Based on interview and record review, the Facility failed to follow their policy by not providing written documentation of a bed hold notice for 1 of 1 residents (R76) reviewed for hospitalizations, in the sample of 29. Findings include: On 4/1/2024 at 12:26 PM, R76 stated that he had been hospitalized recently for water on my legs. R76's Progress Notes, dated 3/21/2024, documented that R76 was sent to the local emergency room (ER) due to complaints of having difficulty breathing as well as a weight gain. On 4/2/2024 at 2:53 PM, V10, Licensed Practical Nurse (LPN), stated that when a resident is transferred to the hospital/ER the nurses fill out a form in the computer (Electronic Medical Record/EMR) and provide the resident with a bed hold policy. On 4/2/2024 at 3:07 PM, R76's Bed Hold Notification was requested. On 4/3/2024 at 8:40 AM via Electronic Mail (Email), V1, Administrator (ADM), stated that she was unable to provide the notice as requested. On 4/4/2024 at 9:05 AM, V12, Business Office Manager (BOM) stated, We are supposed to (provide the bed hold notice), but we haven't been. I'll be honest. We will now. The Facility's Bed Hold Notification undated, documented, When a resident is transferred to the hospital, or when the resident takes a therapeutic leave of absence, they have the right to request that their bed be held until their return. Such request is called a 'Bed Hold'. It continues, The bed hold notification will be issued at the time of transfer and in cases of emergency transfer, notice will be given without 24 hours of the leave.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Facility failed to ensure a resident on blood thinning medication was examined for potential complications following a fall with head injury for 1 of 24 residents (R80) reviewed for quality of care, in the sample of 29. Findings include: R80's Facesheet, dated [DATE], documented that R80 was admitted to the facility on [DATE] and was discharged on [DATE]. R80's Care Plan, dated [DATE], documented that R80 was on a Short term stay in facility for rehabilitation. It further documented that R80 is on anticoagulant therapy, Eliquis (blood thinner medications). It continues to document that the facility was to monitor and report adverse reactions such as blood tinged or red blood in urine and to avoid activities that could result in injury and take precautions to avoid falls. R80's Progress Notes, dated [DATE] at 12:48 PM documented, MD (Medical Director) made aware of resident having blood in catheter tubing. NOR (New Order Received) to hold Eliquis (Blood thinning medication) 2.5 mg (milligrams) HS (bedtime) dose for 3 days and update. R80's Progress Notes, dated [DATE] at 23:24 PM, documented, At 2100 (9 PM) Res (resident) was yelling, 'Help' and when staff went to check on her, she was found lying on R (Right side) on floor in front of recliner. Res states she was leaning over to pick something up off the floor and fell. Res noted to have a large skin tear to RFA (Right Forearm) measuring 16.7 cm (centimeters) x (by) 4.4 cm, skin tear to R lower leg measuring 6/4 cm x 4.5 cm and a small hematoma (bruise) to R side of head measuring 1.1 cm x 0.7 cm. Areas cleansed with steri-strips and dry drsg (dressing) applied. R80's Progress Notes continue to document that R80 was placed on neuro checks and assisted to bed. R80's Progress Notes also documented that R80's MD was notified at 23:23 (11:11 PM). R80's Progress Notes, dated [DATE] at 12:54 PM, documented that R80 was evaluated by Speech Therapy (ST) and diet was changed to pureed. R80's Progress Notes, dated [DATE] at 3:56 AM, documented that R80 was noted with no respiration or pulse and that the time of death 3:37 AM. On [DATE] at 11:18 AM, V10, Licensed Practical Nurse (LPN), stated that R80 came to the Facility covered in bruises and skin tears. V10 continued to state that R80 fell out of her recliner and had a bruise to her head and an extensive skin tear to her arm. V10 also stated that R80 had quite a bit of bleeding when V10 would perform dressing changes as well as R80 having blood in her urine, therefore staff were holding her blood thinning medication. V10 continued to state that he was R80's nurse on the dayshift prior to her expiring the next day (early morning). V10 stated that R80 usually knew V10's name but kept calling him Gail. V10 also stated that there was no other nurse at the Facility named Gail. On [DATE] at 11:39 AM, V6, Registered Nurse (RN) stated, Our doctors would want them (resident) sent to the ER (Emergency Room) and if they didn't, we would suggest it. We would remind them they hit their head and are on a blood thinner. You always have to be familiar with who is on a blood thinner because they could have a brain bleed. If they (resident) was on Coumadin or Eliquis (blood thinning medications) we would definitely send them out (to the ER). On [DATE] at 1:36 PM, V11, RN stated, More than likely the doctor would say to send them out if they had a fall and was on a blood thinner. On [DATE] at 1:18 PM, V16, LPN stated, (R80) hit her head 'a little bit' and had an abrasion on the side of her head. On [DATE] at approximately 1:30 PM, V18, Speech Therapist (ST), stated that R80 came to the facility with a regular diet ordered. V18, also stated that R80 had a decline in condition, was evaluated, and placed on a pureed diet. V18 stated that R80 expired that night. The Facility did not have a Policy addressing the use of anticoagulants and the need for further evaluation after a head injury.

Based on observation, interview and record review, the Facility failed to follow their Contact/Droplet Precautions Policy while administering medications to 1 of 3 residents (R34) reviewed for Transmission Based Precautions (TBP), in the sample of 29. Findings include: On 4/2/2024 at 8:05 AM, V6, Registered Nurse (RN) was observed passing medications. At this time, there was a Contact/Droplet Precaution sign outside of R34's room. At this time, V6 donned a gown and N95 (mask) and was wearing eyeglasses. V6 did not apply gloves. At this time, V6 stated, (R34) has a Coronavirus, but it is not COVID 19. He (R34) went to the ER (Emergency Room) because he had a temp (elevated temperature). He (R34) is on isolation while he is taking his antiviral meds (medications). R34's Progress Note, dated 3/28/2024 at 10:05 PM, documented that R34 returned from the local ER with a diagnosis of a systematic viral illness and was placed on isolation precautions. R34's Progress Note, dated 3/29/2024 at 6:27 AM, documented that R34 continues Droplet isolation due to Coronavirus OC43 and an antiviral medication was ordered by the physician. R34's Progress Note, dated 4/2/2024 at 12:09 PM, documented that R34 continues the antiviral medication. On 4/4/2024 at 10:25 AM, V2, Director of Nursing (DON), stated that R34 was on contact/droplet precautions on 4/2/2024 and that she would expect staff to don a gown, gloves, N95 mask and eye shield while within 6 feet of a resident on contact/droplet precautions. On 4/4/2024 at 12:55 PM, V1, Administrator stated, she would expect gloves to be worn in a resident's room when the resident is on droplet/contact isolation. The Facility's Transmission Based Precautions Policy, dated 7/1/2023, documented, Purpose: To provide staff guidelines for transmission-based precautions to protect residents and themselves while provides cares. Policy: Transmission- Based Precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection or have a laboratory confirmed infection, and is at risk of transmitting the infection to other residents. Responsibility: It is the responsibility of all staff and agents of the facility to adhere to the transmission-based precaution guidelines. It continues, When a resident is placed on transmission- based precautions, appropriate notification is placed on the room entrance door so that personal and visitors are aware of the need for and the type of precaution. It continues, Contact Precautions: Contact Precautions may be implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with he resident or indirect contact with environmental surfaces of resident-care items in the resident's environment. It continues, Staff and visitors will wear gloves (clean-non sterile) when entering the room.

Based on observation, interview, and record review, the facility failed to ensure that out dated Tuberculin Purified Protein Derivative (TB) solution was removed from the 300 hallway medication refrigerator. This failure has the potential to affect all the residents residing on the 300 hall. Findings include: On 04/01/24 at 02:53 PM, the refrigerator in the 300 hall medication room was inspected and observed to have an open vial of TB solution that was half full with an open date of 11-21 written on the vial. On 04/01/24 at 02:55 PM V5, Registered Nurse (RN), stated that yes everyone in the facility uses the TB solution. She continued to state that each hallway may have their own vial but she wasn't sure, and that she isn't sure for how long the solution is good for after it's opened. She continued to state that night shift does the TB test, so she wasn't really a good person to ask that. V5 verified the open date on the TB solution vial was 11-21. On 04/04/24 at 11:35 AM, V1, Administrator, stated that the TB solution should be discarded 30 days after opening. The TB solution box documented, Discard opened product after 30 days. The facility's Medication Storage Policy, dated 07/01/23, documented, Purpose: To provide guidance to facility nursing staff on the proper storage of medication. Policy: The facility stores all drugs and biological's in a safe, secure, and orderly manner and in accordance with state and federal regulations. It continues, 4. Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biological's shall be returned to the dispensing pharmacy or destroyed.

Based on observation, interview, and record review, the Facility failed to ensure resident menus and appropriate serving sizes were followed for 4 of 8 (R3, R5, R6, R7) reviewed for therapeutic diets in the sample of 8. Findings include: 1.R5's Order Summary Report dated 9/13/23 documents R5 is on a regular diet with pureed texture and thin liquid consistency starting on 5/4/22. R5's Diet Card for Lunch on 9/12/23 documents pureed texture with pureed beef tips and mushroom entrée. The Facility's Diet Spreadsheet for Day 17 Pureed documents use of #6 Dip (Scoop=6 ounces) for the Pureed Beef Tips and Mushrooms. On 9/12/23 at 12:12 PM, V6, Interim Dietary Manager, stated, We don't have an extra number six scoop for these, so we are using the two-ounce scoop and giving them three scoops each. V9, Dietary Aide, placed two scoops of pureed meat on R5's plate. 2.R3's Order Summary Report dated 9/13/23 documents R3 is on a No Added Salt (NAS) diet, easy to chew (Mech) (EC7) (Easy to Chew 7) texture, thin consistency. R3's Diet Card for Lunch on 9/12/23 documents regular, easy to chew, NAS diet with beef tips and mushrooms entrée. The Facility's Diet Spreadsheet for Day 17 Regular Easy to Chew (EC7) documents #6 Dip for the Easy to Chew Beef Tips and Mushrooms (EC7). On 9/12/23 at 12:23 PM, V6, Interim Dietary Manager, stated, That scoop (for the mechanically altered meat) is only four ounces, so you (V9, Dietary Aide) will do one of those scoops and one two-ounce scoop. On 9/12/23 at 12:46 PM. V9, Dietary Aide, plated one scoop of mechanically altered meat for R3. V9 stated, We are just running low. I didn't do (make) enough of it. It's my fault. 3.R6's Order Summary Report dated 9/13/23 documents R6 is on a regular diet, regular texture and thin liquid consistency starting 3/3/23. R6's Diet Card for Lunch on 9/12/23 documents regular diet with ice cream. On 9/12/23 at 12:25, V8, Dishwasher, prepared R6's tray. There was no ice cream placed on the tray prior to placing on the meal cart for delivery to resident. 4.R7's Order Summary Report dated 9/13/23 documents R7 is on a regular diet with regular texture and mildly thick (nectar) consistency. R7's Diet Card for Lunch on 9/12/23 documents regular diet with mildly thick liquids and two whole slices of wheat bread at all three meals. On 9/12/23 at 12:44 PM, V8, Dishwasher, prepared R7's tray. There was only one slice of bread on the tray before it was placed in the meal cart for delivery to resident. On 9/12/23 at 3:14 PM, R7 was sitting in his wheelchair outside his room with a sling on his right arm. R7 stated a few words, but primarily used a dry erase board for communication. R7 communicated the Facility is always running out of wheat bread, salami, Swiss cheese, mayonnaise, and strawberry yogurt. On 9/12/23 at 10:34 AM, V3, Certified Nursing Assistant (CNA) stated sometimes the kitchen makes mistakes, but they usually try to correct them. On 9/13/23 at 9:42 AM, V10, Unit Assistant (UA), stated the kitchen often runs out of food. On 9/13/23 at 9:58 AM, V9, Dietary Aide, stated the Facility does get complaints about running out of food items and the dietary manager is aware. On 9/13/23 at 10:02 AM, V13, Dietary Manager, stated the Facility ran out of items before she worked here, but it is no longer a problem. She would expect staff to follow the menus and look at portion sizes when they are making the resident trays. On 9/13/23 at 2:22 PM, V16, Registered Dietitian (RD), stated different scoops are used to ensure residents get the appropriate amount of calories and protein. If a smaller scoop is used, residents will not get enough protein. If this is happening all the time it could lead to weight loss and different things like medications not working the same. She stated it is important for mechanically altered diets to have the correct scoop sizes. On 9/13/23 at 2:55 PM, V2, Director of Nursing (DON), stated she expects dietary staff to follow meal cards. The Facility's Resident Council Meeting Minutes dated 8/7/23 documents, Menu's not being taken at times & not being given what ordered. The Facility's Therapeutic Diets Policy issued 9/1/21 documents, All residents have a diet order, including regular, therapeutic, and texture modification, that is prescribed by the attending physician, physician extender, or credentialed practitioner in accordance with applicable regulatory guidelines. Therapeutic diet is defined as a diet ordered by a physician, or delegated registered or licensed dietitian, as part of the treatment for a disease or clinical condition. The purpose of a therapeutic diet is to eliminate or decrease specific nutrients in the diet (e.g., sodium), or to increase specific nutrients in the diet (e.g., potassium), or to provide food that a resident is able to eat (e.g., mechanically altered diet). Mechanically altered diet means one in which the texture of the diet is altered. Diets are prepared in accordance with the guidelines in the approved Diet Manual and the individualized plan of care.

Based on observation, interview and record review, the facility failed to perform hand hygiene to prevent cross contamination and the spread of infection for 3 of 9 residents (R21, R45, R35) reviewed for infection control in the sample of 34. Findings include: 1. On 03/21/2023 at 12:30 PM, V11, Registered Nurse (RN), and V9, Certified Nurse Assistant (CNA), performed incontinent care for R21. Both V9 CNA and V11, RN, donned and doffed gloves without the benefit of hand hygiene, several times, during the procedure. 2. On 03/21/2023 at 12:45 PM, V8, CNA, and V10, CNA, transferred R45 to the toilet using a gait belt. After R45 was finish using the toilet, V8, with the same gloved hands, took a soapy washcloth and cleansed R45's peri rectal area and buttocks. V8 and V10 then transferred R45 back to her wheelchair with the same gloves they used to cleanse R45 touching the arm rest of R45's wheelchair and gait belt on the resident and then fastened R45 chair alarm seat belt. 3. On 03/21/2023 at 10:55 AM, R35 was sitting on the toilet with call light on, with the sit to stand lift connected to the belt around her. V10, CNA, performed hand hygiene and donned gloves. V10 operated the sit to stand lift and took R35 out of bathroom and to her bedside. V10, with the same gloved hands, took a soap and water washcloth from the sink, cleansed front to back of peri rectal area. While wearing the same soiled gloves, V10 got another washcloth from the sink, cleansed the peri rectal area again, front to back and then back to front with same cloth several times, all without glove changes and benefit of hand hygiene. On 03/22/2023 at 02:25 PM, V2, Director of Nurses (DON), stated that she would expect the staff to perform hand hygiene after they remove their gloves. The facility's policy, Hand Hygiene Protocol, dated 07/26/2021, documented, Use an alcohol based hand sanitizer: Before resident contact. It continues, Before moving from work on a soiled body site to a clean body site on same resident. It continues, Immediately after glove removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to perform complete incontinent care for 2 of 6 residents (R45, R35) reviewed for incontinent care in the sample of 34. Findings include: 1. On 03/21/2023 at 12:45 PM, V8, Certified Nurse Assistant (CNA), and V10, CNA, transferred R45 to the toilet using a sit to stand mechanical lift. After R45 was finish using the toilet, V8 used a soapy wash cloth and cleansed R45's peri rectal area using back and forth strokes and not turning the wash cloth to the clean area. V8 continued to cleanse the buttocks, but did not cleanse the labia, groin area or abdominal folds. V8 and V10 then transferred R45 to her wheelchair. R45's Minimum Data Set (MDS), dated [DATE], documented that R45 requires extensive assist of 2 staff members to use the toilet and was frequently incontinent of urine. R45's Care plan, dated 01/30/2023, documented, TOILET USE: Assist me to the toilet every 2 hours and as needed. I am frequently incontinent and need assistance with hygiene care as needed. 2. On 03/21/2023 at 10:55 am, R35 was sitting on the toilet with call light on, with the sit to stand l mechanical lift connected to the belt around her. V10, CNA, had wash cloths in the sink with warm water and soap. V10 operated the sit to stand lift and took R35 out of bathroom to her bedside. V10 used a soap and water wash cloth to cleanse front to back of peri rectal area but did not cleanse R35's abdominal folds and bilateral groins. V10 used another wash cloth, cleansed the peri rectal area again, front to back and then back to front with same cloth several times. R35's Care plan, dated 06/01/2021, documented, Moisture barrier with incontinent care, Use mild cleansers for peri-care and washing. It continues, TOILET USE: assist me to toilet at least every 2 hours and (As needed). provide incontinent skin care per protocol. R35's admission record, dated 03/22/2023, documented a diagnosis of Malignant neoplasm of bladder. On 03/22/2023 at 2:30 PM, V2, Director of Nurses, stated that she would expect the staff to perform complete incontinent care including abdominal fold, groin areas and labia. The facility policy, Perineal Care policy and procedure, dated 11/2016, documented, Cleanse the perineal area: for female genitalia - use gentle downwards strokes from the front to the back of the perineum, using a clean section of the washcloth or pre-moistened wipe with each stroke.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure medications were properly administered and/or stored for 1 of 5 residents (R64) reviewed for medications in the sample of 34. Findings include: 1. On 03/21/23 at 12:20 PM, R64 was sitting in his room. A medication cup with medications in it was setting on R64's over the bed table. When R64 was questioned about the medication on his over the bed table, R64 stated it was his Gabapentin he takes. He said he knows he should have taken it when the nurse handed it to him, but he didn't because he likes to take it with food. R64's admission Record, print date of 03/22/23, documents R64 has a diagnosis of Peripheral Vascular disease, unspecified, Muscle wasting and atrophy, and Type I Diabetes Mellitus. R64's Minimum Data Set (MDS), dated [DATE], documents R64 is cognitively intact. R64's Care Plan, with admission date of 02/02/23, does not have any documentation regarding R64 being able to administer his own medications. R64's Physician's Order, dated 02/02/23, documents R64 is to receive Gabapentin Oral Tablet 600 by mouth three times a day for Neuropathy related to type 1 diabetes mellitus with diabetic polyneuropathy. On 03/21/23 at 12:35 PM, V4, Licensed Practical Nurse (LPN), stated she handed R64 his pill and then she was called away. V4 stated he usually takes his medications she didn't don't know why he didn't take it this time. On 03/21/23 at 12:37 PM, V4 went in to check on R64 at this time to see if his medication was still sitting in his room. After coming out of his room, V4 stated that R64 just told her that he likes to take his meds with food so now she knows. On 03/21/23 at 12:44 PM, V2, Director of Nursing (DON), stated she would expect the nurse to watch the residents take their medications unless they were assessed and able to administer their own medications. The facility's Medication Administration Policy, dated 1/11/10, documents Objective: To provide accuracy during medication pass to assure quality care for residents. Policy: It is the policy of this facility to accurately administer medication following physician's orders. It further documents 13. Make sure the resident takes the medication. Generally- Do not leave meds at bedside (may be exceptions after thorough assessment and care planning).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure oxygen tubing is dated when placed for weekly replacement and stored in plastic bag when not in use for 5 of 9 residents (R8, R12, R48, R52, R128) reviewed for respiratory care in a sample of 34. Findings include: 1. On 03/21/23 at 9:35 AM, R8 was sitting in her wheelchair in her room. R8 had her oxygen on and there was no date noted to be on the oxygen tubing. On 03/22/23 at 8:45 AM, R8 is sitting in her room in her wheelchair with her oxygen in place. There was no date noted to the oxygen tubing at this time. R8's admission Record, print date of 03/22/023, documents R8 has a diagnosis of respiratory failure with hypoxia. R8's Minimum Data Set (MDS), dated [DATE], documents R8 is moderately cognitively impaired. R8's Care Plan, admission date of 08/29/22, documents R8 has impaired gas exchange, has a diagnosis of respiratory failure with hypoxia, administer oxygen as prescribed or per standing order. R8's Physician's Order, 08/29/22, documents R8 is to receive O2 (oxygen) @ (at) 2L (liters) per N/C (nasal canula). Keep sats (saturations) > (greater) than 90%. May gradually taper. 2. On 03/21/23 at 9:24 AM, R12 was sitting in her room in her wheelchair. The oxygen tubing on her portable oxygen concentrator was not dated. There was no bag with a date on the oxygen concentrator she uses at nighttime. On 03/22/23 at 9:10 AM, R12 was up and in her wheelchair getting ready to go down to the activity room. The oxygen tubing on her portable oxygen concentrator was not dated. R12's admission record, print dated of 03/22/23, documents R12 has a diagnosis of Chronic obstructive pulmonary disease (COPD). R12's MDS, dated [DATE], documents she cognitively intact. R12's Care Plan, admission date of 10/11/22, documents R12 has O2 dependent COPD, and give oxygen as ordered by the physician. R12's Physician's Orders, dated 01/25/23, document R12 is to receive O2 @ 2L per N/C continuously. 3. On 03/21/23 at 9:35 AM, R52 was sitting in her wheelchair in her room. R52 had her oxygen on and there was no date noted to the oxygen tubing. There was a bag taped to the O2 concentrator with the date of 3/6. On 03/22/23 at 8:45 AM, R52 was sitting in her room in her wheelchair with her oxygen in place. There was no date noted to the oxygen tubing at this time. The bag noted on the O2 concentrator had the date of 3/6 wrote on it. R52's admission Record, print date of 03/22/23, documents R52 has diagnoses of COPD and Chronic respiratory failure with hypoxia. R52's Care Plan, with admission date of 07/31/20, documents chronic oxygen therapy r/t (related to) chronic respiratory failure with hypoxia, COPD, and oxygen as per MD (medical doctor) orders. R52's Physician's Orders, dated 08/25/20, documents R52 is to receive O2 2-3 LPM (Liters Per Minute) NC to keep SPO2 (oxygen saturation) above 92%. 4. On 03/20/2023 at 10:56 AM, R128's oxygen tubing was not dated nor was it on R128. There was no respiratory bag in the resident's room either. R128's Health Status note dated, 03/09/2023 at 5:36 PM documented, (Medical Doctor) here to see (R128) (new order) for (oxygen) at 2 (Liters) to keep sats above 90% till Monday, and CBC and BMP (lab tests: complete blood count, basic metabolic profile) to be done 3/16. On Monday remove (oxygen), wait 30 minutes then recheck (oxygen) levels, call MD and update him after you recheck (oxygen) He will decide then if he wants to keep her on it or remove it. R128's Health Status note, dated 03/14/2023 at 10:33 PM documented, (Resident) resting in bed at this time, no change in condition noted. (pulse oximetry) (within normal limits) (with) supplemental O2 There were no physicians order for oxygen nor was it care planned. 5. On 03/21/2023 at 9:54 AM, R48's nasal cannula oxygen tubing was not dated. It was connected to the portable oxygen tank but that was not turned on. There was no respiratory bag in the resident's room either. R48 stated that they have not changed the tubing. R48's Physicians order, dated 03/14/2023 documented, May apply supplemental (oxygen) to keep (pulse oximetry) (greater than) 90% two times a day for (Congestive Heart Failure). On 03/22/2023 at 2:25 PM, V2, Director of Nurses, stated that she would expect the staff to change oxygen tubing weekly. The facility's policy, Oxygen Administration, dated 05/04/ 2018, documented, 14. Keep a plastic bag available to store the oxygen delivery system (cannula or mask) when not in use. Date and initial the bag when placed and change weekly. 15. Guidelines for changing respiratory equipment will be as follows: A. Oxygen tubing-weekly.

Based on observation, interview and record review, the facility failed to complete a restraint assessment including the risk versus benefits of a seat belt with alarm for 1 of 2 residents (R24) reviewed for physical restraints in the sample of 41. Findings include: R24's admission Record, admission date of 9/16/19, documented a medical diagnosis of Alzheimer's disease, Dementia, history of falling, muscle weakness, unsteadiness on feet, urgency of urination. R24's Physician Order Sheet, dated 2/8/22, documented an order for seat belt chair alarm in wheelchair, release every two hours and as needed, order dated 12/9/21. R24's Physical device/Psychoactive Medication initial Quarterly Evaluation, dated for the following; R24's admission quarterly evaluations dated from 2/19/20 through 12/2/20 documented, device recommendations of a lap buddy when up in wheelchair for a medical diagnosis of; symptom interference of with judgement, gait, unable to transfer without assistance, physical limitation, history of falls and balance issues and a medical diagnosis of Alzheimer's dementia. On 1/11/21, documented a physical restraint of a seat-belt with alarm. On 5/17/21, documented a physical restraint of a lap buddy placed over the seat-belt, due to resident had physically destroyed the seat-belt beyond repair. On 8/16/21 and for the last physical restraint evaluation, dated 11/15/21, documented the use of a lap buddy. The facility failed to do an initial evaluation for a physical restraint provided on 12/9/21. R24's Fall Occurrence Report, dated 12/8/21 at 9:00PM, V2, Director of Nursing (DON), documented, R24 was observed in front of nurses station, in a wheelchair, placing self under the lap buddy and sliding out onto the floor. New intervention to be put into place is to discontinue the lap buddy and sensor alarm in chair and add seat belt alarm when in wheelchair. On 2/2/22 at 2:00PM, V2 stated she could not provide an initial evaluation of R24's seat belt restraint that was initiated on 12/9/21. V2 stated she was not aware that a new physical restraint assessments needed to be completed, since R24 was previous placed with a lap buddy physical restraint. V2 continued to state, R24 had literally positioned her body under the lap buddy and to the ground, in which the incident happened so quick, V2 could not prevent the fall. R24's Care Plan, dated 1/11/21, documented, Focus area; entitled, I am at risk for falls r/t (related to) Alzheimer's dementia with poor safety awareness, weakness from CVA, (Cerebrovascular attack), medications that may cause hypotension or dizziness vision and communication impairments and incontinence, initiated, 10/27/19. Intervention, dated 12/9/21, documented, Seat belt alarm while in wheelchair. Release q (every) 2 hours and PRN (as needed) when in direct supervision of staff, and check seat belt alarm for fitting, placement, and working condition every shift and report any damage to the supervisor. The Facility's policy and procedure, entitled, Restraint Program Policy and Procedure, revision date of 11/10/15, documented, Prior to the use of any restraint, each resident is assessed for potential alternatives. During this investigation ,on 1/31/22 through 2/9/22, R24 was observed in a wheelchair, stationed either a the nurses station or propelling herself down halls. R24, had visual and hand helded sensory objects at all times, seat belt alarm attached and sent to room for toileting assistance every one-two hours. On 2/2/22 at 9:30AM, V7, Certified Nurse Aide (CNA), stated she has cared for R24 for a long while and she is one to get up out of her wheelchair unassisted, has had many falls and the seat belt alarm is for her safety. V7 revealed that R24, is capable of removing and attached her seat belt.

Based on observation, interview and record review the facility failed to perform proper hand hygiene to prevent the spread of infection for 3 of 5 (R5, R39, R47) residents reviewed for and infection control in the sample of 41. Findings include: 1. On 02/08/22 at 9:40 AM, V22, Certified Nurse Aide (CNA), provided incontinent care for R5. V22 put gloves on without hand hygiene prior to glove placement, pulled R5's incontinent brief down which was soiled front and back with a large amount of loose smeared brown stool. V22 took a wet cloth and put cleanser on the cloth, cleansed her front perineal area, rolled R5 on her right side, removed the soiled depends, with the same gloves V22 picked up a wet wash cloth and took the bottle of cleanser and put some cleanser on the cloth, cleansed the rectal area. V22 then removed her gloves washed her hands, placed a new incontinent brief down on the bed. On 2/9/22 at 8:45 AM, V2, Director of Nursing (DON), stated, she would expect staff to use appropriate hand hygiene and use hand hygiene prior to applying gloves. The facility Policy and Procedure for Resident Care dated 12/05, revised 11/2016 documents, Policy: Following evidence based practice, glove changes and the performance of hand hygiene during perineal care may be limited to before initiating perineal care, any time gloves are visably soiled, and at the completion of perineal care. 2. On 02/01/22 at 10:30 AM, V8, Licensed Practical Nurse (LPN), placed surgical mask over N95, donned gown. V8 then donned gloves, V8 did not sanitize her hands prior to donning gloves. V8 entered R39's room. 3. On 02/08/22 at 1:15PM ,V15, CNA, had gloves on and used cleansing cloths to perform catheter care for R47. V15 Cleansed penis, pulled foreskin back, cleansed head, then cleansed the catheter tubing. V15 then cleansed R47's groin. V15 removed her gloves. V15 donned new gloves and cleansed R47's scrotum.V15 did not sanitize her hands prior to donning gloves. On 2/08/22 at10:47 AM V2 Director of Nursing (DON) stated that she would expect staff to sanitize hands prior to donning glove. The Facility Donning and Doffing PPE (Personal Protective Equipment) and Isolation Competency, undated, documents performs hand hygiene.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to attempt Gradual Dose Reductions (GDR's) and put resident centered behavior tracking in place for 4 of 5 residents (R18, R27, R33, R53) reviewed for psychotropic medications in the sample of 41. Findings include: 1. R18's Face Sheet, print date of 2/1/22, documents R18 was admitted on [DATE] with diagnoses of Major Depression Disorder and Anxiety. R18's Pharmacy Recommendation, dated 6/29/21, documents, Resident receives the following medication used for depression: Cymbalta 60 mg (milligram) Q (every) AM for Depression since 3/22/2020 resident also continues on Buspar 5 mg bid (twice a day) and hydroxyzine 25 mg q 6 hours prn (as needed) itching. The Centers for Medicare and Medicaid Services (CMS) requires attempts at dosage reductions on antidepressant medications used for managing behavior, stabilizing mood, or treating psychiatric disorders twice a year, in two separate quarters (with at least one month between attempts), within the first year of admission or initiation, and annually thereafter unless clinically contraindicated. Resident is due for an evaluation. Please complete on of the following sections. 1. ( x) Further dose reduction is clinically contraindicated due to: ( ) The continued use in accordance with relevant current standards or practice. A dose reduction at this time would likely impair resident's function or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder as supported by the following CLINICAL RATIONALE AND EVIDENCE OF THE FOLLOWING SYMPTOMS: (no documentation available for review). R18's Pharmacy Recommendation, dated 8/31/21, documents, Resident receives the following medication used for anxiety: on Buspar 5 mg bid for anxiety since 7/31/2020. The Centers for Medicare and Medicaid Services (CMS) requires attempts at dosage reductions on antidepressant medications used for managing behavior, stabilizing mood, or treating psychiatric disorders twice a year, in two separate quarters (with at least one month between attempts), within the first year of admission or initiation, and annually thereafter unless clinically contraindicated. Resident is due for an evaluation. Please complete on of the following sections. 1. ( x) Further dose reduction is clinically contraindicated due to: ( ) The continued use in accordance with relevant current standards or practice. A dose reduction at this time would likely impair resident's function or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder as supported by the following CLINICAL RATIONALE AND EVIDENCE OF THE FOLLOWING SYMPTOMS: (no documentation available for review). R18's Order Summary Report, dated 2/1/22, documents, Buspirone HCL Tablet 5 mg. Give 1 tablet by mouth two times a day for anxiety. Start date of 7/31/2020. R18's Order Summary Report, dated 2/1/22, documents, Cymbalta Capsule Delayed Release Particles 60 mg. Give 60 mg by mouth in the morning for depression. On 2/8/22 at 4:00 PM, V2, Director of Nurses (DON), stated, I review the the pharmacy recommendations and then pass them on to the Doctor. He gives them back to me and I did not see that he had not addressed the reasons he does not want to her to have a dose reduction. 2. R33's Face Sheet, documents R33 was admitted on [DATE] with diagnoses of Alzheimer's Disease, Dementia and Major Depression Disorder. R33's 2/2022 Physician Orders document, Fluoxetine HCl Tablet 10 MG. Give 10 mg by mouth at bedtime for depression. Start date of 8/30/2019. R33's last Pharmacy Gradual Dose Reduction Recommendation for Fluoxetine was 12/08/2020. On 2/8/22 at 4:00 PM, V2 stated that R33 should have had an attempted dose reduction on 12/4/21 and it was missed. 3. R53's Face Sheet, print date of 2/1/22, documents R53 was admitted on [DATE] with diagnoses of Dementia with behaviors and Major Depressive Disorder. R53's 2/2022 Physician Order Summary documents, Alprazolam Tablet 0.25 MG. Give 0.25 mg by mouth every 8 hours as needed for anxiety. Start date of 9/28/21 and Risperdal Tablet 0.5 mg. Give 0.5 mg by mouth two times a day related to unspecified Dementia with Behavioral Disturbance. Start date 10/12/21. R53's 12/2021 - 2/9/2022 Medication Administration Record (MAR) documents, R53 received Alprazolam 0.25 mg tablet 7 times as an as needed medication. R53's Nurses Note, dated 10/5/21 at 3:44 PM, documents, This nurse knocked on residents door. Door slightly ajar. Resident slammed the door and stated, 'this is my room!' This nurse knocked again stating I was the nurse. Resident opened the door and invited this nurse in. Resident is agitated and tearful with increased resp (respiration) rate. Resident went on to state that there were people trying to kill her and her children. Resident stated men and woman were shooting needles out of small guns into her neck. The resident stated there was a woman with a large knife trying to stab her from across the street. Resident then stated that when she was eating she looked at her arm and food began to leak out of her arm like it was blood and had to dive behind a car to keep the small man in the bed in the window from shooting her and her kids. Resident worried he will set her and her children on fire in the middle of the night. Resident also stated that if these people come on her property that they will be arrested, but the police won't do anything to stop them from trying to kill her and her kids. Resident then stated she was awaiting three surgeries to remove her liver, spleen and another part she can't remember. This nurse provided TLC (tender loving care) to resident somewhat successful. Resp even and unlabored, no longer tearful. Resident states she is still worried but not as much. Resident is currently sitting in chair in room. PRN (as needed) acetaminophen administered as ordered c/o (complaint of) pain. Call light within reach. Staff will continue to monitor. R53's Nurse Note, dated 10/5/21 at 10:04 PM, documents, Writer took HS (hour of sleep) meds (medication) into room and noted res (resident) was in the BR (bathroom). Res came out and stated, 'I was hiding in there from those people.' Writer reassured res that the room was safe and that writer had meds for her. Res sat down and proceeded to take meds without difficulty. Res resting quietly in recliner at this time. R53's Nurse Note, dated 10/6/21, documents, Primary care physician stated he wants to be notified on 10/7/21 about residents behaviors following the start of the Risperdal 0.5mg BID. R53's Behavior Tracking does not address the use of Risperdal for hallucinations. R53's Behavior Tracking address exit seeking only. On 1/31/22 at 2:30 PM, V25, Licensed Practical Nurse (LPN), stated that R53 does have hallucinations of her old neighbors trying to kill her and that she has 45 children. V25 stated she doesn't have them as often now but she does still have them. On 2/8/22 at 4:00 PM, V2 stated she thought the initial order for an as needed psychotropics needed to be for 14 days only and then after that is could be long standing. V2 also stated that R53 should be behavior tracked for her hallucinations. 4. R27's current physician orders dated 2/1/2022 documents that R27 is currently receiving Seroquel 37.5mg in the AM and 25mg at hs and Buspar 5mg Three times a day. R27's face sheet dated 11/30/2018 documents that R27 has a diagnosis to include unspecified Dementia with behavioral disturbances. R27's In Home Medical Group (IHMG) sheet dated 8/11/2021 documents increase am dose of Seroquel to 37.5mg. R27's IMHG dated 12/22/2021 documents increase buspar 5mg am and pm Start buspar 2.5mg in afternoon. R27's sheet dated 1/5/2022 documents increase Buspar. R27's physician order dated 2/2/2022 documents Seroquel 25mg at hs and Seroquel 37.5 mg by mouth in the morning. Physician orders dated 2/1/2022 documents Buspirone 5mg three times a day. R27's medication review dated 1/21/2021 documents see report for any noted irregularities and/or recommendations. Report dated 2/13/2021 documents no irregularities. Report dated 3/16/2021 documents no irregularities/or recommendations. Report dated 4/21/2021 documents see report for any noted irrregularities and/or recommendations. The pharmacy note to attending physician dated 4/29/2021 documents pharmacist recommended dose reduction to - trial reduction of seroquel 25mg BID to Seroquel to 12.5mg am and Seroquel 25mg pm. The physician did not mark agree or disagree with any type of rational, The physcian marked further dose reduction clinically contraindicated but to behavioral interventions continue to be attempted. R27's physician orders do not document an attempted dose reduction, but an increase. The Facility Policy Psychotropic Medication dated 11/28/17, documents the requirements for Gradual Dose Reduction must be followed.

Based on observation interview and record review the facility failed to provide food at a palatable temperatures during meal service. This had the potential to affect all 72 residents in the facility. Findings include: Resident Council minutes dated 11/2/21, 12/6/21 and 1/3/22, documented, the food continues to be served cold. The concerns addressed to the dietary manager, with dietary manager documentation of, hot food is always temped where it should be before going onto the steamtable. The Facility's Quality Assurance Performance Improvement, (QAPI) dated, 1/3/22, documented an action Plan titled, COLD food, that addresses issues of, monitor temperatures in the kitchen before serving, with the first tray and last to be served on each cart, monitor pass times, educate staff to keep door closed to cart during serving and random interviews with residents after meals. On 02/07/22 at 11:45 AM, entered kitchen food was placed in the steam table. The following meal service was temped for the following; Ham slices at 152 degrees (F), (Fahrenheit), Peas at 162 degrees( F), Sweet Potatoes at 160 degrees (F), gravy at 150 degrees (F), pureed Ham at 170 degrees (F), pureed Peas at 164 degrees (F) and pureed Sweet Potatoes at 142 degrees (F). On 2/7/22 at 11:50AM, 12 meal trays that contained the meal in Styrofoam closed container, were loaded onto an uninsulated roll hall cart. On 2/7/22 at 11:55AM, the cart was then transferred to the 300 hall, with the first tray delivered by two staff members at 11:55AM, to the residents rooms, with the last tray delivered at 12:05PM with 11 meal trays distributed. On 2/7/22 at 12:07 PM, the 12th meal tray was temperature checked with the following; Ham at 90 degrees (F), peas at 110 degrees (F) and cubed sweet potatoes at 100 degrees (F). On 02/7/22 at 1:04 PM through 1:15PM, the following were interviewed; R19, R6, R42 and R50, they all stated the lunch served today was warm and has been this way for quite a while. On 2/8/22 at 12:30 PM, V1, Administrator, stated he is aware of residents voicing concerns of the food low temperatures with monitoring by kitchen and administration staff. V1 continued to state the kitchen has been serving meals using Styrofoam since October not due to quarantine status, but kitchen staffing. On 2/8/22 at 12:40 PM, V10, Dietary Manager, stated the food is served in Styrofoam due to three kitchen staff out on quarantine status and due to staffing issues, washing meal plates is time consuming. The facility's procedure, entitled, Time and Temperature Standards, dated 6/2018, documented, Serving: Maintain internal temperature at more than 135 degrees (F). The Facility's Resident Census band Conditions of Residents, CMS 672 dated 2/1/22, documented the facility had a census of 72 residents.