**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the safety and supervision was maintained for 2 of 3 residents (R1, R2) reviewed for elopement in the sample of 3. The findings include:On 8/6/2025 R1 was observed in the activity room, sitting in a recliner. R1 looked at surveyor and smiled when surveyor waved at him. R1 was observed at 3:46 PM in the dining room in another activity. R1 was sitting at a table with other residents and their family. R1 was smiling while sitting at the table. R2 was observed on 8/6/2025 sleeping while sitting up, on a couch on the 300 wing. R2 was observed on 8/7/2025 during the lunch meal eating. V2 (unit coordinator/social services) was sitting next to R2 encouraging intakes. R2 was observed being assisted with walking to his room and being provided personal cares. R2 was resistive to care at first, but staff were able to convince R2 to allow them to assist him. On 8/6/2025 at 3:07 PM, V3 (Licensed Practical Nurse-LPN) said she was not working when the incidents occurred. V3 said she was told R1 and R2 both got off the memory care unit. V3 said R1 and R2 both have a wander guard in place. The wander guards work for the main entrance to the memory care unit. They do not work for the exit doors. V3 said at the beginning of her shifts, she checks to make sure all the exit doors are secure and do not open when she pushes on them. V3 said she makes sure the light is blinking; that means the door is secure and locked. V3 said she makes sure the alarm sounds when the handle is pushed in. V3 said R2 is new to the facility and staff. He has been at the facility for less than a week and staff are all getting to know him. He walks a lot. Today he has been pushing the door. It will make the initial sound, and he would walk away from it. He has done it at least once, maybe a couple times. V3 said it was on second shift that R2 got out. She is not sure what shift R1 got out. V3 stated, I am a floor nurse. my job is to keep the residents on the unit as safe as possible.On 8/6/2025 at 3:30 PM, V2 (Memory Care Coordinator/Social Services) said she was not at the facility for either incident. V2 said both incidents happened on second shift. V2 said she wasn't aware of what all happened, or how they both got out. V2 said the exit doors on the memory care unit have a dual alarm and the bar alarm. The dual alarm is on the door and goes off when the door is opened. The bar alarm goes off when the bar is pushed on the door handle. V2 said she does not know what happened to allow both R1 and R2 to get out without the doors alarming. V2 said she knows R2 had triggered the alarm earlier, but she does not know how much later it was before he got out of the building. V2 said she does not know if the door was alarmed or not. V2 said she asked the nurse about R2's incident. V2 said she asked if the door alarm was set. V2 said the nurse said it was flashing and when the handle was pushed in, it alarmed. V2 said she was not sure about the details of when R1 got out of the building. V2 identified V11 (LPN) as the nurse on duty when R2 got out of the building. V2 said V11 is new to the facility. V2 identified V5 (LPN) as the nurse on duty when R1 got out of the building. On 8/6/2025 at 3:50 PM, V5 (LPN) said R1 got out of the building on 7/3/2025, after dinner, between like 6:00 -7:00 PM. V5 said there were certain times where R1 would start having episodes of confusion. R1 would get agitated easily. R1 thought he was supposed to be going home to his wife. V5 said that day we had to redirect him more frequently. R1 went to the end of hall 1, took his walker, banged it up against the door and set the alarm off. V5 said he (V5) was passing medications on hall 300. I heard the Activity Aide say the alarm was off and someone is trying to get outside. V5 said he and V12 (CNA) ran to the door. It was open. V5 said R1 was about 10-15 feet from the door. on the sidewalk. (V12) and I ran out to R1. V5 said they were able to easily redirect R1 back into the building and gave him his after-dinner snack. V5 said he has been told during reports that R1 has tried to get out before by banging his walker against the door and set the alarm off. V5 said the nurse must manually reset the door alarm, after the door is opened and it alarms. V5 demonstrated how the door alarm is reset. V5 said the light could be red but not blinking if the latch is not all the way shut. To reset the alarm, you put the key in, turn it, then you make sure the latch is on the inside of the door, and push on the door to make sure it does not come open. You remove the key. the light will be red at first, then if set right, it will start blinking. V5 said you push the handle in, and the door will beep. At 4:20 PM, V5 came up to this surveyor and said the Aide yelled alarm going off, not alarm is off.On 8/7/2025 at 8/7/25 at 8:39 AM, V8 (Activity Aide) said she has been an activity aide on the Terrace unit since Mid-May. V8 said she was working on 7/3/2025 when R1 got out of the building. V8 said it was between 7:00-8:00 pm. V8 said after dinner we went to the TV room. At first, (R1) was fine, but he gets overstimulated. V8 said R1 gets mad and wants to leave. V8 said she let V5 (LPN) know that R1 wanted to leave the TV room and V5 told her to let him go down the hall and we will watch him. V8 said she saw R1 go down hall 1. She did not see him for about 5 minutes, so she asked V5 if he had seen R1. He said no. V8 said she started looking in resident rooms on hall 1. As she got to the end of the hall, she saw the exit door was opened a crack. V8 said the alarm was not sounding. V8 said she looked out and saw R1 near the end of the sidewalk by the parking lot. V8 said she had her foot holding the door open. she asked R1 what he was doing and R1 said I'm going home. V8 said she kept trying to get him to come in and he said no. V8 said she opened the exit door and yelled for help. V12 (CNA) and V5 (LPN) came out a minute later. They came out the visitor door by the terrace entrance and came around the building. V8 said it took about a minute after they came out to get R1 to come inV8 said R1 gets aggressive at times and punches at staff. V8 said she was not informed R1 was an elopement risk. I'm not aware of an elopement list for residents. V8 said after she got off work, she reported the incident. V8 said it was about two hours after the incident occurred and she does not believe V5 had reported the incident to V1 yet. V8 said I'm guessing someone turned the alarm off and did not reset it, because they got tired of hearing it. V8 said she has seen R2 try to get out. He will push on the door handle, it beeps, and staff redirect him. V8 said a resident is an elopement risk if they wander and talk about wanting to leave.On 8/7/2025 at 4:09 PM, V12 (CNA) said she was working the night R1 got out of the building. V12 said she thinks she was in with another resident providing care. She thinks she was going out of the room to get something and saw R1 outside as she was going past the window. V12 said she let V5 (LPN) know, and they both went out there immediately. V12 said the alarm was not sounding. V12 said she was not aware that R1 was exit-seeking. V12 said she had been employed at the facility for 5 months, but she floats all over the building. V12 said a resident is an elopement risk if they wander. V12 said once we saw R1, he was easily redirected back into the building. I believe he was wearing jeans and a flannel shirt and shoes. V12 said R1 was still on the sidewalk when we went out to get him.R1's progress note dated 7/03/2025 21:27 written by V5 (LPN) showed, While assisting other patients to their bedrooms and CNAs also provide care for other patients in their bedrooms. The tv room staff member monitoring the patients, suddenly she heard exit door alarm sound off. She noted that a patient set the alarm off at one of the exits on the unit by opening a door while exit seeking. The patient then wandered out the door onto the sidewalk outside the door. The patient was 15 steps out the door on the sidewalk. I the Nurse was updated by the CNA, so we then both ran outside to the patient. We then redirected patient to come back into the building and he agreed. Patient had on his shoes and was using his walker with a steady gait and no injuries. Patient is confused and states where am I. Assisted patient to a recliner in the TV room, where a staff member could supervise patient's behaviors and exit seeking attempts. Patient stated where am I, and when can I go home. Offered to toilet the patient and he stated No, I don't have to use the bathroom. Patient assisted back into building by using redirection. Educated the patient on safety and educated patient that exit when opened will set off alarms. Patient unable to learn d/t diminished cognitive skills. Assisted Back to his recliner. Re-locked exit door and set alarm again and alarm is activated and functional. Will continue to monitor. Please see nurse's notes for more details. R1's progress note dated 7/2/2025 showed he was exit-seeking. R1's facility assessment dated [DATE] showed he had severe cognitive impairment, had wandering behaviors daily, used a wheelchair or walker for ambulation, and required supervision or touching assist with walking. R1's care plan initiated on 12/6/2024 showed he was at risk for wandering/Elopement.R1's Elopement Risk Assessments dated 12/6/2024, 3/12/2025, 7/7/2025 and 8/6/2025 all showed he was at risk for elopement.R1's progress note dated 7/03/2025 21:27 written by V5 (LPN) showed, While assisting other patients to their bedrooms and CNAs also provide care for other patients in their bedrooms. The tv room staff member monitoring the patients, suddenly she heard exit door alarm sound off. She noted that a patient set the alarm off at one of the exits on the unit by opening a door while exit seeking. The patient then wandered out the door onto the sidewalk outside the door. The patient was 15 steps out the door on the sidewalk. I the Nurse was updated by the CNA, so we then both ran outside to the patient. We then redirected patient to come back into the building and he agreed. Patient had on his shoes and was using his walker with a steady gait and no injuries. Patient is confused and states where am I. Assisted patient to a recliner in the TV room, where a staff member could supervise patient's behaviors and exit seeking attempts. Patient stated where am I, and when can I go home. Offered to toilet the patient and he stated No, I don't have to use the bathroom. Patient assisted back into building by using redirection. Educated the patient on safety and educated patient that exit when opened will set off alarms. Patient unable to learn d/t diminished cognitive skills. Assisted Back to his recliner. Re-locked exit door and set alarm again and alarm is activated and functional. Will continue to monitor. Please see nurse's notes for more details. R1's progress note dated 7/2/2025 showed he was exit-seeking. R1's facility assessment dated [DATE] showed he had severe cognitive impairment, had wandering behaviors daily, used a wheelchair or walker for ambulation, and required supervision or touching assist with walking. R1's care plan initiated on 12/6/2024 showed he was at risk for wandering/Elopement.R1's Elopement Risk Assessments dated 12/6/2024, 3/12/2025, 7/7/2025 and 8/6/2025 all showed he was at risk for elopement.On 8/6/2025 at 4:25 PM, V6 and V7 (maintenance) tested the alarms on the four exit doors on the memory care unit. V7 said they have not figured out what happened when R1 got out. Maybe someone went out and forgot to reset the alarm. V7 said the exit door on wing 1 is not a normal passage door. V7 said they tested all the doors the next day on the unit and the alarms worked properly. V6 pushed on the handle to the exit door on wing 1 and the alarm beeped. When he opened the door, the alarmed sounded. The wing 1 exit door opened onto a sidewalk that went to the terrace entrance parking lot. Between 4:34 PM-4:40 PM the alarms for the exit doors on wings 2, 3, and 4 were observed. All the doors alarmed when the door was opened. Wing 4 exit door opened to a grassy area, then gravel area, then more grass that led up to the apartments next door. V7 said he is not sure where R2 was found, but it was somewhere between the exit door and the apartments next door. V6 said the facility has ordered new dual alarms because the only one that worked properly when maintenance checked the next day was the dual alarm on wing 1. V6 said the door alarms were working, but not the secondary alarms that were in place. Waiting on new alarms to be delivered. On 8/1:32 PM, V11 (LPN) said she was the nurse working on the terrace unit on 8/3/2025. V11 said R2 wanders. He has terminal restlessness. He can be exhausted and still walk. V11 said she heard the door alarm go off for hall 4. V11 said she reset the alarm, pushed on the door and the door did not give. the red light was blinking. V11 said later, she was informed by another nurse that someone from the apartments behind the terrace called and said an older man was walking behind the terrace. V11 said she went around the building and walked the perimeter. V11 said she saw R2 walking on the sidewalk about 10-15 feet from the hall 4 exit door. V11 said she is a terrible judge of distance. V11 said it was about halfway between hall 3 and hall 4 exit doors. V11 said R2 was just walking. He had on shoes. gray lounge pants and a t-shirt. V11 said it was probably between 7:30-8:00 PM. V11 said the alarm did not go off when R2 went out. V11 said the wing 4 door alarm was not working properly. V11 said she did not know if it was due to the heat/humidity that the door stuck in the jam. V11 said it was solid in the door jam, but there was a small space between the jam and the door and for some reason it knew the door was in the jam but not far enough to alarm. V11 said she walked with R2 around the courtyard and sat on the bench for a few minutes. V11 said R2 wanted to walk again so they walked and sat on the next bench. V11 said she knocked on the window and told a staff member to bring her a wheelchair. V11 said R2 always tries to get out of building to go home. To go to dinner with his kids, or to go to work. V11 said R2 is always going somewhere. On 8/7/2025 at 10:14 AM, V9 (CNA) said she works on the terrace unit 90% of the time. I worked on 8/3/2025 on the terrace. I left at 6:00 PM. V9 said R1 and R2 are both elopement risks. R1 has said he wants to go home. V9 said she has seen R2 push on the exit doors. V9 said she was not sure if there was a list on the terrace of residents at risk of elopement. V9 said R1 and R2 both have a wander guard. The wander guard only works on the main entrance to the Terrace unit. V9 said Sunday evening she got a message saying she had to get marked off on the door again. V9 said the last one time she recalls being marked off for training on the exit doors was about a year and a half ago, adding her timing could be off a little. R2's progress note dated 8/2/2025 showed he was ambulating all over unit, undressing and setting off door alarms. Very difficult to redirect. Did take his medications tonight. Would not stay put to eat any supper. R2's 7/30/2025 BIMS evaluation showed R2 had severe cognitive impairment. R2's 7/30/2025 Elopement assessment showed he had wandering behaviors that could affect the privacy of others, and he was at risk of elopement. R2's Elopement Risk Evaluation dated 7/30/2025 showed he was at risk of elopement. R2's care plan initiated 7/30/2025 showed he demonstrates behaviors that may be interpreted as wandering, pacing, roaming, exit-seeking. Symptoms are manifested by pacing, roaming, or wandering in and out of peers' rooms. R2's progress notes dated 8/3/2025 at 10:58 AM showed he was pacing the unit for extended periods of time, anxiousness, and being easily distracted impair his ability to sit for extended periods of time.R2's progress note dated 8/3/2025 showed a skilled evaluation was done for R2 at 9:39 PM. No documentation of R2's elopement was in the evaluation, or in the progress notes on 8/3/2025.The facility's investigation for R2's 8/3/2025 incident showed typed statements from V11 and V19 (CNA) saying the alarm had been sounding. Neither statement was signed by V11 or V19. Neither statement was handwritten by V11 or V19 (V11 said in interview with this surveyor that the alarm was not sounding). The facility's policy and procedure titled Elopements and Wandering Residents, with a revision date of 12/1/2024, showed, This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk . The policy defines elopement as occurring when a resident leaves the premises. The policy showed 1. The facility is equipped with door locks/alarms to help avoid elopements. 2. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. the policy and procedure showed the procedure for locating a missing resident included a. Any staff member becoming aware of a missing resident will alert personnel using facility approved protocol. (e.g. internal alert code). B. The designated facility staff will look for the resident. C. If the resident is not located in the building or on the grounds, Administrator or designee will notify the police department and serve as the designated liaison between the facility and the police department. The Administrator or designee should also notify the company's corporate office. D. DON (Director of Nursing) or designee shall notify the physician and family member or legal representative. E. Police will be given a description and information about the resident; include any photos. F. All parties will be notified of the outcome once the resident is located. G. Appropriate reporting requirements to the State Survey agency shall be conducted.

Based on observation, interview, and record review the facility failed to ensure residents were issued an advanced beneficiary notice form. This applies to 3 of 3 residents (R9, R83, and R289) reviewed for beneficiary notices in the sample of 19. The findings include: 1. R9's NOMNC (Notice of Medicare Non-Coverage) form signed on 3/6/25 shows R9's last covered day of services from Medicare Part A was 3/8/25. Facility completed SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review form for R9 shows that R9 was provided a NOMNC form but was not provided an ABN (Advance Beneficiary Notice) form. R9's census profile shows R9 still resides in the facility and is using personal insurance is R9's payer source. 2. R83's NOMNC (Notice of Medicare Non-Coverage) form signed on 2/21/25 shows R83's last covered day of services from Medicare Part A was 2/23/25. Facility completed SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review form for R83 shows that R83 was provided a NOMNC form but was not provided an ABN (Advance Beneficiary Notice) form. R83's census profile shows R83 discharged from the facility on 2/28/25 and had a payer source of private pay from 2/24/25 until 2/27/25. 3. R289's NOMNC (Notice of Medicare Non-Coverage) form signed on 3/14/25 shows R9's last covered day of services from Medicare Part A was 3/16/25. Facility completed SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review form for R289 shows that R289 was provided a NOMNC form but was not provided an ABN (Advance Beneficiary Notice) form. R289's census profile shows R289 still resides in the facility and is using private pay as R289's payer source. On 4/30/25 at 12:18 PM, V22 (Social Services Director) said V22 and V24 (Memory Care Coordinator/Social Services) provide the residents with the NOMNC forms. When this surveyor asked V22 and V24 about their ABN form, V22 stated that the form looked familiar, but V22 does not provide it to the residents and V24 stated V24 has never seen the ABN form before. V22 stated V23 (Business Office Manager) would be the one to go over the financial aspect of the discharge process with residents. On 4/30/25 at 12:26 PM, V23 said he does not complete or provide the residents with an ABN form. V23 did say he goes over the financial portion of the discharge, but V23 does not document these interactions anywhere. On 4/30/25 at 12:34 PM, V24 said when V24 provides the residents with the NOMNC form, V24 is not in attendance. Facility Advance Beneficiary Notices policy dated 12/23 states, It is the policy of this facility to provide timely notices regarding Medicare eligibility and coverage . 5. The current CMS (Centers for Medicare and Medicaid)-approved version of the forms shall be used at the time of issuance to the beneficiary (resident or resident representative). Contents of the form shall comply with related instructions and regulations regarding the use of the form. a. For Part A items and services, the facility shall use the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN), Form CMS-1005.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure activity of daily living (ADL) assistance was provided for a dependent resident for 1 of 19 residents (R40) reviewed for ADLs in the sample of 19. The findings include: R40's admission Record dated April 29, 2025, shows she was admitted to the facility on [DATE], with diagnoses including major depressive disorder, osteoarthritis, and alzheimer's disease. R40's Care Plan initiated January 6, 2025, shows R40 has an ADL self-care performance deficit. On April 28, 2025, at 10:06 AM, V4 and V5 Certified Nursing Assistants (CNA) went into R40's room to provide incontinence care. R40 told V4 and V5, I'm wet. V4 CNA told this surveyor that R40 was a get up. Meaning R40 should have been gotten up by night shift early in the morning. V4 removed R40's incontinence brief. There was a thick incontinence pad inside of R40's incontinence brief. Both the pad and R40's incontinence brief were saturated with dark urine from front to back. V4 said she did not know why R40 had an incontinence pad plus an incontinence brief on. V4 also said she does not know when R40's incontinence brief was last changed. On April 29, 2025, at 12:28 PM, V7 CNA said incontinence care should be done at least every two hours so the residents skin stays dry. It helps to prevent sores. V7 said an incontinence pad should not be place with an incontinence brief. R40's Minimum Data Set (MDS) dated [DATE], shows, she does not have any history of refusing cares. R40 is occasionally incontinent of urine and is dependent on staff for toileting and personal hygiene. The facility's Activities of Daily Living (ADLS) policy revised December 1, 2024, shows, A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to initiate a pre-surgical order for a resident prior to his abdominal surgery. The facility failed to implement treatment orders for a resident with compression fractures of her spine. These failures apply to 2 of 19 residents (R43 and R390) reviewed for quality of care in the sample of 19. The findings include: 1. R43's admission Record showed R43 was admitted to the facility on [DATE] with diagnoses of dementia, Alzheimer's Disease, atrial fibrillation (a-fib), and long-term use of anticoagulation medications. R43's current care plan showed R43 was cognitively impaired related to his diagnoses of dementia and Alzheimer's Disease. R43's December 2024 Medication Administration Record (MAR) showed R43 was prescribed Pradaxa 150mg (milligrams), give one tablet twice a day for anticoagulation therapy related to his diagnosis of a-fib. On 4/28/25 at 1:15 PM, V14 (Family of R43) stated, My biggest concern is the lack of communication at the facility. (R43) was a scheduled to have (abdominal) hernia surgery in December (2024). It was originally scheduled for December 11th (2024). When I visited him a few days before the surgery, I found out that they never stopped his blood-thinning medication. They were supposed to stop the medication for three days prior to his surgery. (V15 Nurse for R43's Surgeon) faxed all his pre-op (operation) orders and instructions to them (the facility) at the end of November (2024). Since they didn't stop his medication, we had to reschedule (R43's) surgery. A fax dated 11/27/24, sent from R43's surgeon's office to a fax number at the facility, contained R43's pre-op instructions, orders, and date of the surgery. It showed R43's hernia surgery was scheduled for 12/11/24. The fax showed, Surgery date and pre-op instructions .Please hold (R43's) Pradaxa for 3 days prior to surgery . A progress note dated 12/9/24 for R43 showed R43's hernia surgery was rescheduled for 12/13/24 due to R43's Pradaxa medication not being held three days prior (12/8/24-12/11/24) to his original surgery date of 12/11/24. R43's December 2024 MAR showed R43 was given both doses of his Pradaxa on 12/8/24 and 12/9/24. On 4/29/25 at 12:50 PM, V1 Administrator stated, As far as I can tell, it looks like the doctor's office faxed us (R43's) pre-op date and instructions on November 27th (2024) but we either couldn't find them or didn't get them. There are many (fax) machines here in the facility They re-faxed the orders to us on December 9th (2024) . On 4/30/25 at 10:52 AM, V8 Assistant Director of Nursing was shown the fax, dated 11/27/24 from R43's surgeons office, along with the number of the fax that R43's orders were sent to on that date. V8 stated, That's the fax number to the machine by where our receptionist sits. On 4/29/25 at 10:10 AM, V15 (Nurse for R43's Surgeon) stated she herself faxed R43's pre-op orders, instructions, and confirmed surgery date of 12/11/24 to the facility on [DATE]. On 4/30/25 at 8:23 AM, V15 (Nurse for R43's Surgeon) stated, I know someone from the facility had gotten my initial fax (on 11/27/24) because someone called from the facility on December 6th (2024) to schedule (R43's) two-week post-op appointment for his December 11th surgery. I have it documented in (R43's) chart . V15 was unable to remember the name of the employee from the facility that called on 12/6/24. V15 stated, On December 9th, (V14 Family of R43) called me to tell me they had never held his Pradaxa, so we had to reschedule his surgery. I called the facility and whoever I spoke with told me the fax that I had originally sent had gone to some reception desk at the facility. I then re-faxed the information I had initially sent to the facility on November 27th, which showed a new surgery date of December 13th . 2. R390's admission Record showed R390 was admitted to the facility on [DATE]. R390's hospital discharge instructions and orders dated 4/4/25 showed R390 had a diagnosis of compression fractures to her spine. The orders showed R390 was admitted to the facility with an order for R390 to wear a back brace, for treatment of her spinal fractures, when out of bed. R390's April 2025 Order Summary Report showed an order for R390 To wear back brace when OOB (out of bed) and active. Back brace to be off when in bed. On 4/28/25 at 8:57 AM, R390 was seated in the recliner in her room. No brace was noted to R390's back. On 4/28/25 at 12:30 PM, R390 remained seated in the recliner in her room. No brace was noted to R390's back. On 4/29/25 at 9:00 AM, R390 was seated in the recliner in her room, visiting with family. No brace was noted to R390's back. On 4/29/25 at 9:15 AM, V17 Licensed Practical Nurse stated, (R390) does have a brace for her back she is supposed to wear when she is out of bed. I believe it's because she has fractures in her back. The facility's Consulting Physician/Practitioner Orders (undated) showed, Consulting physician/practitioner orders are those orders provided to the facility by a physician/practitioner other than the resident's attending physician or physician/practitioner who is acting on behalf of the attending physician . For consulting physician/practitioner orders received in writing or via fax, the nurse in a timely manner will . Follow facility procedures for verbal or telephone orders including noting the order, submitting to pharmacy, and transcribing to medication or treatment administration record .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R40's admission Record dated April 29, 2025, shows she was admitted to the facility on [DATE], with diagnoses including bilateral osteoarthritis of knees, anemia, major depressive disorder, osteoporosis, and alzheimer's disease. R40's Care Plan initiated December 30, 2024, shows R40 has had an actual fall related to poor balance and unsteady gait. Sensor alarm place in chair and bed for safety. R40 's Fall Risk Evaluation dated March 24, 2025; shows she has had 1-2 falls in the past three months. R40's gait/balance is not checked and does not contain a total fall risk score. On April 28, 2025, at 10:06 AM, V4 and V5 Certified Nursing Assistants (CNAs) transferred R40 from her bed to her chair. V4 and V5 were holding onto a gait belt, but R40 did not bear any weight on her legs. V4 and V5 transferred R40 to her wheelchair by lifting R40 via the gait belt. R40 needed to be scooted back into the wheelchair and V4 and V5 lifted R40 back by holding under her arms and her legs. R40's bed alarm did not sound when R40 was transferred into her wheelchair nor was a wheelchair alarm applied to her chair. R40's Skin Wound Notes dated March 31, 2025, shows R40 experienced a skin tear during a transfer. R40's Nurses notes show on April 24, 2025, R40 was lowered to the ground by a (CNA) while in the resident bathroom. Resident states her knees quit working. On April 28, 2025, R40 lost her balance during a shower and had to be assisted back in her shower chair by the CNA and R40 experienced another skin tear. On April 30, 2025, at 10:02 AM, V3 CNA said if a resident seems weak before transferring, then she notifies the nurse. V3 said if residents are not bearing weight, then the nurse and therapy needs to re-evaluate them. V3 said if a resident is not bearing weight, then the resident or staff could get injured. V3 said the R40 does not bear weight to her legs. V3 said that R40 has been a very tough transfer. The facility's Safe Resident Handling/Transfers policy revised on December 1, 2024, shows, It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. The resident's mobility needs will be addressed on admission and reviewed quarterly, after a significant change in condition or based on direct care staff observations or recommendation. Based on observation, interview and record review the facility failed to ensure residents were transferred in a safe manner for 2 of 19 residents (R30 and R40) reviewed for safety and supervision in the sample of 19. The findings include: 1. R30's Fall Risk Evaluation dated 4/15/25 showed R30 was at risk for falls due to her history of falls, decreased muscular coordination, and use of ambulatory assistive devices. R30's Restorative assessment dated [DATE] showed R30 required the assistance of one staff member for transfers and toileting. On 4/28/25 at 9:45 AM, R30 was seated in a recliner in her room. R30 told V18 Certified Nursing Assistant (CNA) that she needed to go to the bathroom. V18 CNA transferred R30 from the recliner to a wheelchair by holding onto the waistband of R30's pants and lifting R30 out of the recliner. V18 then wheeled R30 into the bathroom. V18 transferred R30 from the wheelchair to the toilet by holding onto the waistband of R30's pants. No gait belt was used by V18 CNA for either of R30's transfers. On 4/29/25 at 11:35 AM, V19 CNA stated R30 requires the assist of one person for all transfers which means we use a gait belt when transferring her. The facility's Use of Gait Belt policy (undated) showed, It is the policy of this facility to use gait belts with residents that cannot independently ambulate or transfer for the purpose of safety .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents with dementia received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for 2 of 12 residents (R73 and R76) reviewed for dementia care in the sample of 19. The findings include: 1. R73's admission Record dated April 29, 2025, shows R73 was admitted to the facility on [DATE], with diagnoses including neurocognitive disorder with lewy bodies, alzheimer's disease with early onset, anxiety disorder, major depressive disorder, dementia, and a history of falling. R73's Care Plan revised on November 1, 2024, shows, R73 exhibits resistance to cares: (refusing/resisting medication, refusing/resisting activities of daily living assistance, refusing/resisting food and/or fluids; refusing requests to get out of bed, refusing to cooperate with care plan objectives) related to psychiatric illness, severe mental illness, dementia, fear/paranoia, misunderstanding caregiver requests. Create a warm, safe, and inviting environment for care. Emphasize dignity. Emphasize soothing, kind, slow, and compassionate speech. Give resident time to respond verbally and physically. If attempts to redirect are unsuccessful, try switching staff. Remind resident that they are safe, and staff will protect them. Staff to have a wheelchair with them when resident is showing signs of being resistive to cares. On April 28, 2025, at 11:14 AM, V5 Certified Nursing Assistant (CNA) said, Come on [R73] lets go to the bathroom. V5 held R73 hand and guided him to stand up. V4 CNA was standing behind R73. R73 was planting his feet and not walking. V5 was attempting to slowly guide R73 by holding his hand. V4 had both of her hands to R73's back and was pushing R73 towards the bathroom with both of her hands and her body. It took V4 and V5 more than a few minutes to walk R73 to the bathroom as he did not want to walk. On April 29, 2025, at 12:28 PM, V7 CNA said if R73 is not walking somewhere, then she would get a chair so he could sit down. V7 said time should be given to R73 and then re-approach him later. V7 said she sometimes offers R73 snacks or dances with him to help him reach his destination. V7 said it takes R73 a while to get to a destination, he just needs time. 2. R76's admission Record dated April 29, 2025, shows she was admitted to the facility on [DATE], with diagnoses including dementia, anxiety, contusion of scalp, restlessness and agitation, and dementia. R76's Care Plan initiated October 10, 2024, shows R76 may exhibit resistance to cares: Create a warm, safe, and inviting environment for care. Emphasize dignity. If attempts to redirect are unsuccessful, try switching staff. Staff will assist with ambulation as needed with use of assistive devices and give the resident as many choices as possible about care and activities was initiated September 27, 2024. On April 28, 2025, at 11:25 AM, R76 was sitting in the units dining room. R76 kept trying to stand up and walk. V4 CNA stood behind R76, place V4's hands onto R76's shoulders and said hey down and guided R76 to sit back down into the chair and walked away. At 11:29 AM, R76's was continuing to stand and try to walk. The unit manager took R76 for a walk around the unit and then brought R76 back to the dining room and R76 sat down to eat her lunch. On April 29, 2025, at 8:30 AM, V7 CNA was walking the unit with R76 because R76 was continuing to stand up and attempting to walk. On April 29, 2025, at 12:28 PM, V7 said if R76 is trying to stand then staff should try and involve R76 in an activity or take R76 for a walk. The facility's Dementia Care Policy dated December 1, 2024, shows, It is the policy of this facility to provide the appropriate treatment and services to every resident who displays signs of or is diagnoses with dementia, to meet his or her highest practicable physical, mental, and psychosocial well-being. Individualized, non-pharmacological approaches to care will be utilized, to include meaningful activities aimed at enhancing the resident's well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to address an irregularity found by the pharmacist during the monthly medication review for 1 of 5 residents (R73) reviewed for drug regimen review in the sample of 19. The findings include: R73's admission Record dated April 29, 2025, shows R73 was admitted to the facility on [DATE] with diagnoses including neurocognitive disorder with lewy bodies, alzheimer's disease with early onset, anxiety disorder, major depressive disorder, dementia, and a history of falling. R73's Medication Regimen Review Prescriber Recommendation (MRR) dated March 11, 2025, shows, Resident is receiving quetiapine and furosemide but has not had any recent labs evaluated. Please consider: CMP (Comprehensive Metabolic Panel) now and every six months thereafter. The recommendation was signed off by the physician and says the order was faxed to lab on March 21, 2025, by a licensed practical nurse. R73's Medication Regimen Review Prescribe Recommendation dated April 15, 2025, shows, Lab results missing: Prescriber checked to get CMP now and every six months per MRR recommendation from March 2025. However, results are not available, and lab order has not been entered. Please enter order if still indicated by provider. The facility's Advanced Practical Nurse signed off the order and wrote April 21, 2025: Schedule for next lab day if not already done. The facility staff signed, Ordered for April 23, 2025. R73's Order Summary Report dated April 30, 2025, +\| which includes discontinued orders show that no CMP lab draw was ordered in March 2025. An + 06.2 3++3602 |order for CMP to be completed next available lab day and every six months was entered on April 21, 2025. On April 30, 2025, at 10:45 AM, V8 Assistant Director of Nursing (ADON) said she did not see an order entered for R73's labs for March. V8 said the order was entered April 2025. The facility's Medication Regimen Review policy revised December 1, 2024, shows, Facility staff shall act upon all recommendations according to procedure for addressing medication regimen review irregularities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident's medication labeling was legible for 1 of 19 residents (R32) reviewed for medication storage and labeling in the sample of 19. The findings include: R32's Order Summary Report dated April 30, 2025, shows she was admitted to the facility on [DATE], with diagnoses including heart disease, unsteadiness on feet, convulsions, dementia, alzheimer's disease, and anxiety disorder. On April 30, 2025, at 9:53 AM, there was a blue bottle that contained white round pills in the locked memory care unit medication cart. R32's name was legible on the pill bottle label. The medication name was illegible and so was the full dispensed date. V20 Licensed Practical Nurse said she did not know what medication it was, but believed it was a hospice medication. On April 30, 2025, at 10:45 AM, V8 Assistant Director of Nursing (ADON) said medications should be legible and if they are not, then it should be replaced. The facility's Labeling of Medications and Biologicals Policy revised December 1, 2024, shows, All medications and biologicals used in the facility will be labeled in accordance with current state and federal regulations to facilitate consideration of precautions and safe administration of medications. Medication labels must be legible at all times. Any medication label that is soiled, incomplete, illegible, worn, of makeshift must be returned and replaced by the issuing pharmacy, not merely covered.

Based on observation, interview, and record review the facility failed to ensure staff wore the required personal protective equipment (PPE) when providing care to a resident on enhanced barrier precautions for 1 of 19 residents (R63) reviewed for infection control in the sample of 19. The findings include: R63's face sheet printed on 4/28/25 indicated R63 had a feeding tube. On 04/28/25 at 09:35 AM, there was a sign on R63's door indicating R63 was on enhanced barrier precautions. The sign indicated staff must wear gloves and gowns for high-contact resident care activities such as changing an incontinence brief or assisting with toileting. On 04/28/25 at 09:35 AM, R63 was in bed connected to his tube feeding. V10 (Certified Nursing Assistant- CNA) and V11 (CNA) entered the room to provide incontinence care and changed R63's incontinence brief as it was soiled with urine. V10 and V11 had gloves on but no gown. V10 and V11 both touched the tubing of R63's tube feeding while providing incontinence care. On 04/28/25 at 10:01 AM, V10 said for a resident on enhanced barrier precautions staff should wear gloves and gowns when providing care. On 04/29/25 at 11:29 AM, V8 (Infection Control Nurse) said a resident with an implanted medical device such as a tube feeding would be on enhanced barrier precautions. V8 said staff should wear gloves and gowns when providing incontinence care to a resident on enhanced barrier precautions. R63's Care Plan with an initiated date of 5/7/24 showed R63 required enhanced barrier precautions because of a tube feeding. Listed under interventions was for staff to wear the necessary PPE when preforming high contact care activities. The facility's Enhanced Barrier Precautions policy with a reviewed date of 12/1/24 showed enhanced barrier precautions refer to an infection control intervention designed to reduce transmission of multidrug-resistance organisms that employs targeted gown, and gloves use during high contact resident care activities. High contact care activities included changing briefs.

Based on observation, interview, and record review the facility failed to ensure pureed pork was pureed to a pudding-like consistency. This applies to 4 of 4 residents (R390, R60, R339, R1) reviewed for pureed diets in the sample of 19. The findings include: Facility provided list of residents on a pureed diet shows R390, R60, R339, and R1 receive pureed diets. On 4/28/25 at 10:04 AM, V13 (Cook) started the puree process for the pureed pork. V13 measured out and weighed enough pork for four servings of pureed pork. V13 placed the pork into a blender pitcher with broth and started to puree the pork. At 10:09 AM, V13 stopped the blender and tested the consistency. V13 said it wasn't quite ready at that time and that the pork tends to be a little stringy and more difficult to puree. At 10:10 AM, V13 stopped the blender, tested it a second time and said it was much better. V13 placed the pureed pork into a food service pan and into the oven. On 4/28/25 at 10:11 AM, the first finished batch of pureed pork appeared to be lumpy as V13 scooped it into the food service pan. On 4/28/25 at 10:14 AM, V13 began the second batch of pureed pork and weighed out enough for three servings. V13 placed the pork into a blender pitcher with broth and started to puree the pork. At 10:15 AM, V13 stopped the blender and tested the pureed pork and said it was not quite ready. At 10:16 AM, V13 stopped the blender, tested the pureed pork again, and said it was good. On 4/28/25 at 9:58 AM, V13 said the consistency of the purees should be a pudding-like consistency. On 4/28/25 at 1:00 PM, the facility provided test tray of pureed pork was stringy, not fully blended, and required chewing. On 4/28/25 at 1:12 PM, V12 (Food Service Director) agreed that the pureed pork was stringy and not of an appropriate texture. Facility Puree Food Preparation policy dated 12/1/2023 states, . Puree means that all food has been ground, pressed and/or strained to a consistency of a soft, smooth, thick paste similar to a thick pudding.

Based on observation, interview, and record review the facility failed to ensure staff wore the required personal protective equipment for a resident on enhanced barrier precautions for 2 of 3 residents (R2 and R3) reviewed for infection control in the sample of 3. The findings include: 1. R2's Face Sheet printed on 10/15/24 showed R2 had a diagnosis of skin cancer to his left ear. On 10/15/24 at 10:58 AM, V6 (Wound Care Nurse) provided wound care to R2's left ear. R2's left ear had a redden opened area smaller than a pea. R2 stated the wound on his left ear was from skin cancer. While providing wound care, V6 had on gloves but no gown. V6 cleansed the wound, applied the ordered cream, and covered the wound with a dressing. 2. R3's Order Summary Report printed on 10/15/24 showed R3 had an order for a cream to be applied to her right great toe and covered with a band aid. On 10/15/24 at 11:14 AM, V6 provided wound care to R3's right great toe. The bottom of R3's right great toe had a wound that was dark and smaller than 0.5 centimeters. While providing wound care, V6 had on gloves but no gown. V6 cleansed the wound, applied the ordered cream, and covered the wound with a band aid. On 10/15/24 at 12:47 PM, V9 (Infection Control Preventionist) stated residents with wounds, not including unopen surgical wounds, are on enhanced barrier precautions. V9 stated staff should wear gloves and gowns when providing wound care. The facility's Enhanced Barrier Precautions with an implemented date of 5/1/24 showed enhanced barrier precautions refer to infection control intervention designed to reduce transmission of organisms that employs targeted gown and gloves use during high contact resident care activities. The same policy showed high contact activities included wound care to any skin opening requiring a dressing.

Based on observation, interview, and record review the facility failed to ensure residents were treated in a dignified manner. This applies to 2 of 13 residents (R12 & R14) reviewed for dignity in the sample of 13. The findings include: 1. On September 16, 2024, at 1:44 PM, R12 stated, V12 Certified Nursing Assistant (CNA) was short with residents. She has gotten to a point where she doesn't want to ask V12 CNA for anything, she does it herself if she can or will wait for someone else. On September 16, 2024, at 2:47 PM, R14 stated, V12 CNA walked into her room one day without knocking. R14 asked V12 CNA, do you let people walk into your room without knocking? V12 CNA responded, I'm not going to talk about that and walked out of R14's room. V12 CNA then refused to help her. On September 16, 2024, at 9:10 AM, V16 CNA stated, V12 CNA is very rude and always yelling at people. On September 16, 2024, at 9:42 AM, V3 CNA stated, V12 CNA has an attitude problem. On September 16, 2024, at 1:14 PM, V2 Assistant Director of Nursing (ADON) stated, V12 CNA has had lots of complaints about her attitude. Residents complain about how she talks to them and treats them. R12 told her that she doesn't ask V12 CNA for anything. V2 ADON stated, if R12 feels like she can't ask staff for things she needs that is a problem. 2. On September 16, 2024, at 3:53 PM, V7 CNA was sitting at the nursing station on her cell phone. On September 16, 2024, at 2:47 PM, R14 stated, staff are always on their phones. I don't think that's right. On September 16, 2024, at 3:25 PM, V1 Administrator stated, staff are not supposed to be on their cell phones. The facility's promoting/maintaining resident dignity dated December 1, 2023, shows, Policy: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. Compliance Guidelines: .10. Speak respectfully to residents; avoid discussions about residents that may be overheard. 11. Respect the resident's living space and personal possessions .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to assess and implement interventions for a known contracture for 1 of 2 residents (R13) reviewed for range of motion in the sample of 18. The findings include: On 05/06/24 at 09:43 AM, R13 was sitting in the recliner in her room. R13's left hand fingers were curled into the palm of her hand. R13 stated I have a brace, but it hurts me, so I don't wear it. They tried putting a rag, it doesn't hurt but it falls out. I have used a carrot thing, but not lately. R13's most recent Care Plan contains no documentation of R13's contracture or range of motion/restorative needs. R13's Minimum Data Set, dated [DATE] shows R13 had functional limitation in range of motion of impairment to one side to upper extremity and lower extremity. On 05/07/24 at 09:30 AM, V6 Registered Nurse stated R13 has a contracture to her left hand. On 05/07/24 at 12:09 PM, V2 Director of Nursing stated she was not familiar with R13's hand contracture and she was not sure who is doing the assessments or where the assessments are documented. V2 stated there should be an order for devices to prevent contractures from worsening if determined by therapy. V2 stated R13's contracture should be part of her care plan. On 05/07/24 at 01:26 PM, V7 Assistant Director of Nursing stated contractures should be assessed quarterly and should be charted under assessments. V7 said the resident's Care Plan should also reflect the contracture and interventions. V7 stated R13 had a stroke affecting her left side and she has a contracture to her left hand. V7 stated Physical and Occupational Therapy does an evaluation of a resident's contracture and interventions needed including braces if needed. V7 stated these interventions will be reviewed with the physician and orders obtained and the residents plan of care is updated. V7 stated she didn't see any plan of care for R13's left hand contracture. On 05/07/24 at 01:44 PM, V8 Physical Therapy Director said R13 has not been seen by therapy since 2023. V8 said she has not known R13 to have a brace since she started working at the facility in June of 2023. V8 stated if R13 had used a brace as an intervention that should be in her care plan that a brace was tried. V8 said R13 should have assessments done on her contracture to make sure it is not getting worse. V8 said she has not done an assessment on R13 and was not sure who was doing them now. V8 said R13's last recommendation (according to the notes from Occupational Therapy) was a splint or carrot for her hand. R13's Occupational Therapy Discharge summary dated [DATE] shows Discharge recommendations: Patient to wear her splint or carrot on left hand to decrease contracture of hand. R13's most recent Rehab Assessment for Functional Status is dated 6/22/2022 and shows no impairment to upper or lower extremity. The facility's Prevention of Decline in Range of Motion Policy dated 12/1/23 shows The facility in collaboration with the medical director, director of nursing, and as appropriate, physical/occupational consultants shall establish and utilize a systematic approach for prevention of decline in range of motion, including the assessment, appropriate care planning, and preventative care.

Based on interview and record review the facility failed to ensure a resident was safely transferred with a sit to stand lift for 1 of 18 residents (R14) reviewed for safety in the sample of 18. The findings include: R14's Fall Incident Report dated 3/14/24 shows, CNA (Certified Nursing Assistant) reported resident was not standing on the stand lift during transfer to the toilet and started letting go of the grab bars. Lowered to the floor by stand lift. On 5/8/24 at 8:47 AM, V16 (CNA) said that she could not remember if she was transferring R14 on or off of the toilet but R14 was positioned by the toilet when she was being transferred with the sit to stand lift. V16 said that she was not standing up very well and kept letting go of the bars of the lift. V16 said that she was the only one in the room transferring her and she knew that she really needed to pull the call light to get help but could not reach it so she slowly lowered R14 to the floor. V16 said that she thinks R14 was changed to a mechanical sling lift after the incident for her safety. R14's Nurses Note date 3/16/24 shows, Does poor with stand lift transfers. Very frequently bends knees and needs constant cueing to stay standing up straight and not bending over. R14's Physical Therapy Evaluation dated 3/23/24 shows, Therapist consulted with nursing staff informing them of pt (patient) failure to allow for continued treatment and reminded that the staff can downgrade her to a (mechanical sling lift) if they feel it is in the best interest of the patient in order to prevent injury. R14's Fall Incident Report dated 3/25/24 shows, Walking past resident room and heard CNA talking with her stating put your feet back on, entered to observe CNA lowering resident to bed, resident was not positioned enough onto the bed and lowered to floor in sitting position. On 5/7/24 at 9:54 AM, V9 (CNA) said that she was getting R14 up in the morning using a sit to stand lift. V9 said that R14 did not want to get up because it was so early in the morning. V9 said that during the transfer R14 said, I am letting go and let go and slide through the sling and landed on the floor. V9 said that she did not have the strap to hold R14's legs in place applied. On 5/8/24 at 8:30 AM, V15 (Licensed Practical Nurse) said that she was walking down the hallway when she heard V9 telling R14 to put her feet back. V15 said that she walked into the room and R14 was on the stand lift and her left foot was off of the base of the stand lift. V15 said that they tried to get her to put her foot back onto the base but she wouldn't and then they tried to get her back onto the bed but could not do that either, so they lowered her to the ground. V15 said that V9 was the only staff member in the room when she walked into the room. On 5/7/24 at 1:26 PM, V8 (Therapy Director) said that all staff should be using two people to perform sit to stand transfers for the resident's safety. On 5/8/24 at 10:00 AM, V17 (CNA) said that two staff members should always be assisting with sit to stand transfers for the resident's safety. On 5/8/24 at 10:38 AM, V2 (Director of Nursing) said that sit to stand lifts require two staff members to perform. V2 said that if a resident is having trouble using the sit to stand lift, it would be common sense to change them to a mechanical sling lift for their safety.

Based on observation, interview, and record review the facility failed to ensure a resident's head remained elevated above 30 degrees while a tube feeding was infusing for 1 of 1 residents (R393) reviewed for tube feedings in the sample of 18. The findings include: R393's face sheet showed R393 had dysphagia (difficulty swallowing), gastrostomy (tube feeding), and gastro-esophageal reflux disease. On 05/07/24 at 10:01 AM, V3 (Certified Nursing Assistant- CNA) and V4 (CNA) entered R393's room to provide incontinence care. R393 was connected to his tube feeding and the tube feeding pump was infusing at 50 milliliters per hour. V4 lowered R393's head of bed below 30 degrees. R393's head of bed was nearly flat. R393's tube feeding continued to infuse. V3 and V4 provided incontinence care as R393 was incontinent of stool. After providing incontinence care, V3 lowered R393's head of bed all the way down and repositioned R393 high up in bed. R393's tube feeding was not paused while his head of bed was lowered below 30 degrees when receiving incontinence care and being repositioned. On 05/07/24 at 10:11 AM, V5 (Registered Nurse-RN) said a tube feeding should be stopped/paused when a resident's head of bed is lowered less than 30 degrees to limit the possibility of the tube feeding going into a the resident's lungs. R393's Order Summary Report showed an order to elevate the head of bed 30 to 45 degrees at all times while tube feeding is infusing. R393's Care Plan for his tube feedings listed under interventions, The resident needs the [head of bed] elevated 45 degrees during and thirty minutes after tube feed. The facility's Care and Treatment of Feeding Tubes policy with a revised date of 12/1/23 showed, It is a policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible.

Based on observation, interview, and record review the facility failed to ensure staff wore isolation gowns when providing high contact care to a resident on enhanced barrier precautions for 1 of 18 residents (R393) reviewed for infection control in the sample of 18. The findings include: R393's face sheet showed R393 had a gastrostomy (tube feeding). On 05/07/24 at 10:01 AM, on the door to R393's room was a sign indicating R393 was on enhanced barrier precautions. The sign indicated staff were to wear gloves and gowns during high contact resident care activities. V3 (Certified Nursing Assistant- CNA) and V4 (CNA) entered R393's room to provide incontinence care. R393 was incontinent of stool and had his adult incontinence brief changed by V3 and V4. During the incontinence care, V4 assisted R393 to turn and held the tubing of the tube feeding. V3 and V4 did not wear isolation gowns when providing incontinence care. On 05/07/24 at 11:31 AM, V2 (Director of Nursing) said residents that have a catheter or implanted medical devices, such as a tube feeding, are placed on enhanced barrier precautions. V2 said when staff provide high contact care activities staff should wear gloves and gowns. V2 added that providing incontinence care is considered a high contact care activity. The facility Enhanced Barrier Precautions policy with an implemented date of 3/23/24 showed, enhanced barrier precautions 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. High contact resident care activities include providing hygiene and changing briefs.

5. R50's Order Summary Report showed an order for Lorazepam (psychotropic anti-anxiety medication) to be given every 6 hours as needed (PRN) that was started on 2/7/24. There was no duration associated with the order. On 5/7/24 at 9:12 AM, V2 (Director of Nursing) said PRN psychotropic medications should have a duration/stop date. The facility's Use of Psychotropic Medication policy with a implemented date of 12/1/22 showed, PRN orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record and for a limited duration (i.e. 14 days). If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she shall document their rationale in the resident's medical record and indicate the duration for the PRN order. 3. R28's Physician Orders dated 4/17/24 shows Lorazepam Oral Concentration 2 MG/ML Give 0.5 ml orally every 2 hours as needed for restlessness. The orders do not contain a stop date or duration. Based on interview and record review the facility failed to ensure as needed (PRN) psychotropic medications had a duration for 5 of 5 residents (R40, R26, R50, R28, R194) reviewed for psychotropic medications in the sample of 18. The findings include: 1. R40's Physician Orders dated 3/10/24 shows an order for Haloperidol Lactate Concentrate 2 MG/ML Give 0.25 ml my mouth every 2 hours as needed for mild restlessness related to unspecified dementia, moderate, with agitation and an order for Lorazepam Oral Concentrate 2 MG/ML Give 0.25 ml by mouth every 2 hours as needed for anxiety related to unspecified dementia, moderate, with agitation. The orders do not contain a stop date or duration. 2. R26's Physician Orders dated 1/27/24 shows an order for Lorazepam Concentrate 2 MG/ML Give 0.25 ml by mouth every 2 hours as needed for anxiety. The orders do not contain a stop date or duration. 4. R194's Physician's Order Sheet printed on 5/7/24 shows an order for Lorazepam 0.5 milligrams (mg)-Give 1 tablet by mouth every 12 hours as needed for anxiety. The order had a start date of 4/19/24 and there was no end date documented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to report a resident injury to the state agency for 1 of 3 residents (R1) reviewed for injuries in the sample of 6. The findings include: R1's admission Record, printed by the facility on 11/8/23, showed she had diagnoses including enterocolitis due to clostridium difficile (C-diff), generalized osteoarthritis, hypertension, a history of falling, iron deficiency anemia, atrial fibrillation, chronic kidney disease, seizures, unsteadiness on feet, lack of coordination, and weakness. R1's care plan, with a revision date of 11/8/23, showed R1 requires sit to stand by staff to transfer. R1's Order Summary Report, printed by the facility on 11/8/23, showed an order for Vancomycin HCL (hydrochloride) 125 mg by mouth two times a day for suspected C-diff for 14 days. R1's facility assessment dated [DATE], showed she was cognitively intact and required extensive assist of staff for toileting. On 11/8/23 at 9:18 AM, R1 was in her room, sitting in her chair. V9 (R1's daughter) was in the room with R1. R1 was making potholders for her family, with the assistance of V9. R1 mostly used her right hand to make the potholders. R1 tried to lift her arm but was only able to lift it a few inches off her lap. R1 leaned her upper body to the right side to try to get the arm up higher, with no success. R1 was also not able to move her left arm outwards, away from her body when prompted to do so by V9. R1 was alert and oriented. R1 said she would say the girl did not know how to use the stand lift machine. R1 said it hurt when the CNA (Certified Nursing Assistant) started lifting her up with the machine, adding I felt like I was being hung. R1 said she yelled at the girl, but she did not stop when she screamed that it hurt. On 11/8/23 at 10:49 AM, V2 and V3 (CNAs) transferred R1 to the bathroom using a sit-to-stand mechanical lift. R1 was only able to raise her left hand a few inches. V2 assisted R1 by grabbing R1's hand and placing it on the handles of the sit-to-stand lift. During the transfer and toilet assist for R1, V2 cued her a couple of times to stand up straight and R1 followed V2's directions. At 11:16 AM, V2 said she worked a double shift from 10:00 PM on 10/29/23-2:00 PM on 10/30/23 and R1 was fine. V2 said R1 was able to lift her arms above her head and put on her shirt and bra. V2 said staff must do the left side now. V3 said she was the CNA for R1 on 10/31/23 on the day shift (6:00 AM-2:15 PM). V3 said R1 was fine during her shift. On 11/8/23 at 1:41 PM, V4 (CNA) said she worked on 10/31/23 from 2:00 PM-10:00 PM. V4 said she is new to the facility. V4 said every time she would try to wipe R1, she (R1) would try to sit down. V4 said she (V4) would then lower the stand-lift. V4 said she got on the walkie-talkie and told V5 (CNA) that she needed help because she was having trouble with R1. V4 said it was up and down, up, and down. V4 denied R1 complaining of any pain while she was in with her. On 11/8/23 at 2:22 PM, V5 (CNA) said she worked on 10/31/23 from 2:00 PM-10:00 PM. V5 said she transferred R1 from the chair to the toilet, then V4 took over so V5 could go across the hall and finish toileting another resident. V5 said V4 called her to come back to R1's room. V5 said V4 told her R1 kept lowering herself down. V5 said V4 told her that she (V4) said she would raise the stand-lift higher, and R1 would lower herself down again. V5 said R1 said Thank God you're here, she was making my shoulders hurt. V5 said she and V4 switched residents. V5 said when she got R1 back in bed, she noticed the skin tear on R1's left arm. V5 said R1 did not complain of pain while she was transferring her from the wheelchair to the toilet and from the toilet to the bed after toileting. On 11/8/23 at 3:33 PM, V7 (R1's Physician) said something happened during the stand-lift transfer and toileting. V7 said he did not think an MRI (magnetic resonance imaging) was needed for the diagnoses of a complete tear in R1's rotator cuff, because R1 has the textbook signs of a complete rotator cuff tear. V7 said he went to the facility and assessed R1. V7 said he would bet a hundred dollars that it is a complete tear in her rotator cuff. V7 said there are very few things that would cause no pain and the resident not being able to move her arm. On 11/8/23 at 9:23 AM, there was no incident reporting an injury to R1 sent to the state agency. At 12:02 PM, V1 (Administrator) said the facility did not report the incident because there was no CT (computed tomography), MRI or X-ray showing that R1 had a tear to her rotator cuff. V1 said the X-ray results showed degenerative joint disease and the MRI is scheduled for 11/16/23. At 10:17 AM, V1 said the facility had not had any injuries of unknown origin the last three months. On 11/9/23 at 2:08 PM, V1 said the facility is waiting for CT or MRI results to confirm the injury. On 11/9/23 at 3:00 PM, V1 provided the facility's policy on reporting serious injuries, which was part of the facility's 12/1/22 Compliance with Reporting Allegations of Abuse/Neglect/Exploitation policy. The policy showed 2. The Administrator or designee will: a. Notify the appropriate agencies immediately; as soon as possible, but no later than 24 hours after discovery of the incident. In the case of serious bodily injury, no later than 2 hours after discovery or forming the suspicion. V1 was asked if that means the injury should have been reported within 2 hours. V1 said after confirmation of a serious bodily injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure an at-risk resident with a history of falls was safe by not providing supervision to prevent falls for 1 of 8 residents (R40) reviewed for falls in the sample of 18. The findings include: R40's face sheet showed a [AGE] year-old male admitted to the facility on [DATE], diagnosis include dementia, repeated falls, urinary incontinence, chronic kidney disease, and hypertension. On 8/1/23 at 12:50 PM, R40 was alone in his room in the recliner. There was a scabbed area noted to the top of his head. On 8/2/23 at 9:45 AM, R40 was alone in his room in a recliner. On 8/2/23 at 1:29 PM, V17, R40's spouse said she was concerned R40 had five falls here since admission. That's litigation level. V17 said she told the facility on admission R40 slept in a recliner at home and not a bed. V17 said R40 had numerous falls at home (prior to admission) and didn't think he (R40) was well supervised at the facility. On 08/03/23 at 10:22 AM, V2 Director of Nursing DON said when R40 is in a wheelchair and doesn't know what to do is when he self-transfers. V2 said (regarding the 6/27/23 care plan intervention), staff are to stay with the resident and keep him within sight, only applies when he is in his wheelchair. V2 confirms there were no supervision interventions for when R40 was in his room. Regarding R40's 7/20/23 fall (out of bed), V2 said there was agency or float pool staff that would not necessarily have been familiar with the resident. (Regarding the 7/29/23 fall) V2 said I don't know if memory wise he could recall instruction after some time. V2 acknowledged R40 had five falls within a month in his room and said I think the interventions (for fall prevention) are appropriate. V2 said they provide increased supervision, distraction, and activities. V2 said such interventions are not on his plan of care but we need to have those types of interventions in his care plan. The facility's 12/2/22 Fall Risk Assessment Policy showed it is the policy of the facility to provide supervision to each resident to prevent avoidable accidents. An at risk for falls care plan will include interventions, including adequate supervision, consistent with a resident's needs, goals, and current standards of practice in order to reduce the risk of an accident. R40's fall incidents showed 5 falls from 6/27-7/29/23. On 7/3/23 and 7/20/23, R40 fell out of bed. All five falls occurred in the resident's room. R40's room was not in sight of the nurse's station. R40's 6/27/23 10:40 PM fall report showed an unwitnessed fall in his room and a bruise was noted to his abdomen. The 7/3/23 2:55 AM fall report showed an unwitnessed fall as R40 rolled out of bed in his room and a skin tear was noted to the top of his scalp. The 7/9/23 at 2:58 AM fall report showed an unwitnessed fall in his room. The 7/20/23 at 4:40 PM fall report showed an unwitnessed fall (out of bed) and a skin tear to the left knee. The 7/29/23 at 4:35 PM fall report showed a fall in his room. R40's care plan intervention dated 6/27/23 showed staff was to be counseled on staying with the resident and keeping him within sight due to impaired cognition and safety awareness. The fall care plan showed the 7/3/23 and 7/20/23 fall occurred when R40 was trying to get out of bed. The 7/29/23 fall intervention showed to encourage the resident to wait for assistance from staff when attempting to transfer. R40's 6/30/23 facility assessment showed he was not cognitively intact. This assessment showed he required extensive assistance of two plus persons physical assistance to transfer, walk in his room and for toilet use.

Based on observation, interview, and record review the facility failed to ensure medication administration was observed for 1 of 1 resident (R20) reviewed for medication administration in the sample of 18 and 3 residents (R66, R48, R6) outside of the sample. The findings include: 1. On 8/1/23 at 11:55 AM, residents were sitting in the dining rooms waiting for the noon meal. V5 (float RN - Registered Nurse) gave R66 a medication cup with his noon medications and walked away. R66 asked questions about the medications in the cup. V5 checked R66's pills and walked away again. R66 poured the medication into his hand and took them, unsupervised. V5 had already returned to the medication cart and was looking down to prepare medications for R48. At 12:10 PM, V5 (float RN) said she is a float nurse for the corporation and is not familiar with the residents. V5 stated, This is my first day working with these residents. V5 was looking at resident's pictures, asking the residents their names, and asking the dietary staff the residents' names. R66's Face Sheet dated 8/3/23 showed he had diagnoses to include early onset Alzheimer's, obstructive sleep apnea, dementia, Barrett's Esophagus (narrowing of the passage from the mouth to the stomach), and GERD (gastro-esophageal reflux disease). R66's August 2023 MAR (Medication Administration Record) showed R66 had a multivitamin and Omeprazole 20 mg (acid reducing medication) scheduled for 12:00 PM. R66's EMR (Electronic Medical Record) did not contain a medication self-administration assessment, nor did R66's Care Plan show that R66 could take his medications unsupervised. R66's Care Plan (imitated 4/20/23) did show that R66 had impaired cognitive function. On 8/3/23 at 9:56 AM, V13 (float LPN - Licensed Practical Nurse) said she is in the corporate float pool but has only come to the facility since February 2023. V13 said she knows the residents pretty well. V13 said the nurse should watch the resident take the medications. V13 stated, You don't know if they will drop it or someone else may pick it up. There are so many confused residents here. In school they told me, Don't deviate, and I haven't in all these years. I wouldn't walk away from a resident before they take their medication or leave the medication cup in their room. That's not the proper way to give medications. On 8/3/23 at 11:44 AM, V2 (DON - Director of Nursing) said there are not any residents that are allowed to self-administered pills at the facility. V2 said a few residents have saline nasal spray or eye drops and the physician will write an order that the resident may keep them at bedside. V2 said the nurse should be able to visualize the resident taking their medications. The nurse shouldn't turn their back to the resident or prepare the next resident's medications. V2 said it's a safety concern because the resident may drop their medications, stash the pills, or throw them away. V2 said the nurse wouldn't know for sure what medications the resident actually took. V2 said V5 (float RN) had only worked at the facility a couple days and wasn't familiar with the residents yet. The facility's Medication Administration Policy implemented 12/1/22 showed, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines: .15. Observe resident consumption of medication. 2. On 8/1/23 at 11:55 AM, V5 (float LPN) performed the noon medication pass in the dining room. V5 gave R66 his medications and returned to the cart to prepare R48's medication. V5 walked to R48 and handed her the medication cup. V5 turned and walked away, returning to the medication cart to prepare medications for the next resident. R48's Face Sheet dated 8/3/23 at 8:34 AM showed R48 had diagnoses to include, but not limited to polymyalgia, hyperlipidemia, Stage 3 chronic kidney disease, cataracts, low back pain, history of falls, open angle glaucoma, scoliosis, spinal stenosis, and asthma. R48's August MAR showed hydralazine (blood pressure medication) and tylenol were scheduled for the noon medication pass. R48's EMR did not contain a medication self-administration assessment, nor did R48's Care Plan show that R48 could take medications unsupervised. R48's ADL (Activity of Daily Living) self-care deficit Care Plan initiated 5/13/22 showed had confusion. 3. On 8/1/23 at 12:03 PM, V5 (float RN) took a mediation to R20's table. V5 turned away from the resident and returned to the medication cart. V5 did not observed R20 taking her medication. During the Resident Council meeting on 8/2/23 at 10:00 AM, R20 complained that the facility used to use more agency nurses and they didn't know the residents well. They have less of the agency, but now they have other nurses that don't know us. V2 stated, I think they work for company that bought the facility. They are better than agency, but they don't know us well either. That nurse just left me with my medication. She didn't even watch me take them. R20's Face sheet dated 8/3/23 showed diagnoses to include, but not limited to: bladder cancer, history of falling, coronary bypass surgery, lactose intolerance, stage 2 chronic kidney disease, ulcerative colitis, non-celiac gluten sensitivity, and iron deficiency anemia. R20's August 2023 MAR showed gabapentin 400 mg was ordered at 12:00 PM medication pass. R20's EMR did not contain a medication self-administration assessment, nor did R20's Care Plan show that R20 could take medications unsupervised. 4. On 8/1/23 at 12:10 PM, V5 (float RN) said she was a corporate float nurse, and this was her first day working at the facility. V5 was looking at resident's pictures, asking the residents their names, and asking the dietary staff the residents' names. At 12:14 PM V5 prepared R6's gabapentin 800 mg (a large, oval shaped pill) and took it to R6's table. V5 turned her back to R6 and walked back to the medication cart to prepare medications for R45. R6 picked up the medication cup and looked at the large pill. R6 set it back down and waited to take the medication. R6's Face Sheet printed 8/3/23 showed diagnoses to include, but no limited to: paroxysmal atrial fibrillation, Alzheimer's, major depressive disorder, insomnia, polyneuropathy, bilateral hearing loss, macular degeneration, and anxiety. R6's August 2023 MAR showed gabapentin 800 mg at 12:00 PM medication pass. R6's EMR did not contain a medication self-administration assessment, nor did R6's Care Plan show that R6 could take medications unsupervised. R6's Care Plan initiated 12/1/22 showed R6 had impaired cognitive function or impaired though processes related to Dementia.

Based on observation, interview, and record review the facility failed to identify, implement, and document control measures to prevent the growth of opportunistic waterborne pathogens (such as Legionella); failed to establish acceptable ranges for control measures; and failed to identify corrective actions for when control limits are not met. This applies to all residents residing in the facility. The findings include: The facility's CMS 672 Form dated 8/1/23 showed there were 71 residents residing in the facility. On 8/2/23 at 12:32 PM, V18 (IP - Infection Preventionist) said the facility had not had any Legionella outbreaks. V17 said maintenance does the water testing. There is not an outside company that comes in to do any water testing. The Facility's Water Management Program dated 2017 provided basic information about the facility's water sources, elements of a water management program, water flow diagrams, and identification of potential growth locations. This program did not include a list of residents more susceptible to Legionella infection, evidence of collaboration with the local water department, identification of control measures, acceptable ranges for the identified control measures, corrective actions to be taken when the control measure is abnormal, and documentation of all of the previously stated components. The facility's program contained only basic information to start a water management program, but did not represent a facility focused, functioning water management program. On 8/2/23 at 1:45 PM, V1 (Administrator) said she was sent to the room to ask what specific Legionella information was needed. The surveyor explained that the Water Management Plan provided did not identify or show documentation of the facility's control measures used to detect risk for Legionella (i.e., water testing, visual inspection, etc.). V1 stated, I gave you the binder, as far as I know, that's all we have. The surveyor explained the facility needed to provide documentation of monitoring their control measures. V1 paused and replied, Oh, ok. I'll have to see what I can find out. On 8/2/23 at 3:16 PM, V1 provided a large stack of [Facility] Daily Maintenance Rounds. These documents contained entries for the boiler temperature, wing water temperatures, and various other items. These documents did not contain any comments regarding Legionella control measures. The surveyor asked V1 (Administrator) if the facility had contacted the local water department to collaborate with development of their Water Management Plan. V1 replied, No, not that I am aware of, but I've only been here 4 months. And our policy doesn't say that we have to do that. On 8/3/23 at 10:27 AM, V1 (Administrator) and V12 (Maintenance Director) were interviewed. The surveyor reviewed the [Facility] Daily Maintenance Rounds dated 8/2/23 with V12. V12 said this is general maintenance testing, not specific testing for Legionella. V12 said the facility does not currently test for Legionella and no water samples had been taken. V12 explained the water temperatures are taken at various locations in the building, including the boiler and resident care areas. The document showed Wings 1, 3, and 4 had restroom and shower temperatures taken and Wing 6 had a restroom water temperature taken. This document does not show which restrooms were tested and there are no inspection comments associated with the readings. V12 said the facility does not test for chlorine levels in the water supply. V12 said Wing 4 and 7 are currently empty. The surveyor explained how stagnant water is the most likely source for Legionella growth. The surveyor asked if the facility had tested the water in these wings. V1 and V12 replied no. V12 said the hot water is on a recirculating system, but it's hard to say how well it circulates. V1 stated, I could see how Wing 4 could be a potential issue. We updated the rooms and are preparing to place new admissions in those rooms. Wing 4 would be a prime candidate to test the stagnant water because it's been out of use for a while. Wing 7 wouldn't be as big of a concern at this time. The surveyor opened the binder and reviewed facility's current Water Management Program. V12 stated, This vaguely looks familiar. but it looks very basic. I can see how this is the beginning of a water plan. It needs to be more detailed, and we will work on that plan. I looked this issue up and saw this is something new in 2022 and we just haven't gotten around to it. The surveyor asked if the facility identified Residents at Risk for Legionella. V1 (Administrator) looked at the surveyor blankly. (There was no list of residents at risk in the binder). V1 and V12 said they had not met with the city water department, nor were they sure of corrective actions that could be taken to mitigate their risk of developing Legionella in the facility water. V1 (Administrator) stated, I already started researching information when you asked for water testing. We haven't had any residents with Legionella infections, but I understand why it's important to get this program up and running. We don't want any of our residents to be at risk. The facility's Legionella Surveillance Policy dated 12/1/22 showed, It is the policy of this facility to establish primary and secondary strategies for the prevention and control of Legionella infections. Definitions: Legionella is a bacteria found in water that can cause a serious type of pneumonia, Legionnaires' disease. Primary prevention strategy refers to the approaches to prevention and control of Legionella infections in health care facilities with no identified cases . Policy Explanation and Compliance Guidelines: 1. Legionella surveillance is one component of the facility's water management plans for reducing the risk of Legionella and other opportunistic pathogens in the facility's water systems. 2. In the absence of Legionella infections for a period of at least one year, the facility shall implement primary prevention strategies . 4 Principles of Legionella transmission: a. To pose a health risk, Legionella has to grow in numbers and be aerosolized so people can breathe in small, contaminated water droplets. b. Legionella grows best in water temperatures of 77 - 108 degrees Fahrenheit, particularly in water that is not moving or that does not have enough disinfectant (i.e., pH 6.5-8.5) to kill germs. c. Legionella can make people sick when the germs spread in droplets small enough for people to breath in. Medical devices, cooling towers, showers, hot tubs, and fountains create aerosols . e. The incubation period for Legionnaires' disease is generally 2-10 days . Primary Prevention Strategies: . c. Physical controls: i. Cooling towers and portable water systems shall be routinely maintained. Non-portable water systems shall be routinely cleaned and disinfected . D. Temperature Controls: i. Cold water shall be stored and distributed below 68 degrees Fahrenheit. ii. Hot water shall be stored above 140 degrees Fahrenheit and circulated at a minimum return temperature of 124 degrees Fahrenheit .