**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 5's record was reviewed on 3/25/25 at 10:21 a.m. The profile indicated the resident's diagnoses included, but were not limited to, atypical atrial flutter (an abnormal heart rhythm where the electrical signals in the upper chambers beat too quickly and irregularly), and history of pulmonary embolism (a condition where a blood clot travels to the lungs and blocks one or more pulmonary arteries). A quarterly Minimum Data Set (MDS) assessment, dated 3/19/25, indicated the resident received anticoagulant (AC) medication (drugs that help prevent blood clots from forming). The census indicated that the resident had been hospitalized from [DATE] to 3/12/25. A progress note, dated 3/7/25 at 3:21 p.m., indicated the resident presented a tissue with liquid and dark red saliva, and indicated it was from him coughing. He indicated he had coughed up a big glob of blood like a clot earlier when out on LOA (leave of absence) with his friend. The nurse advised the resident he should go to the emergency room (ER) for a workup. The resident agreed and his family, the Director of Nursing (DON), and physician were notified that the resident had been sent to the ER. A progress note, dated 3/8/25 at 4:36 a.m., indicated that the resident was being held for observation. Resident had been diagnosed with lower lobe pneumonia (an infection that inflames the air sacs in the lower sections of the lungs) and influenza A (a highly contagious viral infection that primarily affects the respiratory system). The record lacked documentation of the facility communication to the receiving facility at the time of the transfer. 3. Resident 10's record was reviewed on 3/25/25 at 2:13 p.m. The profile indicated the resident's diagnoses included, but were not limited to, acute pyelonephritis (a sudden, severe bacterial infection of the kidney and renal pelvis), hydronephrosis with renal and urethral calculus obstruction (swelling of one or both kidneys due to a buildup of urine caused by blockages in the kidneys or the tubes carrying urine from the kidneys to the bladder), and unspecified psychosis (a diagnosis used when someone experiences psychotic symptoms [like hallucinations-seeing or hearing things that are not there] but doesn't meet the criteria for a specific psychotic disorder). A quarterly Minimum Data Set (MDS) assessment, dated 12/30/24, indicated the resident had no cognitive deficit and received an antipsychotic medication (medication used to treat psychotic symptoms). During an interview, on 3/24/25 at 1:38 p.m., the resident indicated she had been out to the hospital last week related to a kidney stone. The census indicated the resident had been hospitalized from [DATE] to 3/13/25, and again on 3/14/25 and had returned on the same date. A progress note, dated 3/7/25 at 10:35 a.m., indicated the resident had been sent to the hospital overnight due to fever and hallucinations. The resident was found to be septic (a life-threatening condition that occurs when the body's immune system overreacts to an infection, causing widespread inflammation and damage to multiple organs) and had been transferred to a second hospital location for kidney stone surgery and treatment. The record lacked documentation of the facility communication to the receiving facility at the time of the transfer. A progress note, dated 3/14/25 at 12:43 p.m., indicated the resident had been sent out to the ER due to complaints of shortness of breath (SOB) and hemoptysis (coughing up pf blood). The record lacked documentation of the facility communication to the receiving facility at the time of the transfer. During an interview, on 3/25/25 at 3:08 p.m., the DON indicated she had been unable to find any documentation of the nurses calling report to the hospital for the transfer. The expectation was that report should always be called to the hospital and documentation should be completed of who the nurse provided report to, at the time of the transfer. On 3/26/25 at 9:48 a.m., the DON provided a document, with a revised date of 10/17/24, titled, Transfer and Discharge (including AMA-against medical advice), and indicated it was the policy currently being used by the facility. The policy indicated, .Policy Explanation and Compliance Guidelines .10. For a transfer to another provider .the following information must be provided to the receiving provider .d. All other information to meet the residents' needs, which includes, but may not be limited to, i. Resident status .; ii. Diagnoses and allergies; iii. Medications .; h. Additional information, if any, outlined in the transfer agreement with the acute care provider 3.1-12(a)(3) Based on record review and interview, the facility failed to ensure they communicated with the receiving hospital, and documented their communication when residents were transferred to the emergency room (ER) for 3 of 4 residents reviewed for hospitalization (Residents 6, 5, and 10). Findings include: 1. Resident 6's record was reviewed on 3/25/25 at 10:13 a.m. A quarterly Minimum Data Set (MDS) assessment, dated 3/11/25, indicated the resident was cognitively intact and had a diagnosis of medically complex conditions. A Progress Note, dated 6/23/24 at 6:20 p.m., indicated the resident's sister stated the resident called her and cried with pain from not having a bowel movement (BM). The nurse explained to the resident's sister that the resident had already received an enema and had large results. The resident's sister wanted the resident to be given another enema, and if the pain continued wanted him sent to the hospital. The physician stated to send the resident to the hospital as he just returned from the hospital the prior week for an illeus (intestinal blockage). A Progress Note, dated 6/23/24 at 6:46 p.m., indicated the resident's sister called back and was notified the physician wanted the resident transferred to the emergency room (ER). 911 was called. The note lacked documentation the facility communicated with the receiving hospital. A Progress Note, dated 6/24/24 at 12:38 a.m., indicated the nurse called the hospital for an update, and the resident was admitted for observation related to constipation. A Progress Note, dated 1/14/25 at 1:09 p.m., indicated the resident complained he felt like his lungs were filling up and requested to go to the ER. The resident's family and the physician were notified. The note lacked documentation the facility communicated with the receiving hospital. A Progress Note, dated 1/14/25 at 7:05 p.m., indicated the resident returned to the facility from the hospital. A Progress Note, dated 3/18/25, indicated the resident was transferred to the hospital for evaluation and treatment due to episodes of projectile vomiting. The resident's family and the physician were notified. The note lacked documentation the facility communicated with the receiving hospital. A Progress Note, dated 3/19/25, indicated the resident returned to the facility from the hospital. During an interview, on 3/25/25 at 3:08 p.m., the Director of Nursing (DON) indicated she was unable to find documentation the facility communicated with the receiving hospital when the resident was transferred on 6/23/24, 1/14/25, or 3/18/25.

Based on interview, record review, and observation, the facility failed to ensure food was served at a palatable temperature for 3 of 15 residents reviewed for food temperatures (Residents 7, 13, and 10). Findings include: 1. During an interview, on 3/24/25 at 11:26 a.m., Resident 7 indicated the food was cold when it was served. Resident 7's record was reviewed on 3/26/25 at 9:41 a.m. A quarterly Minimum Data Set (MDS) assessment, dated 2/6/25, indicated the resident was cognitively intact. 2. During a family interview, on 3/24/25 at 11:47 a.m., Resident 13's wife indicated the food was cold when it was served. Resident 13's record was reviewed on 3/26/25 at 1:28 p.m. A quarterly MDS assessment, dated 3/18/25, indicated the resident had a severe cognitive impairment. 3. During an interview, on 3/24/25 at 1:34 p.m., Resident 10 indicated the food was often cold when it was served in her room, and the staff had to warm it up for her. During a continuous observation, on 3/27/25 from 11:16 a.m. to 12:02 p.m., the following was observed. At 11:16 a.m., the first floor dining room steam table was observed with three covered dishes in place. There were no residents or staff in the area. At 11:33 a.m., lunch service began in the first floor dining room. At 11:43 a.m., lunch service was completed in the first floor dining room, the food dishes were placed on a cart, and taken to the dining room downstairs. At 11:45 a.m., Dietary Aide 10 placed the covered dishes on a food warmer in the downstairs dining room and checked the temperatures of the food prior to the start of the lunch service. The meatloaf was 155 degrees Fahrenheit (F), mashed potatoes 155 degrees F, broccoli and cauliflower 132 degrees F, gravy 130 degrees F, and mechanical soft meatloaf 130 degrees F. From 11:50 a.m. to 12:02 p.m., trays were passed in the downstairs dining room and to the rooms on the unit. After the completion of the last tray, at 12:02 p.m., a test tray was plated from the food warmer. At 12:02 p.m., directly after the completion of the last tray on the unit, meatloaf was 142 degrees F, mashed potatoes were 120 degrees F, and broccoli cauliflower was 98 degrees F. During an interview, on 3/27/25 at 12:02 p.m., Dietary Aide 10 indicated the food should have been 130 degrees F or above at the time it was served. Resident Council Minutes, dated 1/21/25, indicated the food was not so cold. On 3/27/25 at 1:40 p.m., the Administrator provided an undated document titled, Food Safety and Sanitation, and indicated it was the policy currently being used by the facility. The policy indicated, .Food Holding Temperatures/Service: Hot food should be served at 135 F or higher 3.1-21(a)(2)

Based on observation, interview, and record review, the facility failed to ensure hair and beard nets were worn in the food service area during meal service during 1 of 4 dining observations. Findings include: During an observation, on 3/24/25 at 11:31 a.m., [NAME] 5 verified the food temperature and served lunch from the kitchen in first floor dining room. [NAME] 5 had facial hair and did not wear a beard net. A contracted service provider cleaned the fish tank in the dining room during the meal service. The contracted service provider entered the kitchen area, with no hairnet, and obtained water from the sink to fill the fish tank while [NAME] 5 served lunch. Registered Nurse (RN) 3 and Certified Nurse Aide (CNA) 4 entered the kitchen area and obtained drinks. RN 3 and CNA 4 did not wear hairnets in the kitchen area. During an interview, on 3/24/25 at 11:35 a.m., [NAME] 5 indicated no staff should have entered the kitchen area without hairnets in place. During an interview, on 3/24/25 at 11:38 a.m., RN 3 and CNA 4 indicated they had not been told they needed a hairnet to enter the kitchen area. On 3/27/25 at 1:40 p.m., the Administrator provided an undated document titled, Food Safety and Sanitation, and indicated it was the policy currently being used by the facility. The policy indicated, .Sanitation .Hair restraints must be worn at all times when in or around food production areas 3.1-21(i)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 5's record was reviewed on 3/25/25 at 10:21 a.m. The profile indicated the resident's diagnoses included, but were not limited to, atypical atrial flutter (an abnormal heart rhythm where the electrical signals in the upper chambers beat too quickly and irregularly), and history of pulmonary embolism (a condition where a blood clot travels to the lungs and blocks one or more pulmonary arteries). A quarterly Minimum Data Set (MDS) assessment, dated 3/19/25, indicated the resident received anticoagulant (AC) medication (drugs that help prevent blood clots from forming). The census indicated that the resident had been hospitalized from [DATE] to 3/12/25. A progress note, dated 3/7/25 at 3:21 p.m., indicated the resident presented a tissue with liquid and dark red saliva, and indicated it was from him coughing. He indicated he had coughed up a big glob of blood like a clot earlier when out on LOA (leave of absence) with his friend. The nurse advised the resident he should go to the emergency room (ER) for a workup. The resident agreed and his family, the Director of Nursing (DON), and physician were notified that the resident had been sent to the ER. The record lacked documentation a Physician's order was obtained, written, or signed by the physician for the hospital transfer. 3. Resident 10's record was reviewed on 3/25/25 at 2:13 p.m. The profile indicated the resident's diagnoses included, but were not limited to, acute pyelonephritis (a sudden, severe bacterial infection of the kidney and renal pelvis), hydronephrosis with renal and urethral calculus obstruction (swelling of one or both kidneys due to a buildup of urine caused by blockages in the kidneys or the tubes carrying urine from the kidneys to the bladder), and unspecified psychosis (a diagnosis used when someone experiences psychotic symptoms [like hallucinations-seeing or hearing things that are not there] but doesn't meet the criteria for a specific psychotic disorder). A quarterly Minimum Data Set (MDS) assessment, dated 12/30/24, indicated the resident had no cognitive deficit and received an antipsychotic medication (medication used to treat psychotic symptoms). During an interview, on 3/24/25 at 1:38 p.m., the resident indicated she had been out to the hospital last week related to a kidney stone. The census indicated the resident had been hospitalized from [DATE] to 3/13/25, and again on 3/14/25, and had returned on the same date. A progress note, dated 3/7/25 at 10:35 a.m., indicated the resident had been sent to the hospital overnight due to fever and hallucinations. The resident was found to be septic (a life-threatening condition that occurs when the body's immune system overreacts to an infection, causing widespread inflammation and damage to multiple organs) and had been transferred to a second hospital location for kidney stone surgery and treatment. The record lacked documentation a Physician's order was obtained, written, or signed by the physician for the hospital transfer. During an interview, on 3/25/25 at 3:08 p.m., the DON indicated she was unable to find documentation that a Physician's Order was obtained, written, or signed for the resident's hospital transfers. On 3/26/25 at 9:48 a.m., the DON provided a document, with a revised date of 10/17/24, titled, Transfer and Discharge (including AMA-against medical advice), and indicated it was the policy currently being used by the facility. The policy indicated, .Policy Explanation and Compliance Guidelines .12. Emergency Transfers/Discharges .a. Obtain physician's order for emergency transfer or discharges .f. Document .the transfer in the medical record 3.1-50 (a)(1) 3.1-50(a)(2) Based on record review and interview, the facility failed to ensure a Physician's Order was obtained and documented for hospital transfers for 3 of 4 residents reviewed for hospitalization (Residents 6, 5, and 10). Findings include: 1. Resident 6's record was reviewed on 3/25/25 at 10:13 a.m. A quarterly Minimum Data Set (MDS) assessment, dated 3/11/25, indicated the resident was cognitively intact and had a diagnosis of medically complex conditions. A Progress Note, dated 6/2/24, indicated the resident's sister came to the facility and requested the resident be sent to the hospital for pain. The nurse called 911. The clinical record lacked documenation a Physician's order was obtained, written, or signed by the phsyician for the hospital transfer. A Progress Note, dated 6/3/24, indicated the resident returned to the facility from the hospital. A Progress Note, dated 6/4/24, indicated the nurse went into the resident's room and found his bedside table covered in water, resident was asleep and holding the cup that had spilled. The resident was difficult to wake up, and not touched his dinner, and was unable to say who he was. The resident stated he did not feel well. The resident's sister, Director of Nursing (DON), and physician were notified. The resident was sent to the hospital. The clinical record lacked documenation a Physician's order was obtained, written, or signed by the phsyician for the hospital transfer. A Progress Note, dated 6/13/24, indicated the resident returned to the facility from the hospital. A Progress Note, dated 6/23/24 at 6:20 p.m., indicated the resident's sister stated the resident called her and cried with pain from not having a bowel movement (BM). The nurse explained to the resident's sister that the resident had already received an enema and had large results. The resident's sister wanted the resident to be given another enema, and if the pain continued wanted him sent to the hospital. The physician stated to send the resident to the hospital as he just returned from the hospital the prior week for an illeus (intestinal blockage). A Progress Note, dated 6/23/24 at 6:46 p.m., indicated the resident's sister called back and was notified the physican wanted the resident transferred to the ER. 911 was called. The clinical record lacked documenation a Physician's order was obtained, written, or signed by the phsyician for the hospital transfer. A Progress Note, dated 9/4/24 indicated the resident had tremors in his arms and hands, was lethargic, complained of severe back pain and his stomach cramping. The resident's sister visited and wanted the resident sent to the hospital. The physician and DON were notified, and 911 was called. The clinical record lacked documenation a Physician's order was obtained, written, or signed by the phsyician for the hospital transfer. A Progress Note, dated 9/6/24, indicated the resident returned to the facility from the hospital. A Progress Note, dated 1/14/25 at 1:09 p.m., indicated the resident complained he felt like his lungs were filling up and requested to go to the ER. The resident's family and the physician were notified. The clinical record lacked documenation a Physician's order was obtained, written, or signed by the phsyician for the hospital transfer. A Progress Note, dated 1/14/25 at 7:05 p.m., indicated the resident returned to the facility from the hospital. A Progress Note, dated 3/18/25, indicated the resident was transferred to the hospital for evaluation and treatment due to episodes of projectile vomiting. The resident's family and the physician were notified. The clinical record lacked documenation a Physician's order was obtained, written, or signed by the phsyician for the hospital transfer. A Progress Note, dated 3/19/25, indicated the resident returned to the facility from the hospital. During an interview, on 3/25/25 at 3:08 p.m., the DON indicated she was unable to find documenation a Physician's Order was obtained, written, or signed for the resident's hospital transfers.

Based on observation, record review, and interview, the facility failed to ensure a urinary catheter tubing (a flexible tube inserted into the bladder to drain urine) and a urinary drainage bag were kept off the floor (Resident 2). Finding includes: On 2/5/24 at 2:16 p.m., Resident 2 was asleep in bed and her catheter drainage bag and tubing were in contact with the floor next to her bed. On 2/6/24 at 10:11 a.m., Resident 2 was asleep in her bed and her catheter drainage bag and tubing were in contact with the floor next to her bed. On 2/6/24 at 12:02 p.m., Resident 2 was resting in her bed and her catheter drainage bag and tubing were in contact with the floor next to her bed. On 2/6/24 at 1:37 p.m., Resident 2 was asleep in her bed and her catheter drainage bag and tubing were in contact with the floor next to her bed. On 2/7/24 at 9:21 a.m., Resident 2 was asleep in her recliner and her catheter drainage bag and tubing were in contact with the floor next to her chair. Resident 2's record was reviewed on 2/6/24 at 10:20 a.m. The profile indicated the resident's diagnoses included, but were not limited to, urinary tract infection (is an infection in any part of the urinary system) and hematuria (blood in urine). A significant change in status Minimum Data Set (MDS) assessment, dated 12/19/23, indicated the resident was cognitively intact and on hospice services. A care plan, dated 9/26/23, indicated the resident had a history of UTI (urinary tract infections). Interventions included but were not limited to administer antibiotic therapy as ordered and monitor intake and output. A care plan, dated 12/28/23, indicated the resident had an indwelling Foley catheter for comfort. Interventions included but were not limited to, change catheter monthly and as needed if not functioning correctly, monitor for signs and symptoms of discomfort on urination, and staff to complete catheter care every shift. A physician order, dated 12/26/23, indicated staff may anchor a Foley catheter using a 16 Fr (French) (diameter of catheter tubing) and 10cc (cubic centimeter) balloon for the resident for comfort per hospice. A physician order, dated 12/26/23, indicated to change Foley catheter every month on the 26th, every night shift. A physician order, dated 12/26/23, indicated to perform Foley catheter care every shift. A nurse's note, dated 12/31/23, indicated the CNA (Certified Nursing Aide) reported foul smelling urine from Resident's 2 catheter. The nurse notified the hospice nurse for approval to collect a urinalysis. A physician order, dated 1/7/24, indicated Ciprofloxacin (antibiotic medication) 500mg (milligram) give 1 tablet by mouth two times a day for UTI for 5 days. During an interview, on 2/7/24 at 9:47 a.m., Registered Nurse (RN) 3 indicated the Foley catheter tubing or the drainage bag should not touch the floor. During an interview, on 2/7/24 at 10:24 a.m., Director of Nursing (DON) indicated the Foley catheter tubing, or the drainage bag should not touch the floor. On 2/7/24 at 11:03 a.m., the DON provided a document, with a revised date of 3/10/23, titled, Catheter Care, and indicated it was the current policy being used by the facility. The policy indicated, .11. Ensure catheter tubing and drainage bags do not touch the floor 3.1-38(a)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to clean and store respiratory equipment according to policy, and failed to conduct resident's lung assessment before and after administering a nebulizer respiratory treatments in 2 of 2 residents reviewed for respiratory therapy (Residents 10 and 172). Findings include: 1. On 2/5/24 11:00 a.m., during a routine observation, Resident 10 was lying in bed with the head of bed slightly elevated. Oxygen administered at 2 Liters (L) per nasal cannula (NC) (a medical device to provide supplemental oxygen therapy to people who have lower oxygen levels). The nebulizer (an electrically powered machine that turns liquid medication into a mist so that it can be breathed directly into the lungs through a face mask or mouthpiece) equipment, the medication chamber for holding the liquid medication, tubing and mask were un-bagged and lying on top of the bedside table. On 2/7/24 at 9:56 a.m., during a routine observation of Resident 10 the nebulizer mask, tubing and reservoir was lying on the bedside table un-bagged. A clear liquid substance was inside of the medication chamber. On 2/07/24 at 10:39 a.m., Resident 10's record was reviewed. Diagnoses included but was not limited to, acute, chronic congestive heart failure (CHF) (a condition that develops when your heart doesn't pump enough blood for your body's needs), type 2 diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high), and chronic obstructive pulmonary disease (COPD) (a group of diseases that cause airflow blockage and breathing-related problems). Physician Orders include but were not limited to, albuterol 2.5 mg/3 ml (milligrams/milliliters) solution (3 ml) inhale 1 vial orally via nebulizer every 6 hours as needed for shortness of breath (SOB) and/or wheezing; albuterol sulfate HFA 90 mcg (micrograms) inhalation 18 gm (grams) 2 puffs inhaled orally every 6 hours as needed for wheezing, SOB (shortness of breath); IPRAT-albuterol 0.5-3(2.5) mg/3 ml, 3 ML inhale 1 vial orally four times a day for SOB, wheezing via nebulizer. A quarterly MDS, dated [DATE], indicated the resident was on continual oxygen. A care plan, dated 3/9/23, indicated the resident had altered respiratory status related to Pulmonary hypertension (a condition that affects the blood vessels in the lungs), COPD, and sleep apnea (a common condition in which your breathing stops and restarts many times while you sleep). Interventions were to administer medication/puffers as ordered. Oxygen settings: as needed (PRN) oxygen (O2) at 2L/min (liters per minute) via nasal cannula. The medical record lacked documentation of lung assessments prior to and after administration of nebulizer treatments for Resident 10. 2. On 2/5/24 at 1:57 p.m., during a routine observation of Resident (172), the nebulizer chamber, mouthpiece and tubing were un-bagged and laying on top of the bedside table. On 2/7/24 at 9:54 a.m., the nebulizer equipment and tubing were un-bagged and laying on top of the nebulizer machine. On 2/07/24 10:28 a.m., Resident 172's record was reviewed. Diagnoses included but was not limited to, acute, chronic congestive heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), chronic obstructive pulmonary disease (COPD) (a group of diseases that cause airflow blockage and breathing-related problems), obstructive sleep apnea (a relatively common condition where the walls of the throat relax and narrow during sleep, interrupting normal breathing), generalized anxiety disorder (a feeling of fear, dread, and uneasiness), and stage 4 (severe) chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should). Physician orders included but are not limited to. Oxygen at 4 liters per minute (LPM) continuously, via nasal cannula; monitor oxygen saturation every shift; Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG (milligrams)/3ML (milliliters) (Ipratropium-Albuterol), 1 application inhale orally four times a day (via nebulizer). A baseline care plan was completed on admission. Record lacked documentation of a care plan for oxygen or nebulizer treatment. The medical record lacked documentation of lung assessments prior to and after administration of nebulizer treatments for Resident 172. On 2/7/24 at 10:05 a.m., during an interview, Registered nurse (RN) 3 indicated she checked the oxygen saturation level and the pulse before initiating a nebulizer treatment. She put the medication solution in the nebulizer chamber and placed the nebulizer mask on the resident. Once the treatment was completed, she cleaned the equipment with water and allowed it to air dry on a clean surface. Once dry she placed the equipment in the dated bag. The nurse acknowledged both residents received scheduled nebulizer treatments four times a day. On 2/7/24 at 10:05 a.m., during an interview RN 3 indicated she checked oxygen saturation and pulse before she began the nebulizer treatment and she put the medication solution in the nebulizer chamber and placed the mask on the resident. She indicated that after the treatment was completed she assessed the residents' lungs. She cleaned the equipment with water and allowed it to air dry on a clean surface, then placed it in the bag. She acknowledged both residents received scheduled nebulizer treatments four times per day. On 2/7/24 at 10:20 a.m., during an interview the Director of Nurses (DON) indicated the nurse should assess the resident before and after the nebulizer treatment. They were to clean the equipment, dry it, then place it back into the bag. Tubing should be dated as well as the bag. The DON acknowledged the pre and post assessments were not completed for the two residents reviewed. On 2/7/2024 at 11:04 a.m., the DON provided a document, titled, Nebulizer Therapy, dated 2/17/21, and indicated it was the policy currently being used by the facility. The policy indicated, . 2. Care of the Equipment .c. Disassemble parts after every treatment .d. Rinse the nebulizer cup and mouthpiece with sterile or distilled water .e. Shake off excess water .f. Air dry on an absorbent towel .g. Once completely dry, store the nebulizer cup and the mouthpiece in a zip lock bag .3. Documentation .a. Record the following information in the resident's medical record .d. Resident vital signs and respiratory assessment pre and post treatment 3.1-47(a)(4) 3.1-47(a)(5) 3.1-47(a)(6)

Based on record review and interview, the facility failed to ensure Registered Nurse (RN) coverage for at least 8 consecutive hours a day for 7 days a week on July 1, 2023 for 1 of 31 days of staffing reviewed. Finding includes: During an interview, on 2/8/24 at 10:30 a.m., the Administrative Assistant indicated she was not sure if there was RN coverage on July 1, 2023, she would need to go back and check the daily schedules. Review of daily nursing schedules provided by the facility indicated there was no RN scheduled for the day of July 1, 2023. Review of the daily staffing report lacked documentation of RN hours for the day of July 1, 2023. During an interview, on 2/8/24 at 11:00 a.m., the Director of Nursing (DON) indicated there was not a RN in the building on the date of July 1, 2023. She indicated there was not one scheduled that day. During an interview, on 2/8/24 at 1:23 p.m., the Administrator indicated he was aware there was not a RN in the building on the date of July 1, 2023. On 2/8/24 at 1:05 p.m., the DON provided a document, with a revised date of 10/17/22, titled, Nursing Services-Registered Nurse, and indicated it was the policy currently being used by the facility. The policy indicated, .1. The facility will utilize the services of a Registered Nurse for at least 8 consecutive hours per day, 7 days per week 3.1-17(b)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 2/06/24 at 10:38 a.m., Resident 7's medical record was reviewed.Diagnosis included but were not limited to, encounter for orthopedic after care following surgical amputation (left foot amputation), iron deficiency anemia (a condition that develops when your blood produces a lower-than-normal amount of healthy red blood cells), and type 2 diabetes mellitus (a disease that occurs when your blood glucose, also called blood sugar, is too high). Physician Orders included but were not limited to, administer one oral 5 milligrams (mg) tablet of Eliquis (anticoagulant medication-a substance that is used to prevent and treat blood clots in blood vessels) by mouth two times a day for AFIB (atrial fibrilation) (an irregular and often very rapid heart rhythm). A Pharmacist consultation report, dated 1/22/24, indicated a boxed warning with a recommendation to ensure the resident's plan of care included recommendation to use an alternative anticoagulant if the Eliquis is stopped for any reason other than pathological (being such to a degree that is extreme, excessive, or markedly abnormal) bleeding or completion of therapy, and to avoid use of neuraxial anesthesia (the placement of local anesthetic in or around the central nervous system) or spinal puncture (a procedure in which a thin, hollow needle is inserted into the lower part of the spine to collect a sample of cerebrospinal fluid), if possible. The physician accepted the and indicated to please implement as written. The medical record lacked documentation indicating the recommendation was implemented as ordered. On 2/7/24 at 8:56 a.m., the Director of Nurses (DON) provided a document titled, Medication Regimen Review, dated 5/20/21, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy Explanation and Compliance Guidelines .7. Timelines and responsibilities for Medication regimen Review .f. Facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities 3.1-48(a)(1) 3.1-48(a)(2) 3.1-48(a)(3) 3.1-48(a)(4) 3.1-48(a)(5) 3.1-48(a)(6) Based on record review and interview, the facility failed to address pharmacy recommendations for 2 of 5 residents reviewed for unnecessary medications (Residents 121 and 7). Findings include: 1. Resident 121's record was reviewed on 2/6/24 at 10:06 a.m. The profile indicated the resident had been admitted to the facility on [DATE], with diagnoses which included, but were not limited to, personal history of pulmonary embolism (PE-when a blood clot gets stuck in an artery in the lung, blocking blood flow to part of the lung). A physician's order, dated 1/30/24, indicated to administer one tablet of Xarelto (anticoagulant medication-a substance used to prevent and treat blood clots in blood vessels) 20 milligrams (mg) oral tablet by mouth in the morning for history of PE. A Pharmacist consultation report, dated 1/31/24, indicated a recommendation to ensure the resident's care plan included guidance to use an alternative anticoagulant if the Xarelto was stopped for any reason other than pathological (being such to a degree that is extreme, excessive, or markedly abnormal) bleeding or completion of therapy, and to avoid use of neuraxial anesthesia (the placement of local anesthetic in or around the central nervous system) or spinal puncture (a procedure in which a thin, hollow needle is inserted into the lower part of the spine to collect a sample of cerebrospinal fluid), if possible. The physician accepted the recommendation and documented the resident was on the medication due to a history of PE. The resident's care plans lacked documentation of any use of anticoagulant medication or history of PE. During an interview, on 2/6/24 at 2:00 p.m., the Director of Nursing (DON) indicated she had never seen a recommendation like that before. She was unsure why the recommendation or the residents use of an anticoagulant, had not been addressed in the resident's care plan.

Based on record review and interview, the facility failed to address pharmacy recommendations for 1 of 5 residents reviewed for unnecessary medications (Resident 2) Finding includes: Resident 2's record was reviewed on 2/6/24 at 10:20 a.m. The profile indicated the resident's diagnoses included, but were not limited to, major depressive disorder (depression is a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily life) and unspecified dementia with mood disturbance (mild cognitive impairment with behavioral disturbances that can include anxiety, depression, and agitation). A pharmacy recommendation, dated 11/9/23, recommended to consider discontinuing Effexor (anti-depressant medication) and reinitiating alternative therapy with Pristiq (anti-depressant) 50mg (milligram) daily. The physician declined the recommendation and indicated he would get with the Psychiatric (Psych) NP (nurse practitioner) to see what she advised. The physician signed the recommendation on 11/14/23. The facility was unable to provide documentation that indicated the physician had spoken with the Psych NP regarding the above recommendation. A physician order, dated 9/26/23, indicated an order for Effexor XR (extended release) 24-hour 75mg. Give 2 tablets by mouth one time a day for anxiety and depression. Review of the resident's February MAR (medication administration record) indicated the resident was still receiving the Effexor medication as ordered. During an interview, on 2/7/24 at 11:37 a.m., the Director of Nursing (DON) indicated the physician should address the pharmacy recommendation in a timely manner and have a rationale for the declination. She indicated that they did not have documentation from the physician or the Psych NP regarding the pharmacy recommendation dated 11/9/23 for Resident 2. On 2/7/24 at 8:56 a.m., the DON provided a document with a revised date of 9/26/23, titled, Medication Regimen Review, and indicated it was the policy currently being used by the facility. The policy indicated, .f. Facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities 3.1-48(a)(3)

Based on observation, interview and record review, the facility failed to ensure insulin medication was labeled and stored according to policy and manufacture guidelines for 1 of 2 medication carts reviewed for medication storage. Findings Include: On 2/8/24 at 9:15 a.m., observation of medication cart 2, with the Assistant Director of Nurses (ADON). An insulin pen labeled Lispro 100 units (U), within a clear plastic bag was unsealed and labeled with a green sticker indicating Refrigerate. A blank date opened was on the outside top of the pen cover. The ADON indicated the medication administration record for the resident of whom the insulin was prescribed, indicated the insulin had been delivered on 2/6/24. The medical record indicated the insulin had not been administered. The ADON acknowledged the insulin pen should have been refrigerated till opened and acknowledged the label lacked documentation of a date indicating when the insulin pen had been opened. On 2/8/24 at 9:30 a.m., during an interview, the Director of Nurses (DON), indicated all insulins must have a label indicating when the medication had been opened. If the insulin was un-opened it must be refrigerated. On 2/8/24 at 10:00 a.m., review of the manufacture guidelines indicated, .Lilly's Non-Branded Insulins Prescribing Information. Patient Prescribing Information, Instructions for Use Unused Pens, Store unused Pens in the refrigerator at 36°F to 46°F (2°C to 8°C). Do not freeze your insulin. Do not use if it has been frozen. Unused Pens may be used until the expiration date printed on the Label, if the Pen has been kept in the refrigerator On 2/8/2024 at 1:05 p.m., the DON provided a document, titled, Insulin Pen, dated 9/28/2, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy . It is the policy of this facility to use insulin pens in order to improve the accuracy of insulin dosing .Policy explanation and compliance guidelines .7. Store unopened insulin pens in a refrigerator .8. Once opened, clearly labeled pens, that have an opened date, may be stored at room temperature in a locked medication cart. Insulin pens do not require refrigeration after opening .9. Insulin pens should be disposed of after 28 days or according to manufacturer's recommendation On 2/8/2024 at 1:05 p.m., the DON provided a document, titled, Storage of Medications Requiring Refrigeration, dated 6/11/21, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy .It is the policy of this facility to assure proper and safe storage of medications requiring refrigeration and to prevent potential alteration of medications by exposure to improper temperature controls .Policy Explanation and Compliance Guidelines .2. The facility will ensure that all drugs and biologicals used will be labeled in accordance with professional standards, including expiration dates (when applicable) and with appropriate accessory and precautionary instructions (such as shake well, take with meals, do not crush, special storage instructions) .3. Facility staff should label all medications with date opened .4. The facility will ensure that all medications and biologicals will be stored at proper temperatures and other appropriate environmental controls according to manufacturer's recommendations to preserve their integrity .b. Refrigerated refers to temperatures maintained between 36 -46 degrees F 3.1-25(j) 3.1-25(m) 3.1-25(n)

Based on observation, record review, and interview, the facility failed to ensure dental services were offered to a resident for 1 of 1 residents reviewed for dental services (Resident 5). Findings include: During the initial observation of Resident 5, on 2/5/24 at 1:43 p.m., the resident was observed with only 1 tooth on her lower jaw. At the same time, the resident indicated she had a partial denture, but it was uncomfortable, and she did not like to wear it. She had not seen a dentist for quite some time. Resident 5's record was reviewed on 2/8/24 at 9:22 a.m. The profile indicated the resident had been admitted to the facility, on 9/28/20, for diagnoses which included, but were not limited to, emphysema (a disorder affecting the alveoli [tiny air sacs] of the lungs), and chronic systolic congestive heart failure (a condition where the heart can't pump with enough force to push enough blood into circulation). A quarterly minimum data set (MDS-part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes) assessment, dated 1/27/23, indicated the resident had no cognitive deficit and no documented concerns with her dental status. A care plan, dated 10/13/20 and revised on 11/20/20, indicated the resident had potential for oral/dental health problems related to no natural teeth and the use of dentures. Interventions included, but were not limited to, coordinate arrangements for dental care and transportation as needed or as ordered. An ancillary services consent, dated 10/7/22, indicated the resident had declined dental services. The record lacked any follow-up documentation of dental services having been offered, consented to, or declined, after 10/7/22. A care plan note, dated 1/18/23 at 2:00 p.m., indicated the resident and the resident's niece had participated in the care plan meeting. The note lacked documentation of an offer for dental services. A care plan note, dated 4/12/23 at 1:39 p.m., indicated the resident and the resident's niece had participated in the care plan meeting. The note lacked documentation of an offer for dental services. A care plan note, dated 7/12/23 at 3:21 p.m., indicated the resident and the resident's niece had participated in the care plan meeting. The note lacked documentation of an offer for dental services. A care plan note, dated 9/6/23 at 2:08 p.m., indicated the resident and the resident's niece had participated in the care plan meeting. The note lacked documentation of an offer for dental services. A care plan note, dated 11/8/23 at 1:37 p.m., indicated the resident had participated in the care plan meeting. The note lacked documentation of an offer for dental services. A care plan note, dated 1/31/24 at 5:49 p.m., indicated the resident and the resident's niece had participated in the care plan meeting. The note lacked documentation of an offer for dental services. During an interview, on 2/8/24 at 10:18 a.m., the Director of Nursing (DON) indicated the facility would address the desire of the residents to receive dental services. She indicated ancillary services were discussed at each care plan meeting. During an interview, on 2/8/24 at 10:31 a.m., the Social Services Director (SSD) indicated the resident had declined dental services in 2022. Ancillary services were discussed at each plan of care meeting. During a telephone interview, on 2/8/24 at 11:03 a.m., Resident 5's niece indicated she felt like her aunt needed seen for dental care. She participated in all of the resident's care plan meeting via telephone. She could not recall ever having been asked specifically about if they wanted dental care at the care plan meetings. They had used the facility contracted dental company before, but they were not happy with them because they didn't or wouldn't do anything for the resident and it costs her a lot of money. When they signed the declination for the service, it was to decline that specific dental carrier. She had told the facility that they would like someone to see her but had not been asked about any other dental services. During an interview, on 2/8/24 at 11:09 a.m., the DON indicated they have had residents who did not like the contracted dental services, in the past. The facility would work with those residents, and or their representatives, to find other dental options and would provide transport for the residents to be seen by the dental service of their choice. On 2/8/24 at 10:38 a.m., the SSD provided a document, dated 5/21/21, titled, Ancillary Services, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy: It is the policy .to ensure that residents have access to and receive proper treatment regarding vision, hearing, dental, and foot care .3. The social service designee and supply clerk will collaborate with family and residents in signing up for additional in-house services. If outside services are warranted, the Life Enrichment Director will set up the appointment and transportation for the resident On 2/8/24 at 10:38 a.m., the SSD provided a document, with a revision date of 5/20/21, titled, Dental Services, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy Explanation and Compliance Guidelines: 1. The dental needs of each resident are identified through the physical assessment and MDS assessment processes .b. Oral care and denture care shall be provided in accordance with identified needs and as specified in the plan of care .2. Residents and/or representatives . are notified of dental services available .3. The Social Services Director maintains contact information of providers of dental services that are available to facility residents at a nominal cost. 4. The facility will .assist the resident with making dental appointments and arranging transportation to and from dental services locations 3.1-24(a)

Based on observation, interview, and record review, the facility failed to ensure pureed food items were prepared in a sanitary manner during 1 of 1 observation of pureed food preparation. Findings include: Cook 9 was observed preparing pureed food, on 11/21/22 at 10:37 a.m. After washing his hands thoroughly and donning gloves, the [NAME] was observed to touch and adjust his facemask and immediately pick up rolls and place them in the blender, with his gloved hands. At one time, the handle from the lid of the blender came loose and fell to the floor. The [NAME] picked up the handle from the floor, placed it on the counter next to the blender, touched and adjusted his facemask with his gloved hand, removed the lid from the blender, and reached in and adjusted the blender blade, with the same gloved hand, without changing his gloves and performing hand hygiene. Throughout the entire procedure, the [NAME] was observed to touch and adjusted his facemask a total of 5 times, without ever changing his gloves and performing hand hygiene. During an interview, on 11/21/22 at 10:43 a.m., [NAME] 9 indicated he was not aware that he had touched his facemask during the pureed preparation. It had become such an automatic reflex to keep his mask up over his nose, since facemasks had become required. He understood that he should have not continued to prepare food, after touching his facemask with his gloves, without first washing his hands and putting on new gloves. During an interview, on 11/21/22 at 11:54 a.m., the Dining Services Supervisor indicated the [NAME] should have performed hand hygiene and changed his gloves when he touched his mask and when he had picked something up from the floor. On 11/21/22 at 10:53 a.m., the Dining Services Director provided an document, dated 3/13/22, titled, Hand Hygiene, and indicated it was the policy currently being used by the facility. The policy indicated, Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors .Policy Explanation and Compliance Guidelines .6. Additional considerations: a. The use of gloves does not replace hand hygiene 3.1-21(3)

Based observation, interview, and record review, the facility failed to ensure staff wore personal protective equipment (PPE) of a face shield when administering medication and providing care to a COVID-19 positive resident in transmission-based precautions (TBP) droplet isolation (used to prevent the spread of pathogens that are passed through respiratory secretions) for 1 of 1 random observation during medication administration (Resident 16). Finding includes: During a random observation of medication administration, on 11/21/22 at 11:18 a.m., a sign was observed posted on Resident 16's door which indicated, transmission-based precautions (TBP) contact droplet isolation room and to don (put on) personal protective equipment (PPE) of an N-95 face mask, a face shield or goggles, a gown, and gloves required to enter the isolation room. Registered Nurse (RN) 8 was observed to don an isolation gown, N-95 face mask, and gloves, then entered Resident 16's TBP droplet isolation room for the medication administration. RN 8 administered to Resident 16 a medication capsule and applied a medicated ointment to the resident's neck. On 11/21/22 at 11:31 a.m., RN 8 indicated she had forgotten to don a face shield prior to entering the droplet isolation room but should have put eye protection on before entering the isolation room. The Director of Nursing (DON), on 11/21/22 at 11:51 a.m., indicated on 11/19/22 Resident 16 had complained of a sore throat, headache, and runny nose, and tested positive for COVID-19. Resident 16 was placed on TBP droplet isolation in his private room. Staff should have worn a gown, gloves, N95 face mask, and a face shield or goggles when they entered the TBP droplet precautions isolation room. On 11/21/22 at 1:30 p.m., the DON provided and identified a document as a current facility policy titled, Transmission-Based Precautions, dated 3/13/22. The policy indicated, .Policy: it is our policy to take appropriate precautions to prevent transmission of infectious agents, based on the agents' modes of transmission .3. Contact Precautions .d. Donning personal protective equipment (PPE) upon room entry and discarding before exiting the room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination (e.g. VRE, C. difficile, noroviruses and other intestinal tract pathogens, RSV) .4. Droplet precautions .d. Healthcare personnel wear a mask for close contact with infectious resident 3.1-18(b)(1) 3.1-18(b)(2)

Based on record review and interview, the facility failed to provide annual education for abuse prevention, and ensure employees had also completed dementia and resident rights training for 3 of 5 randomly selected Healthcare facility employees who had been employed at the facility for greater than one year. This deficient practice had the potential to effect 18 of 18 residents who resided in the facility. Findings include: On 11/21/22 at 1:00 p.m. 10 randomly selected employee files were reviewed, 5 new hires and 5 employees who had worked at the faccility greater than one year. The Director of Nursing (DON), hired on 9/13/16, did not have documentation of abuse training in the past 12 months (one year). Qualified Medication Aid (QMA) 17, hired on 11/1/21, did not have documentation abuse, dementia, or resident rights training in her employee file for the past 12 months (one year). On 11/21/22 at 2:30 p.m., during an interview, the Business Office Manager (BOM) indicated QMA 17 did not have any records of having completed any annual training in her file or the electronic system. Licensed Practical Nurse (LPN) 18, hired on 1/7/21 did not have documentation of abuse training in the past 12 months (one year). On 11/21/22 at 2:50 p.m., during an interview, the DON indicated the facility did not have annual trainings completed for abuse. She started doing annual in-services but has only gotten a few employees done. She was not aware she had to be trained by someone else (not herself). On 11/22/21 at 1:47 p.m., the DON provided a current policy, dated 10/17/22, titled, Continuing Education. This policy indicated Compliance with the facility's standards, policies, and procedures is a condition of employment. This includes compliance with the policies and procedures of this facility's training programs 3.1-13(2)