**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure the resident's environment remained free from accident hazards by not conducting a bed rail/mattress safety assessment prior to implementing the use of side rails for 1 (#36) of 4 (#3, #36, #40, #50) residents reviewed for the use of side rails. Findings: On 05/12/2025 at 3:20 p.m., observation of resident #36 revealed she was up in the wheelchair. Observation of resident #36's bed at that time revealed both the top quarter rail and the bottom quarter rail on the right side of the bed were in the upright position and the left side of the bed was against the wall. On 05/13/2025 at 8:20 a.m., observation of resident #36 revealed she was sitting up in a wheelchair asleep. Observation of resident #36's bed at that time revealed both the top quarter rail and the bottom quarter rail on the right side of the bed were in the upright position and the left side of the bed was against the wall. On 05/14/2025 at 9:45 a.m., observation of resident #36 revealed she was in the bed asleep with both the top quarter rail and the bottom quarter rail on the right side of the bed were in the upright position and the left side of the bed was against the wall. Review of the Bed Safety and Bed Rails policy and procedure revised August 2022: Policy Statement Resident beds meet the safety specifications established by the Hospital Bed Safety Workgroup. Policy Interpretation and Implementation 1. The resident's sleeping environment is evaluated by the interdisciplinary team. 2. Consideration is given to the resident's safety, medical conditions, comfort, and freedom of movement. 3. Bed frames, mattresses and bed rails are checked for compatibility and size prior to use. 4. Bed dimensions are appropriate for the resident's size. 5. Regardless of mattress type, width, length, and/or depth, the bed frame, bed rail and mattress will be within the safety dimensions established by the Food and Drug Administration (FDA). 6. Side Rail Use Assessment Form to determine if side rails are beneficial for the resident. 7. Any worn or malfunctioning bed system components are repaired or replaced using components that meet manufacturer specifications. 8. Bed rails are properly installed and used according to the manufacturer's instructions, specifications and other pertinent safety guidance to ensure proper fit (e.g., ensure proper distance from the headboard and footboard, etc.) Use of Bed Rails 1. Bed rails are adjustable metal or rigid plastic bars that attach to the bed. One-quarter rails are used in this facility. 2. Before using bed rails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards associated with bed rails and obtain informed consent. The following information will be included in the consent: a. The assessed medical needs that will be addressed with the use of bed rails; b. The resident's risks from the use of bed rails and how these will be mitigated; c. The alternatives that were attempted but failed to meet the resident's needs; and d. The alternatives that were considered but not attempted and the reasons. 3. Consent for Bed Rail/Assist Bars Informed Consent for Use will be signed by the resident/responsible party. 4. The staff shall report to the director of nursing and administrator any accidents or incidents associated with a bed or related equipment including the bed frame, side or bed rails, and mattresses. The Administrator shall ensure that reports are made to the Food and Drug Administration or other appropriate agencies, in accordance with pertinent laws and regulations including the Safe Medical Devices Act. On 05/14/2025 at 2:15 p.m. observation of resident #36's room with S2Directeor of Nursing (DON) revealed the upper quarter side rail and the lower quarter side rail were in the raised position on the right side of bed with the left side of bed was against the wall. S2DON stated they just bought some hospital beds from the local hospital and the side rails cannot be removed but can be put in the down position. S2DON confirmed the lower quarter side rail should not have been in the up position. S2DON further confirmed the Physician order for the side rail use was only for the upper quarter rail for resident #36 to use to position herself in the bed. On 05/14/2025 review of the bed rail/mattress safety assessment dated [DATE] revealed it was not complete. Further review revealed the bed rail use assessment form and the bed rails/assist bars informed consent for use were not completed. On 05/14/2025 at 2:15 p.m. an interview with S2DON confirmed the bed rail/mattress safety assessment was not completed prior to the use of the upper and lower quarter rails on resident #36's bed. S2DON further confirmed the bed rail use assessment form, and the bed rails/assist bars informed consent for use were not completed prior to using the upper and lower quarter side rails on resident #36's bed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interview, the facility failed to 1.) review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation and 2.) assess the resident for risk of entrapment from bed rails prior to installation for 1 (#36) of 4 (#3, #36, #40, #50) residents reviewed for bed rails. Findings: Review of the Bed Safety and Bed Rails policy and procedure revised August 2022: Policy Statement Resident beds meet the safety specifications established by the Hospital Bed Safety Workgroup. Policy Interpretation and Implementation 1. The resident's sleeping environment is evaluated by the interdisciplinary team. 2. Consideration is given to the resident's safety, medical conditions, comfort, and freedom of movement. 3. Bed frames, mattresses and bed rails are checked for compatibility and size prior to use. 4. Bed dimensions are appropriate for the resident's size. 5. Regardless of mattress type, width, length, and/or depth, the bed frame, bed rail and mattress will be within the safety dimensions established by the FDA. 6. Side Rail Use Assessment Form to determine if side rails are beneficial for the resident. 7. Any worn or malfunctioning bed system components are repaired or replaced using components that meet manufacturer specifications. 8. Bed rails are properly installed and used according to the manufacturer's instructions, specifications and other pertinent safety guidance to ensure proper fit (e.g., ensure proper distance from the headboard and footboard, etc.) Use of Bed Rails 1. Bed rails are adjustable metal or rigid plastic bars that attach to the bed. One-quarter rails are used in this facility. 2. Before using bed rails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards associated with bed rails and obtain informed consent. The following information will be included in the consent: a. The assessed medical needs that will be addressed with the use of bed rails; b. The resident's risks from the use of bed rails and how these will be mitigated; c. The alternatives that were attempted but failed to meet the resident's needs; and d. The alternatives that were considered but not attempted and the reasons. 3. Consent for Bed Rail/Assist Bars Informed Consent for Use will be signed by the resident/responsible party. 4. The staff shall report to the director of nursing and administrator any accidents or incidents associated with a bed or related equipment including the bed frame, side or bed rails, and mattresses. The Administrator shall ensure that reports are made to the Food and Drug Administration or other appropriate agencies, in accordance with pertinent laws and regulations including the Safe Medical Devices Act. On 05/12/2025 at 3:20 p.m., observation of resident #36 revealed she was up in the wheelchair. Observation of resident 36's bed at that time revealed both the top quarter rail and the bottom quarter rail on the right side of the bed were in the upright position and the left side of the bed was against the wall. On 05/13/2025 at 8:20 a.m., observation of resident #36 revealed she was sitting up in a wheelchair asleep. Observation of resident #36's bed at that time revealed both the top quarter rail and the bottom quarter rail on the right side of the bed were in the upright position and the left side of the bed was against the wall. On 05/14/2025 at 9:45 a.m., observation of resident #36 revealed she was in the bed asleep with both the top quarter rail and the bottom quarter rail on the right side of the bed in the upright position and the left side of the bed was against the wall. On 05/14/2025 review of the record for resident #36 revealed diagnoses in part of unspecified psychosis, unspecified lack of coordination abnormalities of gait and mobility, seizures, dementia, pseudobulbar affect, and intellectual disabilities. Review of the physician order dated 04/13/2025 revealed may use bilateral upper side rails times 1 for bed mobility assistance, definition, safety and security. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident #36 had a brief interview for mental status (BIMS) score of 9 indicating moderate cognitive impairment. Review of the functional abilities revealed no range of motion impairment to both upper and lower extremities and uses a wheelchair. Review of the mobility MDS assessment revealed: Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the bed resident #36 required set up or clean up assistance. Sit to lying: The ability to move from sitting on side of bed to lying flat on the bed resident #36 required set up or clean up assistance. Lying to sitting on side of bed: The ability to move from lying on the back to sitting on the side of the bed and with no back support resident #36 required set up or clean up assistance. Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed resident #36 required partial or moderate assistance. Chair or bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair) resident #36 required partial or moderate assistance. Review of the current plan of care for the use of side rails for resident #36 revealed: Impaired physical mobility due to cerebrovascular accident (CVA) or trans ischemia attack, general mentation and mental health disorders. May use bilateral upper side rails for bed mobility assistance, definition, safety and security. Interventions: Allow adequate time for resident's response, Assist resident in performing movements or tasks, Determine resident's ability to reposition in bed, Determine resident's ability to transfer, Educate resident or representative on safety precautions, Encourage use of prescribed assistive devices, Ensure call light is available to resident, Monitor for environmental barriers to mobility, Utilize repositioning devices in bed. On 05/14/2025 review of the bed rail/mattress safety assessment dated [DATE] revealed it was not complete. Further review of the bed rail use assessment form and the bed rails/assist bars informed consent for use were not completed prior to the use of the side rails. On 05/14/2025 at 2:15 p.m. observation of resident #36's room with S2Director of Nursing (DON) revealed the upper quarter side rail and the lower quarter side rail were in the raised position on the right side of bed with the left side of bed was against the wall. S2DON stated they just bought some hospital beds from the local hospital and the side rails cannot be removed but can be put in the down position. S2DON confirmed the lower quarter side rail should not have been in the up position. S2DON further confirmed the physician order for the side rail use was only for the upper quarter rail for resident #36 to assist in positioning in bed. S2DON further confirmed the bed rail/mattress safety assessment, bed rails/assist bars informed consent for use, and side rail use assessment form had not been completed prior to utilizing the side rails on resident #36's bed.

Based on record review and interviews, the facility failed to ensure that the licensed nurses have the competencies and skill sets necessary to care for residents' needs for 1 (#53) of 1 closed record review. S12Licensed Practical Nurse (LPN) failed to obtain vital signs after she was unable to obtain a pulse oximetry reading. Findings: Review of the medical record for resident #53 revealed an admission date of 02/20/2025 which diagnoses that included acute on chronic congestive heart failure, ischemic cardiomyopathy, atherosclerotic heart disease, hypertension, fluid overload, presence of coronary angioplasty implant/graft, and presence of cardiac defibrillator. Review of the nurses notes for resident #53 dated 02/21/2025 revealed an entry at 9:00 a.m. in which S12LPN documented a pulse oximetry reading was unable to be obtained due to resident #53's cold and swollen fingers. Further review revealed that resident #53 was administered his medications and then became nauseated. On 05/13/2025 at 2:30 p.m., an interview with S12LPN revealed she did not recall if vital signs were taken after being unable to obtain a pulse oximetry reading. On 05/14/2025 at 8:12 a.m., an interview with S5Assistant Director of Nursing (ADON) confirmed that vital signs should have been obtained after S12LPN was unable to obtain a pulse oximetry reading and resident #53 became nauseated. On 05/14/2025 at 11:52 a.m., an interview with resident #53's physician confirmed that he would expect vital signs to be checked when a pulse oximetry reading was unable to be obtained and an individual was nauseated. On 05/14/2025 at 3:15 p.m. S1Administrator and S2Director of Nursing were notified of the survey findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews the facility failed to develop a plan of care for 1 (#28) of 1 (#28) residents for discharge planning and failed to implement the plan of care for 1 (#46) of 1 (#46) residents by failing to place a fall mat on the floor at the bedside. Findings: Resident #28 On 05/12/2025 at 1:18 p.m., an interview with resident #28 revealed she spoke with S7Business Office Manager (BOM), whom was previously the social service director, over 6 months ago about getting her own apartment but she had not heard anything else about it. Review of the record for resident #28 revealed diagnoses including cerebral infarction, non-traumatic intracerebral hemorrhage with dysarthria and dysphagia, type 2 diabetes, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed resident #28 had a brief interview for mental status (BIMS) score of 13 which indicated the resident was cognitively intact. Review of the current plan of care revealed there was no focus area initiated for the resident's request to be discharged to the community. On 05/14/2025 at 2:20 p.m., an interview with S8SSD (Social Services Director) revealed S7BOM did speak with resident #28 a while back about getting her own appropriate apartment for her condition. S8SSD further revealed resident #28 had never asked her about moving into her own apartment. On 05/14/2025 at 2:35 p.m., an interview with S7BOM who was the previous SSD until January 2025 revealed she had spoken to resident #28 several times about getting her own apartment. S7BOM said she even called the State to come to the facility to assess the resident for a waiver and getting her own apartment but they determined resident #28 had too many limitations to be able to find housing in the area. S7BOM further revealed resident #28 also had a family member that lives in another state and had been trying to locate housing in that state for the resident. On 05/14/2025 at 3:16 p.m. an interview with S2Director of Nurses (DON) and S6MDS Coordinator revealed they were not aware resident #28 had been wanting to get her own apartment and there was no plan of care for resident #28 to discharge to the community. Resident #46 Record review revealed resident #46 was admitted to the facility on [DATE]. Resident #46's diagnoses included essential hypertension, stage 2 pressure ulcer of sacral region, retention of urine unspecified, benign prostatic hyperplasia with lower urinary tract symptoms, unspecified osteoarthritis, anemia, hallucinations, chronic obstructive pulmonary disease, and paroxysmal atrial fibrillation. Review of the quarterly MDS assessment dated [DATE] revealed a brief interview for mental status score of 13 which indicated resident #46 was cognitively intact. Further review revealed resident #46 required partial/moderate assistance with toileting, shower/bathe, dressing lower body, putting on/taking off foot wear, personal hygiene, transfers, and walking 50 feet. Review of resident #46's fall risk assessment dated [DATE] revealed a score of 20 which indicated resident #46 was a high risk for falls. Review of the active care plans revealed resident #46 was at risk for falls. An intervention listed was for a fall mat to right side of bed. Review of the active May 2025 physician orders revealed an order dated 01/03/2024 for fall precautions in place/fall mat to right side of bed. On 05/12/2025 at 9:06 a.m., 05/13/2025 at 8:10 a.m., and 05/14/2025 at 8:20 a.m. observations of resident #46's room revealed there was no fall mat noted on either side of resident #46's bed. On 05/14/2025 at 9:00 a.m. an interview with S5Assistant Director of Nursing (ADON) confirmed there was no fall mat on the floor on either side of resident #46's bed. S5ADON further confirmed there should have been a fall mat on the floor beside his bed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure each resident's medication regimen was free from unnecessary medications by failing to administer insulin as ordered for 1 (#32) of 5 (#3, #4, #8, #32, and #36) residents reviewed for unnecessary medications. Findings: Review of the facility's policy and procedure for Administering Medications Policy revised April 2019 revealed the following, in part: Medications are administered in a safe and timely manner, and as prescribed. 4. Medications are administered in accordance with prescriber orders, including required time frame. Review of the medical record for resident #32 revealed diagnoses of schizoaffective disorder, edema, hypokalemia, dementia, muscle wasting, altered mental status, hypothyroidism, diabetes mellitus, and hyperlipidemia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident #32's Brief Interview for Mental Status indicated the resident had severe cognitive impairment for daily decision making, and required assistance with activities of daily living. Review of the current care plan revealed resident #32 had diabetes mellitus and interventions included to obtain fasting serum blood sugar as ordered by the physician and to administer Regular Insulin as ordered by the physician. Review of the May 2025 physician orders revealed an order dated 7/28/2024 for Insulin Regular (Human) 100 units/milliliter, inject 10 units subcutaneously as needed for hyperglycemia if blood sugar is greater than 300. Review of the May 2025 Medication Administration Record (MAR) revealed resident #32's blood sugar reading on 05/04/2025 at 4:00 p.m. was 425 milligrams/deciliter (mg/dL), and on 05/08/2025 at 4:00 p.m. her blood sugar was 381 mg/dL. Review of the record revealed no documented evidence that the insulin was administered as ordered for blood sugar readings greater than 300. On 05/13/2025 at 2:50 p.m. interview with S2Director of Nursing (DON) confirmed the insulin was not given as ordered when resident #32's blood sugar was greater than 300.

Based on observation and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The facility failed to ensure: 1) freezer temperatures were maintained at a level to keep frozen food solid; 2) frozen foods and noodles were properly sealed and not left open to air; 3) storage containers for flour, corn meal, and sugar were free from spills and splatters; 4) frozen chopped meat was thawed appropriately, and 5) hygienic practices were followed during food service. S4Dietary Manager (DM) reported that 53 residents were served meals from the kitchen. Findings: Observation of the kitchen on 05/12/2025 at 8:18 a.m. revealed the following: -the freezer had multiple thawed items including: 2 packs of onion rings, 1 box of waffles, 1 box of egg patties open to air, 1 box of waffles, 1 box of oatmeal raisin cookies, and 1 box of omelets open to air; -the dry storage area had an opened bag of noodles stored in an opened plastic zip bag; -storage containers for flour, corn meal, and sugar were visibly soiled with food particles and a sticky substance; and -frozen chopped ham was in a sink thawing at room temperature. On 05/12/2025 at 9:00 a.m., an interview with S4DM confirmed the areas of concern identified upon observation. On 05/12/2025 at 11:30 a.m., during the lunch meal, S4DM was observed touching serving trays and plates with gloved hands. S4DM then placed the bread on residents' plates without changing her gloves prior to touching the bread with her contaminated gloves. On 05/12/2025 at 11:35 a.m., an interview with S4DM confirmed she should have not touched the bread with the contaminated gloved hands and should be using tongs to place the bread on the residents' plates. On 05/14/2025 at 3:15 p.m., S1Administrator and S2Director of Nursing (DON) were informed of the findings in the kitchen.

Based on record review and interview the facility failed to have quarterly quality assessment and assurance (QAA) meetings with required members of the QAA committee present. The failed practice was evidenced by the facility`s lack of documentation of 4th quarter of 2024 and 1st quarter of 2025 QAA meetings. Findings: Review of the QAA meetings revealed that the facility held meetings in the second and third quarters of 2024. Further review of the QAA meetings binder revealed that the facility did not have QAA meetings in the 4th quarter of 2024 and 1st quarter of 2025 with required participants. Interview with S1Administrator and S2DON on 05/14/2025 at 4:00 p.m. confirmed that the facility was not able to provide documentation of QAA meetings with required participants during the 4th quarter of 2024 and the 1st quarter of 2025.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to: 1) implement policies and procedures for Enhanced Barrier Precautions (EBPs) by not wearing the appropriate personal protective equipment during care for 4 (#7, #8, #11, and #46) of 4 residents, 2) have signage or an indicator outside of rooms to determine residents that should be on EBPs for 6 (#2, #7, #8, #11, #46, and #50) of 6 residents that required EBPs, and 3) ensure infection control practices were maintained during catheter care for 1 (#16) of 1 residents observed for catheter care. Findings: Review of the facility's Enhanced Barrier Precautions policy, not dated, revealed in-part: Policy Statement: Enhanced barrier precautions (EBPs) are utilized to prevent spread of multi-drug resistant organisms (MDROs) to residents. Policy Interpretation and Implementation 1. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organism (MDROs) to residents. 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gowns are applied prior to performing the high contact resident care activity (as opposed to before entering the room). b. Personal protective equipment (PPR) is changed before caring for another resident. c. Face protection may be used if there is also a risk of splash or spray. d. Hand hygiene is to be performed between residents. 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing; b. bathing/showering; c. transferring; d. providing hygiene; e. changing linens; f. changing briefs or assisting with toileting; g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); and h. wound care (chronic wounds, not shorter lasting wounds, such as skin breaks or skin tears). 5. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. 6. EBPs remains in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at risk. 9. Staff are trained prior to caring for residents on EBPs. 10. Avoid posting signs on door/wall (due to privacy). Symbols may be used. Signage can be at the facility's discretion, as long as staff know which residents require EBP. (Orange sticker on the name of resident's room). 11. PPE is available on EBP cart located on each hall where where applicable. Review of the facility's Catheter Care, Urinary policy revised August 2022 revealed in part: 15. Use a clean washcloth with warm water and soap (or bathing wipe) to cleanse and rinse the catheter from insertion site to approximately four inches outward. 18. Discard disposable items into designated containers. Remove gloves and discard into designated container. Wash and dry your hands thoroughly. 19. Reposition the bed covers. Make the resident comfortable. Resident #7 Review of the record for resident #7 revealed diagnoses of atherosclerosis of native arteries of right leg with ulceration of the foot, arterial ulcer right foot, intermittent claudication of right leg, presence of vascular implants and grafts, and surgical amputation of left below the knee. Review of the current physician orders for wound care to the first digit of the right foot revealed the following: clean with wound cleanser, pat dry, apply alginate and cover with dry dressing every other day. On 05/13/2025 at 9:30 a.m., an observation of resident #7's door prior to entering the room to observe wound care revealed there was no indication resident #7 was on EBPs. Observation of wound care to resident #7's right first digit performed by S3Licensed Practical Nurse (LPN) and S2Director of Nursing (DON) revealed S3LPN and S2DON did not wear a gown during wound care. On 05/13/2025 at 2:52 p.m., an interview with S10Certified Nurses Aide (CNA) revealed if a resident was on EBPs there would be a sign on the door indicating the resident was on EBPs. On 05/13/2025 at 2:50 p.m., an interview with S3LPN confirmed she failed to wear a gown during wound care to resident #7. S3LPN further confirmed S2DON also did not wear a gown during wound care. On 05/13/2025 at 2:55 p.m., an interview with S11CNA revealed there were no residents on the hall with EBPs even though resident #7 required wound care. Resident #8 Record review revealed resident #8 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #8's diagnoses included but not limited to the following: hypertension, edema, blister (non-thermal) left lower leg, chronic venous insufficiency, pain, unspecified osteoarthritis unspecified site, muscle wasting and atrophy multiple sites, tremors unspecified, major depressive disorder, bipolar disorder, anemia, diabetes mellitus, anxiety, and dementia. Review of the May 2025 physician orders revealed a treatment order dated 04/23/2025 for a small ruptured blister to left lower extremity as follows: cleanse with dermal wound cleanser and gauze, apply Aquacel silver to wound bed, cover with dry dressing every other day (qod) and as needed (prn). On 05/12/2025 at 10:25 a.m. and 05/13/2025 at 8:25 a.m. observations revealed no signage on resident #8's door indicating resident was on EBPs. On 05/13/2025 at 10:08 a.m. an observation of wound care to resident #8's left lower extremity by S3LPN revealed S3LPN did not wear a protective gown while performing wound care to resident #8. On 05/13/2025 at 1:20 p.m. an interview conducted with S2DON and S3LPN revealed they are using an orange colored sticker by the resident's name outside their door to inform staff the resident required EBPs. S2DON confirmed there was no orange sticker or signage posted outside resident #8's door indicating that resident #8 was on EBPs. S2DON further confirmed S3LPN should have worn a protective gown while providing resident #8's wound care. Resident #11 Review of the record for resident #11 revealed diagnoses of vascular dementia, acute kidney failure, pressure ulcer of sacral region stage 4, chronic obstructive pulmonary disease, peripheral vascular disease and type 2 diabetes mellitus. Review of the current wound care orders to the sacral pressure ulcer revealed the following: clean with wound cleanser, pat dry, apply skin prep to the peri-wound, apply collagen powder to the wound bed, lightly pack with Iodoform gauze, cover with foam, secure with dry dressing every other day. On 05/13/2025 at 8:45 a.m., an observation of resident #11's door revealed no signage indicating resident #11 required EBPs. Further observation of the wound care performed by S3LPN and S2DON revealed S3LPN and S2DON only wore gloves and did not wear a gown during wound care. On 05/13/2025 at 2:50 p.m., an interview with S3LPN confirmed she failed to wear a gown during wound care to resident #11. S3LPN further confirmed S2DON also did not wear a gown during wound care. On 05/13/2025 at 2:55 p.m., an interview with S11CNA revealed there were no residents on the hall with EBPs even though resident #11 required wound care. Resident #46 Record review revealed resident #46 was admitted to the facility 01/02/2024 with diagnoses of essential hypertension, stage 2 pressure ulcer of sacral region, retention of urine unspecified, benign prostatic hyperplasia with lower urinary tract symptoms, anemia, hallucinations, chronic obstructive pulmonary disease, and paroxysmal atrial fibrillation. Review of the quarterly MDS assessment dated [DATE] revealed a brief interview for mental status score of 13 which indicated resident #46 was cognitively intact. Further review revealed resident #46 had an indwelling catheter and a stage 2 pressure ulcer. Review of the May 2025 physician orders revealed an order dated 04/07/2025 for wound care to a stage 2 pressure injury to coccyx: cleanse with dermal wound cleanser, pat dry with gauze, apply skin prep to peri-wound, apply Medihoney to slough, then cover with gauze, cover with foam and secure with border dressing every other day and as needed. Further review revealed an order dated 09/05/2024 for an indwelling catheter 16 French Coude catheter change every 30 days. On 05/12/2025 at 9:06 a.m. and 05/13/2025 at 8:10 a.m., observations outside resident #46's door revealed no signage indicating resident #46 was on EBPs. On 05/13/2025 at 8:32 a.m. an observation of resident #46's wound care to her coccyx by S3LPN revealed S3LPN did not wear a protective gown while providing wound care to resident #46. S2DON was present during resident #46's wound care. On 05/13/20205 at 1:20 p.m. an interview with S2DON and S3LPN revealed resident #46 was on EBPs. S2DON revealed they are using an orange colored sticker by the residents name outside their room to inform staff that residents are on EBPs. An observation of resident #46's name outside his door revealed there was an orange sticker. S2DON confirmed S3LPN should have worn a protective gown while providing wound care to resident #46. On 05/13/2025 at 3:00 p.m. an interview with S12LPN revealed resident #46 was on EBPs related to having an indwelling catheter and a wound on his coccyx. S12LPN revealed the orange sticker beside his name on the door plate indicated he was on EBPs. Resident #2 Review of the medical record for resident #2 revealed an admission date of 12/09/2021. Resident #2 had diagnoses including heart disease, thrombocytopenia, depression, sepsis, aortic valve stenosis, and end stage renal disease. Review of resident #2's quarterly MDS assessment dated [DATE] revealed resident had moderate cognitive impairment for daily decision making and required assistance with actitivites of daily living (ADLs). Review of the physician orders dated 07/03/2024 revealed an order to monitor dialysis access site to right chest wall for signs and symptoms of infection. On 5/12/2025 at 11:00 a.m., interview with resident #2 revealed she had dialysis treatments three times a week and she had a dialysis access in her chest. Observation of the outside of resident #2's room revealed no written signage or an orange dot on the name plate to indicate the resident was on EBPs. On 5/13/2025 at 8:30 a.m. observation of the outside of the resident's room revealed no written signage or an orange dot on the name plate to indicate the resident was on EBPs. On 05/13/2025 at 1:30 p.m. an interview was with S2DON and S3LPN revealed they use an orange colored sticker by the resident's name outside their door to inform staff the resident was on EBPs. S2DON confirmed there was no orange sticker or signage posted outside of resident #2's door to indicate the resident was on EBPs for having a dialysis access. Resident #50 Review of the medical record for resident #50 revealed an admission date of 05/07/2024. Resident #50 had diagnoses including dysphagia, hypoglycemia, schizoaffective disorder, hypothyroidism, hyperkalemia, unspecified intellectual disabilities, cardiomegaly, and pleural effusion. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident #50 had severe cognitive impairment for daily decision making and required assistance with ADLs. On 05/12/2025 at 10:45 a.m. and on 05/13/2025 at 8:10 a.m. observations of resident #50 revealed the tube feeding was infusing at 50 cubic centimeters (cc) per hour. Observations of the outside of resident #50's room revealed no indicator that the resident was to be on EBPs due to having a Percutaneous Endoscopic Gastrostomy (PEG) tube. On 05/13/2025 at 1:30 p.m. an interview was conducted with S2DON and S3LPN revealed they use an orange colored sticker by the resident's name outside their door to inform staff the resident was on EBPs. S2DON confirmed there was no orange sticker or signage posted outside resident #50's door to indicate resident #50 was on EBPs for having a PEG tube. Resident #16 Review of the medical record for resident #16 revealed an admission date of 09/26/2018 with diagnoses that included Parkinsonism, neuromuscular dysfunction of bladder, and abnormal posture. Review of the Annual MDS assessment dated [DATE] revealed a BIMS score of 10 which indicated that resident #16 had moderately impaired cognition. Review of resident #16's current plan of care revealed that catheter care should be performed every shift and as needed. On 05/13/2025 at 11:00 a.m., an observation of indwelling catheter care by S13CNA was performed. S13CNA was noted wiping towards the indwelling catheter insertion site during the catheter care and S13CNA did not change gloves after the task was completed and touched resident #16's gown, bed linens, and rails with contaminated gloves. On 05/14/2025 at 3:15 p.m., S1Administrator and S2DON were notified of the survey findings and confirmed S13CNA did not use proper technique while performing pericare for resident #16.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to protect the resident's right to be free from physical and verbal abuse by staff for 1 (#1) of 3 (#1, #2, #3) residents reviewed for abuse. The facility failed to protect resident #1 from physical and verbal abuse by staff. Findings: Review of the facility abuse and neglect policy dated April 2021revealed it defined abuse as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. The policy also defined willful as the individual must have acted deliberately, not that the individual must have attended to inflict injury or harm. Review of the facility's incident investigation report dated 06/05/2024, at 5:30p.m., revealed the nurse was called to the smoking patio where she found resident #1 on the floor by his wheelchair. He denied any pain or discomfort. The resident had no injuries. Record review revealed resident #1 was admitted to the facility on [DATE] with diagnoses of muscle weakness and Rhabdomyolysis. Review of resident #1's Minimum Data Set assessment dated [DATE] revealed resident #1 was independent with wheelchair use. The assessment also indicated resident #1 had a Brief Interview for Mental Status score of 15 indicating the resident was cognitively intact. On 06/24/2024 at 2:00p.m., interview with resident #1 reported he was not arguing when S5CNA (certified nursing assistant) pushed him over to the ground from his wheelchair on 06/05/2024. He reported he wasn't injured. He refused to say anything more about the incident. On 06/24/2024 at 1:15p.m., interview with S4CNA revealed she was a witness to the incident on 06/05/2024. She reported resident #1 was being rude and talking disrespectfully to the staff. The staff tried to ignore him but he wouldn't stop speaking disrespectfully and inappropriately. S5CNA instructed resident #1 to stop being rude. Resident #1 threatened S5CNA. S4CNA reported she had turned away and did not see resident #1 swing at S5CNA or her response. When she turned around, resident #1 was on the ground. S4CNA reported she heard S5CNA say to resident #1 Now try to get up Mother _____ before walking away. On 06/26/2024 at 1:20p.m., interview with S5CNA revealed several residents and staff were on the smoking porch on 06/05/2024. Resident #1 was cursing and made several sexually inappropriate remarks to her. S5CNA reported she asked him to calm down several times. S5CNA further reported Resident #1 attempted to hit her and she responded by pushing resident #1 with her arms with the intention of pushing his hands away. Resident #1's wheelchair flipped over resulting in him being on the ground. S5CNA then reported she walked away. On 06/26/2024 at 2:50p.m., interview with S3CNA revealed she was a witness to the incident on 06/05/2024. S3CNA reported resident #1 was on the smoking patio cursing and making sexually inappropriate comments about the staff who were outside with him. S3CNA heard S5CNA repeatedly tell resident #1 to stop making inappropriate remarks. S5CNA then walked over to resident #1. Resident #1 threatened to whoop her butt to which S5CNA replied by telling him to try. Resident #1 swung to hit at S5CNA and S5CNA pushed resident #1 tipping over his wheelchair and sending him to the ground. She reported she heard S5CNA call resident #1 a Mother _____ before walking away. On 06/25/2024 at 11:20a.m., an interview with S1AIT (Administrator in Training) and S7DON (Director of Nursing) confirmed there was incident between resident #1 and S5CNA which resulted in resident #1 falling to the ground.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure that residents received care, consistent with professional standards of practice, to prevent pressure ulcers for 1 (#39) of 3 (#12, #16, #39) residents reviewed for pressure ulcers. The facility failed to provide a pressure relieving device while in the wheelchair for resident #39. Findings: Review of the medical record for resident #39 revealed the resident was admitted on [DATE] with diagnoses including diabetes, depression, hypothyroidism, schizoaffective disorder, Vitamin D deficiency, dementia with behavioral disturbances, and muscle wasting with atrophy. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed resident #39 had a Brief Interview for Mental Status (BIMS) score of 3 which indicated the resident had severely impaired cognitive skills for daily decision making. The resident was dependent for toileting hygiene and required partial/moderate assistance with transfers. The resident was incontinent of bowel and bladder. The resident was at risk for developing pressure ulcers. Review of the pressure ulcer scale dated 02/20/2024 revealed the resident was identified as high risk for pressure ulcers. Review of the record revealed the following careplan: at risk for impaired skin integrity/pressure injury. Further review revealed an intervention to provide pressure reducing surfaces on bed and chair. Observation on 04/08/2024 at 10:40 a.m. revealed the resident was in her wheelchair in her room. The wheelchair did not have a pressure relieving device. Further observation on 04/08/2024 at 3:40 p.m. revealed the resident was in her wheelchair in the sitting area. The wheelchair did not have a pressure relieving device. Observation on 04/09/2024 at 8:40 a.m., 1:00 p.m., and 4:00 p.m. revealed the resident was in her wheelchair in the sitting area. The wheelchair did not have a pressure relieving device. Observation on 04/11/2024 at 8:20 a.m. revealed the resident was in her wheelchair in the sitting area. The wheelchair did not have a pressure relieving device. Observation on 04/11/2024 at 11:15 a.m. revealed the resident was in her wheelchair in the secondary dining room. The wheelchair did not have a pressure relieving device. Observation on 04/11/2024 at 1:10 p.m. revealed the resident was in her wheelchair in the sitting area. The wheelchair did not have a pressure relieving device. An interview with S5Certified Nursing Assistant on 04/11/2024 at 12:05 p.m. revealed she was not aware the resident's wheelchair did not have a pressure relieving device. An interview with S4Licensed Practical Nurse on 04/11/2024 at 1:10 p.m. confirmed the resident's wheelchair did not have a pressure relieving device. LPN further confirmed the resident should have a pressure relieving device in her wheelchair. An interview with S2Director of Nursing on 04/11/2024 at 1:35 p.m. confirmed the resident was at high risk for developing pressure ulcers and resident #39 should have a pressure relieving device in her wheelchair.

Based on interviews and record reviews, the facility failed to ensure residents were free from unnecessary medication use for 1 (#26) of 5 (#23, #26, #31, #40, and #48) sampled residents reviewed for unnecessary medications. The physician failed to ensure a psychotropic medication (Alprazolam) was not ordered to be given as needed for a time period greater than 14 days for resident #26. Findings: Resident #26 Review of the record revealed resident #26 had an admission date of 01/31/2019 with diagnoses including type 2 diabetes mellitus with diabetic neuropathy, anxiety disorder, hypertension, unspecified dementia, and chronic obstructive pulmonary disease. Review of the April 2024 Physician's Orders revealed an order dated 11/27/2023 for Alprazolam 0.25 milligrams (mg) 1 tablet by mouth (po) as needed (prn) for anxiety. Review of the Pharmaceutical Consultant Report dated 01/23/2024 revealed pharmacist recommended that Alprazolam (Xanax) prn psychotropic medication should be limited to 14 days. Physician denied the gradual dose reduction and rationale was minimally effective dose given, signed and dated by physician on 01/31/2024. Review of the March 2024 Medication Administration Record (MAR) revealed Alprazolam 0.25 mg po was administered on 03/21/2024. Review of the April 2024 MAR revealed Alprazolam 0.25 mg po was administered on 04/01/2024 and 04/02/2024. An interview on 04/11/2024 at 1:45 p.m. with S2Director of Nursing (DON) confirmed that Alprazolam (psychotropic) should not be administered as needed greater than 14 days. S2DON confirmed that the physician continued a prn psychotropic medication past 14 days for resident #26.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure failed to ensure a resident who is unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 2 (#12 and #38) of 4 (#12, #26, #38, and #59) sampled residents reviewed for activities of daily living (ADLs). Findings: Review of the facility's policy and procedure related to nail care, (revision date 02/01/2024), revealed the following, in part: General Guidelines 1. Nail care includes daily cleaning and regular trimming; 3. Unless otherwise permitted, do not trim the nails of diabetic residents or residents with circulatory impairments; 7. Diabetic nail care to be performed by a Registered Nurse or Provider Resident #12 Review of the record revealed an admission date of 09/26/2023 with diagnoses including myelopathy, chronic obstructive pulmonary disease, enlarged and hypertrophic nails, hammer toe, hyperlipidemia, hypertension, glaucoma, fusion of spine lumbar region, pressure ulcer of sacral region stage 4,and type 2 diabetes mellitus. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed resident #12 has a Brief Interview of Mental Status (BIMS) score of 12 indicating mild cognitive impairment. Further review of the MDS revealed resident requires assistance with ADLs. Review of the careplan dated 09/26/2023 revealed musculoskeletal: requires assistance with ADL's due to decreased mobility: related to occasional incontinence episodes, recent back surgery, chronic pain syndrome, muscle weakness. The interventions included 1-2 person assist with ADLs including hygiene, bathing, and transfers as needed, assist with positioning transfers, and ambulation as necessary 1-2 person assist with transfers. An interview/observation on 04/08/2024 at 2:45 p.m. revealed resident #12 had long, jagged fingernails on bilateral hands. Resident #12 reported she has asked staff to cut her nails. An observation of resident #12 on 04/09/2024 at 8:10 a.m. revealed long, jagged fingernails noted to bilateral hands. An interview on 04/11/2024 at 1:45 p.m. with S2DON (Director of Nursing) confirmed that resident #12 is unable to trim her own nails and a Registered Nurse should have trimmed fingernails. Resident #38 Review of the chart revealed an admission date of 02/08/2022 with diagnoses including unspecified dementia without behavioral disturbance, nicotine dependence, major depressive disorder, alzheimer's disease, chronic obstructive pulmonary disease, history of amputation of right thumb and index finger, other visual disturbances, and type 2 diabetes mellitus. Review of the Quarterly MDS dated [DATE] revealed a BIMS score of 12 indicating mild cognitive impairment. Further review of the MDS revealed resident required assistance with ADLs. Observations of resident #38 on 04/08/2024 at 10:05 a.m., 04/09/2024 at 8:10 a.m., and 04/11/2024 at 9:00 a.m. revealed resident had long, jagged, and dirty fingernails on both hands. An interview with resident #38 on 04/09/2024 at 8:10 a.m. revealed he is unable to trim his own nails. Review of the resident #38's careplan dated 02/08/2022 revealed potential for altered neurological function: Interventions included may use 1-2 person assist with ADLs, hygiene, bathing, and transfers as needed. An interview/observation with resident #38 on 04/11/2024 at 9:00 a.m. revealed resident's fingernails were long, dirty, and jagged on both hands. Resident #38confirmed he was unable to trim his own nails due to amputation of thumb and 1st finger to right hand. An interview on 04/11/2024 at 1:45 p.m. with S2DON confirmed resident #38 was unable to trim his own nails and a Registered Nurse should have trimmed his fingernails.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #6 Review of the record for resident #6 revealed an admission date of 07/28/2014 with diagnoses including paranoid schizophrenia, cerebrovascular accident, chronic obstructive pulmonary disease (COPD), diabetes mellitus, tardive dyskinesia, and hypertension. Review of the Physician's Orders for April 2024 revealed the following orders dated: -01/28/2015 Oxygen (O2) at 2 Liters (L)/minute (min) via nasal cannula (NC) as needed (prn) ; and -11/14/2022 Give all medications via gastrostomy tube (G-tube), flush port with 30 cc of tap water before and after medications. An observation of the administration of G-tube medications for resident #6 on 04/09/2024 at 12:00 p.m. with S9Licensed Practical Nurse (LPN) revealed she did not flush the G-tube with 30 cc of tap water before the administration of medications. An interview with S9LPN confirmed she did not flush G-tube with 30 cc of tap water before medication administration. Observations of resident #6 on 04/08/2024 at 9:21 a.m. and 04/09/2024 at 8:05 a.m. revealed resident had O2 at 3.5 L/minute via NC. Review of the careplan updated on 02/09/2024 revealed resident had the potential for impaired respiratory function related to COPD, chronic bronchitis, cough, nasal congestion, and COVID (COronaVIrus Disease)-19. Interventions included to administer O2 therapy as ordered including O2 at 2L/min via NC prn. Observations of resident #6 on 04/08/2024 at 9:21 a.m. and 04/09/2024 at 8:05 a.m. revealed resident had O2 at 3.5 L/min via N/C. An interview on 04/11/2024 at 1:45 p.m. with S2DON confirmed that resident #6 had an order for 30 cc of tap water flush to be administered prior to medication administration and S9LPN should have flushed the G-tube with 30 cc of tap water prior to administering medications. S2DON confirmed that resident #6's O2 should have been at 2L/min via NC prn. S2DON confirmed that staff did not follow physician's orders for resident #6 by failing to flush the G-tube with 30 cc tap water prior to administration of medications and by not ensuring the O2 was at 2L/min via NC. Resident #26 Review of the record revealed an admission date of 01/31/2019 with diagnoses including cellulitis of right lower limb, type 2 diabetes mellitus with diabetic neuropathy, anxiety disorder, hypertension, unspecified dementia, chronic obstructive pulmonary disease, and acute respiratory failure with hypoxemia. Review of the Physician's Orders for April 2024 revealed an order dated 11/28/2023 for Oxygen at 2 Liters/minute (L/min) via nasal cannula (NC) continuous. Observations of resident #26 during the survey revealed the following: 1.) on 04/08/2024 at 9:28 a.m.- resident had O2 at 3.5 L/min via NC; and 2.) on 04/09/2024 - resident did not have O2 in place; and 3.) on 04/11/2024 at 10:45 a.m. - resident had O2 at 3L/min via NC. Review of resident #26's careplan dated 01/31/2019 revealed impaired breathing patterns: related to COPD, anxiety, allergic rhinitis, and a history of upper respirator infections. Interventions included administer O2 therapy as ordered. An interview on 04/11/2024 at 10:40 a.m. with S7Assistant Director of Nursing (ADON) confirmed that resident #26's O2 concentrator was set at 3L/min during an observation. S7ADON further confirmed resident #26 has an order for O2 at 2L/min via NC continuously and staff were not following physcian's orders. An interview on 04/11/2024 at 1:45 p.m. with S2DON confirmed that staff did not follow physician's orders for resident #6's by failing to administer O2 at 2L/min via NC continuous. Based on observations, record reviews, and interviews, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 (#23) of 1 resident reviewed for edema, 2 (#6 & #26) of 3 (#6, #26, #50) residents reviewed for Oxygen, and 1 (#6) of 1 resident observed during a Percutaneous Endoscopic Gastrostomy (PEG) tube medication administation. The facility failed to: 1. Apply compression stockings as ordered by the physician for resident #23, 2. Administer Oxygen as ordered by the physician for resident #6 and resident #26, and 3. Administer a 30 cubic centimeters (cc) water flush prior to the administration of resident #6's medications as ordered by the physician. Findings: Resident #23 Review of the medical record for resident #23 revealed the resident was admitted on [DATE] with diagnoses including hypertension, dementia with behavioral disturbance, ventricular septal defect following acute myocardial infarction, disorder of kidney and ureter, Alzheimer's disease, and edema. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3 which indicated the resident had severely impaired cognitive skills for daily decision making. The resident required maximal assistance with toileting hygiene and moderate assistance with transfers. The resident was incontinent of bowel and bladder. Review of the physician orders revealed an order dated 10/13/2023 to apply compression stockings every morning and remove compression stockings before bedtime. Review of the medical record revealed a careplan for impaired cardiac output. Further review of the careplan revealed an intervention to apply compression stockings every morning and remove every bedtime as ordered. Observations on 04/09/2024 at 8:40 a.m., 1:55 p.m., and 4:00 p.m. and on 04/11/2024 at 8:20 a.m. revealed resident #23 was sitting in her wheelchair in a common area. Further observation revealed the resident's feet and ankles were edematous and the resident did not have her compression stockings applied. Observation on 04/11/2024 at 11:15 a.m. revealed resident #23 was sitting in her wheelchair in the secondary dining room. Further observation revealed the resident's feet and ankles were edematous and the resident did not have her compression stockings applied. An interview with S5Certified Nursing Assistant (CNA) on 04/11/2024 at 12:00 p.m. revealed she was not aware that resident #23 required compression stockings. An interview with S4Licensed Practical Nurse (LPN) on 04/11/2024 at 12:17 p.m. revealed the resident had an order for compression stockings and she confirmed the resident was not wearing her compression stockings. An interview with S2Director of Nursing (DON) on 04/11/2024 at 1:30 p.m. confirmed resident #23 did not have her compression stockings on as ordered by the physician.

Resident #26 Review of the record revealed an admission date of 01/31/2019 with diagnoses including cellulitis of right lower limb, type 2 diabetes mellitus with diabetic neuropathy, anxiety disorder, hypertension, unspecified dementia, and chronic obstructive pulmonary disease. Review of the April 2024 Physician's Orders revealed an order dated 11/27/2023 for Novolog insulin sliding scale 6 a.m. and 4 p.m: 180-200 give 2 Units (U) subcutaneous (SQ), 201-250 give 3 U SQ, 251-300 give 4 U SQ, greater than 300 give 5 U SQ and call physician. Review of the March 2024 and April 2024 Medication Administration Records (MAR) revealed Novolog insulin had been given with no documentation of sites for the administration of Novolog insulin. An interview on 04/11/2024 at 11:25 a.m. with S7Assistant Director of Nursing (ADON) confirmed that sites should have been documented for insulin administration. S7ADON confirmed that there was no documentation of sites for administration of Novolog insulin for resident #26 for March 2024 and April 2024. An interview on 04/11/2024 at 1:45 p.m. with S2DON confirmed that there was no documentation of sites for administration of Novolog insulin for residnet #26 for March and April 2024. Resident #40 Review of the record revealed an admission date of 12/05/2022 with diagnoses including hypertension, glaucoma, acute embolism and thrombosis of unspecified deep veins of lower extremity, type 2 diabetes without complications, and angina pectoris. Review of the April 2024 Physician's Orders revealed an order dated 03/27/2024 for Mounjaro 2.5 mg/0.5 ml give 2.5 mg SQ every week (Friday) for resident #40. Review of the April 2024 MAR revealed Mounjaro SQ was administered on 04/05/2024 with no documentation of the injection site. An interview on 04/11/2024 at 11:25 a.m. with S7ADON confirmed the injection site should have been documented for the administration of Mounjaro. S7ADON confirmed that there was no documentation of site for administration of Mounjaro for resident #40 on 04/05/2024. Based on record reviews and interviews, the facility failed to ensure nursing staff had appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to ensure nurses documented the site of subcutaneous diabetic injections for 3 (#26, #31, and #40) of 5 (# 23, #26, #31, #40, and #48) sampled residents reviewed for unnecessary medications. Findings: resident #31 Review of the medical record for resident #31 revealed an admission date of 04/12/2021 with diagnoses that included type 1 diabetes, hperlipidemia, anemia, upper respiratory infection, heart disease, chronic kidney disease, osteoarthritis, lack of coordination, convulsions, vascular dementia, and hypertension. Review of the active April 2024 Physician's orders revealed the following orders in regards to resident #31 taking the following medications for type 1 diadetes : Humalog 100 units/ml (milliliter) cartridge inject 10 units subcutaneous before breakfast Ozempic dose pen inject 0.5 mg (milligram) subcutaneous every Friday Humalog 100 units/ml (milliliter) cartridge15 units before lunch and supper at 11:00 a.m. and 4:00 p.m. Administer 10 units of regular Insulin for blood sugars greater than 250 Monitor Blood Sugars before breakfast, before evening meal and 2 hours after evening meal (see sliding scale for Blood sugars order for Blood sugars greater than 250 Review of the March and April Medication Administration Records (MARS) revealed resident #31 received the medication as ordered with no documentation of the sites when resident #31 received a subcutaneous injection. Interview on 4/11/2024 at 8:30 a.m with S2DON (Director of Nursing) confirmed there wass no documentation of the injection sites with each dose of insulin given by the nurses.

Resident #26 Review of resident #26`s record revealed an admission date of 01/31/2019 with diagnoses including cellulitis of right lower limb, type 2 diabetes mellitus with diabetic neuropathy, anxiety disorder, hypertension, unspecified dementia, chronic obstructive pulmonary disease, and acute respiratory failure with hypoxemia. Review of the April 2024 Physician's Orders revealed an order dated 11/27/2023 for Novolog insulin sliding scale 6 a.m. and 4 p.m: 180-200 give 2 Units (U) subcutaneous (SQ), 201-250 give 3 U SQ, 251-300 give 4 U SQ, >300 give 5 U SQ and call physician, Review of the March 2024 and April 2024 Medication Administration Records (MAR) revealed no documentation of the injection sites when Novolog insulin was given as ordered. An interview on 04/11/2024 at 11:25 a.m. with S7Assistant Director of Nursing (ADON) confirmed that injection sites should be documented for insulin administration. S7ADON confirmed there was no documentation of injection sites for Novolog administration in March 2024 and April 2024 for resident #26. An interview on 04/11/2024 at 1:45 p.m. with S2DON confirmed there was no documentation of injection sites for Novolog administration in March 2024 and April 2024 for resident #26. S2DON also confirmed pharmacy consultant did not notify the facility of the irregularities in regards to the nurses not documenting the injection site when insulin was given. Based on record review and interview, the pharmacist failed to identify and report irregularities to the attending physician and the facility's medical director and director of nursing for 2 (#26, #31) of 5 (#23,#26,#31,#40,#48) sampled residents reviewed for unnecessary medications and insulin administration. Findings: resident #31 Review of the medical record for resident #31 revealed an admission date of 04/12/2021 with diagnosis that include type 1 diabetes, hperlipidemia, anemia, upper respiratory infection, heart disease, chronic kidney disease, osteoarthritis, lack of coordination, convulsions, vascular dementia, and hypertension. Review of the April 2024 Physician's orders revealed the following orders in regards to resident #31 taking the following medications for type 1 diadetes : Humalog 100 units/ml (milliliter) cartridge inject 10 units subcutaneous before breakfast Ozempic dose pen inject 0.5 mg (milligram) subcutaneous every Friday Humalog 100 units/ml (milliliter) cartridge15 units before lunch and supper at 11:00 a.m. and 4:00 p.m. Administer 10 units of regular Insulin for blood sugars greater than 250 Monitor Blood Sugars before breakfast, before evening meal and 2 hours after evening meal (see sliding scale for Blood sugars order for Blood sugars greater than 250 Review of the March and April Medication Administration Records (MARS) revealed no documentation of the injection sites when resident #31 received each dose of insulin given. Interview on 4/11/2024 at 8:30 a.m with S2Director of Nursing (DON) confirmed injection sites should be documented for insulin administration and there was no documentation of injection sites for insulin administration related to resident #31 for March 2024 and April 2024. An interview on 04/11/2024 at 1:50 p.m. with the S2DON confirmed that the pharmacist did not notify the facility of the irregularities in regards to the nurses not documenting the injection site when insulin was given.

Based on observations, record reviews, and interviews, the facility failed to ensure the menus were followed for 4 (#25, #36, #55 and #113) of 4 residents who were prescribed pureed diets and 11 (#16, #18, #19, #22, #27, #40, #42, #51, #54, #58, and #363) of 11 residents who were prescribed mechanical soft diets. The facility failed to ensure the menus were followed for 8 (#14, #17, #23, #28, #39, #53, #54, and #58) of 8 residents by not providing 4 ounces of chicken during the 04/08/2024 lunch meal. Findings: Review of the lunch menu approved by the Registered Dietician dated 04/08/2024 revealed the residents receiving a pureed diet should receive pureed cornbread and the residents on a mechanical soft diet should receive moist cornbread. Further review revealed all diets should receive 4 ounces of chicken. Review of the medical records revealed residents #25, #36, #55 and #113 were ordered pureed diets and residents #16, #18, #19, #22, #27, #40, #42, #51, #54, #58, and #363 were ordered mechanical soft diets. Further review revealed residents #14, #17, #23, #28, #39, #53, #54, and #58 received meals from the facility's kitchen. Observation of the lunch meal on 04/08/2024 at 11:30 a.m. revealed residents #25, #36, #55 and #113 who were to receive pureed diets did not receive pureed cornbread. Further observation revealed residents #16, #18, #19, #22, #27, #40, #42, #51, #54, #58, and #363 who were to receive mechanical soft diets did not receive moist cornbread. Observation also revealed residents #14, #17, #23, #28, #39, #53, #54, and #58 who were to receive 4 ounces of chicken received one chicken leg not equivalent to s4 ounces. On 04/08/2024 at 12:06 p.m., an observation with S6Dietary Manager of the amount of chicken from one chicken leg revealed the chicken did not measure 4 ounces. Observation on 04/08/2024 at 12:15 p.m. revealed resident #54 had eaten her one chicken leg. An interview with resident #54 at this time revealed she would like some more chicken. An interview on 04/09/2024 at 12:30 p.m. with S6Dietary Manager (DM) confirmed the residents who received pureed diets were not served pureed cornbread and the residents who received mechanical soft diets were not served moistened cornbread as stated on the menu approved by the Registered Dietician. Further interview with S6DM confirmed one chicken leg did not provide 4 ounces of chicken as stated on the menu approved by the Registered Dietician. During an interview with the S1Administrator on 04/09/2024 at 1:05 p.m., S1Administrator was notified that the menu approved by the Registered Dietician was not followed during the lunch meal on 04/08/2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #50 Review of the electronic health record revealed resident #50 was admitted to the facility on [DATE]. Resident #50's documented diagnoses included, in part, dementia with behavioral disturbance, Alzheimer's disease, and Schizoaffective disorder. Review of the quarterly Minimum Data Set, dated [DATE] revealed resident #50 had a brief interview for mental status score of 03. A score of 00-07 indicates resident #50 was severely cognitively impaired with daily decision making. Further review revealed resident #50 needed extensive assistance with 2+ person physical assistance with personal hygiene and limited assistance with one person physical assistance with eating. On 05/08/2023 at 11:45 a.m., an observation revealed resident #50 sitting in his Geri-chair in the dining room, eating his lunch meal. During the meal service, resident #50 was observed picking up food items from his meal tray (yam patty and cornbread) with his hands and placing them in his mouth for consumption. Further observation revealed the resident's fingernails to both hands were dirty with a black substance observed underneath the nailbeds. On 05/10/2023 at 1:45 p.m., S2Director of Nursing and S5Assistant Director of Nursing were notified of the observation during the lunch service regarding resident #50 handling and eating food items from his meal tray with a black substance observed underneath the nailbeds to both hands. They confirmed resident #50's fingernails should have been cleaned prior handling and consuming the food items. Based on observations, record reviews, and interviews the facility failed to provide assistance for residents who were unable to carry out activities of daily living and received the necessary services to maintain good grooming and personal hygiene for 2 (#1, #50) of 2 (#1, #50 ) residents investigated for ADL (activities of daily living) care. 1) The facility failed to ensure nail care was provided for resident #1 and #50; and, 2) The facility failed to ensure resident #1 was appropriately dressed. Findings: Resident #1 Review of the record for resident #1 revealed he was admitted to the facility on [DATE] with diagnoses including the following: major depressive disorder, vascular dementia, glaucoma, legal blindness, peripheral vascular disease, and transient cerebral ischemic attack. Review of the 04/24/2023 quarterly MDS (Minimal Data Set) revealed the following: Vision: severely impaired, no vision and sees only light; Functional status for personal hygiene: self-performance limited assistance with one person physical assistance, and the resident required setup or clean-up assistance with put on/take off footwear. Review of nurses' notes dated 04/24/2023 revealed resident required one person physical assistance with his bathing and required limited assistance with most ADLs. An observation on 05/08/2023 at 9:41 a.m., revealed resident #1 sitting in a wheelchair in front of the nurses' station. Resident #1 was wearing mixed matched socks (one maroon and one white). Resident #1 was observed to have long, thick fingernails with dirt and grime buildup inside the nailbeds. An interview on 05/08/2023 at 9:45 a.m., with resident #1, revealed that he was blind and he had to have assistance from staff for dressing, grooming, and bathing. Resident #1 further reported that he was going out to a day program and a doctor visit today (referring to 05/08/2023). An observation on 05/09/2023 at 8:10 a.m., revealed resident #1 sitting in a wheelchair in front of the nurses' station. Resident #1 was wearing mixed matched socks and his fingernails were again observed to be long, with dirt, and grime under nailbeds. An interview with S4CNA (Certified Nursing Assistant) on 05/09/2023 at 8:10 a.m., revealed that resident #1 required assistance with dressing, grooming, and she confirmed that he was blind. She confirmed that resident #1 wore mixed-match socks on 05/09/2023. S4CNA also confirmed resident #1 had long fingernails that required trimming. An interview with S2DON (Director of Nursing) on 05/10/2023 at 8:15 a.m., confirmed resident #1 had worn mixed matched socks on 05/08/2023 and 05/09/2023. Further interview with S2DON confirmed that resident #1's fingernails were thick and long and required trimming.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, the facility failed to ensure the resident's environment remains as free of accident hazards as is possible. The facility failed to attempt appropriate interventions after a resident sustained falls for 1 (#15) of 6 (#7, 15, 25, 27, 29 and 41) residents reviewed for accidents. Findings: Review of the facility's Falls-Clinical Protocol Policy revealed in part -Treatment/Management 1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. 2. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation (for example, if the individual continues to try to get up and walk without waiting for assistance). Review of the medical record for resident #15 revealed admission date of 09/06/2022 with diagnoses of dementia, delusional disorder, hypertension, heart disease, polyneuropathy, depressive disorder, anxiety, Alzheimer's disease, and schizophrenia. Review of the quarterly Minimum Data Set, dated [DATE] revealed the resident had severely impaired cognitive skills for daily decision making and required supervision with setup help for bed mobility, transfers, eating and bathing. The resident required supervision with one person physical assist for toileting and hygiene. Review of the medical record revealed a physician's order dated 09/07/2022 for the resident to be on fall precautions. Review of the fall risk assessments dated 09/06/2022, 11/29/2022 and 02/21/2023 revealed the resident was identified as high risk for falls. Review of the care plan revealed the following: At risk for falls related to antipsychotic medication use, Alzheimer's disease, poor balance, depression, poor memory, and polyneuropathy. Further review of the care plan in part revealed the following approaches: Remind resident to ask for assist for all ambulation, redirect as needed, and encourage/remind to ask for assistance with activities of daily living and transfers. On 05/08/2023 at 8:30 a.m. resident #15 was able to communicate but not able to be interviewed. On 05/10/2023 at 9:00 a.m. observation of resident #15 revealed she was sitting in chair in the hallway with her walker beside her. Further observation of the resident revealed she was able to communicate with the surveyor but not able to be interviewed. Review of the Incident/Accident Reporting forms revealed the following: On 02/23/2023 at 5:50 a.m. called to room per CNA (Certified Nursing Assistant). The resident was observed sitting on the floor leaning on her right elbow, noted to have a laceration to the top of the forehead and it was bleeding. Review of the careplan intervention revealed- continue with repeated instructions to call for assistance. On 03/07/2023 at 5:00 a.m. called to the room by CNA. Observed the resident lying on right side on the floor in front on the TV. The resident was not wearing socks or shoes. Review of the careplan intervention revealed - encouraged to dress and put on non-slip socks. On 04/05/2023 at 12:55 a.m. while making rounds this nurse heard a noise in patient's room. The nurse entered the room and observed the resident lying on the floor on her left side. Intervention noted on the Incident/Accident report - Resident instructed to use call light for assistance, encouraged resident to leave door open for monitoring. Review of the careplan intervention revealed - encouraged to use ½ siderail to open side of the bed for bed definition when sleeping. On 04/22/2023 at 7:15 a.m. the resident was found on the floor in front of the wheelchair. The resident tried to get up out of the wheelchair and forgot to lock the wheelchair. Intervention noted on the Incident/Accident report - Resident instructed to use call light for assistance and ensure call light in reach. Review of the careplan intervention revealed - make repeated instructions on safety of locking the wheelchair as needed. 4/27/23 at 2:50 p.m. the resident was walking down the hall and lost her balance and fell. The resident didn't have a wheelchair or rolling walker. Intervention noted on the Incident/Accident report - encouraged resident to leave the door open for monitoring and encouraged resident to use a walker when ambulating. Review of the careplan intervention revealed - Continue frequent instructions given for use of walker or wheelchair (both of which are provided), also to utilize the hand rails in the hallways. On 05/10/2023 at 11:00 a.m. S2DON (Director of Nursing), and S5ADON (Assistant Director of Nursing) were notified of the fall interventions not being appropriate for a resident with severe cognitive skills for daily decision making.

Based on observation, review of the menus, and interviews the facility failed to ensure the menus were followed for 3 (#24, #34 and #35) of 3 (#24, #34 and #35) residents that had an order for a pureed diet. The facility failed to serve the correct dessert listed on the menu for the residents that had an order for a pureed diet. Findings: Review of the facility's Therapeutic Diet policy revealed in part - 14. Menus must be prepared in advance and followed. On 05/08/2023 at 11:30 a.m., observation of the lunch meal revealed sampled resident #24 was ordered a pureed diet. Further observation of the lunch meal revealed resident #24 received a prepackaged pudding cup for dessert. Review of the lunch menu for 05/08/2023 revealed the residents that were ordered a pureed diet should have received pureed bread pudding. On 05/08/2023 at 2:45 p.m., an interview with S6Dietary Manager revealed residents #24, #34 and #35 had a physician's order for a pureed diet and they received a prepackaged pudding cup instead of pureed bread pudding as listed on the menu. On 05/09/2023 at 3:00 p.m., S1Administrator was notified that the residents that had an order for a pureed diet did not receive the dessert that was listed on the menu for the lunch meal on 05/08/2023. On 05/10/2023 at 10:45 a.m., S2DON (Director of Nursing) and S5ADON (Assistant Director of Nursing) were notified of the residents that had an order for a pureed diet did not receive the dessert that was listed on the menu for the lunch meal on 05/08/2023.

Based on observation and interview, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary and orderly environment for the interior of the building. The failed practice was evidenced by a blanket over the dryer vent duct, a hole in the wall behind the dryer, and heavy lint buildup behind dryers. Findings: On 05/09/2023 at 2:10 p.m. an observation of the laundry room revealed a hole was noted in the wall behind the dryer with a cotton blanket wrapped around a dryer vent duct. The blanket and the floor behind dryers had heavy lint buildup. On 05/09/2023 at 2:25 p.m. an observation with S1Administrator of the laundry room confirmed the hole in the wall should be sealed, the cotton blanket should not be covering the dryer vent duct, and the blanket and the floor should not have heavy lint buildup.

Based on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs by failing to ensure lab work was obtained as ordered by the physician for 1 (#27) of 5 (#5, 19, 27, 37, 50) residents whose drug regimens were reviewed. Findings: Review of the medical record revealed resident #27 had diagnoses which included paranoid schizophrenia, depression, hyperlipidemia, chronic venous hypertension, diabetes, insomnia and atrial fibrillation. The resident also had medication orders which included glipizide, Eliquis, trazadone, duloxetine, Depakote, Risperdal, Lasix, potassium chloride, atorvastatin, Lantus insulin, Ozempic, levothyroxine and Humulin R. Review of the physician orders revealed there was an order written on 09/16/2022 to obtain a lipid panel, TSH (Thyroid Stimulating Hormone), Vitamin D, CBC (Complete Blood Count), CMP (Comprehensive Metabolic Panel) and a Hemoglobin A1C in March 2023. Review of resident #27's medical record revealed there was no results for the lab due in March. On 05/09/2023 at 11:30 a.m., interview with #S5ADON (Assistant Director of Nursing)confirmed the March labs were not obtained for resident #27.