Based on observation, record review and interview, the facility failed to develop a comprehensive person-centered care plan for a resident with positioning issues for 1 of 17 residents reviewed. (Resident 11) Finding includes: During an observation, on 9/25/2024 at 11:30 A.M., Resident 11 was leaned over to the left side of his wheelchair while in the dining room and there was a stuffed animal placed in between Resident 11's left arm and the armrest of his wheelchair. The medical record for Resident 11 was reviewed on 9/26/2024 at 3:32 P.M. Diagnoses included but were not limited to: diffuse traumatic brain injury, hemiplegia and hemiparesis following cardiovascular accident, conversion disorder with seizures, anxiety, depression, hypertension, chronic pulmonary obstructive disease, pulmonary embolism, cardiac arrest, contracture of left shoulder, difficulty in walking and coronary artery disease. The record lacked a person-centered care plan for the resident's positioning issues. During an interview, on 9/27/2024 at 9:21 A.M., CNA (Certified Nursing Assistant) 2 indicated if staff noticed Resident 11 was leaning to the left, staff would put the resident in bed and lay him down. During an interview, on 9/27/2024 at 9:28 A.M., the DON (Director of Nursing) indicated facility staff just used pillows to prevent Resident 11 from leaning to the left in his wheelchair. The DON indicated a half-lap tray to prevent the resident from leaning to the left was previously utilized, but Resident 11's mother had requested they quit using the tray. The DON indicated staff should have placed pillows between the resident's wheelchair and his left arm to prevent pressure. The DON indicated preventing Resident 11 from leaning to his left side with pillows should have been included in the resident's current care plan. On 9/30/2024 at 10:28 A.M., the Social Service Director provided a policy titled, IDT Comprehensive Care Plan Policy, dated 8/2023 and indicated the policy was the one currently used by the facility. The policy indicated .each resident will have an interdisciplinary comprehensive person-centered care plan developed and implemented .must include measurable goals and resident specific interventions based on resident needs . 3.1-35(a)

Based on record review and interview, the facility failed to revise care plans for fluid consumption for 1 of 17 residents whose care plans were reviewed. (Resident 4) Finding includes: The record for Resident 4 was reviewed on 9/26/2024 at 1:46 P.M. Diagnoses included, but were not limited to, heart failure, end stage renal disease, diabetes and bipolar disorder. A Quarterly Minimum Data Set (MDS) assessment, dated 6/28/2024, indicated the resident received dialysis. Current Physician's Orders included an order for regular diet and dialysis every Monday, Wednesday and Friday. A current Care Plan, initiated on 5/12/2023, indicated the resident was at risk for a fluid imbalance due to end stage renal disease, heart failure, hypo-osmolality and hyponatremia. Interventions included, but were not limited to: administer medications as ordered and encourage fluids. A current Care Plan, initiated on 5/12/2023, indicated the resident was at risk for constipation due to end stage renal disease, decreased mobility and polypharmacy (multiple drug use). Interventions included, but were not limited to: administer medications as ordered and encourage fluids. A current Care Plan, initiated on 5/15/2023, indicated the resident was at risk for altered nutritional status related to diagnoses of end stage renal disease, morbid obesity and diabetes type 2. Interventions included, but were not limited to: attends dialysis 3 x/week. regular diet. No water pitcher at bedside and communicate with the dialysis Register Dietician. A current Care Plan, initiated on 8/27/2024, indicated the resident had bruising to her left upper arm. Interventions included, but were no limited to: encourage fluids. The care plans for Resident 4 related to fluids contradicted themselves and were not revised to accurately reflect the resident's fluid needs and physician orders. During an interview, on 9/30/2024 at 9:30 A.M., the Director of Nursing indicated the care plans were not updated to and should have been. She indicated previously Resident 4 was consuming too much water. On 9/30/2024 at 10:38 A.M. the Social Service staff provided the policy titled, IDT Comprehensive Care Plan Policy, dated 8/2023, and indicated the policy was the one currently use by the provider. The policy indicated .Care plan problems, goals, and interventions must be reviewed and revised by the interdisciplinary team periodically and following completion of each MDS assessment 3.1-35(d)(2)(B)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a resident received the appropriate therapeutic diet for 1 of 1 residents reviewed for reviewed for dialysis. (Resident 4) Finding includes: The record for Resident 4 was reviewed on 9/26/2024 at 1:46 P.M. Diagnoses included, but were not limited to, heart failure, end stage renal disease, diabetes and bipolar. A Quarterly Minimum Data Set (MDS) assessment, dated 6/28/2024, indicated the resident received dialysis. Resident 4's admission orders initiated 5/12/2023, indicated the diet order was: 3-4 GM (grams) NA (sodium) CCD (controlled carbohydrate diet), no orange or tomato juices or bananas. May have 8 oz milk every day, low NA bologna sandwich 1-2 times week if does not like what is served. A dialysis note/order, dated 10/11/2023, indicated the resident was to receive a diet-1GM K (potassium), 23 GM phosphorus, 2 GM or less NA and 48 oz. fluid restriction. A current Physician's Order Sheet, initiated on 10/25/2023, from the dialysis unit indicated a new order for Nephro (dietary supplement) twice a day until patient starts eating better. Resident 4's current Physician's Orders, dated 9/30/2024, included a regular diet, ordered on 5/12/2023, and there was no order for the Nephro. Resident 4's record lacked the documentation to show the diet order from admission on [DATE] and the Nephro supplement order form 10/25/2023 had been followed. During an interview, on 9/30/2024 at 12:42 P.M., the Director of Nursing indicated she could not provide any further documentation for why the diet had been changed. She indicated the admission diet and the Nephro orders had not been transcribed correctly, and the resident had not received the Nephro supplement. On 9/30/2024 at 12:45 P.M. the Director of Nursing provided the policy titled, Dialysis Care, dated 11/207, and indicated the policy was the one currently used by the facility. The policy indicated . The facility will ensure that each resident receives care and services for the provision of hemodialysis and/or peritoneal dialysis consistent with professional standards of practice including: Ongoing communication and collaboration with the dialysis facility regarding dialysis care and services . 5. The nurse in charge at time of return will review paperwork for new orders and/or notes accompanying the resident 3.1-46

Based on observation and interview, the facility failed to post daily nurse staffing data timely. Finding includes: During an observation on 9/25/2024 at 10:43 A.M., the nurse staffing data posting form was observed to be dated 9/24/2024. During an observation on 9/27/2024 at 8:02 A.M., the nurse staffing data posting fomr was observed to be dated 9/26/2024. During an observation on 9/30/2024 at 8:34 A.M., the nurse staffing data posting form was observed to be dated 9/27/2024. During an interview on 9/30/2024 at 10:44 A.M., the Executive Director indicated the Director of Nursing was responsible for posting the nurse staffing data every morning. A policy was provided by the Regional Director of Nursing on 9/30/2024 at 1:04 P.M. The policy, titled, Posted Staffing Data and Retention Requirements, indicated, .To allow public access to posted nursing staffing data per federal regulations .It is the policy of [facility organization name] to make staffing information readily available in a readable format and publicly posted to residents and visitors at any given time

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure medication carts were free from loose pills and failed to ensure medications were labeled in 1 of 2 medication storage areas observed. (Front hall medication cart) Finding includes: During an observation of the front hall medication cart, on 9/30/2024 at 10:28 A.M. with RN 4, the following was observed: - an opened bottle of Dr. Love [NAME] dietary supplement with no resident identifiers. - opened containers of Equate allergy relief, Equate gas relief and a container of Relaxium sleep tablets all with no resident identifiers. - and there were 3 looses pills in the mediation cart drawers. During an interview, on 9/30/2024 at 10:36 A.M., RN 4 indicated the pill containers should have had labels on them and there should be no loose pills in the medication cart. On 9/30/2024 at 12:45 P.M., the Director of Nursing provided a printed sheet titled Clinical Nurse Highlight- Medication Storage, and indicated this was the policy currently used by the facility. The policy indicated .Medication storage areas should always be clean and orderly . Medications are properly labeled with patient name, lot #, and expiration date. Over-the-counter med's for individual patients should have the patients name and expiration date noted on the medication (follow state regulations) 3.1-25(j)

Based on observation and interview, the facility failed to ensure infection control practices were followed when administering insulin for 1 of 1 resident reviewed for insulin administration. (Resident 13) Finding includes: During an observation, on 9/27/2024 at 7:33 A.M., RN 4 washed her hands and applied gloves. She cleansed Resident 13's left outer arm with an alcohol pad and with an opened hand, she fanned the area she had just cleansed. During an interview, on 9/27/2024 at 7:35 A.M., RN 4 indicated she should not have fanned the area. On 9/30/2024 at 12:45 P.M., the Director of Nursing provided a Skills Competency titled Insulin Pen Administration, dated 10/2019, and indicated the policy was the one currently used by the facility. The policy indicated .14. Cleanse injection site with alcohol swab and allow to dry 3.1-18(a)

Based on interview and record review, the facility failed to ensure the Surety Bond amount was sufficient to cover the Resident's personal fund account. This deficient practice had the potential to effect 31 of 31 residents in the facility. Finding includes: During an interview, on 9/30/2024 at 10:38 A.M., the Business Office Manager (BOM) indicated the Surety Bond amount was $25,000.00 and the resident funds accounts totaled $28,511.66 in June and $26,803.46 in July The Business Office Manager indicated the amount of the surety bond would not cover the total amount in the resident funds account. During an interview, on 9/30/2024 at 1:25 P.M., the Administrator indicated the surety bond would not always cover the total amounts in the resident fund account. She indicated she did not have a policy for the surety bond. 3.1-6(i)

Based on record review and interview, the facility failed to ensure a Resident with a history of constipation and ileus was assessed, medicated and had their physician notified of a lack of bowel movement after 5 days as a result the resident continued to experience bouts of constipation and nausea nad vomiting and was hospitalized 21 days later with a small bowel obstruction for 1 of 3 residents reviewed. (Resident 82) Finding includes: During an initial interview on 10/03/23 at 11:53 A.M., Resident 8 indicated she had recently been hospitalized for abdominal pain. See F684. A record review was completed on 10/05/23 at 9:09 A.M. Diagnoses included, but were not limited to: constipation, history of an ileus, gastroesophageal reflux disease, anemia, bilious vomiting, polycythemia vera, and abnormal weight loss. A Care Plan dated 6/10/2022, and revised 10/5/2023 at 9:52 A.M., indicated Resident 8 was at risk for constipation due to decreased mobility and medications. The goal was to have a soft formed bowel movement at least every three days. The interventions included for an abdominal assessment if no bowel movement for four days, bowel sounds, abdominal distension hyper/hypoactive bowel sounds, abdominal pain or tenderness, document and notify the physician of any abnormal findings, administer medications as ordered, encourage fluids, monitor bowel function, and notify the physician if no bowel movement after the third day. Resident 8's bowel movement record for June 2023, indicated the following: 6/1/2023 Medium 6/2/2023-6/6/2023 None (5 days, no treatment) 6/7/2023 Medium x 2 6/8/2023 Large 6/9/2023-6/10/2023 None (2 days) 6/11/2023 Medium 6/12/2023 None 6/13/2023 Large 6/14/2023-6/16/2023 None (3 days, no treatment) 6/17/2023 Large 6/18/2023 Medium 6/19/2023 Small 6/20/2023-6/21/2023 None (3 days, no treatment) 6/22/2023 Large 6/23/2023 Medium 6/24/2023 Medium 6/25/2023 Large x 2 6/26/2023-6/27/2023 (2 days) Resident 8 did not have any orders for routine bowel medications. She did have as needed medications of Milk of Magnesia suspension 400 milligrams per 5 milliliter give 30 milliliters daily for constipation, and loperamide 2 milligrams give 4 milligrams every four hours for loose stools. The Medication Administration Record for June 2023 indicated Resident 8 received loperamide 4 milligrams on 6/19/2023 at 12:07 P.M. for an unknown reason, 6/19/2023 at 6:11 P.M. for nausea and vomiting, 6/20/2023 at 2:56 P.M. for an upset stomach, and on 6/22/2023 at 9:42 A.M. for nausea and vomiting. Resident 8 received Milk of Magnesia 30 milliliters on 6/26/2023 at 2:39 P.M. for constipation. An SBAR (Situation, Background, Assessment, and Recommendation) form was completed on 6/27/2023 at 5:53 P.M., and indicated Resident 8 was lethargic and not talking clearly. Her skin was pale and warm. Her vital signs were blood pressure 158/95, pulse 99, respirations 16, temperature 97.3, and oxygen saturation of 90%. The nurse's request was for a chest x-ray. No further assessment was documented. A Progress Note on 6/27/2023 at 6:11 P.M., indicated a call was placed to the physician and updated on Resident 8's condition. A new order was obtained to send to the Emergency Department for evaluation and treatment. An emergency room History & Physical report on 6/27/2023, indicated Resident 8 started to complain of some right lower quadrant abdominal pain a few days ago that progressively worsened with associated headache, decreased oral intake and nausea, but no vomiting. The abdominal assessment indicated soft, mild distension to the right lower quadrant with tenderness to palpate, and absent bowel sounds. Resident 8 was admitted to the hospital with a partial small bowel obstruction, right lower quadrant pain, and chronic constipation. On 6/27/2023 at 7:56 P.M. a Computed Tomography scan was completed at the hospital. The results indicated, .Small bowel: Small bowel loops are mildly dilated and partially fluid-filled. There is a possible point in the right anterior pelvis. No bowel wall gas or free air. Colon: The sigmoid colon is filled with stool and was similar on the prior CT scan. Impression: 1. Findings consistent with early or partial small bowel obstruction. Small bowel loops are mildly dilated. Possible transition point in the right pelvis. No free air or bowel wall gas. 2. The sigmoid colon is filled with stool and could represent constipation During an interview with CNA 6 on 10/10/2023 at 10:40 A.M., CNA 6 indicated Resident 8 bowel movements can vary from constipation, loose stools, and sometimes Resident 8 stated she couldn't have a bowel movement at all. She indicated they document bowel movements every shift, informed the nurse if constipation or liquid diarrhea occurred, and informed the nurse if the resident requested a suppository or enema. On 10/10/2023 at 10:46 A.M., LPN 5 indicated the bowel protocol was to administer prune juice, Milk of Magnesia, a suppository, or enema if ordered after three days without a bowel movement and to notify the physician. The facility policy and procedure, titled, Resident Change of Condition Policy, provided by the Director of Nursing on 10/10/2023 at 1:55 P.M. included the following: .3. Non-Urgent Medical Change a. All symptoms and unusual signs will be documented in the medical recorded communicated to the attending physician promptly. Non-urgent changes are a minor change in physical and mental behavior, abnormal laboratory and x-ray results that are not life threatening. b. The nurse in charge is responsible for notifications of physician and family/responsible party prior to the end of assigned shift when a significant change in the resident's condition is noted 3.1-5(a)

Based on interview, and record review the facility failed to care plan interventions for gastrointestinal reflux disease, tremors, and the use of an antidepressant for 1 of 5 residents reviewed. (Resident 24) Finding includes: A record review was completed on 10/6/2023 at 8:57 A.M. Diagnoses included, but were not limited to: systemic lupus erythematous, polyneuropathy, rheumatoid arthritis, depression, and anxiety disorder. A Quarterly Minimum Data Set (MDS) assessment on 9/6/2023 indicated Resident 24 received an antidepressant for seven days of the seven-day look back period. She had severe cognitive impairment. A review of Resident 24's medications indicated she received pantoprazole 40 milligrams daily for gastroesophageal reflux disease since 3/29/2023, benztropine 1.5 milligrams three times daily for tremors since 4/5/2023, and escitalopram oxalate 20 milligrams daily for depression since 7/29/2023. During an interview with the Director of Nursing on 10/10/2023 at 11:05 A.M., she indicated that the MDS (Minimum Data Set) Coordinator works in three buildings, so with the smaller building the Director of Nursing was responsible for making sure care plans were completed. On 10/10/2023 at 11:25 A.M., the Director of Nursing indicated that there were no care plans for gastroesophageal reflux disease, tremors, or use of an antidepressant. A policy titled, IDT [Interdisciplinary Team] Comprehensive Care Plan Policy, was provided by the Social Service Director on 10/4/2023 at 3:14 P.M. The policy indicated, .Create an organized, resident-centered review on a routine basis to improve communication with residents, resident families, and/or representative regarding the resident goals, total health status, including functional status, nutritional status, rehabilitative and restorative potential, ability to participate in activities, cognitive status, psychosocial status, sensory and physical impairments, as well as care and services provided to maintain or restore health and well-being, improve functional level or relieve symptoms .Improve relationships between resident, families and/or representative, and facility care givers through understanding of resident's social history, culture and preferences to enhance the resident's life .Resident, resident's representative, or others as designated by resident will be invited to care plan review .The care plan review may be conducted face to face, via phone conference, video conference, or through written communication per resident and/or representative preference 3.1-35(e)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During an interview with Resident 11 on 10/4/2023 at 9:04 A.M., Resident 11 indicated she does not have care plan meetings, and was not aware of the medications she received. A record review was completed on 10/4/2023 at 11:14 A.M. Diagnoses included history of malignant neoplasm of large intestines, heart failure, and chronic obstructive pulmonary disease. Care Plan Meeting Notes were identified for 2/17/2023 and 6/21/2023 with Resident 11 and her daughter in attendance. A Progress Note on 2/2/2023 at 11:13 A.M., indicated the Social Service Director spoke with Resident 11's daughter regarding a care plan meeting. On 6/19/2023 at 9:53 A.M., a Progress Note indicated Resident 11's daughter called and would schedule a care plan meeting after Resident 11's eye doctor appointment and the meeting was scheduled for 6/21/2023 at 1:00 P.M. During an interview on 10/4/2023 at 1:45 P.M., the Social Service Director indicated care plan meetings were completed with the Minimum Data Set (MDS) assessments. She indicated notification of the care plan meetings were documented in the progress notes. She indicated Resident 11 should have more than the two care meetings that were documented. A review of the MDS assessments indicated the following assessments were completed: 8/16/2023 Annual 5/31/2023 Quarterly 3/8/2023 Quarterly 1/11/2023 Quarterly 10/19/2022 Annual 3. During an interview, on 10/3/2023 at 10:23 A.M., Resident 3 indicated she has not had a careplan meeting since admission. A record review was completed on, 10/4/2023 at 11:28 A.M., and indicated Resident 3's diagnoses included, but were not limited to: Hypertensive heart and chronic kidney disease with heart failure, Stage 5 chronic kidney disease/end stage renal disease, diabetes, arteriovenous fistula, hypotension, atrial fibrillation, bipolar II disorder, morbid obesity, anxiety, obstructive sleep apnea, and anemia in chronic kidney disease. A Quarterly MDS (Minimum Data Set) assessment, dated 8/16/2023 indicated Resident 3 has intact cognition. During an interview, on 10/04/2023 at 2:19 P.M., the Director of Nursing indicated the Resident had a careplan meeting in June and she should have had another one in September. On 10/10/2023, at 2:08 P.M., the Director of Nursing provided the policy titled,IDT Comprehensive Care Plan Policy, dated 8/2023, and indicated the policy was the one currently used by the facility. The policy indicated .Care plan review will be interdisciplinary and should include, to the extent possible, nursing, social services, activities, dietary, therapy, pharmacy, physician, direct care staff and hospice, if indicated. Resident, resident's representative, or others as designated by resident will be invited to the care plan review 3.1-35(c)(2) Based on record review and interviews, the facility failed to ensure care plan meetings, including the resident and/or their representative were conducted timely for 3 of 14 residents reviewed. (Resident 3, 11 and 27) Findings include: 1. The record for Resident 27 was reviewed on 10/4/2023 at 1:26 P.M. Resident 27 was admitted to the facility on [DATE] with diagnoses, including but not limited to: right lower quadrant abdominal swelling, mass and lump, Chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia. The most recent Minimum Data Set (MDS) assessment, completed on 7/28/2023 for an initial admission assessment, indicated the resident was alert and oriented. During an interview with alert and oriented Resident 27, on 10/3/2023 at 11:31 A.M., the resident indicated she did not recall being invited to a care plan meeting. Review of the electronic record, including the observation documentation and the nursing progress notes indicated there was no care plan meeting summary notes. There were two Transitions of care meetings , dated 7/25/2023 and 8/1/2023 held but no care plan meeting held. The only meeting documented to have included the resident, was a Road to Recovery therapy meeting, held on 7/26/2023. The Transitions of Care meetings did not include all of the interdisciplinary department heads and did not include the resident and/or their representative. During an interview with the Administrator, on 10/10/2023 at 1:30 P.M., she indicated the Road to Recovery meeting was a therapy meeting and not a care plan meeting. During an interview with the MDS coordinator, on 10/10/2023 at 11:30 A.M., she indicated she was responsible for three buildings and was not always available for resident care plan meetings. She indicated the care plan meetings were documented in the Observation section of the electronic record and were labeled Care Plan Summary.

Based on record review and interview, the facility failed to ensure a resident received care planned interventions during periods of constipation for 1 of 3 residents reviewed for bowel management (Resident 82). Findings include: 1. During an initial interview on 10/03/23 at 11:53 A.M., Resident 8 indicated she had recently been hospitalized for abdominal pain. See F580. A record review was completed on 10/05/23 at 9:09 A.M. Diagnoses included, but were not limited to: constipation, history of an ileus, gastroesophageal reflux disease, anemia, bilious vomiting, polycythemia vera, and abnormal weight loss. A Care Plan dated 6/10/2022, and revised 10/5/2023 at 9:52 A.M., indicated Resident 8 was at risk for constipation due to decreased mobility and medications. The goal was to have a soft formed bowel movement at least every three days. The interventions included for an abdominal assessment if no bowel movement for four days, bowel sounds, abdominal distension hyper/hypoactive bowel sounds, abdominal pain or tenderness, document and notify the physician of any abnormal findings, administer medications as ordered, encourage fluids, monitor bowel function, and notify the physician if no bowel movement after the third day. Resident 8's bowel movement record for June 2023, indicated the following: 6/1/2023 Medium 6/2/2023-6/6/2023 None (5 days, no treatment) 6/7/2023 Medium x 2 6/8/2023 Large 6/9/2023-6/10/2023 None (2 days) 6/11/2023 Medium 6/12/2023 None 6/13/2023 Large 6/14/2023-6/16/2023 None (3 days, no treatment) 6/17/2023 Large 6/18/2023 Medium 6/19/2023 Small 6/20/2023-6/21/2023 None (3 days, no treatment) 6/22/2023 Large 6/23/2023 Medium 6/24/2023 Medium 6/25/2023 Large x 2 6/26/2023-6/27/2023 (2 days) Resident 8 did not have any orders for routine bowel medications. She did have as needed medications of Milk of Magnesia suspension 400 milligrams per 5 milliliter give 30 milliliters daily for constipation, and loperamide 2 milligrams give 4 milligrams every four hours for loose stools. The Medication Administration Record for June 2023 indicated Resident 8 received loperamide 4 milligrams on 6/19/2023 at 12:07 P.M. for an unknown reason, 6/19/2023 at 6:11 P.M. for nausea and vomiting, 6/20/2023 at 2:56 P.M. for an upset stomach, and on 6/22/2023 at 9:42 A.M. for nausea and vomiting. Resident 8 received Milk of Magnesia 30 milliliters on 6/26/2023 at 2:39 P.M. for constipation. An SBAR (Situation, Background, Assessment, and Recommendation) form was completed on 6/27/2023 at 5:53 P.M., and indicated Resident 8 was lethargic and not talking clearly. Her skin was pale and warm. Her vital signs were blood pressure 158/95, pulse 99, respirations 16, temperature 97.3, and oxygen saturation of 90%. The nurse's request was for a chest x-ray. No further assessment was documented. A Progress Note on 6/27/2023 at 6:11 P.M., indicated a call was placed to the physician and updated on Resident 8's condition. A new order was obtained to send to the Emergency Department for evaluation and treatment. An emergency room History & Physical report on 6/27/2023, indicated Resident 8 started to complain of some right lower quadrant abdominal pain a few days ago that progressively worsened with associated headache, decreased oral intake and nausea, but no vomiting. The abdominal assessment indicated soft, mild distension to the right lower quadrant with tenderness to palpate, and absent bowel sounds. Resident 8 was admitted to the hospital with a partial small bowel obstruction, right lower quadrant pain, and chronic constipation. On 6/27/2023 at 7:56 P.M. a Computed Tomography scan was completed at the hospital. The results indicated, .Small bowel: Small bowel loops are mildly dilated and partially fluid-filled. There is a possible point in the right anterior pelvis. No bowel wall gas or free air. Colon: The sigmoid colon is filled with stool and was similar on the prior CT scan. Impression: 1. Findings consistent with early or partial small bowel obstruction. Small bowel loops are mildly dilated. Possible transition point in the right pelvis. No free air or bowel wall gas. 2. The sigmoid colon is filled with stool and could represent constipation During an interview with CNA 6 on 10/10/2023 at 10:40 A.M., CNA 6 indicated Resident 8 bowel movements can vary from constipation, loose stools, and sometimes Resident 8 stated she couldn't have a bowel movement at all. She indicated they document bowel movements every shift, informed the nurse if constipation or liquid diarrhea occurred, and informed the nurse if the resident requested a suppository or enema. On 10/10/2023 at 10:46 A.M., LPN 5 indicated the bowel protocol was to administer prune juice, Milk of Magnesia, a suppository, or enema if ordered after three days without a bowel movement and to notify the physician. The facility policy and procedure, titled, Resident Change of Condition Policy, provided by the Director of Nursing on 10/10/2023 at 1:55 P.M. included the following: .3. Non-Urgent Medical Change a. All symptoms and unusual signs will be documented in the medical recorded communicated to the attending physician promptly. Non-urgent changes are a minor change in physical and mental behavior, abnormal laboratory and x-ray results that are not life threatening. b. The nurse in charge is responsible for notifications of physician and family/responsible party prior to the end of assigned shift when a significant change in the resident's condition is noted 3.1-37

Based on interview and record review, the facility failed to follow through with physician recommendations for 1 of 1 residents reviewed for urinary tract infections. (Resident 11) Finding includes: During an interview with Resident 11 on 10/4/2023 at 9:07 A.M., she indicated that she recently was on an antibiotic for a urinary tract infection, and had frequent urinary tract infections. A record review was completed on 10/4/2023 at 11:14 A.M. Diagnoses included, but were not limited to: hematuria, overactive bladder, and constipation. A Quarterly Minimum Data Set (MDS) assessment on 8/16/2023, indicated Resident 11 was always incontinent of bladder and bowel. Resident 11 was cognitively intact. A review of Resident 11's urinalysis indicated the following: -On 1/24/2023 she was positive for a urinary tract infection with Citrobacter koseri (a bacteria). Sulfamethoxazole-trimethoprim (an antibiotic) 800-160 milligram twice daily for 7 days was prescribed. -On 3/24/2023 she was positive for a urinary tract infection with Proteus mirabils (a bacteria). Cephalexin (an antibiotic) 500 milligrams three times daily for seven days was prescribed. -On 4/20/2023 she had a negative urinalysis. -On 5/25/2023 she was positive for a urinary tract infection with Citrobacter koseri. Cephalexin 500 milligrams twice daily for five days was prescribed. -On 7/22/2023 she had a negative urinalysis. A urology referral was requested by the nurse practitioner. -On 8/21/2023 she was positive for a urinary tract infection, bacteria unknown as page 2 of the urinalysis was not available. Cephalexin 500 milligrams twice daily for seven days was prescribed. A Nurse's Note on 4/6/2023 at 10:46 A.M., indicated the resident had blood in the urine, a urinalysis was collected and lab work completed. Resident 11 had a referral for urology consultation pending. On 4/10/2023 at 12:41 P.M., a Nurse's Note indicated a telephone call was made for a urology referral, and the receptionist indicated Medicaid was not accepted. A Urologist in the local area would be contacted. On 4/27/2023 at 12:45 P.M., a Nurse's Note indicated normal urinary ultrasound and lab work. The nurse practitioner indicated if changes occurred a referral to urology should be made. A Nurse Practitioner Note on 5/24/2023 at 2:30 P.M., indicated Resident 11 was being seen for blood in her brief, and nursing staff suspected it was coming from the bladder. The assessment/treatment plan indicated possible hematuria/hemorrhoids and if blood continued to have a urology consult. A Physician's Note on 7/5/2023 at 2:30 P.M., recorded as a late entry on 9/3/2023 at 3:06 P.M., indicated hematuria/hemorrhoids resolved, but if reocurred to send to urology. A Nurse Practitioner Note on 7/19/2023 at 12:30 P.M., indicated Resident 11 was visited due to hematuria, and it was a reoccurrence of hematuria. Resident 11 had a history of urinary tract infections. The nurse practitioner spoke with the Director of Nursing (DON), and the DON was concerned that Resident 11's masturbating was causing injury. Resident 11 denied this practice during interview with the nurse practitioner. The assessment/plan indicated hematuria/hemorrhoids: urology referral, and collection of urine for a urinalysis with culture and sensitivity. On 7/24/2023 at 1:49 P.M., a Nurse's Note indicated the nurse practitioner was notified of urinalysis results, and to continue with the urology referral. A Care Plan initiated on 4/9/2023, and revised on 8/29/2023 at 11:13 A.M., indicated Resident 11 had chronic urinary tract infections and was at risk for future infections. During an interview on 10/10/2023 at 10:47 A.M., LPN 5 indicated Resident 11 had not had a urology consultation, and she believed Resident 11 did not want to go to the urologist. On 10/10/2023 at 10:49 A.M., Resident 11 indicated she wanted to see urology, and she believed she currently had another infection. She indicated she had an established urologist that she saw three to four years ago. A current policy titled, Bowel and Bladder Program, was provided by the Director of Nursing on 10/10/2023 at 2:08 P.M. The policy indicated, .The care plan and resident profile must represent the appropriate program and resident specific interventions 3.1-41(a)(2)

Based on observation, record review and interview, the facility failed to ensure respiratory equipment was stored properly for 1 of 1 resident reviewed for oxygen therapy. (Resident 182) Finding includes: During an observation on 10/3/2023 at 9:38 A.M. and at 1:02 P.M., the portable oxygen nasal cannula was lying on the floor under Resident 182's wheelchair, and the nebulizer mask was lying on the bedside table. On 10/4/2023 at 8:56 A.M., the portable oxygen nasal cannula was lying on the wheelchair seat. A record review was completed on 10/4/2023 at 2:31 P.M. Diagnoses included, but were not limited to: chronic obstructive pulmonary disease, anxiety disorder, and respiratory failure with hypoxia. Physician's Orders included oxygen at three liters per nasal cannula continuously, and ipratropium-albuterol nebulizer solution 0.5 milligram-3 milligram give 3 milliliters via inhalation. A Care Plan indicated Resident 182 had symptoms of decreased oxygenation On 10/5/2023 at 9:57 A.M., and 10/6/2023 at 1:52 P.M., the portable oxygen nasal cannula was observed in a wash basin on the wheelchair cushion. During an interview on 10/10/2023 at 10:39 A.M., CNA 6 indicated nebulizer masks and nasal cannulas should be stored in a respiratory bag when not in use. A policy, titled Oxygen Concentrator, was provided on 10/10/2023 at 2:08 P.M. by the Director of Nursing. The policy did not identify storage of oxygen equipment when not in use. 3.1-47(a)4 3.1-47(a)5 3.1-47(a)6

Based on observation, record review and interview, the facility failed to ensure the physician responded timely to pharmacy recommendations for 1 of 5 residents reviewed for medication use. (Resident 4) Findings include: The record for Resident 4 was reviewed on 10/4/2023 at 2:05 P.M. Resident 4 was admitted to the facility with diagnosis, including but not limited to: chronic obstructive pulmonary disease, systolic congestive heart failure, chronic respiratory failure with hypoxia, bipolar disorder and emphysema. The most recent MDS (Minimum Data Set) assessment for Resident 4, completed as a quarterly review on 7/5/2023, indicated the resident was alert and oriented and required the extensive assistance of one staff for bed mobility, ambulation needs, personal hygiene, dressing, and toileting needs. The current physician's orders for medications included adult low dose aspirin and plavix (a medication to prevent blood clotting). A pharmacy recommendation, dated March 1, 2023, recommended the physician consider discontinuing either the aspirin or the Plavix. The physician did not respond to the recommendation until 6/7/2023. During an interview with the Director of Nursing, on 10/10/2023 at 10:30 A.M., she indicated the facility policy was to have the physician address the pharmacy recommendations within 30 days. The facility policy and procedure, titled, LTC (Long Term Care) Facility's Pharmacy Services and Procedures Manual included the following: .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(h)

Based on observation, interview and record review, the facility failed to ensure food items in the freezer were dated/labeled with used by dates, dispose of expired foods, and failed to ensure the dishwasher, freezer, and toaster were clean and in good condition in the main kitchen. This deficient practice had the potential to affect 31 of 31 residents who received meals out of the kitchen. Findings include: During an observation of the kitchen on 10/03/2023 at 9:34 A.M., with Dietary Staff 9, the following was observed: -The freezer had a zip lock bag of diced potatoes undated, a bag of frozen biscuits with a use by date of 7/14/23, an open bag of frozen fish filets with no use by date. -The refrigerator had 3 bowls of cream of wheat undated, an undated bowl of gravy, an undated bowl of mashed potatoes, an undated unopened bag of bologna, and an opened pack of gravy mix with no use by date. - The following spices were noted on the shelf and undated: garden seasoning, baking powder, parsley flakes and ground cinnamon. -The shelf and wall above the stove was covered in a grease like substance. -The top of the dishwasher was dirty and covered in crumbs. -The toaster had a dry substance around the knobs. -The bottom freezer shelf was covered in grit. During an interview, on 10/03/2023 at 10:01 A.M., Dietary Staff 9 indicated the undated items should have dates on them, the expired items should have been thrown away and the wall, shelf, dishwasher, toaster and bottom freezer shelf should have been cleaned. On 10/5/2023 at 12:35 P.M., the Executive Director provided the current policy titled, Cleaning Freezers, dated 2/02. The policy indicated .Freezers will be kept clean and free of ice buildup. 2. Freezer racks and walls will be deep cleaned as needed. 3. Wash shelves and walls with sudsy water. Rinse and sanitize using sanitizing solution. Allow to air dry On 10/5/2023 at 12:35 P.M., the Executive Director provided the policy titled, Cleaning Toaster, dated 2/02. The policy indicated .The toaster will be cleaned after each use On 10/5/2023 at 12:35 P.M., the Executive Director provided the policy titled, Labeling and Dating, dated 5/18. The policy indicated .Processed meats and any item that has been cooked and cooled should be kept no longer than 3 days. Label with the date of storage and the date of discard. The date the product must be consumed or discarded may not exceed the manufacturer's use by date 3.1-21(i)(3)

Based on observation and interview, the facility failed to ensure PPE was worn and hand hygiene performed during medication pass for 1 of 1 observations. Findings include: During an initial medication administration observation on 8/3/22 at 8:28 AM, LPN 2 was observed dispensing tablets from the medication pack into her bare hand then placed them into a medication cup. LPN 2 was observed to do this several times. ABHS (alcohol based hand sanitizer) was not utilized between obtaining each resident's medication. LPN 2 also was observed touching the computer to chart, the top of the medication cart, and the narcotic record. on the medication cart. ABHS was not utilized prior to touching items on the medication cart and dispensing medications into her hand. LPN 2 then opened up the medication cart, obtained a liquid medication bottle (inside a plastic bag) with small plastic syringe. LPN 2 was observed placing the plastic syringe into the liquid medication bottle and drew some medication out. She then placed the plastic syringe (with the medication inside) directly on top of the medication cart without covering it. LPN 2 then picked up a log book, wrote in it, then put the book away, picked up the plastic syringe and emptied the liquid medication into a medication cup. LPN 2 placed the syringe back into the bag with the medication bottle and placed the bag in the medication cart. LPN 2 was observed to clean some of the liquid medication residue from the top of the cart with tissues, then used ABHS. LPN 2 was observed to go in front of her medication cart, obtain some tissues and blow her nose. LPN 2 then placed the tissue inside the trash can next to the medication cart. LPN 2 locked the medication cart, picked up the medication cups and proceeded to walk toward a residents room. LPN 2 did not her wash hands or use ABHS after blowing her nose. LPN 2 then walked into residents room, gave the medication cup to resident then adjust the resident's straw. LPN 2 did not don or doff gloves during the observation. During an observation on 8/3/22 at 8:38 AM, LPN 2 was observed dispensing medication tablets from a medication pack into her bare hands before placing then into medication cup. LPN 2 did not use ABHS in between obtaining medications. During an observation on 8/3/22 at 11:46 AM, LPN 2 explained she would be giving Insulin Aspart 15 units injectable pen. LPN 2 obtained a disposable needle, cleaned around the insulin hub with an alcohol pad then twisted the disposable needle onto the insulin pen. LPN 2 gathered the rest of the supplies, turned to the cart next to her, and donned 2 disposable gloves. She walked through the hallway with the gloves on. LPN 2 knocked on the door with her gloves on. LPN 2 then cleaned the site, gave the insulin, then took one glove off and left the other one while holding the disposable needle inside. LPN2 Walked back through the hallway to her medication cart and placed the disposable needle inside the sharps container with a gloved hand. LPN 2 did not perform hand hygiene after the insulin administration. In an interview on 08/03/22 at 12:27 PM LPN 1 indicated when giving medications, the orders should be checked in the computer, the correct dose verified, as well as date, type of medication, and route reviewed. Then supplies are obtained, hand hyginene performed, and gloves donned. After medication is given, gloves would be doffed, hand hygiene performed, and charting completed in the computer. If insulin is to be given, hand hygiene would be performed, the pen prepped, correct dose verified, prep the resident's skin with alcohol, and insulin would be administered. When handling resident's oral medications, hand hygiene would be performed first, then the medications would be placed into the medication container without touching the medications. In an interview on 8/3/22 at 12:38 PM, the Director of Nursing indicated the facility expected the nurses, during a medication administration, to follow the five rights and perform hand hygiene. A current facility policy, Hand Hygiene Policy, dated 12/21, was provided by the Director of Nursing on 8/3/22 at 1:34 PM. The policy indicated . To provide a standardized approach to Hand hygiene to reduce or minimize the transmission of infection from potential microorganism on the hands of all employees .5 moments of hand hygiene-term that describes the hand hygiene opportunities that prevent infection transmission lined to healthcare activities. Before touching a resident. Before clean/aseptic procedure. After body fluid exposure risk. After touching a resident. After touching resident surroundings A current facility policy, Medication Administration, dated 3/17, was provided by the Director of Nursing on 8/3/22 at 1:34 PM. The policy indicated . Proper hand hygiene is performed before and after and examination gloves worn for administration of topical, ophthalmic, injections, eneteral, rectal, and vaginal medications 3.1-18(a)