**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure residents' privacy and dignity by asking permission prior to entering residents' room for 4 of 13 residents reviewed. (Resident 18, Resident 17, Resident 34, Resident 40). Findings include: 1. During a medication administration observation on 8/14/24 at 7:38 AM, RN 3 entered Resident 18's room without knocking, announcing herself, or asking permission to enter. She proceeded to turn on his light and explain care she was to provide. Resident 18's diagnoses included stroke, heart disease, and dysphagia. Resident 18's BIMS (Brief Interview of Mental Status) most recent 7/17/24 score of 2 indicated a severe mental status deficit. 2. During a medication administration observation on 8/14/24 at 7:46 AM, RN 3 entered Resident 17's room without knocking or asking permission to enter. RN 3 did announce herself as she was walking into the room and tuned on the light, causing Resident 17 covered her head with her blanket. RN 3 announced the care she was to give. Resident 17's diagnoses included stroke, diabetes, adult failure to thrive, and heart disease. Resident 17's BIMS score was a 13 on 6/20/24 and indicated a minimal deficit in mental status. 3. During an interview on 8/14/24 at 11:12 AM during a resident council group interview, Resident 34 indicated the facility was her home. Staff did not respect her space. Resident 34 indicated staff frequently did not knock prior to walking into her room or if they knocked, they tapped once or twice and then entered. Resident 34's diagnoses included diabetes, heart disease, and kidney disease. Resident 34's BIMS score was 12 on 7/1/24 and indicated a minimal decline in mental status. 4. During an interview on 8/14/24 at 11:12 AM during a resident council group interview, Resident 40 indicated the facility staff just knocked on the door and then walked right in. There had been times they talked to her as if she was not an adult or was unable to understand English. Resident 40's diagnoses included heart disease, diabetes, arthritis, and sleep apnea. Resident 40's BIMS score was 14 on 6/16/24 and indicated minimal mental status deficit. An ongoing observation and interview on 8/15/24 from 9:10 AM to 9:36 AM indicated the following: An unidentified CNA (Certified Nurses Aid) knocked and called the resident's name in room [ROOM NUMBER], then entered without waiting for permission to enter. During an interview, RN 2 indicated when entering residents' rooms, staff should knock on the door and wait for an answer. If no answer, one should announce themselves and slowly open door and ask permission to enter. In an interview with the administrator on 8/15/24 at 10:03 AM, she indicated the expectation was for all staff to knock wait for permission to enter whether the door was open or closed. A policy and procedure titled Resident Care Procedure #01: Initial Steps dated 8/2016 and last revised 11/2022, indicated the following: Knock and identify yourself before entering the resident's room. Wait for permission to enter the resident's room. 3.1-3(p)(1)

During interview and record review the facility failed to ensure narcotic medications were handled securely for 4 of 4 residents reviewed. (Resident B, Resident C, Resident D and Resident E) Findings include: A review on 9/5/2023 at 12:10 P.M., of a facility's State Reported Incident provided by the Administrator in Training (AIT) on 9/5/2023 at 11:24 AM indicated on 8/30/2023 at 4:01 PM, an unnamed nurse reported the narcotic count sheet and the narcotic medication on hand did not match for Resident B. An investigation was initiated immediately, included interviews with nurses involved and reviewing the camera footage. The report indicated LPN (Licensed Practical Nurse) 1 was suspended pending the investigation. The facility's follow up report to the investigation, dated 8/31/2023, indicated LPN 1 admitted to placing a Percocet (a narcotic medication used for pain) in her pocket. She indicated she had signed out the Percocet thinking it was scheduled routinely instead of PRN (as needed). She indicated she planned to destroy the medication with the on-coming nurse, however she failed to destroy the medication. When questioned about the whereabouts of the medication, she indicated it had probably dissolved in her pocket when it went through the washing machine. The follow up report also indicated during the investigation it was discovered Resident C had a Medication Card of Ambien (a sedative-hypnotic, to help sleep) with 11 tablets on the card and a Controlled Substance Sign-out Sheet for Norco (a narcotic medication used for pain) indicated 11 tablets remained. However, there was no sign out sheet for the Ambien and no Norco to be counted. The follow-up report indicated the local Police department was contacted and a police report was filed. The facility's investigation included staff interviews on 8/30/23. RN (Registered Nurse) 2 indicated the narcotic count with the off going nurse was correct, but when she was giving medications to Resident C, she realized the narcotic count sheet for Ambien was missing and a pharmacy blister pack for the 11 Norco pills was also missing. RN 2 recounted all other narcotics and all the other medications were counted correctly. RN 2 indicated she notified the DON (Director of Nursing) and the Nurse Manager immediately. A written statement by LPN 1 indicated, on 8/29/23 she had double checked herself on the Narcotic count. She intended to waste one Percocet with oncoming nurse, but put it in her pocket and forgot about it. She indicated she had counted with the oncoming nurse and the count was correct. The statement was signed by LPN 1. 1. A review of Resident B's records began on 9/5/2023 at 2:00 P.M., indicated diagnosis included fibromyalgia, low back pain, atrial fibrillation, hypertension, and heart disease. Resident B's current MDS (Minimal Data Set) Assessments dated 7/18/2023 indicated a BIMS (Brief Interview for Mental Status) score was 14, cognitively intact. The Pain Assessment Interview indicated Resident B had frequent pain and the pain limited their activity. Pain was rated an 08/10 but the resident only received opioid medication on 1 day of the 7 day assessment period. A review of Resident B's orders indicated an order with a start date on 7/19/2023 for Percocet 5-325 mg (milligram, a medication dose measurement) to give 1 tablet by mouth (po) every 4 hours as needed for pain. On 9/5/2023 at 4:00 P.M., the AIT and Nurse Manager provided copies of Resident B's MAR (Medication Administration Record) dated August 2023 and Resident B's Pharmacy sign-out sheets for the Oxycodone/APAP (Percocet) 5-325 mg tablets. These documents were compared with the AIT and Nurse Manager. The pharmacy sign-out sheet beginning on 8/10/23 indicated 30 tablets were received by the facility on 8/8/2023. Documentation indicated the following: On 8/10/23 at 4:45 PM, 1 tablet was signed out on the narcotic sheet by LPN 1. The August MAR was lacking documentation the Percocet was administered on 8/10/2023 at 4:45 PM. On 8/10/23 at 9:00 PM, 1 tablet was signed out on the narcotic sheet by LPN 1. The August MAR was lacking documentation the Percocet was administered on 8/10/2023 at 9:00 PM. On 8/11/2023 at 5:00 PM, 1 tablet was signed out on the narcotic sheet by LPN 1. The August MAR was lacking documentation the Percocet was administered on 8/11/2023 at 5:00 PM. On 8/11/2023 at 9:00 PM, 1 tablet was signed out on the narcotic sheet by LPN 1. The August MAR was lacking documentation the Percocet was administered on 8/11/2023 at 9:00 PM. On 8/15/2023 at 4:00 PM, 1 tablet was signed out on the narcotic sheet by LPN 1. The August MAR was lacking documentation the Percocet was administered on 8/15/2023 at 4:00 PM. On 8/15/2023 at 8:00 PM, 1 tablet was signed out on the narcotic sheet by LPN 1. The August MAR was lacking documentation the Percocet was administered on 8/15/2023 at 8:00 PM. On 8/17/2023 at 3:00 PM, 1 tablet was signed out on the narcotic sheet by LPN 1. The August MAR was lacking documentation the Percocet was administered on 8/17/2023 at 3:00 PM. A new Pharmacy Controlled Substance Record for Resident B indicated 30 Percocet 5-325 mg tablets were received by the facility on 8/16/23 and indicated the following: On 8/17/2023 at 8:30 PM, 1 tablet was signed out on the narcotic sheet by LPN 1. The August MAR was lacking documentation the Percocet was administered on 8/17/2023 at 8:30 PM. On 8/19/2023 at 5:00 PM, 1 tablet was signed out on the narcotic sheet by LPN 1. The August MAR was lacking documentation the Percocet was administered on 8/19/2023 at 5:00 PM. On 8/19/2023 at 9:30 PM, 1 tablet was signed out on the narcotic sheet by LPN 1. The August MAR was lacking documentation the Percocet was administered on 8/19/2023 at 9:30 PM. On 8/20/2023 at 4:00 PM, 1 tablet was signed out on the narcotic sheet by LPN 1. The August MAR was lacking documentation the Percocet was administered on 8/20/2023 at 4:00 PM. On 8/20/2023 at 8:30 PM, 1 tablet was signed out on the narcotic sheet by LPN 1. The August MAR was lacking documentation the Percocet was administered on 8/20/2023 at 8:30 PM. On 8/22/2023 at 3:15 PM, 1 tablet was signed out on the narcotic sheet by LPN 1. The August MAR was lacking documentation the Percocet was administered on 8/22/2023 at 3:15 PM. On 8/20/2023 at 4:00 PM, 1 tablet was signed out on the narcotic sheet by LPN 1. The August MAR was lacking documentation the Percocet was administered on 8/20/2023 at 4:00 PM. On 8/24/2023 at 3:00, 1 tablet was signed out on the narcotic sheet by LPN 1. The August MAR was lacking documentation the Percocet was administered on 8/24/2023 at 3:00 PM. On 8/24/2023 at 8:30 PM, 1 tablet was signed out on the narcotic sheet by LPN 1. The August MAR was lacking documentation the Percocet was administered on 8/24/2023 at 8:30 PM. A new Pharmacy Controlled Substance Record for Resident B indicated 30 Percocet 5-325 mg tablets were received by the facility on 8/24/2023 and indicated the following: On 8/28/2023 at 4:00 PM, 1 tablet was signed out on the narcotic sheet by LPN 1. The August MAR was lacking documentation the Percocet was administered on 8/28/2023 at 4:00 PM. On 8/29/2023 at 4:00 PM, 1 tablet was signed out on the narcotic sheet by LPN 1. The August MAR was lacking documentation the Percocet was administered on 8/29/2023 at 4:00 PM. On 8/29/2023 at 8:00 PM, 1 tablet was signed out on the narcotic sheet by LPN 1. The August MAR was lacking documentation the Percocet was administered on 8/29/2023 at 8:00 PM. On 9/6/2021 at 10:35 A.M., the AIT provided copies of Resident B's records labeled Pharmacy Controlled Substance Record for Percocet 5-325 mg. When compared the August 2023 MAR to the Pharmacy sign-out sheet, it indicated LPN 1 had signed out Percocet 5-325 mg tablets on 8/3/2023 at 5:05 PM and at 9:30 PM. The August MAR was lacking documentation the Percocet 5-325 mg tablets were administered on 8/29/2023 at 5:05 PM and at 9:30 PM. On 8/5/2023 LPN 1 had signed out Percocet 5-325 mg tablets on 8/5/2023 at 5:30 PM and at 9:30 PM. The August MAR was lacking documentation the Percocet 5-325 mg tablets were administered on 8/5/2023 at 5:30 PM and at 9:30 PM. On 8/6/2023 LPN 1 had signed out Percocet 5-325 mg tablets on 8/6/2023 at 3:30 PM and at 7:25 PM. The August MAR was lacking documentation the Percocet 5-325 mg tablets were administered on 8/6/2023 at 3:30 PM and at 7:25 PM. Review of the August 2023 MAR indicated LPN 1 had given evening shift medications on the following dates, 8/3/2023, 8/5/2023, 8/6/2023, 8/10/2023, 8/11/2023, 8/15/2023, 8/17/2023, 8/19/2023, 8/20/2023, 8/22/2023, 8/24/2023, 8/28/2023 and 8/29/2023. 2. A review of Resident C's records began on 9/5/2023 at 3:00 P.M., indicated diagnosis included medical complications of internal fixation device of bone of left lower leg, intervertebral disc degeneration, low back pain, venous insufficiency, heart disease and hypertension. The admission MDS assessment dated , 7/10/2023 indicated a BIMS Score of 13, cognitively intact. The Pain Assessment Interview indicated Resident C had frequent pain and was rated an 08/10. Resident C had major orthopedic surgery and had received opioid medication on 6 days of the 7 day assessment period. Resident C had orders for Zolpidem Titrate (Ambien) 10 mg tablet, give 1 tablet every 24 hours prn for sleep at bed time, started on 7/14/2023 and discontinued on 8/15/2023. A new order for Zolpidem 10 mg tablet, give 1 tablet every 24 hours as needed for trouble sleeping, started on 8/15/2023. The Zolpidem was discontinued when Resident C was discharged on 9/1/2023. The facility did not have a Pharmacy Controlled Substance sign-off record for the Zolpidem. Review of the August 2023 MAR indicated Resident C was administered Zolpidem 4 nights in August. Resident C had orders for Norco (Hydrocodone-Acetaminophen) 5-235 mg 1 tablet every 4 hours as needed for pain, start date 7/18/2023 and a discontinue date of 8/2/2023. A new order for Norco 7.5-325 mg 1 tablet every 4 hours as needed for pain with a start date of 8/2/2023. The Pharmacy Controlled Substance Sign-out sheets were missing for Norco 5-325 mg tablets administered 8/1/23 to 8/2/2023 and Norco 7.5-325 mg administered from 8/2/2023 to 8/16/2023. A Review of the Pharmacy Controlled Substance record for 30 tablets of Norco 5-325 mg had a received date of 8/16 written on the 1st line and indicated the following: On 8/17/2023 LPN 1 had signed out Norco 7.5-325 mg tablets on 8/17/2023 at 5:00 PM and at 9:00 PM. The August MAR was lacking documentation the Norco 5-325 mg tablets were administered on 8/17/2023 at 5:00 PM and at 9:00 PM. On 8/19/2023 LPN 1 had signed out 7.5-Norco 325 mg tablets on 8/19/2023 at 5:30 PM and at 9:30 PM. The August MAR was lacking documentation the Norco 5-325 mg tablets were administered on 8/19/2023 at 5:30 PM and at 9:30 PM. On 8/20/2023 LPN 1 had signed out Norco 7.5-325 mg tablets on 8/20/2023 at 4:00 PM and at 8:30 PM. The August MAR was lacking documentation the Norco 5-325 mg tablets were administered on 8/20/2023 at 4:00 PM and at 8:30 PM. On 8/22/2023 LPN 1 had signed out Norco 7.5-325 mg tablets on 8/22/2023 at 2:15 PM and at 9:00 PM. The August MAR was lacking documentation the Norco 7.5-325 mg tablets were administered on 8/22/2023 at 2:15 PM and at 9:00 PM. Review of the August 2023 MAR indicated LPN 1 had given evening shift medications on the following dates, 8/3/1012, 8/5/2023, 8/6/2023, 8/10/2023, 8/11/2023, 8/15/2023, 8/17/2023, 8/19/2023, 8/20/2023, 8/22/2023, 8/24/2023, 8/28/2023 and 8/29/2023. A review of Resident C's progress notes indicated there was no documentation for administration of the Norco nor the effectiveness of the medication for the pain. An interview with Nurse Manager 3, on 9/6/2023 at 10:00 A.M., indicated she had called the Pharmacy and was informed the Pharmacy had sent the facility 1 blister card with 40 tablets of Norco 5-325 mg on 7/14/2023, and 7 blister cards with 30 tablets each of Hydrocodone/APAP 7.5 mg on the following dates, 7/18/2023, 7/25/2023, 8/2/2023, 8/7/2023, 8/15/2023, 8/23/2023 and 8/29/2023. Nurse Manager 3 indicated they could only find 2 of the 8 Controlled Substance Sign-out records: 1 blister card received on 8/16/23 for 30 tablets and 1 blister card received on 8/30/2023 for Resident C. 3. A review of Resident D's records on 9/6/2023 at 10:20 A.M., indicated diagnoses included , left thigh pain, contracture, stroke with hemiplegia/hemiparesis (weakness or paralysis on one side of the body), aphasia (loss ability to understand or express speech), dysphasia (difficulty swallowing), cognitive communication deficit, and hypertension. Review of the current Quarterly MDS Assessment indicated a BIMS score of 12, moderate cognitive impairment. A Pain Management assessment indicated the resident had pain rarely and rated it 04/10. Resident D received an opioid on 7 days of the 7 day of the assessment period. Resident D had an order for Hydrocodone-Acetaminophen 5-325 mg tablet, to give 1 tablet via Peg Tube (a type of feeding tube into the stomach) every 6 hours and had a start date of 3/5/2023. A review of the Pharmacy Controlled Substance Record for Resident D's Hydrocodone indicated the following when compared with the August 2023 MAR, indicated the Hydrocodone-Acetaminophen 5-325 was sign-out consistently at 12 A.M., 6 A.M., 12 P.M., and 6 P.M. The Pharmacy Controlled Substance Records were missing from 8/6/2023 to 8/19/2023. LPN 1 was the last nurse to sign off the Controlled Substance Record on 8/5/2023 at 6:00 P.M. On 8/29/2023 Resident D's MAR indicated the Hydrocodone-Acetaminophen 5-325 mg at 1800 (6:00 PM) was documented as administered by LPN 1, but was not signed out on the Controlled Substance Record. The sign out record was dated 8/29 and a line drawn through it. In an interview on 9/6/2023 at 11:40 A.M. Nurse Manager 3 indicated she had called the Pharmacy and was informed by the Pharmacy they had sent the facility the following quantities of Hydrocodone 5-325 mg tablets for Resident D. On 7/5/2023-56 tablets, 7/20/2023 - 60 tablets, 8/5/2023 - 60 tablets, 8/18/2023 - 60 tablets, 8/31/2023-60 tablets. She indicated the Controlled Substance Sheets were missing for the shipments on 8/5/2023 - 60 tablets. She also indicated LPN 1 had completed the last card prior to the missing sign-out sheet. 4. A review of Resident E's records on 9/6/2023 at 11:00 A.M., indicated diagnoses included chronic pain, insomnia, emphysema, epilepsy and anxiety. The most current Quarterly MDS Assessment, dated 8/31/2021 indicated Resident E's BIMS score was 10, moderate cognitive impairment. A Pain Management assessment indicated Resident E had pain occasionally, rated a 06/10, and had received opioid medications on 7 days of the 7 day assessment period. Resident E had an order for Hydrocodone-Acetaminophen 5-325 mg tablet, 1 tablet by mouth 3 times a day for pain, start date was 6/1/2023 and Discontinued on 8/4/2023. The Pharmacy Sign-out Sheet was received by the facility on 7/20/2023. It indicated LPN 1 administered the last tablet of the 45 tablets of Hydrocodone-Acetaminophen 5-325 mg on 8/3/2023. An order for Hydrocodone-Acetaminophen 5-325 mg tablet, 1 tablet by mouth 4 times a day for pain and was to be given routinely with a start date was 8/4/2023. The Hydrocodone-Acetaminophen 5-325 mg tablets were signed off consistently 4 times a day through 8/3/2023 at 8:00 PM when LPN 1 signed off the last tablet on the sign-out record. The facility was missing the Pharmacy Controlled Substance Sign-out for Resident E from 8/4/2023 through 8/31/2023, until a delivery on 8/31/2023 of 75 tablets Hydrocodone/APAP 5-325 mg with 2 sign off sheets, 1 sheet for 15 tablets and the other sheet for 60 tablets. These were started on 9/1/2023. On 9/6/2023 at 11:40 A.M., an interview with Nurse Manager 3 indicated she had called the Pharmacy and was informed the Pharmacy had sent the facility the following quantities of Hydrocodone 5-325 mg tablets. On 7/18/2023-45 tablets, 8/2/2023 - 42 tablets, 8/4/2023 - 60 tablets, 8/15/2023 - 60 tablets, 8/30/2023- 15 tablets and 60 tablets. She indicated the Controlled Substance Sheets were missing for the shipments on 8/2/2023 - 42 tablets, 8/4/2023 - 60 tablets and 8/15/2023 - 60 tablets. She also indicated LPN 1 had completed the last card prior to the missing sign-out sheets. LPN 1's employee file indicated LPN 1 had signed a Job Description for Licensed Practical Nurse (LPN) on 8/31/2022. The job description indicated, .Providing medical record documentation in accordance with facility policy and procedures. Completing (24) hour reports, end of shift reports, shift narcotic counts and documenting the destruction of outdated/discontinued medication in the medication destruction record according to facility policy and procedure During an interview with the AIT and Unit Manager 4 on 9/5/2023 at 4:30 P.M., they indicated the investigation for the missing narcotic had only reviewed the residents, who were receiving PRN narcotics on the 200 Hall. The AIT indicated they reviewed the camera footage and LPN 1 was observed to put something in her pocket. LPN 1 was suspended pending the investigation. Unit Manager 4 indicated they had not compared the Pharmacy Controlled Substance Sign-out records with the residents' MARS. LPN 1 admitted she had put the narcotic in her pocket and forgot to destroy it before leaving the facility. They indicated a report to the police and to the State Nursing Board was completed. They indicated they were not aware there were narcotics signed out by LPN 1 and not documented on the Resident's MARS. A current facility policy provided by the AIT on 9/5/2023 at 2:45 P.M., titled, Controlled Substances, revised on 7/2021, indicated, .It is the policy of this facility to store, administer, verify and destroy controlled substances in accordance with Federal, State and Local laws .documentation of a correct count will be maintained for each controlled substance .The facility will be maintaining a count record for the count sheets contained in the count book .Verify the order by checking the Medication Administration Record (MAR) .Obtain the controlled substance count sheet and verify the count is correct .Read label again and prepare the medication for administration according to the procedure for administration by route. Record the amount removed of the controlled substance on the count record and put the correct number of remaining doses on the record .Stay with the resident until the medication is swallowed if dose is orally administered .When a new medication is added to the controlled substance box, a new sheet will be added to the count book .When a medication is remove from the lock box for any reason, the count record will be removed for that drug .The destruction of controlled substances will be performed with 2 licensed nurses at a minimum .Controlled substances will be disposed of in accordance with Local, State, and Federal laws A facility in-service on 8/30/2023 related to Narcotic Counts, indicated, .BOTH nurses are to count together at the medication cart. One reviewing the medication cards and the other the narcotic sheets. Nurse reading off the medication cards should read the resident's name, and name of the medication for each item to be counted. Document that count is completed on the narcotic count sheet. Should the count be off or a discrepancy noted, no one leaves until search is completed of medication carts, MARs reviewed for missing entries and Nurse Manager notification to receive further instructions . A current facility policy, used for the In-service of nurses on 8/30/2023. The policy was provided by the AIT on 9/5/2023 at 2:45 P.M., titled Counting Controlled Substances and responding to Errors in a Controlled Substance Count, indicated, .If the count and sign-out log still disagree, check the sign-out entries to detect a prior error in recording or count .Check the resident's medication records and nurse's noted for doses that might have been given and not recorded This Federal tag relates to Complaint IN00416564. 3.1-28(a)

Based on observation, and interview the facility failed to ensure sanitary practices were observed in the kitchen. 53 of 56 residents to residing in the facility ate food prepared in the kitchen. Findings include: During an observation on, 7/17/23 at 9:03AM, noted floor was slippery. The floor had an oily feel. The area with the slippery, oily feel was from in front of the oven to just beyond the stove top range. The top of the oven had trays and multiple crumbs. The crumbs varied in size and color (yellow, brown, and black) There were 2 hamburgers in the refrigerator with cellophane covering. There was no date labeling on the hamburgers. The dietary aide was unable to determine when the hamburgers were prepared. A hamburger was listed on alternative menu for 7-17-23. The dietary aide 3 had her hair pulled into a bun, the bun was covered with a hair net but the remainder of hair was uncovered. In the walk-in freezer's left furthest corner under the rack was a black substance. It was approximately 1 inch high by a ½ inch wide by 9 inches long. The dietary aide could not identify the substance. In an interview on, 07/18/23 08:25 AM, the Administrator indicated the kitchen staff were to be in-serviced and the dietary manager was informed of cleaning issues. During an observation on, 07/18/23 11:13 AM, Dietary Aide 3 had her hair pulled back into a bun. The bun portion of her hair was covered with a hairnet, the remainder of her hair was uncovered. During an observation on 7/19/23 at 12:14PM Dietary Aide 3 had hair in bun and the hairnet was covering all of hair. The cleaning lists (month of July am and pm) were provided by Administrator on 7/18/23 at 12:18PM indicated the top of the oven was to be cleaned by day shift on 7/7/23 and the exterior of oven was to be cleaned on 7/23/23. There were no other times on cleaning list the outside of the oven was listed to be cleaned. The cleaning list indicated the floor was to be swept and mopped on 7/10/23 by the evening shift. No additional cleaning lists were provided. A policy titled, Freezers with a date 6/2021, provided by the Administrator on 7/18/23 at 12:18PM, indicated .4. Remove shelving units and clean the shelves and walls with warm sudsy water. Rinse and sanitize. Allow to air dry .7. For walk in freezers, mop floors, wash walls and ceilings as needed A policy titled, Floors, Tables, and Chairs with a date 6/2021, provided by the Administrator on 7/18/23 at 12:18PM, indicated .1. Sweep and clean kitchen floors after each meal. Mop thoroughly at least once daily. Move major appliances at least once a month to facilitate cleaning behind and underneath . A policy titled, Leftovers with a date 2/2020, provided by the Regional Nurse Consultant on 7/18/23 at 12:38PM, indicated .2. All foods stored for later use shall be covered, labeled with the food name, and dated with the current date as well as with a use by date . A policy titled, Personal Hygiene and Jewelry with a date 6/2021, provided by the Regional Nurse Consultant on 7/18/23 at 12:38PM, indicated .2. All Dining and Nutrition Services department must wear hair restraints to prevent hair from contacting exposed food . 3.1-4.5-5

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure family and hospice services were notified of a condition change for 1 of 3 records reviewed (Resident C). During an interview on 4/18/23 at 9:35 AM, Resident C's Power of Attorney (POA indicated she received a call at 5:15 AM on 4/6/23 informing her Resident C had passed away. Upon arrival at the facility, staff informed her Resident C had vomited and received medication for vomiting the evening before. The POA indicated the facility had not contacted her about a condition change. During a record review beginning 4/18/23 at 10:36 AM, a Minimum Data Set, dated [DATE] indicated Resident C had diagnoses including hemiplegia following cerebral infarction, gastro-intestinal reflux disease without esophagitis, and hypertension. A progress note dated 4/5/23 7:05 PM was reviewed. The progress note, written by Registered Nurse (RN) 2, indicated Resident C vomited during the evening meal. The progress note indicated Nurse Practitioner (NP) 3 was contacted and orders were received for Zofran, and anti-emetic medication. No attempts to notify the POA or hospice were recorded. An additional progress note written by RN 2, dated 4/6/23 at 9:53 PM, did not indicate any attempts to contact the POA or hospice. A progress note written by Licensed Practical Nurse (LPN) 4, dated 4/6/23 at 6:32 AM, indicated she notified the POA and hospice services upon finding Resident C unresponsive at 5:15 AM. No other attempts to contact the POA or hospice services were recorded on that shift. During an interview conducted on 4/18/23 at 11:58 AM, RN 2 indicated she did not personally attempt to contact the POA because Resident C had stabilized after the ordered medication was ingested. RN 2 indicated a person associated with the POA was present in the building and she assumed he had notified the POA. RN 2 indicated she made one attempt to call hospice services, but there was no answer. RN 2 indicated she might have dialed the wrong number. RN 2 indicated the POA and hospice services should be notified regarding the occurrence of vomiting. Resident C's face sheet, provided by the Director of Nursing on 4/18/23 at 2:20 PM, indicated emergency contacts for Resident C included the POA and Resident C. In an interview on 4/18/23 at 12:15 PM, the POA indicated she did not give the facility permission to notify anyone else of condition changes. In an interview on 4/18/23 at 2:20 PM the DON indicated she believed the POA was made aware, and staff had attempted to notify hospice. The DON indicated notification should be recorded in the medical record. A policy titled Clinician/Family/Resident Representative notification of Change in Condition, last revised 5/19, indicated physician, family and responsible party notification should be notified of condition changes including the presence of emesis. The policy also indicated notification should be documented in the clinical record. 3.1-5(a)(2)

Based on interview and record review the facility failed to ensure fall risk assessments were completed timely on 2 of 2 residents reviewed. (Resident 14 and Resident 151). Findings include: 1) Resident 14's record review began on 9/7/22 at 10:32 AM. Diagnosis included encephalopathy, secondary Parkinsonism, Alzheimer's disease, muscle weakness, and stroke. Falls were documented as occurring on 6/18/22, 7/11/22, 7/12/22, 8/4/22, 8/17/22, 8/28/22, 8/29/22, 8/30/22, and 9/9/22. A fall risk assessment was completed on 3/1/22. There were no other documented fall risk evaluations. In an interview on 9/9/2022 at 2:45 PM, the DON (Director of Nursing) indicated she was unable to show any further documentation of fall risk assessment. The most recent care plan for Resident 14 included a focus of being at risk for falls initiated on 3/1/22. The most recent intervention update was 8/30/22. 2) An interview with Resident 151's POA (Power of Attorney) on 9/9/22 at 11:46 AM indicated Resident 151 fell in the facility on 8/18/22 and required medical care. Resident 151's record review began on 9/9/22 at 2:47 PM, and indicated diagnoses included dementia, seizure disorder, stroke, and history of falls. Resident 151's most current MDS ( Minimum Data Set) assessment indicated their BIMS (Brief Interview for Mental Status) indicated she had moderate cognitive difficulties thus the need for a POA. Resident 151's progress note dated 8/18/22 at 10:23 PM indicated they were found on the floor. An ambulance was called, and Resident 151 was taken to the hospital. A fall risk assessment was not documented on admission or readmission from the hospital. The most recent care plan for Resident 151 included a focus on risk for falls was initiated on 8/19/22. The interventions for falls were last updated 9/1/22. An interview with DON on 9/12/22 at 12:04 PM indicated a fall risk assessment was done upon admission and quarterly thereafter for all residents. A policy titled, Fall Investigation and Risk Evaluation dated 6/2012 with most recent revision on 6/2022, indicated Complete risk evaluations on each resident on admission, quarterly, and with a significant change in the resident that may change their risk for falls 3.1-45(a)

Based on record review and interview, the facility failed to ensure catheter care was completed on every shift for 1 of 1 resident reviewed. (Resident 19) Resident 19's record was reviewed on 9/8/22 10:49 AM. Diagnoses included paraplegia, unspecified, neuromuscular dysfunction of bladder, unspecified, pressure ulcer of right buttock, stage 4, pressure ulcer of sacral region, stage 4, pressure ulcer of left buttock, stage 3, unspecified injury at C1 level of cervical spinal cord, subsequent encounter, urinary tract infection, site unspecified, need for assistance with personal care. Resident T's Quarterly Minimum Data Set Assessment, dated 6/24/22, indicated the brief interview for mental status score was 13 (cognitively intact). Activity of daily living indicated the resident required extensive assistance with bed mobility, locomotion on and off unit, toileting, and personal hygiene. The resident required total assistance with transfers and bathing, had an indwelling catheter, was always incontinent of bowel, had a pressure ulcer, was at risk of developing a pressure ulcer, and had unhealed pressure ulcers, 3- stage 3 pressure ulcers. The resident did not exhibit behavior to reject evaluation or care. An active order, dated 6/27/22, indicated change foley catheter 16 Fr (French) 10 cc (cubic centimeter) as needed for leakage. An active order, dated 6/13/22, indicated Resident to have a catheter leg strap to assist with pulling/tugging/dislodgement. Check for placement and replace if needed every shift. There was no order for foley catheter care. A current care plan, dated 2/7/2022, indicated the resident needed assistance with ADLs (Activity of Daily Living) related to paraplegia. Goal: the resident would maintain current level using care plan interventions as long as disease process allowed. Interventions included Resident needed assist of 1-2 staff with toileting. A current care plan, dated 2/21/22, indicated the resident had an indwelling catheter related to neurogenic bladder. Goals: The resident's care plan interventions would minimize risk for complications. Interventions included change catheter system when clinically indicated or ordered, extra fluids offered with medication, receive fluid of choice with meals, report and staff observe for changes in the color, consistency, and odor of urine, changes in mental status, changes in amount of urine produced, and pain in lower back or lower abdomen, refer to the registered dietician for fluid recommendations, and have catheter leg strap to assist with pulling/tugging/dislodgement. Foley catheter care was not indicated on the resident's care plan. The Task List: Indwelling Catheters, dated 8/15/22-8/13/22 was reviewed. The task list indicated when catheter care was provided. No documentation regarding completion of catheter care was found for day shift on 8/21, 8/25, 8/29, 9/4, and 9/8, evening shift on 8/15, 8/16, 8/18, 8/19, 8/20, 8/21, 8/22, 8/23, 8/24, 8/25, 8/26, 8/27, 8/28, 8/29, 8/30, 8/31, 9/1, 9/2, 9/3, 9/4, 9/5, 9/6, 9/7, 9/8, 9/9, 9/10, 9/11, and 9/12, night shift on 8/16, 8/17, 8/18, 8/20, 8/21, 8/23, 8/26, 8/28, 8/29, 8/31, 9/1, 9/2, 9/3, 9/4, 9/5, 9/6, 9/7, 9/10, and 9/12. No documentation was found to indicate the resident refused catheter care. In an interview on 9/12/22 10:00 AM, C.N.A. 3 indicated catheter care was completed every day and when changing a resident's brief. Catheter care was documented on the form provided by the facility, the information went to administration for review to make sure staff were providing the care they should be providing. When a resident refused care, C.N.A. 3 indicated she would notify the nurse. In an interview on 9/12/22 2:05 PM, LPN 4 indicated catheter care was completed by C.N.A.s and nurses, mostly the nurses. Catheter care was done every shift, and documented in the TAR. An order to do catheter care was generated when a resident had a catheter. When a resident refused catheter care, LPN 4 indicated she would ask the resident why, document on the task, TAR and progress note, and notify doctor when resident refused after 3 attempts. In an interview on 9/13/22 10:42 AM, the DON indicated an order was not needed for catheter care, it was placed on a task sheet. C.N.A.s did the catheter care. Catheter care was performed when a resident was cleaned up after incontinence episodes, and should be done at least 1 time per shift. When a resident refused care, the C.N.A. reported to the nurse, the nurse would speak to the resident then document on the behavior sheet or progress note. A current policy titled Catheter Use Care Policy, dated 5/22, was received from the DON on 9/13/22 at 8:32 AM. The policy indicated Policy .provide proper care while a resident is catheterized including observing for signs of catheter related infections General considerations 1. Catheter care may be completed by licensed nurses or certified nursing assistants. 2 Catheter care will include cleansing the perineal area and external portion of the catheter, draining the collection bag, and placing the tubing and collection bag in the correct position to prevent infection, as well as providing dignity to the resident . Catheter Care: 1. Perform hand hygiene and put on clean gloves. 2. Cleanse the perineal area from center to the outside. 3. Using a clean washcloth to cleanse the catheter at the insertion site outward about 4 inches. 4. Remove gloves and perform hand hygiene. The policy did indicate a frequency for catheter care. 3.1-41(a)(1)