**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the resident representative with written notification of the resident's transfer to the hospital for 1 out of 5 sampled residents, Resident (R) 14. The findings include: Review of R14's Face Sheet revealed the facility admitted the resident on 07/16/2024 with diagnoses of hypertension, type 2 diabetes mellitus with diabetic chronic kidney disease, and hyperlipidemia. Review of R14's hospital Discharge Summary, dated 01/08/2025, revealed she had been hospitalized on [DATE] for vomiting blood and was diagnosed with a pyloric obstruction and a urinary tract infection. Review of R14's Nursing Notes, dated 01/08/2025, revealed R14 returned to the facility via the Emergency Medical Technicians (EMT) after being seen at the Emergency Room, on 01/08/2025, for coffee ground emesis and abdominal pain. Further review revealed the emergency room (ER) had removed 1000 milliliters of gastric contents via a nasogastric (NG) tube, gave her intravenous (IV) Rocephin (to treat her urinary tract infection), and gave two doses of morphine for pain. Review of R14's Transfer/Discharge and Bed Hold Policy Notification, dated 01/08/2025, revealed it was the facility's form for notifying R14 and her Responsible Party (RP) she had a bed hold for the facility for 14 days while she was hospitalized or on therapeutic leave. Further review of the Transfer/Discharge and Bed Hold Policy Notification, revealed it was not signed by the resident or the RP. Instead, written on the signature line was verbal consent via a phone call with RP (Family, F3). It was dated 01/08/2025 and signed by the Director of Health Services (DHS). In an interview on 06/26/2025 at 8:29 AM, R14's RP/F3 stated the facility called her and told her R14 had been experiencing bloody emesis, and the facility was going to send R14 to the ER. RP/F3 further stated the facility verbally told her of the transfer; however, she had not received written documentation of R14's bed hold or the transfer. In an interview on 06/25/2025 at 1:54 PM with the Business Office Manager (BOM), she stated she was unsure if anyone sent a copy of Transfer/Discharge and Bed Hold Policy Notification via mail to the RP for a resident when the resident went to the hospital. She stated a letter was sent to the Ombudsman. In an interview on 06/25/2025 at 1:55 PM with the Social Services Director (SSD), she stated Admissions took care of the bed hold policy. She stated she sent an email to the Ombudsman when a resident was sent to the hospital, and a formal letter was sent once per month to the Ombudsman listing all the residents that went to the hospital for that month. In an interview on 06/25/2025 at 2:02 PM with the admission Coordinator (AC), she stated they asked the resident or RP upon admission if they wished to sign the bed hold policy to hold the resident's bed if they were to be sent out to the hospital. She stated the facility contacted the RP via phone to notify them of the transfer and to remind them about the bed hold policy. She stated, if the RP was in the facility, they would give them a copy of the Transfer/Discharge and Bed Hold Policy Notification. The AC stated the facility never sent the Transfer/Discharge and Bed Hold Policy Notification via mail to the RP but did send a copy of it with the resident to the hospital. She stated the Ombudsman received an email when there was a transfer or discharge of a resident from the facility, and a printed list was sent to the Ombudsman at the end of each month listing those residents that were transferred or discharged from the facility. In an interview on 06/26/2025 at 10:09 AM with the Assistant Director of Health Services (ADHS), she stated the facility did not mail Transfer/Discharge and Bed Hold Policy Notification to residents' RPs when a resident was transferred to the hospital. She stated the RP was called as a form of notification. She stated residents or their RPs signed a bed hold policy upon admission and could change their election at anytime during the resident's stay at the facility. In an interview on 06/26/2025 at 10:50 AM with the Director of Health Services (DHS), she stated the facility did not mail Transfer/Discharge and Bed Hold Policy Notification to residents' RPs when a resident was transferred to the hospital. In an interview on 06/26/2025 at 12:07 PM with the Executive Director (ED), he said the facility did not send out Transfer/Discharge and Bed Hold Policy Notification letters in the mail. He stated the facility did give a copy of the Transfer/Discharge and Bed Hold Policy Notification to the resident when they were transferred from the facility to the hospital. He stated it was the facility's process to call the RP and notify them of the transfer and remind them of the bed hold.

Based on observation, interview, and review of the facility's policies, it was determined the facility failed to ensure staff observed required hand hygiene practices during the plating of food for the meal service. This deficient practice had the potential to affect 45 current residents who received meals from the kitchen. The findings include: Review of the facility's policy titled, Infection Prevention and Control Program, with a review date of 01/01/2023, revealed it was the purpose of the policy to prevent the spread of infection from one person to another. Further review revealed it stated that hand washing was the most important method of infection prevention and control, and hands should be washed after doing cleaning tasks, before and after eating, when using the restroom, or any other task that provided an opportunity for infection. Per the policy, gloves should be worn when encountering items that were intended to be used by a resident. Review of the facility's policy titled, Guidelines for Handwashing/Hand Hygiene, dated 03/20/2017, revealed handwashing was the single most important factor in preventing transmission of infections. Further review revealed hand hygiene was a term that applied to either handwashing or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). The policy stated health care workers should use hand hygiene at times such as before and after preparing/serving meals, drinks, tube feedings, etc. and before or after having direct physical contact with residents. Observation on 06/24/2025 at 11:45 AM of the lunch meal service revealed the admission Coordinator (AC), who was assisting in serving residents lunch in the Dining Room, touched the counter where there were meal tickets; wrote on the tickets with a pen, touching the meal tickets; and did not perform hand hygiene prior to serving plates of food to residents. The AC was also observed on 06/24/2025 at 11:52 AM touching the cart that the food tray was sitting upon and did not perform hand hygiene prior to distributing residents' food. On 06/24/2025 between 11:45 AM and 11:57 AM, it was observed that the AC served plates of food to three separate tables of residents prior to performing hand sanitization. In an interview on 06/24/2025 at 11:05 AM with the AC, she stated hand hygiene should be performed after serving all the residents at a table. Observation on 06/24/2025 at 12:17 PM revealed Dietary Aide (DA) 1 touched her hair and clothing with her gloved hands and did not change her gloves or perform hand hygiene. Further observation of DA1 revealed that she dropped the lid to a cup onto the floor. She picked up the lid and placed it into her pocket with her gloved hand. She did not change her gloves and did not perform hand hygiene. In an interview on 06/24/2025 at 12:37 AM with DA1, she stated gloves should be changed and hand hygiene performed after she touched anything soiled, such as when she picked up the cup lid from the floor. In an interview on 06/26/2025 at 9:58 AM with the Dietary Manager (DM), he stated kitchen staff should change gloves when soiled. He stated he stressed to his staff that wearing gloves was a way to prevent cross-contamination of surfaces. He stated he told staff just because they were wearing gloves did not mean they did not have to change those gloves and perform hand hygiene. He stated his expectation was that staff performed hand hygiene between each plate of food served in the dining room and after serving each tray in a resident's room. He stated staff should use ABHR to hand sanitize between plates/trays served and after three had been served, they should wash their hands with soap and water. He stated his expectation was that staff should also hand sanitize, and if wearing gloves, change gloves after picking up items off the floor or when touching something dirty such as their face, hair, or clothing. In an interview on 06/26/2025 at 10:09 AM with the Assistant Director of Health Services (ADHS), she stated staff should perform hand hygiene between each tray when serving food to residents in their rooms. In the dining room, she stated hand hygiene should be performed after service of all the plates from a tray, unless the staff member touched a surface such as the table or touched the resident. She stated staff should perform hand hygiene if they touched their face, hair or clothing and if they were to pick something up from the floor. She stated any time a staff member touched a contaminated surface they needed to perform hand hygiene and change their gloves if they were wearing gloves. In an interview on 06/26/2025 at 10:50 AM with the Director of Health Services (DHS), she stated her expectation was that staff performed hand hygiene anytime they touched themselves or a contaminated surface. She stated typically all the plates on a tray (approximately three to four plates) were distributed to residents without performing hand hygiene unless the staff member touched something contaminated. She stated staff members wearing gloves who picked up something from the floor should change gloves and perform hand hygiene. In an interview on 06/26/2025 at 12:07 PM with the Executive Director, he stated his expectation was that prior to distributing food in the Dining Room from a tray, staff members should perform hand hygiene, pass the three plates of food on the tray, and if they did not touch a contaminated surface, then perform hand hygiene. He stated, if staff was wearing gloves and picked up trash off the floor, he expected that staff member to change gloves and perform hand hygiene.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the Centers for Medicare and Medicaid Services (CMS), Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to develop and/or implement a person centered Comprehensive Care Plan (CCP) for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for three (3) of eighteen (18) residents; Resident #38, Resident #29, and Resident #12. 1. Review of the CCP for Resident #29 revealed the resident demonstrated exit seeking behaviors and a wander guard would be applied as appropriate. Review of Progress Notes in October 2021, revealed ongoing assessment of need for wander guard; however observations on 11/02/2021 and 11/03/2021 revealed the resident did not have a wander guard. 2.Review of the CCP for Resident #38 revealed his/her preferred activity (s) were music, news via television, and religious services; however observations on 11/02/2021 and 11/03/2021 and review of the medical record revealed the resident's preferred activities based on the comprehensive assessment and care plan were not consistently provided to the resident. 3. Reivew of the CCP for Resident #12 revealed the resident had chronic wounds to his/her bilateral feet. Additionally, the resident's wound would be treated per physician orders. However review of the medical record and observation revealed the resident's dressings were not changed as ordered. The findings include: Review of the facility's policy titled Comprehensive Care Plan Guidelines, dated 05/22/2018 revealed the purpose of the document was to ensure appropriate services and communication to meet the resident's needs, severity/stability of conditions, impairment, disability, or disease in accordance with state and federal guidelines. Additional review revealed the care plan interventions would reflect risk areas that impact the individual resident. Further review revealed pertinent care plan approaches would be communicated to nursing staff. 1. Review of Resident #29's Electronic Medical Record (EMR) revealed the facility admitted the resident, on 06/13/2014, with diagnoses that included Anxiety Disorder, Chronic Pain, Open-Angle Glaucoma, Alzheimer's Disease, Dementia with Behavioral Disturbance, Major Depressive Disorder, and Unspecified Psychosis. Review of Resident #29's Elopement Risk Assessment, dated 05/15/2021, revealed the resident was at risk for elopement related to verbalized statements of leaving; exhibited periods of pacing, agitation or wandering towards an exit; and wandering when agitated. Further, the resident required an exit seeking alarm bracelet/device on the resident which required monitoring for placement and function every shift. Review of Resident #29's CCP, initiated on 05/17/2021, revealed the resident demonstrated exit-seeking behaviors. Additional review revealed the goal was the resident would not elope from the facility. Further review revealed interventions included the resident would be assessed for the need for a wander guard; apply as appropriate. Continued review revealed an additional interventions to evaluate the resident's need for a secure unit and to monitor wandering triggers. Review of Resident #29's Quarterly MDS Assessment, dated 09/18/2021, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of seven (7) out of fifteen (15), which indicated the resident had severely impaired cognition. Additional review revealed the resident had no behavior of wandering present. Further, the resident required an elopement wander alarm which was used daily. Review of Resident #29's Medication Administration Record (MAR), dated 10/01/2021 through 10/31/2021, revealed an order to check placement of wandering system bracelet/device every shift; twice daily. Review of Resident #29's Progress Notes/Clinically at Risk Individual Monitoring, dated 10/09/2021; 10/17/2021; 10/24/2021; and 10/31/202, completed by the Director of Health Services (DHS), revealed the resident had agitated behaviors, especially after 4:00 PM. Further review revealed the resident had no attempts to go to exit doors. However, a wander-guard was in place due to wandering. Review of Resident #29's MAR, dated 11/01/2021 through 11/04/2021, revealed an order to check placement of wandering system bracelet/device every shift; twice daily. However observations, on 11/02/2021 and 11/03/2021, revealed no evidence the resident wore a wander guard on the his/her wrists, ankles or wheelchair. Interview with State Registered Nursing Assistant (SRNA) #2, and SRNA #3, on 11/03/2021 at 4:43 PM, revealed they used the CCP to know if a resident required a wander guard. Per interview, Resident #29 had worn a wander guard on his/her wrist for several years related to wandering around the facility, in the evenings. Additional interview revealed it was important the CCP was followed and the resident always had the device on to ensure he/she was safe and did not leave the facility and wander off. Further, it was all staff's responsibility to ensure interventions were implemented for residents. Interview with Licensed Practical Nurse (LPN) #2, on 11/03/2021 at 5:05 PM, revealed she was assigned to Resident #29 on 11/02/2021 and 11/03/2021 day shift. Per interview, it was her responsibility to ensure resident's care plans were followed. Additionally she ensured care plans were followed by making observations of care and reviewing the care plan for residents she was assigned. Continued interview revealed Resident #29 had wandering behaviors and required a wander guard. Additional interview revealed she was responsibility to ensure placement and function of the wander guard during her shift. Further, it was important the CCP was implemented for residents who were at risk for elopement, to ensure their devices were in place and monitored to keep the residents safe. 2. Review of Resident #38 EMR, revealed the facility admitted the resident on 07/30/2020 with diagnoses including Heart Failure, Unspecified Dementia, Adult Failure to Thrive, Senile Degeneration of the brain, Unspecified Psychosis, and Major Depressive Disorder. Review of Resident #38's CCP, dated 08/05/2020, revealed it was important to the resident to have opportunities to engage in activities, meaningful to the resident. Additional review revealed a goal that staff would take necessary actions to accommodate the resident's routines and preferences to satisfy and engage the resident in activity opportunities. Further review revealed interventions included but were not limited to provide the resident with opportunities to hear/listen to music; ensure the resident keeps up with the news/preferred avenue via television; engage in religious services or practices allowing access to Christian music and broadcasted sermons; and check with the resident on a regular basis to ensure the resident was satisfied with how he/she spent their day. Review of Resident #38's Significant Change MDS Assessment, dated 07/01/2021, revealed the facility assessed the resident to have a BIMS score of three (3), indicating severely impaired cognitive abilities. Further review of the Assessment revealed preferences for Activities that were somewhat important to the resident included listening to music; doing things with groups of people; and participating in religious services or practices. Review of Resident #38's Plan of Care (POC) History Report/Activities, dated August 2021, revealed the resident attended and participated in seven (7) activities during the month. However, there was no documented evidence the resident was offered, attended, or participated music activities, group activities, news, or religious services or practices, per the resident's CCP. Continued review of Resident #38's POC History Report/Activities, dated September 2021, revealed the resident attended and participated in seven (7) activities during the month. However review revealed only once, on 09/30/2021, the resident participated in room music, for fifteen (15) minutes. There was no documented evidence the resident was offered, attended, or participated in group activities, news, or religious services or practices, per the resident's CCP. Additional review of Resident #38's POC History Report/Activities, dated October 2021, revealed the resident attended and participated in six (6) activities during the month. However, all there was no documented evidence the resident was offered, attended, or participated music activities, group activities, news, or religious services or practices, per the resident's CCP. Observations on 11/02/2021, 11/03/2021 and 11/04/2021 revealed the resident was lying in bed. Additional observations revealed the resident's television (TV) was turned off. Further, there was no radio or iPod in the resident's room. Review of Activities Documentation on the EMR for November 2021, with the Life Enrichment Director (LED), on 11/03/2021 at 2:23 PM, revealed no documented evidence the resident was offered, attended, or participated in music activities, group activities, news or religious services or practices, per the resident's CCP. Interview with the LED, on 11/03/2021 at 2:23 PM, revealed he reviewed resident's activity preference with the MDS schedule and ensure the CCP was accurate. Per interview, the IDT worked together to ensure residents engaged in activities of preference per their CCP. Additional interview revealed the LED was familiar with Resident #38's activity preference of music (gospel), and reading the Bible; however review of the POC activity documentation on the EMR, for Resident #38 revealed no documented evidence of those activities for the last three (3) months. The LED stated staff were expected to follow up the CCP and encourage participation in activity. He stated it was important to implement the CCP related to residents choice of activities to enrich their lives and increased their quality of life/care. Resident #38 should be provided opportunities to engage in activities of his/her preference. Interview with SRNA #2, and SRNA #3, on 11/04/2021 at 4:43 PM, revealed Resident #38 loved gospel music and talking with staff; however there were not aware of the residents activity CCP and preferred approaches/interventions. Further, they stated they could not say activities staff did not engage with the resident; however, the only activities they were aware of that activities staff provided were the Daily Chronical and the monthly calendar. Interview with the DHS, on 11/04/2021 at 4:03 PM, revealed it was the responsible of the Interdisciplinary Team (IDT) to ensure the CCP was implemented to meet the needs and goals of all residents. Per the DHS, she reviewed care plans weekly to ensure interventions were implemented for residents. Continued interview revealed she specifically did spot checks herself, to ensure residents were provide care per their CCP. The DHS stated she had not identified an issue with implementation of care plans for residents who required a wander guard or related to residents being provided preferred activities per their CCP. Further, it was important that the CCP was implemented by the IDT to ensure quality of care, quality of life and resident safety. Interview with the Executive Director, on 11/04/2021 at 6:20 PM, revealed she expected a person centered care plan to be implemented by the IDT for all residents. Additionally residents who required wander guards should have wander guards in place to ensure resident safety. Continued interview revealed residents preferred/care planned activities should be honored. Further, it was important for the care plan to be followed to ensure resident needs were met and provided. 3. Review of Resident #12's medical record revealed the facility re-admitted the resident on 02/17/2021, with diagnoses to include Osteomyelitis to bilateral feet, Non-Pressure Chronic Ulcer of the right foot with necrosis of muscle, Cellulitis of right foot, Peripheral Vascular Disease, and Surgical Subcutaneous Tissue-Wound Debridement. Review of Resident #12's Physician Order's, dated 07/02/2021, revealed an order to clean surgical wound sites (bilateral feet) with wound cleanser or normal saline. Apply betadine gauze to area on left foot fifth (5th) metatarsal and to right ankle; wrap with well-padded gauze bandage roll, and apply light cohesive bandage; Change daily on Monday, Wednesday, Friday. Foam dressing to left ankle only. Light/loose application of offloading boots; with no stop date. Review of Resident #12's Quarterly Minimum Data Set (MDS) Assessment, dated 08/03/2021, revealed the resident was assessed to have a Brief Interview of Mental Status (BIMS) score of eleven (11), indicating moderate cognitive impairment. Additional review revealed the resident was assessed to be at risk for pressure ulcers and had pressure reducing devices for his/her bed and chair. Continued review revealed the resident required extensive assist with bed mobility and personal hygiene. The resident and required total assistance for transfers. Record review of Resident #12's CCP, dated 08/17/2020, revealed the resident had chronic wounds to bilateral feet related to osteomyelitis. The goal was the resident's wound will heal without complications. Further interventions included treat per physician orders, notify physician if treatment is not effective and pressure reducing mattress and chair cushion. However, observation on 11/03/2021 at 11:37 AM, of Resident #12's dressing changes, to bilateral feet, with Licensed Practical Nurse (LPN) #1, revealed resident had bilateral offloading boots on, bilateral feet wrapped with cohesive dressings, with gauze bandage underneath, with no date, time, or nurses initials to indicate last dressing change. Additionally, the resident also had an intact foam dressing on his/her left ankle, under gauze wrapping, dated 10/27. There was no documented evidence on the dressing of a year, nurses initials, or time, noted. Interview with LPN #1, on 11/03/2021 at 11:45 AM, who was assigned to Resident #12 on this date, revealed bilateral dressing changes were done every Monday, Wednesday, and Friday. Interview further revealed Resident #12's foam dressing to the left ankle was changed weekly and bilateral boots were on at all times. However, continued interview with LPN #1, on 11/04/2021 at 2:10 PM, revealed she worked on Tuesday, Wednesday and Thursday, therefore she only changed the resident's dressing once a week. Interview with Director of Health Services (DHS), on 11/04/2021 at 4:03 PM, revealed it was her expectation nurses and Minimum Data Set (MDS) Coordinator developed the CCP. Further, it was her expectation the Interdisciplinary Team (IDT) implemented and followed the CCP to meet the needs and goals of each resident. Interview with Executive Director, on 11/04/2021 at 6:20 PM, revealed it was her expectation the person centered care plans were implemented by facility staff for all residents. Additionally, it was important the CCP was implemented to ensure resident care needs were met. Further, she stated the facility Quality Assurance (QA) had not identified any concerns with implementation of the CCP specific to following Physician's Orders for wound dressings. Surveyor: [NAME], [NAME]

Based on observation, interview, record review and review of facility's policy, it was determined the facility failed to ensure an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, for one (1) of eighteen (18) residents, Resident #38. There was no documented evidence Resident #38 participated in his/her preferred activities in August, September, October or November of 2021. Record review revealed the resident attended and participated in minimal activities during the last four (4) months at the facility and he/she had not been consistently offered news via television, music, religous or group activities even though the activity(s) were assessed as his/her preferred activities, and were offered on the facility's monthly activity calendar. In addition, observation of Resident #38, on 11/02/2021, 11/03/2021, and 11/04/2021, revealed the resident was in his/her room, in bed with the lights dimmed and no television or music on his his/her room. The findings include: Interview with the Executive Director, on 11/04/2021 at 8:30 AM, revealed the facility did not have a written policy or protocol related to the activities department programming. Review of the Activity Calendar, dated August 2021 through November 2021, revealed each Sunday at 10:00 AM there were Church Services and at 1:30 PM there was Gospel Music. Continued review of the calendars revealed each day at 10:00 AM there was an activity Broadcast on the facility's television channel. Additionally, Hymn Sing was each Wednesday at 6:00 PM. Further, review revealed weekly activities included but were not limited to music, trivia, bingo, socials, and exercise. Review of Resident #38 Electronic Medical Record (EMR), revealed the facility admitted the resident on 07/30/2020 with diagnoses including Heart Failure, Unspecified Dementia, Adult Failure to Thrive, Senile Degeneration of the brain, Unspecified Psychosis, and Major Depressive Disorder. Review of Resident #38's Comprehensive Care Plan (CCP), dated 08/05/2020, revealed it was important to the resident to have opportunities to engage in activities, meaningful to the resident. The goal was the staff would take necessary actions to accommodate the resident's routines and preferences to satisfy and engage the resident in activity opportunities. The interventions included but were not limited to provide the resident with opportunities to hear/listen to music; ensure the resident keeps up with the news/preferred avenue via television; engage in religious services or practices allowing access to Christian music and broadcasted sermons; and check with the resident on a regular basis to ensure the resident was satisfied with how he/she spent their day. Review of Resident #38's Significant Change Minimum Data Set (MDS) Assessment, dated 07/01/2021, revealed the resident had adequate hearing and vision and had the ability to make him/herself understood and usually could understand others. Continued review revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of three (3), indicating severely impaired cognitive abilities. Additional review revealed preferences for Activities that were somewhat important to the resident included listening to music; doing things with groups of people; and participating in religious services or practices. Further, the resident was assessed with no ambulation or locomotion in his/her room, corridor on or off the unit; the resident used no mobility devices and require extensive to total assistance with bed mobility and transfers. Review of Resident #38's Plan of Care (POC) History Report/Activities, dated August 2021, revealed the resident attended and participated in seven (7) activities during the month. On 08/03/2021 at 11:19 AM, for thirty (30) minutes; on 08/06/2021 at 2:08 PM, for thirty (30) minute; on 08/12/2021 at 3:49 PM, for thirty (30) minutes; on 08/19/2021 at 3:53 PM, for twenty (20) minutes; on 08/23/2021 at 3:46 PM, for thirty (30) minutes; on 08/27/2021 at 10:46 AM, for thirty (30) minutes; on 08/28/2021 at 9:49 AM, for thirty (30) minutes; and on 08/29/2021 at 9:55 AM, for thirty (30) minutes. However, all seven (7) activities were categorized as the Daily Chronical. There was no documented evidence the resident was offered, attended, or participated music activities, group activities or religious services or practices, per the resident's choice/preference of activities. Review of Resident #38's POC History Report/Activities, dated September 2021, revealed the resident attended and participated in seven (7) activities during the month, on 09/02/2021 at 4:41 PM, calendar and newsletter, no time/duration noted; on 09/03/2021 at 12:14 PM, the Daily Chronical for thirty (30) minutes; on 09/09/2021 at 12:15 PM, the Daily Chronical, for thirty (30) minutes; on 09/19/2021 at 1:03 PM, the Daily Chronical, for thirty (30) minutes; on 09/25/2021 at 10:00 AM, the Daily Chronical, for thirty (30) minutes; on 09/28/2021 at 4:17 PM, October Calendar and Newsletter, no time/duration noted. Further review revealed on 09/30/2021 at 2:16 PM, the resident participated in room music, for fifteen (15) minutes. There was no documented evidence the resident was offered, attended, or participated in group activities or religious services or practices, per the resident's choice/preference of activities. Review of Resident #38's POC History Report/Activities, dated October 2021, revealed the resident attended and participated in six (6) activities during the month. On 10/09/2021 at 11:59 AM, for thirty (30) minutes; on 10/14/2021 at 10:48 AM, for thirty (30) minutes; on 10/17/2021 at 10:29 AM, for thirty (30) minutes; on 10/17/2021 at 10:29 AM, for thirty (30) minutes; on 10/18/2021 at 9:55 AM, for thirty (30) minutes; on 10/23/2021 at 3:28 PM, for thirty (30) minutes; and 10/31/2021 at 11:06 AM, for thirty (30) minutes. However, all six (6) activities were categorized as the Daily Chronical. There was no documented evidence the resident was offered, attended, or participated music activities, group activities or religious services or practices, per the resident's choice/preference of activities. Observations on 11/02/2021 at 9:25 AM, revealed the resident was lying in bed, there were no lights on in the room. A large wooden bookshelf blocked the window, the room was dim. Continued observations revealed the resident's television (TV) was turned off. Additional observations revealed the resident was turned to the right side towards the doorway. Further, the resident's eyes were open; however, he/she did not respond to the State Survey Agency (SSA). Observations on 11/02/2021 at 1:18 PM, revealed the resident lying in bed, on his/her right side. The room was dim and the resident's eyes were closed. Additional observations revealed the TV was turned off. Further, there was no radio or iPod in the resident's room. Observations on 11/02/2021 at 3:15 PM, revealed the resident was lying in bed on his/her left side, facing away from the doorway. The room light was on above the bed and the resident's eyes were closed. Further the TV was turned off and there was no other source of music in the room. Observations on 11/02/2021 at 5:16 PM, revealed the resident was lying in bed on his/her right side. Further the resident's eyes were open and when the SSA spoke to the resident, the resident answered direct questions. Interview with the resident at that time revealed he/she was comfortable, slept a lot and enjoyed music. Observations on 11/03/2021 at 8:20 AM, revealed the resident was in bed lying on his/her back. The resident's eyes were closed. Further, the TV was turned off and there was no other source of music in the room. Observations on 11/03/2021 at 10:55 AM, revealed the resident was in bed lying on his/her left side facing the bookshelf. The resident's eyes were closed and the room was dim. Further, the TV was turned off and there was no other source of music in the room. Observations on 11/03/2021 at 2:20 PM, revealed the resident was lying in bed on his/her right side, towards the door. Additional observation revealed the resident's eyes were close. Further the TV was turned off, and there was no other source of music in the room. Review of Resident #38's Activities Documentation on the EMR for November 2021, with the Life Enrichment Director (LED), on 11/03/2021 at 2:23 PM, revealed no documented evidence the resident was offered, attended, or participated in music activities, group activities or religious services or practices, per the resident's choice/preference of activities. Observations on 11/04/2021 1:14 PM, revealed the resident was lying in bed with his/her eyes closed, on his/her left side towards the bookshelf. The room was dim, the lights were off and the blinds were closed. Further observations revealed the resident's TV was turned on and a screen saver, displayed Christian music; however there was no sound. Interview with the LED, on 11/03/2021 at 2:23 PM, revealed he provided oversight over activities by assessing resident needs related to activities and asking residents what they liked to do for fun, on admission, with significant change, quarterly and as needed. These preferences were noted on the MDS Assessment and the CCP. Per interview, there were Activity Associates (AA) who worked under him to assist/work together to ensure residents engaged in activities of preference. Additional interview revealed each morning activities staff delivered the Daily Chronical, which was a facility newsletter, to each resident, and engaged with the residents prompting and encouraging them to attend and participate in activities offered later in the day. Continued interview revealed AAs approached residents unable or unwilling to participate in activities throughout the day and prompted and encouraged activities per the Activity Calendar and provided individualized one (1) on one (1) activities per the resident's preferences. These activities were documented in the POC EMR. Further, the facility had a broadcast channel, which allowed residents to engage in facility activities from their rooms if they were unable to attend activities. Per interview, music and religious services were on the calendar each month and there were four (4) music channels available on resident's TV's and the facility had radios/boom boxes for residents to utilize for music. Further interview revealed the LED was familiar with Resident #38's activity preference of music (gospel), and reading the Bible; however review of the POC activity documentation on the EMR, for Resident #38 revealed no documented evidence of those activities for November 2021. The LED stated activities staff were expected to follow up with all residents to encourage participation in activity. He stated it was important to engage residents to participate in activities of their preference to enrich their lives, which prevented depression and increased their quality of life/care. Resident #38 should be provided opportunities to engage in activities of his/her preference. Interview with State Registered Nursing Assistant (SRNA) #2, and SRNA #3, on 11/04/2021 at 4:43 PM, revealed Resident #38 loved gospel music and talking with staff. Additional interview revealed they had seen him/her TV on in the past but could not recall what was on the TV. Further, they stated they could not say activities staff did not engage with the resident; however, the only activities they were aware of that activities staff provided were the Daily Chronical and the monthly calendar. Interview with the Director of Health Services (DHS), on 11/04/2021 at 4:03 PM, revealed activities were important for all residents. Per interview, she expected residents would be engaged in preferred activities throughout the day. Continued interview revealed it was the responsibility of the whole Interdisciplinary Team (IDT) to interact and identify what resident needs and preferences were and engage/promote activities. Further, it was the IDT's responsibility to ensure activities were provided through daily rounds. Per interview, engaging residents in activities ensured better quality of life for the resident. Interview with the Executive Director, on 11/04/2021 at 6:20 PM, revealed the facility should offer/provide scheduled activities as well as individualized activities to each resident per their choices and preferences. Further interview revealed it was important to honor resident choices for activities.

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed ensure residents received treatment and care in accordance with professional standards of practice, the resident's plan of care and Physicaian's Orders to meet eahc resident's physical, mental and psychosocial needs for one (1) of eighteen (18) sampled resident, Resident #12. The findings include: Review of facility policy titled Guidelines for General Wound and Skin Care, dated 05/23/2018, revealed the purpose of the policy was to provide measures to promote and maintain good skin integrity. Per policy, procedures followed included perform wound treatment and date, time, initial all dressings at time of application. Review of facility policy titled Pressure/Stasis/Diabetic Wound Guidelines, dated 05/10/2016, revealed the policy did not address following physician treatment orders. Interview with the Director of Health Services (DHS), on 11/03/2021 at 11:31 AM, revealed the facility failed to have a written policy or protocol related to following physician treatment orders. However, the DHS stated the facility's Standard of Practice related to clinical practices in the facility was the Lippincott Manual of Nursing Practice, tenth (10th) edition. Review of Resident #12's medical record revealed the facility re-admitted the resident on 02/17/2021 with diagnosis to include Osteomyelitis to bilateral feet, Non-Pressure Chronic Ulcer on right foot with Necrosis of Muscle, Major Osseous Defect on right ankle and foot, Cellulitis of right foot, Peripheral Vascular Disease, and Surgical Subcutaneous Tissue-Wound Debridement. Review of Resident #12's Quarterly Minimum Data Set (MDS) Assessment, dated 08/03/2021, revealed the facility assessed the resident to have a Brief Interview of Mental Status (BIMS) score eleven (11), indicating moderate cognitive impairment. Additional review revealed, the resident was assessed to have surgical wounds and infections on both feet. Treatments included dressing to bilateral feet, surgical wound care, and pressure reducing devices for chair and bed. Further review revealed the resident required extensive assist with bed mobility and was totally dependent for transfers. Review of Resident #12's Physician's Orders, dated 07/02/2021, revealed an order to clean surgical wound sites (bilateral feet) with wound cleanser or normal saline. Then apply betadine gauze to area on left foot fifth (5th) metatarsal and to right ankle; wrap with well-padded gauze bandage roll. Additionally, apply light cohesive bandage; Change daily on Monday, Wednesday, Friday; Foam dressing to left ankle only. Further, light/loose application of offloading boots. There was no documented evidence of a stop date for the order. Record Review of Resident #12's Treatment Administration Record (TAR), dated 10/01/2021 to 10/31/2021, revealed Licensed Practical Nurse (LPN) #9 initialed the TAR, indicating the treatment was completed to his/her bilateral feet, on 10/29/2021 for 6:00 AM - 6:00 PM. Further record review of the resident's TAR, for 11/01/2021 to 11/04/2021, revealed LPN #9 initialed the TAR, indicating the treatment was completed to his/her bilateral feet, on 11/01/2021 for 6:00 AM - 6:00 PM. Further record review of Resident #12's Progress Notes, dated 10/29/2021 through 11/01/2021, revealed no documented evidence treatments to the resident's bilateral feet were not completed per Physician's Orders, on Friday 10/29/2021 or Monday 11/01/2021. Observation on 11/03/2021 at 11:37 AM, of Resident #12's dressing changes to his/her bilateral feet and ankles, by LPN #1, revealed bilateral feet and ankles were wrapped with cohesive dressings with gauze bandage underneath. Additional observations revealed there were no date, time, or initials noted on the dressings. Further observation revealed the resident had an intact foam dressing to his/her left ankle under gauze bandage, noted with a date of 10/27; however there was no year, initials, or time noted. Resident #12's Physician's Order stated the wound dressings would be changed every Monday, Wednesday and Friday. However, two (2) of the dressings in place were not dated and one (1) dressing was dated 10/27; there was no documented evidence the dressing changes were made on 10/29/2021 or 11/01/2021 per Physician's Orders. On 11/04/2021 at 2:13 PM, State Survey Agency (SSA) attempted to contact LPN #9 via telephone; however, she was not available for interview. Interview with Resident #12, on 11/03/2021 at 11:40 AM, revealed the resident did not know when the foam dressing to his/her left ankle was changed. Interview with LPN #1, on 11/03/2021 at 11:45 AM, revealed bilateral dressing changes were done every Monday, Wednesday, Friday. Additionally, the foam dressing on left ankle was changed weekly and the bilateral boots were on at all times. Further interview with LPN #1, on 11/04/2021 at 2:10 PM, revealed after review of the resident's medical record the foam dressing to Resident #12's left ankle was ordered to be changed every Monday, Wednesday, Friday. Interview with Clinical Support Nurse, on 11/03/21 at 05:15 PM, revealed it was her expectation Resident #12's foam dressing to his/her left ankle would be changed daily on Monday, Wednesday, Friday, per Physician's Orders. Interview with Director of Health Services (DHS), on 11/04/2021 at 2:12 PM, revealed it was her expectation that Resident #12's surgical wound sites were cleansed, and dressings changed every Monday, Wednesday, Friday, per Physician's Orders. Additionally, it was her expectation that Resident #12's foam dressing on his/her left ankle was changed every Monday, Wednesday, Friday, per Physician's Orders. Further it was her expectation nurses followed Physician's Orders, and if not, documentation was noted on the TAR or Progress Notes with a rational.

Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to have an effective system in place to ensure each resident received adequate supervision to prevent elopement for one (1) of eighteen (18) residents; Resident #29. On 05/15/2021, the facility assessed the resident to be an elopement risk and to require a wandering system bracelet/device on his/her body. Review of the resident's Progress Notes, Care Plan and interviews with staff revealed the resident had wandering behaviors present; however, State Survey Agency (SSA) observations on 11/02/2021 and 11/03/2021 revealed the resident did not have a wandering system bracelet/device on his/her body per Physician's Orders. The findings include: Interview with the Executive Director, on 11/04/2021 at 8:30 AM, revealed the facility failed to have a policy to outline the procedure and policy related to accident hazard risk(s) including risk for elopement. Review of Resident #29's Electronic Medical Record (EMR) revealed the facility admitted the resident on 06/13/2014, with diagnoses that included Diabetes Mellitus, Hereditary Motor and Sensory Neuropathy, Anxiety Disorder, Chronic Pain, Open-Angle Glaucoma, Alzheimer's Disease, Dementia with Behavioral Disturbance, Unsteady on Feet, History of Falls, Major Depressive Disorder, and Unspecified Psychosis. Review of Resident #29's EMR revealed there was no documented evidence of an Elopement Risk Assessment between January 2021 and 05/15/2021; four (4) months. Review of Resident #29's Physician's Orders, dated May 2021, revealed an order for check placement of wandering system device every shift (twice a day), with a start date of 05/15/2021. Review of Resident #29's Elopement Risk Assessment, dated 05/15/2021, revealed the resident was at risk for elopement because he/she voiced statements of leaving; exhibited periods of pacing, agitation or wandering towards an exit; and wandering when agitated. Further, the resident required an exit seeking alarm bracelet/device on the resident which required monitoring for placement and function every shift. Further review of Resident #29's EMR revealed there was no documented evidence an Elopement Risk Assessment between 05/15/2021 and 11/04/2021; six (6) months. Review of Resident #29's Comprehensive Care Plan (CCP), initiated on 05/17/2021, revealed the resident demonstrated exit-seeking behaviors. The goal was the resident would not elope from the facility. Further review revealed interventions included to assess the need for wander guard and apply as appropriate; evaluate need for secure unit and transfer if needed; and monitor wandering triggers. Review of Resident #29's Quarterly Minimum Data Set (MDS) Assessment, dated 09/18/2021, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of seven (7) out of fifteen (15), which indicated the resident had severely impaired cognition. Additionally, no behavior of wandering was present. Further, the resident had an elopement wander alarm which was used daily. Review of Resident #29's Medication Administration Record (MAR), dated 10/01/2021 through 10/31/2021, revealed an order to check placement of wandering system bracelet/device every shift; twice daily. Further review revealed twice daily nurses initialed the wandering system bracelet/device placement was checked. Review of Resident #29's Progress Notes/Clinically at Risk Individual Monitoring, dated 10/09/2021 at 8:58 PM, completed by the Director of Health Services (DHS), revealed the resident continued to have agitated behaviors, especially after 4:00 PM. Further review revealed the resident had no attempts to go to exit doors. However, a wander-guard was in place due to wandering. Review of Resident #29's Progress Notes/Clinically at Risk Individual Monitoring, dated 10/17/2021 at 8:42 AM, completed by the DHS, revealed the resident continued to have agitated behaviors, especially after 4:00 PM. Further review revealed the resident had no attempts to go to exit doors. However, a wander-guard was in place due to wandering. Review of Resident #29's Progress Notes/Clinically at Risk Individual Monitoring, dated 10/24/2021 at 9:24 PM, completed by the DHS, revealed the resident continued to have agitated behaviors, especially after 4:00 PM. Additional review revealed the resident had no attempts to go to exit doors. However, a wander-guard was in place due to wandering. Further, Psychiatric services suggested and increase in AM dose of antipsychotic medication, which was approved by the Medical Director (MD). Review of Resident #29's Progress Notes/Clinically at Risk Individual Monitoring, dated 10/31/2021 at 9:56 AM, completed by the DHS, revealed the resident continued to have agitated behaviors, especially after 4:00 PM. Further review revealed the resident had no attempts to go to exit doors. However, a wander-guard was in place due to wandering. Further review of Resident #29's Progress Notes revealed no documented evidence of ongoing Risk Monitoring between 11/01/2021 and 11/04/2021. Review of Resident #29's Medication Administration Record (MAR), dated 11/01/2021 through 11/04/2021, revealed an order to check placement of wandering system bracelet/device every shift; twice daily. Further review revealed twice daily nurses initialed the wandering system bracelet/device placement was checked. Observation, on 11/02/2021 at 9:28 AM, revealed staff had just exited the room after assisting the resident to the restroom. Resident #29 was in his/her room sitting in a wheelchair at bedside. Further, a wandering system bracelet/device was not on the resident's wrists, ankles or wheelchair. Observations, on 11/02/2021 at 11:58 PM, revealed the resident was in the main dining room at a table for lunch meal services. Additional observations revealed the resident was in a wheelchair. Further, a wandering system bracelet/device was not on the resident's wrists, ankles or wheelchair. Observations, on 11/02/2021 at 3:16 PM, revealed the resident was in bed watching television; the wheelchair was at bedside. Further, a wandering system bracelet/device was not on the resident's wrists or wheelchair. Observations, on 11/02/2021 at 5:17 PM, revealed the resident was sitting in a wheelchair at bedside. Interview with the resident at this time revealed he/she was unaware of a bracelet or device he/she wore and stated he/she did not wear jewelry. Further observations at this time revealed no wandering system bracelet/device on the resident's wrists, ankles or wheelchair. Observations, on 11/03/2021 at 8:22 AM, revealed the resident sitting in a wheelchair eating breakfast at bedside. Further, a wandering system bracelet/device was not on the resident's wrists, ankles or wheelchair. Observations, on 11/03/2021 at 10:55 AM, revealed the resident continued to sit at bedside in his/her wheelchair. Further, a wandering system bracelet/device was not on the resident's wrists, ankles or wheelchair. Observations, on 11/03/2021 at 2:20 PM, revealed the resident was in bed with his/her eyes closed. Further, a wandering system bracelet/device was not on the resident's wrists or wheelchair. Interview with State Registered Nursing Assistant (SRNA) #2, and SRNA #3, on 11/03/2021 at 4:43 PM, revealed Resident #29 had increased behaviors, agitation and wandered around the facility, in the evenings. Additional interview revealed the resident wore a wandering system bracelet/device on his/her wrist and had worn the device for several years. Further, they had never seen Resident #29 take the wandering system bracelet/device off his/her wrist. Continued interview revealed it was important the resident always had the device on to ensure he/she was safe and did not leave the facility and wander off. Observations, on 11/03/2021 at 5:00 PM, revealed the resident was in the main dining room at a table. Additional observations revealed the resident was in a wheelchair. Further observations revealed a wandering system bracelet/device was not on the resident's wrists, ankles or wheelchair. Interview with Licensed Practical Nurse (LPN) #2, on 11/03/2021 at 5:05 PM, revealed she was assigned to Resident #29 on 11/02/2021 and 11/03/2021 day shift. Per interview, Resident #29 wandered around the facility and required redirection; however she was not certain if the resident wore a wandering system bracelet/device. Additional interview revealed if a resident was assessed to require a wander guard, there would be a Physician's Order for the device. Continued interview revealed the order would populate into the Electronic MAR (EMAR) and would include checking placement and function of the device; which would be the assigned nurse's responsibility to physically check the device before initialing the EMAR. Further, the use of wandering system bracelets/devices for residents at risk for elopement, either actively exit seeking or a history of exit seeking, minimized and/or prevented the resident from going out the exit doors unsupervised. Per interview, it was important for residents who needed the devices to have them on and monitored the device routinely to keep the residents safe and free from injury(s). Continued interview revealed wandering system bracelets/devices were placed by nurses and the common practice in the facility was to place the device on residents above the waist, usually the wrist, to ensure the alarm system caught the bracelet when a resident neared an exit. Devices were never put on ankles or on wheelchairs. On 11/03/2021 at 5:30 PM, the SSA requested LPN #2 point out where Resident #29's wandering system bracelet/device was located. LPN #2 approached Resident #29, while he/she was seated at the dining room table in a wheelchair and spoke with the resident while touching the resident's wrists and ankles. LPN #2 was unable to locate Resident #29's wandering system bracelet/device. Additional interview with LPN #2, on 11/03/2021 at 5:30 PM, revealed LPN #2 and SSA reviewed the current Physician's Orders for Resident #29 on the EMR. An active order for check placement of wandering system bracelet/device twice daily, with a start date of 05/15/2021, was noted. Additional review of Resident #29's EMR, revealed on the November EMAR, LPN #2 had initialed, check placement of wandering system bracelet/device, on 11/02/2021 and 11/03/2021, day shift. Further interview with LPN #2, on 11/03/2021 at 5:35 PM, revealed LPN #2 stated Resident #29 should have a wandering system bracelet/device on, per Physician's Orders. LPN #2 stated it was her responsibility to physically check the resident to ensure the resident was wearing the wandering system bracelet/device and she had inadvertently initialed Resident #29's EMAR that she had checked the wandering system bracelet/device, on 11/02/2021 and 11/03/2021. Further, the LPN stated the resident must have removed the wandering system bracelet/device after she had checked the placement on the resident's wrist. On 11/03/2021 at 5:40 PM, the SSA accompanied LPN #2, to Resident #29's room, and observed LPN #2 as she checked the resident's room for the wandering system bracelet/device. LPN #2 stated she had never known the resident to remove the wandering system bracelet/device; however, she immediately found the wandering system bracelet/device on the room dividing bookshelf, beside the usual place the resident sat in his/her room. The wandering system bracelet/device was behind a house slipper, in the back of the shelf. The bracelet was twisted. LPN #2 stated she would re-apply a wandering system bracelet/device to the resident's wrist. Interview with the DHS, on 11/04/2021 at 4:03 PM, revealed it was the responsible of the Interdisciplinary Team (IDT) to ensure hazards and risk were identified and assessed for all residents. Per interview, residents were initially assessed for risk for elopement on admission and ongoing with the MDS schedule and as needed with any incident. Additionally, residents at risk for elopement would have interventions implemented to reduce the risk for elopement and monitoring in place to ensure compliance with the interventions. Continued interview revealed devices such as wandering system bracelets/devices required a Physician's Order and nurses were expected to lay eyes on the device before initialing off on the order; residents assessed to have a device and ordered to have a device should have a device in place. Per the DHS, she also did spot checks herself to ensure residents with wander system bracelets/devices, in fact had the device on as ordered. Further, the IDT discussed residents clinically at risk, weekly and reviewed their risk and their implemented interventions to determine if any modification were needed. Further interview revealed the DHS had not identified an issue of residents who required a wandering system bracelet/device guard not having them in place or documentation of the device not being accurate. Per interview, it was important to ensure elopement risk interventions, such as a wandering systems bracelet/device was needed and effective to reduce the risk for elopement. Interview with the Executive Director, on 11/04/2021 at 6:20 PM, revealed the facility did not have a written policy or protocol related to outline the procedure and policy related to accident hazard risk(s) including risk for elopement. Additionally, it was her expectation for staff to ensure residents were safe. She expected residents with physician's orders for wandering system bracelet/device to have those devices in place. Further the Executive Director stated nursing staff should to monitor and document placement of those devices accurately. Continued interview revealed the facility had not identified any concerns with elopement risk and wandering system bracelet/devices. Per interview, ensuring wandering devices were in place was important for the residents protection.

Based on observation, interview, record review and review of the facility's polciy, it was determined the facility failed to ensure respiratory care was provided consistent with professional standards of practice and the comprehensive care plan for two (2) of eighteen (18) residents. Observations of Resident #35 and Resident #42 on 11/02/2021 and 11/04/2021 revealed their oxygen tubing was unlabeled and there was no signage in place indicating oxygen was in use in accordance with the facility's policy. Further observation of Resident #42 revealed the tubing was crimped and the humidifier was without moisture. The findings include: Review of the facility's policy, Guidelines for properly Administering Oxygen and any Respiratory procedure, revealed that the steps for the initial application of oxygen include placing a No Smoking/Oxygen in Use sign on the outside of the room entrance door. Further review of the policy revealed that the tubing should be dated for the date it was initiated, then should be changed monthly and as needed. Review of the policy additionally revealed that a humidifier should be used for residents receiving oxygen at 4L or above and to re-check water level in humidifying jar. Interview with the Director of Health Services/Infection Preventionist (DHS/IP) on 11/04/2021 at 04:03 PM revealed that the facility did not use oxygen signage outside resident rooms because it was a non-smoking facility. She further stated that oxygen use should not be a problem in that environment. She additionally stated she would have to look at the facility's oxygen administration policy for how often tubing was changed but stated that the oxygen tubing was not labeled. The DHS/IP stated she would have to check to be sure of details, but the oxygen company came to the facility weekly to change tubing and service the concentrators. Additional interview revealed that the facility relied on the Lippincott Manual of Nursing Practice for guidance on practice issues. Review of oxygen administration practice in Lippincott's Manual of Nursing Practice revealed the standard of practice includes posting No Smoking signs on the patient's door. 1. Record review revealed the facility admitted Resident #35 on 12/30/2012 with diagnoses including Sepsis, Pneumonia and Chronic Obstructive Pulmonary Disease (COPD), Interstitial Pulmonary Disease, and Chronic Oxygen Dependence. Observation of Resident #35 on 11/02/2021 at 9:44 AM revealed he/she was sitting in a wheelchair in a common area with supplemental oxygen applied at 2.5 Liters (L) via portable concentrator. Further observation revealed that tubing was not dated or labeled in any way. Observation of Resident #35 on 11/02/2021 at 4:25 PM revealed he/she was resting in his/her room with oxygen applied per nasal cannula (NC) at 3L, but there was no labeling on the tubing and no signage outside room that indicated oxygen in use. Observation of Resident #35 on 11/03/2021 at 9:37 AM, in his/her room revealed his/her oxygen applied per NC at 3L, and continued lack of label on the tubing, nor signage indicating oxygen use outside the room. Observation of oxygen administration for Resident #35 on 11/04/21 at 2:52 PM in his/her room at 2.5 lpm from concentrator without labeling or signage. Further observation revealed that there continued to be no date or other label on the tubing. Interview with Licensed Practical Nurse ( LPN) #6 on 11/04/2021 at 2:52 PM revealed oxygen tubing should be changed periodically and that she has seen tubing labeled and dated. Further interview revealed she was not aware of policy for changing and dating, or when oxygen tubing and humidifiers were changed. Record review revealed the facility admitted Resident #42 on 07/10/2021 with diagnoses of Encephalopathy, Chronic Respiratory Failure, COPD, and Oxygen Dependence. Observation of Resident #42 on 11/04/2021 at 3:25 PM revealed the resident was resting in room with oxygen applied at 4L with humidification per NC. Further observation revealed no signage that indicated oxygen was in use. Additional observation revealed the humidifier bottle was empty, no date or other label on tubing or humidifier bottle. Still further observation revealed tubing lying on floor and a porton of the tubing was looped inside closed bedside table drawer and two areas on tubing were crimped. Interview with LPN #4 on 11/04/2021 at 03:32 PM revealed oxygen tubing was changed regularly but that she was not aware of the particular details about timing as this taskwas carried out on night shift. She also stated that the facility typically did not post oxygen signage but would have to look up the specific policy for the details. Interview with Executive Director on 11/04/2021 at 6:09 PM revealed there ws no need for oxygen in use signage as the entire campus was smoke free. Further interview revealed that oxygen tubing changes should be documented in Matrix and signed by the nurse. She further stated she would always refer to documentation in Matrix care and was not sure about labeling tubing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of facility's policy, it was determined the facility failed to ensure drugs and biologicals stored in the facility were not expired, labeled, and stored in accordance with currently excepted professional principles; and failed to store medications according to appropriate environmental controls to preserve their integrity for two (2) out of two (2) medication storage rooms, and one (1) out of three (3) medication carts. Observation of the [NAME] hall medication room refrigerator revealed the refrigerator's temperature was thirty-two (32) degrees Fahrenheit. Continued observation of the refrigerator's temperature revealed the temperature was thirty-four (34) degrees Fahrenheit (F). There was no covering for the freezer compartment to keep cold air from escaping into the refrigerator portion of the unit. Additionally, there was not a separate thermometer for the freezer compartment. Further observation revealed there were four (4) boxes of Influenza Fluzone stacked on top of each other directly below the open freezer compartment. The refrigerator was crowded, not allowing for proper air flow. In addition, Acetaminophen suppositories were stored in the door on a shelf. Observation of the Secretariat hall medication room refrigerator revealed the temperature was 48 degrees Fahrenheit. Furthermore, an approximately two (2) inch thick layer of ice had accumulated on the inside of the freezer compartment. Observation of the 300 hall medication cart revealed two (2) loose Loperamide tablets without resident identifying information. One (1) tablet was found on the bottom of the medication cart drawer, and the other was found sticking out of a package of another medication labeled for Resident #21. Further observation revealed an open bottle of liquid potassium chloride 20 milliequivalents/15 milliliters, prescribed to Resident #41, had been discontinued on 10/20/2021. Further observation revealed an undated, opened bottle of Pro-stat liquid protein supplement. The findings include: Review of the facility policy, Medication Storage in the Facility, revised October 2019, revealed the purpose of the policy was to ensure medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations. Continued review revealed all medication dispensed by the pharmacy should be stored in a container with the pharmacy label. Furthermore, the policy revealed medications requiring refrigeration must be kept in a refrigerator at temperatures between thirty-six (36) degrees Fahrenheit and forty-six (46) degrees Fahrenheit. Medications requiring freezing should be kept at fourteen (14) degrees Fahrenheit to negative twenty (-20) degrees Fahrenheit. Additionally, the refrigerator in which vaccines are stored should be checked at least twice daily, per Centers for Disease Control and Prevention (CDC). Review of the Centers for Disease Control and Prevention's (CDC) Vaccine Storage and Handling, updated 09/29/2021, revealed best practices for storage of vaccines include: 1) do not over-pack the refrigeration unit; 2) place vaccine packages in such a way that air can circulate around the compartment to promote air flow; 3) leave two (2) to three (3) inches between vaccine containers, and the refrigerator's walls; 4) do not use the top shelf, floor, or door for vaccine storage as the temperature in these areas may differ significantly from the temperature in the body of the unit. 1. Observation of [NAME] hall medication room refrigerator, on 11/04/2021 at 10:52 AM, revealed the temperature was thirty-two (32) degrees F. Furthermore, observation revealed there was no covering for the freezer compartment to keep cold air from escaping into the refrigerator portion of the unit. Additionally, observation revealed no thermometer for the freezer compartment. Observation also revealed there were four (4) boxes of Influenza Fluzone stacked on top of each other directly below the open freezer compartment. The medication refrigerator was over-packed in such a way that the refrigerator was filled, with insufficient room for proper air flow to occur. Continued observation of the [NAME] hall medication refrigerator temperature, on 11/04/21 at 11:35 AM, revealed the temperature was thirty-four (34) degrees Fahrenheit. 2. Observation of the medication refrigerator in the Secretariat hall medication storage room, on11/04/21 at 11:05 AM, revealed the temperature was forty-eight (48) degrees Fahrenheit. There was not a separate thermometer for the freezer. Additionally, an approximately two (2) inch thick layer of ice had accumulated on the inside of the freezer compartment. Review of the facility's temperature logs for the [NAME] and Secretariat hall refrigerators, dated September 2021, October 2021, and November 2021, revealed the medication refrigerator range should be between thirty-four (34) degrees Fahrenheit and forty-six (46) degrees Fahrenheit. The freezer range should be between zero (0) degrees Fahrenheit and thirty (30) degrees Fahrenheit. Continued review of the temperature logs, dated September 2021, October 2021, and November 2021, revealed the facility was monitoring refrigerator/freezer temperatures once daily, on the evening shift. Furthermore, both medication refrigerators' temperatures dropped below the CDC's, and the facility policy's, recommended low temperature range of thirty-six (36) degrees Fahrenheit on thirteen (13) out of thirty (30) days in September. The [NAME] medication refrigerator was monitored at thirty-four (34) degrees Fahrenheit on September 26 and 27. The Secretariat medication refrigerator was monitored at thirty-four (34) degrees Fahrenheit on September 8, 9, 10, 11, 12, 14, 15, 16, 20, 23, 24. Review of the operating instructions for the Haier HNSE045BB 4.5 Cubic Foot Compact Refrigerator's operating instructions revealed the freezer compartment should be defrosted whenever frost on the wall of the freezer compartment becomes on-eighth (1/8) inch thick. 3. Observation of the 300 hall medication cart, on 11/04/21 at 1:31 PM, revealed two (2) loose loperamide tablets without resident identification information. One (1) tablet was found on the bottom of the medication cart drawer, and the other was found sticking out of a package of another medication labeled for Resident #21. Further inspection revealed an open bottle of liquid potassium chloride 20 milliequivalents/15 milliliters, prescribed to Resident #41, had been discontinued on 10/20/2021. In addition, there was an undated, opened bottle of Pro-Stat liquid protein supplement. Interview with Licensed Practical Nurse (LPN) #4, on 11/04/2021 at 1:38 PM, revealed she was assigned to the [NAME] hall medication cart. LPN #4 assisted SSA Surveyor with observation of the medication cart and medication storage room. When SSA Surveyor observed two (2) loose loperamide tablets without resident identification information, one (1) tablet was sticking out of a box of Resident #21's medication. LPN #4 stated that the loperamide tablets were prescribed to Resident #21's. Further interview revealed that the open bottle of liquid potassium chloride 20 milliequivalents/15 milliliters, prescribed to Resident #41, had been discontinued on 10/20/2021. LPN #4 stated it should have been removed from the medication cart and returned to the pharmacy for disposal. LPN #4 further stated that the nursing staff is responsible for ensuring medications are labeled according to facility process, which is to record the date opened on the medication package when the medication has been opened. Furthermore, LPN #4 stated if an item is found to be expired, labeled, and or stored improperly, the nursing staff is responsible to discard the medication according to policy. LPN #4 stated that the importance was to prevent medication errors and ensure the safety of all residents. Interview with LPN #1, on 11/04/2021 at 1:50 PM, revealed it is the responsibility of the nursing staff to ensure medications are stored according to facility policy and procedure. Any expired medications are discarded according to facility policy to ensure the safety of all residents. All medications and supplements were to be dated when opened. LPN #1 further stated that labeling and storing medication properly was important to ensure the resident's safety. Interview with the Assistant Director of Health Services (ADHS), on 11/04/2021 at 10:52 AM, revealed it is the responsibility of the nursing staff to ensure the medication cart was clean, medications were in the proper place. Any expired scheduled medications should be discarded according to facility policy. Further interview revealed it was the responsibility of the night shift nurses to monitor temperatures for the medication refrigerators nightly. ADHS stated temperature are not monitored by the day-shift nurses. Further interview revealed she was not aware that facility's Medication Storage in the Facility, policy stated that medications requiring refrigeration must be kept in a refrigerator at temperatures between thirty-six (36) degrees Fahrenheit and forty-six (46) degrees Fahrenheit. Medications requiring freezing should be kept at fourteen (14) degrees Fahrenheit to negative twenty (-20) degrees Fahrenheit. Additionally, she was not aware refrigerated vaccines should be monitored, to ensure proper temperature ranges, at least twice daily, per facility policy, and CDC guidelines. The ADHS stated that storing medications and vaccines according to policy and the CDC's recommendations was important for resident safety and the efficacy of the medication. Interview with Director of Health Service (DHS), on 11/04/2021 at 2:30 PM, revealed the nursing staff was responsible to ensure medications are stored properly. She stated that medication carts are randomly checked for proper storage to ensure the facility's policy is followed; however, the DHS stated she had no documentation related to these random audit checks. Additional interview revealed she was unaware there was a discrepancy between the facility policy and the temperature log ranges for refrigeration of medications and vaccines. Furthermore, the DHS stated she was not sure if the medication storage policy given to SSA Surveyor, was current. SSA Surveyor requested an update policy, however, it was not provided by the facility. The DHS revealed that after consult with the facility's pharmacist, it was determined the temperature ranges on the temperature log were incorrect. According to the DHS, she was not aware of facility protocols and CDC guidelines to monitor refrigerated vaccines at least twice daily. Continued interview, on 11/04/2021 at 4:10 PM, with the DHS, revealed it is her expectation that all nursing staff follows facility policy and procedures related to medication storage and labeling. Furthermore, the DHS stated if an item is found to be expired, labeled, and or stored improperly, it is her expectation that nursing staff return or discard the medication according to facility policy. The DHS further stated that the importance was to ensure the integrity of medications and vaccines and to provide safe, quality care for all residents. Interview with the Executive Director (ED), on 11/04/2021 at 6:30 PM, revealed it was her expectation for medication to be stored and labeled appropriately according to facility policy and CDC guidelines. Further interview revealed that it is her expectation that the nursing staff follow current policies and protocols for medication storage. ED further stated that the importance was to ensure the efficacy of all medications and vaccines, and to keep residents safe. 4. Review of facility's policy titled, Medication Storage in the Facility, revised on 10/2019, revealed medication supplies should only be accessible to licensed facility personnel, pharmacy personnel or facility personnel lawfully authorized to administer medications. Further, the policy revealed all medications dispensed by the pharmacy would be stored in the container with the pharmacy label. Review of facility's policy titled, Preparation and General Guidelines: Medication Administration, General Guidelines, revised 11/2018, revealed the policy did not outline procedures related to medication(s) left at the resident's bedside. Review of Resident #145's medical record revealed the facility admitted the resident on 11/02/2021 with diagnoses to include Hemiplegia and Hemiparesis following Cerebral Infarction affecting left non-dominant side, Hypertension, Chronic Kidney Disease, and Anxiety. There was no Minimum Data Set (MDS) Assessment to review because of the resident's recent admission on [DATE]. Observation of Resident #145's medication administration, on 11/04/2021 at 9:01 AM, with Licensed Practical Nurse (LPN) #5, revealed she prepared the resident's medications, which included Nifedipine (blood pressure medication). Per active Physician's Orders, Nifedipine was held if the systolic blood pressure (top number) was less than one hundred (100); which required the nurse to obtain a blood pressure prior to administration of the medication, to ensure the residents blood pressure was within safe parameters (not to low) for the resident to receive the medication. Further observations revealed LPN #5, left the resident's prepared medications at bedside unattended, within the resident's reach, in medication cups. Further observations revealed LPN #5 left the resident's room and entered the hallway, to get the vital sign machine. The nurse was unable to see the resident or the medications sitting at bedside. Interview with LPN #5, on 11/04/2021 at 9:01 AM, revealed it was not common practice for her to leave medications at the bedside unattended. She further revealed leaving medications unattended at bedside was not a good idea because a resident might take the medication(s) prior to blood pressure measurement. Interview with Director of Health Services (DHS), on 11/04/2021 at 4:25 PM, revealed she expected medication to not be left at the bedside when the nurse was not present in the room. Interview further revealed it was important not to leave medications at bedside because another resident might take them and the resident could take the medication before his/her vital signs were measured. Interview with Executive Director, on 11/04/2021 at 6:14 PM, revealed nurses should not leave medication(s) at the bedside and step out of the room. Interview further revealed her expectation was staff would follow the facility policy on medication administration and storage.

Based on observation and interview, it was determined the facility failed to ensure proper sanitation procedures to prevent the outbreak of foodborne illness. Observation during the initial kitchen tour revealed two (2) large steam table pans stored wet, leading to the potential for bacterial growth. The findings include: Observation, on 11/02/2021 at 9:00 AM, revealed two (2) steam table preparation pans stored wet on a shelf near the steam table, stacked among five (5) other steam table preparation pans. Other serving ware on the shelf was observed to be dry. Interview with the Dietary Manager (DM), on 11/02/2021 at 2:56 PM, revealed normally, all dishes were placed onto a cart to air dry; but, there was limited space and the line had to keep moving. She stated dietary staff panicked when surveyors came in and did not place the pans on the cart to air dry as they were supposed to, and the dietary aides currently working were new. She stated she had been checking all day long to ensure it had not happened again. The DM stated the concern for leaving pans wet was that it created an opportunity for bacterial growth because bacteria grew best in dark, moist places. She stated there was no policy regarding drying of dishes. Interview with the Director of Health Services (DHS), on 11/04/2021 at 9:58 AM revealed her expectation was that any type of serving ware used in the kitchen would be stored dry. She revealed the concern would be for bacteria or mold to grow if items were stored wet. Interview with the Executive Director (ED), on 11/04/2021 at 6:05 PM revealed she was uncertain what the danger would be for pans and utensils to be stored wet. The ED stated she would expect dietary to practice safe storage and serving of food.