Based on interview and record review the facility failed to address the loss of a resident's denture and formulate a plan for replacement. This applies to 1 of 3 (R1) in the sample of 3 reviewed for denture care. The findings include: On 5/20/2025 at 11:13AM, V9 Social Services Director said [R1's] upper denture was reported missing on 4/13/2025. V9 said she investigated the missing dentures on 4/14/2025 and they were unable to find the missing upper denture for [R1]. V9 said when residents are admitted to the facility it is explained to them the facility is not liable for missing or lost items unless the facility is liable. V9 said she was unaware if the facility was going to pay for the lost dentures or not. On 5/20/2025 at 10:15AM, V2 Director of Nursing (DON) said [R1] requires assistance with oral care and would not be responsible for them himself. V2 said staff should report missing dentures. The facility failed to provide documentation of any conversation with [R1's] family regarding the lost dentures and replacement/payment agreement prior to the initiation of the survey on 5/19/2025. The Loss Control/Damage Report (Form #NH-553) shows the investigation was began on 4/14/2025 for a missing upper denture plate which was identified on 4/13/2025 and the report was signed off on 4/15/2025. The report does not indicate a resolution or liable party for missing dentures. The facility provided copy of the admission Agreement contact states. W. Indemnification: The Resident will defend, indemnify and hold the Facility harmless from any and all claims, demands, suit and actions made against the Facility by any person resulting from any damage or injury caused by the Resident to any person or property of any person or entity (including the Facility), except in the case of negligence of the Facility's employees and agents. The facility provided Loss/Damage of Dentures revised 6/1/2022 states, the facility shall not be held responsible for replacement/cost of repair of dentures unless the loss or damage is determined to be the result of negligence on the part of the facility, or loss and/or damage occurs when the resident has provided dentures to the facility for safekeeping.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to provide supervision for a resident who was a fall risk, resulting in subsequent falls. This applies to 1 of 3 (R1) residents in the sample of 11 reviewed for falls. The findings include: R1's Resident Face Sheet printed on 5/14/2025 lists the resident as an [AGE] year-old male with medical diagnoses of unspecified dementia, severe, with anxiety and altered mental status admitted on [DATE]. On 5/14/2025 at 12:08PM, V3 Registered Nurse (RN) said she was working on 5/9/2025 with (R1). V3 said a family member came to get her to report a resident had fallen. V3 said (R1) was found in his room on the floor next to his bed. V3 said (R1) stated he was trying to go to the bathroom and had hit his head when he fell. V3 said he did have a small bump on the right side of his head. V3 said (R1) should not have been left in his room unsupervised because of his fall history. V3 said (R1) was sent out to the hospital and returned the same day and all tests were negative. V3 said they were short staffed that day and I'm sure that didn't help the situation. On 5/14/2025 at 12:17PM, V8 Certified Nursing Assistant (CNA) Scheduler said she was working on (R1's unit) on 5/9/2025 helping the two CNAs that were on the unit that day because there had been call-ins. V8 said they would normally have 3 or 4 CNAs on that unit and that day they had two, plus her helping. V8 said she got pulled away from the unit to help off the unit with something and when she came back (R1) had fallen. V8 said (R1) is a fall risk. On 5/14/2025 at 1:54PM, V10 CNA said we were short staffed on the 5/9/2025. V10 said (R1) should have been supervised and was not. V10 said we found him on the floor in his room. V10 said there were only 2 CNAs that day and we were putting people back to bed so (R1) was not supervised and should have been. 5/14/2025 at 1:26PM, V16 RN said on she was working on 5/11/2025 and was the nurse for (R1). V16 said (R1) had been restless that day and was to be kept in the common area. V16 said (R1) was wheeling himself around, stood up and fell. V16 said staff couldn't get to him before he fell. V16 said (R1) fell back and hit his head and there was some bleeding. V16 said (R1) was sent out to the hospital and returned the same day. V16 said the CT scan was negative, and they couldn't find any lacerations. V16 said (R1) did not get any stitches, glue and no fractures. V16 said he should be supervised. V16 said the unit only had 2 CNAs that day at the time of the fall which was around 6:35PM. V16 said 2 CNAs on that unit is not enough. R1's progress notes dated 5/9/2025 at 1:47PM, shows resident was noted on the floor next to the bed. Resident stated he was trying to get up and lost his balance and stated he hit his head. Physician contacted ok to send to emergency room for CT scan. Progress notes from 6:19PM states resident returned from the hospital no new orders and CT scan was negative. R1's Care Plan dated 2/14/2025 to 5/14/2025 shows, resident at risk for falling [related to] weakness from recent illness and new environment started on 2/12/2025. The facility provided All Falls for Facility document printed on 5/14/2025 shows falls for 5/11/2025 and 5/9/2025 for [R1].

Based on interview and record review the facility failed to ensure showers were provided for 5 of 8 residents (R1, R2, R3, R10, R11) reviewed for Activities of Daily Living (ADL's) in the sample of 11. The findings include: On 5/14/25 9:10 AM, R2 said, I am supposed to get two showers a week on Mondays and Thursdays and that doesn't always happen. Last Monday I asked about my shower and the CNA's (Certified Nursing Assistants) just looked at each other and didn't say a word. R2 said she keeps track of what happens at the facility by writing things down, so she has the correct days and times to reference to. On 5/14/25 at 8:36 AM, V4 (CNA) said when the facility is not staffed well enough there are times that they cannot get to residents to get the showers done. On 5/14/25 at 11:21 AM, V8 (CNA Coordinator) said residents should get showers twice a week. If a shower is missed or a resident refused, they should attempt again on the next shift or next day. V8 said if a shower is refused it should be documented in a shower sheet. On 5/14/25 at 1:54 PM, V10 (CNA) said the facility was very short staffed on Friday 5/9/25 and they were not able to do showers for 3 residents including R3, R10 and R11. V10 said that day they were not able to get to everyone on time to do incontinent cares or feeding due to having very low numbers of CNA's working. V10 said R10 had followed her asking about her shower and she felt so bad telling her that she could not do it because they were short staffed. On 5/14/25 at 2:03 PM, R10 said she was told last Friday that she couldn't get a shower because they didn't have enough staff. R10 said, I don't refuse showers we should get them twice a week. The facility provided shower schedule for the Liberty Lane wing shows that residents should receive showers twice a week. R1 should receive showers on Wednesday and Saturday, R2 should receive showers on Monday and Thursday and R3, R10 and R11 should receive showers on Tuesdays and Fridays. The facility provided showers sheets show that 2 showers were not done twice a week for R1 and R2. R1's shower sheets show he received showers on 4/18/25, 4/26/25, 4/30/25, 5/3/25, and 5/11/25. R2's shower sheets show she received showers/bed baths on 4/7/25, 4/14/25, 4/21/25, 4/24/25, 4/28/25, and 5/1/25 there are no documented showers/bed baths for her after 5/1/25. On 5/14/25 V2 (Director of Nursing) was asked for shower sheets for R3, R10 and R11 for 5/9/25 which was a schedules shower day for all of them. V2 said they did not have any shower sheets for those residents for that day. The facility provided Personal Care of Residents Policy revised 12/02 shows each resident shall have proper daily attention and care including as many baths and hair washes as necessary for hygiene needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide adequate staffing to meet the needs of the residents. This failure has the potential to affect all 76 residents residing in the facility. The findings include: The facility completed entrance form titled Facility Data Sheet and the Resident Roster shows the facility census on 5/14/25 was 76. On 5/14/25 at 8:36 AM, V4 CNA (Certified Nursing Assistant) said generally for the Liberty Lane unit which has 27 residents on it they have only 2-3 CNA's for the whole unit. V4 said the unit has a lot of heavy care residents including mechanical lifts. V4 said when staffing is low sometimes showers are missed, and residents have to wait longer because they have to prioritize who they get to first and can lay down. On 5/14/25 at 8:48 AM, V5 and V6 both CNA's said the Liberty Lane unit is a very heavy patient care unit of the facility and they are 13 residents requiring mechanical lifts on that unit. V6 said, When we have only two CNA's that is a big problem because two of us have to be in the room together when we are transferring residents into and out of bed to lay them down and do cares. There are also residents who need feeding assistance and if they are in helping other residents then there are simply not enough staff to get to everyone. V5 said they have to prioritize who gets changed going off from who was last changed. V6 said residents families get upset with us about residents having to wait and we explain it to them why it is. Both said it is very often that the facility is running short of CNA's to care for the residents. V6 said residents should get changed every couple hours and receive showers twice a week and when there is not enough staff this doesn't happen. On 5/14/25 at 9:10 AM, R2 said, I have never been so unhappy in my entire life. I came here after another facility I was at closed down. I wait a long time when I put my call light on. Last evening I put my light on to talk to a nurse at 4 PM and I am still waiting today for that nurse to come. Last Monday I didn't get my shower/bath I asked the CNA's about it and they both looked at each other and didn't say a word. While interviewing R2 she pulled out packets of paper to show this surveyor where she documents everything that happens during the day. R2 had documented that she was last checked or changed at 5:15 AM today and prior to that it was 9:30 PM last evening. R2 said she waits long periods for call lights to be answered, 30 minutes or more, and she can tell when the facility is short staffed which is most days. R2 said she refrains from making a big fuss about the lack of care and staffing at the facility because she feels like she gets dismissed as a [AGE] year old senile resident. R2 said, I have my wits about me. I know what is going on around me. On 5/14/25 at 11:21 AM, V8 (CNA Scheduler) and V2 (Director of Nursing) said staffing is a challenge at the facility especially when there are call ins. V8 went over the recommended staffing numbers which she said is census and not acuity based. There are 4 sections to staff, the Bounce Back wing A and B, Liberty Lane and Memory Lane. V8 said they recommended staffing is 4 CNA's and 2 nurses on Bounce Back for days and evenings and on nights 2 CNA's and 1 Nurse. Liberty Lane staffing is for 1 nurse, and they try to get 3 CNA's but prefer 4 CNA's on days and evenings and 2 CNA's and 1 nurse for night shift. V2 said, We have been trying to have 4 CNA's on each side on days and evenings. On Memory Lane there is 1 nurse and 2-3 CNA's, on days and evenings and a nurse floats over to Memory Lane for med pass on night shift and there are 2 CNA's. V2 said they do hear complaints that there is not enough staff at the facility. V2 said it is company policy that residents get two showers a week. V8 said on 5/9/25 day shift there was numerous call ins, and the facility was short staffed. V2 said she was the only CNA with the 2 nurses for a couple hours on the Bounce Back wings, and the Liberty Lane had only 2 CNA's and a nurse who was training a new staff nurse. V8 said it can be difficult to get everything done on time when there are only 2 CNA's on a unit especially on Liberty Lane because it is a heavier care hallway with lots of residents needing to be transferred via mechanical lifts. V8 said if the staff cannot get to showers, they should offer them on the next shift or the next day. 2 weeks of master staffing schedules showing call ins and the actual staff who worked, from 4/30/25-5/14/25 were reviewed. The schedules show on the following dates the facility did not have the facility recommended number of CNA's to provide care to the residents: 5/1/25, 5/3/25, 5/5/25, 5/9/25, 5/10/25, 5/11/25. On 5/14/2025 at 12:08PM, V3 Registered Nurse (RN) said she was working on 5/9/2025 with (R1). V3 said a family member came to get her to report a resident had fallen. V3 said (R1) was found in his room on the floor next to his bed. V3 said (R1) stated he was trying to go to the bathroom and had hit his head when he fell. V3 said (R1) should not have been left in his room unsupervised because of his fall history. V3 said (R1) was sent out to the hospital and returned the same day and all tests were negative. V3 said they were short staffed that day and I'm sure that didn't help the situation. On 5/14/25 at 1:54 PM, V10 CNA said it happens all the time that the facility is short staffed, and they have told administration many times that they need more help. V10 said on 5/9/25 they were so short staffed that 3 residents (R3, R11 and R12) did not get showers done. V10 said they were not able to get the residents toileted or incontinence care done on a timely basis and the meal trays sat for a long period of time before they were able to pass them because every unit was short staffed. V10 said there was also a fall (R1) had been left in his room unsupervised after therapy and he is someone who is supposed to be observed. V10 said her and another CNA were in resident rooms in the afternoon putting people to bed and could not supervise R1 and the next thing she knew he had fallen and was lying on the floor of his room. A facility provided fall log shows R1 had falls on the following dates, 3/18/25, 4/3/25, 4/19/25, 4/26/25, 4/30/25, 5/9/25, and 5/11/25. On 5/15/25 at 2:03 PM, R10 said it happens a lot that she waits 40-45 mins for her call light to be answered, and she was told last Friday 5/9/25 that she couldn't get a shower because they didn't have enough staff. The facility provided showers sheets show that 2 showers were not done a week for R1 and R2. R1's shower sheets show he received showers on 4/18/25, 4/26/25, 4/30/25, 5/3/25, and 5/11/25. R2's shower sheets show she received showers/bed baths on 4/7/25, 4/14/25, 4/21/25, 4/24/25, 4/28/25, and 5/1/25 there are no documented showers/bed baths for her after 5/1/25. On 5/14/25 V2 (Director of Nursing) was asked for shower sheets for R3, R10 and R11 for 5/9/25 which was a scheduled shower day for all them. V2 said they did not have any shower sheets for those residents for that day. The facility provided Staffing policy revised on 9/18 shows staffing should be based on number, acuity and diagnosis and the facility should ensure adequate staffing will be met to provide resident care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide incontinence care/toileting to a resident that required staff assistance for toileting for 1 of 18 residents (R65) reviewed for activities of daily living (ADLs) in the sample of 18. The findings include: R65's resident assessment dated [DATE] showed R65 required maximum staff assistance for toileting and transfers. R65 had a history of incontinence. The assessment showed R65 was cognitively impaired. On 3/3/25 at 9:17 AM, R65 was seated in a wheelchair in his room. A strong smell of urine was noted in R65's room. At 9:19 AM, V8 and V9 Certified Nursing Assistants (CNA) transferred R65 from his wheelchair to the toilet. The inner left groin and left buttock areas of R65's sweatpants appeared wet with urine. V9 CNA removed R65's brief and stated, Wow, that's (R65's brief) heavy. R65's brief was saturated with urine and a moderate amount of soft stool. R65's buttocks appeared red. V9 CNA looked at R65's pants and stated, These are wet. We need to change his pants. V8 CNA stated, This is my first time changing or toileting (R65) today. I am not sure when he was last changed. It would have been sometime on nights. He was up and dressed when I got here this morning. On 3/4/25 at 10:49 AM, V2 Director of Nursing (DON) stated staff are to toilet and/or provide incontinence care to residents every two hours.

Based on observation, interview, and record review the facility failed to ensure the narcotic reconciliation count was accurate. This applies to 1 of 1 (R274) in the sample of 18 reviewed for narcotics. The findings include: On 3/4/2025 at 8:15AM, the narcotic count was checked for the medication cart with V10 Licensed Practical Nurse (LPN). V10 pulled up R274's narcotic count sheet on their computerized charting. R274s' Tramadol 50mg card was selected. R274 had two Tramadol 50mg cards, one with 30 tablets and the second one had 19 tablets for a total of 49. V10 said the count was off this morning because a nurse forgot to sign out a medication. V10 said [R274] has scheduled Tramadol 50mg three times per day. V10 said she notified [V2 Director of Nursing] this regarding the count being off. On 3/4/2025 at 12:24AM, V2 Director of Nursing (DON) said she was made aware the count was off. V2 said she did investigate why the count was off. V2 said [V10] didn't sign out the Tramadol dose that was given during the 7:00AM - 10:00AM on 3/3/2025, which caused the count to be off. V2 said there was no misappropriation, the nurse just didn't sign out the dose. R274's 14 Day Administration History dated 3/4/2025 shows R274 received all doses of Tramadol 50mg from 2/19/2025 - 3/3/2025, and the AM dose on 3/4/2025. The facility provided Pharmaceutical Procedures revised 1/5/2023 states, . Controlled Substances . individual resident control sheets shall be utilized for all controlled substances. The record shall list for each prescription the following information: . number of doses remaining. a shift count will be done every shift by the off-going and on-coming nurses to verify doses remaining. A shift count form or electronic record will be used for this purpose and signed by both nurses.

Based on observation, interview and record review the facility failed to label an insulin pen with an opened date. This applies to 1 of 1 (R49) in the sample of 18 reviewed for insulin. The findings include: On 3/4/2025 at 8:00AM, R49's Humalog insulin pen was in the medication cart with no opened date, while checking the medication cart on the unit. V10 Licensed Practical Nurse (LPN) said the insulin pen should be dated when opened. On 3/4/2025 at 12:24PM, V2 Director of Nursing (DON) said insulin pens should be dated when opened. R49's Physician Order Report dated 2/3/2025 - 3/3/2025 shows an order for Humalog KwikPen Insulin (insulin lispro) started on 9/22/2025. The facility provided Insulin Administration Procedure revised 02/04 states, . Date insulin vials when opened. Loss of potency may occur when the bottle has been in use >30 days.

Based on observation, interview and record review the facility failed to ensure puree diet textures were smooth. This applies to 3 of 3 residents (R9, R176, R51) for puree diets in the sample of 18. The findings include: The facility's lunch menu for March 3, 2025 shows, Swiss steak with gravy, mashed potatoes and gravy, whole kernel corn, peanut frosted chocolate cake, beverage. The spreadsheet for the lunch meal shows, the same meal except creamed corn instead of whole kernel corn for pureed diets. On March 3, 2025 at 11:10 AM, V4 cook pureed Swiss steak for the noon meal. He pureed it until he thought it was pureed enough. He stated, It's gritty and I don't know how to get rid of the grittiness and plated the Swiss steak. The Swiss steak had small chunks of meat in it and the texture was not smooth. After the Swiss steak was pureed, V5 cook pureed the creamed corn for the noon meal. She pureed it some and stated, it's hard to puree and plated it. The creamed corn had hulls in it and was not smooth. On March 3, 2025 at 1:20 PM, V3 Dietary Manager stated, the puree at the noon meal was gritty and should be smooth. She also identified 3 residents (R9, R176 & R51) receiving pureed diets. The facility's pureed volume method procedure dated July 2020 shows, Objective: To provide guidelines to puree food to appropriate texture for meals. Description: The Pureed Diet is a mechanically altered diet. The diet is designed to permit easy chewing and swallowing. The Regular Diet is modified in consistency and texture by pureeing foods to a smooth mashed potato consistency with no lumps or particles visible .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to implement and follow Enhanced Barrier Precautions (EBP) for 3 of 18 residents (R19, R12, R8) reviewed for infection control in the sample of 18. The findings include: 1. R19's care plan dated 1/7/25 showed R19 is on enhanced barrier precautions due to her wounds on her left calf and mid back . Staff will be provided with appropriate PPE (personal protective equipment) to provide (R19's) care . R19's wound care note dated 2/28/25 showed R19 had a cancerous wound to her right lower back area measuring 2.3 cm (centimeters) x 2.2 cm x 0.2 cm. On 3/3/25 at 9:10 AM, an EBP sign hung on the door to R19's room. R19 was seated on the side of her bed. A large, square gauze dressing was noted to R19's right lower back area. On 3/3/25 at 9:35 AM, V7 Registered Nurse (RN) donned gloves, but no protective gown. V7 then entered R19's room. As R19 laid on her bed, V7 RN removed the dressing from the wound on R19's back. V7 RN provided wound care and applied a new dressing to R19's back wound. 2. R12's Resident Face Sheet dated 12/16/22 showed R12 had a diagnosis of ESBL (Extended Spectrum beta lactamase infection) of his urine. R12's resident assessment dated [DATE] showed R12 was always incontinent of urine. R12 required assistance with toileting/incontinence care. On 3/3/25 at 9:50 AM, R12 was seated in his room. No EBP sign was noted on or around the door to his room. No cart containing PPE equipment was noted outside of R12's room. On 3/4/25 at 8:10 AM, V6 Infection Preventionist was observed placing an EBP sign on the door of R12's room and placing an isolation cart full of PPE outside of his room. On 3/4/25 at 10:41 AM, V6 Infection Preventionist stated, I was notified yesterday that (R12) has a history of ESBL of his urine. I was not aware of that previously. I put him on EBP precautions this morning. He does also have a history of urinary incontinence. V6 stated EBP precautions are required for all patients that have urinary catheters, intravenous access, feeding tubes, wounds, and a history of colonized ESBL. V6 stated any nursing staff providing wound care must wear a gown and a protective gown. The facility's Enhanced Barrier Precautions policy dated 8/8/22 showed, It is the policy of the facility to use proper PPE (Personal Protective Equipment) during high-contact resident care opportunities for transfer of MDROs (Multi-drug resistant organisms) to staff hands and clothing . Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP may be indicated, when Contact Precautions do not otherwise apply, for residents with the following: a. Wounds or indwelling medical devices . b. Colonization with an MDRO . Examples of MDROs include . ESBL-producing Enterobacteriaceae . Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions may include: Dressing, bathing/showering, transferring, providing hygiene, changing briefs or assisting with toileting, device care or use . wound care . 3. On 3/3/2025 at 9:00AM, an enhanced barrier precautions (EBP) sign was observed on the door frame of R8's room. V11 Student Nurse was observed coming out of R8's bathroom while pushing R8 in a wheelchair, without gown and gloves on. V11 said she was helping R8 in the bathroom. V11 said she was unsure why [R8] was on isolation precautions. On 3/3/2025 at 9:09AM V10 Licensed Practical Nurse (LPN) said staff working with residents on EBP should have a gown and gloves on. V10 said gown and gloves are worn to prevent the spread of infection. V10 said [R8] is on EBP for wounds. On 3/4/2025 at 1:26PM, V2 Director of Nursing (DON) said if a resident is on EBP and staff are helping the resident, in direct physical contact with the resident staff should wear gown and gloves. R8's Physician Orders dated 2/3/2025 - 3/3/2025 shows an order for Enhanced Barrier Precautions with a start date 1/1/2025. The facility provided Enhance Barrier Precautions (EBP) policy adopted 8/8/2022 states, . EBP are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities . EBP may be indicated . for residents with any of the following . wounds or indwelling medical devices.

Based on interview and record review the facility failed to complete resident comprehensive assessments in a timely manner. This applies to 4 of 4 residents (R1, R21, R26 and R177) reviewed for comprehensive assessments in the sample of 18. The finding include: On 3/4/25 R1's Minimum Data Set (MDS) Assessment Tracking shows that R1's Comprehensive Assessment was due to be completed on 1/25/25. It is listed as In Process. On 3/4/25 R21's Minimum Data Set Assessment Tracking shows that R21's Comprehensive Assessment was due to be completed on 12/11/24. It is listed as In Process. On 3/4/25 R26's Minimum Data Set Assessment Tracking shows that R26's Comprehensive Assessment was due to be completed on 12/11/24. It is listed as In Process. On 3/4/25 R177's Minimum Data Set Assessment Tracking shows that R125's first admission Comprehensive Assessment was due to be completed on 1/18/25. It is listed as In Process. On 3/44/25 at 12:31 PM V2 (Interim Director of Nursing (DON)/MDS Coordinator) stated, Last week I think I sent out 2 emails that had 10+ people that showed that my part was completed. They were behind. I passed them off to the people that need to finish their parts. When I first started, we were about 3 months behind so that took some time to get caught up. At 1:30 PM V2 stated, When we lost our DON in September, I took over as interim DON but and I can't do both that and keep up with the MDSs.

Based on interview and record review the facility failed to complete resident significant change assessments in a timely manner. This applies to 4 of 4 residents (R24, R25, R48 and R49) reviewed for significant change assessments in the sample of 18. The finding include: On 3/4/25 R24's Minimum Data Set (MDS) Assessment Tracking shows that R24's Significant Change Assessment was due to be completed on 1/30/25. It is listed as In Process. On 3/4/25 R25's Minimum Data Set Assessment Tracking shows that R25's Significant Change Assessment was due to be completed on 1/29/25. It is listed as In Process. On 3/4/25 R48's Minimum Data Set Assessment Tracking shows that R48's Significant Change Assessment was due to be completed on 1/22/25 . It is listed as In Process. On 3/4/25 R49's Minimum Data Set Assessment Tracking shows that R49's Significant Change Assessment was due to be completed on 2/20/25. It is listed as In Process. On 3/44/25 at 12:31 PM V2 (Interim Director of Nursing (DON)/MDS Coordinator) stated, Last week I think I sent out 2 emails that had 10+ people that showed that my part was completed. They were behind. I passed them off to the people that need to finish their parts. When I first started, we were about 3 months behind so that took some time to get caught up. At 1:30 PM V2 stated, When we lost our DON in September, I took over as interim DON but and I can't do both that and keep up with the MDSs.

Based on interview and record review the facility failed to complete resident quarterly assessments in a timely manner. This applies to 4 of 4 residents (R17, R50, R58 and R224) reviewed for quarterly assessments in the sample of 18. The finding include: On 3/4/25 R17's Minimum Data Set (MDS) Assessment Tracking shows that R17's Quarterly Assessment was due to be completed on 1/1/25. It is listed as In Process. On 3/4/25 R50's Minimum Data Set Assessment Tracking shows that R50's Quarterly Assessment was due to be completed on 1/8/25. It is listed as In Process. On 3/4/25 R58's Minimum Data Set Assessment Tracking shows that R58's Comprehensive Assessment was due to be completed on 1/15/25. It is listed as In Process. On 3/4/25 R224's Minimum Data Set Assessment Tracking shows that R224's Quarterly Comprehensive Assessment was due to be completed on 1/15/25. It is listed as In Process. On 3/44/25 at 12:31 PM V2 (Interim Director of Nursing (DON)/MDS Coordinator) stated, Last week I think I sent out 2 emails that had 10+ people that showed that my part was completed. They were behind. I passed them off to the people that need to finish their parts. When I first started, we were about 3 months behind so that took some time to get caught up. At 1:30 PM V2 stated, When we lost our DON in September, I took over as interim DON but and I can't do both that and keep up with the MDSs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure physician prescribed medication was obtained and administered for 1 of 3 residents (R1) reviewed for pharmacy services in the sample of 5. The findings include: R1's face sheet shows he was admitted to the facility on [DATE] with diagnoses including: adult failure to thrive, urinary retention, unspecified dementia, and protein calorie malnutrition. R1's nursing progress notes show he was sent to a local emergency room on 9/11/24 for increased weakness, confusion and having amber colored urine in his indwelling Foley catheter. Nursing progress notes show R1 returned from the hospital on 9/12/24 at 2:30 PM and was diagnosed with a urinary tract infection (UTI). R1's 9/12/24 After Visit Summary from a local community hospital shows his discharge medications to include levofloxacin (Levaquin) (an antibiotic) 500 mg. (milligrams) to be taken daily for 5 days for a UTI. R1's Physician Order Report for 9/1/24-9/26/24 shows an order for R1 to begin levofloxacin 500 mg to be given daily for 5 days beginning 9/12/24 between 3:00-6:00 PM. R1's Medication Administration Record from 9/12/24-9/26/24 shows he did not receive his scheduled levofloxacin on 9/12/24 or 9/13/24 with the reason coded as Not Administered: Drug/Item unavailable. On 9/26/24 at 12:01 PM, V12 (Licensed Practical Nurse) said the facility has an onsite medication distribution system called stat safe which has numerous medications available they can access. V12 said she was not aware that R1 missed 2 days of his antibiotic and she would have called the pharmacy to see where the medication was. On 9/26/24 at 12:20 PM, V7 (Registered Nurse) said she noticed a few days later that R1 had missed 2 doses of his antibiotic and if she was the nurse who was scheduled to have given the antibiotic, she would have called the pharmacy to find out where the medication was or obtain it from the state safe and given it. V7 said the facility pharmacy can be slow at delivering medications. On 9/26/24 at 1:33 PM, V6 (Pharmacist) said they received the order for R1's levofloxacin on 9/12/24 at 2:57 PM and delivered it to the facility on 9/13/24 at 2:10 AM. V6 said the consequence of R1 missing the doses of antibiotics could result in worsening systems of his infection or becoming septic. On 9/26/24 at 1:43 PM, V3 (R1's physician) said he does not recall the facility calling him to inform him that R1 missed the 2 doses of his antibiotic. V3 said this medication was ordered by the hospital physician so it should have been followed and given as scheduled. The facility provided list of medications inside the safe stat medication box shows levofloxacin 250 mg. and 500 mg. were both inside. The facility provided Pharmaceutical Procedures Policy revised on 1/5/23 shows the facility and pharmacy should provide the residents with the appropriate distribution and administration of medications.

Based on interview and record reviewed the facility failed to notify a resident's Power of Attorney (POA) after the resident left the facility. This applies to 1 of 3 (R1) residents reviewed for notification. The findings include: On 9/16/2024 at 9:18AM, V3 Registered Nurse (RN) said on 9/10/2024 at 6:30PM [R1] wanted to leave the facility to go back home. V3 said [R1] left the facility AMA (Against Medical Advice) and was advised by staff to remain in the facility. V3 said [R1] left the facility with V4 (R1's Significant Other) in V4's car, who also brought [R1] to the facility from the hospital. V3 said she did not contact V5 (R1's Power of Attorney - POA) after R1 left the facility. V3 said she would normally contact the POA if a resident leaves the facility but did not in this case. On 9/16/2024 at 9:56AM, V2 DON (Director of Nursing) said facility staff notify the Power of Attorney (POA) when a resident leaves the facility. On 9/16/2024 at 9:03AM, V6 RN said when a resident discharges the physician, DON, and POA are notified of a resident's discharge. On 9/16/2024 at 10:38AM, V7 Hospital Unit Manager stated on 9/5/2024 at 12:37PM [R1's] surgical consent was completed via telephone by [R1's] POA. V7 said [R1] did not sign her own consent. V5 is listed as R1's Power of Attorney for Health Care since of 4/2/2018.

Based on observation, interview, and record review the facility failed to provide wound care as ordered and failed to follow physician orders regarding high blood sugar readings. This applies to 2 of 2 residents (R2 & R31) reviewed for quality of care in the sample of 19. The findings include: 1. R2's Face Sheet showed a current admission date of 3/22/23 with diagnoses to include chronic ulcer of the left lateral (side) foot, stroke, and weakness. On 2/14/24 at 1:24 PM, R2's left lateral wound was covered with a 4 inch by 4 inch adhesive bordered dressing. On 2/14/24 at 1:24 PM, V17 Registered Nurse (RN) removed the dressing and the skin directly beneath the bordered adhesive dressing was red and inflamed. The dressing was dated 2/11/24. On 2/14/24 at 1:35 PM, V17 stated the date on the dressing was the date that it was changed. V17 stated, based on the appearance of R2's skin under the bordered dressing, it seemed as if the dressing had not been changed since 2/11/24 (3 days prior). V17 said, in addition to the dressing not being changed daily, the dressing she removed was not the correct dressing. V17 stated R2's skin was not tolerating the bordered adhesive dressing and a gauze wrap should have been applied on 2/11/24. V17 stated the dressing also should have been changed daily. R2's 2/14/24 Physician Orders for the left lateral foot showed, .cover with [non-adherent] dressing and wrap with 4-inch gauze wrap. Special Instructions: use [gauze wrap] due to redness from island dressing (bordered adhesive bandage). The order showed it was a daily dressing change. R2's Treatment Administration History showed the treatment to the left foot was documented as being done on 2/12/24 and 2/13/24. (Despite dressing dated 2/11/24) R2's Wound Evaluation and Management Summary (wound care physician note) from 2/9/24 showed the wound to the left lateral foot was an arterial wound and should be changed three times per week. (R2's electronic charting showed the order was entered as a daily dressing change.) On 2/15/24 at 10:09 AM, V2 Director of Nursing (DON) stated R2's orders should reflect the orders on R2's physician wound care note. V2 said the orders in the computer were for a daily dressing change; however, the wound doctor had ordered the dressing changes to be done every three days. V2 stated dressing changes can be uncomfortable for residents and should only be done when needed or ordered. On 2/15/24 11:51 AM, V2 stated R2's bordered dressing, which was removed by V17 on 2/14/24, was not the correct dressing. V2 said the dressing should have been a gauze wrap due to the irritation the bordered dressing was causing R35's skin. 2. R31's Face Sheet showed a current admission date of 6/26/23 with diagnoses to include diabetes and cognitive communication deficit. R31's Physician Order Report showed an order for sliding scale rapid acting insulin (Dosage of insulin is dependent upon blood sugar readings.) to be given three times a day before meals. The order showed, in addition to the sliding scale insulin, Special Instructions: Blood sugar greater than 400 give 12 units and call doctor. The order was started on 11/8/23 and was active as of 2/15/24. R31's Blood Sugar showed on 2/6/24 at 9:43 PM a value of 516. R31's Blood Sugar showed on 2/3/24 at 8:41 AM a value of 403. R31's Blood Sugar showed on 2/1/24 at 8:27 PM a value of 426. R31's Blood Sugar showed on 12/5/23 at 11:50 AM a value of 489. On 2/15/24 at 10:04 AM, V2 Director of Nursing stated the order to notify a physician for blood sugars greater than 400 is a typical order for sliding scale insulin. V2 said the reason to notify the physician is a reading over 400 is a high value and the provider may want to order additional insulin. V2 said the blood sugar values at night should have also been called to the physician. V2 said if the nurse contacted the physician there should either be a progress note or an electronic record of the physician notification. (Documentation of physician notification for the out-of-range blood sugars was requested.) On 2/15/24 at 11:40 AM, V2 stated, she was not able to find any documentation the physician was notified of R31's blood sugars greater than 400 for the dates requested. The facility's Change in Resident's Condition policy (revised 12/2002) showed, The nurse will notify the resident's attending physician when .there is a need to alter the resident's treatment significantly .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to implement Physician ordered interventions. This applies to two of four residents (R11 and R42) reviewed for pressure injuries in the sample of 19. The findings include: 1. The facility face sheet for R11 shows a diagnosis of pressure ulcer of the sacral region. The facility assessment dated [DATE] shows R11 to be cognitively intact and requires moderate assistance with activities of daily living. The care plan dated 7/17/22, shows R11 was admitted to the facility with a stage 4 pressure ulcer to her sacrum. The interventions show a low air mattress on her bed and to change her wound dressing as ordered by Physician or wound nurse. The Physician orders dated February 2024 shows R11 is to have an air loss mattress to her bed and her sacral dressing wound care is to be completed daily. The wound Physician notes dated 2/9/24 shows the dressing is to be changed three times a week by the staff nurses, and a low air loss mattress is to be on R11's bed. On 2/14/24 at 9:57 AM, no low air mattress was observed on R11's bed. On 2/14/24 at 10:30 AM, V10 Memory Care Director when asked if R11 had an air mattress, said Is she supposed to? On 2/15/24 at 10:30 AM, V9 LPN (Licensed Practical Nurse) said R11 gets the dressing to her sacrum changed every day. V9 said the wound Physician sees her every Friday to apply the inner dressing and the staff nurses change the secondary dressing every day. On 2/15/24 at 11:12 AM, V2 Director of Nursing said she has an air mattress added to R11's bed on 2/14/24 after she was told R11 did not have one. V2 said she was not aware that R11 was supposed to have her dressing changed three times a week to her sacrum. V2 said the nurses are to follow the Physician orders. The treatment administration record for February 2024 shows the treatment was completed by the staff daily. 2. R42's face sheet printed on 2/14/24 showed diagnoses including but not limited to acute embolism and thrombosis of deep veins of lower extremity, cellulitis of lower limb, and pressure induced deep tissue damage of right heel. R42's facility assessment dated [DATE] showed no cognitive impairment and a stage 4 pressure ulcer. R42's February 2024 physician order report showed an order start dated 11/11/23 for boots to be worn at all times to float heels. R42's wound evaluation dated 2/9/24 showed a right heel, stage four pressure ulcer measuring 0.6 x 0.6 x 0.3 centimeters. The report showed a treatment plan to off-load the wound. The treatment plan for the wound was for a collagen sheet with gauze island dressing three times per week. R42's February 2024 physician order report showed the treatment to be done daily, not three times per week as order by the wound physician. R42's treatment administration report for February documented the treatments had been on a daily basis. On 2/13/24 at 9:43 AM, R42 was seated in a wheelchair in her room. A pair of purple heel protectors were lying on the bed. R42 wore socks on both feet and her heels were directly on the floor. R42 was trying to hold her right foot up off the ground. R42 said she has a sore on that heel, and it hurts to leave it on the cold floor. At 10:30 AM, R42 was in a group activity with V5 (Activity Aide). R42 was not wearing any heel protectors and was holding her right foot up, off the floor. At 11:45 AM, R42 was self-propelling her wheelchair out of her room. She was not wearing any socks and was using her bare feet to push the wheelchair across the hall. On 2/14/24 at 12:29 PM, R42 was seated at the group dining table and her feet were resting directly on the floor. There were no heel protectors on her feet. On 2/14/24 at 12:16 PM, V4 (Licensed Practical Nurse) stated R42 has a pressure ulcer on her right heel. She is seen weekly by the wound doctor and the wound nurse follows him. R42 gets daily dressing changes to the heel and wears heel protectors. R42 can push herself in the wheelchair and the boots reduce pressure to the area. V4 said the dressing gets changed daily and was done for the day. V4 said it would be changed again tomorrow. On 2/14/24 at 2:37 PM, V2 (Director of Nurses) said R42 needs heel protectors on all day. She likes to sit in her chair most of the day and the boots help prevent pressure to her heels. She has a wound on the right heel and there is the potential for it to get worse if they are not on. V2 said physician orders are an intervention and should be followed to ensure proper wound healing. On 2/15/24 at 12:43 PM, V2 stated R42 was incorrectly getting the heel wound dressings changed on a daily basis. The order was just corrected today and will be done three times per week as ordered. R42's care plan showed a focus area related to pressure ulcers and was start dated 7/6/21. Interventions included treatment/dressings as ordered by MD. The facility's Pressure Injury Prevention and Treatment Protocol policy revision dated 10/24/22 states: An individualized plan of care will be developed for the resident following the guidelines of the assessment. Special devices will be used to relieve pressure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure fall interventions were in place (R48) and failed to provide a safe transfer (R49) for 2 of 2 residents reviewed for safety in the sample of 19. The findings include: 1. R48's face sheet printed on 2/15/24 showed diagnoses including but not limited to early onset Alzheimer's disease, dementia with agitation, osteoarthritis of the knee, amnesia, anxiety, and repeated falls. R48's facility assessment dated [DATE] showed moderate cognitive impairment. The same assessment showed partial/moderate staff assistance required for bed mobility, sit to stand positioning, and transfers. The last six months of the facility's fall log showed R48 had five falls. The falls occurred in R48's room when he was attempting to self-transfer or rolling himself out of bed. R48's care plan showed a focus area related to risk for falls start dated 4/5/23. Interventions included: Place mats on floor next to bed and keep bed in low position and Dysem (anti-slip pad) placed on top of cushion in wheelchair. On 2/13/24 at 9:07 AM, R48 was sitting in his room alone and in a wheelchair next to the bed. The room door was closed and there was no staff present. R48 was confused and answered questions with nonsense words. On 2/15/24 at 9:12 AM, R48's room door was closed and R48 was sleeping in bed. The bed was in the high position, two fall mats were laying up against the wall, and there was no anti-slip pad in the wheelchair. At 9:35 AM, V4 (Licensed Practical Nurse) and this surveyor entered R48's room. V4 stated R48 has had several falls in the past. He has poor safety awareness and self-transfers a lot. V4 said, He tries to get out of the bed or the wheelchair by himself. The bed should not be up this high and the mats should be on the floor. He should have an anti-slip pad in the wheelchair to prevent him from sliding out. (R48's) door should be open unless care is being provided. He is a high fall risk and doesn't understand the directions to wait for help from staff. On 2/15/24 at 10:28 AM, V2 (Director of Nurses, Fall Coordinator) stated resident falls are reviewed and interventions are put into place to reduce the potential for more falls. V2 said R48 is very impulsive and does not use the call light. R48 likes to self-transfer and has rolled out of bed in the past. R48 has dementia and the room door needs to remain open as needed. There is the chance of R48 falling again and being injured when fall interventions are not in place. The facility was unable to provide any policies related to fall prevention. 2. R49's face sheet printed on 2/14/24 showed diagnoses including but not limited to dementia, anxiety, heart disease, and prostate cancer. R49's facility assessment dated [DATE] showed moderate cognitive impairment and partial/moderate staff assistance required for transfers. On 2/13/24 at 9:25 AM, V6 (Resident Assistant) and V7 (Certified Nurse Aide) transferred R49 from his wheelchair to the bed using a mechanical lift. V7 operated the lift while V6 stood next to the lift during the transfer. R49 was laid on the bed and V7 provided incontinence care. On 2/13/24 at 11:36 AM, V7 and V8 (Certified Nurse Aide) stated resident assistants can only pass water, make beds, or stock linens. They cannot provide any hands-on care to the residents. They are not allowed to feed or transfer residents. A certified nurse aide is required for that. On 2/14/24 at 2:30 PM, V2 (Director of Nurses) stated resident assistants cannot provide direct care. V2 said all mechanical lift transfers require two certified nurse aides. It is needed for safety and to ensure a resident does not fall. CNAs are trained on how to do the transfers properly. Resident assistants do sit through the training just so they understand how the lifts work but are not able to do the actual transfers. V2 said R49 is a mechanical lift transfer, and two CNAs are needed for all transfers. The facility's Safe Resident Handling policy revision dated 11/12 states under the procedure section: 5. When using Full Mechanical Lift or Sit to Stand Mechanical Lift, two members are used with additional help as needed.

Based on interview and record review the facility failed to implement physician ordered weight loss interventions for a resident with weight loss. This applies to 1 of 4 residents (R35) reviewed for weight loss in the sample of 19. The findings include: R35's Face Sheet showed a current admission date of 5/11/21 with diagnoses to include abnormal weight loss, dementia, depression, and nausea. R35's 12/29/23 dietitian note showed, she weighed 108 pounds. The note showed, .considered underweight for age per BMI (body mass index) of 20. Wt. (weight) loss of 6 percent in 1 month and 14 percent in 6 months noted . The note showed she was on a liquid nutritional supplement drink twice a day. The note showed a recommendation to increase the supplement to three times a day. R35's 1/16/24 dietitian note showed R35 weighed 107 pounds, .weight loss of 10% in 6 months . The note showed R35 was still ordered the nutritional supplement drink twice daily. The note showed, [R35] continues to lose wt. Recommend review for increasing [nutritional drink] to TID (three times daily) . R35's Request for Dietary Change PCP (primary care provider) FAX Report from 1/16/24 showed the provider agreed with increasing the nutritional drink to three times a day. The fax was signed by the provider on 1/17/24. (On 2/15/24, the facility was unable to produce a fax for the dietitian's recommendation from 12/29/23.) R35's Physician Order showed from 11/2/23 through 2/15/24, R35 was ordered to receive the nutritional supplement only twice daily. The order was changed to three times daily on 2/15/24. On 2/15/24 at 10:17 AM, V2 said, R35's order for her nutritional supplement had not been changed to three times daily. V2 stated R35 has had weight loss due to decreased intake because of her progressing dementia. V2 said increasing the nutritional supplement to three times a day was an intervention to combat her weight loss. V2 said she does not know why the order was not carried out in December 2023 or January 2024. R35's Vitals Report showed her weight has remained stable at approximately 108 pounds from 11/1/23 through 2/1/23.

Based on observation, interview and record review, the facility failed to ensure food temperatures on steam tables were 135 degrees Fahrenheit or above prior to serving, failed to ensure the dish machine temperature for the wash cycle reached the appropriate temperature, failed to ensure staff documented the dish machine temperatures on the daily logs, and failed to ensure dietary staff were knowledgeable regarding how to properly test the dish machine to ensure the proper temperatures were obtained for sanitation. This has the potential to affect all the residents in the facility. The findings include: The CMS 671 form dated 2/13/24 showed 68 residents resided in the facility. The facility's Order Report by Category documents, printed by the facility on 2/14/24, showed all the residents in the facility take food by mouth. On 2/13/24 at 12:03 PM, V16 (Dietary Aide) took the temperatures of the food on the steam table on the 200-unit, prior to serving. The temperature of the meatloaf was taken five times prior to serving. The meatloaf temperatures were as follows: 119.1 degrees Fahrenheit, 131.6 degrees Fahrenheit, 115.3 degrees Fahrenheit, 119.3 degrees Fahrenheit, and 127.4 degrees Fahrenheit. V16 took the temperature of the pureed meatloaf. The pureed meatloaf was 128.9 degrees Fahrenheit. After obtaining the temperatures for all the food that would be served and documenting in the temperature log binder, V16 started serving the food to the residents on the 200-unit. After serving the residents on the 200 unit, the pans of food were loaded back into the heated cart and taken to the 100-unit (this surveyor did not observe the pans being loaded and taken to the 100 unit). On 2/13/24 at 12:36 PM, V16 took the temperatures of the food on the steam table on the 100-unit. V16 verified that this was the same food that was brought from the 200 unit. The temperatures were taken from the two front pieces of meatloaf by V16. The first two pieces were 140.6 degrees Fahrenheit and 153.6 degrees Fahrenheit. This surveyor asked V16 to check the temperatures of a couple more pieces (due to this surveyor not observing the food being placed in the heated cart and taken to the 100-unit). The next two temperatures for the meatloaf were 94.6 degrees Fahrenheit, and 114.6 degrees Fahrenheit. The facility's 200-unit Food Temperature Log showed on 2/13/24 V16 documented a temperature of 120.4 degrees Fahrenheit for the meatloaf on the 200 unit and 127.4 degrees Fahrenheit for the pureed meatloaf on the 200 unit. These temperatures do not match the temperatures observed. The facility's 100-unit Food Temperature Log showed on 2/13/24 V16 documented a temperature of 180 degrees Fahrenheit for the meatloaf on the 100 unit. This temperature does not match the temperatures observed. On 2/14/24 at 9:20 AM, V15 (Food Services Supervisor-FSS) said the food temperatures should be at least 135 degrees Fahrenheit on the steam tables to prevent the food from going into the danger zone where bacteria can grow; to prevent food-borne illness. The facility's February 2024 High Temperature Dish Machine Temperature Log showed no temperatures were recorded into the log for the dish machine for any of the meals on 2/8/24; 2/9/24; 2/10/24; and 2/11/24. The facility's 08/2019 Proper Food Preparation/Holding Temperature document, provided by the facility on 2/14/24, showed food held in a warming cabinet or on a steam table should be kept at 135 degrees Fahrenheit. The facility's 08/2019 Food Temperatures-Measuring Procedure showed hot foods should be held at 135 degrees Fahrenheit, at least, or higher. On 2/13/24 at 9:28 AM, V14 (Diet aide/dishwasher) said she thinks the facility's dishwashing machine is a high temperature dishwasher and not a chemical dishwashing machine. V14 had been running trays of dirty dishes through the dish machine. The gauges on the first cycle this surveyor observed showed the wash cycle temperature was 144 degrees Fahrenheit. V14 said she was not sure how to test the temperature to ensure the gauges were correct. V14 grabbed a couple of bottles from the shelf adjacent to the dish machine and said she thinks those bottles are used to test the dish machine. V14 said whenever she works, she just records the temperature that is on the gauges that are on the outside of the machine. The temperature gauges on the second set of dishes ran through the dishwashing machine were 147 degrees Fahrenheit for the wash cycle. At 9:38 AM, V15 (FSS) came in and said the temperatures are checked by placing a strip that is in the temperature logbook onto a dish and running it through the machine. V15 said the strip should turn orange if the correct temperature is obtained. On 2/14/24 at 9:17 AM, V14 (Dietary Aide/Dishwasher) handed the temperature logbook to the surveyor and said some of the dietary staff are not filling out the temperature log for the dishwasher. V14 said she has been filling out the temperature log for the dish machine on the days that she works. V14 said she just writes down the temperature that shows on the gauges on the outside of the machine. V14 said she does not run a test strip through the machine like V15 did the previous day. At 9:20 AM, V15 (FSS) was asked about the missing information on the Dish Machine Temperature logs. V15 said it has been an ongoing thing. The staff are new, and they write the temperatures in the wrong columns, or do not fill out the temperature logs. At 9:23 AM, V15 said it is important to test the dish machine to ensure it is working properly, to ensure the temperatures are high enough to sanitize the dishes. V15 said this is important to prevent food-borne illness, because the dishwasher is not a chemical dishwasher, so it is important to make sure the water is hot enough to sanitize. The facility's 08/2019 Dish Machine High Temperature Recording Procedure showed Hot water is used for sanitizing in high temperature dish machines, not a chemical sanitizer. Therefore, it is important to record wash temperatures and final rinse temperatures three times a day. After all three meals, before you wash meal dishes, check and record dish machine wash and final rinse temperatures .The policy showed goal temperatures were located on the metal plate located on the front of the dish machine. Appropriate temperatures are as follows; Wash Temperature 150-160 degrees Fahrenheit .Staff will test the dish machine periodically with 180 degree Fahrenheit test strips for accuracy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to perform testing on day 5 of an outbreak of Covid-19 in the facility and failed to report a covid-19 positive case to the local health department. This has the potential to affect all the residents in the facility. The findings include: The CMS form 671 dated 2/13/24 showed 68 residents resided in the facility. On 2/13/24 at 8:30 AM, a sign on the front entrance indicated that the facility had a positive covid case in the building. On 2/14/24 at 1:54 PM, V2 (Director of Nursing-DON) and V11 (the facility's Infection Preventionist) said they are both doing Infection Preventionist duties, until V11 gets fully trained in the position, as V11 has only been in the facility for a couple of weeks. V2 said V12 (Certified Nursing Assistant-CNA) tested positive for Covid-19 on 2/6/24. V2 said V12 had tons of symptoms. V2 said she thinks all the residents and staff on the unit the CNA worked on (the memory lane unit) were tested on [DATE]. V2 said they (the staff and residents on the memory care unit) were tested on e more time after that on day 3. V11 (The facility's Infection Preventionist-IP nurse) said V13 (the previous IP nurse) reported the positive case to NHSN (National Healthcare Safety Network). V11 said she was not sure if it was reported to the local health department. V2 (DON) said she was not aware if the local health department was notified either. V2 said she did not report it to the local health department herself. V2 said one positive case of Covid-19 signifies an outbreak. Both V2 and V11 said when a resident or staff member tests positive, testing should be done on days 1, 3 and 5, with the day the first positive test result was obtained being day zero. V2 and V11 said if no new positive cases, the facility stops testing, but continues to monitor for symptoms for 14 days. V2 and V11 were asked to provide the testing logs and proof that NHSN and the local Health Department were notified of the positive Covid-19 case in the facility. The facility's schedule showed on 2/4/24, V12 worked a double shift on the memory lane unit (second shift and the overnight shift). On 2/15/24 at 8:50 AM, V2 and V11 were interviewed again. V2 said V18 (RN working the memory care unit) tested all the residents and staff on the memory lane unit on 2/7/24. V2 said the facility did not report the positive case to the local Health Department. V11 said V13 (the facility's previous IP nurse) reported the positive case to the NHSN site on 2/8/24. V11 provided a document showing the case was reported on 2/8/24. V2 said the facility should have tested the residents and staff on the memory unit on day 5 which would have been 2/12/24, according to V2. On 2/15/24 at 9:07 AM, V2 said according to our policy, the local health department should have been notified. V2 said it is important to make sure the local Health Department is aware of the positive Covid-19 case and get instructions on what we may need to do differently. V2 said the residents on memory lane do come out of the memory lane unit to go to the beauty shop, restorative-exercise group, and some other activities. V2 said it is important to test to make sure no other residents or staff are positive, so that it does not spread. The facility's testing documents showed residents on the memory lane unit and staff were tested on [DATE] and 2/10/24. (that was day 1 and day 4). No further testing was performed. The facility's Covid-19 policy and procedure, with a revision date of 08/28/23, showed Return to Work Criteria Following Exposure: After Exposure: 1. Have a series of three viral tests for SARS-CoV-2 infection. a. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test, and if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5 .Notifications: 1. Local health department and other government agencies as required will be notified if Covid-19 is diagnosed in either residents or staff.

Based on interview and record review, the facility failed to complete a physicians order for UA (urinalysis) and C&S (culture and sensitivity) in a timely manner. This applies to 1 of 3 residents (R45) reviewed for Catheter/UTI. The findings include: R45's Face sheet shows her diagnoses to include, UTI (urinary tract infections), cognitive communication deficit, and dementia. R45's Progress Notes shows the following time line: On 12/21/22 at 11:04 AM, the Physician ordered UA and C&S. On 12/21/22 at 2:54 PM, An attempt to get the necessary urine from the resident failed. On 12/22/22 at 1:20 PM, An attempt to get the necessary urine from the resident failed. On 12/22/22 at 9:25 PM, UA obtained and placed in the refrigerator. (This surveyor asked the facility to provide the results of the UA, and C&S from this specimen but the results could not be found). On 12/27/22 at 2:48 PM, an attempt to get the necessary urine from the resident failed. On 12/29/22 at 2:44 PM, an attempt to get the necessary urine from the resident failed. On 12/30/22 at 1:07 AM, urine sample was obtained via straight catheterization. On 1/2/23 at 4:04 PM, UA result was sent to the Physician. On 1/3/23 at 2:53 PM, The facility received Physician orders for R45 to start an antibiotic for a UTI. On 01/19/23 at 12:28 PM, V3 RN (Registered Nurse) said, she does not know what happened to the first specimen. V3 said, if the normal laboratory doesn't pick the sample up, then the facility should have sent it to the (local hospital) lab. V3 said, it's important to do Physician ordered labs as ordered because the labs could show us what's going on with the resident like infection or chemical imbalances. Delaying the labs could delay treatment to the resident. On 01/19/23 at 10:08 AM, V2 DON (Director of Nursing) said, she doesn't know what happened to that specimen obtained on 12/22/22. V2 said, it was a holiday weekend so maybe our normal lab didn't pick it up, so it should have been sent to our local hospital lab. V2 could find no results for the specimen drawn on 12/22/22. R45's 12/30/22 urinalysis shows turbid (cloudy) urine that was positive for nitrates, and leukocytes. The culture for the same date shows greater than 100,000 colonies/milliliter of Escherichia coli. The Lab/Diagnostic Policy and Procedure (Revised 11/28/17) shows, it is the Policy to provide means of quality diagnostic lab services for the residents. The Purpose is to provide residents a means of diagnostic service promptly and conveniently. The same document shows under the category, Procedures, a. Provision has been made for promptly and conveniently obtaining required clinical laboratory .services from a clinical laboratory or diagnostic services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the resident received respiratory care and services that is in accordance with professional standards of practice for 3 (R7, R34, R44) of 4 residents reviewed for oxygen therapy in the sample of 15. The findings include: 1. R44's face sheet provided by the facility on 1/19/23 showed she was last admitted to the facility on [DATE] with diagnoses to include acute respiratory disease, pulmonary hypertension, malignant lungs, and rheumatic tricuspid insufficiency. R44's Physician order report dated 12/19/22 to 1/19/23 showed, 1/7/23, O2 (oxygen) 2L (liters) NC (nasal cannula), continuous for SOB (shortness of breath). R44's facility assessment dated [DATE] showed that she is cognitively intact (Brief Interview for Mental Status Score 15) and was on oxygen therapy. R44's care plan revised on 1/10/23 showed, R44 has a diagnosis of COPD (chronic obstructive pulmonary disease)/emphysema/asthma. The same care plan showed an intervention to administer oxygen at current rate as ordered. On 01/17/23 at 12:13 PM, in R44's room, the nebulization mask with its medication container was on the night stand, open to air (not covered in a bag). There was no date on the O2 tubing. On 01/18/23 at 9:15 AM, in R44's room, the nebulization mask had medication in its medication container. The mask with the container was on the night stand, open to air (not covered in a bag). No staff was present in the room. On 01/18/23 at 10:55 AM, R44 was sitting near the exit of the unit on a chair. R44's portable O2 concentrator was hanging on her walker and the nasal cannula was in her nostrils. R44 said that she is using O2 at 2L continuously. The O2 concentrator showed that it was set at 2L, but the dial on the concentrator showed that it was empty (needle on the red color of the indicator). V10, unit nurse, looked and said that the machine does show that it was empty. V10 asked R44 if she can feel the air coming from the nasal cannula. R44 said that she is not sure. On 01/18/23 at 2:35 PM, R44 was sitting at her bedside with O2 being administered at 2L continuous via NC connected to the bedside O2 concentrator. R44's walker was nearby with the portable concentrator and the nasal cannula attached to it. The NC hanging on the walker was open to air and was not covered/bagged. 2. R34's face sheet provided by the facility on 1/19/23 showed she was last admitted to the facility on [DATE] with diagnoses to include transient cerebral ischemic attack, acute respiratory disease, fracture of left femur and dementia. R34's Physician order report dated 12/19/22 to 1/19/23 showed, 12/6/22, O2 (oxygen) per NC (nasal cannula) PRN to keep saturation at >92%. R34's facility assessment dated [DATE] does not indicate that R34 is on oxygen therapy. R34's current care plan (revised on 10/11/22) is not updated to address the diagnosis of acute respiratory disease. On 01/18/23 at 10:00 AM, R34 was sitting on the recliner in her room. The O2 concentrator at her bedside was turned off. No date was on the humidifier bottle or tubing. One set of n/c was hanging on the flowmeter knob, uncovered/not bagged. Another set of n/c & tubing was laying on the floor next to the concentrator. V4 (RN-registered nurse) was informed about the nasal canula on the floor. V4 came to the R34's room, saw the NC and tubing on the floor and the ones hanging on the knob uncovered/not bagged. V4 said that R34 is on O2 PRN (as needed). 3. R7's face sheet provided by the facility on 1/19/23 showed she was last admitted to the facility on [DATE] with diagnoses to include pneumonia and congestive heart failure. R7's Physician order report dated 12/19/22 to 1/19/23 showed, ipratropium-albuterol solution for nebulization: 1 vial inhalation while awake, three times a day R7's facility assessment dated [DATE] does not indicate that R7 is on oxygen therapy or on treatment with ipratropium-albuterol. R7's current care plan (revised on 1/17/23) is not updated to address the diagnosis of pneumonia and the MD orders for nebulization therapy. On 1/17/23 at 10:40 AM, A nebulization mask with the container for the medication was on the bedside table uncovered/not bagged in R7's room. 1/18/23 at 09:45 AM, A nebulization mask with the container for the medication was on the bedside table uncovered/not bagged in R7's room. 1/19/23 at 10:00 AM, A nebulization mask with the container for the medication was on the bedside table uncovered/not bagged in R7's room. On 1/19/23 at 11:00 AM, V2, (DON - Director of Nursing) stated that it is the nurse's responsibility to check if the portable concentrator is full or needs a refill. V2 also stated that Nebulization masks and nasal cannulas should be kept bagged when not in use so that it does not collect dust & be a potential portal for infection. The facility's policy titled 'oxygen therapy and safety' with a revision date of 4/9/20 stated, Procedure 1. Safety is the responsibility of all staff 4. Oxygen therapy. b. Turn on flowmeter to 2 L/min to test for appropriate flow of oxygen .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observation, Interview, and Record Review the facility failed to cleanse and sanitize hands and equipment to prevent cross contamination for 4 of 4 residents (R18, R51, R260, and R258) reviewed for infection control in the sample of 15. The findings include: 1. R18's Physician order report dated 12/19/22 to 1/19/23 (last admitted on [DATE]) showed, 1/12/23, Gentamycin in NaCl (sodium chloride) piggyback; 100 mg/100 ml; IV (intravenous); 100 ml/hour; once a day. R18's facility assessment dated [DATE] showed that he is cognitively intact (Brief Interview for Mental Status Score 15) and was on IV medications. On 01/18/23 at 9:00 AM, V10 (RN-registered nurse) collected her supplies and entered R18's room. V10 did not wash her hands or use hand sanitizer before putting on a pair of gloves. V10 adjusted the clothing of R18 to be able to access the IV site, re-positioned his arm and changed her gloves without performing any hand sanitization. V10 withdrew half a milliliter of blood in a syringe, placed it on the bedside table, flushed the IV line with NSS (normal saline solution) and started the gentamycin infusion. After the procedure, V10 removed her gloves, picked up all of the unused supplies (one syringe of NSS flush) and the contaminated items (used alcohol swabs, used gloves, syringe with half a milliliter of blood in it) and walked out of R18's room. V10 went to the medicine cart, pulled open the top drawer, placed the unused syringe of NSS in it, put her hands in her pocket and then used hand sanitizer for her hands. 2. R51's face sheet provided by the facility on 1/19/23 showed that he was last admitted to the facility on [DATE] with diagnoses to include post-surgical infection and long-term use of anti-coagulants. R51's Physician order report dated 12/19/22 to 1/19/23 showed PT/INR test, one time, 07:00 AM. R51's facility assessment dated [DATE] showed that R51 has severe cognitive impairment (Brief Interview for Mental Status Score 6). On 1/18/23 at 9:30 AM, V10 was in R51's room, in the process of drawing blood into the pipette to test his PT/INR. V10 had gloves on. Only a quarter of the pipette was filled. R51's finger was bloody. V10 cleaned the finger with alcohol swab & placed the blood-stained swab on R51's bed. With the used gloves on, V10 removed the strip from the PT/INR test machine & reinserted the same strip. With the same used gloves on and with the pipette with blood in her hand, V10 walked up to the door of the room & turned on the light switch. Then she came back to R51's bedside and placed the pipette on the machine to insert the blood from the pipette into the machine. V10 said that the machine did not give a reading and that she will repeat the procedure after some time. V10 removed her used gloves and placed them on R51's bed. V10 did not clean the machine or wash her hands or use hand sanitizer. V10 placed the machine and the box of strips back into its pouch, closed the pouch, picked up all the used items including the used gloves and the used pipette and left the room. On 1/19/23 at 11:00 AM, V2 (DON-Director of Nursing) stated that PT/INR machine should be cleaned after use and before storing it. V2 stated that V10 should not have turned on the light switch with her used gloves on. V2 stated that V10 should have brought in a sharps container along with her supplies for the procedure and discarded the used lancets, pipettes, blood-stained swabs into the sharps container before leaving the room. V2 stated that V10 should have discarded her used gloves in the trash container. V2 stated that V10 should have washed her hands with soap and water after the procedure. V2 stated that V10 should have washed her hands with soap and water before starting an IV medication. V2 stated that V10 should have taken a sharps container to discard the used syringe with blood in it. V2 stated that other than sharps or blood-stained items, V10 should have discarded all other used items in the trash and washed her hands before leaving the room. V2 stated that with contaminated hands V10 should not have touched any other surfaces like the medicine cart, or her pockets. V2 stated that hand washing is necessary to prevent cross contamination and potential infection. The facility's policy titled 'standard precautions' with a revision date of 08/09 stated, Procedure 2. Gloves . c. change gloves between tasks and procedures d. remove gloves promptly after use . 5. a. Handle resident care equipment soiled with blood, In a manner that prevents skin . exposure . and transfer of other infectious agents to other residents and environments. The facility's policy titled 'PT/INR Portable Draw' states to wash hands before and after the procedure. 3. R18's Resident Face Sheet, provided by the facility on 1/19/23, showed he had a diagnosis of diabetes mellitus. R18's Physician Order Report dated 12/19/23-1/19/23 showed he had an order for insulin lispro three times a day per sliding scale (based on blood sugar levels). R258's Resident Face Sheet, provided by the facility on 1/19/23, showed he had a diagnosis of type II diabetes mellitus. R258's Diabetes care plan showed a goal that his blood sugar will be maintained within normal limits. The care plan showed Accuchecks (blood sugar levels) as ordered. R260's Resident Face Sheet, provided by the facility on 1/19/23, showed he had a diagnosis of diabetes mellitus due to an underlying condition with diabetic nephropathy. R260's Physician Order Report dated 12/19/23-1/19/23 showed an order for Accuchecks twice weekly. R260's Diabetes care plan showed R260's blood sugar will be maintained within normal limits during this quarter. The care plan showed Accuchecks as ordered. On 1/18/23 at 11:07 AM, V10 (Registered Nurse-RN working the Bounce Back Unit of the facility on 1/18/23) obtained a blood sample from the right third digit of R18's right hand to check his blood sugar levels with a glucometer (a device used to test blood sugar levels). After obtaining the blood sugar level, V10 walked back down to the medication cart and placed the glucometer inside the top drawer of the medication cart, directly on top of the other glucometer that was in the medication cart. V10 placed the container that held the test strips for the glucometer directly on top of the glucometer she used to test R18's blood sugar levels. V10 did not disinfect the glucometer after obtaining the blood sample from R18. At 12:05 PM, V10 said she should have disinfected the glucometer after using it to prevent the spread of disease and germs. On 1/18/23 at 12:16 PM, V2 (Director of Nursing-DON) said the nurses should disinfect the glucometer after use by wiping the glucometer down with a disinfectant and keeping the glucometer wet per manufacturer's instructions. V2 said it is important to do this to prevent the spread of bacteria and blood borne pathogens. V2 was asked to provide the instructions for the disinfectant that should be used to clean the glucometers after use. On 1/19/23 V2 provided a container of Micro-Kill One germicidal alcohol wipes, along with a printed copy of the instructions for use. The instructions showed: Disinfecting: To disinfect hard, non-porous surfaces, use one or more wipes, as necessary, to thoroughly wet the surface to be treated. Treated surface must remain visibly wet for one minute to achieve complete disinfection of all pathogens listed on this label. On 1/19/23, V2 provided a list of residents currently residing on the Bounce Back Unit of the facility that received Accuchecks to determine their blood sugar levels. The list showed R18, R258 and R260 were the residents on the unit that received Accuchecks. V2 said the glucometers in the medication cart on that unit would only be used for the residents on that unit. The facility's policy and procedure titled Standard Precautions, with a revision date of 08/09, showed 5. Resident-Care Equipment: a. Handle resident-care equipment soiled with blood, body fluids, secretions, and excretions in a manner that prevents skin and mucous membrane exposure, contamination of clothing, and transfer of other infectious agents to other residents and environments. b. Ensure that reusable equipment is not used for the care of another resident until it has been appropriately cleaned and single use items properly discarded. The facility's policy and procedure titled Glucose Monitoring (Even Care G2), with a revision date of 11/15, showed How to Clean/Disinfect the EvenCare G2: The EvenCare G2 machine should be disinfected between uses, using a validated disinfecting agent .