**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews, the facility failed to ensure residents who required respiratory care received the care and services consistent with professional standards by failing to properly store CPAP (Continuous Positive Airway Pressure) face device for 1 (#29) of 1 (#29) residents reviewed for respiratory care. Findings: Review of resident #29's medical diagnoses revealed in part: Obstructive sleep apnea, chronic respiratory failure with hypercapnia, dependence on other enabling machines and devices. Review of resident #29's current Physicians orders revealed the following: Check CPAP every shift to make sure filled with distilled water at all times. Assist resident with CPAP machine: on at HS (bedtime) and off AM (morning) Diagnosis: sleep apnea. Review of resident #29's Care Plans revealed the following: I'm at risk for altered oxygen exchange related to diagnosis of sleep apnea with appropriate approaches like elevate head of bed and assist resident with CPAP machine setting on 7, put on at 8 pm and off at 8 am as well as outcomes. Review of Minimum Data Set, dated [DATE] revealed the following: BIMS (Brief Interview for Mental Status) score: 11 (moderately impaired) Section I Active Diagnosis: medically complex Obstructive sleep apnea Section O Special Treatments, Procedures, and Programs G1 Non-invasive Mechanical Ventilator -yes- G3 - CPAP During observations on 06/23/2025 at 9:00 a.m., 12:30 p.m., 2:25 p.m., and 06/24/2025 at 7:35 a.m. resident #29's CPAP head gear was sitting on top of a small refrigerator next to her bed. The head gear was not in any type of bag or container. During an interview on 06/24/2025 at 7:40 a.m., S4 LPN (Licensed Practical Nurse) acknowledged that resident #29's CPAP headgear should have been stored in a bag and not just left on top of the refrigerator. During an interview on 06/24/2025 at 9:50 a.m., S1 DON (Director of Nursing) acknowledged that resident #29's CPAP head gear should have been stored in a bag when not in use.

Based on record review and interviews, the facility failed to ensure a resident with an order for psychotropic medication as needed (PRN) was not subjected to chemical restraints for 1 (#61) of 5 (#29, #33, #43, #61 and #63) residents reviewed for unnecessary medications. The facility failed to ensure Resident #61's PRN order for psychotropic medication was limited to 14 days. Findings: Review of Resident #61's medical record revealed an admit date of 03/29/2022 with diagnoses of but not limited to chronic kidney disease and dementia. Review of Resident #61's June 2025 physician's orders revealed an order for Atarax/Hydroxyzine 25mg (milligrams) give one tablet three times a day PRN for anxiety for one year. Review of Resident #61's June 2025 MAR (Medication Administration Record) revealed documentation that Resident #61 was administered Atarax/Hydroxyzine 25mg twice for anxiety. During an interview on 06/24/2025 at 1:30 p.m. S2 LPN (Licensed Practical Nurse) confirmed Resident #61 was prescribed Atarax/Hydroxyzine 25mg PRN for anxiety ordered for 1 year. During a phone interview on 06/25/2025 at 10:45 a.m. S5 NP (Nurse Practitioner) confirmed there was not a rationale for ordering Resident #61's PRN Atarax/Hydroxyzine 25mg for 1 year and confirmed it should have been ordered with a 14 day limit.

Based on record review and interviews, the facility failed to ensure narcotic records were maintained and reconciled for 1 (Cart A) of 3 (Cart A, Cart B, Cart C) medication carts reviewed. This had the potential to affect any of the 11 residents receiving narcotics from Cart A. Findings: Review of the facility's Medication Narcotic Count policy dated 04/11/2011 revealed in part: Procedure: III. Each nurse who is going off duty, along with the nurse that is coming on duty, counts the narcotics together. Each nurse signs the form Narcotic Control Record validating that these two (2) nurses counted all narcotics inside the narcotic drawer of the medication cart and that these drugs were reconciled with the individual Resident Narcotic Records stating the amount of drugs that are inside the narcotic drawer. Cart A: Review of medication Cart A's Narcotic Control Record on 06/23/2025 at 10:45 a.m. revealed 2 nurses had not signed validating all narcotics inside the narcotic drawer had been counted and reconciled with the individual resident narcotic records each shift as required. Further review of the Narcotic Control Record logs for Cart A from 01/01/2025 to 06/23/2025 revealed: 4 missing signatures for January 2025 narcotic count, 7 missing signatures for February 2025, 9 missing signatures for March 2025, 13 missing signatures for April 2025, 14 missing signatures for May 2025, and 9 missing signatures for June 2025. During an interview on 06/23/2025 at 10:45 a.m., S3 LPN (Licensed Practical Nurse) confirmed the Narcotic Control Records for Cart A's narcotic reconciliation were not fully completed and should have been. During an interview on 06/24/2025 at 10:30 p.m., S1 Director of Nursing verified the Narcotic Control Records for Cart A's narcotic reconciliation were not completed as required and should have been.

Based on record reviews and interview the facility failed to ensure the resident's representative was notified of a resident's change in health condition for 2 residents (#2, #4) out of 4 residents records reviewed. The facility failed to notify Resident #2 and Resident #4's representatives of acquired pressure injuries. Findings: Review of the facility policy titled Change in a Resident's Condition or Status dated 06/13/2016 included: -Purpose: It is the policy of ______ that ______ shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). -Procedure: 2. A significant change of condition is a decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions is not self-limiting); b. Impacts more than one area of the resident's health status; c. Requires interdisciplinary review and/or revision to the care plan; . 3. Unless otherwise instructed by the resident, the Staff Nurse will notify the resident's family or representative (sponsor) when: b. There is a significant change in the resident's physical, mental, or psychosocial status; . 4. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition of status 5. Regardless of the resident's current mental or physical condition, the Nursing Supervisor/Charge Nurse will inform the resident/responsible party or representative of any changes in his/her medical care or nursing treatments 6. The Staff Nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Review of Resident #2's record revealed Resident #2 acquired an unstageable pressure injury to his left ischium and a stage 3 pressure injury to his right gluteal fold on 05/18/2024, a deep tissue injury to his scrotum and an arterial ulcer to his left outer ankle on 05/29/2024, and an unstageable pressure injury to his right heel on 06/03/2024. Further review of Resident #2's record failed to reveal Resident #2's representative was notified of Resident #2's acquired pressure injuries. Review of Resident #4's record revealed Resident #4 acquired a stage 2 pressure injury to her left inner ankle on 05/03/2024 and a stage 2 pressure injury to her left inner foot on 06/03/2024. Further review of Resident #2's record failed to reveal Resident #4's representative was notified of Resident #4's acquired pressure injuries. During an interview on 07/16/2024 at 10:14 a.m. S1 Director of Nursing reviewed Resident #2 and Resident #4's records and acknowledged there was no documentation that the resident's representatives were notified of the resident's acquired pressure injuries.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview, the faciltiy failed to ensure reportable incidents were reported to the State Survey and Certification Agency for 1 (#86) of 2 (#86, #91) residents reviewed for accidents. The facility failed to report an elopement for Resident #86. Findings: Review of Resident #86's medical records revealed an admit date of 06/30/2022 with the following diagnoses, in part: difficulty in walking/not elsewhere classified, age-related physical debility, Alzheimer's disease/unspecified, muscle weakness (generalized) and cognitive communication deficit. Review of Resident #86's MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) 03 indicating severely impaired cognition. Review of Resident #86's Incident Tracking revealed an incident dated 04/16/2024 at 3:47 p.m. - elopement - front of building - nurse was notified by ward clerk on west wing that resident was outside of the front of the facility, walking around the parking lot - assessed resident and notified family and MD (Medical Director) - no injury. Quality indicators: baseline cognition - name YES, other - confused/disoriented. Review of Facility's SIMS (Statewide Incident Managment System) Reports failed to reveal a report for Resident #86's elopement on 04/16/2024. During an interview on 05/22/2024 at 9:40 a.m., S1 Director of Nursing acknowledged Resident #86's elopement on 04/16/2024 was not reported to the State Survey and Certification Agency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to develop and implement a comprehensive person-centered care plan for 1 (#86) of 2 (#86, #91) sampled residents reviewed for accidents. The facility failed to ensure a plan of care for elopement had beed developed and implemented for Resident #86 who had a history of elopement. Findings: Review of Facility's Wandering, Unsafe Resident Policy and Procedure (10/17/2017) revealed: - Purpose: will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement. - Procedure: .The resident's care plan will indicate the resident is at risk for elopement or other safety issues. Interventions to try to maintain safety will be included in the resident's care plan. Review of Resident #86's medical records revealed an admit date of 06/30/2022 with the following diagnoses, in part: difficulty in walking/not elsewhere, age-related physical debility, Alzheimer's disease/unspecified, muscle weakness (generalized), unspecified non-displaced fracture of second cervical vertebra and cognitive communication deficit. Review of Resident #86's MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) 03 indicating severely impaired cognition. Review of Resident's Comprehensive Care Plan revealed the following and approaches: - At risk for altered thought processes - staff will assist resident to make simple decision, reality orientation prn (as needed). - At high risk for falls/injury r/t (related to) impaired mobility/unsteady gait/history of falls -04/16/2024 elopement - notified by front desk that was outside the front of the facility walking; No injuries noted. Instructed to notify nurse before going outside alone - voiced understanding. Front desk notified she cannot leave facility without assistance of family or staff. Further review failed to reveal approaches for wandering/elopement. Further review of care plan failed to reveal interventions to prevent elopement. Review of Resident #86's Incident Tracking revealed an incident dated 04/16/2024 at 3:47 p.m. - elopement - front of building - nurse was notified by ward clerk on west wing that resident was outside of the front of the facility, walking around the parking lot. During an interview on 05/22/2024 at 8:40 a.m. S2 MDS Nurse acknowledged the only interventions on Resident #86's care plan for elopement was telling the resident to notify the nurse when she goes outside and notifying the front desk she is not to go outside without staff or family. During an interview on 05/22/2024 at 9:40 a.m. S1 Director of Nursing acknowledged the only interventions on Resident #86's care plan for elopement was telling the resident to notify the nurse when she goes outside and notifying the front desk she is not to go outside without staff or family.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure residents' medical records reflected the resident's advance directive wishes for 1 (#82) of 32 residents reviewed for advance directives in the initial pool. The facility failed to ensure Resident #82's medical record was consistent with the resident's wishes for DNR (Do Not Resuscitate). Findings: Review of the facility's Advance Directive policy dated [DATE] revealed in part: Purpose: It is the policy of __________ that advance directives will be respected in accordance with state law and facility policy. Procedure: 1. Upon admission of a resident to our facility, the social services director or designee will provide written information to the resident concerning his/ her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate advance directives. 4. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. Review of face sheet revealed Resident #82 was initially admitted to the facility on [DATE] with a current admit date of [DATE]. Further review of Resident #82's face sheet revealed full code. Resuscitate: yes. Review of Resident #82's Medical Record (paper chart) revealed: STOP DO Not Resuscitate signed on [DATE]. No code order Certification Statement Form: Do not use a feeding tube, respirator or resuscitation, signed by responsible party on [DATE] and physician signed on [DATE] and [DATE]. Review of Resident #82's care plan revealed I am a full code and I do wish for CPR (cardiopulmonary resuscitation) to be performed with approaches for CPR to be provided to resident as per consent. During an interview on [DATE] at 12:00 p.m. S3 LPN (Licensed Practical Nurse) Unit Manager reported she would check the residents' medical chart in the advance directive tab to determine code status. S3 LPN Unit Manager reviewed Resident #82's medical record (paper chart) and reported the face sheet, facility's code status sheet and No Code order Certification Statement form should all match and confirmed Resident #82's code status did not match throughout the medical record. During an interview on [DATE] at 12:15 p.m. S1 DON (Director of Nursing) reported S4 Social Services Director (SSD) should ensure resident code status/advance directive wishes matched. During an interview on [DATE] at 2:30 p.m. S4 SSD reported Resident #82 was a full code upon admit until the resident and family completed the admission agreement. S4 SSD reported after completing the admission agreement the family chose for Resident #82 to be a DNR. S4 SSD confirmed Resident #82's code status was not updated when family made decision to make Resident #82 a DNR. S4 SSD reported when Resident #82's code status changed, the system should have been updated to reflect Resident #82's DNR status and a new face sheet should have been printed and placed on the chart.

Based on personnel record reviews and interview, the facility failed to ensure an annual performance review was completed for 1 [S7 Certified Nurse Assistant (CNA)] out of 5 CNA personnel records reviewed. Findings: Review of S7 CNA's personnel record revealed S7 CNA worked for the facility through an agency and had done so since 12/15/2020. Further review of S7 CNA's personnel record failed to reveal documentation of annual performance reviews. During an interview on 05/22/2024 S1 Director of Nursing reviewed S7 CNA's personnel record and acknowledged there was no documentation of annual performance reviews.

Based on personnel record reviews and interview, the facility failed to provide at least 12 hours of in-service training per year that included dementia management, resident abuse prevention, and care of the cognitively impaired for 1 [S7 Certified Nurse Assistant (CNA)] out of 5 CNA personnel records reviewed. Findings: Review of S7 CNA's personnel record revealed S7 CNA worked for the facility through an agency and had done so since 12/15/2020. Further review of S7 CNA's personnel record failed to reveal documentation of at least 12 hours of in-service training per year that included dementia management, resident abuse prevention, and care of the cognitively impaired. During an interview on 05/22/2024 S1 Director of Nursing reviewed S7 CNA's personnel record and acknowledged there was no documentation of at least 12 hours of in-service training per year that included dementia management, resident abuse prevention, and care of the cognitively impaired.

Based on record reviews and interviews, the facility failed to ensure dietary services were provided in a safe, sanitary environment to prevent contamination and food borne illness for 98 residents served a meal tray from the kitchen as reported by S5 Assistant Dietary Manager. The facility failed to label frozen uncooked chicken out of its original package in the walk in freezer and failed to clean the meat slicer after each use. Findings: Observations during the initial tour of kitchen with S5 Assistant Dietary Manager on 05/20/2024 at 8:00 A.M. revealed a large unlabeled and undated rectangular silver pan containing frozen uncooked chicken in the walk in freezer and dried debris to bottom of covered meat slicer. During an interview on 05/20/2024 at 8:00 A.M. S5 Assistant Dietary Manager confirmed the frozen uncooked chicken should have been labeled and dated. S5 Assistant Dietary Manager reported the meat slicer should have been cleaned after each use. During an interview on 05/20/2024 at 11:50 A.M. S5 Assistant Dietary Manager confirmed 98 trays were served for breakfast.

Based on record reviews and an interview, the facility failed to ensure 4 out of 4 glucometers reviewed were maintained in safe operating condition for 11 (#41, #12, #29, #69, #5, #87, #7, #46, #64, #302, #75) residents residing in the facility with orders for glucose monitoring. S3 LPN (Licensed Practical Nurse) Unit Manager provided a list of 11 (#41, #12, #29, #69, #5, #87, #7, #46, #64, #302, #75) residents who resided on Hall A, Hall B, Hall C, and Hall D that received glucometer checks. Findings: Review of facility's Obtaining A Fingerstick Glucose Level policy dated 11/6/2017 revealed in part: Purpose: It is the policy of _________ to obtain a blood sample to determine the resident's blood glucose level. Procedure: Ensure that equipment and devices are working properly by performing any calibrations or checks as instructed by the manufacturer or this facility. Review of facility's glucometer control logs for January 1, 2024 through May 21, 2024 with S3 LPN (Licensed Practical Nurse) Unit Manager revealed glucometer checks were not done on the following dates: Hall A's: January 2024: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10,11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 25, 28, 30, 31 February 2024: 2, 3, 4, 5, 7, 8, 10. 11, 12, 13, 14, 16, 17, 18, 19, 20, 21, 22, 26, 29 March 2024: 3, 6, 7, 11, 12, 13, 16, 17, 18, 19, 26, 27, 28 April 2024: 1, 2, 4, 9, 10, 12, 13, 14, 15, 17, 18, 19, 20, 23, 24, 28, 29 May 2024: 1, 2, 4, 5, 6, 7, 8, 11, 12, 13, 16, 17 Hall B's: January 2024: unable to provide documentation that glucometer checks were done for the entire month of January 2024. February 2024: unable to provide documentation that glucometer checks were don for the entire month of February 2024. March 2024: 2, 7, 13, 25 April 2024: 3, 8, 9, 10, 16, 17 May 2024: 1, 2, 8, 9, 10, 11, 16 Hall C's: January 2024: 1, 2, 6, 18, 19, 20, 21, 22, 25, 26, 30 February 2024: 2, 4, 6, 7, 8, 10, 12, 15, 16, 18, 19, 21, 25, 26, 27 March 2024: 3, 5, 6, 10, 11, 12, 14, 15, 16, 17, 18, 19 April 2024: 1, 3, 5, 9, 14, 16, 26, 29, 30 May 2024: 1, 15, 17, 18 Hall D's: January 2024: 2, 3 February 2024: 3, 4, 5, 12, 15, 16, 21, 25 March 2024: 1, 5, 18, 19 During an interview on 05/22/2024 at 1:10 p.m. S3 LPN (Licensed Practical Nurse) Unit Manager reported glucometer checks should be done daily by the floor nurse on the overnight shift, and further acknowledged glucometer checks were not done.

Deficiency Text Not Available

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Based on observation, interview, and record review the facility failed to ensure proper infection control techniques were practiced to prevent urinary tract infection for 1 (Resident#79) of 2 residents (Resident #79 and Resident #71) that were reviewed for Indwelling Catheters. Findings: Review of facility's Perineal Care Policy dated 11/03/2010 revealed, in part, staff should wash the rectal area by wiping from the base of the labia towards and extending over the buttocks. Observation on 04/11/2023 at 10:45 a.m., revealed S10 CNA (Certified Nursing Assistant) performing catheter care and fecal incontinence care for Resident #79. Further observation revealed, S10 CNA wiped stool from Resident #79's rectal area forward, into Resident #79's vaginal area on six separate occasions. In an interview on 04/11/2023 at 11:05 a.m., S10 CNA stated she should not have wiped Resident #79's stool from back (rectal area) to front (vaginal area). In an interview on 04/11/2023 at 11:12 a.m., S1 DON (Director of Nursing) stated S10 CNA should not have wiped Resident #79's stool from the rectal area to vaginal area on six separate occasions.

Based on record reviews and interviews, the facility failed to have a process in place to monitor vaccination status of employees, volunteers, and contractors for 1 (S9 CNA [Certified Nursing Assistant]) of 3 contracted employees (S9 CNA, S14 CNA, and S8 LPN [Licensed Practical Nurse]) reviewed for COVID-19 vaccination status. Findings: Review of facility provided list of contacted staff working in the building on 04/10/2023 revealed, in part S9 CNA and S8 LPN were working in facility on 04/10/2023. Review of the facility's Staff Vaccination Matrix revealed, in part, S9 CNA was not listed on the Contract Staff Vaccinations log. Review of S9 CNA's time sheet revealed, in part, that he worked at facility on 03/17/2023, 03/20/2023, 03/26/2023, 03/27/2023, 03/30/2023, 03/31/2023, 04/01/2023, 04/02/2023, 04/06/2023, 04/09/2023, and 04/09/2023. In an interview on 04/10/2023 at 4:55 p.m., S1 DON (Director of Nursing) stated the process for verifying COVID-19 vaccination of contracted staff is that agency's email her the employees' vaccination cards or exemptions before they start working at the facility. S1 DON further stated that she could not find an email or documentation regarding the Covid-19 vaccination status of S9 CNA, who was reported to be working in the facility on 04/10/2023 day shift. In an interview on 04/11/2023 at 9:03 a.m., S1 DON stated she could not find documentation of S9 CNA's vaccination status after looking through her documents yesterday, and that she had to contact staffing agency to email her S9 CNA's vaccination status this morning.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to ensure an injury of unknown origin was thoroughly investigated for 1 (#336) out of 3 (#38, 336, #13) residents reviewed for accidents. Findings: Review of Resident #336's medical record revealed diagnoses of, but not limited to displaced bimalleol fracture low leg, closed fracture with routine healing, unspecified fracture shaft of left tibia, unspecified fracture shaft of left fibula, weakness, bed confinement status, unspecified dementia without behavioral disturbances. Review of MDS (Minimum data sets) dated 3/9/2023 revealed a BIMS (Brief Interview of Mental Status) of 99 with being severely impaired-never/rarely made decisions. Review of Incident dated 3/26/2023 at 10:45 AM: @ 10:45 Upon CNA (Certified Nurse Assistant) rounding CNA notified writer after pericare at 11:05 to come assess resident lower left limb. Writer assessed noticed left foot had a potential injury and notified ADON (Assistant Director of Nurses) @ 11:07 RN (Registered Nurse) shift supervisor. @11:35 ADON notified NP (Nurse Practitioner) of potential injury to left lower limb @ 11:45 911 called @11:50 EMS (Emergency Medical Service) arrived @12:00 EMS transported patient to local hospital RP (responsible party) [NAME] called; no answer @ 2nd RP. No number available 3rd RP called; He is aware verbalized understanding @ 12:46 1st RP called back she is aware of current situation and verbalized understanding DON (Director of Nursing) aware. Staff actions at time of incident: at the time of potential injury staff assessed resident head to toe and placed resident in a comfortable position until EMS arrived. During an interview on 4/11/2023 at 1:00 p.m. Resident # 336's RP reported about 2 weeks on Sunday, March 26, 2023 she was notified Resident #336 had a left tibia fibula fracture in the facility. Resident #336's RP reported she was unsure how the left tibia/ fibula fracture occurred. Resident #336's RP further reported the orthopedic surgeon indicated with Resident #336's bones not being good he was unable to tell how the fracture occurred. Resident #336's RP reported she has not been able to get any answers of how Resident #336's left leg was fractured. Resident #336's RP further reported she requested details from the staff about how the fracture occurred and the only response she received was the CNA came in to get Resident #336 ready for breakfast and saw her foot was deformed and the nurse called 911. During a telephone interview on 4/11/2023 at 2:00 p.m. Resident #336's RP reported she had a meeting with S20 Administrator and S18 Unit Manager on Wednesday or Thursday after Resident #336's left leg fracture occurred. Resident #336's RP reported S20 Administrator and S18 Unit Manager did not have any information about the incident at the time. Resident #336's RP reported S20 Administrator informed her protocol was followed and an investigation was opened on Monday, March 27, 2023. During an interview on 4/11/2023 at 1:45 p.m. S2 ADON (Assistant Director of Nursing) reported she asked staff to write statements and these were the only two written statements from the 11PM CNA and 7AM CNA S2 DON reported staff were interviewed but did not have any documentation of their statements. During an interview on 4/11/2023 at 1:50 p.m. S20 Administrator, S1 DON, and S2 ADON reported no one witnessed the actual incident and camera footage was not reviewed. During an interview on 4/11/2023 at 2:00 p.m. S1 DON reported the investigative process is a collective effort with the supervisors. S1 DON reported S2 ADON was working on the day of the incident and started the investigation and S1 DON confirmed she completed the investigation.

Based on record reviews and interviews the facility failed to ensure 1(#336) out of 3 (#38, #336, #13) residents reviewed for accidents received care and treatment in accordance with professional standards of practice and by following Resident #336's comprehensive care plan. Findings: Review of Resident #336's medical record revealed diagnoses of but not limited to displaced bimalleol fracture low leg, closed fracture with routine healing, unspecified fracture shaft of left tibia, unspecified fracture shaft of left fibula, weakness, bed confinement status, unspecified dementia without behavioral disturbances Review of MDS (Minimum Data Sets) dated of 3/09/2023 revealed a BIMS (Brief Interview of Mental Status) of 99 with being severely impaired-never/rarely made decisions. Review of Functional Status revealed Resident #336 had impairment on both sides with range of motion with upper and lower extremities Review of Resident #336's Comprehensive Care Plan revealed the following problems and approaches dated 3/26/2023: Fall sent to local hospital left lower tibia/fibula ankle fracture, returned the same day with splint/ace bandage with approaches including splint and ace bandage to left lower extremity, follow up appointment next day, Ortho: increase monitoring to more than once every 2 hours. Review of Resident #336 March 2023 Electronic Health Record and Medical Record including Interdisciplinary notes from March 27, 2023 through April 5, 2023 failed to reveal assessment and monitoring of Resident #336 of ace and bandage to left lower extremity. Review of Resident #336 emergency room discharge note dated 3/26/2023 revealed a follow up care appointment the next business day with an orthopedic physician. During an interview on 4/11/2023 at 1:00 p.m. Resident # 336's RP (responsible party) reported about 2 weeks on a Sunday Resident #336 went to the emergency room for left tibia/fibula fracture that was set with a cast/splint in the emergency room and was discharged back to facility on the same evening. Resident #336 was to be referred to an orthopedic physician the next business day. Resident #336's RP reported the orthopedic physician denied Resident #336 referral and Resident #336 was then referred to a second orthopedic physician which also denied her referral. Resident #336's RP reported the following Monday, April 4, 2023 a third orthopedic physician agreed to evaluate her. Resident #336 reported she attended the third orthopedic appointment with Resident #336 and when the third orthopedic physician removed Resident #336's cast, findings included a 35 degree angle break across the ankle in the same place, breakdown in skin behind knee, and a wound on top of foot. Resident #336 RP reported the third orthopedic physican gave them options (1) to set and bandage tibia/fibula fracture, (2) place a pin from knee down and bandage, (3) amputate and will not have to continue care and questionable treatment. Resident #336's RP reported Resident #336 remained in the facility until having a left above the knee amputation on 4/05/2023. During an interview on 4/11/2023 at 3:30 p.m. S16 LPN (Licensed Practical Nurse) reported proving care for Resident #336 while she had a splint/cast to her left lower extremity. S16 LPN reported while Resident #336 was in splint/cast ongoing monitoring of pedal pulses, foot discoloration was done but there was not a special form to complete and she did not document her findings in Resident #336's medical record. During an interview on 4/12/2023 at 7:55 a.m. S17 LPN reported she provided care for Resident #336 on April 3, 2023 while she had a splint/cast in place. S17 LPN reported she did not assess Resident #336's left lower extremity in a splint/cast. S17 LPN reported she only charts on skilled residents and maybe S18 Unit Manager handled that. During an interview on 4/12/2023 at 8:40 a.m. S18 Unit Manager reported Resident #336 was sent out to the emergency room on Sunday 3/26/2023 and returned that evening around 6:55 p.m. with a splint/cast in place to left leg. S18 Unit Manager confirmed Resident #336 went out for surgery with the third orthopedic physician on 4/05/2023 and returned to facility on 4/10/2023. During this time, S18 Unit Manager reported she did not assess Resident #336's pulses as the splint/cast was wrapped covering her feet and could only observe the toes and above the knee. During an interview on 4/12/2023 at 11:10 a.m. S13 Nurse Practitioner reviewed progress notes dated 3/27/2023 and reported observing Resident #336 one time since she returned to the facility from the emergency room visit on 3/26/2023. S13 Nurse Practitioner reviewed progress notes from 3/27/2023 and reported Resident #336 had a splint in place to stabilize the fracture when she returned from the emergency room and only her toes were visible from underneath the splint. S13 Nurse Practitioner reported Resident #336 went out for surgery on 4/05/2023 for left above the knee amputation and returned to the facility on 4/10/2023. During a telephone interview on 4/12/2023 at 2:56 p.m. S15 Medical Director did not recall being notified regarding a delay in referral appointment for Resident #336 to Orthopedic. S15 Medical Director reported the facility is not always required to notify him they can notify the nurse practitioner that is in the building. S15 Medical Director reported the nurse practitioner was in the facility on 3/27/2023 and assessed Resident #336. S15 Medical Director reported in a case where a dressing is in place for stabilization he would not remove the dressing but Resident #336 should have been monitored for capillary refill. During an interview on 4/12/2023 at 3:40 p.m. S19 Evening Shift Supervisor reported while Resident #336's left lower extremity was placed in a splint, assessment should have been completed daily for capillary refill, touch the toes, and make sure splint dressing is not too tight or constricting blood flow. S19 Evening Shift Supervisor reported there is no flow sheet to chart this assessment but monitoring for Resident #336 in cast/splint but should have been documented in the interdisciplinary notes. During an interview on 4/12/2023 at 4:00 p.m. S1 DON (Director of Nursing) comfirmed an intervention for increase in monitoring to more than once every two hours for Resident #336 was added to the care plan after placement of splint/ ace bandage to left lower extremity. S1 DON reviewed Resdient #336's medical record and confirmed there was no documentation of increase monitoring. .

Based on interviews and record reviews, the facility failed to have a process in place to ensure residents were free from significant medication errors for 1 sampled resident (Resident #22) of 5 (Resident #13, Resident #22, Resident #30, Resident #57, and Resident #79) sampled residents with physician orders for antibiotics. Findings: Review of Resident #22's nurse's note dated 04/10/2023 revealed, in part, an order was received for Zyvox (an antibiotic used to treat skin infections) 600 milligrams (mg) two times a day for 10 days due to culture of right toe pressure ulcer that was positive for pseudomonas aeruginosa and enterococcus faecalis (two different types of bacteria). Review of Resident #22's April 2023 physician orders revealed, in part, an order dated 04/10/2023 for Zyvox 600 mg two times a day for 10 days. Review of Resident #22's April 2023 electronic medication administration record (eMAR) revealed, in part, Zyvox 600 mg two times a day for 10 days was not given for the 9:00 p.m. doses on 04/10/2022 and 04/11/2022. In an interview on 04/12/2023 at 2:54 p.m., S11 LPN (Licensed Practical Nurse) stated Resident #22 was not on Zyvox 600 mg two times a day for 10 days, and that she could not produce a medication card for Resident #22's Zyvox 600 mg two times a day for 10 days. S11 LPN reviewed Resident #22's physician orders, and agreed Resident #22 had an order for Zyvox 600 mg two times a day for 10 days. S11 LPN further indicated Resident #22's Zyvox was not given due to there being no medication card to give Zyvox 600 mg two times a day for 10 days. S11 LPN further agreed she should not have documented that the 9:00 a.m. dose of Zyvox 600 mg was given on 04/12/2023. Review of facility's Consolidated Delivery Sheets from the pharmacy dated 04/10/2023 revealed, in part, no documentation that Zyvox 600 mg was delivered to facility. In an interview on 04/12/2023 at 3:00 p.m., S12 Unit Manager stated Resident #22's Zyvox 600 mg two times a day for 10 days was not sent to the facility by pharmacy due to needing a prior authorization. S12 Unit Manager further stated Resident #22 did not receive a dose of Zyvox 600 mg for the 9:00 a.m. administration time on 04/10/2023, 04/11/2023, or 04/12/2023, and Resident #22 did not received a dose of Zyvox 600 mg for the 9:00 p.m. administration time on 04/10/2023 and 04/11/2023. S12 Unit Manager stated Resident #22 had not received any doses of Zyvox 600 mg since it was ordered on 04/10/2023 because the facility did not have Resident #22's Zyvox 600 mg. In an interview on 04/12/2023 at 3:30 p.m., S1 DON (Director of Nursing) stated Resident #22 did not receive a dose of Zyvox 600 mg for the 9:00 a.m. administration time on 04/10/2023, 04/11/2023, or 04/12/2023, and Resident #22 did not received a dose of Zyvox 600 mg for the 9:00 p.m. administration time on 04/10/2023 and 04/11/2023 because the facility did not have Resident #22's Zyvox 600 mg.

Based on observations, interviews, and record review, the facility failed to ensure proper infection control measures were followed to prevent the development and transmission of communicable disease, infection or COVID-19 by failing to: 1. Ensure staff performed hand hygiene per facility policy during incontinence care for 2 (Resident #52 and Resident #79) of 3 residents (Resident #52, Resident #30, and Resident #79) observed for incontinence care, and during wound care for 1 (Resident #22) of 2 residents (Resident #22 and Resident #52) observed for wound care; 2. Ensure staff handled soiled linen in a manner to prevent cross contamination of surfaces when S6 CNA (Certified Nursing Assistant) placed multiple towels soiled with feces and urine on the floor for 2 (Resident #52 and Resident #30) of 2 residents observed during incontinence care; 3. Ensure staff wore Personal Protective Equipment (PPE) when entering the room of 1 (Resident #52) of 1 resident on contact isolation (process of isolating a resident to prevent the spread of infection) for Vancomycin-Resistant Enterococcus (VRE) (a bacteria that is resistant to medication typically used to treat infection). 4. Ensure contracted staff were tested for COVID-19 during broad based testing after an outbreak of COVID-19 in facility. Findings: 1. Review of facility's Perineal Care Policy dated 11/03/2010 revealed, in part, staff are to remove gloves and wash and dry hands thoroughly before repositioning bed covers, placing the call light within reach of resident, and making resident comfortable. Review of the facility's Infection Control Guidelines for All Nursing Procedures dated 04/19/2018 revealed, in part, staff should wash hands after handing items potentially contaminated with blood, body fluids, or secretions and after contact with blood, body fluids, or mucous membranes. Further review revealed, in part, staff should clean hands with an alcohol-based hand rub if not visibly soiled. Review of the facility's Handwashing and Hand Hygiene policy dated 09/02/2016 revealed, in part, hand hygiene should be performed after assisting resident with personal care, after removing gloves, and after handing clean or soiled dressings. Further review revealed, in part, hand hygiene is always the final step after removing and disposing of PPE, and that glove use does not replace hand hygiene. Review of the facility's Pressure Ulcer Injury Treatment policy revised 12/07/2018 revealed, in part, gloves should be removed and hand hygiene should be performed after removing soiled dressing and after completing wound care. Resident #52 Review of Resident #52's physician orders revealed, in part, order dated 04/09/2023 for contact precautions for 14 days. Review of Resident #52's Nurses note dated 04/09/2023 revealed, in part, VRE detected in urine culture and contact precautions were initiated. Observation on 04/10/2023 at 12:30 p.m. revealed S6 CNA did not remove her soiled gloves or perform hand hygiene after performing incontinence care of Resident #52. Further observation revealed S6 CNA touched Resident #52's bed controls, Resident #52's blanket, and Resident #52's call light button while wearqing gloves she had used during Resident #52's incontinence care. In an interview on 04/10/2023 at 12:55 p.m., S6 CNA stated she should have changed gloves and performed hand hygiene before touching Resident #52's bed controls, Resident #52's blanket, and Resident #52's call light button after performing Resident #52's incontinence care. In an interview on 04/10/2023 at 1:15 p.m., S1 DON (Director of Nursing) stated S6 CNA should have performed hand hygiene and changed gloves between performing incontinence care and touching Resident #52's bed controls, Resident #52's blanket, and Resident #52's call light button. Resident #22 Review of Resident #22's physician orders revealed, in part, order dated 04/03/2023 to cleanse with wound cleanser, pat dry, apply topically Sodium Chloride soaked gauze to right foot wound, then cover with dry gauze, wrap with Kerlix, and secure with tape daily. Observation on 04/11/2023 at 8:30 a.m., revealed S2 ADON (Assistant Director of Nursing) did not perform hand hygiene after removing old dressing from Resident #22's right foot, and did not perform hand hygiene or change gloves between cleansing Resident #22's right foot wound and dressing Resident #22 right foot wound with wet to dry dressing. Further observation revealed, S2 ADON did not remove gloves or perform hand hygiene after finishing Resident #22's right foot wound care and readjusting Resident #22's covers and using Resident #22's remote to adjust her bed. In an interview on 04/11/2023 at 8:45 a.m., S2 ADON stated she should have performed hand hygiene after removing old dressing from Resident #22's right foot wound. S2 ADON also stated that she should have changed her gloves and performed hand hygiene between cleaning Resident #22's right foot wound and applying wet to dry dressing to Resident #22's right foot wound. S2 ADON further stated that she should have performed hand hygiene and changed gloves after performing Resident #22's right foot wound care and touching Resident #22's blanket and remote. Resident #79 Observation on 04/11/2023 at 10:45 a.m., revealed S10 CNA performed fecal incontinence care for Resident #79. S10 CNA applied gloves, and applied barrier cream to Resident #79's buttocks. Further observation revealed, S10 CNA then reached for a wet towel and wiped Resident #79's face, and opened four drawers in Resident #79's room without changing gloves or performing hand hygiene. In an interview on 04/11/2023 at 11:05 a.m., S10 CNA stated she should have changed gloves and performed hand hygiene after applying barrier cream to Resident #79's buttocks, and before wiping Resident #79's face or opening four drawers in Resident #79s room and did not. In an interview on 04/11/2023 at 11:12 a.m., S1 DON stated S10 CNA should have changed gloves and performed hand hygiene after applying barrier cream to Resident #79's buttocks, and before wiping Resident #79's face or opening four drawers in Resident #79s room. 2. Resident #52 and Resident #30 Review of the facility's Soiled Laundry and Bedding Policy dated 11/16/2016 revealed, in part, that soiled laundry shall be handled in a manner that prevents gross microbial contamination of the air and the persons handling the linen. Further review revealed, in part soiled laundry contaminated with potentially infectious materials must be handled as little as possible and with minimum agitation. Further review revealed, in part contaminated laundry should be placed in bags or containers and environmental services will retrieve bags with contaminated laundry for processing. Observation on 04/10/2023 at 12:30 p.m. revealed S6 CNA threw multiple towels, soiled with urine and feces, on the ground throughout Resident #52's incontinence care. Observation on 04/10/2023 at 12:48 p.m., revealed, S6 CNA threw multiple towels soiled with urine and feces on the bathroom floor while performing incontinence care on Resident #30. In an interview on 04/10/2023 at 12:55 p.m., S6 CNA stated that she should not have thrown multiple towels soiled with urine and feces on the ground in both Resident #52's and Resident #30's rooms. In an interview on 04/10/2023 at 1:15 p.m., S1 DON stated S6 CNA should not have thrown multiple towels soiled with urine and feces on the floor in Resident #52's and Resident #30's rooms. 3. Resident #52 Review of the facility's Isolation-Categories of Transmission- Based Precautions Policy dated 03/12/2018 revealed, in part, infection with multi-drug resistant organisms require residents to be placed on contact precautions, and while caring for resident, staff should change gloves after having contact with infective material, and remove gloves and perform hand hygiene. Further review revealed, in part, staff should wear a disposable gown upon entering the Contact precaution room. Observation on 04/10/2023 at 11:47 a.m., revealed a bedside table outside of Resident #52's room with PPE including gowns, gloves, alcohol based hand sanitizer, and Sani-Wipes. No signage on the door indicated what type of isolation precautions were appropriate for residents. Observation on 04/10/2023 at 12:30 p.m. revealed S6 CNA completed incontinence care for Resident #52, removed PPE and exited the resident's room. Further observation revealed S6 CNA then walked past the PPE cart outside of Resident #52's door, and re-entered Resident #52's room without putting on a protective gown (part of the PPE for contact isolation). S6 CNA was then observed wiping down contaminated surfaces in Resident # 52's room with disinfecting wipes without a protective gown on. In an interview on 04/10/2023 at 12:55 p.m., S6 CNA stated she should have put on all required PPE before entering Resident #52's room and did not put on PPE before entering Resident #52's room. In an interview on 04/10/2023 at 1:11 p.m., S7 IP (Infection Preventionist) stated that staff should always wear PPE when going into rooms for residents on contact isolation precautions, not just when they are performing direct care for residents on contact isolation precautions. In an interview on 04/10/2023 at 1:15 p.m., S1 DON stated S6 CNA should have worn PPE when going into Resident #52's room. 4. Review of facility provided list of contracted staff working in the building on 04/10/2023 revealed, in part S8 LPN and S9 CNA were working in facility on 04/10/2023. In an interview on 04/10/2023 at 12:17 p.m., S8 LPN stated she worked at facility on 03/26/2023, 04/02/2023, and 04/05/2023 but was not tested for COVID-19 by facility on those dates. Review of S9 CNA's time sheet revealed, in part, S9 CNA worked at facility on 03/17/2023, 03/20/2023, 03/26/2023, 03/27/2023, 03/30/2023, 03/31/2023, 04/01/2023, 04/02/2023, 04/06/2023, 04/09/2023, and 04/09/2023. In an interview on 04/12/2023 at 9:15 a.m., S9 CNA stated he worked at the facility between 03/25/2023 and 04/06/2023 and was not tested for COVID-19 by the facility or his agency. Review of the facility's Outbreak Testing Logs revealed, in part, that staff members were tested for COVID-19 between 03/30/2023-04/01/2023, 04/02/2023-04/04/2023, and 04/05/2023-04/06/2023. Further review of Outbreak Testing Logs revealed, in part, S8 LPN and S9 CNA were not tested by facility during broad based testing. In an interview on 04/11/2023 at 9:03 a.m., S1 DON stated facility did not test S8 LPN or S9 CNA during broad based outbreak testing because they were contracted staff, and should have been tested by their own agencies when facility reported that they were in outbreak status. S1 DON further stated that facility does not have a specific policy regarding testing for COVID-19, but that they do follow CDC guidelines recommending broad based outbreak testing protocol of testing all residents and staff 24 hours after 1st positive COVID-19 test of outbreak, 48 hours after first test (Day 3), and 48 hours after second test (Day 5). In an interview on 04/11/2023 at 3:00 p.m., S1 DON stated she contacted staffing agency for S8 LPN, and that staffing agency could only provide documentation S8 LPN was tested and was negative for COVID-19 on 04/03/2023. S1 DON further stated that she could provide no documentation that S9 CNA was tested by his agency during the outbreak broad based testing dates.