Based on observations, interviews, and record reviews, the facility failed to ensure residents were addressed in a dignified manner and the facility failed to ensure a resident was assisted during meal service in a dignified manner for 2 of 3 dining observations. (Residents 56 and 31). Findings include: 1. During the lunch meal observation in the activity dining room, on 12/12/24 at 12:41 p.m., Resident 56 was sitting at a table eating her lunch when CNA 5 addressed the resident as Honey. CNA 5 stated from the opposite table, Honey use your silverware to Resident 56. Resident 56's record was reviewed, on 12/16/24 at 1:48 p.m. The profile indicated the resident's diagnosis included, but were not limited to, unspecified dementia, severe, with anxiety (a person who is experiencing a significant level of cognitive decline where the exact type of dementia is not known, and alongside this cognitive impairment, they are also exhibiting symptoms of anxiety) and cerebral infarction affecting right dominant side (a stroke (cerebral infarction) has occurred in the right hemisphere of the brain, which is considered the dominant side for most people causing symptoms like weakness or paralysis on the left side of the body. A quarterly Minimum Data Set (MDS) assessment, dated 11/26/24, indicated the resident had severe cognitive impairment and was independent with eating. A care plan, dated 5/15/24, indicated the resident had personal preferences in regards to her care based on her personal preferences assessment. Interventions included, but were not limited to, call me by my first name. The record lacked a care plan indicating resident preferred to be called, Honey. 2. During the lunch meal observation on the rehab unit, on 12/16/24 at 1:17 p.m., CNA 5 was standing up next to Resident 31 assisting her with lunch meal. CNA 5 continued to assist with feeding the resident while standing next her. CNA 5 addressed Resident 31 as Honey. She asked Resident 31, How are you doing Honey? She proceeded to feed the resident and asked, Sweet girl, are you hungry? Resident 31's record was reviewed, on 12/16/24 at 2:01 p.m. The profile indicated the resident's diagnosis included, but were not limited to, unspecified dementia (a person who is experiencing a significant level of cognitive decline where the exact type of dementia is not known) and syndromes with complex partial seizures (most common type of seizures in adults, they can last between 30 seconds and 2 minutes). The record lacked a care plan indicating resident preferred to be called, Honey or Sweet girl. An annual Minimum Data Set (MDS) assessment, dated 10/1/24, indicated the resident had severe cognitive impairment and was a maximum assist with eating. During an interview, on 12/16/24 at 1:27 p.m., the Director of Nursing (DON) indicated staff should not stand up next to a resident to assist with feeding. The staff should sit next to the resident while assisting with a meal. She further indicated staff should address residents by their preferred name. She would do some training with staff on making sure to address residents by their preferred name and in a dignified manner. On 12/16/24 at 1:53 p.m., the Administrator provided a document with a revised date of July 2017, titled, Assistance with Meals, and indicated it was the policy currently being used by the facility. The policy indicated, .Residents shall receive assistance with meals in a manner that meets the individual needs of each resident .3. Residents who cannot feel themselves will be fed with attention to safety, comfort, dignity, for example: a. Not standing over residents' while assisting them with meals On 12/16/24 at 1:53 p.m., the Administrator provided a document with a revised date of January 2019, titled, Resident Rights, and indicated it was the policy currently being used by the facility. The policy indicated, .1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights included resident's right to: a. a dignified existence b. be treated with respect, kindness, and dignity 3.1-3(a)

Based on interview and record review, the facility failed to monitor a resident's weight as ordered for 1 of 4 reviewed for nutrition (Resident 59). Finding includes: During an interview, on 12/12/24 at 11:14 a.m., Resident 59 indicated he had some weight loss when he first came to the facility, but he thought his weight had stabilized now. Resident 59's record was reviewed on 12/17/24 at 10:18 a.m. The profile indicated the resident's diagnosis included, but were not limited to, chronic kidney disease, stage 3 (a person has moderate damage to their kidneys where they are not filtering waste effectively, resulting in mild to moderate loss of kidney function), prediabetes (you have a higher-than-normal blood sugar), and repeated falls. An admission Minimum Data Set (MDS) assessment, dated 11/22/24, indicated the resident was cognitively intact and had an admission weight of 210 pounds. A care plan, dated 11/20/24, indicated the resident was at risk for nutritional deficits related to chronic kidney disease stage 3 and prediabetes. Interventions included, but were not limited to, weights as directed and observe and report to MD (medical doctor) for signs and symptoms of malnutrition. A physician order, dated 11/20/24, to obtain a weight daily for 3 days then weekly times 4 weeks. Review of Resident 59's weights in the electronic health record indicated the following: a. dated 11/20/24 at 2:44 p.m. - 208.5 pounds and documentation was struck out in error on 11/25/24 by nurse. b. dated 11/20/24 at 2:51 p.m. - 210 pounds and documentation was struck out in error on 11/25/25 by nurse. c. dated 11/25/24 at 11:55 a.m. - 197 pounds d. dated 12/4/24 at 12:36 p.m. - 201.6 pounds e. dated 12/11/24 at 4:28 p.m. - 196 pounds f. dated 12/16/24 at 1:50 p.m. - 199 pounds The record lacked documentation of a weight being obtained until 11/25/24. Review of an admission evaluation, dated 11/19/24 at 5:37 p.m., the record lacked documentation of a weight for Resident 59 was recorded. Review of Treatment Administration Record (TAR) for November 2024 lacked documentation of a daily weight being completed on 11/21/24 and 11/22/24. The record lacked documentation of a resident's refusal to obtain his weight. Review of a care plan note, dated 11/25/24 at 12:23 p.m., indicated Resident's current weight was 210 pounds and on a regular diet. During an interview, on 12/17/24 at 11:54 a.m., the Director of Nursing (DON) indicated she could not find where Resident 59 had daily weights completed per the physician order in his electronic health record. Daily weights for 3 days and the weekly for 4 weeks was a standard order that would be placed in the electronic health record for new admissions. Review of a paper report sheet, dated 11/19/24, was provided by the DON and indicated it had a weight of 198.7 pounds for Resident 59. The DON indicated the weight was not placed in the electronic health record at the time of admission by the nurse and the DON placed it in the record on 12/17/24. On 12/17/24 at 12:57 p.m., the Administrator provided a document with a revised date of March 2019, titled, Weight Assessment and Intervention, and indicated it was the policy currently being used by the facility. The policy indicated, .1. The nursing staff will measure weight on admission .2. Weights will be recorded in each individual's medical record .3. If a resident declines to participate in a weight loss goal or weights being obtained, the resident's wishes will be documented, and those wishes will be respected 3.1-37

Based on observation, record review, and interview, the facility failed to ensure a resident's indwelling urinary catheter (a thin, flexible tube that is inserted into the bladder through the urethra to drain urine), drainage bag and tubing were maintained in a manner to prevent contact with the floor for 1 of 2 residents reviewed for urinary catheters (Resident 1). Findings include: During the initial pool observation, on 12/13/24 at 8:50 a.m., Resident 1 was observed in her bed and the bed was in the low position. Her indwelling urinary catheter drainage bag (catheter bag) was observed in contact with the floor. At the same time, the catheter's tubing was observed sitting on the electrical cord for the resident's oxygen concentrator (a medical device that supplies oxygen-enriched air by removing nitrogen from the air around the patient). The electrical cord was observed in contact with the floor. During a random observation, on 12/13/24 at 3:10 p.m., the resident was observed in her bed. The bed was observed in the low position. The resident's catheter bag was observed to be in contact with the floor. During a random observation, on 12/16/24 at 1:10 p.m., the resident was observed in her bed in the hallway outside of her room due to a temporary power outage. Her bed was in the low position. The resident's catheter bag was observed to be in contact with the floor. During a random observation, on 12/16/24 at 1:53 p.m., the resident was observed in her bed which had been moved back into her room. Her bed was in the low position. The resident's catheter bag was observed to be in contact with the floor. Resident 1's record was reviewed on 12/16/24 at 2:10 p.m. The profile indicated the resident's diagnoses included, but were not limited to, stage 3 chronic kidney disease (mild to moderate damage to the kidneys where they are less able to filter waste and fluid out of the blood), stage 4 pressure ulcer to sacral region (a very severe wound on the skin over the tailbone area where the damage extends through all layers of skin, potentially exposing muscle, bone, and tendons), and muscle wasting an atrophy (the loss of muscle tissue and strength). A significant change Minimum Data Set (MDS) assessment, dated 10/18/24, indicated the resident had severe cognitive deficit, had an indwelling urinary catheter, and received hospice services. A care plan, dated 10/17/24, indicated the resident had a Foley (brand name) catheter related to wounds. The interventions lacked documentation of monitoring the catheter bag or tubing from coming in contact with the floor. A physician's order, dated 10/17/24, indicated that the resident have a 16 French (Fr) (size of a catheter described in French units) catheter. A physician's order, dated 10/17/24, indicated for staff to perform catheter care (a set of practices that help prevent infection and maintain the health of a catheter and the surrounding area) every shift two times a day. During an interview, on 12/16/24 at 2:41 p.m., the Director of Nursing (DON) indicated the resident's catheter bag was likely in contact with the floor due to her bed being in the low position. Catheter bags and tubing should never come in contact with the floor. On 12/16/24 at 3:01 p.m., the Administrator (ADM) provided a document, with a revised date of September 2014, titled, Catheter Care, Urinary, and indicated it was the policy currently being used by the facility. The policy indicated, .Infection Control .2.b. Be sure catheter tubing and drainage bag are kept off the floor 3.1-41(a)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to assess a resident's condition for complications before and after hemodialysis treatments (a procedure that removes waste products and excess fluid from the blood when the kidneys are no longer functioning properly) which were received at a certified dialysis facility for 1 of 2 residents reviewed for dialysis (Resident 49). Findings include: On 12/12/24 at 11:34 a.m., during observation and interview, Resident 49 indicated when she received hemodialysis on Monday, Wednesday, and Friday. The staff did not check the access site (also known as vascular access, a surgically created opening in the body that allows a patient to receive hemodialysis) in her left arm after returning from dialysis treatment. She indicated when she returned yesterday 12/11/24, the access site bled and soaked through the bandage on her arm. She indicated she changed the bandage using the supplies she had in her room. On 12/13/24 at 3:30 p.m., during observation after the resident returned from dialysis. A dressing was covering the left forearm dialysis access site. The resident indicated the nurse had not checked the dressing for bleeding since returning earlier. On 12/16/24 at 9:23 a.m., reviewed the medical record of Resident 49. The resident was admitted to the facility on [DATE]. Diagnosis included but were not limited to end stage renal disease (a permanent condition that occurs when the kidneys are no longer able to function and require dialysis or a kidney transplant to sustain life), dependence on renal dialysis, type 2 diabetes mellitus with diabetic chronic kidney disease (a disease that occurs when your blood glucose, also called blood sugar, is too high). A Physician order, dated 4/13/24, indicated the resident was to have dialysis - FYI (for your information) - Dialysis Treatments 3 X (times) week at 10 a.m. A care plan, dated 4/14/24, indicated Resident 49 had a diagnosis of end stage renal disease and was at risk for complications with dialysis treatment. Interventions included but were not limited to, go to dialysis 3 days a week, to administer medications as ordered, to observe for pain at site, and to notify physician if pain is present. The record lacked a care plan for access site observation for bleeding, swelling or abnormalities. A Physician order, dated 4/15/24, indicated staff were to check access site for bruit (a whooshing or swooshing sound that can be heard near the access site with a stethoscope) and thrill (a vibration or buzzing sensation that can be felt by placing your fingers just above the incision line) daily on return shift. Staff were to document Y (yes) if monitored and N (no) if thrill or bruit were absent. Staff were to select chart code Other/See Nurses Notes and record findings if N (no) was selected and document abnormalities. A Physician order, dated 4/15/24, indicated staff were to assess vitals (blood pressure, pulse, respiration, temperature) on return from dialysis every Monday, Wednesday, and Friday. Task was scheduled to be completed on return from dialysis-on-dialysis days. A quarterly Minimum Data Set (MDS) assessment, dated 10/14/24, indicated the resident was cognitively intact. On 12/13/24 at 3:20 p.m., during interview with Licensed Practical Nurse (LPN) 8, she indicated the nurse checked the access site each shift after administration of dialysis. On 12/13/24 at 3:40 p.m., during an interview, the Director of Nursing indicated the nurse should assess the resident after the dialysis resident returned from dialysis to ensure the site was not bleeding. The DON acknowledged an order to check for bleeding at the access site had not been obtained from the physician prior to interview. A Physician order, dated 12/13/24, indicated twice a day staff were to check dialysis access site for bleeding every shift, and notify MD (medical doctor) if symptoms. On 12/16/2024 at 10:40 a.m., the Director of Nursing provided a document, titled, Dialysis dated 11/28/2016, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy .Based on comprehensive assessment of a patient, the facility must ensure that patient(s) who require dialysis receive such services, consistent with professional standards of proactive .Post Dialysis .5. Monitor shunt site on a routine basis. Notify physician if any unusual problems are noted with shunt site (tenderness, bleeding) .General guidelines .4. Monitor for any complaints or observations at vascular access site 3.1-37(a)

Based on record review and interview, the facility failed to ensure behavior monitoring was completed for 1 of 5 residents reviewed for unnecessary medications (Resident 30). Findings include: Resident 30's record was reviewed on 12/16/24 at 9:36 a.m. The profile indicated the resident's diagnoses included, but were not limited to, alcoholic cirrhosis of the liver with ascities (a condition where the liver is damaged by chronic alcohol consumption and has a buildup of fluid in the abdomen), visual hallucinations (seeing things that are not there), other chorea (a movement disorder that causes involuntary, rapid, and irregular muscle contractions that affect the face, arms, legs, and trunk), anxiety disorder (a mental health condition that causes excessive and persistent feelings of fear, dread, and uneasiness that interfere with daily life), major depressive disorder (a mental health condition that can cause a persistent feeling of sadness, hopelessness, and a lack of interest in activities), and irregular muscle contractions that affect the face, arms, legs, and trunk. A quarterly Minimum Data Set (MDS) assessment, dated 9/9/24, indicated the resident had no cognitive deficit and no documented behaviors. A care plan, with a revision date of 3/20/24, indicated the resident was at risk for ineffective coping related to a significant traumatic event. The resident was counseling a patient who committed murder. Interventions included, but were not limited to, administer medications as ordered and collaborate care with medical and psychiatric service providers as needed. A care plan, dated 2/4/20, indicated the resident was at risk for emotional and physical distress related to a history of physical, emotional, and mental abuse. The resident reported her former spouse threatened her with a gun. Interventions included, but were not limited to, administer medications as ordered and collaborate care with medical and psychiatric service providers as needed. A physician's order, dated 1/18/21, indicated to monitor behaviors of depression and tearfulness and document the number of episodes, interventions, and outcomes, every shift and as needed. A physician's order, dated 1/18/21, indicated to monitor behaviors of insomnia and document the number of episodes, interventions, and outcomes, every shift and as needed. A physician's order, dated 1/18/21, indicated to monitor behaviors of visual hallucinations and document the number of episodes, interventions, and outcomes, every shift and as needed. A Pharmacy recommendation, dated 2/28/24, indicated to evaluate the resident's medications of Cymbalta (antidepressant medication) 90 milligrams (mg) daily and Risperdal (antipsychotic medication) 0.5 mg at bedtime, for symptoms the depression, pain, and hallucinations, and consider dose reductions. The facility's behavior committee reported the resident was still symptomatic and recommended a dose reduction of the medications be contraindicated. The physician agreed with the behavior committee's recommendation and documented that no dose reduction should be completed. Review of the resident's February 2024 Treatment Administration Record (TAR) and progress notes lacked documentation that the resident had exhibited any behavioral symptoms during the month. A Pharmacy recommendation, dated 5/29/24, indicated to evaluate the resident's medication of Ativan (antianxiety medication) 0.5 mg two times daily for anxiety. The physician indicated to continue the therapy as ordered and documented that the resident continued to be symptomatic. Review of the resident's May 2024 TAR, and progress notes lacked documentation that the resident had exhibited any behavioral symptoms during the month. A Pharmacy recommendation, dated 8/26/24, indicated to evaluate the resident's medication of Cymbalta 90 mg daily for depression and pain. The facility's behavior committee reported the resident was still symptomatic and recommended a dose reduction not be completed at that time. The physician agreed with the behavior committee's recommendation and drew an arrow which pointed to the statement of the behavior committee's recommendation and documented the continued same-symptomatic. Review of the resident's August 2024 TAR lacked documentation that the resident had exhibited any behavioral symptoms during the month. The progress notes for August 2024, indicated the resident was stable and lacked documentation of any behaviors during the month. During an interview, on 12/16/24 at 2:07 p.m., the Director of Nursing (DON) indicated the physician made his decision regarding dose reductions based upon the recommendation from the behavior committee. The behavior committee received their information about the resident's behaviors by talking with the nurses. The nurses did need more education on completing the TAR resident's exhibit behaviors. During an interview, on 12/17/24 at 9:20 a.m., the Social Services Director (SSD) indicated she felt the reason that the behaviors were not being documented in the TAR was related to how the new system allowed for documentation by the Certified Nursing Assistants (CNAs). Under the old company's system, the CNAs should directly document behaviors into their Point of Care (POC) system, and it went to the TAR. The new system no longer allowed for that to happen. The nurses were the only ones who were able to document on the TARs. The nurses were laxed in documentation of behaviors. On 12/17/24 at 2:43 p.m., the DON provided a document, with a revision date of September 2022, titled, Behavioral Assessment, Intervention, and Monitoring, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy Interpretation and Implementation .Assessment .3. The nursing staff will identify, document, and inform .about specific details regarding changes in an individual's .behavior .4. New onset or changes in behavior will be documented .Monitoring: 1 .the IDT (interdisciplinary team) will .document .improvements or worsening in the individual's behavior 3.1-43(a)(1)

Based on observation and record review, the facility failed to ensure a medication error rate of less than 5 percent with an error rate of 21.43 percent for 3 of 4 residents reviewed for medication administration (Residents 169, 14 and 26). Findings include: 1. On 12/17/24 at 7:45 a.m., observed Registered Nurse (RN) 15, prepare and administer medications to Resident (169). Ferrous Sulfate 1 tablet and Klor-Con 1 tablet were removed from medication card and crushed. Medications were then administered to the resident in applesauce. On 12/17/24 at 9:30 a.m., the medical records of Resident 169 were reviewed. The resident was admitted with diagnosis including but not limited to anemia (a condition that develops when your blood produces a lower-than-normal amount of healthy red blood cells) and hypokalemia (a condition where the level of potassium in your blood is lower than normal). Physician orders included but not limited to administer 1 tablet ferrous sulfate EC (enteric coated) (tablets or capsules with a coating that prevents the medication from dissolving in the stomach and instead allows it to pass into the small intestine, where it can be absorbed) 325 mg (milligrams) administer by mouth once daily for anemia, and administer 1 tablet Klor-Con 20 meq (milliequivalent) administer by mouth once daily for hypokalemia. On 12/17/24, the Director of Nursing (DON) provided a document titled, oral dosage forms that should not be crushed. The list included medications that were enteric coated (EC) and Klor-Con a slow-release medication (medications that release a consistent amount of the drug over a longer period of time). 2. On 12/17/24 at 8:05 a.m., observed Registered Nurse (RN) 15 prepare and administer medications to Resident (14). Ferrous sulfate 1 tablet and Myrbetriq ER 1 tablet were removed from medication card and crushed. Medications were then administered to the resident in applesauce. On 12/17/24 at 10:00 a.m., the medical record of Resident 14 was reviewed. The resident was admitted with diagnosis including but not limited to, anemia, benign prostatic hyperplasia (a condition in which the prostate gland is larger than normal). Physician orders included but were not limited to an order, dated 2/2/24, for 1 tablet ferrous sulfate EC (enteric coated) 325 mg to be administered by mouth once a day for anemia. A physician order, dated 2/2/24, for 1 tablet Myrbetriq ER (extended release) to be administered by mouth once a day for overactive bladder. On 12/17/24, the Director of Nursing (DON) provided a document titled, oral dosage forms that should not be crushed. The list included medications that were enteric coated (EC) and Klor-Con a slow-release medication (medications that release a consistent amount of the drug over a longer period of time). The medications Myrbetriq (mirabegron) and Ferrous sulfate were listed as slow-release medication on the do not crush document. 3. On 12/17/24 at 9:00 a.m., observed Registered Nurse (RN) 17 prepare and administer Basaglar insulin and Admelog SoloStar insulin to Resident (26). RN 7 adjusted the insulin pens to the prescribed dose to be administered to the resident. The RN did not prime the insulin administration pen according to manufacture guidelines. Priming the pen ensures all of the prescribed insulin was administered to the resident by removing the air space within the needle. The RN went into the resident's room, left the door open and did not pull the curtain to provide privacy to the resident. The RN advised the resident that she was going to administer the insulin in his abdomen. The RN administered the insulin and counted to ten during administration of insulin, and immediately removed the insulin needle. On 12/17/24 at 10:30 a.m., the medical record of Resident 26 was reviewed. The resident was admitted with diagnosis including but not limited to Type 2 diabetes mellitus (a disease that occurs when your blood glucose, also called blood sugar, is too high). A Physician orders included but were not limited to. An order, dated 7/7/24, for Basaglar insulin 100 unit/ml (milliliter) 40 units subcutaneously (under the skin) two times a day for type 2 diabetes. A Physician order, dated 11/19/24, Admelog SoloStar insulin 100 unit/ml. Administer as per sliding scale (a type of insulin prescription that adjusts the amount of insulin a person takes based on their blood sugar level) before meals. On 12/17/24 at 9:05 a.m., during interview, RN 17 indicated she did not know if the insulin pen should be primed before administration, and indicated she counted to ten while administering the insulin. She acknowledged she should have closed the door when she administered insulin to the resident. On 12/17/2024 at 1:57 p.m., the Director of Nursing (DON) provided a document, titled, SOP-Insulin Preparation and Administration, dated 5/20/20, and indicated it was the policy currently being used by the facility. The policy indicated, .2. Procedure .h. Procedure for insulin pen .v. Attach need to the pen .vii. Remove air from insulin pen .1. Turn the dial to 2 units .3. Gently tap pen to remove air bubbles .viii .Press the inject button .Select the correct dose of insulin on the pen by turning the dial to the number of units you need to inject .3. Insulin Administration Procedure .b. provide privacy .i. Close doors, curtains and or room curtains as needed .j. insert needle .k. push plunger with thumb at a moderate steady pace until insulin is completely administered, approximately 5-10 seconds 3.1-48(c)(1)

Based on observations, interviews, and record reviews, the facility failed to ensure medication were labeled properly for 3 of 4 medication carts reviewed for medication storage (Residents 58, 26, and 2). Findings include: On 12/17/25 at 8:00 a.m., medication storage cart A was observed. Tresiba Insulin pen prescribed for Resident 2. Pharmacy dispensed date was 11/14/24. Date opened was not indicated on the insulin pen. On 12/17/24 at 8:20 a.m., medication storage cart 1 was observed. Lantus Insulin pen prescribed for Resident 58. Pharmacy dispensed date was 11/19/24. Date opened was not indicated on the insulin pen. On 12/17/24 at 9:00 a.m., medication storage cart B was observed. Basaglar Insulin pen prescribed for Resident 26. Pharmacy dispensed date was 11/28/24. Date opened was not indicated on the insulin pen. On 12/17/24 at 8:05 a.m., during interview Registered Nurse (RN) 15 indicated insulin pens should be dated when opened and an expiration date added to label. On 12/17/24 at 9:05 a.m., during interview Qualified Medication Aide (QMA) 18 indicated insulin pens should be dated when opened and an expiration date added. On 12/17/24 at 9:08 a.m., during interview RN 17 indicated insulin pens must be dated when opened, if no date was on the pen or if in doubt the pen was thrown out. On 12/17/24 at 9:30 a.m., the medical record of Resident 58 was reviewed. The resident was admitted to the facility with diagnosis including but not limited to, Type 2 diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high), and acute kidney failure (a condition where the kidneys suddenly stop working properly). A Physician Order, dated 12/12/24, for Lantus SoloStar insulin 100 units/ml (milliliter), iInject 10 units subcutaneous (under the skin) daily for diabetes. On 12/17/24 at 9:40 a.m., the medical record of Resident 26 was reviewed. The resident was admitted with diagnosis including but not limited to, Type 2 diabetes, chronic obstructive pulmonary disease (COPD) (a group of diseases that cause airflow blockage and breathing-related problems). A Physician order, dated 7/7/24, for Basaglar insulin 100 units/ml inject 40 units subcutaneous (under the skin) daily for diabetes. On 12/17/24 at 10:00 a.m., the medical record of Resident 2 was reviewed. The resident was admitted with diagnosis including but not limited to, type 2 diabetes, and chronic kidney disease (the kidneys are damaged and can't filter blood the way they should). A Physician order, dated 10/15/24, for Tresiba flex touch insulin solution 100units/ml, inject 15 units subcutaneous daily for type 2 diabetes. On 12/17/2024 at 1:57 p.m., the Director of Nursing (DON) provided a document, titled, Specific Procedures for all Medications, dated 5/20/20, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure .5. Check expiration date on package/container. When opening a multidose container, place the date on the container, place the date on the container 3.1-25(j) 3.1-25(m) 3.1-25(n)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to honor food preferences of 1 of 1 resident reviewed for dietary preferences (Resident 49) Findings include: On 12/12/24 at 11:25 a.m., during observation and interview, Resident 49 indicated she had asked several times not to be served vegetables and the facility continued to put them on her plate. On 12/12/24 at 12:27 p.m., observation of the dietary tray slip of Resident 49 indicated the dietary slip food dislikes did not indicate the resident did not want vegetables. On 12/16/24 at 9:00 a.m., the medical record of Resident 49 was reviewed. The resident was admitted to the facility on [DATE]. Diagnosis included but were not limited to end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life, dependence on renal dialysis (a treatment that filters waste and excess fluid from your blood when your kidneys can no longer perform this function), and type 2 diabetes mellitus (a disease that occurs when your blood glucose, also called blood sugar, is too high) with diabetic chronic kidney disease (the kidneys are damaged and can't filter blood the way they should). A Physician order, dated 4/15/24, ordered a CCHO (controlled carbohydrate) diet, regular texture, thin (liquids) consistency. Only one serving of dairy daily, no oatmeal or sausage no more OJ (orange juice) no more juices until CA (calcium) levels lower, no pudding, cottage cheese, no milk products, limit amount of breads, pizza, cereal, crackers. A quarterly Minimum Data Set (MDS) assessment, dated 10/14/24, indicated the resident was cognitively intact. A care plan, dated 4/14/24, indicated the resident was at nutritional risk. Interventions included but were not limited to RD (Registered Dietitian) to evaluate and make diet change recommendations as needed, and to provide Diet: CCHO regular texture, thin consistency, 1800 ml (milliliters) fluid restriction. Review of activity preference form, dated 4/16/24, which was completed on admission the record did not indicate any dietary preferences. On 12/12/24 at 12:25 p.m., during an interview, Employee 7 indicated the residents choose from a menu each day and decide what they want to eat. If they do not want what was served they could get the substitute. She indicated the activities department staff asked the residents their preferences and recorded it on the diet menu selection forms. On 12/16/24 at 11:01 a.m., during an interview, Employee 6 indicated she asked the residents daily if they wanted what was on the menu. She recorded choices and turned it into dietary department. She indicated the preferences were then recorded on the diet slip and indicated Resident 49 had told her previously she did not like vegetables. On 12/16/24 at 11:08 a.m., during an interview the Administrator indicated she updated the dietary tray slip all the time. She provided a copy of the current dietary tray slip for Resident 49 and indicated the resident did not like cooked vegetables and it was on the updated dietary slip. On 12/16/2024 at 2:45 p.m., the Administrator provided a document, titled, Resident Food Preferences , dated 7/2023, and indicated it was the policy currently being used by the facility. The policy indicated, .Individual food preferences will be assessed upon admission and updated as needed. Reaseonable efforts will be made to accommodate resident choices and preferences .2. When possible, staff will interview the resident directly to determine current food preferences based on history and life patterns related to food and mealtimes 3.1-20(c)(7)

Based on observation, interview, and record review, the facility failed to ensure undated and expired foods were disposed of for 1 of 2 kitchen observations. Findings include: During a food storage observation with [NAME] 3 on 12/12/24 at 9:50 a.m., the walk in refrigerator contained a clear plastic container with a lid that had corn, the corn was dated 12/5/24. There was a clear plastic bag of lettuce with a delivery dated 10/31/24, the lettuce was brown and wilted inside the bag. Three cucumbers were found on a shelf in an open and undated plastic bag. During an interview, on 12/12/24 at 9:52 a.m., [NAME] 3 indicated food was good for 3 days once it was opened and placed in a new container. She indicated the corn should have been disposed of by now and the lettuce was no longer good because it was delivered in October and was brown and wilted. She was unsure why they hadn't been disposed of them by now because she was not the person responsible for that. [NAME] 3 indicated food should be labeled once it was delivered to the facility and she had no idea when the cucumbers were delivered and how long they were in the walk-in refrigerator. The cucumbers would have to be disposed of since they were not labeled properly. On 12/12/24 at 10:30 a.m., the Administrator provided an undated document, titled, Keeping Food Safe for the Residents in Cloverleaf Facility, and indicated it was the policy currently being used by the facility. The policy indicated, .8. When to Discard Food .c. Food is over 72 hours old. d. If there is no identification or date on the item On 12/12/24 at 12:57 p.m., the Administrator provided a document with a revised date of July 2014, titled, Food Receiving and Storage, and indicated it was the policy currently being used by the facility. The policy indicated, .Foods shall be received and stored in a manner that complies with safe food handling practices .7. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date) 3.1-21(i)(3)

Based on record review and interview, the facility failed to follow the antibiotic stewardship protocol program for 1 of 5 residents reviewed for antibiotics (Resident 46). Findings include: On 12/17/24 11:14 a.m., the medical record of Resident 46 was reviewed. The resident was admitted to the facility with diagnosis of, but not limited to, Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), chronic obstructive pulmonary disease (COPD) (a group of diseases that cause airflow blockage and breathing-related problems), urinary retention (a medical condition that occurs when a person is unable to empty their bladder or has difficulty starting or maintaining a steady urine flow), and history of recurrent urinary tract infections (bacteria in the urine, resulting in an infection). A Physician order, dated 8/31/24, indicated to administer one capsule of Ampicillin 500 mg (milligram) via (by way of) G-tube (a tube that is surgically inserted through the abdomen and into the stomach to provide nutrition, fluids, and medicine) daily for prophylactic (something that prevents or protects). A quarterly Minimum Data Set (MDS) assessment, dated 11/11/24, indicated the resident had a cognition deficit, required max assistance of two persons, received nutrition and medications through gastric tube and was currently on an antibiotic. A care plan, dated 11/11/24, indicated the resident was on antibiotic therapy related to recurrent urinary tract infections. Interventions included but not limited to, collect labs as ordered and report results to physician, administer medications as ordered, and notify physician of any change or worsening of condition. The medical record indicated the resident had been on an antibiotic since previous admission. Documentation lacked evidence of physician assessment to determine the need for prophylactic long-term use of an antibiotic. Documentation lacked evidence of physician education or education being provided to the responsible party regarding long term use of antibiotics. On 12/17/24 at 2:00 p.m., during an interview, the Director of Nurses (DON) indicated the resident was on antibiotic therapy for history of chronic urinary tract infections. She indicated the resident was admitted with the antibiotic and diagnosis of VRE (Vancomycin-Resistant Enterococci, is a type of bacteria that has become resistant to many antibiotics, including vancomycin) and indicated the antibiotic had been administered for some time at the previous facility the resident resided in. She indicated the resident had multiple urinalysis (analysis of urine by microscopical means to test for the presence of disease) and culture (a lab test that checks for bacteria or other microorganisms in urine to help diagnose a urinary tract infection (UTI) of the urine) while at the other facility. A urinalysis and culture were completed at the facility upon admission and no additional testing had been repeated. On 12/18/24 at 1:00 p.m., during review of the antibiotic stewardship program with the DON and Infection Prevention Nurse, both indicated the facility utilized the McGeer's criteria surveillance tools for infections in the long-term care facility. On 12/18/24 at 2:30 p.m., during interview with the Medical Director and the DON. The Medical Director indicated the resident was on long term antibiotics because the family wanted her to be on an antibiotic due to previous history of urinary tract infections. The Medical Director acknowledged the resident was probably resistant to penicillin, (resistance occurs when bacteria develop the ability to withstand the effects of antibiotics), since she had VRE when she was admitted . He indicated at the time of admission the bacteria causing the infection was sensitive to the antibiotic. (Sensitivity occurs when a bacterial pathogen is inhibited or not inhibited by exposure to certain antibiotics). The Medical Director indicated he would be discontinuing the medication and trying alternate non-antibiotic measures to prevent re-occurrence of infection. On 12/11/2024 at 11:00 a.m., the Administrator provided a document titled, Antibiotic Stewardship, dated July 20, 2018, and indicated it was the policy currently being used by the facility. The policy indicated, .1. The purpose of our Antibiotic Stewardship Program is to monitor the use of antibiotics in our residents .4. If an antibiotic is indicated, prescribers will provide complete antibiotic orders including the following elements .d. Duration of treatment; 1. Start and Stop Date, or 2. Number of days of therapy The Centers for Disease Control and Prevention (CDC) webpage, The Core Elements of Antibiotic Stewardship, accessed online at: https://www.cdc.gov/antibiotic-use/hcp/core-elements, indicated, . Improving antibiotic prescribing and use is critical to effectively treat infections, protect patients from harms caused by unnecessary antibiotic use, and combat antibiotic resistance

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to notify the dialysis center nurse of changes of condition related to low blood pressures for 1 of 1 resident reviewed for dialysis (Resident 53). Findings include: On 11/1/23 at 12:10 p.m., Resident 53 was observed in his room sitting on the side of the bed. The resident indicated he was very dizzy and had been vomiting. The resident indicated he had several episodes of dizziness and nausea. On 11/2/23 at 10:09 a.m., the clinical record of Resident 53 was reviewed. The record indicated the resident had diagnoses included but not limited to, end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), type 2 diabetes (a disease that occurs when your blood glucose, also called blood sugar, was too high), heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs) and dependence on renal dialysis (a treatment for people whose kidneys are failing. Dialysis does the work of your kidneys, removing waste products and excess fluid from the blood). A physician's order, dated 7/9/2023, indicated staff were to clean the Peritoneal Dialysis (PD) exit site, apply Mupirocin (Pea Size) amount to exit site daily, apply a dressing, and secure with paper tape one time a day. A physician's order, dated 7/9/2023, administer Peritoneal Dialysis solution two 6 Liter (L) bags total, over 12 hours per [NAME] Dialysis Machine. Start at 8 p.m., remove when completed one time a day. Call results to PD Nurse at 2 p.m. every day for new orders and set up peritoneal dialysis for night shift. A physician's order, dated 7/9/2023, follow instructions in book one time a day. Monitor PD exit site every shift for signs and symptoms of infection two times a day. Report any swelling or leaking of fluid to PD nurse immediately. A Physician's order, dated 7/27/23, indicated to check clarity of PD (peritoneal dialysis) drain fluid in toilet prior to resident using toilet and flushing in morning. If cloudy inform dialysis every night shift. A quarterly Minimum Data Set (MDS) assessment, dated 8/25/23, indicated the resident was on dialysis during the assessment period. He was cognitively intact during the assessment period. A care plan, dated 4/6/23, indicated resident was at risk for nutritional deficits related to ESRD (end stage renal disease), CHF (congestive heart failure). A care plan, dated 8/2/22 with a revision date of 6/19/23, indicated the resident had a diagnosis of end stage renal disease and was at risk for complications with dialysis treatment. The peritoneal dialysis flow sheet record indicated: on 1/23/23 B/P (blood pressure) reading 98/56, on 2/6/23 B/P reading 94/49, on 2/22/23 B/P reading 96/54, on 6/5/23 B/P reading 92/61, on 6/12/23 B/P reading 99/56, on 6/16/23 B/P reading 96/61, on 7/13/23 B/P reading 91/53, on 7/25/23 B/P reading 94/53, on 9/30/23 B/P reading 103/57, on 10/2/23 B/P reading 95/49, on 10/17/23 B/P reading 86/58, on 10/2/23 B/P reading 95/49, on 11/1/23 B/P reading 88/57. The medical record lacked documentation of dialysis center nurse notification of the low blood pressure readings of 9 out of 12 documented blood pressure readings. On 11/2/23 at 10:23 a.m., Registered Nurse 16 indicated if the resident has low B/P she would notify the dialysis unit. During a phone interview with the Dialysis Manager, on 11/2/23 at 11:08 a.m., she indicated the facility nurse was to call the dialysis center every day with a report of dialysis administration and information including vital signs. The facility nurse was to notify the dialysis center if a blood pressure was low, this would generate a call from the nurse to give additional orders. On 11/3/23 at 2:28 p.m., the Director of Nursing (DON) provided a document stating it was a record of when they were to call dialysis center for abnormal vital signs or changes in condition. The document titled, Clinical Education and Training, July PD Patient Lesson. When to call your nurse, dated 2017, indicated, the dialysis document indicated, .please call peritoneal dialysis nurse right away, cloudy . bag ., abdominal . pain ., fever ., drainage or crust at the exit site ., redness ., swelling ., pain . contamination ., transfer set . loose ., transfer set falls off ., cap falls off ., tip of transfer set touches anything The facility administrator did not provide a policy for notification of change of condition to dialysis center. 3.1-5(a)

Based on observation, interview, and record review, the facility failed to ensure nail care was provided to dependent residents for 2 of 24 residents reviewed for activities of daily living (ADL) (daily tasks related to resident care and hygiene) (Residents 121 and 46). Findings include: 1. On 10/31/23 10:57 a.m., Resident 121's fingernails were observed untrimmed with chipped nail polish on all the fingernails and dark debris underneath the nails. On 11/1/23 at 2:44 p.m., Resident 121's fingernails were observed untrimmed with chipped nail polish on all the fingernails and dark debris underneath the nails. On 11/2/23 at 8:12 a.m., Resident 121's fingernails were observed untrimmed with chipped nail polish on all the fingernails and dark debris underneath the nails. On 11/2/23 at 11:25 a.m., Resident 121's fingernails were observed untrimmed with chipped nail polish on all the fingernails and dark debris underneath the nails. On 11/2/23 at 11:29 a.m., Registered Nurse (RN) 16 observed Resident 121's fingernails and indicated the resident's fingernails were too long and needed to be cleaned, trimmed, and the old nail polish removed. Resident 121's clinical record was reviewed on 11/3/23 at 9:23 a.m. The resident's diagnoses included, but were not limited to, dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain) and Parkinson's disease (progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement). An admission Minimum Data Set (MDS) assessment, dated 10/3/23, indicated Resident 121 had a severe cognitive impairment and required substantial/maximal assistance for showers and personal hygiene. A care plan, dated 9/26/23, indicated the resident required assistance with ADL's due to the diagnoses of dementia and Parkinson's disease. Interventions on the care plan included, but were not limited to, complete bathing and personal hygiene with staff assistance. Review of Resident 121's clinical record for October 2023 and November 2023 lacked documentation the resident had refused nail care. 2. On 10/31/23 at 11:47 a.m., Resident 46's fingernails were observed untrimmed and jagged, with dark debris underneath the fingernails. On 11/1/23 at 9:31 a.m., Resident 46's fingernails were observed untrimmed and jagged, with dark debris underneath the fingernails. On 11/2/23 at 11:47 a.m., Resident 46's fingernails were observed untrimmed and jagged, with dark debris underneath the fingernails. On 11/2/23 at 12:09 p.m., Registered Nurse (RN) 18 observed Resident 46's fingernails and indicated the resident's fingernails were too long and needed to be cleaned and trimmed. Resident 46's clinical record was reviewed on 11/2/23 at 2:18 p.m. The resident's diagnoses included, but were not limited to, dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain) and heart failure. A quarterly Minimum Data Set (MDS) assessment, dated 8/9/23, indicated the resident had a moderate cognitive impairment and required substantial/maximal assistance for showers and personal hygiene. Review of Resident 46's clinical record for October 2023 and November 2023 lacked documentation the resident had refused nail care. The Administrator (ADM) provided and identified a document as a current facility policy, titled Fingernails/Toenails, Care of, dated February 2018. The policy indicated, .Purpose .The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections .General Guidelines .1. Nail care includes daily cleaning and regular trimming .2. Proper nail care can aid in the prevention of skin problems around the nail bed .4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin . Documentation .The following information should be recorded in the resident's medical record .1. The date and time that nail care was given .2. Any difficulties, abnormal conditions, problems or complaints made by the resident with his/her hands or feet or any complaints related to the procedure .3. If the resident refused the treatment and the intervention taken .4. The signature and title of the person administering the care and/or recording the data 3.1-38(a)(3)(E)

Based on record review and interview, the facility failed to ensure pharmacy recommendations were completed for 1 of 5 residents reviewed for unnecessary medications (Resident 11). Finding includes: On 11/1/23 at 11:43 a.m., Resident 11's clinical record was reviewed. The resident's diagnosis included, but were not limited to, osteoarthritis (degeneration of joint cartilage and underlying bone causing pain and stiffness) and pain in the left ankle and joints of the left foot. A current physician's order, dated 2/15/23, indicated Tylenol Tablet (acetaminophen) (pain medication) 325 milligrams (mg), give 650 mg by mouth three times a day related to pain in left ankle and joints of left foot and osteoarthritis. A current physician's order, dated 2/15/23, indicated Tylenol Tablet (acetaminophen) 325 mg, give 2 tablets by mouth every 4 hours as needed for pain/fever. A pharmacy consultation report, dated 4/30/23, indicated Resident 11 had current orders for Acetaminophen recommended the maximum of acetaminophen dose was 4000 mg in 24 hours, but may need to be lower for residents with impaired kidney and/or liver dysfunction. Review and check off if one of the following may be added to all orders containing acetaminophen, maximum dose of 4000 mg in 24 hours of acetaminophen from all sources, maximum dose of 3000 mg in 24 hours of acetaminophen from all sources, or other. The pharmacy consultation report had not been addressed nor signed by the physician. On 11/3/23 at 9:55 a.m., the Director of Nursing (DON) indicated the 4/30/23 pharmacy recommendation was not completed until today,11/3/23. DON indicated she had contacted the physician about the recommendation and wrote on the pharmacy recommendation to change the acetaminophen dose to every 8 hours. Resident 11 had not received acetaminophen more than 4000 mg in 24 hours at any time. All pharmacy medication regimen review (MRR) recommendations should be addressed in a timely manner by the facility and the resident's physician. On 11/3/23 at 12:07 p.m., the DON provided and identified a document as a current facility policy titled, 9.1 Medication Regimen Review, dated 11/28/16. The policy indicated, .7. Facility should encourage Physician/Prescriber or other Responsible Parties receiving the MRR and the Director of Nursing to act upon recommendations contained in the MRR .8. Facility should alert the Medical Director when MRRs are not addressed by the attending physician in a timely manner .11. The attending physician should address the consultant pharmacist's recommendation no later than their next scheduled visit to the facility to assess the resident, either 30 or 60 days per applicable regulation 3.1-25(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure expired insulin medications were disposed of properly for 1 of 1 medication rooms reviewed for medication storage (Resident 9), and the facility failed to ensure medications and biologicals were labeled and stored according to policy for 1 of 1 treatment carts and 1 of 1 medication carts observed for medication and biological storage (Resident 46, 34, 10, 8, and 48). Findings include: During an observation of Hall, A medication storage room, on [DATE] at 2:10 p.m., the medication refrigerator had a Lantus Solostar insulin glargine (diabetic insulin injection for blood sugar) 100 units/milliliter (ml), 3 ml prefilled pen for Resident 9. The pen had an opened date of [DATE] with an instruction label to discard unused portion after 28 days. During an observation of the medication cart located on A hall, on [DATE] at 2:45 p.m., the cart had an opened bottle of Gentamicin (antibiotic eye drops) 0.3% eye drops for Resident 46 with no opened date. A received date of [DATE] was on the box with instructions to instill three drops in right eye three times per day for seven days. During an observation of the treatment cart located on A hall, on [DATE] at 2:55 p.m., to the following was found: a. An opened bottle of Nystatin powder (antifungal powder) 100,000 units/gram for Resident 34 was unbagged with no opened date and stored amongst an opened tube of benzoyl peroxide acne treatment gel 5% (topical skin treatment) for Resident 2 and an opened tube of Biofreeze gel (topical for pain relief) for Resident 2. b. An opened tube of Diclofenac Sodium topical gel 1% (used to treat pain and inflammation) for Resident 10 with no opened date and no lid cap. c. An opened tube of Venelex wound dressing (topical wound treatment) for Resident 10 not inside manufacturer's box with no opened date. A second opened tube of the Venelex for Resident 10 inside manufacturer's box with no opened date. d. An opened bottle of Nystatin powder 100,000 units/gram for Resident 8 with no opened date. e. An opened bottle of Nystatin powder 100,000 units/grams for Resident 48, unbagged with no opened date. f. Opened and unlabeled tube of Medihoney wound and burn dressing (topical wound treatment) with no opened date. During an interview, on [DATE] at 2:33 p.m., the Assistant Director of Nursing (ADON) indicated the insulin pen located in the refrigerator was expired and needed to be destroyed. On [DATE] at 11:47 a.m., the Administrator (ADM) provided a document, with a revised date of [DATE], titled, Storage and Expiration Dating of Medications, Biologicals, Syringes, and Needles, and indicated it was the policy currently used by the facility. The policy indicated, .4. Facility should ensure that medications and biologicals that: (1) have an expired date on the label . are stored separate from other medications until destroyed or returned to the pharmacy or supplier. 5. Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened or opened . When ophthalmic solutions and suspensions are opened the bottle should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened bottle . 6. Facility should destroy and reorder medications and biologicals with soiled, illegible, worn, makeshift, incomplete, damaged, or missing labels or cautionary instructions .17. Facility should destroy or return all discontinued, outdated/expired, or deteriorated medications or biologicals in accordance with Pharmacy return/destruction guidelines and other Applicable Law 3.1-25(j) 3.1-25(k) 3.1-25(o)

Based on record review and interview, the facility failed to review and track facility wide antibiotic stewardship for 4 of 12 months reviewed. Findings include: On 11/2/23 at 9:08 a.m., the Infection Preventionist Nurse (IP) indicated there was no documentation of tracking, facility mapping or antibiotic stewardship for the months of October 2022, November 2022, December 2022, nor October 2023. Review of April and May 2023 antibiotic use and infection tracking documentation indicated an increase in residents with urinary tract infections and upper respiratory infections. The IP nurse on 11/3/23 at 9:00 a.m., provided documentation indicating in-services were completed on 6/22/23 for perineal care and hand hygiene. Training record lacked documentation of education in urinary tract infection prevention, upper respiratory infection, and identification of signs and symptoms of infections. The IP nurse could not provide facility antibiotic stewardship policy and procedure. 3.1-18(b)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to provide at least 80 square feet per resident in multiple occupancy resident rooms for 2 of 50 resident rooms observed (rooms [ROOM NUMBERS]). Findings include: On 11/03/23 at 12:50 p.m., the Administrator provided a copy of a waiver request letter, dated 10/24/22. The letter indicated a waiver had been requested for rooms [ROOM NUMBERS] of the facility. During a maintenance tour with the Maintenance Director, on 11/03/23 at 12:08 p.m., rooms [ROOM NUMBERS] were measured. The current measurements of the rooms, were as follows: a. room [ROOM NUMBER], licensed for 3 beds, measured 226.2 total square feet. Square footage per resident equaled 75.4 square feet. At the same time, 1 bed was observed in the room. b. room [ROOM NUMBER], licensed for 3 beds, measured 226.2 total square feet. Square footage per resident equaled 75.4 square feet. At the same time, 1 bed was observed in the room. During an interview, on 11/03/23 at 12:11 p.m., the Maintenance Director indicated each of the rooms were licensed for 3 beds. Currently, each room had 1 bed in each room. The facility was requesting a waiver for the rooms. 3.1-19(l)(2)

2a. During a dining observation, on 10/30/23 at 12:40 p.m., Certified Nursing Assistant (CNA) 3 used hand sanitizer in preparation of serving trays in the dining room. The CNA stood at the door in the dining room waiting for a tray to be handed to her, she adjusted the face mask on her face, moved her hair behind her left ear, touched her nose, and crossed her arms in front of her chest. The CNA obtained a tray from the kitchen and picked up the tray card, she then received another tray from the kitchen. The CNA held a tray in each hand and proceeded out of the kitchen down the hallway to take two residents their lunch trays. No hand hygiene was performed during this observation. 2b. During a dining observation, on 10/30/23 at 12:53 p.m., CNA 3 used hand sanitizer in the dining room and then placed her hands on her hips. The CNA moved a chair closer to a dining room table, adjusted her scrub top, moved a dietary card in front of a resident, and then sat down to assist the resident with her meal. No hand hygiene was performed before assisting the resident with her meal. During an interview, on 10/31/23 at 10:26 a.m., CNA 5 indicated staff should not touch their face, adjust their glasses, or adjust their clothes without performing proper hand hygiene when they are serving in the dining room. During an interview, on 11/1/23 at 1:51 p.m., CNA 21 indicated staff should use hand sanitizer in between residents when passing trays. She indicated if staff had to touch their face or clothing items then they should wash their hands before serving a resident their tray or when they assist a resident to eat. On 11/2/23 at 9:05 a.m., the Administrator provided a document, with a revised date of July 2014, titled, Preventing Foodborne Illness - Food Handling, and indicated it was the policy currently being used by the facility. The policy indicated, .3. All employees who handle, prepare, or serve food will be trained in the practices of safe food handling and preventing foodborne illness On 11/2/23 at 9:05 a.m., the Administrator provided a document, with a revised date of January 2019, titled, Handwashing/Hand Hygiene, and indicated it was the policy currently being used by the facility. The policy indicated, .6. Use an alcohol-based hand rub alternatively or soap and water for the following situations: .b. before and after direct contact with residents .n. before and after eating or handling food . o. before and after assisting a resident with meals 3.1-21(i)(1) 3.1-21(i)(3) Based on observation, interview, and record review, the facility failed to ensure food was covered when delivered to the units and the facility failed to ensure hand hygiene was completed when assisting residents to eat for 1 of 2 dining observations. Findings include: 1. On 10/30/23 at 11:59 a.m., dietary staff delivered an uncovered meal cart with Residents' trays to the A hall, with uncovered brownies on disposable plates on all of the uncovered meal trays. On 10/30/23 at 12:09 p.m., dietary staff delivered an uncovered meal cart with Residents' trays to the B hall, with uncovered brownies on disposable plates on all of the uncovered meal trays. On 10/30/23 at 12:14 p.m., dietary staff delivered a second uncovered meal cart with Residents' trays to the B hall, with uncovered brownies on disposable plates on all of the uncovered meal trays. On 10/30/23 at 12:36 p.m., dietary staff delivered an uncovered meal cart with Residents' trays to the A hall dining room, with an uncovered plate of food on a meal tray and uncovered brownies on disposable plates on all of the uncovered meal trays. On 11/02/23 at 11:56 a.m., the Dietary Manager (DM) indicated, food was to be covered when being transported to the units. On 11/02/23 at 12:51 p.m., the Administrator (ADM) indicated, all food items on meal trays delivered to outside of the designated meal area should be covered until they are served to the residents. At that time, ADM provided and identified a document as a current facility policy, titled, Serving of Food (Point of Service), dated 7/2023. The policy indicated, .Guidelines .1. All dishware/utensils being transported to point of service areas will be covered to prevent any cross contamination .8. Meals served outside of designated meal areas: .c. All food items on meal trays delivered to areas outside the designated meal area will be covered until they are served to the resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A. Based on observation, interview, and record review, the facility failed to ensure an adequate infection control program was implemented to track the COVID-19 positive and potentially exposed residents which had the potential to effect 68 of 68 residents that reside in the facility. B. Based on observation, interview, and record review, the facility failed to follow infection control precautions, COVID-19 testing protocols, and ensure tracking for a COVID-19 outbreak for 68 of 68 residents reviewed for infection control. Findings include: A. On 11/2/23 at 9:01 a.m., the Infection Prevention Nurse (IP) indicated she was tracking for end dates to remove COVID-19 positive residents from the droplet isolation rooms. Residents would be in isolation for 10 days. She indicated she was given a new policy on 11/1/23 for droplet isolation end dates. Residents who had been exposed to COVID 19, would be in isolation for 10 days as well. The residents would be returning to their rooms once the 10 days of isolation was ended. If the resident was symptomatic after 10 days, they would stay on the designated COVID-19 unit. She was unable to identify or provide the exact number of COVID-19 positive residents at the facility. She would need to obtain the information. The staff were to report when they exhibit symptoms of COVID to a member of the management team. Once she received the notification, she had staff come to the facility and met the employee outside of the building to be tested. If it was after hours a nurse on the A unit would test the staff. She posted notification signs on the entry door. The notification signs indicated the facility was in an outbreak and should not come into the building if they were exhibiting symptoms. They were not assessing residents for COVID-19 symptoms unless they tested positive for COVID-19. She indicated if she was working on a unit, she would assess any resident who had symptoms such as cough, shortness of breath, fever. The IP nurse was testing the residents every 7 days, testing and testing results were in the medication administration record (MAR), in the tracking log, and or in the nurse's progress notes. Staff must clean all reusable equipment between resident use. If reusable equipment was used within an isolation room, the equipment must be disinfected immediately after it was removed from the isolation room. On 11/3/23 at 9:00 a.m., the IP nurse provided two documents titled, WEST Outbreak testing, dated 10/25/23 and Station A outbreak testing day 7, dated 11/1/23. The document identified each resident by name and room number. The IP nurse indicated this was what she used for outbreak tracking and testing. On 11/3/23 at 9:00 a.m., the IP nurse provided a document and indicated it was a tracking log for employees. The log had employee names with collection date, collection time, run time, result, applicator/cartridge lot #, testing employee's name and testing employee signature. Collection dates were from 9/19/23 to 11/1/23. On 11/3/23 at 9:00 a.m., the IP nurse indicated on 10/25/23, the Director of Nursing talked with the corporate office and a decision was made to do an isolation unit instead of just isolating residents in their rooms. Residents who tested COVID positive were moved to the C unit. The IP nurse indicated the first 3 residents were positive on 10/24/23, on 10/25/23, the facility had an overabundance of residents testing positive for COVID. The Medical Director advised he only wanted those residents tested who were symptomatic and she indicated the Medical Director was aware of what the facility policy indicated. On 11/3/23 at 11:27 a.m., the IP nurse provided a copy of the daily nursing schedule and indicated the employees who were highlighted in green were tested on the date they worked at the facility and had tested positive for COVID. On 11/2/23 at 9:05 a.m., a.m., the Administrator provided a document, titled, Coronavirus Disease (COVID-19)-Testing Residents dated, May 2023, and indicated it was the policy currently being used by the facility. The policy indicated, Testing Asymptomatic Residents .a. A symptomatic resident with close contact with someone with SARS0CoV-2 infection should have a series of three viral tests for SARSn-CoV-2 infection .b. 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 .Testing is not generally recommended for asymptomatic people who have recovered from [NAME]-CoV-2 infection in the prior 30 days .Testing residents with Signs or Symptoms of COVID-19 .1. Any resident (regardless of vaccination status) with even mild symptoms of COVID-19 receives a viral test as soon as possible .a. Because it may be difficult to tell the difference between influenza, COVID-19, and other acute respiratory infections based on symptoms alone, testing for pathogens other than SARS-CoV-2 may be conducted based on recommendations from the infection preventionist and providers .Additional Measures During Outbreak Investigation .1. In the event of ongoing transmission within a facility that is not controlled with initial interventions, strong consideration is given to use of empiric (observation) use of transmission-based precautions for residents and work restriction of staff with higher-risk exposures .3. As part of the broad-based approach, testing will continue on affected unit(s) of facility-wide every 3-7 days until there are no new cases for 14 days .Documentation .1. For symptomatic resident testing, the following is documented .a. The date and time the symptoms were identified .b, the date and time the test was conducted .c. the date and time the results were obtained and .d. actions taken by the facility .2. For facility outbreak testing, the following is documented .a. the date the case was identified .b. the dates that all other residents were tested .c. the dates that residents who tested negative were retested and .d. the results of all tests The facility documentation lacked evidence of empiric (observation) of all residents with respiratory symptoms. On 11/2/23 at 9:05 a.m., the Administrator provided a document, titled, Coronavirus Disease (COVID-19) - Infection Prevention and Control Measures dated, June 2023, and indicated it was the policy currently being used by the facility. The policy indicated, Policy interpretation and Implementation .c. identifying and managing ill residents and staff .e. a process to make everyone entering the facility aware of recommended actions to prevent transmission to others if they have any of the following three criteria .(1) A positive viral test for SARS-CoV-2 .(2) Symptoms of COVID-19 or .(3) close contact with someone with SARS-CoV2 infection (for residents and visitors) or a higher risk exposure (for healthcare personnel [HCP]) .f. implementing source control measures .respiratory assessment of Covid-19 positive residents .following current environmental infection prevention and control recommendations CDC Viral Respiratory Pathogens Toolkit for Nursing Homes, Last Reviewed September 28, 2023, indicated, Continue active surveillance to identify others with respiratory viral illness (e.g., daily or every shift review of symptoms among residents and HCP) and manage people who were exposed or infected (e.g., use of source control, work restriction for HCP, use of Transmission-based Precautions). B1. On 11/2/23 at 9:27 a.m., the IP nurse provided a document titled, All Staff PPE Refresher Oct.19, 2023. The document indicated to please read and sign on signature sheet at back of in-service. The document contained information for glove use, wearing masks and gowns. The untitled and undated signature page contained 62 signatures. On 11/3/23 at 9:00 a.m., the IP nurse provided a document titled, Hand Hygiene Inservice-online. The instructions to the staff indicated .to read, sign signature sheet and follow directions on attached sheet. Print out the last page of online which shows you completed it, sign and date that copy and turn in. The untitled and undated signature sheet indicated; 8 employee's signatures. The IP nurse indicated she had not completed a handwashing competency with any of the staff at the time of the training or since the facility had been in outbreak. On 11/3/23 at 9:00 a.m., the IP nurse indicated she did not have verification of training for staff in correct hand hygiene and donning or doffing PPE. However, she tried to verbally communicate with staff and she had not completed staff competency in donning or doffing PPE. On 11/3/23 at 9:00 a.m., the IP nurse provided a document titled, Hand Hygiene Inservice Interactive. The document was dated, May 19. The in-service directed the staff to enter a QR code to register for the in-service. She indicated she had not completed handwashing competency of staff. B2. On 10/30/23 at 11:56 a.m., during a routine observation Certified Nurse Aide (CNA) 6 was observed entering into a droplet isolation precaution room (isolation precautions used to prevent the spread of pathogens that are passed through respiratory secretions and do not survive for long in transit) without first donning (to put on) personal protective equipment (PPE). Droplet Transmission based precaution signs were posted on the outside of the door and PPE was in a bin next to the door in the hall. CNA 6 stood in the room and spoke to Registered Nurse 7 regarding PPE equipment. CNA 6 left the isolation room and continued to provide care to other residents on the unit without washing or sanitizing her hands. On 10/30/23 at 12:00 p.m., CNA 3 was observed providing assistance to a resident in a droplet precautions isolation room. The CNA removed her PPE and removed the mechanical lift from inside of the isolation room and placed the lift in the hall against the wall. The CNA left the lift in the hall and failed to sanitize the mechanical lift after use in an isolation room. The CNA continued to provide assistance to other residents in the unit without first washing or sanitizing her hands after leaving an isolation room. On 10/30/23 at 1:00 p.m., CNA 9 was observed in a droplet isolation room doffing (take off) PPE. CNA 9 was observed placing gloved hands on the inside of her isolation gown and removing the gown from the inside outward. B3. On 10/30/23 at 12:09 p.m., Housekeeper 8 was observed mopping and cleaning rooms while the meal trays were being passed on the unit. The housekeeper entered several droplet isolation rooms and mopped the floors. Housekeeper 8 was not observed to change mop water or cleaning supplies. On 10/30/23 at 12:11 p.m., Housekeeper 8 entered a droplet isolation room. Transmission based precaution signs were posted on the door outside of the room. Housekeeper 8 failed to don PPE prior to entering the droplet isolation room. The housekeeper cleaned and mopped the room and continued to clean other rooms including non-isolation rooms on the unit. On 11/2/23 at 10:29 a.m., Housekeeper 24 indicated she used a housekeeping cart designated for COVID-19 use. She would clean two or more positive rooms, then would change the water and mop head before cleaning other non-isolation rooms. Housekeepers were not allowed to clean rooms when meal trays were being passed. B4. The following observations were observed on the COVID unit where the residents were in Droplet Isolation (when a resident has an infection with germs that can spread to others by speaking, sneezing, or coughing): On 11/1/23 at 2:09 p.m., the Certified Nursing Assistant (CNA) 22 exited a resident's room and removed her personal protective equipment (PPE). The CNA removed her gloves, gown, shoe covers, and then her face shield. She then went into the staff bathroom. The CNA exited the bathroom and placed on a gown, shoe covers, tied the gown around her neck, grabbed a face shield, and walked over to a resident still holding the face shield in her hand. She leaned down next to the resident holding her Broda (tilt in space position chairs with comfort seating) chair with one hand and face shield in another hand. The CNA pushed the resident while in her chair down the hallway and into her room. The CNA placed on her face shield just prior to entering the resident's room while holding it against the resident's chair down the hallway. On 11/1/23 at 2:21 p.m., CNA 21 went to the linen cart and grabbed washcloths and walked over to the nurse's station and set the washcloths on the counter while she talked to the nurse for a minute at the nurse's station and proceeded back to the linen cart to grab a brief (incontinence item). She obtained the sit to stand (a device to help assist residents from a sitting to a standing position) lift from the hallway and proceeded down the hallway to a resident's room. While the CNA was putting on her PPE she set the washcloths and brief on the sling (offers back support up to shoulder area and under the thighs) to the lift equipment. On 11/1/23 at 2:25 p.m., CNA 22 exited a resident's room and left the Hoyer (an assistive device that allows residents to be transferred between a bed and chair) lift in the hallway. The CNA removed her PPE in the following order: removed gloves, gown, show covers, then her face shield. No sanitizing of the Hoyer lift was observed. CNA 22 placed on new PPE and no hand hygiene was observed in between placing on new PPE equipment. On 11/1/23 at 2:30 p.m., CNA 22 exited room [ROOM NUMBER] and went to the linen cart. The CNA grabbed bed linens, washcloths, and towels, the CNA held the bed linens and other supplies against her isolation gown while walking down the hallway and proceeded back into the resident's room to assist the other CNA on the unit. No hand hygiene was performed before entering back into the resident's room. On 11/1/23 at 2:34 p.m., CNA 21 exited room [ROOM NUMBER] removed her PPE and went to linen cart and grabbed a fitted sheet. The CNA held the fitted sheet against her scrub top and took the sheet to CNA 22 in room [ROOM NUMBER]. On 11/1/23 at 2:39 p.m., CNA 22 exited room [ROOM NUMBER] with the sit to stand lift. The sit to stand lift and the sling were left in the hallway and no sanitization of the device or sling was observed. The CNA obtained the Hoyer lift from the hallway and placed it in room [ROOM NUMBER] for use. On 11/1/23 at 2:47 p.m., Licensed Practical Nurse (LPN) 23 entered room [ROOM NUMBER] with no face shield on. The nurse left the room and grabbed two incontinence briefs from the linen cart. She proceeded back into the room with no face shield on. She provided incontinence care and left the room with dirty trash. On 11/1/23 at 2:52 p.m., CNA 22 exited room [ROOM NUMBER] with the Hoyer lift and left it in the hallway. No sanitizing of the Hoyer lift was observed. On 11/1/23 at 2:55 p.m., CNA 22 obtained the Hoyer lift from the hallway and placed it in room [ROOM NUMBER] for use. On 11/1/23 at 3:06 p.m., CNA 21 brought the Hoyer left out of room [ROOM NUMBER] and placed in in the hallway. No sanitizing of the Hoyer lift was observed. On 11/1/23 at 3:12 p.m., CNA 21 pushed a female resident in her wheelchair to the shower room to toilet her. No PPE was worn by the CNA except for a face shield and mask. On 11/2/23 at 3:17 p.m., CNA 21 pushed a female resident in her wheelchair to the shower room to toilet her. No PPE was worn by the CNA except for a face shield and mask. During an interview, on 11/2/23 at 9:08 a.m., the infection control nurse indicated the lift equipment should be cleaned between residents. She further indicated bed linens, washcloths, and towels should not be held against the body. The staff should be holding it away from their body to avoid contact. The infection control nurse indicated the staff should be wearing PPE when providing care to a resident who was in isolation, this includes, bathing, toileting, and transferring. During an interview, on 11/2/23 at 9:18 a.m., the IP nurse indicated she had tried to speak with staff in regard to proper donning (placing on) and removing PPE but she did not have any documentation of the education being provided. She provided a policy that demonstrates the proper procedure for donning and removing PPE, she indicated staff should be aware of the procedures. The IP nurse indicated staff should be performing hand hygiene after they removed their PPE. On 11/2/23 at 9:05 a.m., the Administrator provided a document with a revised date of July 2014, titled, Cleaning and Disinfection of Resident Care Items and Equipment, and indicated it was the policy currently being used by the facility. The policy indicated, .3. Durable medical equipment must be cleaned and disinfected before reuse by another resident On 11/2/23 at 9:05 a.m., the Administrator provided a document with a revised date of January 2019, titled, Handwashing/Hand Hygiene, and indicated it was the policy currently being used by the facility. The policy indicated, .b. before and after direct contact with residents .l. after removing gloves .m. before and after entering isolation precaution settings On 11/2/23 at 9:05 a.m., the Administrator provided a document, titled, Infection guidelines for all nursing procedures dated, August 2012, and indicated it was the policy currently being used by the facility. The policy indicated, .General guidelines .2. Transmission based precautions will be used whenever measures more stringent than Standard Precautions are needed to prevent the spread of infection .4. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% ethanol or isopropanol for all the following situations .5. Wear personal protective equipment as necessary to prevent exposure to spills or splashes of blood or body fluids or other potentially infectious materials On 11/2/23 at 9:40 a.m., the Administrator provided an undated document, titled, Example of Safe Donning and Removal of Personal Protective Equipment, and indicated it was the policy currently being used by the facility. The policy indicated, .remove gloves .goggles .gown .face mask .perform hand hygiene immediately after removing all PPE On 11/2/23 at 9:40 a.m., the Administrator provided a document with a revised date of February 2018, titled, Bed, Making an Unoccupied, and indicated it was the policy currently being used by the facility. The policy indicated, .1 . Do not let the sheet touch your clothing or the floor On 11/2/23 at 11:07 a.m., the Administrator provided a document, titled, Cleaning and Disinfecting Resident rooms dated, August 2013, and indicated it was the policy currently being used by the facility. The policy indicated, General Guidelines .6. Floor mopping solution will be replaced every three resident rooms or changed no less often than at 60-minute intervals .Steps in the procedure .Resident Room Cleaning .8. When cleaning rooms of residents in isolation precautions, use personal protective equipment as indicated .9. When possible, isolation rooms should be cleaned last, and water discarded after cleaning room The CDC guideline for transmission-based droplet precautions indicate, Transmission-Based Precautions are the second tier of basic infection control and are to be used in addition to Standard Precautions for patients who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission . Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens .Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens. Source: CDC Guideline for Isolation Precautions, January 7, 2016 3.1-18(b)(1) 3.1-18(b)(4)

Based on observation, interview, and record review, the facility failed to ensure residents' dignity while dining was provided in a timely manner to ensure residents received a palliative and hot meal for 2 residents randomly observed during 1 of 2 dining observations (Residents 28 and 8). Findings include: During a dining observation in the main dining room, on 7/28/22 at 12:37 p.m., Certified Nursing Assistant (CNA) 6 served Resident 28 and Resident 8 their lunches of beef Manhattans (shredded beef, mashed potatoes, and gravy on a slice of bread) and mixed vegetables on one plate, a piece of pie on a smaller plate, and a cup of juice. Resident 28 was observed seated in a high back wheelchair with her eyes closed when the meal was placed on the table in front of her. Resident 8 was observed seated in a wheelchair staring out the dining room window when the meal plates and drink were placed on the table in front of her. On 7/28/22 at 12:58 p.m., Resident 28 was observed seated in a high back wheelchair with her eyes closed and unassisted with the lunch meal plates in front of her while CNA 6 served and assisted another resident with their lunch meal. Resident 8 was observed to pick up her fork and slowly got a bite of pie. On 7/28/22 at 1:03 p.m., CNA 6 was observed seated next to and assisting Resident 28 with bites of her lunch meal. CNA 6 was observed touching her face, adjusting her medical face mask, and brushed her hair back from her face with her bare unwashed hand. Then CNA 6 picked up Resident 28's spoon and gave the resident bites of food without sanitizing her hands. Resident 8, unassisted, was observed holding her fork and slowly got a bite of the pie. On 7/28/22 at 1:15 p.m., CNA 6 went over to Resident 8 and asked if she wanted help. Resident 8 did not reply. CNA 6 walked away and sat down by Resident 28. CNA 6 was observed wiping the back of her neck and forehead and then adjusted her face mask with her bare hand, then gave Resident 28 bites of food without sanitizing her hands. On 7/28/22 at 1:48 p.m., Resident 28 had eaten all the vegetables and took a bite of the Manhattan and told CNA 6 the bread was no good. CNA 6 repeated the bread is no good, as CNA 6 gave Resident 28 another spoonful of mashed potatoes. Resident 8 was observed, unassisted, holding her fork then slowly getting a bite of pie. On 7/28/22 at 1:51 p.m., CNA 6 wiped Resident 28's mouth with a napkin, asked Resident 28 if she was done, removed the clothing protector and pushed Resident 28's wheelchair out of the main dining room. On 7/28/22 at 1:53 p.m., Dietary Aide 5 came into the main dining room and asked Resident 8 if she was finished with her lunch. Resident 8 did not reply. Dietary Aide 5 took Resident 8's lunch plates away, with the beef Manhattan and vegetables untouched and the pie partially eaten. Resident 8 held her cup and took a few sips of the drink, then wiped her mouth with a napkin. Resident 8, seated in the wheelchair was then pushed out of the main dining room back to her room by staff. 1. Resident 28's record was reviewed, on 8/3/22 at 9:47 a.m., a Minimum Data Set (MDS) assessment, dated 6/22/22, indicated Resident 28 had a severe cognitive impairment and required extensive assistance of one staff for eating. 2. Resident 8's record was reviewed, on 8/1/22 at 1:28 p.m., a Minimum Data Set (MDS) assessment, dated 5/10/22, indicated Resident 8 had moderate cognitive impairment and required limited assistance (resident highly involved in activity and staff provided guided maneuvering of limbs or other non-weight-bearing assistance) of one staff physical assistance. On 8/2/22 at 2:14 p.m., the Director of Nursing (DON) indicated the staff should have assisted resident 28 with her meal when the meal plate was brought to the resident in the dining room. DON indicated staff should wash or sanitize their hands before assisting a resident with eating and anytime staff touch their face, hair, or face masks. The Administrator (ADM), on 8/4/22 at 9:42 a.m., provided and identified a document as a current facility policy, titled Assistance with Meals, dated July 2017, which indicated, Residents shall receive assistance with meals in a manner that meets the individual needs of each resident .Dining Room Residents: .1. All residents will be encouraged to eat in the dining room .2. Facility Staff will serve resident trays and will help residents who require assistance with eating .3. Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity 3.1-3(a)

Based on record review and interview, the facility failed to ensure a resident's dialysis (a process of purifying the blood of a person whose kidneys are not working normally) access site was accurate on the care plan for 1 of 1 residents reviewed for dialysis (Resident 74). Findings include: Resident 74's record was reviewed on 8/1/22 at 10:53 a.m. A quarterly Minimum Data Set (MDS) assessment, dated 7/13/22, indicated the resident was cognitively intact and received dialysis (a process of purifying the blood of a person whose kidneys are not working normally). Diagnoses on the resident's profile included, but were not limited to, end stage renal disease (longstanding disease of the kidneys leading to failure). A care plan, revised 7/13/22, indicated the resident had a diagnosis of end stage renal disease and was at risk for complications with dialysis treatment. The dialysis access site was in the chest. The resident preferred hemodialysis. A physician's order, dated 7/14/22, indicated check access site for bruit (a rumbling sound that can be heard) and thrill (a rumbling sensation that can be felt) daily. The order lacked documentation the resident had a dialysis access site to the chest. During an interview, on 8/2/22 at 1:30 p.m., Resident 74 indicated his dialysis access site was a fistula (an access site created for a patient to receive dialysis) to his left forearm. There was no access site in his chest. During an interview, on 8/2/22 at 1:44 p.m., Licensed Practical Nurse (LPN) 16 indicated the resident's dialysis access site was a fistula. There was no port in the resident's chest. During an interview, on 8/2/22 at 1:54 p.m., the Director of Nursing (DON) indicated the resident's dialysis access site was a fistula. During an interview, on 8/3/22 at 9:43 a.m., the DON indicated she reviewed the resident's dialysis care plan and it indicated the resident had a dialysis access site to his chest. This was not accurate, and she updated the care plan to reflect the correct access. On 8/3/22 at 9:43 a.m., the DON provided a document titled, Care Plans, Comprehensive Person-Centered, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy Interpretation and Implementation: 1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person centered care-plan for each resident .8. The comprehensive, person-centered care plan will: .b. Describe any services that are to be furnished to attain or maintain the resident's highest practicable physical .well-being .13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change 3.1-35(b)(1)

Based on interview and record review, the facility failed to ensure a restorative program (a person-centered nursing care designed to improve or maintain the functional ability of residents, so they can achieve their highest level of well-being possible) was in place to provide Range of Motion (ROM) to a resident with a contracture for 1 of 1 residents reviewed for limited ROM (Resident 21). Findings include: During the initial pool interview, on 7/28/22 at 11:07 a.m., Resident 21 indicated she had a contracture left hand and wanted her fingers to be exercised. The facility used to provide her these services through the restorative program, but there was no longer a restorative program at the facility. The program had just suddenly stopped a few weeks ago. Resident 21's record was reviewed on 8/2/22 at 2:35 p.m. The profile indicated the resident's diagnoses included, but were not limited to, hemiplegia and hemiparesis following a cerebral infarction (stroke) affecting the left side of the body (paralysis of partial or total body function on one side of the body, whereas hemiparesis is characterized by one-sided weakness, but without complete paralysis) and contracture of left hand (a hand deformity that usually develops over years). An annual minimum data set (MDS) assessment, dated 5/31/22, indicated the resident had no cognitive deficit and had received Occupational Therapy (OT) (a form of therapy for those recuperating from physical or mental illness that encourages rehabilitation through the performance of activities required in daily life) minutes and received restorative program of passive (PROM-the space in which a part of the resident's body moves when someone or something is creating the movement) and active (AROM-the space in which the resident moves a part of their body by using their own muscles) ROM. A care plan, dated 9/8/20 and revised on 5/31/22, indicated the resident was unable to independently range joints and was at risk for contractures related to cerebral vascular accident (CVA) (stroke) with left sided affected and contracture to left hand. A goal, with a target date of 9/26/22, indicated the resident would tolerate passive range of motion exercises as indicated in individualized restorative nursing program through next review with no complaints of pain or redness/swelling to joints. Interventions included, but were not limited to, nurse to review program routinely addressing progress towards goals, record minutes of task completed in plan of care, and staff to set up and complete PROM to left upper extremity and left lower extremity 10 repetitions times 3 sets at least 6 days weekly. A care plan, dated 8/26/20 and revised on 9/2/20, indicated the resident required assist with activities of daily living (ADL's) (daily self-care activities) due to CVA with left side affected. A goal, with a target date of 9/26/22, indicated the resident would participate in ordered therapy through the next review. Interventions included, but were not limited to, restorative programs as indicated. A restorative nursing program evaluation, dated 5/31/22 at 12:31 p.m., indicated the resident was on an active range of motion program and required a passive range of motion restorative program. The resident required restorative nursing program due to left sided hemiparesis and hemiplegia. The resident was at risk for decline due to her diagnoses which included, but were not limited to, progression of left sided affected due to CVA. The resident would be encouraged to complete the program at least 6 days weekly. OT program treatment encounter notes, dated 5/25/22 through 6/21/22, indicated the resident had 14 treatment encounters, during the time period. An OT program discharge summary, for services dated 5/25/22 through 6/21/22, recommended the resident receive restorative ROM program services and indicated the resident's prognosis to maintain her current level of functioning was good with consistent staff follow-through. During an interview, on 8/3/22 at 10:40 a.m., Restorative Certified Nursing Assistant (CNA) 11 indicated she used to function as a restorative aide, but there was no longer an active restorative program at the facility. She was unsure why the program had stopped. All of the CNA's had been trained to do ROM and they would try to do as much as they could when time allowed. During an interview, on 8/3/22 at 10:44 a.m., the Therapy Director indicated the resident was in therapy up until a few of weeks ago. Therapy recommended she continue with the restorative program, but the facility no longer had an active restorative program. During an interview, on 8/3/22 at 10:50 a.m., the Director of Nursing (DON) indicated the facility still had a restorative program but due to COVID-19 and staffing shortages, the restorative staff needed to be pulled to the floor as CNAs and, at the current time, the program could not function as a full-time program. All of the CNAs had been trained to provide ROM to all residents who needed it. During an interview, on 8/3/22 at 11:43 a.m., the resident indicated she had not been getting any ROM from the aides. They work with her up several times a day, when getting her out of bed, cleaning her up, and getting her dressed, and still don't do anything with her ROM. On 8/3/22 at 2:33 p.m., the Administrator provided an undated document, titled, Restorative Nursing Program, and indicated it was the policy currently being used by the facility. The policy indicated, . Policy: .Residents who are referred by .therapy, physician, or nursing, will be evaluated .for a Restorative Nursing Program .Definitions/Staff Roles/General Concepts .The CNA will follow the plan of care .Procedure Evaluation and Documentation .7. The CNA will document minutes of activity assigned 3.1-42(a)(2)

Based on observation, interview, and record review, the facility failed to ensure a resident did not experience a significant weight loss of more than 5% in 30 days and more than 10% in 180 days and staff did not notify the physician and the resident's responsible party of the significant weight loss for 1 of 1 resident reviewed for nutrition (Resident 8). Finding includes: During a dining observation in the main dining room, on 7/28/22 at 12:37 p.m., Certified Nursing Assistant (CNA) 6 served Resident 8 her lunch of a beef Manhattan (shredded beef, mashed potatoes, and gravy on a slice of bread) and mixed vegetables on one plate, a piece of pie on a smaller plate, and a cup of juice. Resident 8 was seated in a wheelchair and observed staring out the dining room window when the meal plates and drink were placed on the table in front of her. On 7/28/22 at 12:58 p.m., Resident 8 was observed to pick up her fork and slowly ate a bite of pie unassisted by staff. On 7/28/22 at 1:15 p.m., CNA 6 went over to Resident 8 and asked if she wanted help. Resident 8 did not reply. CNA 6 walked away and sat down by another resident. Resident 8 picked up her fork and slowly ate a bite of the pie. On 7/28/22 at 1:48 p.m., Resident 8 was observed, unassisted, holding her fork then slowly eating a bite of the pie. The remainder of the lunch meal, the beef Manhattan and mixed vegetables, were untouched by the resident. On 7/28/22 at 1:53 p.m., Dietary Aide 5 came into the main dining room and asked Resident 8 if she was finished with her lunch. Resident 8 did not reply. Dietary Aide 5 took Resident 8's lunch plates away, with the beef Manhattan and vegetables untouched and the pie partially eaten. Resident 8 held her cup and took a few sips of the drink, then wiped her mouth with a napkin. Resident 8, seated in the wheelchair, was then pushed out of the main dining room back to her room by staff. Resident 8's record was reviewed on 8/1/22 at 1:28 p.m. Diagnoses included but were not limited to unspecified dementia with behavioral disturbance (problems with reasoning, planning, judgment, memory, and other thought processes caused by brain damage from impaired blood flow to the brain), heart failure, dysphagia (difficulty swallowing), acquired deformity of neck, and unspecified lack of coordination. A quarterly Minimum Data Set (MDS) assessment, dated 5/10/22, indicated the resident had a moderate cognitive impairment and required limited assistance (resident highly involved in activity with staff provided guided maneuvering of limbs or other non-weight-bearing assistance) of one staff physical assist for eating. An active physician's order, dated 7/18/19, indicated for the dietitian to evaluate the resident for nutritional intervention, if needed. An active physician's order, dated 8/21/19, indicated to offer the resident a snack cake daily at 10 a.m. and 4 p.m. with the house supplement for decreased consumption. An active physician's order, dated 1/6/21, indicated to offer resident any type of pastry with breakfast daily. A care plan, date initiated 6/15/20 and revised on 9/24/21, indicated the resident had dysphagia related to dementia and was at risk for aspiration (choking). Interventions included, but were not limited to alternate liquids and solid bites, encourage resident to eat slowly and take small bites and small single sips, observe for signs and symptoms of aspiration (SOB [shortness of breath], coughing, choking, elevated temperature, lung sounds) and report if noted, provide appropriate diet consistency as order by MD (physician), sit upright as close as possible to 90 degrees as possible, and therapy to evaluate and treat as indicated. An active physician's order, dated 1/3/22, indicated the resident was to have a regular/general diet, mechanical soft ground meat texture with thin consistency. A Registered Dietician (RD) note, dated 2/15/22, indicated the resident weighed 135.5 pounds (lbs.) on 2/1/22 and had triggered for significant weight change in February of 6.4% weight loss in 30 days and 5.8% loss over 180 days. RD recommended to continue regular/general diet, mechanical soft ground meat texture thin consistency with house supplements between meals twice a day and ice cream or Magic Cups with lunch and dinner trays. RD will continue to monitor the resident's intake and weight trends and will provide additional recommendations as needed. An Interdisciplinary weight team (IDT) note, dated 2/22/22, indicated Resident 8's current weight was 135.5 lbs., with average consumption of 26% to 50% of a regular mechanical soft diet with thin liquids, multivitamin supplement intervention (MVI) with minerals, house supplement twice a day with 100% consumed, offered snack cake twice a day with 62% consumed, and magic cup added twice a day for weight loss. Resident 8 was added to Nutritional at Risk (NAR) and weekly weights. An active physician's order, dated 2/28/22, indicated to add Resident 8 to NAR and obtain weights weekly due to weight loss. An IDT note, dated 3/12/22, indicated Resident 8's current weight was 132.4 lbs., with average consumption of 0-25% of a regular mechanical soft diet, thin liquids, MVI with minerals, house supplement twice a day with 80% consumed, offer snack cake twice a day with 52% consumed, magic cup added twice a day with 71% consumed. Resident 8 to continue on NAR and weekly weights. An RD note, dated 3/21/22, indicated the resident weighed 131.5 lbs. and had triggered for significant weight change in March of 8.4% weight loss in 90 days and 2.3% loss over 30 days with the resident's decrease in intake possibly related to decline in cognition. RD recommended resident to continue current interventions. No new nutritional interventions. An IDT note, dated 4/13/22, indicated Resident 8's current weight was 129.8 lbs., with average consumption of 51% to 75% of a regular mechanical soft diet, thin liquids, MVI with minerals, house supplement twice a day with 91% consumed, offer snack cake twice a day with 52% consumed, magic cup added twice a day with 87% consumed. Recommended increased house shake to three times a day. Resident 8 to continue NAR and weekly weights. Physician and the resident's responsible party notified of weight loss. An active physician's order, dated 4/13/22, indicated a house supplement (a supplemental drink) 120 milliliters (ml) three times a day. An RD note, dated 4/27/22, indicated Resident 8 weighed 129.8 lbs. and had triggered for significant weight change in April of 10.4% loss in 90 days and 9.4% loss in 180 days. RD recommended to continue regular/general diet, mechanical soft ground meat texture thin consistency with house supplements three times a day and magic cup twice a day, will continue to monitor and provide additional recommendations as needed. No new nutritional interventions. An IDT note, dated 5/3/22, indicated Resident 8's current weight was 130 lbs. with average consumption of regular mechanical soft diet with thin liquids of 0% to 25% consumed, magic cup twice a day with 100% consumed, and house supplement three times a day with 96% consumed. The resident ate meals in the dining room with set up assistance only. Continue with current plan of care. A care plan, date initiated 6/11/20 and revised on 5/26/22, indicated the resident was at risk for potential alteration in nutrition or weight status. Interventions included, but were not limited to, observe and report to physician signs or symptoms of significant weight loss, which was 3 pounds in a week, over 5% in one month, and over 10% in 3 months or 6 months, and Registered Dietician (RD) to evaluate and make diet change recommendations PRN (as needed). An active physician's order, dated 6/7/22, indicated Magic Cup (ice cream supplement) two times a day for weight loss. An IDT note, dated 6/8/22, indicated Resident 8's current weight was 127.7 lbs. with average consumption of regular mechanical soft diet with thin liquids of 26% to 50% consumed, magic cup twice a day with 66% consumed, and house supplement three times a day with 80% consumed, and received snacks twice a day with 75% consumed. The resident ate meals in the dining room with set up assistance only. Continue with current plan of care. An RD note, dated 6/13/22, indicated Resident 8 weighed 131.1 lbs. and had triggered for significant weight change in June of 11.4% loss in 180 days, which was up from the last review. RD recommended to continue regular/general diet, mechanical soft ground meat texture thin consistency with house supplements three times a day and magic cup twice a day. A progress care plan note, dated 7/5/22 at 12:32 p.m., indicated a care plan meeting was held on that day with Resident 8 and the resident's responsible party invited but declined to attend the meeting. Resident 8's current weight was 127.8 lbs. with diet of regular/mechanical soft ground meat for meals and magic cup/house supplement drink for supplements. No nursing/care concerns at that time. An RD note, dated 7/6/22, indicated the resident had triggered for significant weight change in July of 12.1% loss in 180 days and 5% loss in 30 days. RD recommended to continue regular/general diet, mechanical soft ground meat texture thin consistency with house supplements three times a day and magic cup twice a day, with nursing to encourage good intake of food and supplements. RD will continue to monitor and provide additional recommendations as needed. An IDT note, dated 7/7/22, indicated Resident 8's current weight was 127.8 lbs., with average consumption of regular mechanical soft diet with thin liquids of 51% to 75% consumed, magic cup twice a day with 35% consumed, and house supplement three times a day with 81.6% consumed, and received snacks twice a day with 40% consumed. The resident ate meals in the dining room with set up assistance only. Continue with current plan of care. A Nutritional Risk Assessment, dated 8/1/22, indicated Resident 8 had significant weight change over 30, 90, 180 days and weighed 118.4 lbs. The resident was on a regular mechanical soft diet with ground meat, fed self with staff supervision of 25% intake of most meals and 0% intake of bedtime snacks. BMI (body mass index) of 19.1 normal weight, however, cause for malnutrition given the resident's low food intake. Resident to continue physician's orders for magic cup twice a day and house supplements three times a day. RD recommended Resident 8 be evaluated if additional nursing help was needed at mealtime. The medical record lacked documentation the physician and the resident's responsible party had been notified of the resident's significant weight loss. During an interview, on 8/4/22 at 11:23 a.m., the RD indicated she had completed Resident 8's annual nutritional risk assessment and the resident had significant weight loss for 30 days and 180 days. The RD indicated she was going to start a new intervention of possible staff assistance with meals for the resident. All of the RD's notes and documentation went into the facility's electronic computer system for the Administrator (ADM), Director of Nursing (DON), and Assistant Director of Nursing (ADON) to review and it was their responsibility to notify the resident's physician and the resident's responsible party of the significant weight loss. On 8/4/22 at 9:24 a.m., the ADM provided and identified a document as a current facility policy titled, Weight Monitoring and Weight Loss Intervention, dated 9/13/14. The policy indicated, .Policy: All residents will be weighed on admission, readmission and at least monthly. More frequent weights may be obtained as per facility policy .Weight loss intervention will be implemented for those residents experiencing significant unplanned weight loss .Guidelines: Weight loss intervention is implemented to prevent further weight loss and to maintain/improve the resident's nutritional status .Steps: .1. 5% weight loss in 30 days .Notify physician and responsible party .3. 10% weight loss in 180 days .Continue Step 1 .Referral to physician/specialist as recommended .4. Additional steps .Review with Interdisciplinary weight team until weight has stabilized. Keep records of interventions implemented and the progress made 3.1-46(a)(1)

Based on record review and interview, the facility failed to ensure physician documentation of rationale for declination of gradual dose reductions (GDRs) for 3 of 5 residents reviewed for unnecessary medications (Residents 40, 56, and 52). Findings include: 1. Resident 40's record was reviewed on 7/29/22 at 2:06 p.m. The profile indicated the resident's diagnoses included, but were not limited to, major depressive disorder with recurrent, severe psychotic symptoms (a distinct type of depressive illness in which mood disturbance is accompanied by either delusions, hallucinations, or both). An annual Minimum Data Set (MDS) assessment, dated 4/19/22, indicated the resident had no cognitive deficit, had a mood severity score of 6 (scores of 5-9 are classified as mild depression), and received medications which included, but were not limited to antidepressants. A quarterly MDS assessment, dated 6/25/22, indicated the resident had no cognitive deficit, had a mood severity score of 6 and received medications which included, but were not limited to antidepressants. A care plan, dated 3/29/20 and revised on 5/6 22, indicated the resident was on an antidepressant medication related to diagnosis of depression. A goal with a target date of 9/24/22, indicated the resident would be free from discomfort or adverse reactions related to antidepressant therapy through the review date. Interventions included but were not limited to gradual dose reduction (GDR) as per facility policy educate the resident and significant other on the reduction. A document titled, Note to Attending Physician/Prescriber, dated 2/28/22, indicated to review Abilify (aripiprazole-antidepressant medication to treat depression) 2 milligrams (mg) at bedtime, Lexapro (escitalopram oxalate-antidepressant) 5 mg daily, and Trazodone (antidepressant and sedative-to promote calm or induce sleep) 50 mg at bedtime for major depression for continued use. The physician had checked to continue the therapy as ordered. The document lacked documentation of a physician rationale. The physician had signed and dated the document on 3/12/22. A current physician's order, dated 6/5/20, indicated give one 2 mg tablet of aripiprazole at bedtime related to major depressive disorder, recurrent, severe with psychotic symptoms. A current physician's order, dated 6/6/20, indicated give one 50 mg tablet of Trazodone hydrochloride (HCl) by mouth one time a day related to major depressive disorder, recurrent, severe with psychotic symptoms. A current physician's order, dated 6/25/22, indicated give one 20 mg tablet of escitalopram oxalate by mouth one time a day for mood. 2. Resident 56's record was reviewed on 7/29/22 at 2:24 p.m. Diagnoses included but were not limited to anxiety (intense, excessive, and persistent worry and fear about everyday situations) and psychotic disorder (mental disorder characterized by a disconnection from reality). A quarterly Minimum Data Set (MDS) assessment, dated 7/4/22, indicated the resident was cognitively intact, received medications which included, but were not limited to, antianxiety (medication to treat anxiety) and antipsychotic (medication to treat psychotic disorder) medications on a routine basis. A care plan, date initiated 11/28/18 and revised on 3/4/19, indicated the resident received an antianxiety medication and was at risk for drug related side effects. Interventions included, but were not limited to give antianxiety medications ordered by physician, observe for side effects and effectiveness, pharmacy to review resident's medications routinely with recommendations as indicated, quarterly and prn (as needed) GDR (gradual dose reduction) as per facility policy. A document, titled Note to Attending Physician/Prescriber, dated 2/28/22, indicated the resident received Buspirone (antianxiety medication) 10 milligrams (mg) TID (three times a day) for psychosis and anxiety. Current Federal Regulations require that all psychopharmacological medications be reviewed periodically. It is time to evaluate this therapy. The physician had checked to continue the therapy as ordered. The document lacked documented physician rationale. The physician had signed and dated the document on 3/5/22. A current physician's order, dated 2/22/19, indicated Buspirone tablet 10 mg. Give one tablet orally three times a day for anxiety. 3. Resident 52's record was reviewed on 8/2/22 at 9:21 a.m. Diagnoses included but were not limited to depression (mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily life), anxiety (intense, excessive, and persistent worry and fear about everyday situations) and delusions (type of mental health condition in which a person cannot tell what is real from what is imagined). A quarterly Minimum Data Set (MDS) assessment, dated 7/7/22, indicated the resident had a moderate cognitive impairment, received medications which included, but were not limited to, antianxiety (medication to treat anxiety), antipsychotic (medication to treat delusional disorder), antidepressant medication (medication used to treat depression/anxiety disorder) on a routine basis. A care plan, date initiated 10/10/20 and revised on 3/29/22, indicated the resident received an antianxiety medication and was at risk for drug related side effects. Interventions included but were not limited to give antianxiety medications ordered by physician, observe for side effects and effectiveness, pharmacy to review resident's medications routinely with recommendations as indicated, quarterly and prn (as needed) GDR (gradual dose reduction) as per facility policy. A document titled, Note to Attending Physician/Prescriber, dated 2/28/22, indicated the resident received Lorazepam (antianxiety medication) 1 milligram (mg) three times a day (TID), Zyprexa (medication used to treat certain mental disorder) 5 mg two times a day (BID), and Prozac (antianxiety medication) 40 mg daily for anxiety and delusions. Current Federal Regulations require that all psychopharmacological medications be reviewed periodically. It is time to evaluate this therapy. The physician had checked to continue the therapy as ordered. The document lacked documented physician rationale. The physician had signed and dated the document on 3/2/22. A current physician's order, dated 5/11/22, indicated give one tablet of Lorazepam 0.5 mg by mouth three times a day for anxiety. A current physician's order, dated 7/22/21, indicated give one tablet of Zyprexa tablet 5 mg by mouth two times a day related to delusional disorders. A current physician's order, dated 12/14/20, indicated give one capsule of Prozac 40 mg by mouth one time a day for depression. On 8/1/22 at 12:01 p.m., the Administrator provided and identified a document as a current facility policy titled, Documentation/Communication of Consultant Pharmacist Recommendations, dated 5/21/18. The policy indicated, .Policy: The consultant pharmacist works with the facility to establish a system whereby the consultant pharmacist observations and recommendations regarding residents' medication therapy are communicated to those with authority and/or responsibility to implement the recommendations and responded to in an appropriate and timely fashion .Procedure: .3. Recommendations are acted upon and documented by the facility staff and/or the prescriber. If the prescriber does not respond to recommendation directed to him/her within a reasonable timeframe, the Director of Nursing and/or the consultant pharmacist may contact the Medical Director 3.1-48(b)(2)

Based on observation, interview, and record review, the facility failed to ensure an opened multi-dose vial of tuberculin (TB) protein derivative solution (a sterile solution containing the growth products of or specific substances extracted from the tubercle bacillus and used in the diagnosis of tuberculosis) had documentation of the date the vial was opened for use for 1 of 2 medication storage rooms reviewed. Findings include: During an observation tour of the B-wing medication storage room, on 8/4/22 at 9:24 a.m., no open date was observed on an opened multi-dose vial of TB protein derivative solution. During an interview, on 8/4/22 at 9:53 a.m., the Director of Nursing (DON) indicated the TB vial would have been used for both residents and staff. The nurse who had opened the vial must have just forgotten to put the date opened on the vial. All of the nurses should know that any multi-dose vial of medication should have a open date documented on the vial. On 8/4/22 at 10:17 a.m., the DON provided a document, dated 5/21/18, and revised on 5/20/20, titled, Specific Procedures for All Medications, and indicated it was the policy currently being used by the facility. The policy indicated, .Procedure: .5 .When opening a multi-dose container, place the date on the container 3.1-25(j) 3.1-25(k)(6)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to provide at least 80 square feet per resident in multiple occupancy resident rooms for 2 of 50 resident rooms observed (rooms [ROOM NUMBERS]). Findings include: On 8/1/22 at 11:10 a.m., the Administrator provided a copy of a waiver request letter, dated 9/22/21. The letter indicated a waiver had been requested for rooms [ROOM NUMBERS] of the facility. During a maintenance tour with the Maintenance Director, on 8/4/22 at 9:58 a.m., rooms [ROOM NUMBERS] were measured. The current measurements of the rooms, were as follows: a. room [ROOM NUMBER], licensed for 3 beds, measured 226.2 total square feet. Square footage per resident equaled 75.4 square feet. At the same time, 2 beds were observed in the room. b. room [ROOM NUMBER], licensed for 3 beds, measured 226.2 total square feet. Square footage per resident equaled 75.4 square feet. At the same time, 2 beds were observed in the room. During an interview, on 8/4/22 at 10:11 a.m., the Administrator indicated each of the rooms were licensed for 3 beds. Currently, each room had 2 beds in each room. The facility was requesting a waiver for the rooms. 3.1-19(l)(2)

Based on observation, interview, and record review, the facility failed to ensure staff wore a beard or hair restraints when in the kitchen for 2 of 2 days of observations in the kitchen, failed to ensure hand hygiene was completed prior to assisting a resident with their lunch meal for 1 of 1 resident observed for dining (Resident 28), and failed to ensure hand hygiene was completed prior to pureeing residents' food for 1 of 1 observation of pureed food. Findings include: 1. During an observation in the facility kitchen, on 7/28/22 at 10:07 a.m., Dietary Aide 5 was observed to wear a hairnet and a medical face mask. The medical face mask failed to fully cover dietary aide 5's beard, leaving the sides and bottom of his beard exposed, while he washed dishes at the dishwasher and put away clean dishes in the kitchen. Dietary Aide 5 indicated he had forgotten to shave that morning before coming to work. On 7/28/22 at 1:41 p.m., Dietary Aide 5 was observed in the facility kitchen washing dishes at the dishwasher wearing a hairnet and medical face mask. The medical face mask failed to fully cover Dietary Aide 5's beard. On 7/28/22 at 1:46 p.m., Dietary Manager (DM) indicated Dietary Aide 5 was wearing a hairnet and surgical mask but was not wearing a beard cover. All staff should wear hairnets and beard covers when in the kitchen. On 7/29/22 at 9:33 a.m., Dietary Aide 5 was observed in the facility kitchen washing dishes at the dishwasher wearing a hairnet and medical face mask. The medical face mask failed to fully cover Dietary Aide 5's beard. On 7/29/22 at 11:55 a.m., the Director of Nursing (DON) indicated staff were going today to purchase beard restraints. All staff should wear hairnets and beard restraints when in the kitchen. 2. During a continuous dining observation in the main dining room, on 7/28/22 at 12:37 p.m. to 1:53 p.m., Certified Nursing Assistant (CNA) 6 served Resident 28 lunch of a beef Manhattan (shredded beef, mashed potatoes, and gravy on a slice of bread) and mixed vegetables on one plate, a piece of pie on a smaller plate, and a cup of juice. Resident 28, seated in a high back wheelchair, was observed with her eyes closed when the meal was placed on the table in front of her. On 7/28/22 at 12:58 p.m., Resident 28, seated in a high back wheelchair was observed with her eyes closed and unassisted with the lunch meal plates in front of her, while CNA 6 served and assisted another resident with their lunch meal. On 7/28/22 at 1:03 p.m., CNA 6 was observed seated next to and assisting Resident 28 with bites of her lunch meal. CNA 6 was observed touching her face, adjusting her medical face mask, and brushed her hair back from her face with her bare unwashed hand, then CNA 6 picked up Resident 28's spoon and gave the resident bites of food without sanitizing her hands. On 7/28/22 at 1:15 p.m., CNA 6 was observed wiping the back of her neck and forehead and adjusted her face mask with her bare hand, then gave Resident 28 bites of food with a spoon without sanitizing her hands. On 7/28/22 at 1:48 p.m., Resident 28 had eaten all the vegetables and took a bite of the Manhattan and told CNA 6 the bread was no good. CNA 6 repeated the bread is no good, as Resident 28 took another spoonful of mashed potatoes from CNA 6. On 7/28/22 at 1:51 p.m., CNA 6 wiped Resident 28's mouth with a napkin, asked Resident 28 if she was done, removed the resident's clothing protector, and pushed Resident 28's wheelchair out of the main dining room. CNA 6 was not observed to sanitize her hands. On 8/2/22 at 2:14 p.m., the Director of Nursing (DON) indicated staff should have assisted Resident 28 with her meal when the meal plate was brought to the resident in the dining room and staff should wash or sanitize their hands before assisting a resident with eating and anytime staff touched their face, hair, or face masks. 3. During an observation in the facility kitchen of pureed food preparation, on 8/3/22 at 11:00 a.m., [NAME] 18 was observed to puree meat and sauce in the food processor without sanitizing her hands. [NAME] 18 took the used processor pan to the dishwasher, sprayed the soiled pan with water, then placed the processor pan into the dishwasher, wiped her wet hands with a paper towel, took a cleaned cookie sheet to the clean dishes area and stacked it on the other clean cookie sheets, picked up a piece of trash off of the floor and placed the trash into a lidded trash bin touching the trash can lid to open the trash bin with her bare hand, grabbed the wet processor pan from the dishwasher rack and put the wet food processor pan back onto the processor machine, without washing or sanitizing her hands. Next, [NAME] 18 retrieved a container of potato salad from the refrigerator and placed several scoops of the potato salad into the wet food processor container and pureed the potato salad. [NAME] 18 placed the pureed potato salad into a pan, then took the soiled processor pan to the dishwasher, sprayed the soiled pan with water, then placed the processor pan into the dishwasher and wiped her wet hands with a paper towel, ran the dishwasher to clean the processor pan, shook off the excess water from the pan then placed the wet processor pan back onto the processor machine. [NAME] 18 retrieved a container of coleslaw and placed several scoops of the coleslaw into the wet food processor pan and pureed the slaw. [NAME] 18 placed the pureed slaw into a pan, then took the soiled processor pan to the dishwasher, sprayed the soiled pan with water, then placed the processor pan into the dishwasher, wiped wet hands with a paper towel, grabbed an ice scoop and placed ice into a large bowl, then placed the coleslaw bowl onto the ice in the bowl. Next, [NAME] 18 put on oven mitts and removed a pan from the oven, removed the oven mitts and removed the foil covering the meat in the pan with her bare hand, opened the trash container lid, placed the foil into the trash bin, washed her hands, then placed the used paper towel into the lidded trash bin, touching the lid as she threw away the paper towel. On 8/3/22 at 11:31 a.m., Dietary Manager (DM) indicated the cook should have washed her hands prior to pureeing the foods in the processor and after spraying the dirty processor pan. [NAME] 18 should have allowed the food processor pan time to dry before using it again. 4. On 8/3/22 at 12:30 p.m., during a second dining observation, the Human Resources Director was observed walking into the kitchen without a hair restraint to speak with kitchen staff . The Human Resources Director, on 8/3/22 at 12:32 p.m., indicated she had forgotten to place a hair restraint on when she went into the kitchen. The Director of Nursing (DON), on 7/29/22 at 11:55 a.m., provided and identified a document as a current facility policy, titled Dress Code and personal Hygiene, dated 2009, which indicated, .The organization has strict requirements regarding hair: .Employees will wear hairnet that completely covers the hair while in the kitchen or serving food .There are no authorized substitutes for the required hair covering .Beard and mustache must be covered with effective hair restraint The Administrator (ADM), on 8/4/22 at 9:42 a.m., provided and identified a document as a current facility policy, titled Assistance with Meals, dated July 2017, which indicated, Residents shall receive assistance with meals in a manner that meets the individual needs of each resident .Dining Room Residents: .1. All residents will be encouraged to eat in the dining room .2. Facility Staff will serve resident trays and will help residents who require assistance with eating .3. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity The Administrator (ADM), on 8/4/22 at 9:45 a.m., provided and identified a document as a current facility policy, titled Personnel Standards, dated 5/23/19, which indicated, .Policy: Dining Services personnel shall follow sanitary standards .c. Hands must be washed after each trip to the restroom, after leaving storage rooms, dumpster areas, washrooms, etc., after touching hair, mouth, or nose, and at any other time necessary 3.1-21(i)(1) 3.1-21(i)(3)