2. R4's admission diagnoses include but not limited to obstructive and reflux uropathy, hydronephrosis with renal and urethral calculous obstruction, benign prostatic hyperplasia of lower urinary tract and urine retention. R4 Minimal Data Set documents in part, Section C. Brief Interview of Mental Status (BIMS) score of 14 indicating R4 is cognitively intact. Section H. Appliances: A. Indwelling catheter Yes. On 8/11/24 at 10:47 am, R4's indwelling catheter drainage bag was hanging on the bed frame facing the entrance of the doorway in a clear plastic bag not in a privacy bag. R4's POS (Physician Order Set) documents in part, Catheter (Foley Catheter) size 16 FR (French) with balloon of 10 ml (Milliliter) for urinary retention. R4's Care plan documents in part, Focus: R4 has an Indwelling Catheter due to Obstructive Uropathy. On 8/11/24 at 10:49 am, V11 RN (Registered Nurse) stated that the urinary bag should be covered in a blue bag. I (V11) do not remember the name of the bag, to promote dignity and privacy for the resident. On 8/13/24 at 1:30 pm, V3 RN stated that a privacy bag should be on the urinary drainage bag. The urinary drainage bag should be covered to promote residents' dignity and privacy. Facility policy titled Catheter Care dated 3/7/23, documented in part, Purpose: To prevent infection and maintain resident comfort and dignity. General Guidelines: 10. Maintained drainage bag inside of a privacy bag on bed frame whenever possible. Based on observation, interview and record review, the facility failed to ensure that a indwelling catheter drainage bag was covered in a privacy bag. This failure affected two residents (R4 and R33) reviewed for privacy and dignity in the sample of 34 residents. Findings include: 1. On 08/11/2024 at 10:34 am, R33 was observed in bed resting with R33's indwelling catheter hanging on the lower part of R33's bed, facing the entrance of the doorway, and without a drainage bag cover. On 08/11/2024 at 12:50 pm, surveyor inquired about the R33's indwelling catheter drainage bag with V3 (Registered Nurse, RN, Nursing Supervisor) and V3 stated, Indwelling catheters should be dated with a date of insertion and placed in a privacy bag. When V3 was asked regarding the importance of indwelling catheters being placed inside of a indwelling catheter privacy bag, V3 stated for infection prevention and for the dignity of the resident. R33's face sheet shows that R33 has a diagnosis which includes but not limited neuromuscular dysfunction of bladder, acute and chronic respiratory failure with hypoxia, pressure ulcer of the sacral region stage 4, and Alzheimer's disease. R33's Brief Interview for Mental Status (BIMS) dated 07/30/24 does not document a BIMS score for R33 and indicates that R33 has memory problems. R33 was not able to answer questions asked by surveyor. R33's physician order sheet (POS) dated 08/07/24 shows that R33 has orders for record catheter output every shift; catheter care change indwelling catheter once a month and PRN (as needed) every night shift starting on the third and ending on the 3rd every month. R33's care plan dated 08/07/24 documents in part: Focus: (R33) has a indwelling catheter . Intervention/Tasks: Catheter : R33 have a FR (French) 16 catheter. Position, catheter bag and tubing below the level of the bladder and away from entrance room door. The facility's undated policy and titled Resident Rights and Dignity documents, in part Policy: Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Policy interpretation and Implementation: 11. Standards of care practices that may compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by: a. Helping the resident to keep urinary catheter bags covered discreetly. The facility's policy dated 03/07/2023 and titled Catheter Care documents, in part: Policy: It is the policy of the facility that each resident residing in the facility with a urinary catheter will receive catheter care every shift and as needed. Procedure: General Guidelines: 10. Maintain drainage bag inside of a privacy bag on the bed frame whenever possible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide ADL (Activity of Daily Living) care for one dependent resident (R23) to maintain personal hygiene and dignity. This failure affected one resident (R23) out of a sample size of 34. Finding include: R23 has a diagnosis of but not limited to Multiple Sclerosis, Type 2 Diabetes Mellitus, Chronic Diastolic Heart Failure, Hypertensive Heart Disease with Heart Failure and Muscle Weakness. Progress noted dated 8/12/2024 at 3:51pm by V26 (Director of Social Services) documents R23 has a Brief Interview of Mental Status score of 06. On 8/11/2024 at 10:56am surveyor observed R23's fingernails on her right hand to have a black substance under the nails. Surveyor also observed R23 scratching her head several times while interviewing R23. On 8/11/2024 at 11:17am stated that her fingernails are dirty because she has not had her hair washed in at least a month and she has been scratching her head and scalp. R23 said, Of course I would like a shower, my hair washed, and fingernails cleaned and that the itchy scalp annoys the hell out of her. On 8/11/2024 at 2:49pm V7 (Registered Nurse-RN) stated that residents receive showers at least twice a week and as needed by the CNA's. On 8/12/2024 at 10:23am V27 (RN) stated showers are offered at least once a week and if a resident refuses a shower then they will get a bed bath and hair washing depends on the resident. On 8/12/2024 at 1:41pm V3 (RN/Nursing Supervisor) stated nail care, is the responsibility of the CNA and can be provided on shower days and as needed. V3 stated that it is expected that resident fingernails are cleaned and there is no visible dirt underneath the fingernails. R23's Minimum Data Set (MDS) dated [DATE] documents, in part, Personal Hygiene: the ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands: Partial/Moderate assistance. ADL (Activities of Daily Living) policy with an effective date of 5/05/2023 documents, in part, residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADL's and residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain grooming and personal hygiene. Undated Job Description titled Certified Nursing Assistant documents, in part, the primary purpose of the job position is to provide each of the assigned resident with routine activities of daily living and provides and assists personal care assistance to assigned residents as directed (bathing, grooming/hygiene). Undated policy titled Resident Rights and Dignity documents, in part, each resident shall be cared for in a manner that promotes and enhances quality of life, dignity and 1. resident shall be treated with dignity and respect at all times, 2. Treated with Dignity means a resident will be assisted in maintaining and enhancing his or her self esteem or self-worth and 3. Resident will be groomed as they wish to be groomed (hairstyles, nails).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure medications for one resident (R16) was administered to the resident at the scheduled time. This failure affected one resident (R16) and has the potential to affect all residents in the sample size of 34. Findings include: R16 has a diagnosis of but not limited to End Stage Renal Disease, Insomnia, Depression, Benign Prostatic Hyperplasia, Chronic Obstructive Pulmonary Disease, Pulmonary Hypertension and Acute on Chronic Diastolic Heart Failure. Minimum Data Set (MDS) dated [DATE] does not document a Brief Interview of Mental Status score. R16's Order Summary Report with active orders as of 8/12/2024 does not document an order for self-administration of medication or Bedside Medication Storage. R16's Care plan focus dated 12/13/2022 documents, in part, administer meds as ordered. On 8/11/2024 at 12:20pm surveyor observed 2 clear small medicine cups sitting on a small table on the side of the dresser in R16's room. There was 1 small clear medicine cup that had 10 pills, and the other cup had a box with eye drops. On 8/11/2024 at 12:21pm V28 (R16's Personal Companion) stated she is required to take a picture of the morning medications before they are administered to R16 and yes, these pills are the morning meds. V28 stated that R16 sleeps a lot the day after dialysis and we are required to let him sleep and not disturb him and when R16 wakes up and eats than I will let the nurse know so that they can take his vitals and give him his medicine. On 8/11/2024 at 12:25pm V7 (Registered Nurse-RN) stated R16's daughter has requested that R16 receive his medicine when R16 wakes up. V7 stated that V28 will call me when R16 wakes up so that I can take his vitals and administer his medications. V7 stated that V28 is required to take a picture of the meds when they (R16's medications) are scheduled and the daughter wants the medications pulled when they are scheduled. V7 stated that she signed them out when she left them to the caregiver in R16's room. On 8/12/2024 at 10:23am V27 (RN) stated that if a resident refuses their medicine than we can discard and chart accordingly unless it is still in the allowable timeframe to give the medicine which is one hour before and one hour after the scheduled medication time and that medications should not be left at the bedside. On 8/12/2024 at 10:50am surveyor observed R16's EMAR (Electronic Medication Administration Record) that displayed R16's 9:00am medications in red. On 8/12/2024 at 11:01am V4 (RN) stated that red means the medications are past due. On 8/12/2024 at 5:00pm surveyor reviewed R16's Medication Administration Record (MAR)for 8/11/2024 documents R16 should receive 10 oral medications that are scheduled at 9:00am. On 8/13/2024 at about 9:20am surveyor reviewed R16's Medication Administration Audit Report (MAAR) for 8/11/2024 that documents R16's 9:00am blood pressure medication (Midrodrine HCL 10mg TID {three times a day} was administered at 8:13am. On 8/13/2024 at 1:41pm V3 (RN/Nursing Supervisor) stated the expectations are for the nurses to administer medications one hour before and one hour after the scheduled medication time. V3 also stated, If a resident does not have an order to self-administer medications then medications cannot be left at the bedside and medication administration documentation should occur after the medication has been given. V3 stated the initials in the box on the MAR means that the medication was administered, the time on the MAAR is the time the medication was given and in PCC (Point Click Care software) red indicates that the medication is past due or past the scheduled medication time. On 8/14/2024 at 8:30am V29 (Primary Physician) stated Yes, R16 has trouble sleeping and is usually worn out after dialysis so I will give the nurses instructions for R16 not to be disturbed and to give the 9:00am medication after R16 wakes up. V29 also stated there is definitely an understanding with the nurses that if R16 is sleeping that he should not be disturbed and I (V29) will suggest that they wait to give R16 the 9:00am medications. Yes, R16 can still get the 5:00pm dose because his body accommodates and he can still get that 5:00pm dose. Undated policy titled Medication Management Self Administration of Medicines documents, in part, staff shall identify and give it to the Charge Nurse any medications found at the bedside that are not authorized for bedside storage. Medication Administration policy with an effective date of 10/25/2014 documents, in part, medications are administered as prescribed in accordance with good nursing principles and practices, Administration: 2. Medications are administered in accordance with written orders of the prescriber, and Documentation (including electronic): D. The individual who administers medication dose records the administration on the resident's MAR directly after the medication is given. Undated Job Description titled Staff Nurse, documents, in part, the primary role of this employee is to provide direct nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident and ensures that resident's medications are administered, in accordance with standards of practice.

Based on observation, interview, and record review the facility failed to ensure that the urinary drainage bag was hanging below the bladder. This failure affected one resident (R4) reviewed in a sample of 34. Findings include: R4's admission diagnoses of Obstructive and reflux uropathy, hydronephrosis with renal and urethral calculous obstruction, fall, benign prostatic hyperplasia of lower urinary tract and urine retention. On 8/11/24 at 10:47 am, R4's was sitting in a chair in the room. R4's indwelling catheter drainage bag was hanging on the bed frame above the level of the bladder. R4 Minimal Data Set documents in part, Section C. Brief Interview of Mental Status (BIMS) score of 14. R4 is cognitively intact. Section H. Appliances: A. Indwelling catheter Yes. R4s POS documents Catheter (Foley Catheter) size 16 FR (French) with balloon of 10 ml (Milliliter) for urinary retention. R4's Care plan documents in part, Focus: I have Indwelling Catheter due to Obstructive Uropathy. On 8/11/24 at 10:49 am, V11 RN (Registered Nurse) stated that the urinary bag should be below the groin level for drainage and gravity. If the urinary bag is above the groin level, it could cause back flow that could cause an UTI (Urinary Tract Infection). On 8/13/24 at 1:30 pm, V3 RN stated that the urinary drainage bag should be place low to allow drainage by gravity. It should be lower than the point of insertion. If it is not below the insertion site it could cause improper drainage, back flow of urine, discomfort, and possible urinary retention. Facility policy titled Catheter Care dated 3/7/23, documented in part, Purpose: To prevent infection and maintain resident comfort and dignity. General Guidelines: 2. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder.

Based on observation, interview and record review, the facility failed to label and date oxygen equipment (oxygen tubing and nebulizer mask); and failed to properly contain oxygen equipment (nebulizer mask) per the facility policy. These failures affected one residents (R33) reviewed for oxygen equipment, in a total sample of 34 residents. Findings include: R33's face sheet shows that R33 has a diagnosis which includes but not limited neuromuscular dysfunction of bladder, acute and chronic respiratory failure with hypoxia, pressure ulcer of the sacral region stage 4, and Alzheimer's disease. R33's Brief Interview for Mental Status (BIMS) dated 07/30/24 does not document a BIMS score for R33 and indicates that R33 has memory problems. R33 was not able to answer questions asked by surveyor. 08/11/24 at 10:35 am, R33 was observed in bed resting with 3 liters (L) nasal canular (NC) of oxygen administering, R33's oxygen tubing undated, and R33's nebulizer mask undated and uncontained. On 08/11/24 at 12:49 pm, this observation was brought to the attention of V3 (Registered Nurse, RN, Nursing Supervisor) and V3 stated that oxygen tubing should be changed once a week on the night shift. V3 also stated that nebulizer mask should be labeled with a date and bagged when not in use. When R3 was asked regarding the importance of labeling the oxygen tubing and ensuring that the nebulizer mask was placed in a bag when not in use V3 stated, For sterility, cleanliness and for infection prevention. R33's Physicians Order Sheet (POS) dated 10/08/2022 shows that R33 has orders to Change oxygen humidifier bottle and nasal canular once weekly every night shift and PRN (as needed). Label with date and nurse initials. The facility's document dated 01/01/2020 and titled Respiratory Care- Prevention of Infection documents, in part: Policy: Staff will follow protocol to minimize risk of infection related to respiratory care. Purpose: The purpose of this policy is to guide prevention of infection associated use of respiratory equipment, including oxygen, nebulizer's etc. among residents . Procedure: Infection Prevention Related to Oxygen Administration: Change the oxygen cannulas and tubing every seven (7) days, or per state regulations (whichever is stricter) or as needed, date and label.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a personal freezer has a temperature log and a personal refrigerator has no ice built up for 1 (R16) resident and failed to ensure the personal refrigerator has a temperature log for 1 (R46) resident. These failures affected 2 (R16 and R46) residents reviewed for personal food in the total sample of 34 residents. Findings include: 1. On 08/11/2024 at 10:50am, there was a small refrigerator inside R46's room. There was no temperature log on the front or sides of the refrigerator. R46 stated I (R46) have my (R46) ice cream inside the refrigerator. On 08/11/2024 at 10:54am, V6 (RN Nurse Supervisor) checked R46's personal refrigerator and stated there is one [NAME] chocolate ice cream cup and 4 Blue Ribbon cups inside the freezer. V6 also stated there are no expiration dates written on the cups. V6 checked R46's personal refrigerator for temperature log. V6 stated there is no temperature log for R46 personal refrigerator. On 08/11/2024 at 11:05am, V6 stated honestly, we (facility) don't have a temperature log for his (R46) personal refrigerator. I (V6) have no idea when they put the refrigerator in his (R46) room. On 08/13/2024 at 9:22am, V3 (RN Nursing Supervisor) stated the Dietary Staff should check the personal refrigerator to ensure the food are still viable, the temperature is in operating temperature between 36F to 46F and to ensure the refrigerator is working properly as it should be. On 08/13/2024 at 10:48am, V3 stated personal refrigerator should be checked daily by the Dietary Staff. R46's (Active Order As Of: 08/12/2024) Order Summary Report documented, in part Diagnoses: (include but not limited to) dementia, protein-calorie malnutrition, and hypertension. Dietary- Regular/General diet Regular texture, regular (thin liquid) consistency. Status: Active. Order Date: 08/01/2024. Start Date: 08/01/2024. R46's (05/02/2024) Minimum Data Set documented, in part Section C0500. BIMS (Brief Interview for mental status) Summary Score: 14. Indicating R46's mental status as cognitively intact. The (08/13/2024) email correspondence with V3 documented, in part In regard to checking the personal refrigerator temperature daily: The purpose of this task is to ensure that the refrigerator is in proper operating temperature/function. It also a ensures that the contents of the refrigerator are kept at consistent and desirable temperature that ensures food safety. A copy of the (undated) Refrigerator Temperature Log indicated 'Date' from 1 through 31 on the first column and 'Temperature' on the second column. The (undated) Policies and procedures regarding use and storage of food brought to resident from outside the facility documented, in part The following steps must be taken to ensure proper handling of food or beverage. A temperature log will be kept in front of the refrigerator. The (undated) Food brought in by family or visitors personal refrigerators policy documented, in part Policy: Clients may accept food from family or visitors. The health are community provides visitors with information on safe food handling practices. Procedure: Food or beverages brought in by family or visitors may be stored in the client's personal refrigerator. Personal refrigerator temperatures are maintained at 41F or below. 2. R16 has a diagnosis of but not limited to End Stage Renal Disease, Insomnia, Depression, Benign Prostatic Hyperplasia, Chronic Obstructive Pulmonary Disease, Pulmonary Hypertension and Acute on Chronic Diastolic Heart Failure. Minimum Data Set (MDS) dated [DATE] does not document a Brief Interview of Mental Status score. On 8/11/2024 at 12:17pm surveyor observed R16's personal refrigerator freezer with a large amount of ice that had built up inside and outside of the freezer. R16 also has a separate personal freezer that had no temperature log. On 8/12/2024 at 10:00am V14 (Dietary Manager) stated that the dietary aides are responsible for completing the temperature log daily unless there is a private sitter or personal companion, then they (private sitter or personal companion) are responsible. V14 stated that R16 has a personal companion who is responsible for defrosting the freezer. V14 stated that it was her (V14) fault that R16's freezer had no log and that it slipped her mind to bring new temperature log for the resident. Undated policy titled Policies and Procedures Regarding use & Storage of Food Brought to Resident from outside the Facility documents, in part, a temperature log will be kept in front of the refrigerator. Undated policy titled Policies and Procedures Regarding use & Storage of Food Brought to Resident from outside the Facility documents, in part, personal refrigerator temperatures are maintained at 41 degree Fahrenheit or below and refrigerators are cleaned regularly to maintain a safe and sanitary environment for food storage.

Based on observation, interview, and record review the facility failed to ensure that a medication cart was kept locked. This failure has the potential to affect all 15 residents on the 6th floor unit. Findings include: On 08/11/24 facility presented a census of 15 residents on the 6th floor unit. On 08/11/24 at 9:56 am, Surveyor observed the 6th floor medication cart unlocked, unattended, with the third drawer of the medication cart slightly opened, medication cards exposed, and not in view of licensed nurse. Between 9:56 am and 10:01 am, no licensed nurse in view of medication cart. On 08/11/24 at 10:07 am, V4 (Registered Nurse, RN) returned to the 6th floor medication cart and Surveyor brought this observation to V4(RN). V4 stated It (referring to the 6th floor medication cart) should be locked to make sure no one touches it (referring to the 6th floor medication cart). When V4 was asked regarding the importance of ensuring the medication cart is locked when not in use or in visibility of the nurse, V4 stated, So that the medications are safe. If a patient (resident) gets the medications it can be unsafe. They (referring to the residents) can take the medication and either a medication error can occur, or it can cause death. On 08/13/24 at 11:40 am, V3 (Registered Nurse, RN, Nursing Supervisor) stated that medication carts should be locked when not in attendance by the nurse for the safety of the residents and the contents of the cart. V3 also stated that the medication cart should only be accessed by the nursing staff or nursing supervisor on duty. When V3 was asked regarding what could happen if a medication cart is left unlocked and unattended by the nurse on duty, V3 stated that a medication error, loss of medications and the safety of the resident and staff can be compromised. The facility's policy dated 05/01/2018 and tilted Storage of Medications documents, in part: Policy: Medications and biological's are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only by licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedures: B. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) permitted to access medications. Medication rooms, carts, emergency kits/boxes, and medication supplies are locked when not attended by persons with authorized access.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure two residents (R33 and R56) intravenous site (IV) was labeled with a date; failed to ensure staff sanitize the medication tray after use for two residents (R18 and R29); failed to ensure the trash receptacle for residents on isolation was not outside the resident room and was not side by side with the PPE (Personal Protective Equipment) bin for one resident (R211); and failed to ensure a resident (R211) who was positive for COVID 19 maintain contact/droplet isolation precautions in efforts to prevent the spread of COVID 19; including failure to prevent a resident's (R212) exposure. These failures affected five residents (R18, R29, R33, R56, R212 and R211) and has the potential to affect all 15 residents on the 6th floor unit. Findings include: 1. On 08/11/24 facility presented a census of 15 residents on the 6th floor unit. On 08/11/24 at 10:10 am, R211 was observed sitting in a wheelchair, in R212's room, without wearing a facemask. R212 was also observed not wearing a facemask. On 08/11/24 at 10:31 am, R56 was observed in bed awake, alert with an IV site to R56's right hand that was not labeled with a date. R56 stated that R56 has had R56's right hand IV site for a while. On 08/11/24 at 10:34 am, R33 was observed in bed, not alert with an IV site to R33's left arm that was not labeled with a date. On 08/11/24 at 12:50 pm, V3 (Registered Nurse, RN, Nursing Supervisor) stated that peripheral IV sites should be labeled with a date so that the nurse knows when the IV was inserted. When V3 was asked regarding the importance of dating peripheral IV sites V3 stated, So staff knows when to change the IV site and dressing ,and to prevent the IV site from getting and infection. On 08/13/24 at 11:36 am, V3 (Registered Nurse, RN, Nursing Supervisor) stated that residents who have a positive COVID 19 status are isolated in a private room and remain alone in the residents room. V3 explained that residents with a positive COVID 19 status will have all the residents services performed alone in the residents room. V3 also explained that residents with positive COVID 19 status should not come out the residents room to socialize in other residents rooms or with other residents. V3 stated if a resident with a positive COVID 19 status leaves out of the room the resident should wear a mask. When V3 was asked regarding the importance of a resident who is positive COVID 19 status is maintained in a Droplet/COVID 19 isolation room V3 stated, To prevent the spread of the disease to staff and other residents and ultimately to protect the residents. R33's face sheet shows that R33 has a diagnosis which includes but not limited neuromuscular dysfunction of bladder, acute and chronic respiratory failure with hypoxia, pressure ulcer of the sacral region stage 4, and Alzheimer's disease. R33's Brief Interview for Mental Status (BIMS) dated 07/30/24 does not document a BIMS score for R33 and indicates that R33 has memory problems. R33 was not able to answer questions asked by surveyor. R56's face sheet shows that R56 has a diagnosis which includes but not limited to sepsis due to Escherichia coli, urinary tract infection, type 2 diabetes mellitus with diabetic chronic kidney disease. R56's Brief Interview for Mental Status (BIMS) dated 06/28/24 shows that R56 has a BIMS score of 15 which indicates that R56 is cognitively intact. R211's face sheet shows that R211 was admitted to the facility on [DATE] with diagnosis with include but not limited to COVID 19 onset on admission [DATE]. R211's Brief Interview for Mental Status (BIMS) dated for submission of 08/15/24 shows that R211 has a BIMS score of 15 which indicates that R211 is cognitively intact. R212's face sheet shows that R212 has a diagnosis which includes but not limited to periprosthetic fracture around internal prosthetic left hip joint subsequent encounter, anemia, essential hypertension, and gastro-esophageal reflux disease. R212's Brief Interview for Mental Status (BIMS) dated for submission of 08/15624 shows that R212 has a BIMS score of 14 which indicates that R212 is cognitively intact. R33's POS shows that R33 does not have orders for R33's left arm IV site on 08/11/24. R56 POS dated 07/11/24 documents, in part: Nursing to insert PIV (peripheral intravenous) and manage. R211's Physician Order Sheet (POS) dated 08/11/24 shows that R211 has orders for Transmission Based Precautions (contact/droplet) for COVID 19 every shift active 08/11/24 The facility's document dated 09/01/2016 and titled Peripheral IV Dressing Changes documents, in part: Policy: Peripheral IV dressings will be changed when needed to prevent catheter-related infections associated with contaminated, loosed or soiled catheter-site dressings . Procedure: 7. Label dressing with date, time, and initials. The facility's policy dated 05/06/2024 and titled Coronavirus documents, in part: General: The facility continues to be focused on minimizing the impact of COVID 19 and other respiratory infections on the residents in the facility, who are at higher risks of severe outcomes due to respiratory viral infections . Procedure: 1. Contact -Droplet Transmission Based Precautions will be put in place when a resident is suspected to have COVID 19 or is tested positive for COVID 19. This means wearing a gown, gloves, facemask, and goggles or a face shield. The facility will post information, like posters and flyers that remind patients, staff, and visitors to practice good respiratory and hand hygiene . 5. Management of Residents: I. g. Pending transfer or discharge, place a facemask on the patient and isolate him/her with the door closed. h. Limit transport and movement of the patient/resident outside of the room. Resident should wear a facemask to contain secretions. 2. On 08/12/2024 at 9:03am during the Medication Administration task with V16 (Registered Nurse), V16 prepared R13's medications. V16 placed R13's medication cup on the medication tray. On 08/12/2024 at 9:04am, V16 knocked at R13's door and mentioned R13's name, entered R13's room, and placed the medication tray on top of R13's bedside table and administered R13's medications. On 08/12/2024 at 9:07am, V16 placed the medication tray he (V16) used for R13 on top of the 7th floor medication cart without sanitizing the medication tray; opened the electronic health record and documented the medication administration. V16 opened R18's eMAR (electronic Medication Administration Record) and stated R18's medications are to be crushed. On 08/12/2024 at 9:15am, V16 prepared R18's medications. V16 placed R18 medications on the same medication tray he (V16) used for R13. On 08/12/2024 at 9:17am, V16 placed the medication tray that contained R18's medications on the table where R18 was eating and administered R18's medications. On 08/12/2024 at 9:22am, V16 placed the medication tray that he (V16) used for R13 and R18 on top of the medication cart without sanitizing the medication tray; opened R29's eMAR and stated that R29's medications are also crush with nectar thick liquid. On 08/12/2024 at 9:27am, V16 placed 4 med cups on the medication tray he(V16) used for R13 and R18 and counted the medications he (V16) prepared for R29 and stated there are 4 pills I (V16) prepared for (R29). On 08/12/2024 at 9:28am, V16 knocked at R29's door. Entered the room and placed the medication tray, which contained R29's medications, on R29's night stand. V16 administered R29's medications. On 08/12/2024 at 9:32am, V16 placed the medication tray he (V16) used for R13, R18 and R29 without sanitizing the medication tray. This surveyor inquired if V16 still has medications to pass. V16 checked the electronic health record and stated I (V16) still have to pass medications to (R16). V16 opened the medication storage room and brought out Nephro Therapeutic Nutrition 237ml and placed it on the medication tray he (V16) used for R13, R18 and R29. At this point, surveyor inquired how many times V16 sanitized the medication tray between residents. V16 stated I (V16) did not sanitize the medication tray between residents. I (V16) am supposed to sanitize the medication tray between residents with Lysol wipes. I (V16) forgot to sanitize the medication tray. The importance of sanitizing the medication tray between use is to prevent cross contamination. On 08/13/2024 at 9:24am, V3 (RN Nursing Supervisor) stated the medication tray should be sanitized between residents to prevent cross contamination. R13's (08/12/2024) Medication Admin(administration) Audit Report indicated that V16 documented administration of R13's medications at 09:08(am). R18's (08/12/2024) Medication Admin(administration) Audit Report indicated that V16 documented administration of R18's medications at 09:22(am). R29's (08/12/2024) Medication Admin(administration) Audit Report indicated that V16 documented administration of R29's medications at 09:32(am). The (08/13/2024) email correspondence with V3 documented, in part 4. Medication Tray - The expectation of medication tray is to be disinfected after every use between residents. The purpose of this task is to promote infection control and prevent cross contamination and spread of germs between residents. 3. On 08/12/2024 at 9:39am there was a contact and droplet precautions signs posted by R211's door. There was a trash receptacle, that was slightly open noted with blue color material, outside of R211's room. Beside the trash receptacle was also a PPE (Personal Protective Equipment) bin. Inside the room was V15 (Registered Nurse) wearing gown, gloves, mask, and faceshield. This surveyor walked towards the 6th floor nurse's station and waited for V15. When V15 got on to the nurse's station, this surveyor requested to see the Infection preventionist. On 08/12/2024 at 9:56am, with V3 (RN Nursing Supervisor) this surveyor opened the trash receptacle located outside of R211's room via a foot pedal; inside the receptacle were gowns, gloves and faceshield. V3 stated the trash bin should be inside the room of the resident on contact/droplet precautions to prevent further contamination of the outside of the isolation room. The trash bin should not be beside the PPE bin to prevent contaminating the outside of the PPE bin. R211's (Active Order As Of: 8/13/2024) Order Summary Report documented, in part Diagnoses: (include but not limited to) Covid-19. Order Summary. Transmission Based Precautions (contact/droplet) for Covid-19 Active 8/11/2024. R211's census list documented that R211 was admitted on [DATE]. R211's (08/11/2024) Care plan documented, in part I am admitted with Covid-19 infection. All services are done inside the room to prevent the spread of infection. R211's (08/09/2024) Printable discharge Form documented, in part Pt (patient) is Covid positive. The (undated) Contact Precautions poster documented, in part Providers and staff must also: Discard gloves before room exit. Discard gown before room exit. The (undated) Droplet Precautions poster documented, in part Everyone must: Remove face protection before room exit. The (08/13/2024) email correspondence with V3 documented, in part 5. Trash Receptacle - The expectation of trash receptacle use for transmission based precautions is that the trash receptacle shall be placed inside the residents room. The purpose of this is to prevent spread of infection and to contain whatever transmissible organism is being isolated. The (05/06/2024) coronavirus documented, in part GENERAL: (Facility) continues to be focused on minimizing the impact of COVID- 19 and other respiratory infections on the residents in the facility, who are at higher risk of severe outcomes due to respiratory viral infections. Important facts: 2. Transmission: COVID- 19 is spread from person to person by respiratory droplets between people who are in close contact with another. While there is not yet evidence for spread from surfaces or objects (fomites) this may also be a possible mechanism of transmission. Procedure. 1. A Contact Droplet Transmission Based Precaution will be put in place when a resident is suspected to have COVID-19 or is tested positive for COVID-19 this means wearing a gown, gloves, face mask, and goggles or face Shields. The facility will post information, like posters and Flyers that remind patients, staff, and visitors to practice good respiratory and hand hygiene. 4. Source control. If used during the care of a resident for which a NIOSH- approved respirator or face mask is indicated for personal protective equipment, they should be removed and discarded after the resident care encounter.

Based on observation, interview and record review, the facility failed to post the daily nursing staffing. This failure has the potential to affect all 59 residents residing in the facility. Findings include: On 8/11/24 at 9:00 am, facility census of 59 residents. On 8/11/24 at 9:00 am, upon entrance to the facility, the facility's daily staff posting was not posted or observed in the lobby. On 8/12/24 at 9:45 am, no facility's daily staff posting or observed in the lobby. On 8/12/24 at 9:45 am, V24 (Receptionist) showed the surveyor the Nursing Department Daily Schedule for 8/12/24 and stated that the daily schedule is the only sheet we have. The daily schedule was behind the receptionist desk, not visible. On 8/13/24 at 11:56 am, V1(Administrator) stated. I (V1) told the DON (Director of Nursing) about the staffing posting and the DON said it was not specific on what they wanted on the posting. I do not know why we got away from doing it. I told the scheduler moving forward what the daily staff posting should look like. We had it posted, just not in the proper format. Surveyor inquired to V1 if behind the reception desk is considered posting and visible, V1 stated, No. V1 stated that the daily schedule was the only thing we had for staffing. Surveyor inquired to V1 if they had knowledge on the regulatory requirements for posting staffing, V1 did not respond to the surveyor question and stated that every facility does it different. Facility Policy titled Daily Staff Posting dated 6/6/24, documents in part, Purpose: The purpose is to provide residents and families with daily staffing hours per shift to ensure proper nursing care is provided in the facility. The (Rev. 208; Issued:10-21-22; Effective: 10-21-22; Implementation:10-24-22) State Operations Manual documented, in part §483.35(g) Nurse Staffing Information. §483.35(g)(1) Data requirements. The facility must post the following information on a daily basis: (i) Facility name. (ii) The current date. (iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: (A) Registered nurses. (B) Licensed practical nurses or licensed vocational nurses (as defined under State law). (C) Certified nurse aides. (iv) Resident census. §483.35(g)(2) Posting requirements. (i) The facility must post the nurse staffing data specified in paragraph (g)(1) of this section on a daily basis at the beginning of each shift. (ii) Data must be posted as follows: (A) Clear and readable format. (B) In a prominent place readily accessible to residents and visitors. GUIDANCE §483.35(g) The facility ' s staffing data document may be a form or spreadsheet, as long as all the required information is displayed clearly and in a visible place.

Based on observation, interview ,and record review, the facility failed to ensure residents are free from physical restraints for 1 resident (R47) out 3 residents reviewed for restraints, in a sample of 15. Findings include: On 05/11/2023 at 10:45 AM, R47 was at the nurse's station, behind the desk. R47's wheelchair was pushed close to the desk, with her bilateral lower extremities underneath the desk, preventing her from being able to stand up. R47 was restless and trying to get up. There was no nurse or CNA (Certified Nursing Assistant) at the desk monitoring R47. R47 was placed behind the desk, with her wheelchair locked, and left by herself. On 05/11/2023 at 11:00 AM, V25 (Certified Nursing Assistant) stated, We place (R47) behind the desk because she is a high fall risk, so we put her behind the desk so that she doesn't get up. On 05/11/2023 at 11:17 AM, V24 (Registered Nurse) stated she is the nurse for R47. V24 stated they usually put R47 at the nurse's station because she tends to get up on her own. V24 stated R47 has had multiple falls and needs to have close observation because she tends to get up. V24 stated they make sure to lock the wheelchair when they put R47 behind the desk of the nurse's station. V24 stated the intention of locking the wheelchair is to make sure the wheelchair does not move. On 05/11/2023 at 2:15 PM, V2 (Director of Nursing) stated R47 is at high risk for falls. V2 stated, She will get up so we put her by the desk to watch her because she will try to get up. She has to be watched one on one all the time. She cannot verbalize her thoughts because she has dementia. R47's Facesheet (10/1/2022) documents in part: unspecified dementia, hemorrhage, sequelae of cerebral infarction, dysphagia, restlessness, and agitation. R47's MDS Section C, Cognitive Patterns (2/7/2023) documents in part: BIMS (Brief Interview for Mental Status) score - 99. Enter 99 if resident is unable to complete the interview. This means R47 is not cognitively intact. R47's care plan had no documentation of placing R47 behind the nurse's station, so close to the desk where she cannot get up. Facility's abuse policy (undated) documents in part: It is the policy of Self Help Home that each resident will be free from abuse. Abuse can include verbal, mental, physical, sexual abuse, corporal punishment or involuntary seclusion. The resident will also be free from physical or chemical restraints imposed for purpose of discipline or convenience and that are not required to treat the resident's medical symptoms. Facility's Physical Restraints policy (undated) documents in part: Resident of the Self Help Home will be assessed and provided for an appropriate assistive device to attain and maintain his/her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints. The use of physical or mechanical method, material or equipment which restricts freedom of movement for convenience and/or to discipline is prohibited in this facility. Physical restraints include but not limited to leg restraints, arm restraints, hand mitts, soft ties or vests, lap cushions, and lap trays that resident cannot remove easily. Also included is using devices in conjunction with a chair, such as trays, tables, bars or belts in which the resident can not remove easily and/or prevents the resident from rising.

Based on observation, interview, and record review, facility failed to follow their policy to use gait belts to transfer residents who require limited to extensive assistance with partial, toe-touch, or non-weight bearing restrictions for 1 (R47) resident out of 4 residents reviewed for falls in a sample of 15. Findings include: On 05/11/2023 at 10:45 AM, R47 was at the nurse's station behind the desk. R47's wheelchair was pushed close to the desk, with her bilateral lower extremities underneath the desk, preventing her from being able to stand up. R47 was restless and trying to get up. There was no nurse or CNA at the desk monitoring R47. On 05/11/2023 at 11:00 AM, V25 (Certified Nursing Assistant) transfered R47 from her wheelchair to her bed, without using a gait belt. V25 held R47 underneath her armpits and lifted R47 from her wheelchair and sat her down on her bed. On 05/11/2023 at 11:15 AM, V24 stated, (R47) is actually one person assist. Everyone is required a gait belt for transfer. We received an in-service about using weight belt. The CNA might have forgotten. The CNAs are also being in-serviced for using gait belt. Gait belt is important to use because you get a good grip on the belt and resident to prevent the resident from falling. (R47) has fallen before, so using a gait belt on her is very important. V24 stated R47 is an extensive assist resident. On 05/11/2023 at 2:15 PM, V2 (Director of Nursing) stated, You assist residents by how much they can help. A lot of times if they are non-weight bearing, they need more assistance. We use a gait belt to help those who are extensive assist. R47's care plan documents in part: I had an actual fall on 9/9/2022, 9/15/2022, 1/1/2023, and 2/17/2023 where I stood up from my wheelchair, lost my balance and fell. Staff to make sure that someone is keeping an eye on me since I tend to get up when I am sitting in the wheelchair. Get her up when restless. R47's MDS section G, Functional Status (2/7/2023) documents in part: Transfer, how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position. R47 was scored at a 3 for transfer. The coding chart explains that a score of 3 means the resident is extensive assist. Facility's Transfer-Non Mechanical Lift (7/2018) policy documents in part: It is the policy of the Self Help Home to use gait belts to transfer residents who require limited to extensive assistance with partial, toe-touch, or non-weight bearing restrictions.

Based on observation, interview, and record review, the facility failed to maintain accurate record of residents for 3 out of 15 residents (R111, R17, and R47) for a total sample of 15 residents reviewed for resident's record. Findings include: 1. On 05/09/2023 at 12:25 PM, V3 (Infection Preventionist/IP) was asked about R111, and what the facility is doing to prevent spread of Lyme's disease. V3 said, (R111) had Lyme's disease diagnosis upon admission. (R111's) Lyme's disease is still active and is still being treated with antibiotics. Yes, there is a poster for enhanced barrier precautions near the door of (R111) for staff to use proper PPE including gown and gloves. Documents were requested from V3 (IP), including care plan. V3 presented R111's care plan that does not reflect the following documentation: Dated 05/01/2023 staff to wear gloves and gowns (Enhanced Barrier Precautions) during high-contact resident activities to reduce transmission of resistant organism. V3 was asked about the removal in the care plan of documentation related to wearing of PPE (personal protective equipment) for a resident with Lyme's disease infection. V3 said, I think (V16, Minimum Data Set Coordinator) just made modification today. I do not know why V16 removed it. At 12:40 PM. V16 said, I modified (R111's) care plan today (05/09/2023) as resolve. V16 was asked why she (V16) removed it, Yes, it was after I knew that you were requesting it, that I resolved and removed it. If you want, I can just click and unresolve it. Further review of R111's care plan was found that performance of proper handwashing techniques, to minimize microorganism transmissiond dated as initiated on 05/02/2023d was also resolved and removed on the same date, 05/09/2023, after request. 2. R17 diagnoses include but are not limited to: end stage renal disease, dependence on renal dialysis. On 5/10/23 at 11:37 AM, V2 (Director of Nursing) stated, (V20's, Medical Doctor) last note (for R17) was 4/20/23. There was nothing about putting dialysis on hold just to decrease to once a week. (V20) wrote the note today (5/10/23) to suspend the dialysis. The nurse put in the order today to put dialysis on hold. There was no order prior to today. (R17) last went to dialysis 4/24/23. I did not know dialysis was put on hold. (R17's) daughter told me about putting dialysis on hold. I called (V20) to see if (V20) was aware that dialysis was on hold. (V20) said (V20) was aware. (V20) discussed with the nephrologist. I asked (V20) to put it in writing. The order was put in today after getting a verbal order from (V20). R17 Physician Order Summary documents in part: Dialysis 1x/week (Monday only) on hold for now; order date 5/10/23 (the day surveyor discussed R17's dialysis treatments with V2). R17 Physician Progress Note, effective date 5/10/2023, documents in part: Pt had discussion with nephrologist. As patient is not having fluid pulled during dialysis and with weight downtrending, plan is to hold dialysis indefinitely and monitor weights, swelling and electrolytes. On 5/10/23, surveyor requested the most recent dialysis communication between the facility and the dialysis center. Surveyor was presented a communication dated 4/24/23. 3. On 05/11/2023 at 11:00 AM, surveyor observed V24 (Registered Nurse) and V25 (Certified Nursing Assistant) change R47's wound dressing. R47 has a stage three pressure ulcer on her sacrum. On 05/11/2023 at 11:51 AM, V27 (Minimum Data Set/ MDS Coordinator) and V17 (MDS Coordinator) stated R9 and R22 are the two residents with wounds. Those are only two residents with wounds. The form 672 is updated every Friday. The Matrix is updated every Friday. At this time, Surveyor informed V27 and V17 that R47 also has a wound. Surveyor handed V27 and V17 the full resident matrix. V17 stated, (R47) is not included in the matrix. I may have clicked the wrong resident when updating the matrix.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow enhance barrier precautions procedure by not wearing proper PPE (personal protective equipment) for 1 resident (R111) that currently treated for Lyme's disease infection, and the facility failed to follow policy for hand hygiene during treatment of wound for 1 resident (R47), in a sample reviewed for Infection Control. Findings include: R111 is [AGE] years old, initially admitted on [DATE] with diagnosis of Lyme's Disease. R111 was unable to be interviewed. R111 has a BIMS (Brief Interview for Mental Status) of 2, indicating R111 is cognitively impaired. R111 has an order for antibiotic (Ceftriaxone) to inject intramuscularly for Lyme's disease until 05/22/2023. R111's care plan by V (Infection Preventionist) for Infection reads as follow: Dated 05/01/2023 staff to wear gloves and gowns (Enhanced Barrier Precautions) during high-contact resident activities to reduce transmission of resistant organism. Dated 05/02/2023 perform proper handwashing techniques, to minimize microorganism transmission. On 05/09/2023 at 11:43 AM, in the hallway, isolation setup was seen in a plastic compartment with drawers full of PPE (personal protective equipment). V5 (Registered Nurse) stated, This (holding the compartment and placing it near R111's door) is for (R111); he has Lyme's disease. (R111) is currently on contact isolation, and (R111) is currently taking antibiotic for Lyme's disease. V5 was asked about Lyme's disease and said, I think it is a bacterial infection that is why (R111) is taking an antibiotic. (R111) used to have peripheral line, but now his antibiotic is being administered through IM (intramuscular) injection. Nursing staff needs to use gown, gloves, mask, and face shield. V5 was asked where is R111? V5 went into his (R111's) room and could not find R111. V5 then became anxious, and asked V6 (Certified Nursing Assistant) the whereabouts of R111. V5 said, Do you know where (R111) is? V6 replied, (R111) is at therapy on 8th floor. After few minutes, R111 was seen exiting elevator with a staff assisting R111, without any PPE. V6 then assisted R111 to go to his room, also without PPE. After few minutes, V5 came back and said, I just want to clarify, (R111) is not in contact isolation, but on enhanced barrier precautions (pointing at a poster near the door of R111's room). V5 was asked to read the poster. V5 said, Everyone must: clean their hands, including before entering, and when leaving the room. Providers and staff must also wear gloves and gown for the following high-contact resident care activities, including transferring. V5 was asked about R111 assistance during transfers and ambulation. V5 said, Yes, (R111) needs close contact and assistance during ambulation and transfer related to his cognition. And based on that paper, staff needs to wear gown and gloves. On 05/09/2023 at 12:25 PM. V3 (Infection Preventionist) was asked about R111, and what the facility is doing to prevent spread of Lyme's disease. V3 said, (R111) had a Lyme's disease diagnosis upon admission. (R111's) Lyme's disease is still active and is still being treated with antibiotics. Yes, there is a poster for enhanced barrier precautions near the door of (R111) for staff to use proper PPE including gown and gloves. Lyme's Disease Transmission per CDC (Centers for Disease Control and Prevention) information dated 01/20/2023, in part reads: The Lyme disease bacteria causing human infection in the United States, Borrelia burgdorferi and, rarely, B. mayonii, are spread to people through the bites of infected ticks. Borrelia burgdorferi is spread primarily by the blacklegged tick (or deer tick, lxodes scapularis) in the northeastern, mid-Atlantic, and north-central United States, and by the western blacklegged tick (l. pacificus) in the Pacific Coast states. Borrelia mayonii is rarely found in ticks and has only been detected in blacklegged ticks in the north-central United States. 2. On 05/11/2023 at 11:11 AM, V24 (Registered Nurse) assisted by V25 (Certified Nursing Assistant), performed dressing change to R47's coccyx pressure ulcer. During whole procedure, V24 and V25 were not seen performing hand hygiene. V24 said, I did perform hand hygiene near the Nurse's Station. V24 was seen touching/contacting high touched area including treatment cart, door, and other surfaces from the Nurse's station going inside R47's room prior to dressing change. V24 was then asked why hand hygiene was not performed after taking off old dressing, cleaning wound, and putting a new dressing? V24 said, Yes, I should have performed hand hygiene, but I forgot. Hand Hygiene policy dated 07/2018, in part reads: It is the policy of the facility to perform hand hygiene in accordance with national standards from the Centers for Disease Control and Prevention and the World Health Organization. Hand hygiene is to be performed: Prior to caring for a resident. When moving from a contaminated body site to a clean body site such as when changing a brief or wound dressing. After caring for a resident including after removing gloves. And after contact with resident environment.

Based on observation, interview, and record review, the facility failed to provide residents with private space for resident council meetings, and failed to notify resident representative (Ombudsman) with resident council meeting date changes. These failures have the potential to affect all 55 residents living in the facility. Findings include: On 5/9/2023 at 10:10 AM, V28 (Ombudsman) said the facility sends her a calendar (schedule) for resident council meeting, then when she gets here, the meeting has been changed or already happened, and no one at the facility lets her know of the changes. On 5/11/2023 at 1:15 PM, V27(Activity Director), said she sets and she puts together residents who will attend resident council meetings for the residents, because that is what she was told to do, and the facility had to have resident council meetings. V27 said the residents who attend resident council meetings have dementia, and do not talk much during resident council meetings, and the meetings are not private because staff have to be present in all meetings to take/write the meeting minutes for the residents. V27 said the residents who attend the meetings do not verbalize any needs. V27 further said she sends V28 (Ombudsman) the calendar for the year's resident council meeting dates, and if V27 moves or changes the meeting dates, she does not see the need inform V28, because V28 has not verbalized to V27 that she (V28) would like to attend resident council meetings, and she (V27) has never seen V28 in the facility; therefore, V27 does not think V28 wants to attend the resident council meetings. V27 commented residents who are alert can verbalize their needs to their social workers, therefore, they do not need to attend resident meetings because their needs are met. V27 said the current resident president has been sick for the last two to three months, and has not been able to attend to resident council meetings. V27 said she has not recruited another resident for resident council president, but was thinking of recruiting R34 as the resident council president. On 05/10/23 at 10:57 AM, in R261's (resident council president) room, R261 stated the Activities Department arranges for resident council meetings, and are present in all meetings, which are held once a month. R261 was observed to have a difficult time speaking and spoke in a whisper, and was observed with a private care giver in her room. R261 stated she has not been attending resident council meetings due to decline in health,and said she did not know who the Ombudsman is. R261's MDS (Minimum Data Set) section C (Cognitive patterns), dated 2/14/2023, documents R261's BIMS (Brief Interview for Mental Status) score is 8 out of 15, meaning R261 is cognitively moderately impaired. R261's medical diagnosis includes, but is not limited to, unspecified Dementia. On 05/10/23 at 11:05 AM, during resident council meeting, R43 said there were fewer meetings because the resident council president was sick. R43's MDS (Minimum Data Set) section C (Cognitive patterns), dated 4/11/2023, document R43's BIMS (Brief Interview for Mental Status) score is 13 out of 15, meaning R43's is cognation is intact. n 05/10/23 at 11:05 AM, during resident council meeting, R24 waited for V27 to leave the room (V27 had been requested to reave the room during resident council meeting; V27 left the room but was within ear shot of the resident council meeting room) to take residents downstairs, and said to surveyor, Staff is always present in all meetings and residents find it hard to say anything negative or say their concerns for fear of what they say coming back to them. R24's MDS (Minimum Data Set) section C (Cognitive patterns), dated 2/7/2023, document R24's BIMS (Brief Interview for Mental Status) score is 14/15, meaning R24's is cognation is intact. Policy titled: Resident council policy, no date, documents: -Staff members may not attend Resident Council meeting unless given a formal invitation from the Council -Resident Council Meetings are private and confidential -Annual elections shall be held in order for the residents to vote for council officials

Based on observation, interview, and record review, the facility failed to properly secure controlled medications for 3(R261, R27, R36) residents reviewed in a sample of 15 residents. Findings include: On 5/9/2023 at 1:00 PM, surveyor with V4 (Registered Nurse-RN) while inspecting 7th floor medication room, observed medication refrigerator not locked, with padlock hanging on the side of the fridge lock handle. Inside the medication fridge was observed: Inside the fridge were observed R261 medications as follows: -Two full vials, plus half a vial of Morphine Sulphate (liquid), 30mL, 5mg/mL -One vial of Lorazepam 2mg/mL R261has medical diagnosis that include but not limited to: Severe Aortic Stenosis, polymyalgia rheumatica, sarcopenia, nondisplaced fracture of lateral malleolus of left fibula, initial encounter for closed fracture. R261's Physician orders dated 2/15/2023 document: - Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML (Morphine Sulfate). Give 0.25 ml by mouth every 2 hours as needed for moderate pain (1-5) -Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML (Morphine Sulfate). Give 0.5 ml by mouth every 2 hours as needed for severe pain (6-10) -Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML (Morphine Sulfate). Give 0.25 ml by mouth every 1 hours as needed for dyspnea/air hunger/SOB(Shortness of breath) or RR (Respirations)>(greater than)24/min (hold if RR falls below 12/min) There were 4 pens of insulin basaglar labeled with R27's name in the fridge. R7's medical diagnosis includes but not limited to: type 2 diabetes mellitus with diabetic nephropathy. R27's physician orders dated 8/2/2023 document: -Basaglar KwikPen Solution Pen-injector 100 UNIT/ML (Insulin Glargine) Inject 8 unit subcutaneously in the evening for DM(Diabetes) Type 2 Four unopened pens of Trulicity pens were observed in the fridge labeled with R36's name. R 36's medical diagnosis includes but not limited to: type 2 diabetes mellitus without complications, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R36's Physician orders 11/12/2022 document: -Dulaglutide Solution Pen-injector 3 MG/0.5ML Inject 0.5 milliliter subcutaneously one time a day every Sat for DM(Diabetes) 2 V4 said fridge for medication should be locked because there are controlled medications in the fridge like morphine. V4 further stated the policy is to lock the medication in the fridge with a double lock for security reasons to prevent medications from being mishandled and or misused. On 5/10/2023 at 10:37AM, V2 (Director of Nursing -DON) said all narcotics in the fridge in the medication room should have been double locked and said, There is the lock for the fridge, then the main door, and both the fridge door and the main door should be locked because there are controlled medications in the medication room and the medication fridge should be double locked with only the nurses having the key to prevent mishandling. Policy titled Controlled Substance Storage, dated 10/25/2014, documents: -Schedule 11-V and other medications subject to abuse or diversion are stored in a permanently affixed, double -locked compartment separate from all other medications as per state regulation. -Controlled-substances that require refrigeration are stored within a locked box within the refrigerator. This box must be attached to the inside of the refrigerator.

Based on observation, interview, and record review, the facility failed to dispose/discard expired medications in one two medications carts/medication room/storage reviewed. This failure has the potential to affect 21 residents receiving medications from the 7th floor medication cart/storage room, in a sample of 55. Findings include: On 5/09/2023 at 12:34 PM, surveyor with V4(Registered Nurse-RN), while inspecting medication cart on 7th floor observed expired medications on the cart: 1. Insulin Lispro, labelled with R27's name, with opened by date of 3/27/2023, and another insulin Lispro vile opened, and with expiration date of 4/27/2023. V4 said, Once insulin is opened, it stays for 30 days, and then should be discarded. After 30 days, the opened insulin is no longer potent and should be discarded. Once the insulin is opened, the manufacture's expiration date is surpassed by the date the insulin was opened and should be discarded after 30 days. R27's medical diagnosis include but not limited to: type 2 diabetes mellitus with diabetic nephropathy, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R27's physician order sheet dated 4/28/2023 document: Insulin Lispro Solution Inject as per sliding scale: if 201 - 250 = 1 unit; 251 - 300 = 3 units; 301 - 350 = 5 units; 351 - 400 = 7 units below 60 & above 400 call MD, subcutaneously before meals and at bedtime related to type 2 diabetes mellitus with diabetic nephropathy. 2. Omeprazole 20mg bottle labelled with R21's name was observed with worn off label that was not legible, no open by date, no instructions visible. V4 said she does not know when the medication expires and stated, This medicine for (R21) comes as a mail order. V4 further said there is no expiration date on the bottle of medication, and she said, I don't know when it will expire or when it was opened. This medication should have an opened by date, expiration date and/or instructions for administering the medications. R21's medical diagnosis include but not limited to type 2 diabetes mellitus without complications, pure hypercholesterolemia, unspecified. R21's Physician order sheet, dated 1/14/2023, documents: Omeprazole Oral Tablet Delayed Release 20 MG (Omeprazole) Give 1 tablet by mouth one time a day for anticholinergics 3. Bottle of Acetaminophen 325 mg per tablet (house stock) with expiration date of 3/2023. V4 said expired medications should not be in the medication cart, and should be discarded. V4 said giving expired medications to residents can cause adverse effects on the resident. On 5/10/2023 at 10:37 AM, V2 (Director of Nursing -DON) said, Expired medications must be discarded and should not be available in the medication cart to decrease the risk of being given to residents. Expired medications lose potency and can affect a resident who receives it negatively. Policy titled ID1 Storage of Medication, dated 05/01/2028 documents: -The expiration date of the vial or container will be [30] days unless the manufacturer recommends another date -All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining.

Based on observation, interview, and record review, the facility failed to ensure the kitchen was free of expired food products. This failure has the potential to affect 52 residents residing in the facility receiving food from the kitchen. Findings include: On 5/9/23, surveyor observed: Refrigerator #1: -Horseradish with beets; opened 3/7/23 -Lingonberries stirred with sugar; opened 3/28/23 -Nonfat yogurt; expiration date 4/25/23 -Cottage cheese; expiration date 5/7/23 Walk-in refrigerator (kitchen): -Feta cheese; opened 3/19/23; expiration date 1/3/23 -Light and Fit Nonfat yogurt; expiration 4/28/23 Dry storage containers/bins: -Polenta; prep date 11/10/22; use by date 1/11/23 -CousCous; prep date 3/3/23; use by date 3/30/23 Milk refrigerator (basement): -Lowfat yogurt; best by 4/14/23 On 5/10/23 at 1:21 PM, V34 (Dietary Supervisor) stated, There should be no expired food items in the kitchen. We do FIFO (first in first out) method, where we use the old item first. The team lead and person that gets deliveries and everyone in the kitchen is supposed to check the dates. When staff opens something from the refrigerator or shelf, they put the open date and the 6 day period for the discard on the item and check for the manufacturer expiration date. Expired foods can lead to food poison, diarrhea/dehydration, illness, stomach cramps in the resident. 5/10/23 at 1:36 PM, V35 (Cook) stated,When food is expired, I put it in the garbage. It's no good. The resident can get sick if food is expired. When something is opened, put the opened date on it and the date at 6 days. After 6 days it's thrown out. I check the manufacturer date first, if expired then throw it away. On 5/10/23 at 2:38 PM, V36 (Director of Dining Services) stated, Of course, there should not be expired foods in the kitchen. If food is expired, there is a risk of somebody getting sick, diarrhea, vomiting, hospitalization. Opened items are labeled with the date opened and 6 days forward. On the sixth day it should be used or thrown out by the end of the day when the kitchen closes. So not to use expired items, all kitchen staff that handles food is responsible for labeling and discarding if expired. Facility policy Refrigerated Food, 2017, documents in part: Refrigerated food prepared in the healthcare community is labeled with the date to discard or to use by. This includes leftovers. The discard/use by date will be a maximum of six days after preparation. Refrigerated Potentially Hazardous Food (PHF) or Time/Temperature Controlled for Safety (TCS) foods are labeled with the date received and if not opened, are discarded by the manufacturer's expiration date. If opened, the cold food item is labeled with the date opened and the date by which to discard or use by. Facility policy Storage of Refrigerated Foods, 2018, documents in part: Food in the refrigerator is covered, labeled and dated with a use by date. Facility policy Storage of Dry Goods/Foods, 2018, documents in part: Opened products are labeled, dated with the use by date and tightly covered to protect against contamination from insects and rodents.

Based on observation, interview, and record review, the facility failed to follow their policy on ensuring and monitoring all HCP (Healthcare Personnel) Covid-19 vaccination status, and failed to ensure all HCP had complete documentation and records as to Covid-19 vaccination status. These failures have the potential to affect all 55 residents living in the facility. Findings include: On 05/09/2023 at 10:54 AM, V3 (Infection Prevention) submitted a document titled Covid-19 Staff Vaccination Status for Providers that listed 178 staff. V3 said it represents staff that are employees of facility. V3 was asked if the list includes contracted staff, agency staff, and providers. V3 said, Not all are included. Another request was made to V3 to provide list the names of contracted companies, how often services are provided that includes, all therapist, nurses, nursing assistants, hospice staff, medical doctors, and other HCP (healthcare personnel). V2 (Director of Nursing) asked, Only for this week? V2 was requested to include at least few months before or since last survey for contracted staff that worked in the facility. V3 then submitted 2 separate lists, first list included nursing staff that are contracted to agency. The second list, was for rehab, therapists, volunteers, hospice, nurse practitioners, medical doctors, dentists, and care givers. Then another list was submitted by V2, with a title List of Contract Agencies. V2 said, Not all staff on this list of agencies are included on the list (referring to the 2 lists of HCP/Healthcare Personnel), because they did not work for a long time. On 05/09/2023 at 1:36 PM, V7 (Occupational Therapist) and V8 (Occupational Therapist Student) were seen on the floor. V7 said, Yes, me and (V8) are therapist. Yes, we perform direct care to residents. Upon checking all the lists provided by facility, V8 was not included. Prior to formal and comprehensive review of Infection Control and Prevention, V3 was instructed to bring all proof of vaccination for all HCP/healthcare personnel for verification. On 05/10/2023 1:09 PM. V3 (Infection Preventionist) was asked if she (V3) brought all proof of vaccination for staff employees and contracted employees. V3 said, Yes, I have it. V3 was informed that review will be comprehensive, and proof of vaccination will be asked to be presented during review. V3 said, I understand, vaccination card or proof of vaccination will be presented during review. V3 was then asked to present the following HCP/healthcare personnel proof of vaccination: 3 facility employees, scheduled to work, as documented on staffing schedule for the current week were V9 (Certified Nursing Assistant), V10 (Certified Nursing Assistant), and V11 (Certified Nursing Assistant). V3 checked her binder, and was not able to find the information. Every time I mentioned the name of HCP/healthcare personnel, V3 was using her phone by texting/messaging. V3 was asked what was she doing? V3 replied she was informing V2 (Director of Nursing) about my request. Since V3 was unable to provide information for the first 3 staff, V12 (Certified Nursing Assistant), V13 (Certified Nursing Assistant/Agency) and V14 (Certified Nursing Assistant/Agency) were also requested to present proof. V3 was not able to present proof upon checking multiple binders. V3 said, To be honest, for all of those staff you were asking, I cannot find their vaccination cards in the binders. I think it is with Human Resource because they collect their vaccination cards. Yes, me and (V2) are supposed to collect all proof of vaccination. And I agree, even if the staff matrix for Covid vaccination documents that staff received full vaccination, anyone can just record it. Most important is proof of vaccination. V3 was also informed V8 was not included on the list while seen in facility. V3 said, I think I knew who you are taking about. I think (V8) is new. That is why we do not have any vaccination information regarding (V8). Further review of the list provided by facility that includes medical doctors/physicians was compared to primary care physician doctors that was listed on the floor census. Many of medical doctors were not includes on the list including V17, V18, V19, V20, V21, V22, and V23. On 05/11/2023 at 09:52 AM, V2 (Director of Nursing) said, Yes, there are many doctors not included on the list. I know they should be included. Per facility testing documentation, V38 (Certified Nursing Assistant) was tested positive for Covid-19 on 04/04/2023. On 05/11/2023 at 10:41 AM, V2 said, I have bad news for all of you; we have 1 resident that has tested Covid-19 positive. (R112) tested positive. (R112) is exhibiting symptoms so we did Covid-19 testing. I will give you update, because we are now starting to do contact tracing. R112's notes, dated 05/11/2023, reads: Covid-19 testing via anterior nares swab, done. Result positive. Employee Covid-19 Vaccination Policy, dated as revised 09/25/2022, in part reads: Employees have a shared responsibility to assist in the prevention of the spread of infection to residents, co-workers, and the community by taking reasonable precautions, including Covid-19 vaccinations to reduce the transmission of Covid-19 disease. As a result, in keeping with Executive Order that skilled nursing facility employees be fully vaccinated. Under scope, all employees and volunteers at the facility and therapy contractors. All current facility employees, in all classifications (full-time, part-time, temporary/interns, etc.) are required to receive Covid-19 vaccination(s). Employees are required to provide proof of vaccination. Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2 Updated Sept. 23, 2022, in part reads: Healthcare Personnel (HCP): HCP refers to all paid and unpaid persons serving in healthcare settings who have the potential for direct or indirect exposure to patients or infectious materials, including body substances (e.g., blood, tissue, and specific body fluids); contaminated medical supplies, devices, and equipment; contaminated environmental surfaces; or contaminated air. HCP include, but are not limited to, emergency medical service personnel, nurses, nursing assistants, home healthcare personnel, physicians, technicians, therapists, phlebotomists, pharmacists, dental healthcare personnel, students and trainees, contractual staff not employed by the healthcare facility, and persons not directly involved in patient care, but who could be exposed to infectious agents that can be transmitted in the healthcare setting (e.g., clerical, dietary, environmental services, laundry, security, engineering and facilities management, administrative, billing, and volunteer personnel). For this guidance, HCP does not include clinical laboratory personnel.

Based on observation, interview, and record review, the facility failed to ensure bottles of eye drops were dated when opened. This failure affected two residents (R21 and R30) of ten residents reviewed for medication storage, in a total sample of 35 residents. Findings include: On 3/7/22 between 11:10am and 11:20am during the observation of medication carts and medication rooms, on the eighth floor with V3 (RN/Registered Nurse), the following medications were observed opened with no open dates: R21's 2.5 ml (milliliters) bottle of Latanoprost Ophthalmic solution 0.005%(Percent). R30's 2.5 ml bottle of Latanoprost Ophthalmic solution 0.005%. V3 was asked if the eye drops should be opened without labeling them with the open dates; V3 stated Latanoprost should have an open date because it will expire after six weeks. On 3/8/22 at 1:15pm, V2 (Director of Nursing) stated V2 spoke with the Pharmacist, and the Pharmacist said it's good for 6 weeks at room temperature after opening. On 3/9/22 at 10:45am, V1 (Administrator) presented the storage guidelines for Xalatan (Latanoprost) revised August 2011. This document states, Protect from light. Store unopened bottles under refrigeration at 36 to 46 degrees Fahrenheit. Once a bottle is opened for use, it may be stored at room temperature up to 77 degrees Fahrenheit for 6 weeks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to track the status of influenza and pneumococcal vaccinations and consents for three residents (R29, R37, and R40), in a sample of 7 residents. Findings include: 1. On 3/09/22 at 9:25 AM, R29's electronic immunization record had no influenza or pneumococcal vaccines documented. No consents for either vaccine were found in the electronic medical record. R29 was not listed on the influenza or pneumococcal immunization report provided to the surveyor by V10 (Infection Preventionist). R29 was admitted on [DATE]. 2. On 3/09/22 at 10:34 AM, V10 stated V10 is still working on obtaining the Influenza/Pneumococcal consents for the residents requested 3/08/2022. V10 stated R37 is from the assisted living portion of the facility, and V10 will have to obtain the consents from them. R37 is currently in the short-term rehab. On 3/09/22 at 11:53 AM, R37's electronic immunization record had no influenza or pneumococcal vaccines documented. No consents for either vaccine were found in the electronic medical record. R37 was not listed on the influenza or pneumococcal immunization report. R37 was admitted on [DATE]. 3. On 3/09/22 at 11:54 AM, R40's electronic immunization record had no influenza or pneumococcal vaccines documented. No consents for either vaccine were found in the electronic medical record. R40 was not listed on the influenza or pneumococcal immunization report. R40 was admitted on [DATE]. On 3/09/22 at 3:10 PM, the surveyor asked V10 (Infection Preventionist) if there is a specific policy on tracking of influenza and pneumococcal vaccination status for residents. V10 stated, I don't believe there is a specific policy. V10 stated the immunization report provided to the surveyor was run from the electronic medical record, and that's where the consents and immunizations are documented. The surveyor asked V10, how do you know who is due for a pneumonia or influenza vaccine? V10 stated the floor nurses are responsible for checking the vaccination status. V10 stated, Moving forward, I can take over the task and create a more streamlined process. On 3/10/2022 at 10:16 am, the surveyor interviewed V2, DON (Director of Nursing) and asked if a resident declines influenza/pneumococcal vaccination and is eligible to receive the vaccine, what is the expectation for following up with the resident? V2 stated they do follow up with the residents or the resident's family yearly to see if they want to be vaccinated. So, the expectation for someone who refused vaccination in the past is to follow up the next year. The surveyor asked who is responsible for making sure residents are up to date with the influenza and pneumococcal vaccinations? V2 stated the nurses on the floor check the vaccination status, and audits are done from the electronic medical record. V2 stated V2's supervisor has an admission audit form. V2 stated V2 also talks with the staff, especially for new admissions, to make sure that they have current vaccinations. V2 stated V10 (Infection Preventionist) offered to take over the responsibility of tracking influenza and pneumococcal vaccinations and consents. The surveyor asked V2 what is the importance of making sure that influenza and pneumococcal vaccinations are up to date? V2 stated, Aside from compliance, we want to make sure our residents are protected. V2 stated a lot of the residents in the facility are immunocompromised so the best way to protect them is to make sure they have been vaccinated. The facility policy titled Influenza and Pneumococcal Immunizations for Residents, dated 7/2018, has no procedure for tracking of influenza and pneumococcal vaccines.