/2025 at 10:28 AM, observed R65's room without garbage cans to dispose of Proper Personal Equipment when exiting a positive COVID-19 resident's room. On 1/13/2025 at 10:29 AM, V3 RN stated that R65 is positive of COVID-19.

Based on interview and record review, the facility failed to follow policies and procedures for immunization of residents against COVID-19 in accordance with national standards of practice. The facility failed to vaccinate eligible residents with the COVID-19. The facility failed to document the refusal and/or the benefits and side effects in the resident's electronic medical records. This deficient practice affected 3 residents (R1, R17 and R74) reviewed for COVID-19 immunizations in a total sample size of 49 residents and has the potential to affect all eligible residents that reside at the facility. This deficient practice has the potential to affect all 87 eligible residents that reside at the facility. Findings include: Review of records for R1, R17 and R74 from admission date to 1/14/25 and there were no findings of documentation of COVID-19 vaccine offering or education of the vaccine. Review of physician orders for R1, R17 and R74 from admission to 1/14/25 show no orders of COVID-19 vaccination. Immunization records for R1, R17 and R74 have no current COVID-19 vaccination listed. On 1/15/25 at 1:49pm, V2 (Infection Preventionist/Director of Nursing/DON) was unable to produce a list of residents that the facility had given the pneumococcal and COVID-19 vaccines to. V2 said, I (V2) do not have any documentation that (R1, R17 and R74) received or declined the pneumococcal or COVID-19 vaccine. (facility) hasn't had pneumonia or COVID-19 clinics since I've been here. They've (pneumonia and COVID-19 clinics) been booked. I've been here since April (April 2024). Pneumonia and COVID-19 vaccines are important to prevent infection and a facility breakout. V2 stated that the COVID-19 and pneumococcal vaccines should be offered on admission, if eligible, and the resident has the right to decline. V2 stated that if the resident declines the vaccine, the refusal should be documented in the EMR (electronic medical record) as well. When asked if vaccination education should be provided to the resident prior to offering the COVID-19 and pneumococcal vaccines, V2 replied, Yes. Facility's policy titled, COVID-19 Vaccination Guidelines- Residents and Employees, revised date 12/09/24, documents, in part, To minimize the risk of resident's acquiring, transmitting, or experiencing complications from SARS-CoV-2 (COVID-19). The facility shall provide pertinent information about the significant risks and benefits of vaccines to residents (or resident's legal representative) . Before offering the COVID-19 vaccine, each resident or the resident's representative will be provided education regarding the benefits and risks and potential side effects of the COVID-19 vaccine. The resident's medical record includes documentation that indicates, at a minimum, the following: That the resident or resident representative was provided education regarding the benefits and potential risks associated with COVID-19 vaccine; Each dose of the COVID-19 vaccine administered to the resident, or If the resident did not receive the COVID-19 vaccine due to medical contraindications or refusal. Facility policy titled, Resident Rights, reviewed date 1/04/19, documents, in part, Purpose: To promote the exercise of rights for each resident, including any who face barriers (such as communication problems, hearing problems and cognition limits) in the exercise of these rights. A resident, even though determined to be incompetent, should be able to assert these rights based on his or her degree of capability.

Based on observation, interview and record review, the facility failed to clean the dryer lint screen thoroughly to provide a safe environment for the residents. This failure has the potential to affect all 87 residents at the facility. Findings include: On 1/15/25 at 10:15 am, V1 (Administrator) said, the Laundry Manager (V19) is busy with Life Safety, but I know laundry and can answer any questions for you. On 1/15/25 at 10:45 am, this surveyor, with V1 (Administrator) observed 2 dryers in the laundry room. Dryer #1 was not in use but did have linen inside it. Dryer number 2 had just finished while V1 and this surveyor were present. This surveyor requested V1 (Administrator) to open the lint compartment dryer #1. The lint compartment floor was clean however the lint screen was fully covered with lint. This surveyor requested V1 (Administrator) to open the lint compartment dryer #2. The lint compartment floor had loose lint on the floor and the lint screen was fully covered with lint. On 1/15/25 at 10:52am, V1 (Administrator) stated the dryer lint traps should be cleaned out daily so the linen can be properly dried and to prevent the lint from catching fire. V1 said that the employees in laundry are responsible for cleaning out the lint traps. On 1/15/25 at 12:31pm, V20 (Laundry Aide) said, I clean out the lint traps. Normally, I clean them out when I come in because when I leave for the day there is usually a load in there. The purpose for cleaning out the lint traps is to not start a fire and also not to accumulate a bunch of dust and dirt. I did not clean them (lint traps) out this morning cause I was late and rushing. Facility policy titled, Section: Laundry Services/Maintenance Subject: Safety Procedures or Dryers in Laundry Department, dated 2/09/2024, documents, in part, Purpose: To Staff and equipment from possible fires. 1. Clean lint screens can be maintained at least every 3 loads or every 2 hours by the laundry personnel. (Whichever comes first) 2. Always keep the motor vents free from lint. This is the responsibility of the maintenance department to be done weekly. 2. Cleaning lint screens according to the schedule. Facility job description titled, Laundry Aide, documents, in part, Remove . lint . from equipment . Facility job description titled, Administrator, dated 5/2/17, documents, in part, The Administrator directs the day to day functions of the facility in accordance with the federal and guidelines, standards, and regulations that govern the nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times . Ensure that a11 facility personnel, residents, and visitors follow established safety regulations to include fire protection/prevention, smoking regulations, infection control etc. Ensure that the facility is maintained in a clean and safe manner for resident comfort and convenience by assuring that necessary equipment and supplies are maintained to perform such duties/services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow their policy and procedure to maintain air temperatures between 68 degrees Fahrenheit (F) to 79 degrees F within resident rooms and common areas in winter months which affected R2 and has the potential to affect all 82 residents in the facility. Findings include: R2's admission Record documents, in part, that R2's diagnoses include dementia and epilepsy. R2's Minimum Data Set (MDS), dated [DATE], documents, in part, that the Staff Assessment for Mental Status was conducted due to R2 rarely being understood with R2's cognitive skills for daily decision making as moderately impaired with short and long term memory problems. On 12/9/24 at 12:48 pm, when asked how often does V3 (Maintenance Director) check the air temperatures in the facility. V3 stated, I am supposed to do it every day. I cannot every day. There's just no time. I will do when someone is complaining. On 12/9/24 at 12:55 pm, this surveyor and V3 performed an environmental tour in the facility for air temperature readings. V3 utilized an electronic air temperature thermometer with an infrared beam. V3 observed pointing air temperature thermometer infrared beam (at chest level) on the 1st floor in the hallway in between the east parlor room and the main elevator obtaining an 84 degree F reading. V3 stated, It's going to stay on 84 (degrees) because of the radiators. V3 obtained air temperature reading of the 1st floor hallway (center unit) as 83 degrees. V3 stated that there are 2 types of heat sources in the facility which are central air heat coming from the ventilation in the ceilings and the radiators. V3 stated that some areas have no central air, some only have the radiators, and some areas have both heating sources. V3 stated that when it's too warm, then staff open up the windows 4 inches, and V3 will shut off the boiler to decrease the heat in the facility. When asked what the range for air temperatures should be in the facility, V3 stated 68 to 75 (degrees). V3 stated that V3 has had the boiler turned off since Saturday at noon for the radiator heat, and one boiler is still working, but it's only on for domestic hot water, not for to supply heat. V3 stated that V3 will turn on the boiler for 1 to 2 hours during the day and adjust it for the night, but the weather outside plays a part. When asked the maximum air temperature in the facility, V3 stated, Max is 80 to 85 (degrees). This surveyor and V3 continued on the tour walking into west unit on the 4th floor, and V3 stated, You can feel that it's warmer. V3 obtained R2's room air temperature with infrared thermometer with a reading of 80 degrees F. R2's window in room is observed open 4 inches, propped open with a gloves box. When asked if V3 had been alerted or called about this room being too warm, V3 stated, No, No. V3 showed that R2's room has the radiator and the central air heat. On the wall inside R2's room, this surveyor observed a straight knob sticking out from a panel labeled low, medium, high and off. V3 stated that nurses have a special key that they can turn this knob to control the central air heat in the rooms that have it, including R2's room. This surveyor and V3 end this environmental tour on the ground floor observing the boiler room. Two boilers observed and labeled # 1 and # 2 with an additional yellow tank that V3 explained is for domestic water only with the external temperature gauge clearly reading 110 degrees. V3 stated that the boilers (#1 and #2) heat the water, pump and circulate the water through the pipes, and it returns through the system to keep the building warm. When asked how is V3 regulating the temperature of the water within the boiler tanks #1 and #2, V3 stated that V3 will turn on the boiler for 1 to 2 hours because it depends on what the weather is outside. V3 will adjust the tank after 3 pm before V3 goes home from working V3's day shift. On 12/9/24 at 1:15 pm, R2 observed standing in the dining/activity room pulling out the small drawer of a storage dresser and then closing it. V8 (Certified Nursing Assistant, CNA) supervising R2 and stated that R2 is nonverbal and will continually keep moving around but does not talk. R2 was not able to be interviewed by this surveyor. On 12/9/24 at 1:50 pm, V9 (R2's Family Member, Power of Attorney, POA) stated that V9 visited R2 in the facility on 11/28/24 where the facility appeared to feel warmer than normal. V9 stated that on 12/1/24 during another visit to the facility, V9 talked to V7 (Licensed Practical Nurse, LPN) about the excessive heat in R2's room. On 12/9/24 at 3:14 pm, V7 (Licensed Practical Nurse, LPN) stated that V7 works regularly with R2, and R2 is alert, confused, oriented to self and needs frequent redirection. V7 stated that V7 remembers V9 (R2's Family Member, POA) visiting last week and asked V7 why is it so hot in R2's room. V7 stated that V7 informed V9, Unfortunately, it's been like that. Management is doing something about it. V7 stated that V7 opened up R2's window. V7 stated that when V7 came to work the following day, R2's room remained hot with a fan in R2's room, but V7 stated for safety reasons, V7 did not leave R2's fan in the room saying, it could fall on (R2). When asked about V7 using a special key to turn the knob in R2's room to decrease the heat, V7 stated that V7 did not do that and just opened R2's window. V7 stated that V7 did not inform V1 (Administrator) or V3 (Maintenance Director) on 12/1/24 about V9's concern of excessive heat. On 12/10/24 at 12:34 pm, this surveyor reinterviewed V3 after facility policy and air temperature log review. V3 stated that the older thermostats that are on resident rooms and dining room walls are not working, not accurate. They are not connected to the heating sources in the facility. V3 stated that there are no functioning thermostats in the nurse's stations or common areas of the facility. When asked about V3 documenting the air temperatures on the different units (east, center, and west) on each floor, V3 stated that V3 was supposed to put down the room number on the air temperature log that V3 was checking, but V3 did not. V3 stated, I shut off the boiler today at 5 am. If a resident room is too hot during night, they open the window or will use the key to turn down the air flow in rooms. I showed you (surveyor) the boiler room, there is a temperature gauge for the yellow tank and that's for the domestic water. But I didn't know that there's another gauge for the boiler for the heat also. I was on the phone yesterday for 2 hours with the previous maintenance director and they said there's a mark here and a mark here, like a minimum and a maximum, but I don't know which mark is which. I turned the knob to move the gauge lower since it was next to the one mark, and I will test it. This is a trial period. V3 confirmed that V3 turned the knob on the gauge on the boiler yesterday before leaving work. When asked if V3 took air temperature readings today in the facility, V3 stated, No, and now corporate wants me to check it (air temperatures) two times a day. On 12/10/24 at 1:19 pm, this surveyor performed a tour of the nurse's stations in the facility. No thermometer was observed in the 4th floor nurse's station with V17 (LPN) stating that there is no thermometer in the 4th floor nurses station and that this is the only nurse's station on the floor. One thermostat (name is same as one that V3 stated is not working or accurate) is noted inside the 3rd floor nurse's station. When asked if this is accurate, V18 (LPN) said, I think it's broken. I don't think it's working. They said that something broke. On 12/10/24 at 2:30 pm, V1 (Administrator) stated that the staff can open a window, offer a fan or the nurse can use the special key to turn the dial down in rooms where it's too warm. V1 stated the air temperature is too excessive still, then staff will call (V3). V1 stated that V3 would notify V1 if there are concerns with heat in the facility. V1 stated that V1 did speak with V9 (R2's Family Member/POA) about R2's room being too hot on an unknown date at the end of November to the beginning of December 2024 and that a room window was opened for the higher heat in R2's room. On 12/10/24 at 3:36 pm, this surveyor showed V1 (Administrator) the air temperature log readings of 80 degrees and higher. V1 stated that V3 did not inform V1 of these air temperature readings of 80 degrees and higher. When asked if V3 is to be following the facility's air temperature policy and procedure, V1 stated, Yes. This surveyor and V1 reviewed the air temperature policy with the facility air temperature range being maintained between 68 and 79 degree F for residents, visitors and staff in facility. V1 stated that the purpose of maintaining these specific air temperature readings per facility policy is to be comfortable, those are comfortable temperatures. On 12/10/24 at 3:12 pm, this surveyor and V3 toured the boiler room again. V3 stated that V3 has adjusted both boilers, #1, and #2. V3 stated, There were no marks on there gauge (on boiler), so I was guessing. V3 showed this surveyor inside a panel where the temperature gauges are for the boilers. On the inside of the door of the panel, written in marker, it reads: Turn clockwise to raise water temperature and lower heat exchange, turn counterclockwise. Two black marks are noted with a small needle (gauge) in the middle that V3 turned the black dial counterclockwise which moved the needle in the middle of the two black marks. When asked V3 about turning the black dial clockwise to warm the boiler water, V3 stated, Yes. V3 stated that V3 called the previous maintenance director yesterday and that's when V3 found out about how to adjust the boiler temperatures. V3 stated that the writing on the inside panel has been there since way before (V3) started. V3 stated that V3 turned the black dial counterclockwise yesterday on 12/9/24 to decrease the facility air before V3 left the facility. When asked if V3 performed air temperatures today (12/10/24), V3 stated that V3 did not. V3 stated that it feels better in the facility, not as warm. When asked how V3 can make this statement without measuring the air temperature, V3 stated, I can feel it. V3 stated that V3 did not inform V1 (Administrator) of the logged temperatures from November and December 2024. V3 stated, If it's 85 degrees, then I (V3) let (V1) know. If it's 81 (degrees), then yes, I am supposed to, but I open up a window. Facility document titled Air temperature documents, in part, columns with dates, initial and temperature readings for ground, 1st, 2nd, 3rd and 4th floors with units on the east, middle and west areas of the facility. At the bottom of each Air temperature log sheet, **Please note actions taken for high or low temperatures on the back of this form. There is no documentation noted on the back of the log sheets reviewed (9/30/24 to 11/29/24 log and 12/2/24 to 12/9/24 log). The following temperatures are documented: 10/29/24: 1st floor center unit with temperature of 80 degrees F. 2nd floor east unit with temperature of 90 degrees F. 2nd floor west unit with temperature of 80 degrees F. 4th floor west unit with temperature of 80 degrees F. All temperature entries signed by V3. 10/30/24: 1st floor west unit with temperature of 90 degrees F. 3rd floor center unit with temperature of 80 degrees F. All temperature entries signed by V3. 11/5/24: 1st floor center unit with temperature of 80 degrees F. 1st floor west unit with temperature of 80 degrees F. 4th floor center unit with temperature of 80 degrees F. 4th floor west unit with temperature of 80 degrees F. All temperature entries signed by V3. 11/8/24: Ground floor with temperature of 80 degrees. 1st floor center unit with temperature of 80 degrees F. 1st floor west unit with temperature of 82 degrees F. 2nd floor center unit with temperature of 81 degrees F. 2nd floor west unit with temperature of 80 degrees F. 3rd floor center unit with temperature of 80 degrees F. 3rd floor west unit with temperature of 80 degrees F. 4th floor center unit with temperature of 82 degrees F. 4th floor west unit with temperature of 81 degrees F. All temperature entries signed by V3. 11/11/24: 1st floor west unit with temperature of 82 degrees F. 2nd floor east unit with temperature of 81 degrees F. 2nd floor east unit with temperature of 81 degrees F. 2nd floor center unit with temperature of 82 degrees F. 2nd floor west unit with temperature of 81 degrees F. 3rd floor center unit with temperature of 81 degrees F. 3rd floor west unit with temperature of 81 degrees F. 4th floor center unit with temperature of 81 degrees F. 4th floor west unit with temperature of 82 degrees F. All temperature entries signed by V3. 11/19/24: Ground floor with temperature of 80 degrees. 1st floor west unit with temperature of 81 degrees F. 2nd floor east unit with temperature of 80 degrees F. 2nd floor center unit with temperature of 80 degrees F. 2nd floor west unit with temperature of 80 degrees F. 3rd floor center unit with temperature of 80 degrees F. 3rd floor west unit with temperature of 80 degrees F. 4th floor center unit with temperature of 80 degrees F. 4th floor west unit with temperature of 81 degrees F. All temperature entries signed by V3. 11/25/24: Ground floor with temperature of 80 degrees. 1st floor center unit with temperature of 81 degrees F. 1st floor west unit with temperature of 80 degrees F. 2nd floor east unit with temperature of 80 degrees F. 2nd floor center unit with temperature of 80 degrees F. 3rd floor center unit with temperature of 80 degrees F. 3rd floor west unit with temperature of 81 degrees F. 4th floor center unit with temperature of 81 degrees F. 4th floor west unit with temperature of 80 degrees F. All temperature entries signed by V3. 11/29/24: 1st floor center unit with temperature of 81 degrees F. 1st floor west unit with temperature of 81 degrees F. 2nd floor east unit with temperature of 81 degrees F. 2nd floor center unit with temperature of 80 degrees F. 2nd floor west unit with temperature of 81 degrees F. 3rd floor center unit with temperature of 80 degrees F. 3rd floor west unit with temperature of 80 degrees F. 4th floor center unit with temperature of 81 degrees F. 4th floor west unit with temperature of 80 degrees F. All temperature entries signed by V3. 12/2/24: Ground floor with temperature of 80 degrees. 1st floor center unit with temperature of 81 degrees F. 1st floor west unit with temperature of 81 degrees F. 2nd floor east unit with temperature of 82 degrees F. 2nd floor center unit with temperature of 83 degrees F. 2nd floor west unit with temperature of 82 degrees F. 3rd floor center unit with temperature of 81 degrees F. 3rd floor west unit with temperature of 82 degrees F. 4th floor center unit with temperature of 82 degrees F. 4th floor west unit with temperature of 83 degrees F. All temperature entries signed by V3. 12/5/24: Ground floor with temperature of 84 degrees. 1st floor center unit with temperature of 84 degrees F. 1st floor west unit with temperature of 83 degrees F. 2nd floor east unit with temperature of 84 degrees F. 2nd floor center unit with temperature of 83 degrees F. 2nd floor west unit with temperature of 84 degrees F. 3rd floor center unit with temperature of 83 degrees F. 3rd floor west unit with temperature of 82 degrees F. 4th floor center unit with temperature of 83 degrees F. 4th floor west unit with temperature of 83 degrees F. All temperature entries signed by V3. 12/9/24: Ground floor with temperature of 84 degrees. 1st floor center unit with temperature of 84 degrees F. 1st floor west unit with temperature of 85 degrees F. 2nd floor east unit with temperature of 85 degrees F. 2nd floor center unit with temperature of 83 degrees F. 2nd floor west unit with temperature of 832 degrees F. 3rd floor center unit with temperature of 84 degrees F. 3rd floor west unit with temperature of 84 degrees F. 4th floor center unit with temperature of 83 degrees F. 4th floor west unit with temperature of 84 degrees F. All temperature entries signed by V3. Facility document titled Daily Census and dated printed on 12/9/24 at 9:54 am documents, in part, that 82 residents reside in the facility. On 12/11/24 at 2:29 pm, V3 stated that V3 performed a recheck of air temperatures in the facility on 12/11/24 in the morning with the maximum reading today is 78 degrees, and V3 documenting the air temperatures on a new facility temperature log with resident room numbers and common areas. Facility policy Indoor Space Temperature-Resident Rooms; Common Areas and dated June 2024 documents, in part, All nursing facilities must maintain a temperature of not less than 68 degrees Fahrenheit or more than 79 degrees Fahrenheit in the winter months . These temperatures would have been always maintained, and in all areas of the building accessible to residents, employees, and visitors, except for the kitchen and laundry room. Every facility should also have centralized wall thermometers at every nurse's station and common area that will show both the room temperature and relative humidity. These can be purchased at any home improvement store or bought through our purchasing department. Heating Season: The heating season generally is from mid-October to mid-May. Heat will be provided to maintain interior temperatures at an appropriate range of 68 to 78 degrees during normal occupied hours. In implementing this policy, Facilities seeks to ensure that all heated spaces are as close to 71 degrees as possible. In practical terms, this means temperatures may be in the 71-75-degree range. Temperatures may be allowed to drop to as cold as 68 F . Temperature readings are taken at the thermostats that are placed throughout the facility. Facility job description titled Maintenance Director and dated 5/2/2017 documents, in part, Position Title: Maintenance Director. Reports To: Administrator. Summary: The primary purpose of the Maintenance Director is to plan, organize, develop, and direct the overall operation of the Maintenance Department in accordance with current, federal, state and local standards, guidelines, and regulations governing our facility, and as may be directed by the Administrator, to assure that our facility is maintained in a safe and comfortable manner. Essential Duties and Responsibilities: Plan, develop, organize, implement, evaluate, and direct the Maintenance Department, it's programs and activities . Ensure that supplies, equipment, etc. (and other things) are maintained to provide safe and comfortable environment. Promptly report equipment or facility damage to the Administrator . Make periodic rounds to check equipment and to assure that necessary equipment is available and working properly.

Based on observation, interview, and record review the facility failed to ensure that call light is within reach for two residents (R2 and R3) in the sample reviewed for call lights. This failure affected R2 and R3 whose call light were not within reach while in bed. Findings include: On 08/14/24 at 10:50am, R2 observed in bed with call light not within reach. R2 was asking for help from the surveyor and when asked to use the call light to call the facility staff R2 stated I don't know where it is. R2's call light was observed on the floor not within R2's reach. When this observation was showed to V4 LPN (Licensed Practical Nurse) assigned to R2 and was asked about the facility policy and protocol. V4 stated the residents should have the call light within their reach. At 11: 05am, R3 noted in bed shouting for help with incontinent care call light noted on the bedside floor. V5 and V6 CNA (Certified Nurse's Aides) stated rounds are made every two hours and call lights should be within the resident reach in case they need help. At 12:21pm, V2 (Director of Nursing) stated call lights should be placed within the resident's reach. The facility Call Light policy presented with revision date 02/02/18 documented that the purpose of the policy is to respond to resident's request and needs in a timely and courteous manner. Listed guidelines include but not limited to all residents that have the ability to use call light shall have the nurse call light system available at all times and within easy reach accessibility to the resident at the bed side or other reasonable accessible location.

Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that personal hygiene and incontinent care was provided for two residents R2 and R3 who rely on staff assistance with ADLs (Activity of Daily living). This failure affected R2 and R3 who were not rendered incontinent care in a timely manner, and this has the potential to affect all the 20 residents residing on the 4th floor. Findings include: On 08/14/24 at 10:50am, R2 observed in bed all covered up. R2 asked whether the surveyor will help in cleaning R2 up because R2 is wet and had stool although R2 was trying not to let it out for a long time. R2 stated I also a have migraine headache and it's hurting bad since during the night. V4 LPN was made aware and V4 stated the CNA's (Certified Nurse's Aides) are busy and have not gotten to R2 yet but V4 will get another (CNA) to help. At 10:58am, V5 (CNA) assigned to R2 stated she has been busy taking care of other resident and has not assisted R2 in incontinent care. When the surveyor asked when the last time R2 was checked for incontinence, V5 stated at around 7:30am but R2 did not say R2 was wet. V5 stated that rounds are made every two hours, and the incontinence rounds are done at the same time. V4 and V5 were observed turning R2 on the right side, R2 was noted wet to the cloth incontinent pad and with a bowel movement. V4 then stated anyway R2 is new to the facility, and we (facility) do not leave any resident lying in bed. We will get R2 up. V4 stated R2 should have been changed but they (CNA's) are busy. During this observation R3 was in bed in an adjacent room shouting for help. From the room doorway, surveyer observed R3 shouting and with dry brownish substance all over their fingers, hair, linens, side rails, side table, food tray and plates and foul strong urine and stool odor from the room. R3 was asking for help from the surveyor saying, please help me. The visitor for R3 who stated she was a friend from R3's church asked the surveyor and V4 whether there was staff who could have helped in cleaning R3 up, stating no one should be left like this. V4 stated they (CNAs) were all busy at this time and I (V4) will attend to R3 later. When asked in V4's professional opinion what can happen to a resident left in urine and stool without incontinent care in a timely manner, V4 stated that the resident can have skin impairment when left longer in the urine or stool. R2's medical record admission showed that R2 was a new admit of 08/12/24 with diagnosis that includes but not limited to Non-displaced fracture of base of neck of left femur, subsequent encounter for closed fracture with routine healing, Aftercare following joint replacement surgery, presence of left artificial hip joint, history of falling, generalized anxiety disorder, presence of artificial hip joint, Alzheimer's disease and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. R3's medical record admission record showed that R3 was admitted on [DATE] with diagnosis that includes but not limited to displaced bicondylar fracture of right tibia, subsequent encounter for closed fracture with routine healing, repeated falls, bilateral primary osteoarthritis of knee, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, unspecified glaucoma, and right knee pain. R3's medical record MDS (Minimum Data Set) facility assessment tool section GG documented that R3 is dependent on staff for personal hygiene, coded self-care: Toileting hygiene coded 01 dependent on staff, shower/bathe self-coded 01 dependent. Personal hygiene coded as 02 substantial/maximal assistance indicating that helper does more than half the effort. Transfer from chair to bed and bed to chair coded as 01 dependent indicating that helper does all the effort. Eating coded as 02 substantial/minimal assistance indicating that helper does more than half the effort. R3's plan of care for ADL's (Activities of Daily Living) initiated date 06/22/24 documented that R3 has an ADL self-care/mobility performance (functional abilities) deficit. Listed interventions include but not limited to toilet hygiene and toilet transfer with documentation that R3 usual performance is dependent (staff). The facility policy on Incontinence care with revised date 1/16/18 documented that the purpose is to prevent excoriation and skin breakdown, discomfort and maintain dignity. Guidelines documented that incontinent resident will be checked periodically in accordance with the assessed incontinent episodes or every two hours and provided perineal and genital care after each episode. Listed procedure includes assisting resident to a comfortable position and placed call light in reach.

Based on observation, interview, and record review the facility failed to ensure that the medication cart and treatment carts were locked when not in use and when not in visual proximity of the nurse to prevent tampering and accidental hazard. This failure has the potential to affect all the resident on the 1st, 2nd and 3rd floor of the facility. Findings include: On 08/14/24 at 11:24am, the 3rd floor medication cart was noted unlocked and not within the visual proximity of the V7 RN (Registered Nurse).cAt 11:25pm, V7 stated that the facility protocol/ policy is that the medication cart should be locked when not in use or when the nurse is not around to see the cart. At 11:35am, the nurse's station door was noted left wide open with a medication left unlocked and no nurse in attendance in the nursing station. When the surveyor brought this observation to V9's LPN (Licensed Practical Nurse) attention and asked about the facility policy/protocol on medication storage and medication cart, V9 stated that the medication should be stored in a locked medication cart. V9 stated I (V9) just went to answer the call light because the CNA (Certified Nurse's Aide) assigned to this side of the floor was on lunch break. V9 stated, I should have locked the cart for safety, so no one could get into it (referring to the medication cart). At 11:50am, the 1st floor nurse's station treatment cart was noted unlocked and not within the view of the nurse. When this observation was brought to V12's (RN) attention and shown the unlocked cart, V12 stated it is a treatment cart and it should be locked when not in use. V12 stated because he was not the treatment nurse, he did not notice that the cart was left unlocked. Both the surveyor and V12 opened the cart and V12 stated there were treatment medications in here and it should be locked to prevent patient and others from taking medication from the cart because only authorized persons should be opening the medication carts. At 12:20pm, V2 DON (Director of Nurses) stated that the medication cart and the treatment carts are to be locked when not within eyesight of the nurses. V2 stated the nurse's station door does not have any locks on them so when the medication cart is in the nurse's station they should be locked. V2 stated some of the nurses are new graduates and more in-services must be done to ensure that they understand the effects it might have on the resident's safety. V2 stated they follow their pharmacy policy on medication storage. The facility policy for Storage of medication with no revision date documented in part that medications and biologicals are stored safely, securely, and properly. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedures listed includes but not limited to medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access.

Based on observation, interview, and record review the facility failed to follow current standards of infection control practices on use of gloves. This failure has the potential to affect all the 24-resident residing on the 3rd floor of the facility. Findings include: On 08/14/24 at 11:22am, V7 RN (Registered Nurse) was observed on the 3rd floor walking around with gloved hands. V7 stated I was just trying to get to the nurse's station so I (V7) can take them off and wash my hands. When asked about the facility policy/protocol for infection prevention and control, V7 stated gloves are not to be worn in the hallways, I (V7) should have removed them after I (V7) used it. At 11:36am, surveyor noted R6 walk out of the isolation room and without hand hygiene went straight to the clean cart with supplies in the hallway touching the supplies and taking out supplies. When V9 LPN (Licensed Practical Nurse) was made aware of the observation. V9 stated that the clean cart is usually placed near the nurse's station. V9 stated R6 is on contact precaution isolation for MRSA in the right wound and should not be touching the general supplies for infection prevention and control. V9 stated R6 needs to be supervised. At 12:21pm, when V2 (Director of Nursing) was made aware of this observation and asked about the use of gloves policy and protocol. V2 stated that gloves should not be worn in the hallways, they should be changed after use, used gloves should be discarded at the door of the room when used and that resident in isolation contact should not be going into the clean linen cart / supplies cart. I (V2) will have to in-service on that. The facility policy on Proper Hand Washing and Glove use with no revised date documented under guidelines that all employees will use proper glove usage in accordance with State and Federal sanitation guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that the call light device was within reach for one resident (R114). This failure has the potential to affect one resident out of a sample size of 41 residents. Findings Include: R114 has a diagnosis of but not limited to Urinary Tract Infection, Paroxysmal Atrial Fibrillation, Depression, and Abnormalities of Gait. R114 has a Brief Interview of Mental Status score of 99. R114's Minimum Data Set, dated [DATE] documents Impairment on both sides for lower extremity. On 1/22/2024 at 10:58am surveyor observed R114 sitting in a chair that was across from his bed where the call light would not reach. Surveyor inquired if R114 could reach the call light and R114 said no. On 1/22/2024 at 11:01am V3 (RN) stated it (call light device) is here, but I don't think he (R114) can reach it and R114 does understand the purpose and how to use the call light. On 1/24/2024 at 1:25pm V2 (DON) stated the call light device should be anywhere the patient is and within their reach and the purpose of the call light device is for the resident to communicate their needs to staff. Care Plan focus: fall related to weakness, poor safety awareness dated 1/17/2024 documents place call bell/light within easy reach. Facility's policy: Answering the Call Light with a last reviewed date of 1/2017 documents, in part, when the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 1/22/24 at 10:43am, R9 was observed in bed, positioned on her right side, on a Low Air Loss (LAL) mattress. This surveyor observed the following layers of linen under R9's body on the LAL mattress: a flat sheet and a quadruple folded flat sheet. R9 was also wearing an incontinent brief which made a total of 6 layers under R9's body. On 1/22/24 at 11:18am, R9 was in her room being provided care by V18 (Registered Nurse, RN) and V34 (Certified Nursing Assistant, CNA). When V18 was asked how many layers of linen the nursing staff are to place on top of the LAL mattress (linens in between the top of the LAL mattress and the resident), V18 stated that only 1 layer of linen should be placed on top of the LAL mattress. When asked how many layers are on top of R9's LAL mattress, V18 stated that there are 6 layers including the incontinence brief. R9's admission Record documents, in part, R9's diagnoses including but not limited to: Alzheimer's disease, unspecified dementia, osteoporosis, essential (primary) hypertension and abnormal weight loss. R9's Minimum Data Set (MDS), dated [DATE], documents, in part, R9's Brief Interview for Mental Status (BIMS) score is 99, which indicates that R9 was unable to complete the interview. R9's Skin Conditions (section M) documents, in part, that R9's Skin and Ulcer/Injury Treatments include a pressure reducing device for bed. R9's Patient Risk Profile, dated 12/14/23, documents a Braden score of 12 which shows R9 is at high risk for developing a pressure ulcer injury. R9's Care Plan, with initiated on 10/2/22 with last review completed on 12/26/23, documents, in part, a focus of (R9) is at risk for skin breakdown related to impaired bed mobility and incontinence to bladder and bowel with an intervention of Provide alternating pressure mattress. R9's Order Summary Report documents, in part, an active order (dated 2/1/23) for Specialty Mattress: alternating pressure. R41 has an admission diagnosis of but not limited to dementia, atherosclerotic heart disease, vitamin B12 deficiency, vitamin D deficiency and hyperlipidemia. R41's functional status for mobility requires substantial/maximal assistance to roll left and right, sit to lying, and sit to stand. On 1/22/24 at 11:30 am, R41 was lying on an air loss mattress with multiple layers between R41 and the low air loss mattress. The layers observed under R41 consisted of a flat sheet, a flat sheet folded multiple times for a draw sheet that was positioned under R41's lower back and buttock, and an incontinent brief. On 1/22/24 at 11:40 am, V18 RN (Registered Nurse) stated that it should only be one layer on an air loss mattress. R41's (1/10/24) Skin and wound evaluation form documented in part, stage 2: Partial-thickness skin loss with exposed dermis, location left gluteus. Wound measurement area 1.5 cm (Centimeter), length 1.0 cm, width 1.5cm. R41's care plan documented in part, Focus: R41 has potential/actual impairment to skin integrity related to impaired physical mobility and incontinence .with an intervention of pressure relief mattress. Based on observations, interviews, and record reviews, the facility failed to ensure residents lying on a low air loss mattress were not over layered with sheets, incontinence briefs and/or pads for 2 residents (R9 and R41); and failed to ensure the low air loss mattress was set based on the resident weight for 1 resident (R23). These failures affected 3 (R9, R23, and R41) residents reviewed for prevention of pressure injury/ulcer in the total sample of 41 residents. Findings include: On 01/22/24 at 10:14am, R23 was lying on low air loss mattress. The setting was at 300 pounds. This observation was pointed out to V5 (Registered Nurse). V5 stated the setting is at 300lbs; the setting of the low air loss mattress is based on the resident's weight. I (V5) don't know why its set like that. On 01/23/2024 at 2:36pm, V37 (Treatment Nurse) stated the low air loss mattress is used to prevent pressure injury. The setting is always based on the resident's weight. We (facility) need to have the correct firmness of the mattress because if it is too firm, it will act as a regular mattress, defeating the purpose of the low air loss mattress. We (facility) definitely cannot make the setting 100lbs higher than the resident's weight. It will be too firm and may cause pressure injury. On 01/23/2024 at 2:41pm, V37 stated for resident using a low air loss mattress, there should be a flat sheet and a draw sheet. We don't recommend the use of a blanket as draw sheet because it is too thick and defeats the purpose of the low air loss mattress. If a resident is wearing an incontinence brief, we don't recommend the use of an incontinence pad; both cannot be used. Ideally, not recommending that because it is putting too much layers, which defeats the purpose of the low air loss mattress. A flat sheet, a draw sheet and incontinence brief or pad is okay. Use of fitted sheet on low air loss mattress prevents the low air loss mattress from inflating properly hence defeating the purpose of the low air loss mattress. R23's (Active Order As Of: 01/23/2024) Order Summary Report documented, in part Diagnoses: (include but not limited to) Alzheimer's disease, adult failure to thrive, and heart failure. R23's (12/03/2023) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 99. C0700. Short-term Memory OK. 1 Memory problem. C0800. Long-term Memory OK. 1. Memory problem. Section M. Skin Conditions. M0150. Risk of Pressure Ulcers/Injuries. Yes. M1200. Skin and Ulcer/ Injury Treatments. B. Pressure reducing device for bed. R23's (01/22/2024) weights and Vitals summary documented, in part 01/22/2024 weight 100 lbs. R23's (12/16/2023) Care Plan documented, in part Focus: is at risk for skin breakdown r/t (related to impaired bed mobility, incontinence, poor nutrition transfer and self-care deficit. Goal: The resident will maintain or develop clean and intact skin. Interventions: Maintain pressure relief mattress (LAL mattress). The (undated) Mattress Operation Manual documented, in part General. The system is designed for prevention, treatment, and management of pressure ulcers. the pump is a smart pump simple to operate and easy to use, constantly providing pressure redistribution and support patients. The system is intended to reduce the incidence of pressure ulcers while optimizing patient comfort. Pump Unit. Press minus or plus button to select the correct patient weight. Weight/Pressure set up. Users can adjust the air mattress to a desired firmness according to the patient's weight or the suggestion from a health care professional. The (undated) facility provided document 'Can you put a fitted sheet on a low air loss mattress? documented, in part Fitted sheets should not be used over low air loss mattress because they compress the air cell and restrict air flow. Thin knit or jersey material flat sheets should be used instead. The (6/28/23, 12/16/23, 1/19/24) In-Services Skin Care Preventions documented, in part Use of low air loss mattress. Use only flat sheet on top of mattress. No fitted sheet. PSI (pressure per square inch) setting must be adjusted to resident's weight.

Based on observations, interviews and record reviews, the facility failed to check and document the temperatures of residents' personal refrigerators daily and failed to maintain an appropriate temperature in a resident's personal refrigerator. These failures affected 3 (R10, R42 and R57) residents reviewed for personal food in the total sample of 41 residents. Findings include: On 01/22/24 at 10:20 AM, there was a refrigerator inside R10's room. This surveyor requested V5 (Registered Nurse) to check the refrigerator. V5 opened the refrigerator and checked the temperature and it stated temperature is 48F. Surveyor requested to check for temperature log, V5 checked for the temperature log and stated there is no temperature log. Inside R10's refrigerator were a tub of yogurt, cartons of milk and juice. On 01/22/24 at 10:36 AM, there was a refrigerator inside R57's room. This surveyor requested V5 to check the refrigerator. V5 stated the temperature is 42F. There are bottles of boost and soda. There is no temperature log. On 01/23/2024 at 3:04pm, V2 (Director of Nursing) stated we have to make sure the resident's food are safe. If the resident's personal refrigerator temperature is above 40F we have to address it with maintenance whether or not the refrigerator is functioning. Adjustment has to be made so the temperature is within the range. The expectation is to have the temperature within the acceptable range for the safety of the resident. Nursing should check the temperature and expired food items in the refrigerator daily. R10's (Active Order As Of: 01/23/2024) Order Summary Report documented, in part Diagnoses: (include but not limited to) hypertensive heart disease. R10's (11/24/2023) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating R10's mental status as cognitively intact. R57's (Active Order As Of: 01/22/2024) Order Summary Report documented, in part diagnoses (include but not limited to) COPD (chronic obstructive pulmonary disease) and unsteadiness on feet and need for assistance with personal care. R57's (10/22/2023) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 99. C0700. Short-term Memory OK. 1 Memory problem. C0800. Long-term Memory OK. 1. Memory problem. The (01/23/2024) Food Safety Requirement Policy and Procedure documented, in part It is the policy of this facility to provide safe and sanitary storage, handling, and consumption of all foods including those brought to residents by family and other visitors. Educate and inform. 8. Perishable food such as meat, poultry, fish and dairy products must be frozen or refrigerated immediately after receipt. 12. All refrigerators will be at/or below 41 degrees F (Fahrenheit). Refrigeration. A. a potential cause of foodborne illness is improper storage of PHF/TCS (Potentially Hazardous Food/Time/Temperature Control for Safety Food) food. Refrigerators including those in resident rooms must be in good repair and keep foods at or below 41 degrees F. b. Document the temperature of external and internal refrigerator gauge. Refrigerators must be 41 degrees or less. R42 has a diagnosis of but not limited to Acute and Chronic Respiratory, Bilateral Primary Osteoarthritis, Dysphagia, Oropharyngeal Phase, and Hypertension. R42 has a Brief Interview of Mental Status score of 11. On 1/22/2024 at 10:11am surveyor observed R42 without a temperature log for her personal refrigerator. On 1/22/2024 at 10:51am V4(RN) stated that we do not have logs for personal refrigerators.

Based on observation, interview, and record review, the facility failed to assess a resident's ability to safely self-administer medications and/or treatments. This failure affected 1 (R57) resident reviewed for self-administration of medication and has the potential to affect 7 ambulatory residents on the 2nd floor in the total sample of 41 residents. Findings include: The (undated) Ambulatory residents list on the 2nd floor documented that there were 7 ambulatory residents on the 2nd floor. On 01/22/24 at 10:36 AM, there was a tube of cortisone lotion in R57's room. This observation was pointed out to V5 (Registered Nurse). V5 stated I (V5) don't think she (R57) has an order to have the cortisone lotion at bedside. Let me (V5) check her (R57) record. On 01/22/24 at 10:43 AM, V5 stated I (V5) have her (R57) cortisone in the cart. I (V5) don't know why she (R57) has another cortisone lotion in her (R57) room. On 01/23/2024 at 3:02PM, V2 (Director of Nursing) stated there should be no medications at bedside for patient safety and facility safety. Medications used for treatment should be in the treatment cart. R57's (Active Order As Of: 01/22/2024) Order Summary Report documented, in part diagnoses (include but not limited to) COPD (chronic obstructive pulmonary disease) and unsteadiness on feet and need for assistance with personal care. Order Summary. Hydrocortisone External Cream 2.5% apply to under breast/skin folds topically as needed for skin flares or itchy area for 2 weeks twice a day. Of note, there was no order to keep at bedside. R57's (10/22/2023) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 99. C0700. Short-term Memory OK. 1 Memory problem. C0800. Long-term Memory OK. 1. Memory problem. The (undated) facility provided document indicated that R57 has no self-Administration (of medications) assessment. No care plan for self-administration (of medication) and R57 is not competent to do self-administration (of medication). The (1/2017) Self-Administration of Medications documented, in part Policy Statement: Residents in our facility who wish to self-administer their medication may do so, if it is determined that they are capable of doing so. Assessment for Self-Administration of Medications. 1. As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities, to determine whether a resident is capable of self-administering medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that four residents (R5 R6, R7, and R28) who depend on staff assistance for their ADL (Activities of Daily Living) care received shaving. This failure affected four of 41 residents reviewed for ADL care and shaving. Findings include: On 01/22/24 at 10:30 am, R5 was observed in R5's room in bed awake and alert with facial hair to R5's lip and chin. When R5 was asked regarding R5 being shaved at the facility, R5 stated, They (referring to staff) don't trust me with a razor, so they give me a razor whenever they are up to it. When R5 was asked regarding if R5 wanted to be shaved R5 stated, Well yes, if I (R5) had a razor. On 01/22/24 at 10:35 am, R28 was observed in R28's room in bed awake and alert with facial hair (beard) to R28's lip and chin. When R28 was asked regarding R28 being shaved at the facility, R28 stated, I (R28) do not know how long it's been since I've been shaved. They (referring to the staff) shave me whenever they feel like shaving me (R28). On 01/22/24 at 10:38 am, R7 was observed in R7's room in bed awake and alert ungroomed with facial hair unshaved. When R7 was asked regarding R7 being shaved at the facility, R7 stated, I (R7 have to wait for them (referring to staff) to shave me. On 01/22/24 at 10:52 am, R6 was observed in R6's room in bed awake and alert with facial hair (mustache) to R6's upper lip area. When R6 was asked regarding R6 being shaved at the facility, R6 stated, I (R6) am shaved when they (referring to staff) are able to do it. On 01/24/24 at 9:32 am, R5 was observed in room in bed awake and alert with facial hair to R5's lip and chin still visible. This observation was brought to V9 (Certified Nursing Assistant, CNA) and V9 stated, Yes, she (R5) needs to be shaved. I (V9) will do it today. When V9 was asked regarding shaving residents, V9 stated that the CNA's are responsible for shaving the residents at the facility as needed. V9 stated that it is important to shave the residents at the facility for the resident's dignity. On 01/24/24 at 9:40 am, R28 was observed in R28's room in bed awake and alert with facial hair (beard) to R28's lip and chin still visible. This observation was brought to V24 (CNA) and V24 stated, Yes, she (R28) needs shaving. When V24 was asked regarding shaving the residents at the facility, V24 stated that the CNA's are responsible for shaving the resident as needed. V24 stated that it is important to shave the residents at the facility to improve the resident's hygiene. On 01/24/24 at 9:42 am, R6 was observed in R6's room in bed awake and alert with facial hair (mustache) to R6's upper lip area still visible. This observation was brought to V7 (CNA) and V7 stated that the residents are shaved in the resident's beauty shop. V7 was asked the importance of ensuring the residents are shaved and V7 stated that V7 did not understand what the surveyor was asking. On 01/24/24 at 9:45 am, R7 was observed in R7's room in bed awake and alert ungroomed with facial hair still visible. This observation was brought to V24 (CNA) and V24 stated, He (R7) needs shaving. I (V24) will shave him today. On 01/24/24 at 9:46 am, V18 (Registered Nurse, RN) stated that the CNA's are responsible for shaving the residents. V18 explained that CNAs shave the residents whenever the residents get a shower and as needed. V18 stated that it is important for the residents to be shaved for the resident's self-esteem and dignity. On 01/24/24 at 9:54 am, V2 (Director of Nursing, DON) stated that shaving is done by the CNA's or nurses. V2 stated that shaving should be done at least weekly and as needed. V2 stated the importance of the residents being shaved is for infection control. V2 stated that it is important for the residents to be shaved for the resident's appearance and for the resident to follow the resident's normal routine. R5's Minimum Data Set (MDS) dated [DATE] shows that R5 requires setup or clean up assistance for personal hygiene. R5's has a Brief Interview for Mental Status (BIMS) score of 14 which indicates that R5 is cognitively intact. R5 has a diagnosis which includes but not limited to memory deficit following cerebral, hemiplegia and hemiparesis, chronic obstructive pulmonary, age-related osteoporosis, chronic kidney disease, essential hypertension, and vitamin D deficiency. R5's care plan dated 09/04/2022 documents, in part: Focus: R5 has Activities of Daily Living (ADL) and self-care performance deficit related to (r/t) activity intolerance and impaired mobility stroke . personal hygiene requires set up assistance. R6's MDS dated [DATE] shows that R6 requires partial/moderate assistance for personal hygiene. R6's BIMS shows that R6 has a BIMS score of 14 which indicates that R6 is cognitively intact. R6 has a diagnosis which includes but not limited to hypertensive heart disease, hyperlipidemia, lymphedema, unilateral primary osteoarthritis, spinal stenosis, dementia, and presence of urogenital. R6's care plan dated 09/10/22 documents, in part: Focus: R6 has impaired ADL and mobility self-care performance related to muscle weakness. Interventions: Evaluate resident ability to perform ADL/IADL (Activities of Daily Living/Instrumental Activities of Daily Living) . Provide assistance with ADL's/IADL as needed . Set-up items for personal hygiene. Allow R6 to complete as much as possible. Assist as needed. R7's MDS dated [DATE] shows that R7 requires partial/moderate assistance with personal hygiene. R7 has a BIMS score of 15 which indicates that R7 is cognitively intact. R7 has a diagnosis which includes but not limited to intervertebral disorder, major depressive disorder, mild cognitive impairment, personal history of traumatic, malignant neoplasm of prostate, abnormal posture, and history of falling. R7's care plan dated 12/06/23 documents, in part: Focus: R7 has a self-care deficit: Bathing, dressing, feeding related to weakness, confusion and unsteadiness . Interventions: Evaluate residents' ability to perform ADL/IADLs . ADLs as much as possible, bed mobility, transfer, walking, dressing, grooming and AROM (Active Range of Motion). R28's MDS dated [DATE] shows that R28 requires supervision or touching assistance. R28 has a BIMS score of 15 which indicates that R28 is cognitively intact. R28 has a diagnosis which includes but not limited to: hemiplegia and hemiparesis, paroxysmal atrial fibrillation, non-rheumatic aortic, type 2 diabetes mellitus, coronary angioplasty, chronic kidney disease, anemia, weakness, need for assistance and anxiety. R28's care plan dated 01/16/24 documents, in part: Focus: R28 has an ADL self-care performance deficit and impaired physical mobility due to weakness related to leg ulcers and multiple chronic illnesses including history of hemiplegia and hemiparesis due to CVA (Cerebral Vascular Accident). The facility's document dated 08/2021 and titled Supportive Activities of Daily Living (ADLs) documents, in part: Policy Statement: Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Policy Interpretation and Implementation: 1. Residents will be provided with care, treatment, and services to ensure that their activities of daily living (ADL) do not diminish unless the circumstances of their clinical condition (s) demonstrate that diminishing ADL are unavoidable. 2. A Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care).

Based on observation, interview and record review the facility failed to ensure medication carts are secured and locked while unattended. These failures have the potential to affect 46 residents residing on the second and third floors. Findings include: On 1/23/24 at 9:40am, with V33 (Registered Nurse, RN), during observation of medication pass the following was observed: Multiple employees and residents were seen passing by the medication cart while V33 was preparing medications to administer to R314. V33 stated that the medication cart contains all 21 resident's medications on the second floor. V33 went into R314's room to administer her (R314) medications and left the medication cart in the hallway, unlocked and unattended. While V33 was administering medications to R314, the medication cart was not visible to V33. When asked why the medication cart should be locked when unattended, V33 stated that anyone can come and open the medication cart. On 1/23/24 at 10:20am, with V4 (Registered Nurse, RN), during observation of medication pass the following was observed: Multiple employees and residents were seen passing by the medication cart while V4 was preparing medications to administer to R18. V4 stated that the medication cart contains all 25 resident's medications on the third floor. V4 went into R18's room to administer her (R18) medications and left the medication cart in the hallway, unlocked and unattended. While V4 was administering medications to R18, the medication cart was not visible to V4. When asked why the medication cart should be locked when unattended, V4 stated that the medication cart should have been locked when in the room because his (V4) back was turned away from the medication cart. On 1/23/24 at 2:16pm, V2 (Director of Nursing, DON) stated that medication carts should always be locked when the nurse is not within proximity to the cart. When asked if the medication cart should be locked if a nurse is in a resident's room and the medication cart is outside the resident's room, V2 stated Absolutely. V2 stated that the nurse should lock the medication cart whenever they are not looking at it. Facility presented policy titled, Administering Medications, with revised date of 4/19. This policy states in part: During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide.

Based on observations, interviews, and record reviews, the facility failed to ensure staff donned and doffed appropriate PPE (personal protective equipment) prior to entering and before exiting Droplet and Contact Precaution rooms in an effort to prevent the spread of infectious microorganism including COVID-19. This failure affected 2 (R4 and R30) residents reviewed for communicable disease and have the potential to affect all 25 residents on the 3rd floor. Findings include: The (01/22/2024) facility census documented that there were 25 residents on 3rd floor. On 01/22/2024 at 1:04pm, there was a sign posted by R30's door Droplet & Contact Precautions. V6 (Housekeeping) was wearing a surgical mask and gloves. V6 entered R30's room without donning gown and Face shield, wiped R30's bathroom; exited R30's room without doffing the gloves, got the mop from the housekeeping cart and reentered R30's room without changing gloves, and without donning gown, N95 mask and Face shield. V6 mopped R30's bathroom and floor; exited R30's room without doffing gloves, placed mop head in the bucket. These observations were pointed out to V4 (Registered Nurse). V4 stated he (V6) is supposed to wear proper PPE before entering (R30)'s room because R30 is still on isolation. He (V6) should be donning N95, gown and Face shield and take these off upon exit of the room to avoid or minimize the spread of virus; trying to contain the virus. This surveyor inquired about appropriate use of PPE (personal protective equipment). V6 stated I (V6) don't speak English. On 01/22/2024 at 1:17pm, there was a sign posted by R4's door Droplet & contact Precautions. V6 donned gloves and donned N95 mask on top of a regular mask, took a piece of paper towel from the housekeeping cart and entered R4's room without donning gown and Face shield. At this time, V8 (Registered Nurse) came, and this surveyor pointed out to V8 that V6 entered R4's room without donning appropriate PPE. V8 stated he (V6) should have gown, Face shield, hair restraint and socks. He (V6) should not be wearing the N95 on top of a regular mask. On 01/22/2024 at 1:20pm, V4 (Registered Nurse) stated today is her (R30) 10th day on isolation and she (R30) is off isolation tomorrow. On 01/23/24 11:28 AM, V14 (Infection Preventionist) stated it is expected of staff to wear proper PPE when entering a resident room on covid isolation. Staff should don N95 mask, Face shield, gown and gloves. Before exiting, staff should remove gloves, gown, and the N95 mask replaced with surgical mask. As for the Face shield, it has to be disinfected with Microkill. The importance of donning and doffing of PPE appropriately is to minimize the spread of Covid-19. It also protects the staff and other residents. They are expected to follow the sign by the resident's door and the sign also make's them aware of who are on isolation. He (V6) is assigned to work on 3rd floor. R4's (Active Order As Of: 01/23/2024) Order Summary Report documented, in part Diagnoses: (include but not limited to) abnormal finding of lung field and acute respiratory failure with hypoxia. Order Summary: Contact and droplet precautions every shift for Covid-19 for 10 days. Start date: 01/15/2024. End Date: 01/25/2024. R4's (10/29/2023) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 12. Indicating R4's mental status as moderately impaired. R4's (1/15/2024) COVID-19 Consent for Testing & Results form documented, in part Result: positive. R4's (01/15/2024) Care Plan documented, in part Focus: (R4) turned COVID+ per Rapid test done on 1/15/24. Goal: will not have severe outcomes like hospitalization or death through the course of illness which may last for several weeks or earlier to some individuals. Interventions: Keep on STRICT ISOLATION (CONTACT / DROPLET) x 10 days (1/15/24 - 1/25/24) Read isolation precaution protocol posted by the resident's room which includes but not limited to: *Wearing full PPE when entering the room - discarding gloves. R30's (Active Order As Of: 01/23/2024) documented, in part Diagnoses: (include but not limited to) personal history of Covid-19 and chronic obstructive pulmonary disease. R30's (12/24/2023) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 06. Indicating R30's mental status as severely impaired. R30's (1/12/24) Covid-19 Consent for Testing & Results Form documented, in part Result: Positive. R30's (01/23/2024) Care Plan documented, in part Focus: Resident turned COVID positive on 1/12/24. Goal: will not have severe outcomes like hospitalization or death through the course of illness which may last for several weeks or earlier to some individuals. Interventions: Keep on STRICT ISOLATION (CONTACT / DROPLET) x 10 days (1/12/24 - 1/22/24) Read isolation precaution protocol posted by the resident's room which includes but not limited to: Wearing full PPE when entering the room - discarding gloves. The (1/22/2024) Isolation Tracking documented, in part Name: (R4). Isolation Precaution: Contact and Droplet. Reason: Covid Positive. Start Date: 1/15/2024. Stop Date: 1/25/2024. Name: (R30). Isolation Precaution: Contact and Droplet. Reason: Covid Positive. Start Date: 1/12/2024. Stop Date: 1/22/2024. The (undated) Droplet & Contact Precautions sign documented, in part Staff: Required: Gown & Gloves. Procedure mask with eye protection. The (1/2024) Coronavirus Disease (COVID-19) Infection Prevention and Control Measures documented, in part Policy Statement: This facility follows commended standard and transmission-based precautions, environmental cleaning and social distancing practices to prevent the transmission of COVID-19 within the facility. Policy Interpretation and Implementations. 2. While in the building, personnel are required to strictly adhere to established infection prevention and control policies, including: c. Appropriate use of PPE (personal protective equipment). d. Transmission-based precautions, where indicated. Personal Protective Equipment. Residents with Suspected or Confirmed Covid-19 Infection. HCP (healthcare personnel) who enter the room of a resident with suspected or confirmed SARS-CoV-2 infection should adhere to Standard precautions including Transmission-Based Precautions and use of NIOSH approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (goggles or Face shield that covers the front and sides of the face). PPE including N95 should be discarded and new applied between each resident encounter. The (04/2013) Isolation - Categories of Transmission-Based Precautions documented, in part Transmission-based precautions shall be used when caring for residents who are documented or suspected to have communicable diseases or infection that can be transmitted to others. Contact Precautions. Gloves and Hand Washing During Contact Precautions. C. Gloves and Handwashing. 1. Wear gloves when entering the room. 3. Remove gloves before leaving the room and perform hand hygiene. Gowns during Contact precautions. D. Gown. 1. Wear disposable gown upon entering. 2. After removing the gown, do not allow clothing to contact potentially contaminated environmental surfaces. Droplet Precaution. Mask During Droplet Precautions. C. Mask. 1. Put on mask when entering the room or cubicle.

Based on observation, interview, and record review the facility failed to accurately log dish machine temperatures. This failure has the potential to affect all 66 residents who receive oral nutrition in the facility. Findings include: On 1/22/24 at 10:00 am surveyor reviewed the dishwashing temperature log with V26 (Dietary Manager) and observed lunch temperature prefilled with a temperature of 165 (wash) and dinner temperature prefilled with a temperature of 185 (final). Prefilled temperature for 1/23/24 for dinner 165 (wash) and 185 (final). Prefilled temperature for 1/24/24 for dinner 185 (wash) and 185 (final). On 1/22/24 at 10:15 am, Surveyor inquired to V26 (Dietary Director) why is temperatures recorded on the log for lunch and dinner for 1/22/24, 1/23/23; and 1/24/24 for dinner? V26 stated that the log sheet should be filled out after the wash cycle and final rinse is complete. I do not know why it was already filled out. On 1/22/24 at 10:20 am, Surveyor inquired to V29 (Dishwasher), why was lunch and dinner prefilled on the dishwashing temperature log? V29 (Dishwasher) stated, I made a mistake prefilling the temperature log sheet. V29 stated that the dinner temperatures were filled out by the other dishwasher. On 1/22/24 at 3:00 pm, V28 (Dishwasher) stated, I (V28) was trained to put the temperatures on the log sheet because it's always 165. Surveyor inquired to V28 how long has V28 been working in the facility? V28 stated, I've been here for 6 years. I put the temperatures on the sheet for whoever is going to be working. On 1/24/24 at 12:26 pm, V26 (Dietary Director) stated that an in-service was done with staff on recording dish washer temperatures. V26 stated that the staff cannot do a temperature ahead of time because it can compromise the health of the residents if the temperatures is not above 150 degrees. The machine has to run five or six times before it is safe to start washing the dishes. Surveyor inquired to V26 if the wash temperature is always 165, which is documented on the dishwashing temperature log sheet from January 11th to January 22nd for Breakfast, lunch, and dinner? V26 stated that the temperatures are not always 165 and the temperatures should change. Facility Job description (6/2021) titled, Director of Dining Service, documents, in part, Essential Job Functions: Check to make sure that daily cleaning and documentation is being completed as required. Facility Job description (6/2021) titled, Dishwasher, documents, in part, Essential Job Functions: Monitor dishwasher temperatures. Perform daily temperature monitoring and document as required. Facility Policy titled Mechanical Cleaning and Sanitizing, Undated, documents in part, Procedure: High Temperature Dishwashers; Dish machines using hot water for sanitizing may be used if the temperature of the wash water is no less than that specified by the manufacturer, which may vary from 150 degrees Fahrenheit to 165 degrees Fahrenheit, depending on the type of machine and if the final rinse temperature is no less than 180 degrees Fahrenheit.

Based on observations, interviews, and record reviews, the facility failed to provide an accurate person-centered care plan for ADL (Activities of Daily Living) related to transfers for 2 out of 19 residents reviewed for accuracy of care plan. This failure has the potential for facility staff to follow incorrect care plan interventions related to transfers. Findings include: On 03/14/2023 at 11:17 AM, R63 was found inside the shower room with V10 (Certified Nursing Assistant/Agency) transferring R63 with a sit to stand lift. After elevating the lift on a high position with the resident suspended and only the sling attached to R63 giving support of R63's full weight, the lift stopped working. V10 went to the door with her head outside of the door looking side to side for staff but was not able to find any of the staff. Then V10 went back to R63 who was complaining of pain on his arms. V10 took the remote control of the lift, but no matter how many times V10 pushed the button to make R63 move down, the lift does not respond. Writer then went to the Nurse's Station and informed V11 (Registered Nurse) that there was a resident hanging on the lift inside the shower room. V11 nodded but did not go to the shower room. V12 (Restorative Aide) finally went to the shower room. Again, V11 was informed by writer. V11 said, I did not come because I thought V12 was already responding to you. Now with V11, V12 and V10 in the shower room, V12 manually maneuvered to take off both arms of R63 who was expressing pain. V12 then said, The lift is plugged, once it is plugged it will be in a charging mode and will not perform. It only works when it is in a battery mode and unplugged. V12 said, When transferring a resident with a lift, any kind of lift, it must be performed by at least 2 persons. V12 was informed that R11 was seen earlier with V13 (Certified Nursing Assistant) about to transfer R11 with Hoyer lift.; and that no other staff was present except V13. V12 said, Sometimes staff will prepare a resident for transferring and call for help when resident is ready to be transferred. V12 was then requested to go to R11's room to check if R11 was being safely transferred by V13 with another staff assisting. On 03/14/2023 at 11:33 AM, upon entering the room, R11 was already transferred by V13 (Certified Nursing Assistant) with Hoyer lift without any other staff present. V12 said, Again, as I said earlier. All lifts must be performed for transferring a resident with at least 2 persons. V13 said, I transferred R11 by myself because all other CNAs (Certified Nursing Assistant) are busy doing other residents. But I agree, safety of the resident is more important than doing my job fast. Next time I will wait for help. On 03/16/2023 at 11:20 AM, V16 (MDS Coordinator/Restorative Supervisor) said, Yes, there is an inconsistency with both R63 and R11's care plans on ADLs (Activity of Daily Living) specific to transfers. It should be documented as 2 persons assist because MDS assessment under functional status coded 2-person extensive assist on transfer. Fall care plan is correct because it documents 2-person assist during transfer. R63 and R11 both need full assistance during transfers. This may be caused by change of electronic health record system; but I can manually change interventions in the care plan. Both (R63 and R11) are using lifts. When using mechanical lift like sit-to-stand or Hoyer lifts there must be 2 persons doing the transfer. One person maneuvering the resident, and the other person operating the lift. The reason is for safety of resident to avoid or prevent fall. On 03/16/2023 at 01:23 PM. V18 (Rehab Manager / Physical Therapist) said, Yes, any mechanical lift use must be performed by 2 persons. R63 declined and on bed bound status, same as R11. We do not transfer residents, it is the nurses who does transferring. Fall Care Plans: Both R63 and R11's plan of care on fall intervention, read in part that during transfer using lift there must be 2-persons performing the transfers. ADL (Activity for Daily Living) on transfer under interventions, in part reads: Transfer with 1 person assist.

Based on observations, interviews, and record reviews, the facility failed to follow their safety protocols on transfers of 2 out of 4 residents (R63 and R11) of the the total sample of 19 residents reviewed for hazard and accidents transferring 2 residents with mechanical lifts (sit-to-stand and Hoyer) with only 1 person performing the transfers. These failures have resulted in 1 resident (R63) hanging suspended on the sit-to-stand lift complaining of pain; and another resident (R11) having the potential for fall. Findings include: On 03/14/2023 at 11:17 AM, R63 was found inside the shower room with V10 (Certified Nursing Assistant/Agency) transferring R63 with a sit to stand lift. After elevating the lift on a high position with the resident suspended and only the sling attached to R63 giving support of R63's full weight, the lift stopped working. V10 went to the door with her head outside of the door looking side to side for staff but was not able to find any of the staff. Then V10 went back to R63 who was complaining of pain on his arms. V10 took the remote control of the lift, but no matter how many times V10 pushed the button to make R63 down, the lift does not respond. Writer then went to the Nurse's Station and informed V11 (Registered Nurse) that there was a resident hanging on the lift inside the shower room. V11 nodded but did not go to the shower room. V12 (Restorative Aide) finally went to the shower room. Again, V11 was informed by writer. V11 said, I did not come because I thought V12 was already responding to you. Now with V11, V12 and V10 in the shower room, V12 manually maneuvered to take off both arms of R63 who was expressing pain. V12 then said, The lift is plugged, once it is plugged it will be in a charging mode and will not perform. It only works when it is in a battery mode and unplugged. V12 said, When transferring a resident with a lift, any kind of lift it, must be performed by at least 2 persons. V12 was informed that R11 was seen earlier with V13 (Certified Nursing Assistant) about to transfer R11 with Hoyer lift; and that no other staff was present except V13. V12 said, Sometimes staff will prepare resident for transferring and call for help when resident is ready to be transferred. V12 was then requested to go to R11's room to check if R11 was being safely transferred by V13 with another staff assisting. On 03/14/2023 at 11:33 AM, upon entering the room, R11 was already transferred by V13 (Certified Nursing Assistant) with Hoyer lift without any staff present. V12 said, Again, as I said earlier, all lifts must be performed for transferring resident with at least 2 persons. V13 said, I transferred R11 by myself because all other CNAs (Certified Nursing Assistant) are busy doing other residents. But I agree, safety of the resident is more important that doing my job fast. Next time I will wait for help. On 03/15/2023 at 02:56 PM. V2 (Director of Nursing) said, Best practice when using mechanical lift in transferring resident; whether Sit to Stand or Hoyer lifts must be 2 or more persons. That is for the safety of the resident. It depends on the situation, personal opinion, 2-person should be the correct way to transfer resident with a lift. After submitting the policy for Safe Lifting and Movement of Residents, V2 said, Yes, it does not show that at least 2 persons needs to be during transfers with equipment. But it's in an old policy and we will review, and are in the process of modifying the policy that I will provide to you soon. On 03/16/2023 at 11:20 AM. V16 (MDS Coordinator / Restorative Supervisor) said, When using mechanical lifts like sit-to-stand or Hoyer lifts there must be 2 persons doing the transfer. One person maneuvering the resident, and the other person operating the lift. The reason is for safety of resident to avoid or prevent fall. On 03/16/2023 at 01:23 PM. V18 (Rehab Manager / Physical Therapist) said, Yes, any mechanical lift use must be performed by 2 persons. R63 declined and on bed bound status, same as R11. We do not transfer residents, it is the nurses who does transferring. Fall Care Plans: Both R63 and R11's plan of care on fall intervention, read in part that during transfer using lift there must be 2-persons performing the transfers. Safe Lifting and Movement of Residents Policy dated as updated 03/2023, in part reads: To protect the safety and well-being of staff and residents, and to promote quality of care, this uses appropriate techniques and devices to lift and move residents. Under Use of Mechanical Lifting Devices, mechanical lifting devices such as Hoyer lift or Sit to Stand Device shall be used for heavy lifting, including lifting, and moving residents, when necessary, Check battery if fully charged before using it. There must be at least 2 persons when using lifts

Based on observation, interview and record review, the facility failed to follow their policy to account for the correct number of narcotics in the residents individual controlled substance record for 1 (R67) out of 3 residents reviewed for pharmaceutical services in a sample of 19. Findings include: On 03/15/23 at 11:38 AM, surveyor counted narcotics with V11 (Registered Nurse) on the 3rd floor medication cart. While counting with V11, R67's Lorazepam every 4 hours as needed pill box has 14 pills and 32 pills in R67's Lorazepam every 6 hours scheduled pill box. On 03/15/2023 at 11:39 AM, surveyor reviewed the Individual control substance record for R67's Lorazepam with V11. R67's Narcotics Individual Controlled Substance Record for Lorazepam PRN Q4 PRN (every 4 hours as needed) documents in part: 2/16 amount remaining 19. 2/17 amount remaining 18 with no nurse's signature. 2/18 amount remaining 1 with V11's signature. R67's Narcotics Individual Controlled Substance Record for Lorazepam scheduled Q6 (every 6 hours) documents in part: 3/15 amount remaining 30 pills remaining. On 03/14/2023 at 11:40 AM, V11 (Registered Nurse) stated that he (V11) will figure out what happened to the medications. On 03/15/2023 at 12:00 PM, V11 stated, What might have happened is that, when they gave the scheduled every 6 hours Lorazepam, the nurse might have given the lorazepam from the every 4 hours as needed pill box and not the scheduled. So, I (V11) moved two pills from R67's every 6 hours scheduled lorazepam pill box to R67's every 4 hours as needed pill box making the count 16. The nurse who gave the medication to R67 was V33 (Registered Nurse) On 03/15/2023 at 12:02 PM, surveyor again reviewed R67's Narcotics Individual Controlled Substance Record for Lorazepam PRN Q4 with V11. R67's Narcotics Individual Controlled Substance Record for Lorazepam PRN Q4 this time documents in part: 2/17, 12 PM, 0.5 pill given, V33's signature, remaining count 18. 3/13, amount given: wasted, amount remaining: 16. On 03/15/2023 at 12:03 PM, surveyor asked V11, How did this signature get here when it wasn't there before? V11 responded, I (V11) went downstairs and have V33 sign R67's Narcotics Individual Controlled Substance Record for Lorazepam PRN Q4. V11 stated the nurse should sign the Narcotics Individual Controlled Substance Record the moment the medication is administered and not back dating. V11 also stated that he (V11) did not accurately document administration when he (V11) gave the Lorazepam on the 2/18. On 03/15/2023 at 12:05 PM, surveyor asked V11, Don't you do narcotic count in the morning at the start of your shift? V11 stated, I (V11) do but I did not count accurately and catch this discrepancy. On 03/15/2023 AT 2:24 PM V2 (Director of Nursing) stated, I (V2) expect them to do the narcotic count at the beginning of the shift and at the end. Every time they give a narcotic, the nurse who administered it, needs to sign it out. If they do not give a medication, they should not sign it. Narcotics in the fridge such as morphine should be double locked. If it has a potential for somebody to break in the refrigerator and remove and abuse the medication. V2 stated, No one mentioned to me (V2) about any narcotic discrepancy. On 03/16/2023 at 11:00 AM, V33 (Registered Nurse) stated that she (V33) was the nurse who gave R67 her (R67) medication. V33 stated she (V33) did not sign the R67's MAR and forgot to sign R67's Narcotics Individual Controlled Substance Record for the scheduled every 6 hours Lorazepam, the day she (V33) gave R67 the Lorazepam. On 03/16/2023 at 12:00 PM, V3 (Assistant Director of Nursing/Infection Preventionist) stated that the correct and expected documentation of medication administration is that only the nurse who administers the medication should sign off on the MAR and the Narcotics Individual Controlled Substance Record. R67's Medication Administration Record for 02/2023 documents in part: Lorazepam Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth every 6 hours, 2/17/2023, 1 pill administered by V11. Facility's Documentation of Medication Administration policy (1/2017) documents in part: Administration of medication must be documented immediately after it is given. Documentation must include as a minimum: Signature and title of the person administering the medication, date and time of administration. Facility's Controlled Substances policy (8/2021) documents in part: An individual resident-controlled substance record must be made for each resident who will be receiving a controlled substance. This record must contain signature of nurse administering medication. Nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services.

Based on observation, interview, and record review, the facility failed to follow their policy to ensure the narcotics in the refrigerator are stored in a separate locked container separate from any non-controlled medications for 2 medication refrigerators reviewed for medication storage and labeling. Findings include: On 03/15/2023 at 12:25 PM, surveyor observed and reviewed the 4th floor refrigerator with medications. Surveyor observed the medication refrigerator is in the nurse's station where the nurse sits to document. There is no locked door to go into the nurse's station. Surveyor found liquid lorazepam, and liquid morphine, not in a separate lock box, and with all other medications such as insulin. There was an empty separate brown lock box was broken and not locking. On 03/15/2023 at 12:27 PM, V34 (Registered Nurse) stated that he (V34) is the nurse for all of the 4th floor. V34 stated there is no separate locked medication room. V34 stated the refrigerator is next to them where the nurse sits in the nurse's station. V34 stated the narcotics should be behind a double lock separate from all other non-controlled medications. V34 stated this is important so no one removes and abuses the narcotics. On 03/16/2023 at 10:07 AM, surveyor observed and reviewed the 3rd floor refrigerator with medications. Surveyor observed the refrigerator is in the nurse's station where the nurse sits to document. There is no locked door to go into the nurse's station. Surveyor found liquid lorazepam, and liquid morphine, not in a separate lock box, and with all other medications such as insulin. On 03/16/2023 at 10:08 AM, V11 stated he (V11) is the nurse for all of the residents on the 3rd floor. V11 stated there is no separate locked medication room. V11 stated the narcotics should be behind a double lock separate from all other non-controlled medications. On 03/15/2023 AT 2:24 PM V2 (Director of Nursing) stated, Narcotics in the fridge such as morphine should be double locked; if it has a potential for somebody to break in the refrigerator and remove and abuse the medication. Facility's controlled substance policy (8/2021) documents in part: Controlled substances must be stored in the medication room in a locked container, separate from containers for any non-controlled medications. This container must remain locked at all times, except when it is accessed to obtain medications for residents.

Based on observation, interview, and record review, the facility failed to ensure the kitchen was free of expired food products and failed to ensure the kitchen was free from potential contamination. These failures have the potential to effect 71 residents that take food by mouth of 72 residents residing in the facility. Findings include: On 3/14/23, Surveyor observed an opened bag of frozen french fries in a freezer with a manufacturer expiration date of 8/4/22 and an opened date of 1/29/23 written on the bag by staff. On 3/14/23, Surveyor observed 4 containers of basil pesto in a freezer with manufacturer best by date of 1/7/23. On 3/14/23, Surveyor observed 6 plastic containers of jellied cranberry sauce in the dry storage area with manufacturer expiration date of 5/8/21. On 3/14/23 at 10:15 AM, V35 (Dining Service Director) stated Staff should check the expiration dates before opening items. On 3/14/23, Surveyor observed V37 (Field Tech with pest control) enter the kitchen dishwasher area with mask worn below the chin, not covering mouth or nose, and wearing a winter skull hat. V37 was talking on the telephone. V37 was not wearing gloves or a hairnet. V37 opened a pest control box located under the dishwasher countertop area. V37 then leaned over cleaned silverware while continuing to talk on the telephone with mask worn below the chin, not covering mouth or nose. On 3/14/23 at 10:30 AM, V37 stated that V37 checked in at the front desk, not with anyone in the kitchen. V37 stated that V37 was not instructed to wash hands. V37 stated that V37 did not wash hands when V37 entered the kitchen area. On 3/14/23 at 10:35 AM, V35 (Dining Service Director) stated that V37 should have checked in with kitchen staff, should have had a mask on correctly and should have washed hands. V35 stated that by not doing that, there is a possibility for contamination in the kitchen. On 3/16/23 at 10:45 AM, V36 (Cook) stated We can't have expired foods. Spoiled food can harm the residents. They could get food poisoning. A lot of residents have low immune systems and if they are served spoiled food, they can get more sick. Kitchen staff and anyone else in the kitchen should wear a mask, hairnet, and wash hands so they don't bring in contamination. If the kitchen and food is contaminated, residents can get sick. Facility policy Labeling and Dating Foods, 2010, reads in part: A manufacturer's expiration date will be honored first. Potentially hazardous foods that contain a Sell by date, such as cottage cheese, milk, soft cheeses, non-cured deli-meats will be labeled with the date it is opened and a use by date which is either the 6th day it is opened or the Sell by date, whichever is sooner. Commercially processed foods that have been prepared and packaged by a food processing plant will be labeled with the date it is opened. This will be discarded either on the 6th day or the Best Used By date. Facility policy Hand Washing, 2010, reads in part: Dietary employees will practice safe food handling to prevent foodborne illness. Dietary employees will thoroughly wash their hands and exposed areas of their arms with soap and water at the following times: 1. Upon entering the kitchen at the beginning of the shift. Facility policy Hair Restraints/Jewelry/Nail Polish, 2010, reads in part: Hairnets will be worn at all times in the kitchen. [NAME] guards or masks will be worn as indicated if needed. Facility policy Personal Protective Equipment - Using Face Masks - Level 1, last reviewed 8/2021, reads in part: Purpose To guide the use of masks. Objectives 1. To prevent transmission of infectious agents through the air.

Based on observation, interviews, and record reviews, the facility failed to follow the Covid-19 Vaccine Policy for Staff by not including in the Staff Matrix multiple Certified Nursing Assistants vaccination status working through agency agreement performing direct care to residents. These failures have the potential to affect 72 residents living in the facility in preventing the risk of Covid-19 infections. Findings include: On 03/15/2023 at 11:58 AM, V3 (Infection Preventionist / Assistant Director of Nursing) submitted a Matrix for staff vaccination status. V3 was asked if all staff performing direct care to residents are included on the Matrix? V3 said, Yes, all staff are included. Therapist that are working with residents are on the last part. Upon full review of the Matrix there was no Nursing Staff that was working directly with the residents listed on the Matrix. V3 was asked about the lack of nursing staff from the agency working on the floor? And that on 03/14/2023 V10 (Certified Nursing Assistant / Agency) was seen working direct care to residents. V13 said, Oh, I missed it. I will make sure for future monitoring to include all agency staff working direct care with residents to be included on the Matrix. Facility had an outbreak last January this year (2023), but I don't think it was related to agency nursing staff performing direct care not being monitored. Under the Matrix of Facility there are 161 staff (including employed and agency therapist staff). Two (2) staffs have exemption, which resulted to 98.75%. Matrix did not include Certified Nursing Assistants (CNA) that agency was providing. On the schedule that facility provided (3/12/2023 to 3/18/2023) there were multiple CNAs from the agency working on all floors and all shifts performing direct care V10, V18, V19, V20, V21, V22, V23, V24, V25, V26, V27, V28, V29, V30, and V31. Facility also submitted a list of Covid-19 Positive for both residents and staff for the month of January 2023 with 16 persons (residents and staffs) combined. Covid-19 Vaccine Policy of facility dated 01/2023 as updated, in part reads: It is the policy of the facility that all (100%) facility staff, regardless of clinical responsibility or resident contact must receive the first dose of a two-dose Covid-19 vaccine or one-dose Covid-19 vaccine prior to providing any care, treatment, or other facility services. All staff who are fully vaccinated are recommended to receive a Covid-19 booster. Facility Staff and Staff refers to individual who provide any care, treatment, or other services for the facility and/or residents, employees including: - Individuals who provided care, treatment, or other services for the facility and/or its residents, under contract or by other arrangement.