**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident who did not experience a change in payor source was given the choice/opportunity to remain in his room for 1 of 1 resident reviewed for room transfers. (Resident C) Findings includes: The clinical record for Resident C was reviewed on 9/10/24 at 2:10 p.m. The diagnoses included, but were not limited to, traumatic brain injury, muscle weakness, abnormalities of gait and mobility and spastic hemiplegia affecting the left nondominant side. The resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated he was cognitively intact. The resident was admitted to the facility in room [ROOM NUMBER] during his rehabilitation therapy timeframe. When the resident's therapy was competed, the resident was moved to another room without giving him the option to remain in his current room. The new room the resident was provided, did not provide the resident with an adequate bathroom and space for living. During an interview, on 9/6/24 at 4:20 p.m., Resident C indicated the room he was currently in was too small for him to use the bathroom. He was given a bedside commode to use. He did not know why he had to leave room [ROOM NUMBER] which accommodated his needs. During an interview, on 9/10/24 at 3:05 p.m., the Executive Director (ED) indicated the resident was moved on 8/22/24 from room [ROOM NUMBER] to room [ROOM NUMBER]. The resident was moved because he was no longer receiving therapy services and was not considered a short-term resident. His payor source did not change. The resident was not given the choice to remain in room [ROOM NUMBER]. During an interview, on 9/11/24 at 2:51 p.m., Staff Member 2 indicated the resident was upset he had to leave room [ROOM NUMBER] for a smaller room. The resident was not given a choice to stay in room [ROOM NUMBER]. The resident was no longer on the therapy program. He was now on a long-term care restorative program. During an interview, on 9/11/24 at 1:05 p.m., the ED indicated the resident should have been given the choice to remain in room [ROOM NUMBER] or be moved to a different room in the facility. This citation relates to Complaint IN00442214. 3.1-12(a)(14)(A) 3.1-12(a)(14)(B)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to thoroughly investigate allegations of a staff member working while impaired and the potential residents' physical or emotional suffering from the impaired staff member's interactions for 1 of 1 staff member reviewed for allegation of abuse. (CNA 12) Finding includes: A Facility Reported Incident (FRI), dated 5/24/24, indicated Resident B had voiced concerns by social media. The resident indicated a male employee refused drug testing when it was reported he was altered. The staff was terminated due to refusal of the testing and left the building. The facility completed resident interviews, staff interviews, skin assessments, and education as deemed necessary. The clinical record for Resident B was reviewed on 7/10/24 at 12:25 p.m. The diagnoses included, but were not limited to, fusion of the spine in the lumbar region, generalized anxiety disorder, depression, and chronic obstructive pulmonary disease. An undated note from social media was provided by the Administrator on 7/11/24. The note was a copy of the social media post by Resident B. The resident indicated a male staff had touched her in an inappropriate manner and was extremely drunk. The male staff was dismissed from his job. The FRI, dated 5/24/24, did not include the allegation of Resident B being touched in an inappropriate manner. The full investigation of the incident was requested from the Administrator on 7/9/24, and again on 7/11/24 at 1:50 p.m. The resident interviews were provided on 7/11/24 and no staff interviews were included. The staff interviews along with the complete investigation were again requested. On 7/12/24 at 10:34 a.m., the completed investigation of the incident including the staff interviews was again requested. The Administrator indicated the Clinical Support was reviewing the file. The staff interviews were not provided by the facility until 7/12/24 at 11:45 a.m. A staff statement by the Assistant Director of Nursing (ADON), dated 5/13/24, indicated Resident B's husband called her to report the resident had concerns about a male CNA who provided care to her. The resident was in her room and indicated she was okay. The resident was asked about the concerns with the male CNA, and she indicated the CNA was acting weird and she could smell alcohol on his breath. The CNA kept getting close to her and putting his hand near her chest and shoulder area. The resident denied CNA 12 had touched her inappropriately. The investigation documents or statement from the ADON during the interview with Resident B did not include how the resident felt or her emotional status after the interaction with CNA 12. A staff statement by the ADON, dated 5/13/24, indicated CNA 12 was brought by the nurse in [NAME] Hall to the other side of the building since the nurse was questioning if the CNA was impaired. The CNA was already in the [NAME] Hall by the linen closet. The CNA looked confused and then he found a pillowcase and gave it to the resident who requested it. The CNA was asked to go to the ADON office and was not walking in a straight line. CNA 12 sat down and could hardly keep his eyes open and was slurring his words. The Administrator was called and sent a Reasonable Suspicion Checklist for Drug and Alcohol Screening Form. CNA 12 continued with signs of impairment including slurred and rambling speech, typing slowly on his cellular phone, kept closing his eyes, and staring. CNA 12 indicated he would never hurt a resident. CNA 12 admitted to drinking on the job and decided to not get tested. The Administrator had set up an Uber ride to take CNA 12 home. A staff statement by RN 13, dated 5/13/24, indicated CNA 12 was oriented to the evening shift on [NAME] Hall. He only assisted one resident to lay down, weighed another resident, passed one dinner tray, and toileted one resident. CNA 12 was not responding to call lights. RN 13 had to show CNA 12 where the linen closet was located 4 times and where the soiled utility room was 3 times. The CNA took a dirty brief into the clean linen room. Two residents had complained CNA 12 had run over their feet while assisting them to the bathroom. He did not act like he knew what he was doing. CNA 12 had very bloodshot reddened eyes and he was dozing at the nurse's station. RN 13 asked CNA 12 to go to the [NAME] unit to assist. He had to be physically assisted to go to [NAME] Hall. The ADON was informed he appeared to be impaired. The staff statements from the ADON and RN 13 did not indicate the exact amount of residents CNA 12 cared for while on duty and did not clarify how many residents were toileting since RN 13's statement indicated one resident was toileted and 2 residents had their feet ran over while being assisted to the bathroom. A staff statement by the Administrator, dated 5/14/24, indicated Resident B was interviewed about her interaction with CNA 12. Resident B indicated the CNA was acting oddly, was confused, asked the same question multiple times and was offering her assistance out of bed. Resident B was worried the CNA might try to touch her although he did not. The investigation documents or statement from the Administrator during the interview with Resident B did not include how the resident felt or her emotional status after the interaction with CNA 12. A psychiatric Nurse Practitioner note, dated 5/20/24, indicated the resident had increased depression due to the recent passing of her mother. The progress notes and facility investigation did not include the NP being informed of a possible interaction with CNA 12. The progress notes and facility investigation did not include a psychosocial assessment from the Social Services Director. The complete investigation provided by the facility only included three resident skin checks and 4 resident check list questions about abuse. The facility documents or investigation did not include statements from the residents about interactions with CNA 12. The facility documents or investigation did not indicate if these were the residents who complained of having their feet run over by CNA 12. During an interview, on 7/11/24 at 1:50 p.m., the Administrator indicated he was working at the facility on 5/13/24 and he had seen CNA 12 between 3:00 p.m. and 5:00 p.m. and did not notice anything unusual. Later in the day, he received a call from the ADON, and she indicated CNA 12 was not acting right. CNA 12 was staring off into space. He talked to CNA 12 on the telephone, and he refused to let the drug screen be completed. The CNA was assisted out of the facility and to his home. The ADON had talked to Resident B, and she said she was okay, and nothing had occurred. The investigation started the next day. Resident B stated CNA 12 was going to try to touch her although he did not. The resident's husband was upset about the situation, and he said CNA 12 touched the resident. Resident B again stated the staff did not touch her. He did not know if social services had documented any conversations or follow up with Resident B. The incident occurred on 5/13/24 and was not reported until 5/24/24 when Resident B put her concerns on a social media post. The resident's son had called after the social media post and after the resident was discharged to report she had past sexual abuse and would get nervous if she thought it could happen again. A current policy, titled Abuse-Conducting and Investigation, dated as last reviewed on 6/17/24 and received from the Administrator at entrance, indicated .It is the policy of this facility that allegations of abuse .are promptly and thoroughly investigated. The facility will prevent further abuse, neglect, exploitation and mistreatment from occurring while the investigation is in progress .Resident have the right to live at ease in a safe environment without the fear of retaliation when allegations are reported .The alleged victim will be examined for any signs of injury, including a physical examination or psychosocial assessment, if needed .The facility must thoroughly collect evidence to allow the Administrator to determine what actions are necessary [if any] for the protection of residents. Depending on the type of allegation received, it is expected that the investigation would include, but is not limited to .Conducting observations of the alleged victim, including identification of any injuries as appropriate, the location where the alleged situation occurred, interactions and relationships between staff and the alleged victim and/or other residents .Conducting interviews with, as appropriate, the alleged victim and representative, alleged perpetrator, witnesses, practitioner, interviews with personnel from outside agencies .Conducting record review for pertinent information related to the alleged violation, as appropriate, such as progress notes .The administrator/designee will review the Incident Report for completeness and assure that the physician and resident representatives have been notified of the circumstance .The written summary of the investigation should include, but is not limited to A review of the Incident Report .An interview the person[s] reporting the incident .An interview with the resident, if appropriate .Interviews with staff members on all shifts having contact with the resident at the time of the incident .Interviews with the resident's roommate, family, and/or visitors who may have information about the incident .Interviews other residents who received care of services from the alleged perpetrator .A review of all circumstances surrounding the incident .Emotional support and counseling will be provided to the resident during and after the investigation, as needed This citation relates to Complaint IN00435305. 3.1-28(d)

Based on interview and record review, the facility failed to submit a discharge MDS (Minimum Data Set) assessment upon discharge, making the assessment greater than 120 days since the last submitted assessment for 1 of 2 residents reviewed for resident assessments. (Resident 67) Finding includes: The clinical record for Resident 67 was reviewed on 7/12/24 at 3:10 p.m. The diagnoses included, but were not limited to, hypo-osmolality (nutrient levels in the blood are lower than normal), hyponatremia (low sodium level in the blood), alcohol abuse, pneumonia, cystitis (infection in the bladder), dysphagia (difficulty swallowing), and protein calorie nutrition. An admission MDS assessment, dated 2/9/24, indicated it was submitted 2/9/24 and was approved. A discharge MDS assessment, dated 5/1/24, indicated the assessment was pending and was not submitted. During an interview, on 7/12/24, the MDS Coordinator indicated the discharge assessment should have been completed and submitted. During an interview, on 7/12/24 at 3:28 pm, the Administrator indicated the facility used the RAI manual, there was no facility policy. 3.1-31(b)

Based on interview and record review, the facility failed to resubmit a PASARR (Preadmission Screening and Record Review) for a resident after a new mental health diagnosis and medication were added for 1 of 3 residents reviewed for PASARR. (Resident 70) Finding includes: The clinical record for Resident 70 was reviewed on 7/10/24 at 9:52 a.m. The diagnoses included, but were not limited to, major depressive disorder, moderate vascular dementia, psychotic disorder with delusions, and sleep disorder. A medical diagnosis list indicated the resident was added a diagnosis of mild major depressive disorder on 2/2/24 A physician's order, with a start date of 2/3/24, indicated the resident was prescribed sertraline (an antidepressant medication) 25 mg (milligram). A PASARR, with a notice date of 4/24/23, indicated Resident 70 was evaluated and had no mental health diagnosis or mental health medications There was no record of another PASARR being completed after the major depressive disorder diagnosis or antidepressant medication were added. During an interview, on 7/12/24 at 10:37 a.m., the Social Services Director (SSD) indicated the resident did not do another PASARR after the added diagnosis and medication. The resident should have had another PASARR completed, and it was just missed. A current policy, titled Pre-admission Screening and Resident Review (PASARR), dated as reviewed on 9/25/23 and received from the Administrator on 7/12/24 at 3:30 p.m., indicated .A negative Level I screen permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later .Any resident with newly evident or possible serious mental disorder, ID or a related condition must be referred, by the facility to the appropriate state-designated mental health or disability authority for review. Examples of individuals who may not have previously been identified by PASARR to have MD, ID or a related condition include, but is not limited to: a. A resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting the presence of a mental disorder 3.1-16(d)(1)(A) 3.1-16(d)(1)(B)

Based on observation, interview and record review, the facility failed to notify the physician of blood glucose levels out of the physician's parameters and to follow-up on a hospice order for a Broda chair (chair which helps accommodate residents with impaired mobility) for 3 of 3 residents reviewed for quality of care. (Resident L, C and 136) Findings include: 1. During an interview, on 7/10/24 at 10:00 a.m., Resident L indicated he had high blood sugar readings while being at the facility. The clinical record for Resident L was reviewed on 7/10/24 at 3:16 p.m. The diagnoses included, but were not limited to, mild chronic stage 2 kidney disease, hypertensive heart disease with heart failure, and type 2 diabetes with diabetic neuropathy. A current physician's order, with a start date of 7/26/23, indicated to notify the physician for blood sugars greater than 400. A facility vital log indicated Resident L had the following blood sugars: On 3/26/24, his blood sugar was 433. On 3/27/24, his blood sugar was 452. On 3/27/24, his blood sugar was 432. On 3/28/24, his blood sugar was 426. On 4/1/24, his blood sugar was 493. On 4/2/24, his blood sugar was 531. On 4/5/24, his blood sugar was 444. On 4/11/24, his blood sugar was 423. On 4/26/24, his blood sugar was 434. During an interview, on 7/11/24 at 10:53 a.m., the Administrator indicated he did not see any call outs to the physician for the high blood sugars. 2. During an interview, on 7/10/24 at 12:02 p.m., Resident C's family member indicated the resident's blood sugar readings were in the 400 and 500 range and the facility did not try to give her a different insulin. The clinical record for Resident C was reviewed on 7/10/24 at 10:37 a.m. The diagnoses included, but were not limited to, type 2 diabetes mellitus, generalized anxiety disorder, and generalized muscle weakness. A physician's order, dated 3/24/24, indicated to check the fasting blood sugar one time a day. A physician's order, dated 3/24/24, indicated to notify the physician for blood sugars less than 60 or greater than 400. The resident had the following blood sugar readings: a. On 5/22/24 at 6:16 a.m., the blood sugar was 429. b. On 6/4/24 at 6:13 a.m., the blood sugar was 453. c. On 6/7/24 at 6:16 a.m., the blood sugar was 448. d. On 6/9/24 at 6:12 a.m., the blood sugar was 538. e. On 6/12/24 at 6:05 a.m., the blood sugar was 436. c. On 6/13/24 at 5:34 a.m., the blood sugar was 437. A physician's order, dated 6/9/24, indicated to recheck the blood sugar at 7:30 a.m., and notify the physician if the reading was greater than 400. The progress notes showed the physician was only notified on the elevated blood sugar on 6/9/24. 3. During an observation, on 7/10/24 at 11:45 a.m., Resident 136 was lying in bed in her room with her eyes closed. During an observation, on 7/11/24 at 3:37 p.m., the resident was lying in bed in her room and her eyes were closed. During an observation, on 7/12/24 at 1:50 p.m., the resident was lying in bed in her room, her eyes were closed, and the room was darkened. The clinical record for Resident 136 was reviewed on 7/12/24 at 1:56 p.m. The diagnoses included, but were not limited to, hemiplegia and hemiparesis affecting the right dominant side, chronic obstructive pulmonary disease, and pressure ulcers. During an interview, on 7/11/24 at 3:37 p.m., CNA 10 indicated the resident was on hospice, was totally dependent for care, and did not get out of bed on the evening shift. During an interview, on 7/11/24 at 3:47 p.m., LPN 11 indicated the resident was fairly new and was on hospice. The family preferred for the resident not to get out of bed. A physician's order indicated to be admitted to Hospice with a diagnosis of hemiplegia and hemiparesis following a cerebral infarction. A hospice social worker note, dated 7/3/24, indicated the resident's daughter stated the resident was very social prior to her strokes and she still enjoyed having companionship although she was unable to talk as much as she would like to. During an interview, on 7/10/24 at 11:55 a.m., the Activity Director indicated the resident would get up in her Broda (chair for positioning) although she did not know what time of day she got up. The resident did not have a Broda chair in her room. During an interview, on 7/12/24 at 2:19 p.m., the Hospice Registered Nurse (RN) indicated the Broda chair was ordered upon admission to hospice on 7/3/24. The hospice had some changes in leadership, and it was just missed for approval. Since the Broda chair was ordered, it was an expectation the resident would be getting up in the Broda chair. The resident had a decline in condition although was not in the active phase of dying. The facility staff and the hospice staff would determine in collaboration how long the resident would be up daily. The Broda chair would be approved today as soon as the RN got the request to the correct person in hospice. A Hospice Services Agreement, approved on 7/19/21, indicated .Hospice will ensure that all Hospice Services are provided to Hospice Patients in a manner which meets or exceeds professional standards and principles that apply to individuals providing services in Facility. Hospice will provide all reasonable and necessary Hospice Services to Hospice Patients in a timely manner and accordance with each Hospice Patient's Hospice Plan of Care .Hospice Services will include .medical direction and management of the Hospice Patient .medical supplies, durable medical equipment .Coordination of Services .Hospice will participate, upon request, in interdisciplinary and other care planning conferences required to coordinate the Hospice Services, Facility Services, and other services provided to an individual Hospice Patient .Hospice shall retain professional management responsibility for Hospice Services provided in accordance with the Hospice Plan of Care A current policy, titled Changes in Resident's Condition or Status, dated as last reviewed on 8/9/23 and received from the Administrator on 7/12/24 at 10:55 a.m., indicated .This facility will notify the resident, his/her primary care provider, and resident/resident representative of changes in the resident's condition or status . This citation relates to Complaint IN00436564. 3.1-37(a)

Based on observation, interview and record review, the facility failed to turn and reposition a resident every 2 hours as ordered to promote healing and to prevent future pressure injuries for 1 of 4 residents reviewed for pressure ulcers. (Resident 50) Finding includes: During an observation, on 7/8/24 at 1:26 p.m., Resident 50 was sitting up in bed waiting for her lunch tray. She was paralyzed from the waist down with her right arm severely limited in range of motion and function with severe muscle wasting. The clinical record for Resident 50 was reviewed on 7/11/24 at 3:36 p.m. The diagnoses included, but were not limited to, paraplegia, type 2 diabetes mellitus, neuromuscular dysfunction of bladder, abnormal posture, depression, colostomy, indwelling urethral catheter, seizures, stage 3 and 4 pressure ulcers of sacral region, right and left buttock stage 3 pressure ulcers, recurrent moderate major depressive disorder, generalized anxiety disorder, and chronic obstructive pulmonary disease. A physician's order, dated 11/15/22, indicated to turn the resident every two hours for comfort and wound healing. If the resident is asleep, turn her anyway, per resident. A care plan, initiated on 11/30/22, indicated to turn the resident every 2 hours due to limited mobility, pressure ulcer, and to prevent new pressure injuries. It indicated she was dependent for bed mobility. A Skin/Wound note, dated 6/8/24 at 12:28 p.m., indicated the resident was compliant with every 2-hour turning. A care management note from the facility interdisciplinary team, dated 6/20/24 at 11:02 a.m., indicated the resident had a pressure wound to her coccyx which had been there for several years, did not get out of bed except for showers, and she was to be turned and repositioned every 2 hours to promote wound healing. The certified nursing assistant (CNA) task record, dated 6/13/24 through 7/12/24, indicated the resident required extensive assistance of 1 person for bed mobility. It indicated the task of bed mobility did not occur on some night shifts (6/16/24, 6/17/24, 6/20/24). The CNA task record, dated 6/28/24 through 7/11/24, indicated the charting of every 2-hour turns was missing on: 6/28/24 for 10:00 a.m., 12:00 p.m., 4:00 p.m., 6:00 p.m., and 8:00 p.m. 6/30/24 for 12:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m., 6:00 p.m., and 8:00 p.m. 7/1/24 for 5:00 p.m., 7:00 p.m., and 11:00 p.m. 7/2/24 for 2:00 a.m., 4:00 a.m., 6:00 a.m., 4:00 p.m., and 6:00 p.m., 7/3/24 for 4:00 p.m., 6:00 p.m., and 11:00 p.m. 7/4/24 for 12:00 a.m., 2:00 a.m., 10:00 a.m., 6:00 p.m., 8:00 p.m., and 10:00 p.m. 7/5/24 for 12:00 a.m., 2:00 a.m., 3:00 p.m., 5:00 p.m., 7:00 p.m., and 11:00 p.m. 7/6/24 for 3:00 a.m., 5:00 a.m., 9:00 a.m., 4:00 p.m., 6:00 p.m., and 11:00 p.m. 7/7/24 for 10:00 a.m., 3:00 p.m., and 11:00 p.m. 7/8/24 for 4:00 p.m., 6:00 p.m., 8:00 p.m., and 10:00 p.m. 7/9/24 for 12:00 a.m., 3:00 a.m., and 5:00 a.m. 7/10/24 for 12:00 a.m., 2:00 a.m., 4:00 a.m., 6:00 a.m., 5:00 p.m., 7:00 p.m., 9:00 p.m., and 11:00 p.m. 7/11/24 for 12:00 a.m., 2:00 a.m., 4:00 a.m., 6:00 a.m., and 8:00 a.m. A Skin/Wound note, dated 7/01/24 at 1:33 p.m., indicated the resident continued to have a slow healing sacrococcygeal wound. The resident was to be turned and repositioned every 2 hours and to utilize a wedge cushion for positioning. The physician was updated regarding continued skin issue. During an interview, on 7/8/24 at 1:26 p.m., the resident indicated she was supposed to be turned every 2 hours, but evenings and nights often did not turn her. They waited for her to turn her call light on and ask, despite her telling them she wanted to be woken up every 2 hours during the night. She did not want to have to call and/or wake herself up with an alarm because it was far more disruptive to her sleep and made it more difficult for her. She indicated it was very important to her because she had chronic pressure wounds which she really wanted to heal and because she did not want to get any new wounds. During an interview, on 7/10/24 at 11:14 a.m., the resident indicated, on 7/9/24, she had been turned around 4:00 p.m., and then took a nap. She turned her call light on after she woke up around 8:00 p.m., and believed she was turned about 20 minutes later. She was then not turned again until roughly 1:00 a.m. and 5:00 a.m. She indicated this was a regular occurrence, especially on evening and night shift except for when certain CNAs were on duty. She had complained about this multiple times, and she had personally told CNAs she wanted to be woken up every 2 hours no matter what. It had been an on-going issue, and this was why she even had an order to turn every 2 hours even when she was sleeping. During an interview, on 7/12/24 at 9:59 a.m., the Social Services Director indicated during the resident's care plan meeting, on 6/25/24, there was a nursing concern of evening/night CNAs not always turning every 2 hours. The Director of Nursing (DON) was present at the meeting and was addressing the issue. This was not the first time the resident had brought this issue up. During an interview, on 7/12/24 at 10:23 a.m., the Director of Nursing (DON) indicated every 2-hour checks and turning had been an ongoing concern. She had re-educated the CNAs to turn even when Resident 50 was asleep and to set alarms on their phones to help them remember. The facility had several brand-new CNAs who had just completed their certifications. During an interview, on 7/12/24 at 10:32 a.m., CNA 1 indicated they would try to turn her on even hours because it usually worked out better and to make it easier to remember. The resident had often complained that the night staff only turned her during their last round before the day shift came on. She tried to remind other staff members during their report/hand-off. A current job description, titled Certified Nursing Aide (CNA) Job Description: Primary, dated 11/10/16 and received from the Administrator on 7/11/24 at 1:30 p.m., indicated .The Certified Nursing Aide is responsible for providing routine daily nursing care to assigned patients to assure patient safety and attain or maintain the highest practicable physical .well-being .Must be able to lift, turn, move, position, and transport patients .Must be able to accurately document and chart patient care A policy for preventing pressure ulcers and/or routine turning of residents was requested on 7/12/24. The facility indicated they did not have a policy, and they did not provide one. 3.1-40(a)(2)

2. During an observation, on 7/08/24, Resident H was in the hallway in her wheelchair with her foley catheter in a dignity bag. The clinical record for Resident H was reviewed on 7/10/24 at 9:50 a.m. The diagnoses included, but were not limited to, peripheral vascular disease, retention of urine, polyneuropathy, acquired absence of left leg above the knee, restless legs syndrome, cerebral infarction without residual deficits, and obstructive and reflux uropathy. A physician's order, dated 2/2/24, indicated indwelling catheter to straight drainage. Size: 18 Fr Bulb: 30 cc. Change for infection, obstruction, or when the closed system was compromised as needed. A progress note, dated 4/3/24 at 4:47 p.m., indicated the resident complained the Foley catheter was leaking. The nurse deflated the balloon, advanced the catheter and re-inflated the balloon. The electronic medical record did not include a physician's order for the procedure of deflating the balloon, advancing the catheter, and re-inflating the balloon of the catheter. A progress note, dated 4/4/24 at 11:24 a.m., indicated the Foley catheter was lying on the resident's bed with the balloon still inflated. A new 18 Fr 30 cc Foley catheter was placed utilizing aseptic technique. A progress note, dated 4/9/24 at 6:00 p.m., indicated the Foley catheter was found lying in the resident's incontinence brief with the balloon intact. A new 18 Fr 10 cc Foley catheter was placed utilizing aseptic technique. During an interview, on 7/10/24 at 11:35 a.m., the resident indicated her catheter was not secured in any way to her leg to prevent pulling or dislodgement. The electronic medical record did not include documentation of the use of a device to secure the catheter for the resident. A current policy, titled Indwelling Urinary Catheter (Foley) Management, dated as reviewed on 8/24/23 and received from the Administrator on 7/10/24 at 3:10 p.m., indicated .The facility will ensure .Insertion, ongoing care, and catheter removal protocols that adhere to professional standards of practice and infection prevention and control procedures .If .leakage occur, replace the catheter and collecting system using aseptic technique and sterile equipment .Keeping the catheter anchored to prevent excessive tension on the catheter, which can lead to urethral tears or dislodging the catheter. This citation relates to Complaint IN00436564. 3.1-41(a)(2) Based on interview and record review, the facility failed to follow the physician's orders for indwelling urinary catheters for 2 of 3 residents reviewed for indwelling catheters. (Resident C and H) Findings include: During an interview, on 7/10/24 at 12:02 p.m., Resident C's family member indicated the resident's catheter needed to be changed the day she was being discharged and the staff would not listen. The family decided to take the resident to the emergency room after her discharge from the facility so they could put in a new catheter. The clinical record for Resident C was reviewed on 7/10/24 at 10:37 a.m. The diagnoses included, but were not limited to, type 2 diabetes mellitus, obstructive reflux uropathy (urine backing up in the kidneys), generalized anxiety disorder, and generalized muscle weakness. A care plan, dated 12/2/23 and revised on 6/21/24, indicated the resident had obstructive uropathy and had an indwelling urinary catheter. The interventions included, but were not limited to, catheter care every shift and educating the resident and family on catheter care. A physician's order, dated 6/3/24, indicated an indwelling catheter to straight drainage, size 22 French (Fr indicates diameter of catheter) with 30 cc bulb. Change the indwelling catheter for infection, obstruction, or when the closed system was compromised. A progress note, dated 6/14/24 at 2:11 p.m., indicated Resident C was crying and stated something was wrong with her catheter. The catheter bag was on the floor with the resident sitting on the bed and the catheter tubing was taut and hematuria (blood in the urine) was noted. The nurse offered to deflate the balloon and reposition the Foley catheter. The resident initially refused and then the daughter stated she would take the resident to the emergency room and have a new catheter put in. The resident consented and the catheter balloon was deflated, then the indwelling catheter was advanced, and the balloon was re-inflated. The catheter was draining tea colored urine. The progress note did not include a notification to the physician of the blood in the catheter tubing. A progress note, dated 6/14/24 at 3:55 p.m., indicated the resident was discharged with her daughter and the daughter indicated she was taking the resident to the emergency room. During an interview, on 7/10/24 at 2:50 p.m., RN 9 indicated Resident C did her all her own catheter care. During an interview, on 7/10/24 at 3:31 p.m., the Director of Nursing (DON) indicated it was a nursing measure to deflate a catheter bulb, advance the catheter and to re-inflate the catheter bulb. The resident had a huge risk of infection. The facility did not need to get the deflating of the catheter bulb, advancing the catheter and re-inflation of the bulb cleared by the urologist. The facility would not notify the urologist or physician of the blood in the catheter unless it was a huge amount of blood. Usually, blood in a catheter would resolve on its own in 24 hours.

Based on interview and record review, the facility failed to ensure transportation was available for dialysis for 1 of 1 resident reviewed for dialysis. (Resident 18) Finding includes: During an interview, on 7/9/24 at 10:06 a.m., Resident 18 indicated she had to be hospitalized about a month ago when the facility did not have transportation to dialysis on a Saturday. The facility did not tell the resident until the last minute there was no transportation. The clinical record for Resident 18 was reviewed on 7/11/24 at 11:44 a.m. The diagnoses included, but were not limited to, dependence on renal dialysis, type 2 diabetes mellitus, end stage renal disease, congestive heart failure, right lower leg amputation at level between knee and ankle and acquired absence of the left leg below the knee. A care plan, dated as last revised on 4/9/24, indicated the resident had chronic congestive heart failure. The interventions included, but were not limited to, observing and reporting signs of congestive heart failure including shortness of breath on exertion. A care plan, dated as last revised on 5/14/24, indicated the resident received hemodialysis outside of the facility. The interventions included, but were not limited to, dialysis treatments as ordered. A care plan, dated as last revised on 7/2/24, indicated the resident was at risk for fluctuations in weight related to hemodialysis and fluid imbalances. The interventions included, but were not limited to, reporting any shortness of breath, abnormal breath sounds, and to notify the physician of increasing shortness of breath, increased anxiety or inability to lie flat. A physician's order indicated the resident was to receive dialysis on Tuesdays, Thursdays and Saturdays. A progress note, dated 6/1/24 at 9:24 a.m., indicated the transportation to dialysis was canceled and the facility was unable to take the resident to dialysis. A progress note, dated 6/2/24 at 8:07 a.m., indicated the resident had called 911 and told 911 she could not breathe. The resident indicated she had missed dialysis the day before. A hospital note, dated 6/2/24, indicated the diagnoses were fluid overload, pulmonary edema, congestive heart failure, and acute respiratory failure with hypoxia. The resident was not able to go to dialysis on 6/1/24 due to a transportation issue. The resident had felt short of breath the entire night and was not able to breathe normally this morning. Nephrology was consulted for dialysis needs. The resident received hemodialysis on 6/2/24 with significant improvement in shortness of breath. A progress note, dated 6/4/24 at 6:34 p.m., indicated the resident had returned to the facility from the hospital stay. During an interview, on 7/12/24 at 10: 25 a.m., the Activities Director indicated the transport company used on Tuesdays and Thursday for dialysis would not provide transportation on Saturdays. The transport company who usually transported Resident 18 on Saturdays had staff on vacation and were not available for the transport on 6/1/24. There was a miscommunication and the facility only found out on 6/1/24 about 20 minutes prior to the usual pick-up time for dialysis. The facility was going to call a cab for the transport although the dialysis center was not able to assist the resident to get out of a cab and into the facility. The resident had to miss dialysis on 6/1/24 since the facility could not find transportation to dialysis. An Agreement for Dialysis Services with U.S. Renal Care, approved on 7/19/21, indicated, .Provider is in the business of providing dialysis services. Facility is a licensed health care facility in the business of providing skilled nursing services .Provider shall furnish the equipment, supplies, instruments and other items necessary to provide the Services .Transportation of Residents .Facility shall have the responsibility for arranging suitable transportation of the residents to and from Provider, including the selection of the mode of transportation, qualified personnel to accompany the resident and transportation equipment usually associated with this type of transfer .Facility shall .be responsible for all costs of transportation associated with the transfer of resident to and from Provider and Facility. Facility shall be responsible for, and shall provide the necessary personnel for, assisting the resident in entering into and exiting from Provider 3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure an order for side rails was obtained and an assessment for side rails was completed prior to the use of side rails for 1 of 3 residents reviewed for accident hazards. (Resident D) Finding includes: During an interview, on 7/9/24 at 9:02 a.m., Resident D indicated she used the side rails for mobility assistance while in bed. During an observation, on 7/9/24 at 10:25 a.m., Resident D was in bed with the side rails in the raised position. During an observation, on 7/11/24 at 9:37 a.m., Resident D was asleep in bed with both side rails in the raised position. The clinical record for Resident D was reviewed on 7/10/24 at 9:22 a.m. The diagnoses included, but were not limited to, generalized muscle weakness, unspecified protein-calorie malnutrition, attention and concentration deficit, and insomnia. The physician's orders did not include an order for the use of the side rails. The electronic health record did not include a side rail assessment. The electronic health record did not include a signed consent for the use of the side rails. The electronic health record did not include appropriate alternatives attempted prior to installation of the side rails. The care plan did not include the use of the side rails. During an interview, on 7/11/24 at 9:46 a.m., the Administrator indicated Resident D was given a new bed and it already had the side rails. He indicated they had missed obtaining an order or an assessment for the use of the side rails. During an interview, on 7/11/24 at 9:29 a.m., the Administrator indicated they obtained blanket consent from everyone in the facility even if they did not need the side rails at the time. A current policy, titled Bed Rails- Safe and Effective Use of Bed Rails, dated as last revised on 12/30/22 and received from the Administrator on 7/11/24 at 10:00 a.m., indicated .To prevent entrapment and other safety hazards associated with bed rail use .The facility must attempt to use appropriate alternative prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements .Assess the resident for risk of entrapment from bed rails prior to installation .Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation .If bed rails are determined to be appropriate for use with a resident, a reassessment of bed rail(s) use will be assessed at a minimum quarterly and potentially with a change of condition utilizing the Evaluation of Use of Bed Rails Form (Quarterly) .If a bed rail will be utilized, the risks and benefits of bed rail(s) usage will be reviewed with the resident and/or resident representative and consent will be obtained prior to installation of the bed rails or as soon a practically possible. The facility should use the Med-Pass Consent for Use of Bed Rails (LCCA-574) .The facility will document alternative to the use of a bed rail(s) and how these alternatives did not meet the resident's assessed needs prior to the utilization of a bed rail(s). 3.1-45(2)

Based on observation, interview, and record review, the facility failed to address an annual gradual dose reduction (GDR) for an anti-depressant and an antipsychotic for 1 of 5 residents reviewed for unnecessary medications. (Resident J) Finding includes: During an observation, on 7/8/24 at 12:30 p.m., Resident J was smiling and engaged in conversation with the surveyor. The resident was sitting up in her wheelchair, waiting for her lunch tray. During an observation, on 7/9/24 at 10:15 a.m., the resident was up in her wheelchair. The resident was smiling and eager to engage in conversation. The resident was very talkative. During all other observations, between 7/10/24 and 7/12/24, Resident J was smiling, talkative, and readily engaged in conversation. The clinical record for Resident J was reviewed on 7/10/24 at 2:29 p.m. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease, type 2 diabetes mellitus with hyperglycemia and polyneuropathy, schizoaffective disorder bipolar type, affective mood disorder, major depressive disorder, malignant neoplasm of brain, mild cognitive impairment, history of falling, generalized anxiety disorder, and pain. A physician's order, dated 3/26/20, indicated bupropion (an anti-depressant) 150 milligram (mg) tablet, give 1 tablet by mouth one time a day related to major depressive disorder. A physician's order, dated 5/3/23, indicated olanzapine (an antipsychotic) oral tablet 10 mg, give 1 tablet by mouth two times a day related to schizoaffective disorder, bipolar type. The last GDR for bupropion was contraindicated on 3/26/20. A psychosocial note, dated 3/26/2020 at 12:41p.m., indicated resident's bupropion was up for GDR. Resident is doing well and making positive adjustments in light of recent increased precautions associated to COVID-19. GDR will be contra-indicated today due to present circumstances. There was no annual GDR recommendation for bupropion between 6/1/23 and 7/12/24. The last GDR for the olanzapine was accepted on 4/24/23. There was no annual GDR recommendation for olanzapine between 4/24/23 and 7/12/24. No other GDRs for bupropion or olanzapine were recorded in the electronic medical record. All GDRs for Resident J were requested on 7/10/24 at 2:30 p.m. During an interview, on 7/11/24 at 3:45 p.m., the Administrator indicated he had provided all available GDRs. He did not find any GDR requests from pharmacy during the monthly reviews for bupropion. The last GDR for olanzapine was 4/24/23. The Administrator indicated he believed no one had looked at bupropion again since the order said the GDR was contraindicated on 3/26/20. He did not realize it was denied due to the Covid situation at that time. A current policy, titled Unnecessary Medication, dated as last reviewed on 8/09/23 and received from the Administrator on 7/12/24 at 10:15 a.m., indicated .ensure only mediations required to treat the resident's assessed condition are being used, reducing the need for and maximizing the effectiveness of medications .Gradual Dose Reduction (GDR)- This is the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued .The facility's medication management process will support and promote .Selection and use of medications in doses and for the duration appropriate to each resident's clinical conditions, age, and underlying causes of symptoms 3.1-48(b)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure medications administered orally were separated from topical medications and eye drops, to store cleaning supplies separately from medications, correctly label OTC (over the counter) medications, date opened medications, and routinely dispose of medications after the date of expiration for 4 of 4 medication carts reviewed. (medication cart 1, medication cart 2, medication cart 3, and medication cart 4) Findings include: During a medication cart observation with Qualified Medical Assistant (QMA) 6, on [DATE] at 11:06 a.m., medication cart 1 was observed to have the following: a. The top right drawer had two medication cups containing one pill in each cup not labeled with the resident's names or with the medication name. b. The bottom right drawer had an unlabeled nebulizer machine (a device which turned liquid medication into a mist to be inhaled into the lungs through a mask or mouthpiece) c. The top left drawer had Smooth Nighttime eye ointment, dated opened [DATE]. d. A Saline Nose Spray without a date opened. During a medication cart observation with QMA 6, on [DATE] at 11:19 a.m., medication cart 2 was observed to have the following: a. The top left drawer had ear wax removal drops improperly stored next to Ferrocite oral tablets. b. The second left drawer had OTC vitamin C tablets not labeled with the dose of the medication, the administration directions, or the physician's name. c. The bottom left drawer had mupirocin ointment (an ointment put onto the skin to treat a skin infection) stored in the medication cart instead of being stored in a treatment cart. d. The bottom left drawer had sanitizer wipes stored next to oral medications. During an interview, QMA 6 indicated the sanitizer wipes should not be stored next the oral medications and the ointment should have been stored in the treatment cart. During a medication cart observation with QMA 7, on [DATE] at 11:34 a.m., medication cart 3 was observed to have the following: a. The top drawer had oral medications stored next to eye drop medications without a divider between the two medications. b. The second drawer had Refresh Eye Tears (eye drops which help with dry eye) opened, dated [DATE], and more than 30 days past the discard after opening date. c. The second drawer had Polyvinyl alcohol eye drops (eye drops which help with dry eye) opened, dated [DATE], and more than 30 days past the discard after opening date. During an interview, on [DATE] at 11:45 a.m., QMA7 indicated the eye drops were good for 90 days once opened. During a medication cart observation with RN 8, on [DATE] at 11:49 a.m., medication cart 4 was observed to have the following: a. Glucose gel (to treat low blood sugar) unopened and past expiration date of 4/2024. A current policy, titled .Storage and Expiration Dating of Medications, Biologics, dated as last revised on [DATE] and received from the Administrator on [DATE] at 1:47 p.m., indicated .Topical (external) use medications or other medications should be stored separately from oral medications when infection control issues may be a consideration .Facility should ensure that test reagents, germicides, disinfectants, and other household substances are stored separately from medications .Facility should ensure that medication and biologicals that: (1) have an expired date on the label; (2) have been retained longer tan recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier .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 .Medications with a manufacturer's expiration date expressed in month and year (e.g. [DATE]) will expire on the last day of the month .When an ophthalmic solution or suspension has a manufacturers shortened beyond use date once opened, facility staff should record the date opened and the date to expire on the container .Facility should destroy and reorder medications and biologicals with soiled, illegible, worn, makeshift, incomplete, damaged or missing labels or cautionary instructions .Facility personnel should inspect nursing station storage areas for proper storage compliance on a regularly scheduled basis. Facility should request that Pharmacy perform a routine nursing unit inspection for each nursing station in Facility to assists Facility in complying with its obligations pursuant to Applicable Law relating to the proper storage, labeling, security and accountability of medications and biologicals . 3.1-25(j) 3.1-25(o)

Based on record review and interview, the facility failed to ensure a MDS (Minimum Data Set) assessment was accurate for 1 of 1 resident reviewed for resident assessments. (Resident 42) Finding includes: The record for Resident 42 was reviewed on 4/24/23 at 3:29 p.m. Diagnoses included, but were not limited to, type 2 diabetes mellitus, acute kidney failure, and hemiplegia and hemiparesis following cerebral infarction. A quarterly MDS assessment, dated 3/28/23, indicated the resident received insulin 7 days out of the last 7 days. During a review of the physician orders, the resident's insulin had been discontinued 8/2022. During an interview, on 4/24/23 at 11:19 a.m., the MDS Coordinator indicated she marked the March 28, 2023, MDS assessment as the resident was receiving insulin. She indicated she was not aware Victoza (a non-insulin medication which lowers blood sugar) was not insulin. The resident was receiving Victoza and not insulin. The MDS should have only been coded for receiving injections and not insulin. A current policy, titled Resident Assessment Instrument & Care plan Development, dated as revised on 8/16/22 and received from the Administrator on 4/26/23 at 4:45 p.m., indicated .The facility will follow the procedures set forth in the Resident Assessment Instrument [RAI] User's Manual 3.0 when completing the MDS, Care Area Assessment, and Comprehensive Care Plan .A facility must make a comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument [RAI] specified by CMS 3.1-31(d)(3)

Based on interview and record review, the facility failed to ensure a resident with congestive heart failure received daily weights and the physician was notified of a weight gain as ordered for 1 of 3 residents reviewed for quality of care. (Resident 33) Findings include: During an interview, on 4/20/23 at 2:00 p.m., Resident 33 indicated she had lost weight. The resident had an order for daily weights and was not always weighed daily. The record for Resident 33 was reviewed on 04/24/23 at 10:32 a.m. Diagnosis included, but were not limited to, heart failure, hypertension, vascular dementia, atrial fibrillation (irregular, rapid heartbeat), Alzheimer's disease, and cognitive communication deficit. A physician's order, dated 5/11/22, indicated daily weights and to notify the physician if there was a plus or minus of 3 pounds a day or 5 pounds a week or if there was a 5% plus or minus change in 30 days. Notify the physician and Director of Nursing (DON) for all refusals as soon as possible. A physician's order, dated 6/26/22, indicated furosemide (a diuretic) tablet 20 mg (milligrams), to give 3 tablets by mouth twice a day related to heart failure and edema (swelling). A care plan, dated as revised on 11/16/22, indicated the resident was at risk for fluctuation in weights related to congestive heart failure. The interventions included, but were not limited to, daily weights. The Medication Administration Record (MAR) indicated a daily weight was not taken on 3/1/23, 3/23/23 and 3/29/23. The MAR indicated the physician should have been notified of the following weights: a. A weight gain of 4.4 pounds on 3/14/23. b. A weight gain of 4.7 pounds on 4/21/23. During an interview, on 4/25/23 at 9:13 a.m., the DON indicated if the resident was a daily weight and had congestive heart failure they needed to be weighed daily. The physician's order should be followed, and the physician notified of a weight gain. During an interview, on 4/25/23 at 2:39 p.m., the DON did not have weights for 3/1/23, 3/23/23 and 3/29/23 and the facility did not have a policy for congestive heart failure. A current policy, titled Changes in Resident's Condition or Status, received from the Administrator on 4/25/3 at 3:08 p.m., indicated .The facility will notify the resident, his/her attending physician, and representative (sponsor) of changes in the resident's condition and/or status. The following will outline the process. 1. Nursing services will be responsible for notifying the resident's attending physician when: b. There is significant change in the resident's physical, mental, or emotional status. c. The resident refuses treatment of medications and reason(s) why .4. All notifications must be made as soon as practical, but in no case will such notification exceed twenty-four (24) hours 3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure the controlled substance record used was provided by the pharmacy and not altered by facility staff for 1 of 3 medication carts observed for medication storage. (Ross Hall) Findings include: During an observation of Ross Hall medication cart, on 4/26/23 at 11:15 a.m., the following was observed for Resident 11: 1. Resident 11's controlled substance record from the pharmacy for lorazepam 0.5 mg indicated there were 27 tablets remaining. 2. The card for the lorazepam 0.5 mg contained 25 tablets. 3. The controlled substance record from the pharmacy for hydrocodone-acetaminophen 5-325 milligrams indicated 26 tablets remained. 4. The card for the hydrocodone-acetaminophen had 26 tablets. 5. The controlled substance records for the medications had been switched by the staff and the counts for the medication were off by one tablet. A controlled substance record, dated 4/24/23, indicated hydrocodone-acetaminophen 5-325 milligram tablets. The hydrocodone-acetaminophen had a line drawn through it with an arrow pointing below and Lorazepam 0.5 milligrams was handwritten and highlighted. A controlled substance record, dated 4/24/23, indicated lorazepam 0.5 mg tablets. The lorazepam had a line drawn through it with an arrow pointing below and Hydrocodone-acetaminophen 5-325 milligrams was handwritten and highlighted. During an interview, on 4/26/23 at 11:20 a.m., QMA 3 indicated the controlled substance records had been switched. During an interview, on 4/26/23 at 11:45 a.m., the Director of Nursing indicated the controlled substance records should not have been switched. A current policy, titled Storage and Expiration Dating of Medications, Biologicals, received from the Administrator, on 4/27/23 at 4:45 p.m., indicated .applying with its obligations pursuant to Applicable Law relating to proper storage, labeling, security and accountability of medications and biologicals .facility personnel should .inspect storage areas for proper storage compliance 3.1-25(e)(2) 3.1-25(e)(3)

Based on observation, interview and record review, the facility failed to ensure expired food was discarded, the refrigerator did not contain employee lunches and the dishwasher was washing at the recommended temperature. The deficient practice had the potential to affect 67 of 68 residents who received food from the kitchen. Findings include: During an observation, on 4/20/23 at 11:36 a.m., the walk-in refrigerator had a container of creamed corn and a container of cottage cheese with expiration dates of 4/17/23. The 3-door refrigerator had a yellow sack which contained the Dietary Manager's lunch. During an observation, on 4/20/23 at 11:45 a.m., the Dietary Manager (DM) started the dishwasher. She indicated the wash cycle temperature needed to be at least 160 degrees. The temperature dial on the dishwasher was stationary at 140 degrees during the wash cycle. She was given a thermometer by the [name of company] technician to place into the machine to get a temperature when the machine ran through a cycle. She placed the thermometer in the dishwasher and ran two cycles. She opened the dishwasher and removed the thermometer. The thermometer had a temperature of 123 degrees. The machine was missing two bolts at the bottom left and when the dishwasher was running water was coming out of the holes. During an interview, on 4/20/23 at 11:36 a.m., the DM indicated the container of creamed corn, and the cottage cheese was expired and should have been discarded. During an interview, on 4/20/23 at 11:53 a.m., the DM indicated the temperature on the dishwasher should be at least 160 degrees and the temp was 123 degrees when she used the thermometer. They had a technician out twice and who told the facility nothing was wrong. The dishwasher was also missing two bolts on the lower side of the dishwasher and water was coming out of the holes when the dishwasher was in use. During an interview, on 4/20/23 at 2:03 p.m., the Service Employee with [name of company] indicated the dishwasher was getting up to the recommended temperature when he arrived at the facility. The temperature was 160 degrees, and it was found nothing was wrong. An Installation and Operation Manual from [name of appliance company] indicated the water requirements for the wash temperature was a minimum of 150 degrees Fahrenheit and a recommended wash temperature of 160 degrees Fahrenheit. During an interview, on 4/20/23 at 2:04 p.m., the Administrator indicated when he checked the temperature with the DM it went up to 150 degrees and did not hold at the recommended temperature. During an interview, on 4/20/23 at 2:05 p.m., the Maintenance Director indicated he could not understand why the temperature did not stay at the correct temperature. He thought it could be because they were doing laundry at the same time as running the dishwasher. During an interview, on 4/21/23 at 9:15 a.m., the Administrator indicated the dishwasher had to go through 5 cycles to get the recommended temperature. During an interview, on 4/21/23 at 9:33 a.m., the DM indicated since the dishwasher did not get up to the recommended temperature this had a potential to have bacteria left on the plates, cups and silverware which could cause the residents to become sick. A current policy, titled Sanitation, received from the Administrator on 4/24/3 at 9:57 a.m., indicated .Residents in long-term care facilities are especially vulnerable to organisms and all persons associated with the handling of food be trained in this area .Food-borne illnesses can usually be prevented by proper storage, preparation, distribution, handing and serving of food .Any food not in its original container must be labeled with the date and contents and must be securely covered .The dish machine should be clean inside and out .There is no outdated food (over 72 hours old or per manufacturer's guidelines 3.1-21(i)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the resident hallways and a bathroom were clean and in good repair for 2 of 4 hallways and 1 of 10 bathrooms observed for the environment. ([NAME] and Ross Hall) Findings include: During an observation of the Ross Hall, on 4/20/23 at 1:49 p.m., the following was observed: 1. The beige carpet on the lower half of the wall below the handrails had several bubbled areas all throughout the hallway and appeared like the carpet was coming off the wall. 2. The carpet on the floor in the hallway was faded and worn. During an observation of the [NAME] hallway, on 4/21/23 at 11:08 a.m., the following was observed: 1. The carpet on the floor in the hallway between room [ROOM NUMBER] and room [ROOM NUMBER] had a hole larger than the size of a softball. 2. The carpet on the floor in the hallway between room [ROOM NUMBER] and room [ROOM NUMBER] had two very large dark stains. 3. The carpet on the wall between room [ROOM NUMBER] and room [ROOM NUMBER] was bubbled up and coming apart from the wall. 4. The ceiling light between room [ROOM NUMBER] and room [ROOM NUMBER] had one bulb out and there was dirt and debris in the light fixture cover. 5. The bathroom of room [ROOM NUMBER] had multiple dead bugs in the windowsill. During an observation and interview, on 4/26/23 at 11:54 a.m., the Administrator indicated he had quotes for the removal of the carpet on the walls. The quotes included laminate to replace the floor carpet. He indicated he was not sure when the bathroom of room [ROOM NUMBER] was last cleaned and noted the dead bugs in the windowsill. The carpet in the hallways on the floor and wall were supposed to have been replaced last year and it was not done yet. A current policy, titled Plant Operations-General Policy, received from the Administrator on 4/26/23 at 4:45 p.m., indicated .A safe, clean, and structurally sound environment shall be achieved in the facility through the development and implementation of the Plant Operations Program, the development and training of personnel, and the evaluation of goals in the department to assure correlation with the goals of the facility .The maintenance and operation of all facilities, buildings, grounds, structures, plant components, utilities .internal and external lighting, and grounds are the primary responsibilities essential to the Plant Operations Program .Where authorized, all maintenance responsibilities will include .Repairs .Alterations .Minor construction .Remodeling .Facility personnel will perform all duties when feasible .Outside contractors will be utilized when necessary A current policy, titled Housekeeping-General Policy, reviewed on 7/28/2022 and received from the Administrator on 4/26/23 at 4:45 p.m., indicated .It is the responsibility of the Executive Director through the Environmental Services Director to assure that Housekeeping Policies are implemented and followed .The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely 3.1-19(f)(5)

Based on interview and record review, the facility failed to ensure a notice of non-coverage was provided within 48 hours of the loss of benefits for 1 of 3 residents reviewed for Beneficiary Protection Notices. (Resident 21) Finding includes: A document, titled SNF Beneficiary Protection Notification Review, indicated Resident 21's last covered date of Part A (Medicare Part A) was on 4/18/22. The document was not provided to the resident's representative for their signature to show they acknowledged the loss of covered benefit until 04/18/22. During an interview, on 05/02/22 at 1:43 p.m., the Administrator indicated notification was normally 3 days prior to the discharge of services. During an interview, on 05/02/22 at 1:58 p.m., the Administrator indicated Resident 21's document titled Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage was signed on 04/13/22 by the resident's representative. Physical therapy extended the resident services to 04/18/22. A new Beneficiary Protection Notice was not provided to the resident/representative to indicate the covered benefit would end on 04/18/22. During an interview, on 05/05/22 at 10:15 a.m., Social Services Worker (SSW) 1 indicated the business office sends out the letters of Notice of Medicare Non-Coverage to the resident and representatives. During an interview, on 05/05/22 at 10:27 a.m., the Business Office Manager (BOM) indicated the facility had 48 hours to notify the resident or representative of the end of the resident's benefit. They should have sent out the beneficiary notice within 48 hours. A current facility policy, titled Denial or End of Benefits, dated as revised on 3/30/21 and received by the Administrator on 05/02/22 at 3:14 p.m., indicated .The Denial or End of Benefits process is in place to help the resident and family understand their options and needs that they might have regarding their care .Upon end of coverage under Medicare, the resident and family will receive a notice that specifically states the reason for non-coverage .Managed Care Organization (MCO's) will supply the resident/patient with a denial notice .The resident must be made aware that home care services require authorization and approvals, as appropriate by the MCO .Upon discharge, all residents will receive a list of community resources. The Social Services Director or representative will be available to help families in this process 3.1-4(f)(2) 3.1-4(f)(3)

Based on record review and interview, the facility failed to update a Preadmission Screening and Resident Review (PASARR) for a resident with a diagnosis of psychosis who was prescribed an antipsychotic medication for 1 of 1 resident reviewed for PASARR (Resident 46). Finding includes: The record for Resident 46 was reviewed on 5/4/22 at 10:54 a.m. Diagnoses included, but were not limited to, major depressive disorder, psychotic disorder with delusions due to known physiological condition, cognitive communication deficit, anxiety disorder and dementia with behavioral disturbance. A PASARR level I, completed on 8/18/21 indicated the only mental health diagnosis was an anxiety disorder. The resident did not have a dementia/neurocognitive disorder. There were no known mental health behaviors which affected interpersonal interactions. The resident medications included sertraline (an antidepressant) related to anxiety. A PASARR disability was not present because there was no evidence of a PASARR condition of an intellectual/developmental disability or a serious behavior health condition. If changes occurred or new information refuted the findings, a new screen must be submitted. A physician's order, dated 2/28/22, indicated risperidone (an antipsychotic) 0.5 mg (milligram) two times a day related to the psychotic disorder with delusions. A psychiatry progress note, dated 1/28/22, indicated the resident had paranoid delusions and to continue the risperidone 0.5 mg twice daily. The resident was suspicious/paranoid. During an interview, on 5/4/22 at 2:26 p.m., the Director of Nursing (DON) indicated she did not know who prescribed the risperidone or how it came about. The resident was not referred for another PASARR when the diagnosis of psychoses and the medication risperidone was prescribed. A current facility policy, titled Pre-admission Screening [PASARR], dated 5/6/19 and received from the Executive Director on 5/5/2022 at 2:15 p.m., indicated .Ensure Level I screening has been completed on all potential admissions prior to admission .As part of the Pre-admission Screening and Resident Review [PASARR] process, the facility is required to notify the appropriate state mental health authority or state intellectual disability authority when a resident with a mental disorder [MD] or intellectual disability [ID] has a significant change in their physical or mental condition. This will ensure that residents with a mental disorder or intellectual disability continue to receive the care and services they need in the most appropriate setting .Any resident with newly evident or possible serious mental disorder, ID or a related condition must be referred, by the facility to the appropriate state-designated mental health or intellectual disability authority for review .Examples of individuals who may not have previously been identified by PASARR to have MD, ID or a related condition include .NOTE .this is not an exhaustive list .A resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting the presence of a mental disorder [where dementia is not the primary diagnosis] .Referral for Level II Resident Review Evaluations Is Required for Individuals Previously Identified by PASARR to Have Mental Illness, Intellectual Disability/Developmental Disability, or a Related Condition in the Following Circumstances .A resident who demonstrates increased behavioral, psychiatric, or mood-related symptoms .A resident whose significant change is physical , but with behavioral, psychiatric or mood-related symptoms, or cognitive abilities, that may influence adjustment to an altered pattern of daily living .A resident whose condition or treatment is or will be significantly different than described in the resident's most recent PASARR Level II evaluation and determination .[Note that a referral for a possible new Level II PASARR evaluation is required whenever such a disparity is discovered .] 3.1-16(d)(1)(a)

Based on interview and record review, the facility failed to follow up with the audiology company to obtain hearing aids for 1 of 1 resident reviewed for hearing (Resident 12). Finding includes: During an interview, on 4/17/2022 at 4:33 p.m., Resident 12 indicated someone came to test him for hearing aids 2 months ago and he had not heard anything about when the hearing aids would arrive. The record for Resident 12 was reviewed on 4/29/22 at 1:20 p.m. Diagnoses included, but were not limited to, paraplegia, unspecified bilateral hearing loss and major depressive disorder. A care plan, revised 5/5/2020, indicated the resident had hearing loss. The interventions included, but were not limited to, refer to audiology. A [name of company] audiology report, dated 11/12/2021, indicated the resident had moderate to severe sensorineural hearing loss in his right ear and mild to profound sensorineural hearing loss in the left ear. He had a history of occupational noise exposure. The company was waiting on physician's approval for the hearing aids. During an interview, on 4/29/2022 at 3:12 p.m., the Executive Director (ED) indicated he did not know the resident had been seen by audiology services in November 2021 and was not aware of the order for medical clearance for the hearing aids. During an interview, on 4/29/22 at 3:45 p.m., the ED indicated the audiology services had sent an email with a form for the facility to sign about the physician's approval and the facility did not receive the email with the form so the hearing aids had not been ordered yet. The facility had not provided a policy for ancillary/hearing services upon exit. 3.1-39(a)(1)

Based on observation, interview and record review, the facility failed to ensure a Foley Catheter bag and tubing was maintained in a sanitary manner for 1 of 3 residents reviewed for catheters (Resident 54) and failed to assess 1 of 1 resident reviewed for constipation. (Resident 31) Findings include: 1. During a random observation, on 04/27/22 at 1:24 p.m., Resident 54 was observed in her wheel chair, the Foley Catheter drainage line was noted to be on the floor. At that time, QMA 6 indicated she would inform the nurse and CNA 8 picked up the line and tucked it into a dignity bag hanging under the wheel chair. During a random observation, on 04/28/22 at 9:27 a.m., the catheter drainage bag was noted to be hanging on the side of the bed and the drainage line was on the floor. During a random observation, on 05/02/22 at 09:42 a.m., the Scheduler was informed the catheter line was laying on the floor. At that time, she indicated the drainage line was too long and the line should have been kept off of the floor. During a random observation, on 05/04/22 at 11:57 a.m., the catheter drainage bag was found on the floor at the bedside. During an interview, on 05/04/22 at 11:59 a.m., QMA 7 indicated the drainage bag should have been placed in a dignity bag off the floor. The record for Resident 54 was reviewed on 05/05/22 at 11:23 a.m. Diagnoses included, but were not limited to, chronic kidney disease, obstructive and reflux uropathy (urine can't flow partially or completely through the ureter, bladder, or urethra due to an obstruction) and bladder neck obstruction. A physician's order, dated 01/14/20, indicated the resident was to have an indwelling catheter to straight drainage related to an acute kidney injury. 2. The record for Resident 31 was reviewed on 04/28/22 at 10:01 a.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD-a disease which caused airflow blockage and breathing related problems), emphysema and a history of pneumonia. A bowel movement report, provided by the Executive Director on 05/02/22 at 12:18 p.m., indicated Resident 31 did not have a bowel movement on 12/02/21 (day 1), 12/03/21 (day 2) this day also had missing documentation, 12/04/21 (day 3) this day also had missing documentation, 12/05/21 (day 4) and 12/06/21 (day 5). The physician's order, dated 11/15/21, indicated to give hydrocodone-acetaminophen (a narcotic pain medication) 5 milligrams/325 milligrams every six hours. The physician's orders indicated Resident 31 did not have an order for routine or PRN (as needed) laxatives during the time period of 12/02/21 to 12/19/21. A care plan, initiated on 11/26/21, indicated Resident 31 was on pain medication therapy and to observe for and report adverse reactions, and listed constipation as one of the adverse reactions of pain medication therapy. The nursing notes did not include any bowel assessment on December 05, 2021 (day 4). A typed up timeline, provided by the Director of Nursing on 05/05/22 at 9:41 a.m., indicated on 12/01/21 the resident had a bowel movement. On 12/02/21, Hospice documents reported no bowel concerns. On 12/04/22, prune juice was implemented with every meal. On 12/05/21, a laxative was needed but not given. On 12/06/21, the physician assessment indicated regular bowel movements and on 12/07/21 hospice documented normal bowel sounds. During an interview, on 05/05/22 at 8:31 a.m., LPN 4 indicated the bowel protocol was; if a resident did not have a bowel movement on day 4 to give the resident a laxative. If they did not have a laxative order then contact the physician for an order. A bowel assessment should be completed prior to administering oral medications. He indicated the night shift was responsible for running a bowel movement report and reviewing it. The Director of Nursing would also check the report. Residents requiring intervention for no bowel movements would be carried out on the day shift. During an interview, on 05/05/22 at 9:41 a.m., the Director of Nursing indicated Resident 31 should have been given a laxative on the fourth day of no bowel movement. She further indicated no bowel assessment was completed, as she was unable to find a documented bowel assessment. They did give the resident prune juice with all meals on December 4th, 2021 (day 3 of no bowel movement). A current facility policy, titled Bowel Protocol, dated as last reviewed on 07/19/21 and provided by the Executive Director on 05/04/22 at 9:29 a.m., indicated .Purpose .To provide effective interventions for signs and symptoms of constipation .Common causes .medication side effects .Common symptoms .Absence of .bowel movement .Nursing staff document the resident's bowel movement each shift .If no bowel movement is recorded for three days, do the following on day four .Assess for signs and symptoms of constipation .If no bowel movement is recorded for four days, do the following on day five .administer routine or PRN (as needed) laxative A current facility policy, titled Indwelling Urinary Catheter (Foley) Management, dated 04/01/22 and provided by the Executive Director on 05/02/22 at 3:14 p.m., indicated .The facility will ensure that residents admitted with a urinary catheter .will have .ongoing care .that adhere to professional standards 3.1-41(a)(2)

Based on observation, interview and record review, the facility failed to store nebulizer supplies in a sanitary manner for 1 of 1 resident reviewed for respiratory care (Resident 31). Finding includes: During an observation, on 04/27/22 at 1:04 p.m., the nebulizer (a machine used to deliver breathing treatments by inhalation via a mouth piece) was found in a wheel chair seat with the mouth piece lying next to it. The mouth piece was not stored in a bag. During an interview, on 04/27/22 at 1:10 p.m., QMA 3 indicated the nebulizer was stored like that because the resident had anxiety if not stored in her chair. During an observation, on 04/28/22 at 9:44 a.m., the nebulizer mouth piece was found in the wheelchair seat. It was not stored in a bag. During an observation, on 04/29/22 at 9:45 a.m., the nebulizer mouth piece was found in the wheelchair seat. It was not stored in a bag. During an observation, on 05/02/22 at 2:01 p.m., the nebulizer mouth piece was found stored between the mattress at the foot of the bed and the footboard. It was not in a bag. The record for Resident 31 was reviewed on 04/28/22 at 10:01 a.m. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD-a disease which caused airflow blockage and breathing related problems), emphysema and a history of pneumonia. A physician's order indicated to administer Ipratropium-Albuterol Solution 0.5-2.5 3 milligrams /3 milliliters every four hours for chronic obstructive pulmonary disease. The care plan did not include storing the nebulizer in the wheel chair, unbagged due to anxiety. During an interview, on 05/04/22 at 9:53 a.m., the Director of Nursing indicated the medication was to be emptied out of the nebulizer well and the parts were to be stored in a bag, not left out and open to contamination. A current facility policy, titled Nebulizer Equipment Care, dated as revised on 02/01/22 and provided by the Executive Director on 05/02/22 at 12:40 p.m., indicated nebulizer equipment was to be stored at the bedside, but did not address proper storage of nebulizer equipment. 3.1-47(a)(6)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During an observation, on [DATE] at 10:08 a.m., QMA 3 brought a medication card containing 25 tablets of clonazepam (an anti-anxiety medication) 0.5 mg (milligrams) for Resident 63 to the nurses station. The facility received 30 tablets of clonazepam 0.5 mg, on [DATE], from the pharmacy. The directions noted on the card was to give clonazepam 0.5 mg tablet by mouth two times a day. The record for Resident 63 was reviewed on [DATE] at 1:55 p.m. Diagnoses included, but were not limited to, Parkinson's disease, major depressive disorder, cognitive impairment, seizures, mood (affective) disorder, anxiety disorder, dystonia and hypertension. A physician's order, dated [DATE], indicated to give clonazepam disintegrating 0.25 mg tablet by mouth two times a day. A physician's order, dated [DATE], indicated to discontinue clonazepam disintegrating 0.25 mg tablet. A physician's order, dated [DATE], indicated to give clonazepam disintegrating 0.5 mg 1 tablet by mouth two times a day. A facility document, titled Controlled Substances Record, indicated Resident 63 received 5 incorrect doses of clonazepam 0.5 mg tablet on [DATE] at 8:00 p.m., [DATE] at 8:00 a.m., and 8:00 p.m., and [DATE] at 8:00 a.m., and 8:00 p.m. During an interview, on [DATE] at 10:08 a.m., QMA 3 indicated the medication card did not match the order. During an interview, on [DATE] at 10:14 a.m., the Director of Nursing (DON) indicated clonazepam disintegrating tablets and clonazepam tablets were not the same medication. She indicated the clonazepam 0.5 mg tablet was intended to be given when the medication came in from the pharmacy. A current facility policy, titled Psychotropic Medication Use, dated as revised on [DATE] and received from the Executive Director (ED) on [DATE] at 11:58 a.m., indicated .A psychotropic drug is any medication that affects brain activities associated with mental processes and behavior .should not use psychotropic medications to address behaviors without first determining if there is a medical, physical, functional, psychological, social or environmental cause of the resident's behaviors .Facility staff should take a holistic approach to behavior management that involves a thorough assessment of underlying causes of behaviors and individualized person- centered non-drug and pharmaceutical interventions .Staff should become familiar with the cultural, medical, and psychological information about the resident to identify potential environmental and other triggers to prevent or reduce behavioral symptoms and/or distress, types and the consequences of behaviors exhibited by the resident and interventions that may be indicated for a specific behavior type .Psychotropic medications may be used to address behaviors only if non-drug approaches and interventions were attempted prior to their use .Psychotropic medications to treat behaviors will be used appropriately to address specific underlying medical or psychiatric causes of behavioral symptoms .Antipsychotic medications used to treat Behavioral or Psychological Symptoms of Dementia [BPSD] must be clinically indicated, be supported by an adequate rational for use, and may not be used for a behavior with an unidentified cause .Facility staff should monitor the resident's behavior pursuant to Facility policy using a behavioral monitoring chart or behavioral assessment record for residents receiving psychotropic medication for organic mental syndrome with agitated or psychotic behavior .Facility staff should document the number and/or intensity of symptoms and the resident's response to staff interventions A current facility policy, titled Administration of Medication, dated as revised on 10/04 and received by the ED on [DATE] at 3:14 p.m., indicated .All medications are administered safely and appropriately. A physicians order is required for administration of medication .Check Medication Administration Record (MAR) prior to administering medication .Read medication label and compare to the MAR to ensure that there is no discrepancy between the MAR and the medication label. Ensure medication is not expired .If a discrepancy is noted, check the physician's order before administering the medication. Correct the MAR if needed and/or contact the pharmacy for the correct labeling of the medication A current facility policy, titled Physicians Orders, dated as revised 1/2018 and received by the Infection Preventionist on [DATE] at 02:05 p.m., indicated .A physician must personally approve in writing a recommendation that an individual be admitted to a facility. A physician, physician assistant or nurse practitioner must provide orders for the resident's immediate care .As a means of validation, any orders taken verbally or be telephone must be read back in their entirety to the person giving the orders; the order is noted with RAV (read-back and verified) A current facility policy, titled LTC Facility's Pharmacy Services and Procedure Manual, dated as revised [DATE] and received by the DON on [DATE] at 10:39 a.m., indicated .Administration Errors: In the event of an administration error, Facility staff should follow Facility policy relating to medication administration errors: Dose error: Facility administers to the resident a medication dose that is greater than or less than the amount ordered by the Physician/Prescriber .Route error: Facility administers to the resident a medication dose by a route other than that ordered by Physician/Prescriber or a wrong site of administration 3.1-48(a)(3) 3.1-48(c)(2) Based on observation, interview and record review, the facility failed to ensure delusions were monitored for a resident who was prescribed an antipsychotic medication and to ensure the appropriate dose and form of a medication was administered to a resident who was prescribed an anti-anxiety medication for 2 of 6 residents reviewed for unnecessary medications (Residents 46 and 63). Findings include: 1. The record for Resident 46 was reviewed on [DATE] at 10:54 a.m. Diagnoses included, but were not limited to, major depressive disorder, psychotic disorder with delusions due to a known physiological condition, cognitive communication deficit, anxiety disorder and dementia with behavioral disturbance. A psychiatry progress note, dated [DATE], indicated the resident had paranoid delusions and to continue the risperidone 0.5 mg twice daily. The resident was suspicious/paranoid. The resident remained confused as to why she was at the facility and wanted to go home. The resident indicated she had not been seen by a doctor and would like some answers. The resident was inquisitive, concerned and a bit confused although not angry or demanding. A physician's order, dated [DATE], indicated to give risperidone (an antipsychotic) 0.5 mg (milligram) two times a day related to the psychotic disorder with delusions. A psychiatry note, dated [DATE], indicated the resident was oriented to person, place and time. The resident indicated she was not doing well, had no appetite, didn't sleep well, was sad and lonely. The psychiatry notes did not include any specific delusions or paranoia. A care plan, dated [DATE], indicated the resident had impaired cognitive ability and impaired thought processes related to dementia and psychosis. The interventions included, but were not limited to, administer medications as ordered and allow extra time for the resident to respond to questions and instructions. A care plan, dated [DATE], indicated the resident used psychotropic medications related to psychosis. The interventions included, but were not limited to, administer the psychotropic medication as ordered, discuss with physician and family regarding the need for ongoing use of the medication, review behaviors and alternate therapies attempted. A care plan, dated [DATE], indicated the resident and her daughter had behavior problems with verbal aggression to staff, refusals to sign the leave of absence book and inappropriate cursing to staff. The interventions included, but were not limited to, administer medications as ordered, explain all procedures and explain why the behavior was inappropriate. The care plans did not include monitoring for paranoid delusions or what the paranoid delusions included. During an interview, on [DATE] at 1:51 p.m., the Social Service Director (SSD) and Social Services Worker 1 indicated they did not know what the resident's psychoses or symptoms were in relation to the use of the antipsychotic risperidone and the diagnosis of psychosis.

Based on observation, interview and record review, the facility failed to implement surveillance mapping and trending for three residents with urinary tract infections who resided in the same hallway reviewed for infection control surveillance. (Residents 12, 45 and 65) Findings include: During an observation, on 4/27/22 at 4:09 p.m., the room for Residents 12 and 45 had a sign for isolation and the room for Resident 65 had a sign for isolation. LPN 5 indicated all three residents were on contact isolation for urinary infections and Resident 12 and 45 both had ESBL (extended spectrum beta-lactamase produced by bacteria which can't be killed by many of the antibiotics used to treat infections and most infections are spread by direct contact with infected body fluids) and she thought Resident 65 had the same. 1. The record for Resident 12 was reviewed on 4/29/22 at 1:20 p.m. Diagnoses included, but were not limited to, paraplegia, neuromuscular dysfunction of the bladder and benign prostatic hyperplasia. A care plan, dated as revised on 6/24/2021, indicated the resident had an indwelling catheter related to neurogenic bladder. The interventions included, but were not limited to, catheter care every shift, contact precautions related to ESBL (started on 6/15/2021). A care plan, dated as revised on 10/13/21, indicated the resident had ESBL. The interventions included, but were not limited to, maintain contact precautions, provide catheter care every shift and notify the physician of signs or symptoms of infection. A care plan, dated 3/24/2022, indicated the resident was on an intravenous antibiotic related to a urinary tract infection. A urine culture report, dated 3/17/2022, indicated the resident had morganella morganii (an organism known to possess inducible ESBL). 2. The record for Resident 45 was reviewed on 4/29/22 at 2:41 p.m. Diagnoses included, but were not limited to, history of traumatic brain injury, quadriplegia, ESBL resistance and a history of urinary tract infections. A physician's order, dated 4/26/2022 through 5/1/2022, indicated cefepime (an antibiotic) solution 1 gram/50 ml (milliliter) intravenously every 12 hours related to ESBL. A care plan, dated 4/28/22, indicated the resident had ESBL. The interventions included, but were not limited to, administer antibiotic as ordered. 3. The record for Resident 65 was reviewed on 5/5/2022 at 1:30 p.m. Diagnoses included, but were not limited to, quadriplegia, calculus of ureter, gross hematuria and neuromuscular dysfunction of the bladder. A physician's order, dated 3/21/2022, indicated contact precautions related to ESBL in the urine. A urine culture report, dated 4/11/22, indicated the resident had proteus mirabilis which produces ESBL. During an interview, on 5/4/2022 at 10:10 a.m., the Infection Prevention (IP) nurse indicated she had not started the infection tracking logs or the facility mapping logs. The previous IP left in February 2022 and she took over as the IP the end of February. She had not investigated if Residents 12, 45 and 65 who resided in the same hall with the same type of urinary infections were a trend. There was no staff education regarding hand hygiene or other staff education initiated due to the infections. During an interview, on 5/5/2022 at 9:54 a.m., the Executive Director (ED) indicated they did not have discussions about the trending of urinary infections during quality assurance and performance (qapi) meetings. The IP was given the facility surveillance mapping and tracking forms and had not completed them. A NHSN (National Healthcare Safety Network) Urinary Tract Infection document, dated January 2022, indicated .Urinary tract infections (UTIs) are the fifth most common type of healthcare-associated infection .it has been estimated that each year, more than 13,000 deaths are associated with UTIs . A current facility policy, titled Infection prevention and control program, dated 2/15/2021 and received from the IP nurse on 5/5/2022 at 2:05 p.m., indicated .The facility must establish an infection prevention and control program .that must include, at a minimum, the following element .A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment and following national standards . A current facility policy, titled Infection Prevention and Control Program (IPCP) and Plan, reviewed on 7/25/2019 and received from the Executive Director on 4/28/2022 at 8:28 a.m., indicated .Identifying and prioritizing risks are accomplished through the following .Surveillance Activities by using the Infection Prevention and Control Surveillance Plan .Surveillance activities, including data collection and analysis, are used to identify infection prevention and control risks by pertaining to the following .Resident, Licensed independent practitioners, staff .visitors and family as warranted .Identify specific issues and trends using the Infection Prevention and Control Risk Assessment results, monthly data collection and summary report .Initiate action plans when issues and trends are identified using information from the risk assessment form, monthly data collection and summary report .Data is trended over time and reviewed quarterly to determine trends in infection processes .Examples of goals might include the following .Enhancing hand hygiene .Interventions implemented may include the following .A facility-wide hand hygiene program 3.1-18(b)(1)(A) 3.1-18(b)(2)

Based on interview and record review, the facility failed to have a process to review, discuss and implement strategies to decrease the use of antibiotics which did not meet the standard McGeer criteria (guidelines used to assess antibiotic initiation appropriateness) for the use of antibiotics for 3 of 3 residents reviewed for antibiotic use (Resident 12, 45 and 65). Finding includes: 1. The record for Resident 12 was reviewed on 4/29/2022 at 1:20 p.m. Diagnoses included, but were not limited to, paraplegia, neuromuscular dysfunction of the bladder and benign prostatic hyperplasia. An Infection Surveillance Infection form, dated 3/31/2022, indicated the resident had a catheter associated urinary tract infection and the McGeer criteria was not met. The onset of the infection was 3/23/22. The resident did not have an elevated temperature, leukocytosis (elevated white blood cell count), acute changes in mental status or an acute functional decline. The antibiotic prescribed was Tobramycin. The form did not include a discussion with the interdisciplinary team on the use of antibiotics which did not meet the McGeer criteria. 2. The record for Resident 45 was reviewed on 4/29/2022 at 2:41 p.m. Diagnoses included, but were not limited to, history of traumatic brain injury, quadriplegia, ESBL (extended spectrum beta-lactamase produced by bacteria which can't be killed by many of the antibiotics used to treat infections and most infections are spread by direct contact with infected body fluids) resistance and a history of urinary tract infections. An Infection Surveillance form, dated 5/2/2022, indicated the resident had a catheter associated urinary tract infection and the McGeer criteria was not met. The onset of the infection was 4/26/2022 and the antibiotic prescribed was cefepime. The resident did not have an elevated temperature, leukocytosis, acute change in mental status or an acute functional decline. The form did not include a discussion with the interdisciplinary team on the use of antibiotics which did not meet the McGeer criteria. 3. The record for Resident 65 was reviewed on 5/5/2022 at 1:30 p.m., Diagnoses included, but were not limited to, quadriplegia, calculus of ureter, gross hematuria and neuromuscular dysfunction of the bladder. An Infection surveillance form, dated 3/31/22, indicated the resident had a long term catheter associated urinary tract infection. The McGeer criteria was not met and the antibiotic prescribed was meropenem. The onset of the infection was 3/21/22. The resident did not have a fever, leukocytosis, acute change in mental status or an acute functional decline. An Infection surveillance form, dated 4/27/22, indicated the resident had long term treatment of an infection which was not specified on the form. The onset of the infection was 3/19/2022. The McGeer criteria was not met. The resident did not have a fever, leukocytosis, acute change in mental status or an acute functional decline. The antibiotic prescribed was trimethoprim. The forms did not include a discussion with the interdisciplinary team on the use of antibiotics which did not meet the McGeer criteria or the rationale for the use of the antibiotics. During an interview, on 5/5/2022 at 9:54 a.m., the Executive Director (ED) indicated the corporate staff and the IP (Infection Prevention) nurse would have discussions about the antibiotics meeting McGeers criteria although he did not know where the information was documented. During an interview, on 5/5/2022 at 1:10 p.m., with the IP nurse and clinical support, the IP nurse indicated the Infection control sheet for Resident 45 did not meet McGeer criteria. She should have marked leukocytosis on the sheet and she did not. The clinical support nurse indicated the resident had been in the hospital and was admitted back to the facility with the antibiotic. The physician would review the orders. If the orders were approved by the physician, the facility counted it as a discussion about the use of the antibiotic. The IP indicated Resident 12 did not meet McGeers criteria on 3/23/22 for the use of the antibiotic. She indicated a person could have a urinary infection and not have any symptoms. The clinical support nurse indicated the physician would make the order for the antibiotic and determine if it was necessary. Resident 65 had been in the hospital and was being treated for a urinary tract infection and was readmitted to the facility. The IP and the clinical support nurse were not able to provide information about the formal process to review the use of antibiotics, to define if an antibiotic was unnecessary and what type of procedure was followed if an antibiotic was determined unnecessary. A current facility policy, titled Antibiotic Stewardship, dated as reviewed on 12/27/21 and received from the Executive Director on 4/28/2022 at 8:28 a.m., indicated .Antibiotics are among the most frequently prescribed medications in nursing homes. According to the Centers for Disease Control and Infection [CDC], an estimated 70% of nursing home residents receive one or more courses of antibiotics during a year. Studies have shown that 40-75% of the antibiotics prescribed in nursing homes may be unnecessary or inappropriate. Frail and older adults are at significant risk of harm from antibiotic overuse including increased adverse drug events, increased drug interactions, increased risk of Clostridium difficile, and colonization and/or infection with antibiotic-resistant organisms .The World Health Organization [WHO] cites antibiotic resistance as one of the three biggest threats to human health .Any action taken to improve antibiotic use is expected to decrease adverse drug events, prevent emergence of resistance, and lead to better outcomes .It is the policy of the facility to maintain an Antibiotic Stewardship Program [ASP] with the mission of prompting the appropriate use of antibiotics to treat infections and reduce possible adverse events associated with antibiotic use .The facility's ASP will incorporate the seven core elements outlined by the CDC .Facility leaders will demonstrate support and commitment to safe and appropriate antibiotic use .The Director of Nursing, Infection Preventionist, Pharmacy Consultant and Medical Director are the facility leads responsible for promoting and overseeing antibiotic stewardship .Consultant pharmacists facilitate antibiotic stewardship interventions through antibiotic drug regiment reviews and participation in QAPI [quality assurance and performance improvement] meetings .Implement policies and practices to improve antibiotic use .Process measures for tracking antibiotic stewardship track how and why antibiotics are prescribed. Process measures include review of .clinical documentation during clinical meetings and ongoing reviews of the completeness of prescribing documentation to include, dose, route, duration and indication for use .Provide regular feedback on antibiotic use and resistance to prescribing clinicians, nursing staff and other relevant staff through QAPI meetings, staff education and provider specific feedback .Provide resources to clinicians, nursing staff, residents and families about antibiotic resistance and opportunities for improving antibiotic use .Team role .Accountability for activities that support the antibiotic stewardship mission .Define standards for antibiotic prescribing, communication, and other stewardship actions for staff and clinical providers credentialed to deliver care in the home .Communicate prescribing standards to staff and providers .Utilize antibiotic-use and other data to ensure that procedures and other best practices are followed and refined as needed .Antibiotic Stewardship Actions .Antibiotic stewardship actions are conducted to enable or to measure these key elements of care .knowing when to be concerned about an infection in a resident, what clinical and historical information to gather for the provider, when to submit diagnostic specimens to the laboratory, how to quantify and assess appropriateness of antibiotics prescribed, and how to identify adverse outcomes that might be associated with antibiotics .At 72 hours after antibiotic initiation or first dose in the facility, each resident should be reassessed for consideration of antibiotic need 3.1-(b)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to secure chemicals and razors in a safe manner in 1 of 1 randomly observed shower room. (The [NAME] Hall Shower Room) Finding includes: During a random observation, on 05/02/22 of the [NAME] Hall Shower Room, the storage cabinet was found with a broken lock. The storage cabinet contained two spray bottles of Virex cleaning solution. Two disposable razors were also found unsecured in the shower room. The shower room did not have a door lock to prevent residents from entering. During an interview, on 05/02/22 at 10:48 a.m., LPN 5 indicated the lock on the storage cabinet was broken and the razors should have been discarded and not left lying out. During an interview, on 05/02/22 at 10:52 a.m., the Executive Director indicated all shower rooms were locked up with a key pad entry. During an observation of the [NAME] Hall Shower Room door, with the Executive Director on 05/02/22 at 11:03 a.m., it was observed there was no lock on the door to prevent it from freely opening. At that time, the Executive Director indicated a lock needed to be put on the door, and the chemicals should have been locked up. A current facility policy, titled Resident Rights, dated as revised on 11/09/16 and provided by the Executive Director on 04/27/22 at 1:30 p.m., indicated .The resident has a right to a safe .environment A current facility policy, titled Hazardous Drugs/Chemicals and Safety Data Sheets (SDSs), was provided by the Executive Director on 05/05/22 at 12:00 p.m., but it did not cover safe storage of cleaning chemicals or personal use sharps items like razors. 3.1-19(f)