Based on observations, interviews, and records reviewed, for one Resident (#55) of 23 sampled residents, the facility failed to treat each resident with respect and dignity and care for each resident in a manner that promotes maintenance or enhancement of his/her quality of life while recognizing his/her individuality. Specifically, for Resident #55, the facility failed to identify and maintain the Resident's wishes to grow a handlebar mustache. Findings include: Review of the facility's policy titled Resident Right and Organizational Ethics and Resident Rights and Overview, dated 10/17, indicated but was not limited to: -individual rights will be retained by all residents/patients of the facility -this facility will protect and promote the rights of each patient/resident as described below -residents have the right to the quality of life that supports independent expression, choice, and decision-making, consistent with all applicable laws and regulations -residents have a right to perform or refuse to perform tasks in or for the facility -residents have a right to refuse care or treatment as permitted by law Resident #55 was admitted to the facility in July 2017 with diagnoses which included hemiplegia and/or hemiparesis (paralysis on one side of the body) following a stroke and heart disease. Review of the Minimum Data Set (MDS) assessment, dated 3/5/25, indicated Resident #55 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15, had limited range of motion on one side, and was dependent on facility staff for personal hygiene (combing hair, shaving, washing/drying face). Review of Resident #55's Care Plan Report, on 3/27/25, indicated but was not limited to: -personal hygiene/oral care: He/she is totally dependent on staff for personal hygiene and oral care, date 9/26/2018 Further review of Resident #55's Care Plans failed to identify his/her wish to grow his/her mustache and preference to not have it trimmed. On 3/27/25 at 9:23 A.M., the surveyor observed Resident #55 with a mustache that was growing out and away from his/her face approximately one inch in length that was curling into his/her mouth while talking. During an interview on 3/27/25 at 9:23 A.M., Resident #55 said sometimes the nursing assistants cut his/her mustache even when he/she tells them he/she does not want it cut. Resident #55 said he/she tells the staff not to cut his/her mustache, but they do it anyway. On 3/31/25 at 1:18 P.M., the surveyor observed Resident #55 with a mustache that had been trimmed and no longer had long pieces growing out and away from his/her face. During an interview on 3/31/25 at 1:18 P.M., Resident # 55 said it happened again over the weekend. When he/she told the nursing assistant to leave his/her mustache, the nursing assistant did not listen. Resident #55 said now there was not much left of his/her mustache and it was almost gone. Resident #55 said it seems like no matter what you want, it was their (the nursing assistants) decision and it was their way or the highway. During an interview on 3/31/25 at 2:05 P.M., Certified Nursing Assistant (CNA) #2 said Resident #55 did not want the facility staff to touch his/her mustache. CNA #2 said sometimes Resident #55 does not always want to complete his/her personal hygiene but she knows the trick and if you get to talk to him/her, he/she will say yes. CNA #2 said she had Resident #55 for the last three days and shaved his/her beard and trimmed the long pieces of his/her mustache. During an interview on 3/31/25 at 2:41 P.M., CNA #1 said Resident #55 does not want his/her mustache touched and will fight if staff try. CNA #1 said the facility does trim his/her mustache to keep it from going into his/her mouth. During an interview on 3/31/25 at 4:30 P.M., Nurse #2 said staff should not touch Resident #55's mustache because he/she does not like it to be touched or trimmed and can be behavioral if you try. During an interview on 3/31/25 at 4:39 P.M., the Infection Control Nurse (covering for the Unit Manager on this date) said if he/she did not want his/her mustache touched it should be care planned and followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement the person-centered plan of care for one Resident (#74), out of 23 sampled residents. Specifically, the facility failed to implement the care plan interventions for safe swallowing strategies for a resident with oropharyngeal dysphagia (a condition that affects the movement of food and liquid from the mouth to the esophagus during swallowing). Findings include: Resident #74 was admitted to the facility in February 2025 with diagnoses of dementia and dysphagia. Review of the Minimum Data Set (MDS) assessment, dated 3/4/25, indicated Resident #74 scored 9 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident had a moderate cognitive impairment. The MDS further indicated Resident #74 had a swallowing disorder as presented by complaints of pain or difficulty while swallowing, had a mechanically altered diet and received supervision for eating (helper provides verbal cues or touching assistance as the resident completes the task). Review of the care plans indicated Resident #74 needed assistance with activities of daily living, was independent for eating, but required 1 (staff) to 8 (resident) supervision with intermittent cues. Review of the unit Dining Needs list indicated Resident #74 was independent with eating and required 1:8 supervision with intermittent cues. Review of the Speech Therapy Progress Notes indicated the following: -3/18/25: Resident in bed at lunch, impulsive for rate, benefiting from moderate cues to alternate solids and liquids; Nurse educated on need for supervision during mealtime to decrease impulsivity and increase swallow safety -3/24/25: Resident in bed at lunch, requires minimum cues to promote safe swallow strategy; Speech Language Pathologist (SLP) educated nurse for recommendations of upright and out of bed for all meals -3/26/25: Resident in bed, of note SLP with prior education to staff for {Resident} need to be upright and out of bed for meals; minimum to moderate verbal cues provided in addition to the already placed visual for resident to alternate solids and liquids On 3/27/25 at 8:48 A.M., the surveyor observed Resident #74 sitting up in bed, eating breakfast alone. The Resident had a full cup of milk, a full cup of orange juice and a cup of coffee. The Resident was eating scrambled eggs out of a small bowl (as indicated on the meal ticket). The surveyor observed a sign on the overbed table in large writing that said, 1 bite then 1 sip. The Resident was not observed to be taking any sips of liquids while eating eggs, finished the eggs and started eating a yogurt. An additional sign hung in the Resident's room (within eye level of the Resident) that said, Safe Swallow Strategies: small bites, [NAME] sips, take 1 bite, then 1 sip, go slow. During an interview on 3/27/25 at 11:20 A.M., Resident #74 said the sign on the table said to take one bite and one sip and that he/she did this so that they didn't cough. Review of the Speech Therapy Progress Notes indicated the following: -3/28/25: Resident seated in bed despite prior education to nursing staff, SLP re-educated staff for importance of upright and out of bed positioning for swallow safety during mealtime. Resident able to recall safe swallow strategies prior to intake, however, requires moderate verbal cues throughout intake to promote safe swallow strategies. Review of the SLP Discharge summary, dated [DATE], indicated Resident #74 had a goal of being trained safe swallow strategies 80% of the time with minimum to moderate cues and met this goal on 3/31/25 with 85% with moderate cues. Review of the functional skills indicated Resident #74's swallowing abilities required distant supervision and the following strategies were recommended: upright position and out of bed when Resident is able, alternation of liquids/solids, rate modification and size modification (bite size). On 4/1/25 at 8:50 A.M., the surveyor observed Resident #74 in bed alone, finishing his/her breakfast. A staff member was observed to stop at the room and ask if the Resident was finished eating and the Resident replied no, the staff member left the room. On 4/2/25 at 8:33 A.M., the surveyor observed Resident #74 out of bed, in the unit day room for breakfast. The Resident was provided a breakfast tray of French toast. The Resident was observed during the meal cutting up his/her French toast and taking bites. The Resident was not observed to alternate solids and liquids. The staff were not observed to cue the Resident to alternate solids and liquids. The visual aids provided by the SLP were not observed on the table for the Resident. During an interview on 4/2/25 at 9:48 A.M., Certified Nursing Assistant (CNA) #3 said Resident #74 was dependent on two staff members for activities of daily living (such as changing, washing). She said there were times Resident #74 required three staff to get out of bed and that was why the Resident was not out of bed sometimes for breakfast. She said the Resident refuses physical assistance with eating and will say I'm not a baby. She said she had not provided any supervision during meals in which the Resident did not get out of bed. She said sometimes the SLP would be there for meals and watch for swallowing issues. She said if the Resident was in his/her room for a meal, the staff would go back and forth down the hall to see if the Resident had completed the meal. During an interview on 4/2/25 at 9:55 A.M., Nurse #3 said Resident #74 can refuse to get out of bed sometimes and that was why the Resident was in bed during meals. He said Resident #74 will sometimes eat too fast and that was why there were visual aids to remind the Resident to eat slower. He said the Resident does not always need cueing but sometimes did. During an interview on 4/2/25 at 10:05 A.M., Unit Manager #3 said she had been at the facility for two weeks and had not received any education from the SLP during that time or on 3/31/25 when Resident #74 was discharged from Speech Therapy. She said Resident #74's care plan indicated the Resident required 1:8 supervision for eating with intermittent cues. She said she was not sure what those cues were as the care plan did not indicate. She said based on the information in the medical record, if Resident #74 were eating in his/her room then they needed to be supervised. During an interview on 4/2/25 at 10:58 A.M., the SLP said Resident #74 was discharged from Speech Therapy on 3/31/25. She said prior to being admitted to the facility the Resident had a swallow study at the hospital and had been experiencing silent aspiration (a condition where food, liquid, or other substances enter the lungs without the person noticing. It is characterized by the absence of obvious symptoms such as coughing, choking, or difficulty breathing). She said she had initiated swallowing strategies for Resident #74 which included making sure the Resident was sitting upright and the Resident could eat in bed as long as the Resident was upright. She said the Resident did not require constant supervision, but intermittent supervision with cueing from staff. She said the Resident needed verbal cues to take a sip between bites. She said it did not have to be between every single bite, but maybe every couple of bites and that was what staff should be reminding the Resident.

Based on record review and interview, the facility failed to ensure one Resident (#62), in a sample of 23 residents, had been seen by a physician/Nurse Practitioner (NP) every 60 days. Findings include: Review of the facility's policy titled Essential Guidelines for Licensed Independent Practitioners, dated as reviewed September 2024, indicated but was not limited to the following: -In keeping with Company, State, Federal, and JCAHO (Joint Commission on Accreditation of Healthcare Organizations) regulations for long term care facilities, the following requirements apply to physicians and/or licensed independent practitioners treating patient/residents within facilities; -Patient/Residents require reassessment and an updated medical care plan at a minimum of every 30 days for the first 90 days, every 60 days thereafter, and as needed in between as indicated by clinical condition; -Progress notes and signed and dated physician orders are required at each physician visit. Resident #62 was admitted to the facility in May 2020. Review of Physician's Progress Notes indicated Resident #62 was seen by the Physician on 4/16/24, and by the NP on 7/2/24, indicating 76 days between the visits. During an interview on 4/2/25 at 10:15 A.M., the Clinical Nurse Consultant said she contacted Physician #2 that day to obtain all records of Resident #62's Physician/NP/PA encounters in the past year. The Clinical Nurse Consultant said in addition to the 4/16/24 and 7/2/24 visits, the Physician said she saw the Resident on 10/25/24. The Clinical Nurse Consultant said the Physician had not previously provided the facility documentation of the 10/25/24 visit because the Physician converted to different documentation software and did not know how to print or transfer her documentation to the facility. Review of the Resident's medical record on 4/2/25 indicated Physician #2 completed a medical note in Resident #62's medical record on 4/1/25 with an Effective Date of 10/25/24. Resident #62's medical record indicated 114 days between the NP's visit on 7/2/24 and the Physician's visit on 10/25/24, and that it had been 158 days since the Physician's visit on 10/25/24. During an interview on 4/2/25 at 10:15 A.M., the Clinical Nurse Consultant said Physician #2 could only locate documentation for provider encounters on 4/16/24, 7/2/24, and 10/25/24 and could not locate any documentation of visits after 10/25/24. During an interview on 4/2/25 at 11:48 A.M., the Clinical Nurse Consultant said Physician visits should occur every 30 days for the first 90 days after admission, and every 60 days thereafter. The Clinical Nurse Consultant said Physician #2 and her NP visited the facility on a weekly basis, however, per documentation, Resident #62 had not been seen by a provider since October 2024. The Clinical Nurse Consultant said the length of time between visits and lack of documentation must have been an oversight.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to ensure the main kitchen floor and ceiling were maintained in a sanitary and safe condition. Findings include: Review of the 2022 Food Code by the Food and Drug Administration (FDA), revised 1/2023, indicated but was not limited to the following: 1-2 Definitions 1-201 Applicability and Terms Defined 1-201.10 Statement of Application and Listing of Terms. Easily Cleanable. (1) Easily cleanable means a characteristic of a surface that: (a) Allows effective removal of soil by normal cleaning methods; (b) Is dependent on the material, design, construction, and installation of the surface; and (c) Varies with the likelihood of the surface's role in introducing pathogenic or toxigenic agents or other contaminants into food based on the surface's approved placement, purpose, and use. Smooth means: (3) A floor, wall, or ceiling having an even or level surface with no roughness or projections that render it difficult to clean. 6-201.12 Floors, Walls, and Ceilings, Utility Lines. Floors that are of smooth, durable construction and that are nonabsorbent are more easily cleaned. Requirements and restrictions regarding floor coverings, utility lines, and floor/wall junctures are intended to ensure that regular and effective cleaning is possible and that insect and rodent harborage is minimized. 6-201.13 Floor and Wall Junctures, Coved, and Enclosed or Sealed. (A) In FOOD ESTABLISHMENTS in which cleaning methods other than water flushing are used for cleaning floors, the floor and wall junctures shall be coved and closed to no larger than 1 mm (one thirty-second inch). On 3/27/25 at 8:52 A.M. and on 4/1/25 at 11:42 A.M, the surveyor observed the following during the initial tour of the main kitchen: -cracked and/or crumbled floor grout throughout kitchen, including at the floor wall joint and in the walk-in refrigerator; -areas of receded floor grout where tile depth was more apparent than in non-receded areas; -debris and/or water settled in the cracked, crumbled, and/or receded floor grout. During an interview on 3/27/25 at 8:55 A.M., the Food Service Director (FSD) said the kitchen flooring and grouting, excluding some small areas of repaired grout, was original to the building and about [AGE] years old. On 3/31/25 at 11:50 A.M., the surveyor observed the following in the main kitchen: -uneven and missing wall covering behind the three-bay sink; -openings in the wall area behind the three-bay sink. During an interview on 4/1/25 at 12:10 P.M., the FSD and surveyor observed the walls and flooring in the main kitchen. The FSD said the kitchen walls should have no holes or protruding wall covering, and the flooring should be maintained in a way it could be easily cleaned and not harbor debris or moisture. During an interview on 4/2/25, the Administrator said he expected the kitchen walls and flooring to be in good condition with no holes or compromised areas that could harbor debris and/or moisture. The Administrator said he expected the kitchen to be maintained in a safe and sanitary condition and the walls and flooring should be fixed.

Based on observation and interview, the facility failed to ensure a secure handrail was in place on one Unit (East 2) out of four total Units. Findings include: On 3/31/25 at 2:30 P.M., the surveyor observed and tested the handrails on the East 2 unit. The surveyor was able to move three separate pieces of handrails with minimal effort in three different areas on the unit where the handrails had come loose from the wall. The surveyor observed residents walking in the hallway on the East 2 unit. During an interview on 3/31/25 at 3:35 P.M., the Director of Nurses said all handrails should be affixed securely to the wall. She said the handrails were used by residents and should not be loose or unsecure. During an interview on 3/31/25 at 3:50 P.M., the Administrator said the handrails not being securely fashioned to the walls were a concern and having them repaired was a priority for safety. He said there was not a specific process for identifying broken handrails but he depends on staff to inform the maintenance department when they are loose. He said the handrails in all locations should be securely fashioned to the wall and not be able to be moved so if a resident leans on it or uses it for support it is secure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 3/27/25 at 8:39 A.M., the surveyor observed Room East 108 with brown discoloration on the edge of the white ceiling, where it meets the wall. The surveyor observed the wall with bumps, bowing in certain spots, and to have cracked plaster. On 4/1/25 at 12:05 P.M., the surveyor observed the Whirlpool tub room, adjacent to the back wall of room East 108. The white ceiling in the room had large chipped and bubbling paint which was discolored brown. During an interview on 4/1/25 at 12:35 P.M., Maintenance Staff #1 said the discolored ceiling in the Whirlpool tub room was related to the tub room upstairs and water getting on the floor. He said he can tell the ceiling had been patched and painted previously, but it kept happening. He said the ceiling in room [ROOM NUMBER] also had water that came down from the tub room above the adjacent tub room. He said parts of the bumpy wall were from previously trying to patch and repaint. He said he did not know if there were any plans to fix the leaking water, the discolored ceilings, or the bowed wall. During an interview on 4/1/25 at 12:40 P.M., the Administrator said he did not know there had been water leaking from the above Whirlpool room and would need to have a plumber take a look. He said he could see the bowed wall in room [ROOM NUMBER] and the cracking plaster. 3. On 3/27/25 at 8:34 A.M., the surveyor observed a window air conditioner in room [ROOM NUMBER], which was actively turned on. The vents where the air came out had visible black spots all over the internal structure of the air conditioner. The air filter was laden with gray dust particles. During an interview on 4/1/25 at 3:57 P.M., the Maintenance Director said all window air conditioners get cleaned prior to being put away for the season. He said if a Resident requested to have their window air conditioner in year-round then the housekeeping staff should notify maintenance when it needed to be cleaned. During an interview with observation on 4/1/25 at 4:00 P.M., the Maintenance Director said the vent where the air comes out had black spots and the filter was dirty. He removed the filter which was observed to be laden with thick dust on both sides of the filter. Based on observations and interviews, the facility failed to ensure the residents' environment was clean, comfortable, and homelike. Specifically, the facility failed: 1. To ensure two ([NAME] 1 and East 2) out of four units were homelike, comfortable, and in overall good repair; 2. To ensure the Whirlpool tub room and room [ROOM NUMBER] East were free of water damage; and 3. To maintain and clean the window air conditioner in room [ROOM NUMBER] East. Findings include: Review of the facility's policy titled Environment of Care, dated 9/24, indicated but was not limited to the following: -Responsibilities of the maintenance department will include but not to be limited to painting, mechanical repairs (electrical, plumbing), and grounds keeping. -The facility has a program of preventative maintenance and safety, which are to be implemented by the maintenance department. Review of the facility's policy titled Environment of Care- EOC manual, dated 9/24, indicated but was not limited to the following: -The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized homelike setting. These characteristics include: a. Clean, sanitary, and orderly equipment. 1. On 3/27/25 at 8:30 A.M., during the initial tour of the [NAME] 1 unit, the surveyor observed the following: -room [ROOM NUMBER]'s baseboard heater was in two pieces on the floor and was in need of repair. -room [ROOM NUMBER]'s bathroom had molding peeling away from the wall with dark brown areas on the wall, cracks in wall visible under sink and around the toilet. -room [ROOM NUMBER] had an approximately 9-inch round crack in the wall with chipped paint surrounding it. -The unit dining room had scratches along the entirety of one wall. During an interview on 3/31/25 at 12:19 P.M., Residents #95 and #108 said they have never seen anyone from the maintenance department painting on the unit or observed anyone doing preventative maintenance repairs. Resident #108 said he/she has been a Resident for about four months and has noticed that the maintenance department does not care about aesthetics of the building. Resident #95 said he/she tries to not look at the big hole because it is hideous, but it has been there since before he/she was admitted . During an interview on 3/27/25 at 11:30 A.M., Resident #87 said the bathroom in his/her room has been in disrepair for months, he/she said staff have been in there, but the cracks and holes must not have been reported to maintenance. He/She said the bathroom is not looking good and should be fixed to be in better condition. On 3/31/25 at 2:00 P.M., the surveyor observed the director bring a box of completed work orders in a metal box with hundreds of folded pieces of paper inside. Upon review of the work slips in the box, five were found undated and unsigned by the maintenance director, indicating they had not been completed. During an interview on 3/31/25 at 2:37 P.M., the Maintenance Director said he collects work order slips from the unit and places the slips in a box when completed. He said only completed work orders are put in the box and he wasn't sure why there were incomplete ones in there. He said they must have been missed or placed in there accidentally. He said he completes safety rounds and is aware that there is a need for some basic upkeep to the facility, but he must triage concerns based on safety not appearance. On 3/31/25 at 3:50 P.M., during a tour of the East 2 unit, the surveyor observed the following: -room [ROOM NUMBER]- the threshold where the rug meets the resident room was missing -room [ROOM NUMBER]- the threshold where the rug meets the resident room was taped with silver duct tape -room [ROOM NUMBER]- the baseboard was peeling away from the wall -room [ROOM NUMBER]- the toilet seat was broken -The electrical outlet in the hallway was not secured to the wall -The AC box in hallway was not in good repair with moving and unsecured parts within reach -The door to the tub room would not close tightly, it was left ajar approximately 3 inches and unable to be shut -room [ROOM NUMBER] and room [ROOM NUMBER] were missing molding outside of the resident doors During an interview on 4/1/25 at 1:50 P.M., the Administrator said the areas the surveyor identified should not look the way they do. He said it is the responsibility of all staff members to identify issues in the environment and report them. He said these concerns should be repaired and the residents should have a homelike environment. He said that the maintenance director should be completing the work slips before storing them in the box. He said there should not be any holes in any walls.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who has an activated Health Care Proxy (HCP), the Facility failed to ensure that staff promptly notified Resident #1's Health Care Agent (HCA) when he/she experienced a change in status with a decline in condition, which resulted in the need for new physician's orders related to a change in his/her treatment plan. Findings include: Review of the Facility Policy titles, Change on Resident Condition, dated as last revised 06/2024, indicated that the Facility shall promptly notify the resident, his/her Attending Physician, and the resident's representative of changes in the resident's medical/mental condition and/or status. The Policy further indicated that unless otherwise instructed by the resident, the nurse will notify the resident's representative when there is a significant change in the resident's physical, mental, or psychosocial status. Resident #1 was admitted to the Facility in February 2023, diagnoses include Alzheimer's type dementia, acquired hypothyroidism with history of thyroid cancer, left parotid (salivary gland that sits in front of the ear) mass, dysphagia (difficulty swallowing), and chronic stage three (3) kidney disease (moderate loss of kidney function, often not reversible). Review of Resident #1's Physician Substitute Decision Making Form, dated 02/14/24, indicated his/her Health Care Proxy (HCP) had been invoked. Review of Resident #1's Annual Minimum Data Set (MDS) Assessment, dated 02/14/24, indicated he/she was severely cognitively impaired, had scored a 0 out of 15 (0-7 indicates severe cognitive impairment, 8-12 indicates moderate cognitive impairment, 13-15 indicates cognitively intact) on the Brief Interview for Mental Status. The MDS also indicated that Resident #1 only sometimes understood what was being asked of him/her and only sometimes made his/herself understood. During a telephone interview on 07/17/24 at 3:33 P.M., Resident #1's Health Care Agent (HCA) said that on 03/20/24, she had received a phone call from a nurse at the Facility informing her that Resident #1 was exhibiting signs of a decline in condition. The HCA said that the nurse informed her that he/she had more lethargic, had been running a fever, and as of 03/18/24, Resident #1 required the use of oxygen via nasal cannula. The HCA said when the nurse called her on 03/20/24, that it was the first time she was made aware that Resident #1 was not felling well and had needed oxygen. The HCA said she should have been informed of his/her medical decline as soon as he/she began exhibiting signs of the decline. Review of Resident #1's Nurse Progress Note, dated 03/18/24, indicated he/she had a fever of 102.1 degrees Fahrenheit (F), nursing administered Acetaminophen (Tylenol) as ordered with effect, and the physician had been notified. Review of Resident #1's Nurse Progress Note, dated 03/18/24 and written at 9:37 P.M., indicated that he/she was found to be sleepy for most of the shift, responsive to tactile stimuli, his/her oxygen saturation (Sat, fraction of oxygen-saturated hemoglobin relative to total hemoglobin in the blood) level was 88 percent (normal range 92 - 96%), and his/her temperature was 100 degrees F. The Note further indicated that the Nurse Practitioner (NP) had seen Resident #1 that shift and initiated new orders for the following; a stat chest x-ray due to hypoxia and fever; DuoNeb's (Ipratropium/Albuterol solution inhaled through a nebulizer) every four hours, and administration of oxygen at 2 Liters (L) via nasal cannula to keep his/her oxygen (O2) saturation levels above 90 percent. Review of Resident #1 Physician's Orders, dated 03/18/24, indicated to obtain a stat chest x-ray secondary to fever, hypoxia (low levels of oxygen in your body tissues), rhonchi (gurgling or bubbling sound typically heard during inspiration and expiration), provide oxygen at 2 L via nasal cannula to maintain oxygen saturation above 90 (%)percent and administer Ipratropium-Albuterol, 3 milliliters, inhale orally four times a day for congestion. Review of Resident #1's Nurse Progress Note, dated 03/19/24 and written at 9:19 P.M., indicated he/she had been lethargic, O2 sat level was 88 percent on room air, he/se required oxygen at 2 L, moist cough, and he/she ate poorly at breakfast. Further review of Resident #1's medical record and nurse progress notes, dated 03/18/24 and 03/19/24, indicated there was no documentation to support nursing notified the HCA of his/her decline in condition. During an interview on 07/18/24 at 1:41 P.M., Nurse #1 said that he would call to inform Resident #1's HCA with any changes in his/her condition, but could not recall notifying his/her HCA on 03/18/24 with the changes in Resident #1's medical condition. During an interview on 07/18/24 at 12 :57 P.M., the Unit Manager said that she was unaware if Nurse #1 had called to inform Resident #1's HCA of the decline in his/her condition on 03/18/24. The Unit Manager said it is the Facility's expectation that all changes in condition be reported to a resident's HCA in a timely manner. During an interview on 07/18/24 at 2:42 P.M., the Assistant Director of Nurses (ADON) said that the nursing staff should have informed Resident #1's HCA of the noted changes in condition on 03/18/24 and 03/19/24, including the abnormal vital signs and need for new physicians orders, in a timely manner. During an interview on 07/18/24 at 3:56 P.M., the Director of Nurses (DON) said that if a resident has an activated HCP, nursing staff are expected to call the HCA with any changes in condition, such as medication changes, treatment changes, and all other significant changes in the resident condition. The DON said that once a nurse either calls a physician or an HCA, a nurse progress note should be written.

2. Resident #100 was admitted to the facility in November 2023 with the following diagnoses: complete traumatic amputation of right lower leg, type II diabetes, cerebral palsy (neurological condition causing functional limitations), and muscular dystrophy (group of diseases that cause progressive weakness and loss of muscle mass). Review of the most recent MDS assessment, dated 2/7/24, indicated the Resident was cognitively intact as evidenced by a BIMS score of 14 out of 15. Review of the medical record failed to indicate that a Social History, Psychological, and Spiritual Assessment in the medical record was completed. During an interview on 4/30/24 at 11:02 A.M., Social Worker #2 said she did not complete a psychosocial comprehensive assessment. She said the Resident was seen by the Consultant Psychotherapist. She said the only assessment completed was the information the Consultant Psychotherapist put in her progress note. During an interview on 4/30/24 at 11:09 A.M., Social Worker #1 said the facility and the Consultant Psychotherapist work collaboratively but the expectation is that a comprehensive psychosocial assessment is completed by a facility social worker. She said that there is different information included in the comprehensive psychosocial assessment such as an assessment for trauma. She said because the comprehensive psychosocial assessment was not complete the Resident was not assessed for trauma. During an interview on 4/30/24 at 11:41 A.M., Resident #100 confirmed that since admission no one assessed him/her for past trauma. He/she asked if the surveyor meant emotional or medical trauma (like hospitalization and sudden amputation). He/she said they experienced someone close to him/her dying suddenly in a homicide, he/she was in a serious accident resulting in serious injury, and witnessed a family member experience health issues that impacted him/her. The Resident said the Consultant Psychotherapist was aware of this history but unsure if facility staff were aware and he/she was never asked about triggers or how to avoid re-traumatization. Based on record review, interviews, and policy review, the facility failed to develop a person-centered plan of care which included trauma informed approaches and identified triggers to avoid potential re-traumatization for two Residents (#10, #100), out of a total sample of 23 residents. Specifically, the facility failed: 1. For Resident #10, to identify triggers related to his/her known history of post-traumatic stress disorder (PTSD- a mental health condition that is triggered by an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being) to avoid potential re-traumatization; and 2. For Resident #100, to complete a trauma assessment resulting in the facility failing to provide trauma informed care. Findings include: Review of the facility's policy titled Trauma Informed Care and Post-Traumatic Stress Disorder (PTSD), revised 9/2023, indicated but was not limited to the following: - The facility will strive to provide that residents who are trauma survivors receive culturally competent, trauma informed care in accordance with professional standards of proactive (sic) and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. - Goal is establishing an atmosphere of calm and safety and attempt to avoid escalation of PTSD reaction. - The key to managing residents with history of trauma is interdisciplinary assessment and developing a good care plan based on knowledge of the resident. - The identification of problems, goals, approaches can best be determined by considering what is the best provision for direct care. - The care plan is reviewed at admission, the quarterly and in response to significant changes in the resident's condition. - The care plan review includes the entire interdisciplinary team and all levels of direct care staff. - Resident will be assessed upon admission to facility to identify any history trauma/PTSD. - If a history of trauma or PTSD is identified staff will develop a care plan inclusive of potential triggers and how to avoid re-traumatization. - Care plan will be reviewed at admission, quarterly, and in response to significant change. 1. Resident #10 was admitted to the facility in January 2023 with diagnoses including anxiety, depression, and PTSD. Review of the Minimum Data Set (MDS) assessment, dated 1/31/24, indicated that the Resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the Resident was cognitively intact. Further review of the MDS assessment indicated Resident #10 had an active diagnosis of PTSD. During an interview on 4/30/24 at 9:05 A.M., Resident #10 said he/she had a history of PTSD and trauma related to childhood and adult events. Resident #10 said these incidents have resulted in anxiety and depression. Resident #10 said he/she sees a psychotherapist in the facility every other week who he/she can talk to as needed. Review of Resident #10's active Physician's Orders indicated but was not limited to: - 2/2/23: May be seen by psych for evaluation, behavior, medication review and/or related testing and follow-up as needed. - 5/3/23: 1:1 Psychotherapy 2-4 times per month Review of the Social History, Psychological and Spiritual Assessment, dated 2/1/23, indicated Resident #10 had a history of traumatic events related to childhood. Review of the assessment failed to indicate triggers related to the traumatic events. Furthermore, the Trauma/PTSD section of the evaluation was incomplete. Review of the annual Social History, Psychological and Spiritual Assessment, dated 1/17/24, indicated Resident #10 had a history of traumatic events related to childhood. Review of the assessment failed to indicate triggers related to the traumatic events. Furthermore, the Trauma/PTSD section of the evaluation was incomplete. Review of Resident #10's individualized care plan indicated a diagnosis of PTSD related to childhood and adult events. Further review of the care plan indicated trauma/PTSD potential triggers indicated on the Social Service Assessment. The care plan failed to indicate specific triggers related to Resident #10's trauma/PTSD history. Review of the facility's consultant Psychiatrist service notes, dated 1/15/24 and 4/22/24, indicated Resident #10 had diagnoses of PTSD, anxiety, and depression. The documentation indicated Resident #10 receives 1:1 psychotherapy visits in the facility. Further review of the documentation failed to indicate specific triggers related to Resident #10's trauma/PTSD. Review of the facility's consultant Psychotherapy service notes, dated 11/27/23, 12/13/23, 1/15/24, 1/24/24, 2/14/24, 2/19/24, 3/6/24, and 4/7/24, documented Resident #10's diagnoses including anxiety, depression, and PTSD. The documentation indicated Resident #10 continues to participate and benefit from services provided but did not indicate specifics related to traumas or the Resident's triggers. Review of the consultant Psychotherapy Treatment plan, dated 11/20/23, indicated Resident #10 has a history of PTSD related to family. The treatment plan indicated the continued use of psychotherapy services to help Resident #10 and provide emotional support. The treatment plan fails to indicate any triggers related to Resident #10's history of trauma and/or PTSD. Review of the medical record failed to indicate facility staff collaborated with the Resident representative, or any other health care professional that provided care to the Resident to gather information related to the Resident's PTSD to develop a person-centered plan of care that identified potential triggers or trauma with interventions to prevent re-traumatization. During an interview on 4/30/24 at 10:25 A.M., Nurse #2 said Resident #10 had diagnoses of trauma and PTSD. Nurse #2 said she did not know of any specific triggers related to Resident #10's trauma and PTSD history. Nurse #2 said she believed his/her trauma was related to relationships with his/her family members. During an interview on 4/30/24 at 11:02 A.M., the Director of Social Services said when residents come into the facility a social history and trauma assessment is completed. The Director of Social Services said documentation regarding a resident's history of trauma and/or PTSD would be listed on this assessment. The Director of Social Services said this assessment is completed on admission, annually, and as needed when new information is provided or discovered regarding trauma and/or PTSD history. The Director of Social Services said information related to triggers for a resident with trauma or PTSD history would be indicated on their care plan. The Director of Social Services and the surveyor reviewed the information for Resident #10 including care plans and trauma assessments. The Director of Social Services said the Social History, Psychological and Spiritual Assessment completed on admission was incomplete and did not reflect the Resident's triggers related to their PTSD history. The Director of Social Services said the identification of triggers should be clearly indicated on the assessment. The Director of Social Services said the Resident's care plan should better reflect triggers related to trauma and/or PTSD.

Based on observation, interview, policy review, and record review, the facility failed to follow Enhanced Barrier Precautions guidelines while performing wound care for one Resident (#51), out of one observed wound care treatment. Findings include: Review of the facility's policy titled Enhanced Barrier Precautions, dated as new 4/29/24, indicated but was not limited to the following: -Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities -EBP are used in conjunction with standard precautions and expand the use of Personal Protective Equipment (PPE) to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of Multi-drug Resistant Organisms (MDRO) to staff hands and clothing -EBP are indicated for residents with any of the following: -Infection or colonization with a Center for Disease Control (CDC) targeted MDRO when Contract Precautions do not otherwise apply -Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO -A wound or indwelling medical device without secretions or excretions that are unable to be covered or contained and are not known to be infected or colonized with any MDRO Resident #51 was admitted to the facility in December 2019 with diagnoses including Bullous Pemphigoid (formation of blisters between the skin layers). Review of the current Physician's Orders for April 2024 included the following: -Maintain enhanced barrier precautions (wear gloves and a gown for the following high contact activities; wound care due to Extended spectrum beta-lactamase (ESBL) a bacteria colonized (presence of bacteria) in urine -Diprolene Ointment 0.5% apply to right breast topically every day and evening shift related to Bullous Pemphigoid -Diprolene Ointment 0.5% apply to right outer breast topically every day and evening shift related to Bullous Pemphigoid -Diprolene Ointment 0.5% apply to right upper breast topically every day and evening shift related to Bullous Pemphigoid -Diprolene Ointment 0.5% apply to left breast topically every day and evening shift related to Bullous Pemphigoid On 4/29/24 at 3:11 P.M., the surveyor observed a sign on Resident #51's door that indicated but was not limited to the following: -Stop; Enhanced Barrier Precautions; Providers and staff must wear a gown and gloves for high contact care activities, including wound care On 4/29/24 at 10:56 A.M., the surveyor observed Nurse #1 provide wound care to Resident #51's bilateral breasts as follows: -Nurse #1 entered Resident #51 room and performed hand hygiene. -Nurse #1 cleansed the bedside table, put a barrier on the table, placed supplies and the Diprolene ointment on the barrier, removed her gloves and performed hand hygiene. -Nurse #1 then donned (applied) gloves, but was not observed to don a protective gown, and assisted Resident #51 with lifting her hospital gown. -Nurse #1 applied the ointment as ordered to Resident #51 right breast wound, doffed (removed) her gloves, performed hand hygiene and donned gloves. -Nurse #1 applied the ointment as ordered to Resident #51 right breast outer wound, doffed her gloves, performed hand hygiene and donned gloves. -Nurse #1 applied the ointment as ordered to Resident #51 right breast upper wound, doffed her gloves, performed hand hygiene and donned gloves. -Nurse #1 applied the ointment as ordered to Resident #51 left breast wound, assisted Resident #51 with lowering her hospital gown, doffed her gloves, and performed hand hygiene. At no time throughout the treatment did Nurse #1 don a protective gown. During an interview on 4/29/24 at 11:34 A.M., Nurse #1 said she should have had a protective gown on while providing wound care because Resident #51 is on EBP precautions for his/her wounds. During an interview on 4/29/24 at 11:39 A.M., the Assistant Director of Nursing (ADON) said her expectation is for gown and gloves to be worn while providing wound care for a resident on EBP precautions. She said Resident #51 wounds are not draining any fluid; however, he/she is on EBP precautions for an MDRO infection and gown and gloves are required to provide wound care. During an interview on 4/29/24 at 11:52 A.M., the Director of Nursing (DON) said wound care is considered a high contact care activity and her expectation is for staff to wear a gown and gloves while performing high contact care activities when a resident is on EBP precautions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and interview, the facility failed to provide education, assess eligibility, and offer Pneumococcal Vaccinations per the Centers for Disease Control and Prevention (CDC) recommendations and facility policy for three Residents (#9, #67, and #52), out of a total sample of five residents. Specifically, the facility failed to ensure that staff offered, assessed, and provided education on the recommended 20-Valent Pneumococcal Conjugate Vaccine (PCV20) (an active immunizing agent used to prevent infection caused by certain types of pneumococcal bacteria). Findings include: Review of the facility's policy titled Infection Control, Pneumococcal Vaccine, dated as reviewed 9/2023, indicated but was not limited to the following: - residents admitted to or residing in the facility will be offered the Pneumococcal conjugate vaccine (PCV 13, PCV 15 or PCV 20) based on availability of the vaccine and the individual's previous vaccination history. This vaccine is only administered once for all adults. - the facility will adhere to the recommendations of CDC for the administration of pneumococcal vaccines. All precautions, allergy history, recommendations will be reviewed based on the latest Vaccine information sheet (VIS) from CDC. - the facility will have a system in place to assure the resident's receive additional immunizations at appropriate time intervals, as indicated. - the Director of Nurses (DON) will ensure the vaccines are offered and informed consent is obtained from each resident admitted to or residing in the facility, if immunization is appropriate and desired. - informed consent will include the most current literature available on the risks and benefits of the vaccine using the CDC VIS. Review of the CDC website Pneumococcal Vaccine Timing for Adults greater than or equal to 65 years (cdc.gov), dated 3/15/23, indicated but was not limited to the following: -For adults 65 and over who have not had any prior pneumococcal vaccines, then the patient and provider may choose Pneumococcal conjugate vaccine (PCV) 20 or PCV15 followed by Pneumococcal polysaccharide vaccine (PPSV) 23 one year later. -For adults 65 and over who has had Pneumococcal Conjugate Vaccine 13 (PCV13) and Pneumococcal Polysaccharide Vaccine 23 (PPSV23) and it has been 5 years or greater since the last Pneumococcal Vaccination, then the patient and the vaccine provider may choose to administer the 20-Valent Pneumococcal Conjugate Vaccine (PCV20). During an interview on 4/26/24 at 10:06 A.M., Unit Manager #2 said the immunization consents are done once upon admission and then not again. She said they are kept in the chart and the Infection prevention nurse (IPN) then comes and follows up on who needs vaccinations. She said the nurses complete the forms with the residents as part of the admissions process and from there the IPN takes care of any necessary follow up. During an interview on 4/26/24 at 10:44 A.M., Nurse #4 said when a new admission comes in the nurse admitting the resident completes the immunization consents and provides the residents with the Vaccine Information Sheet (VIS) that goes along with the vaccinations on the consent/declination form. She said she is unsure who takes over with ensuring the vaccinations are received or readdressed with the residents after that. Resident #9 was admitted to the facility in May 2022 and is [AGE] years old. The most recent Brief interview for Mental Status (BIMS), dated 2/14/24, indicated the Resident is cognitively intact with a score of 15 out of 15. Review of Resident #9's medical record indicated but was not limited to the following: - immunization record indicated the Resident received PPSV 23 in 2014 - pneumococcal vaccine consent/declination in the record indicated in May 2022 the Resident signed to consent to PPSV 23, but there was no response to the PCV 13 vaccine and the PCV 20 vaccine was not an option at the time - there was no evidence in the record the PCV 20 vaccine had ever been offered to the Resident since admission to the facility in 2022 During an interview on 4/26/24 at 11:32 A.M., Resident #9 said he/she gets all the vaccines offered to him/her. He/she said they were not aware they had the option to receive the PCV 20 vaccine and had not ever been provided information on it or been offered it and was interested in getting the information to remain fully vaccinated. Resident #67 was admitted to the facility in March 2021 and is [AGE] years old. Review of the most recent BIMS, dated 2/11/24, indicated the Resident was moderately cognitively impaired with a score of 9 out of 15 and his/her healthcare proxy (HCP) was activated. Review of the medical record indicated but was not limited to the following: - pneumococcal vaccination consent/declination in the record, indicated the Resident had previously received the PPSV 23 and PCV 13 vaccinations in an unknown timeframe in November 2021, the PCV 20 vaccination was not indicated on the consent form on file - there was no evidence in the record the PCV 20 vaccine had ever been offered to the Resident or his/her HCP since November 2021 During an interview on 4/26/24 at 10:00 A.M., Unit Manager #1 said immunizations, including the pneumococcal vaccines are offered to residents once upon admission and not after that, that she is aware of. She said she keeps a book to track who signed to consent to vaccines and has received them. She said the vaccine consent form signed by Resident #67 did not include information or offer the Resident the PCV 20 vaccine at the time it was completed. Review of the medical record for Resident #67 including: notes, consents, care plans and orders failed to indicate the Resident or his/her responsible party was ever offered information to make an informed decision on the PCV 20 vaccination. Resident #52 was admitted to the facility in January 2024 and is [AGE] years old. Review of the most recent BIMS, dated 4/10/24, indicated the Resident was moderately cognitively impaired with a score of 11 out of 15 and his/her HCP was activated. Review of Resident #52's medical record indicated but was not limited to the following: - immunization record failed to indicate any information regarding any of the pneumococcal vaccinations - pneumococcal vaccine consent/declination in the record indicated in January 2024 the Resident signed the form, but failed to complete the form indicating consent or declination of the PPSV 23, PCV 13, PCV 15 and PCV 20 vaccinations - there was no evidence in the notes, care plans, or orders that the Resident or his/her HCP had the vaccinations readdressed to determine whether or not the Resident would be receiving the vaccines During an interview on 4/26/24 at 12:41 P.M., the IPN said the facility was having individual unit managers track their residents' vaccinations, but following admission, she did check to see if the resident's or their responsible parties signed to consent to any vaccines. She said there is no process for assuring the residents or their responsible parties are re-offered vaccinations following a declination or that the PCV 20 immunization was ever offered to any long-term residents once it became available. She reviewed the information and concerns with the surveyor regarding the lack of pneumococcal vaccinations being offered and said the process is clearly not working and needs improvement, since they are not meeting the CDC guideline as they should be. During an interview on 4/26/24 at 1:29 P.M., the Director of Nurses (DON) and IPN met with the surveyor. Upon review of the surveyor's concerns with the pneumococcal immunization program, the DON said the facility policy for pneumococcal vaccinations is not currently being followed as it should be and the process needed to be fixed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure one Resident's (#155) right to be informed of, and participate in, his/her treatment plan was honored when his/her Health Care Agent, which was not invoked, made treatment decisions, out of a total sample of 22 residents. Findings include: Review of the facility's handbook titled Resident Rights, dated as revised October 2022 indicated resident rights included but was not limited to: -right to be informed of, and participate in, his/her treatment. Resident #155 was admitted to the facility in December 2022 with diagnoses that included coronary disease, history of diabetes, and bipolar disorder. During an interview on 12/27/22 at 9:10 A.M., Resident #155 said he/she had been admitted for short term care. Resident #155 said there was poor communication between him/her and the staff, including the physician. Resident #155 said medication changes had occurred and the facility staff or physician had not informed him/her of the changes, when they occurred. The Resident said he/she thought they no longer had diabetes, unless they ate foods that were high in sugar because they no longer received insulin. Resident #155 said he/she was not clear what medication changes occurred or why. Review of the medical record indicated Resident #155 signed and consented to the care and treatment at the facility. The medical record indicated he/she was alert and oriented had a Health Care Proxy (HCP) and it was not invoked. Review of the medication orders from 12/8/22 through 12/28/22 (current orders) indicated the following medication changes: -Insulin Glargine (diabetic medication) administer 9 units, via an insulin pen, daily was administer from 12/9/22 through 12/20/2022 and then discontinued. -Insulin Lispro [NAME] KwikPen (diabetic medication) administer 3 units, via an insulin pen, before breakfast, lunch, and dinner was administered from 12/8/22 through 12/20/22 and then discontinued -Insulin Lispro [NAME] KwikPen (diabetic medication) administer via sliding scale four times per day (before meals and at bedtime) via injection from 12/8/2022 through 12/20/22 and then discontinued -Metformin 500 milligram (mg) (diabetic medication) orally once a day, started on 12/14/22 through 12/20/22 and increased to 500 mg twice daily on 12/20/22 -Risperidone (antipsychotic) 0.25 mg daily from 12/10/22 through 12/22/22, when it was increased to 0.5 mg daily -Bupropion (antidepressant) 100 mg daily from 12/9/22 through 12/22/22, then decreased to 50 mg daily on 12/22/22 Record review failed to indicate the Resident was informed of the changes in his/her diabetic medication and psychotropic medications. Review of the medical record indicated a Family Member had sent a letter to the facility on [DATE] and the facility staff sent a copy of the letter to the Resident's physician on 12/21/22. The Family Member indicated he/she was the go between between the facility and the Resident's outside prescriber (psychiatrist). The Family Member provided a history of the Resident's psychotropic medications and informed the facility of her (the family member's) goals. The Family Member directed the facility to increase the Risperidone and decrease the Bupropion. In addition, the Family Member stated an electrocardiography (EKG) test should be done (EKG was done on 12/22/22). Record review indicated the Family Member's treatment decisions were implemented beginning on 12/22/22 and there was no indication of the Resident's participation and knowledge. The medical record did not indicate the Family Member's participation in the treatment of the Resident was authorized. During an interview on 12/27/22 at 11:30 A.M., Unit Manager #3 said there was a Family Member who makes decisions, and he/she deals directly with the Resident's Physician. During an interview on 12/29/22 at 10:46 A.M., Social Worker #1 said she was aware the Family Member is directing care. She said the facility's practice for a Resident Representative to participate in treatment decisions is for an Authorization for Disclosure of Information form to be completed and consented to by a Resident who does not have an invoked HCP. The Social Worker reviewed the medical record and said that an Authorization for Disclosure of Information form was not completed or consented to by Resident #155.

Based on observations, interviews, and record review, the facility failed to ensure an alleged perpetrator (Nurse #1) did not have access to an alleged victim (Resident #20) following an allegation of sexual abuse. The total sample was 22 residents. Findings include: Resident #20 was admitted to the facility in June 2019. Review of the Minimum Data Set (MDS) assessment, dated 10/13/22, indicated Resident #20 scored a 15 out of 15 on the Brief Interview for Mental Status, indicating the Resident was cognitively intact. During an interview on 12/27/22 at 3:45 P.M., Resident #20 said he/she had been raped on 12/24/22 or 12/25/22 by four or five men. The surveyor immediately notified Unit Manager #2. The surveyor observed Unit Manager #2 interview Resident #20. Resident #20 said he/she had been dragged out of their room by four or five men and rectally raped over a barrel. He/she said one of the men was a family member and one of the men was Nurse #1. The Resident said he/she was not sure if Nurse #1 physically participated but had watched the rape occur. The Resident said he/she had been crying off and on for a couple of days and that no one believed him/her. During an interview on 12/27/22 at 4:02 P.M., Unit Manager #2 said she had notified the Director of Nurses, who entered the room at this time with the Unit Manager and another nurse to complete a skin check for Resident #20. During an interview on 12/27/22 at 4:08 P.M., Unit Manager #2 said there was no evidence of trauma, and she was notifying the physician. On 12/27/22 at 4:09 P.M., the surveyor observed Nurse #1, the alleged perpetrator, at the medication cart at the nurses' station. On 12/27/22 at 4:32 P.M., the surveyor observed Nurse #1 on the unit and going into resident rooms. During an interview on 12/27/22 at 4:45 P.M., the Director of Nurses said the police had been contacted, laboratory work had been ordered and the Resident would now have two staff members to provide care at a time. When the surveyor inquired who the alleged perpetrators were, the Director of Nurses said the Resident had identified a family member. The surveyor inquired about the allegation in which Nurse #1 was one of the men involved, the Director of Nurses said she was unaware the Resident had mentioned Nurse #1 in the allegation to the Unit Manager and that Nurse #1 was still on the unit. During an interview on 12/29/22 at 12:55 P.M., Resident #20, with tearful eyes, said he/she kept thinking about the rape. She said Nurse #1 was there for the rape and this made him/her sad because Nurse #1 was a good nurse. A review of the facility investigation was conducted on 12/30/22 at 8:30 A.M. Review of the investigation included a statement from Unit Manager #2 indicating Resident #20 had made an allegation of sexual abuse and had indicated a family member and Nurse #1 were there during the rape. Review of the investigation included a statement from Nurse #1, which indicated the nurse was informed by Resident #20 on 12/27/22 that he/she was raped by a family member. Review of the Medication Administration Record indicated on 12/27/22 at 4:28 P.M. Nurse #1 administered 2 units of insulin in the abdomen of Resident #20, 45 minutes after the allegation was made. During an interview on 12/30/22 at 10:36 A.M., Nurse #1 said he went to the room of Resident #20 on 12/27/22 sometime between 4:00 P.M. and 5:00 P.M. to check their blood sugars. When he entered the room, Resident #20 was tearful and told Nurse #1 that he/she had been raped. Nurse #1 said he immediately went and notified Unit Manager #2 and the Unit Manager said she was already aware. During an interview on 12/30/22 at 11:20 A.M., the Director of Nurses said Nurse #1 was identified by Resident #20 during the initial interview with Unit Manager #2 on 12/27/22 at 3:45 P.M. and Nurse #1 had continued to have access to Resident #20, until the Director of Nurses was notified by the surveyor on 12/27/22 at 4:45 P.M.

Based on observation, interview, policy review, and record review, the facility failed to ensure Resident #67 was provided care in accordance with professional standards of practice from a total sample of 22 residents. Specifically, the facility failed to ensure: a. orders were in place for fingerstick blood tests, and b. bilateral seizure pads were in place and the Resident's foot was elevated on pillows while in bed according to physician's orders. Findings include: Review of the facility's policy titled Nursing Care of the Resident with Diabetes Mellitus, last revised December 2015, included but was not limited to: Glucose Monitoring -The management of individuals with diabetes mellitus should follow relevant protocols and guidelines; -The Physician will order the frequency of glucose monitoring; -Residents whose blood sugar is poorly controlled or those taking insulin may require more frequent monitoring; -Finger sticks (capillary blood samples (CBG)) measure current blood glucose levels. Resident #67 was admitted to the facility in December 2020 with diagnoses including diabetes mellitus, type 2 and right leg amputation above the knee. a. Review of the December 2022 Physician's Orders included but was not limited to the following orders for antidiabetic medication: -Humalog KwikPen Solution Pen-injector 200 unit/milliliter, inject 8 units subcutaneously before meals for diabetes (ordered 9/28/21); -Humalog KwikPen Solution Pen-injector 200 unit/milliliter, inject subcutaneously before meals as per sliding scale (initiated 12/15/20): if 200-250= 2 units; 251-300= 4 units; 301-350= 6 units; 351-400= 8 units; 401-600= 10 units; CBG greater than 400, call Physician/Nurse Practitioner Review of September, October, November, and December 2022 Medication/Treatment Administration Records (MAR/TAR) indicated nursing staff measured Resident #67's CBG three times a day. Further review of the Physician's Orders failed to include an order for fingerstick blood tests three times a day to measure the Resident's CBG. b. Review of the December 2022 Physician's Orders included but was not limited to the following: -Seizure pads to bilateral upper side rails at all times, check placement every shift (ordered 12/11/20); and -Keep LLE (left lower extremity) elevated off bed with pillows (ordered 11/19/20) On 12/27/22 at 9:25 A.M., the surveyor observed Resident #67 lying in bed with bilateral side rails up and no seizure pads in place. The Resident's left lower extremity was lying directly on the mattress and not elevated with a pillow as ordered by the Physician. On 12/28/22 at 11:03 A.M., the surveyor observed Resident #67 lying in bed with bilateral side rails up and bilateral seizure pads in place. The Resident's left lower extremity was lying directly on the mattress and not elevated with a pillow as ordered by the Physician. During an interview on 12/28/22 at 11:04 A.M., the Resident's Health Care Proxy (HCP) asked the surveyor what the blue pads on either side of the Resident's side rails were for. The HCP said she visits the Resident five days per week and had never seen them before today. At 11:07 A.M., Certified Nursing Assistant (CNA) #4 entered the Resident's room. CNA #4 said that she often has Resident #67 on her assignment and has never seen the pads before. On 12/30/22 at 11:53 A.M., the surveyor observed Resident #67 lying in bed. The Resident's left lower extremity was lying directly on the mattress and not elevated with a pillow as ordered by the Physician. During interviews on 12/30/22 at 9:15 A.M. and 3:12 P.M., the surveyor and Unit Manager #1 reviewed Resident #67's medical record. She said there should have been orders in place to do finger stick blood sugars to obtain CBGs prior to 12/23/22 and staff should not have done the blood testing without a Physician's order. She said the Resident should have had seizure pads in place and his/her left lower extremity elevated according to Physician's orders.

Based on observation, policy review, interview, and record review, the facility failed to ensure staff provided care for a Peripherally Inserted Central Catheter (PICC - a long catheter inserted through a peripheral vein then into the central vascular system to administer intravenous (IV) treatments over a long period of time) for one Resident (#157), out of a total sample of 22 residents. Specifically, the facility failed to ensure PICC line flushes, assessment, tubing changes, and dressing changes were completed and documented before and after the catheter became occluded (blockage of the access line) which caused a delay in administering the Resident's antibiotics to treat a serious infection. Findings include: Review of the facility's policies for PICC/Central Venous Access Device (CVAD) for flushing, for Catheter needleless connector changes, for Catheter dressing change and for clearing Catheter Occlusions (dated as reviewed January 2022) included but was not limited to: -Flushing is performed to ensure and maintain patency -A physician's order is required to flush a PICC -Document date and time of flushing, flushing agents, and amounts, on the Medication/Treatment Administration Record (MAR/TAR) -Dressing changes and assessment are to be provided at specific intervals and with a specific technique and will occur according to the PICC orders -A physician's order for the care, maintenance, and schedule of dressing change of the PICC is required -Assessment of the PICC site should occur before, during, and after medication administration, during dressing changes and at minimum once a shift -With each site assessment the PICC should be assessed for redness, drainage, swelling, external catheter length, presence of sutures, tenderness, warmth, and patency and documented in the clinical record. -A catheter occlusion can be caused by a thrombotic buildup, a medical condition known as fibrin - is a fibrous protein involved in the clotting of blood or by non-thrombotic cause - a drug precipitate and/or a mechanical factor, such as kinked tubing, suturing tight and or a poor positioning of the PICC catheter -An occlusion impacts the access of the device's patency -To prevent an occlusion from occurring and ensuring the PICC line can be accessed, the licensed nursing staff are required to routinely assess the PICC, and ensure the physician orders for flushes, care, assessment, and treatment are followed. Performing the proper flushing procedure immediately before and after a medication infusion ensures the PICC is working properly and not occluded -If an occlusion occurs the licensed staff should be competent to do the procedure or contact a prescriber who is competent to clear the occlusion with a thrombolytic agent (a medication that dissolve clots). -A physician's order is required -The licensed nurse should document the procedure in the Resident's medical record, including but not limited to: the date and time, site assessment, flushing agent and volume, any complications and the Resident's response. Resident #157 was admitted in December 2022 with diagnoses including heart failure, chronic kidney disease, and an acute infection of the heart (endocarditis). Review of the medical record indicated Resident #157 had a double lumen PICC line in the left arm for intravenous (IV) antibiotic administration. Further review indicated orders for Cefepime (an antibiotic) IV at 9:00 A.M. and Vancomycin (an antibiotic) IV at 5:00 P.M. Review of a Physician's Order, dated 12/9/22, for Care of the PICC line indicated: - Pre-flush the PICC with 10 milliliters (ml) of Normal Saline (NS) prior to medication administration - Post flush with 10 ml of NS after medication administration - Flush all lumens at least every 12 and/or 24 hours and as needed, as the infusion was not continuous - Document total catheter length and external catheter length on admission - Document baseline arm circumference every shift and as needed - Document external catheter length weekly with weekly dressing change - In addition, per facility policy, care of PICC line includes: - Change catheter site dressing every week and as needed with transparent dressing - Monitor IV site every shift and document in the nurses' notes - Change dressing on admission and change every 24 hours and label with date/time/initials. Review of the MAR and TAR for 12/9/22 through 12/29/22, failed to indicate the nursing staff had transcribed the physician's orders for the care of the PICC line onto the administration records. The MAR and TAR failed to indicate the PICC had ever been flushed, assessed, and included the external catheter length, arm circumference, or the PICC dressing had been changed as ordered by the physician. Review of Nursing Notes from 12/9/22 through 12/29/22, revealed no documentation in the nursing notes that included an external catheter length or an arm circumference on any shift, including the 3:00 P.M. -11:00 P.M. shift each day. Review of a Nurse's Note, dated 12/11/22 at 5:00 P.M., indicated one of the two lumens was occluded / blocked and not accessible for medication administration. The nurse documented she contacted the prescriber who ordered holding the Resident's antibiotics until the occlusion was cleared by the Infusion service. Review of the Infusion Nurse's Note, dated 12/12/22 at 10:00 A.M., indicated during her visit she removed the PICC line caps and cleared the blockage. The note indicated the Infusion Nurse observed blood clots surrounding the PICC line and she changed the dressing and inserted an IV stat lock (device that holds the IV in place and helps prevent occlusions). Review of the medical record indicated that after the Resident's PICC line became occluded, there was no additional documentation in the nurses' note or the MAR/TAR that the licensed staff were caring for the PICC line as ordered and as outlined in the facility policy. During an interview on 12/29/22 at 8:41 A.M., Nurse #5 said she documented the administration of medications and treatment on the MAR. After not finding the treatment and care of the PICC on the MAR, Nurse #5 reviewed the TAR. Nurse #5 said she could not find documentation the flushes, dressing changes, and care of the PICC line had been done. She said there was no other location this information could be documented. During an interview on 12/29/22 at 11:37 A.M., Unit Manager #3 said she could not explain why the orders for the care and treatment of the PICC had not been entered onto the MAR or the TAR. She said her expectation was for the staff to transcribe the physician's orders onto the administration records. She said she was pretty sure the staff were flushing the PICC line but could not say if they were flushing it as ordered. The surveyor inquired about the note she had written on 12/12/22 regarding the blockage of the PICC. She said she had not observed the PICC at the time of the occlusion and wrote the nurse's note for the nurse. The surveyor inquired when the last time was the staff had changed the Resident's dressing. The Unit Manager said she did not know and when she asked Nurse #5, she said she did not know. On 12/29/22 at 11:40 A.M., the surveyor observed the Resident's PICC line following the interview. The surveyor observed multiple layers of the transparent dressing to be bunched up. There were layers of tape securing the dressing onto the arm. The dressing was visibly soiled, and a large amount of blood was visible around the PICC site and had seeped onto to the Resident's left upper arm. The date on the dressing was 12/12. During an interview on 12/29/22 at 11:45 A.M., the surveyor shared the observation with the Unit Manager and Nurse #5, and neither could explain why the dressing had not been changed since the Infusion Nurse had cleared the occlusion/blockage on 12/12/22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the facility failed to ensure residents were provided respiratory care in accordance with professional standards of practice for two Residents (#22 and #28) receiving Oxygen therapy, out of a sample of 22 residents. Findings include: [NAME] NURSING PROCEDURES, 8th edition Oxygen: all Oxygen delivery systems should be checked at least once each day -verify the practitioner's order for the Oxygen therapy, because Oxygen is considered a medication or therapy and should be prescribed -monitor the patient's Oxygen saturation level by pulse oximetry to assess response to Oxygen therapy - assess the patient frequently for signs and symptoms of hypoxia, such as restlessness, decreased level consciousness, increased heart rate, arrhythmias, perspiration, dyspnea, use of accessory muscles, yawning or flared nostrils, cyanosis, and cool, clammy skin, obtain vital signs, as needed. DOCUMENTATION: record the date and time of Oxygen administration, the type of delivery device, the Oxygen flow rate, the patient's vital signs, skin color, respiratory effort, and breath sounds. Review of the facility's policy titled Use of Oxygen, last revised September 2022, included but was not limited to: -Oxygen is administered only on the order of the Physician; -Physician's order shall include: liters of flow and vehicle of administration; -Pre-filled disposable humidifier bottles should be used when indicated. All bottles should be dated and changed every seven days. 1. Resident #22 was admitted to the facility in December 2019 with diagnoses including chronic obstructive pulmonary disease (lung disease that blocks airflow and makes it difficult to breathe). Review of the Minimum Data Set (MDS) assessment, dated 12/1/22, indicated Resident #22 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15, and received Oxygen therapy while a resident at the facility. During an interview on 12/27/22 at 12:15 P.M., the surveyor observed Resident #22 lying in bed awake. Oxygen tubing was noted to be connected to the concentrator with a refillable humidifier bottle containing water, with a nasal cannula (a lightweight tube which on one end splits into two prongs which are placed in the nostrils and from which a mixture of air and oxygen flows) in place in the Resident's nostrils. The concentrator was on and set to a flow rate of 4.0 liters/minute. Resident #22 said that he/she uses Oxygen continuously, day and night due to difficulty breathing. On 12/29/22 at 11:05 A.M., the surveyor observed Resident #22 sitting up in bed. Oxygen tubing was noted to be connected to the concentrator with a refillable humidifier bottle of water, with a nasal cannula in place in the Resident's nostrils. The concentrator was on and set to a flow rate of 4.0 liters/minute. Review of the medical record indicated the following Physician's Order: -Administer Oxygen at 2 liters/minute via nasal cannula (nc), prn (as needed) to maintain Oxygen saturation over 92% (2/28/22) There was no Physician's Order in place for the use of humidified Oxygen including maintenance of the humidification device and no order for Oxygen use continuously. Review of the December 2022 Medication/Treatment Administration Records failed to indicate staff recorded the date and time of Oxygen administration, and the Oxygen flow rate. During an interview on 12/30/22 at 9:09 A.M., the Administrator and surveyor observed Resident #22 sitting up in bed. The oxygen tubing was noted to be connected to the concentrator with a refillable humidifier bottle, with a nasal cannula in place in the Resident's nostrils. The concentrator was on and set to a flow rate of 4.0 liters/minute. The Resident said that his/her Oxygen should be set to 2 liters and not 4 liters. The surveyor reviewed Resident #22's medical record with the Administrator. He confirmed that the Physician's orders indicated Oxygen is ordered as needed (prn) at 2 liters/minute and do not indicate humidified Oxygen. 2. Resident #28 was admitted to the facility in June 2022 with diagnoses including chronic obstructive pulmonary disease. Review of the MDS assessment, dated 11/2/22, indicated Resident #28 was cognitively intact as evidenced by a BIMS score of 15 out of 15 and received Oxygen therapy. During an interview on 12/27/22 at 1:30 P.M., Resident #28 said that he/she had to tell the Nurse this morning that the humidifier cup (bottle) attached to the oxygen concentrator needed more water. The Resident said he/she has received Oxygen therapy since being admitted to the facility in June. The surveyor observed oxygen tubing connected to the concentrator with a refillable bottle of water, with a nasal cannula in place in the Resident's nostrils. The concentrator was on and set to a flow rate of 2.0 liters/minute. On 12/28/22 at 2:32 P.M., the surveyor observed Resident #28 lying in bed sleeping. Oxygen tubing was noted to be connected to the concentrator with a refillable bottle of water, with a nasal cannula in place in the Resident's nostrils. The concentrator was on and set to a flow rate of 2.0 liters/minute. On 12/29/22 at 10:45 A.M., the surveyor observed Resident #28 sitting upright in bed. The oxygen tubing was noted to be connected to the concentrator with a refillable bottle of water, with a nasal cannula in place in the Resident's nostrils. The concentrator was on and set to a flow rate of 2.0 liters/minute. Review of the medical record indicated the following Physician's Order: -Oxygen at L via NC to keep saturation above 88% (10/19/21) The Physician's order failed to indicate a liter flow for Oxygen administration and failed to include the use of a humidifier bottle including maintenance of the humidification device. Review of the December 2022 Medication/Treatment Administration Records failed to indicate staff recorded the Oxygen flow rate and refilled or replaced the humidifier bottle. During an interview on 12/30/22 at 9:15 A.M., the surveyor and Unit Manager #1 reviewed Resident #28's medical record. Unit Manager #1 confirmed that the Oxygen order is incomplete and must include a liter flow rate, and there is no order for humidified Oxygen with maintenance instructions.

2. Resident #25 was admitted to the facility in February 2022 with a diagnosis of anxiety. Review of the Physician's Orders indicated an order written on 3/24/22 for Ativan (an antianxiety medication) 0.5 milligrams (mg), give one tablet every 8 hours as needed for anxiety. The order indicated the end date as indefinite. Review of the medical record indicated this order was in place from 3/24/22 through 11/3/22 (over seven months.) Review of the Physician's orders indicated an order written on 11/28/22 for Ativan 0.5 mg, give one tablet every 8 hours as needed. The order indicated the end date was indefinite. Review of the Physician's Progress Notes and Orders failed to indicate a rationale for the extended use of the as needed antianxiety medication or a duration for use. During an interview on 12/30/22 at 9:38 A.M., Unit Manager #2 reviewed the medical record with the surveyor and said the Ativan should have had a stop date when originally ordered so that the physicians could have evaluated and documented the justification for use. Based on record review, policy review, and staff interviews, the facility failed to ensure drug regimens were free from unnecessary medications for 2 Residents (#155 and #25), from a sample of 5 residents with potential unnecessary medications. Specifically, the facility failed to ensure 1. For Resident #155, an antipsychotic medication ordered as needed (PRN) was limited to 14 days and was reviewed by the physician with a documented rationale for continued use. 2. For Resident #25, a psychotropic medication ordered as needed (PRN) was limited to 14 days and was reviewed by the physician with a documented rationale for continued use. Findings include: Review of the facility's policy titled Antipsychotic Medication Use, dated September 2022, indicated antipsychotic medication will be used based on a comprehensive assessment. Residents who have not used psychotropic drugs are not given those drugs unless such drug therapy is necessary to treat a specific condition, as diagnosed and documented in the clinical record and informed written consent must be obtained and documented prior to the administration of any antipsychotic medication. The policy indicated when psychotropic medications are prescribed, a specific condition or targeted behavior that warrants the use of the medication shall be documented in the medical record. 1. Resident #155 was admitted to the facility in December 2022 with diagnoses that included bipolar disorder. Record review, including the Hospital Discharge Record, dated 12/8/22, indicated Seroquel 100 milligrams (mg) every 4 hours as needed (PRN) for delirium and anxiety in the hospital setting. The record indicated the Resident cleared considerably and has not voiced anxiety and stated it was controlled. Review of the Physician's Order for Resident #155, dated 12/8/22, indicated Seroquel 100 mg give one tablet by mouth every four hours as needed (PRN). The physician's order did not include the required re-evaluation in 14 days. Review of the Medication Administration Record (MAR), dated 12/8/22, indicated Resident #155 received Seroquel 100 mg by mouth on 12/9/22 12/17/22, 12/19/22, and 12/20/22 for anxiety. Review of the medical record indicated, on 12/22/22, the Pharmacist notified the physician of the requirement for a medical justification for use and the 14-day timeframe. During an interview on 12/29/22 at 10:45 A.M., Unit Manager #3 said she was unsure why Resident #155 was receiving PRN Seroquel. She did not know and could not find the physician's justification for the antipsychotic PRN order.

Based on observations, interviews, and record reviews, the facility failed to ensure pressure relieving devices were utilized following professional standards for 3 Residents (#59, #20, and #66), in a sample of 7 residents with pressure ulcers. Specifically, the facility failed to ensure 1. For Resident #59, an ROHO cushion (an inflatable seat cushion) was checked for proper inflation to promote pressure ulcer healing; 2. For Resident #20, the proper use of a gel seating cushion by placing a folded sheet between the Resident and the cushion; and 3. For Resident #66, the pressure relieving air mattress was consistently set to optimize wound healing. Findings include: 1. Resident #59 was admitted to the facility in June 2021 with an unstageable pressure area to the left buttock. Review of the Physical Therapy Progress Notes indicated on 6/25/21 Resident #59 was provided with a 3-inch high ROHO cushion related to the pressure area on the buttock. Review of the wound consultant Physician's Wound Evaluation and Management Summary, dated 12/23/22, indicated Resident #59 had a stage 4 pressure wound to the sacrum (lower back) for greater than 162 days. The wound was noted to be 0.8 centimeters (cm) in length by 0.6 cm in width by 0.2 cm in depth with 20 percent necrotic (dead) tissue and 80 percent granulation tissue (when wound is healing). Review of the Physician's Orders included an order for the ROHO cushion to be checked every night shift (11:00 P.M. to 7:00 A.M.) for inflation. Review of the ROHO cushions operating manual indicated the following: -Do not use a product that is under-inflated or over-inflated, because the product benefits will be reduced or eliminated, resulting in an increased risk to skin and other soft tissue. -Carefully follow the instructions for inflation, placement, and hand check -The check would be performed while the person is on the cushion by sliding one hand between the cushion and the pelvic bony prominence; move fingers up and down between the bony prominence and the wheelchair base; check to ensure there is between a 0.5 inch and 1 inch space between the bony prominence and the wheelchair base and adjust the inflation level as necessary. - After setting up the cushion the first time, perform a hand check frequently, at least once a day. On 12/27/22 at 12:45 P.M., the surveyor observed Resident #59 to be sitting up in the wheelchair, on an ROHO cushion. On 12/28/22 at 4:50 P.M., the surveyor observed Resident #59 in bed. The surveyor observed a wheelchair next to the bed with an ROHO cushion which appeared saggy. When pressing two hands flat on the cushion, the center of the cushion lost air (redistributing the air to cells on the outer parts of the cushion) and the surveyor was able to feel the base of the wheelchair. On 12/29/22 at 10:56 A.M., the surveyor observed Resident #59 to be in his/her room working with Physical Therapy. At this time, the Director of Rehabilitation said the ROHO cushion was used to redistribute the pressure while the Resident was sitting in the wheelchair. The surveyor inquired if the ROHO cushion was inflated properly. The Physical Therapy Assistant pressed on the front left corner of the cushion and said it was inflated. Neither physical therapist completed a hand check to check for proper inflation of the cushion. During an interview on 12/30/22 at 11:51 A.M., the wound consultant Physician said Resident #59 had a wound that would heal then re-open at times and the Resident was high risk for wounds related to their diagnoses and medications, such as the current use of a steroid. At this time, the surveyor inquired about the ROHO cushion inflation for Resident #59. The wound consultant Physician picked up the ROHO cushion, which visibly flopped to the side, and said the cushion was not inflated properly. During an interview on 12/30/22 at 1:30 P.M., the Director of Nurses said she had reviewed the physician's order for checking the inflation of the ROHO cushion as the staff on the overnight shift were unable to complete a proper hand check for inflation if the Resident was not in the wheelchair at the time. 2. Resident #20 was admitted to the facility in June 2021 with a diagnosis of cauda equina syndrome (nerve damage at the lower part of the spine). Review of the medical record for Resident #20 indicated the Resident had a hospitalization in October 2022 and returned with a stage 2 pressure ulcer on the coccyx (bony prominence at end of spine). Review of the care plans for Resident #20 included interventions of using a pressure reducing cushion on the wheelchair. During an interview on 12/28/22 at 9:15 A.M., Resident #20 said he/she had an open area on his/her buttock. He/she said their buttock was uncomfortable when sitting up in the wheelchair. The surveyor observed the wheelchair to be in the Resident's room with a pressure relieving cushion on the wheelchair, on top of the pressure relieving cushion was a sheet folded over multiple times. On 12/28/22 at 3:05 P.M., the surveyor observed Resident #20 seated in the wheelchair. The surveyor observed a folded sheet to be between the Resident and the pressure relieving cushion. On 12/29/22 at 12:55 P.M., the surveyor observed Resident #20 to be seated in the wheelchair. The surveyor observed a folded sheet to be between the Resident and the pressure relieving cushion. During an interview on 12/30/22 at 9:04 A.M., Unit Manager #2 said Resident #20 should not have a folded sheet between the Resident and the cushion as this would prohibit the cushion from providing pressure relief. 3. Resident #66 was admitted to the facility in November 2022 with diagnoses including a history of falls and a fractured pelvis. Review of the medical record indicated Nursing staff identified a 2-centimeter pressure area to Resident #66's coccyx on 12/13/22. The Physician was notified and ordered the following wound care interventions: -Allevyn (water/bacteria-proof adhesive dressing indicated for moderate to high exudating wounds) to coccyx every 48 hours (12/13/22) -Santyl 250 unit/grams, apply to wound bed followed by calcium alginate and cover with dry protective dressing, every day shift (12/17/22) On 12/27/22 at 12:00 P.M., the surveyor observed Resident #66 lying in bed on an air mattress. The air mattress unit was on and set to 240 pounds (lbs.). On 12/28/22 at 2:34 P.M., the surveyor observed Resident #66 lying upright in bed awake. The air mattress unit was on and set to 180 lbs. On 12/29/22 at 9:02 A.M., the surveyor observed Resident #66 lying upright in bed. The air mattress unit was on and set to 240 lbs. Review of Resident #66's weight record indicated on 12/14/22, the Resident weighed 148.6 lbs. Review of the medical record failed to indicate a Physician's order for the use of the air mattress. During an interview on 12/20/22 at 9:15 A.M., Unit Manager #1 confirmed there was no order for Resident #66's air mattress. She said there should be a Physician's order in place for its use that includes specific settings to promote healing of Resident #66's pressure ulcer.

Based on observations, interviews, and record review, the facility failed to maintain an environment free of accident hazards for one Resident (#44), out of a sample of 22 residents. Specifically, the facility failed to ensure that effective care plan interventions were developed and implemented to prevent nine falls in a six month period. Findings include: Review of the facility's policies titled Falls Program Policy and Incident Reporting, both last revised September 2022, included but was not limited to: -Purpose: To prevent the actual occurrence of falls and reduce the risk of any injury from a fall; -Residents experiencing a fall will receive appropriate care with investigation of cause; -Care plan will reflect new intervention initiated if fall should occur; -When an incident involving a resident occurs, a nurse will document the incident in a nursing note and complete an incident report. Be sure the form is complete. These reports shall contain information that is pertinent, factual, accurate, objective, and concise; and -Incidents involving residents that fall will have a Fall Investigation Form and Post-Fall Evaluation Form completed by a designated member of Nursing Administration Resident #44 was admitted to the facility in December 2017 with diagnoses including Parkinson's disease, muscle weakness, and cognitive communication deficit. Review of the Minimum Data Set (MDS) assessment, dated 9/21/22, indicated Resident #44 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status score of 7 out of 15, required extensive assistance of staff for all activities of daily living, had a history of falls, utilized a wheelchair, and was unsteady and only able to stabilize with assistance when moving from a seated position to standing. Review of Resident #44's Interdisciplinary Care Plans included but was not limited to: -Problem: Resident is at risk for falls (9/4/18) -Interventions: Check on Resident more frequently to see if he/she needs assistance (9/4/18); Dycem to wheelchair seat (under cushion), check placement every shift (9/25/18); Anti-rollback brackets to Resident's wheelchair related to Resident often forgets to apply brake (3/30/21); ensure Resident has his/her Reacher (4/20/21); self-releasing Velcro alarm belt- Resident able to release on command, used as an alert to staff (5/31/22) -Goal: Resident will be free from any major injuries related to fall through the review date (9/4/18) Review of the medical record indicated Resident #44 had nine falls from June 2022 to December 2022. Review of the falls indicated: 1. 6/21/22 at 11:30 A.M., the Resident was observed by a Nurse trying to push a bedside table into his/her room from the hallway and slid off the seat of a wheelchair onto the leg and footrest of the wheelchair. The investigation indicated the following interventions were in place at the time of the fall: Velcro alarm seatbelt, shoes and wheelchair. The investigation failed to indicate if Dycem was in place in the wheelchair seat at the time of the fall. An intervention identified on the care plan to prevent future falls was: staff to offer adult coloring books and colored pencils when Resident is in wheelchair. 2. 7/5/22 at 11:00 A.M., the Resident was observed by a Nurse lowering him/herself to the floor in front of their closet. The investigation failed to indicate if Dycem was in place on the wheelchair seat. An intervention identified to prevent future falls was: offer the option to fold clothing on overbed table instead of floor. 3. 7/23/22 at 10:00 A.M., the Resident was observed by a Nurse sliding off the wheelchair while trying to reach and arrange his/her stuff (left side of bed). The Resident landed on his/her buttocks and did not strike his/her head. The investigation indicated the following interventions were in place at the time of the fall: socks, Dycem. An intervention identified to prevent future falls was: non-skid strips to left side of bed. 4. 8/3/22 at 10:45 A.M., the Resident was found lying on his/her back on the floor next to the bed between the bed and closet. The Resident reported reaching for something across from the bed and slipped off the bed. The investigation indicated the following interventions were in place at the time of the fall: socks, Reacher was found on the floor. An intervention identified to prevent future falls was: Reacher velcroed to bedside table; to be kept on right side when Resident in bed. 5. 8/6/22 at 10:30 A.M., Resident found sitting on the floor in the bathroom near the sink. Resident told Nurse he/she slid out of the wheelchair. The investigation indicated the following interventions were in place at the time of the fall: socks, alarm. The investigation failed to indicate if Dycem was on the wheelchair seat at the time of the fall. An intervention identified to prevent future falls was: Dycem to the top of the wheelchair cushion. 6. 8/21/22 at 12:30 P.M., Resident was found kneeling on the floor in the bathroom in front of the wheelchair. The Resident said he/she slid out of the wheelchair while brushing his/her teeth. The investigation indicated the following interventions were in place at the time of the fall: socks, wheelchair, alarms. The investigation failed to indicate if Dycem was in place on the wheelchair seat and on top of the seat cushion at the time of the fall. An intervention identified to prevent future falls was: offer Resident assistance with oral care after lunch. 7. 8/30/22 at 1:00 P.M., Resident was found on the floor beside the bed on right side. Call light was in place, bed alarm was ringing. The Resident's left leg was outwardly rotated, lump on left side of head; sent to hospital for further evaluation. The investigation indicated the following interventions were in place at the time of the fall: socks, bed alarm. An intervention identified to prevent further falls was: Resident returned from the hospital with a diagnosis of a urinary tract infection. An intervention identified to prevent future falls was: continue frequent monitoring. 8. 11/21/22 at 10:30 A.M., Resident found on the floor at the bedside. The investigation indicated the Resident's roommate witnessed the fall and said the Resident removed the alarmed lap belt and fell to the floor. The investigation indicated the following interventions were in place at the time of the fall: lap belt. The investigation failed to indicate if any other interventions were in place at the time of the fall. An intervention identified to prevent further falls was: Resident to remain in hallway. 9. 12/1/22 at 8:45 P.M., Resident found lying on his/her stomach on the floor in the hallway near the nursing station. The investigation indicated the following interventions were in place at the time of the fall: socks, wheelchair. The investigation failed to indicate if Dycem, Velcro alarm seat belt or any other interventions were in place at the time of fall. Interventions identified to prevent further falls were: staff educated to keep floor around Resident as clean as possible to avoid attempting to pick up items, new order urinalysis, culture and sensitivity, psychiatric evaluation. During an interview on 12/30/22 at 9:15 A.M., the surveyor and Unit Manager #1 reviewed Resident #44's falls and medical record. Unit Manager #1 said most of the fall investigations were not complete and should have included what interventions were in place at the time of the falls to determine what interventions are effective and which are not. She said after reviewing each fall in detail, there were no effective interventions in place to prevent further falls. She said the Resident needs supervision because he/she has cognitive impairment, is impulsive, has poor safety awareness and tries to get up and walk frequently. On 12/30/22 at 9:35 A.M., Unit Manager #1 and the surveyor observed Resident #44 seated in a wheelchair in the hallway with an alarmed seat belt in place. Unit Manager #1 checked the wheelchair for placement of Dycem underneath and on top of the wheelchair cushion. She showed the surveyor the Dycem underneath the cushion, but said it was not in place on top of the cushion but should be.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and policy review, the facility failed to store food in accordance with professional standards for food service safety and maintain a sanitary kitchen environment. Findings include: Review of facility's kitchen policy titled Food Storage and Preparation, dated August 2017, and reviewed with no changes in September 2022, indicated but was not limited to the following: -All food items will be wrapped properly and tightly, or stored in clean, covered containers clearly marked, including the preparation date and discard date. -All temperature control for safety foods (TCS), ready to eat (RTE) or leftover foods will be labeled and dated with the date the food was prepared and a discard date. -All ready to eat salads or leftovers will be discarded within five calendar days from the preparation day, including day one. -Dry Storage: Once the package has been opened, the product should be stored in a clean sanitized tightly covered container, clearly labeled with common name of the food and dated. -Preparing salads: cover, label, and date (the date of preparation and the date to be consumed by or discarded) prior to storage. Review of facility's policy dated Food Safety for Your Loved One, not dated, indicated but was not limited to the following: -Food or beverages must be labeled and dated to monitor for food safety -Foods or beverages that have passed the manufacturer's expiration date will be thrown away. On 12/27/22 at 8:22 A.M., the surveyor observed the following in the main kitchen: -The inside of the plate warmer (a metal free standing device used to keep plates warm prior to plating the food) had debris including dust and crumbs inside where plates are stored. -The metal shelf used for drying pots and pans had stains and dust on the metal grates, which hold the pots and pans. On 12/27/22 at 8:30 A.M., the surveyor observed the walk-in refrigerator. The surveyor observed that various items with loosely (not tightly) unsealed plastic wrap over the top including rice labeled 12/22 (day 5), ham dated 12/25, pork labeled 12/20 (day 7) and uncovered ham not labeled/dated. There was raw bacon, unwrapped, unpackaged in a cardboard box exposed to the air. The surveyor observed plastic containers that held various food items with unsecure lids on them including macaroni dated 12/25, whipped cream open to air (no date) and a container with pears (no date). During an interview on 12/27/22 at 8:30 A.M., Dietary Aide #1 said the plastic containers do not seal, and the kitchen needs new ones. When shown the various items in the walk-in fridge, he said that the food in the box and with plastic wrap were not covered completely. He also said that it did not look like they were keeping up with the cleaning schedule for the fridge/freezer and was not sure who should have cleaned it. He said the dated items should have been thrown out after 3 days. During an interview on 12/29/22 at 8:40 A.M., the surveyor observed that the metal rack for drying pans had dust on and between the metal grates. The Food Service Director noticed the dust and said he would have it cleaned. He acknowledged that the second metal drying rack had rust throughout. On 12/29/22 at 9:00 A.M., the surveyor and the Food Service Director observed the plate warmer to have crumbs and dust inside, where the clean plates were kept. At this time the Food Service Director removed the inside part of the plate warmer and said he had not known this could be removed to be cleaned and it should have been part of the kitchen deep cleaning. On 12/29/22 at 9:37 A.M. the surveyor observed the following in the [NAME] 2 unit kitchenette: -Cream of wheat package was loose in a drawer (no expiration date or original box) -A partial loaf of sliced bread with best by 12/27/22, two days prior -The toaster had layers of crumbs inside and rust on top between the openings -A container of Tater Tots was in a disposable cup with a lid in a cabinet above the fridge. It was not dated and not refrigerated. On 12/29/22 at 9:45 A.M., the surveyor observed the following in the East 1 unit kitchenette: -The toaster had layers of crumbs inside and there was rust on the top between the openings. On 12/29/22 at 10:01 A.M., the surveyor observed the following in the East 2 unit kitchenette: -oatmeal bars with an expiration date of 12/21/22 (8 days past) above the sink cabinet During an interview on 12/29/22 at 3:20 P.M., while touring the units' kitchenettes, the Food Service Director said items should be thrown out on the expiration dates or the best by dates.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and policy review, the facility failed to establish and maintain an infection prevention and control program to help prevent the development and potential transmission of communicable diseases and infections in the facility. Specifically, the facility failed to: 1. Ensure that healthcare personnel performed hand hygiene per the facility policy during a clean dressing change for Resident #66; 2. Ensure that healthcare personnel performed hand hygiene, and donned (put on) and doffed (took off) the appropriate personal protective equipment (PPE) prior to entering resident rooms as indicated by posted signs outside of resident rooms; and 3. Follow infection control procedures while administering a COVID-19 Binax test. Findings include: 1. Resident #66 was admitted to the facility in November 2022 with diagnoses which included fracture of lumbosacral spine and pelvis. Review of the facility's policy titled Dry/Clean Dressings, revised September 2013, indicated but was not limited to the following: -Clean bedside stand. Establish a clean field. -Place the clean equipment on the clean field. Arrange the supplies so they can be easily reached. -Tape a biohazard or plastic bag on the bedside stand or use a waste basket below clean field. -Position resident and adjust clothing to provide access to affected area. -Wash and dry your hands thoroughly. -Put on clean gloves. Loosen tape and remove soiled dressing. -Pull glove over dressing and discard into plastic or biohazard bag. -Wash and dry your hands thoroughly. -Open dry, clean dressing(s) by pulling corners of the exterior wrapping outward, touching only the exterior surface. -Label dressing with date, time and initials. Place on clean field. -Using clean technique, open other products (i.e., prescribed dressing; dry, clean gauze). -Wash and dry your hands thoroughly. -Put on clean gloves. -Assess the wound and surrounding skin for edema, redness, drainage, tissue healing progress and wound stage. -Cleanse the wound with ordered cleanser. If using gauze, use clean gauze for each cleansing stroke. Clean from the least contaminated area to the most contaminated area (usually, from the center outward). -Use dry gauze to pat the wound dry. -Apply the ordered dressing and secure with tape or boarded dressing per order. Label with date and initials to top off dressing. -Discard the disposable items into the designated container. -Remove disposable gloves and discard into designated container. Wash and dry your hands thoroughly. -Reposition the bed covers. Make the resident comfortable. Review of current Physician's Orders for Resident #66 indicated: - Coccyx: Cleanse with normal saline wash, apply Santyl to wound bed followed by Calcium Alginate and cover with DPD every day shift for wound management, dated 12/17/22. On 12/28/22 at 3:35 P.M., the surveyor obtained permission from Resident #66 to be present during a wound dressing change and observed the following: -Nurse #3 performed hand hygiene and set up dressing supplies on the overbed table. -Nurse #3 removed the soiled dressing. -Nurse #3 removed her soiled gloves and put on a clean pair of gloves. -Hand hygiene was not performed after removing soiled gloves or prior to putting on new gloves. -Nurse #3 reached into her pocket for scissors and cut wound supplies. -Nurse #3 did not change gloves or perform hand hygiene after reaching into her pocket and scissors were not cleansed prior to use. -Nurse #3 cleansed wound, applied Santyl, applied calcium alginate, and applied dry protective dressing. -Nurse #3 then assisted Resident to a comfortable position and covered him/her. During an interview on 12/28/22 at 3:52 P.M., Nurse #3 said she did not perform hand hygiene during the dressing change because she did not bring any hand sanitizer into the room. During an interview on 12/29/22 at 3:47 P.M., the Director of Nurses (DON) said the expectation is for hand hygiene to be performed during wound care with glove changes. 2. Review of the facility's policy titled Isolation- Categories of Transmission-Based Precautions, revised October 2018, indicated but was not limited to the following: -When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door so that personnel and visitors are aware of the need for and type of precaution. -The signage informs the staff of the type of CDC (Centers for Disease Control) precaution(s), instructions for use of PPE, and/or instructions to see a nurse before entering the room. -Staff will follow PPE donning and doffing process outlined by CDC. Review of the posted signs indicated: -Enhanced barrier precautions: everyone must clean their hands, including before entering and when leaving the room. Providers and staff must also wear gloves and a gown for high-contact resident care activities. - Droplet barrier precautions: everyone must clean their hands, including before entering and when leaving the room. Make sure their eyes, nose and mouth are fully covered before room entry. Remove face protection before room exit. A. Resident #155 was admitted to the facility in December 2022 with diagnoses which included coronary artery bypass graft (CABG) after cardiac arrest and diabetes. On 12/28/22 at 11:27 A.M., the surveyor observed two precautions signs on the door entrance of Resident # 155's room indicating both enhanced barrier precautions and droplet precautions were required. On 12/28/22 at 11:33 A.M., the surveyor observed Social Worker #1 in Resident #155's room talking with the Resident. Social Worker #1 was wearing only a surgical mask. During an interview on 12/28/22 at 11:38 A.M., the surveyor and Social Worker #1 reviewed the posted precaution signs and Social Worker #1 said she should have put on eye protection prior to entering Resident #155's room. During an interview on 12/28/22 at 12:22 P.M., the Infection Control Nurse said the expectation for droplet precautions is all staff don eye protection, in the form of goggles or a disposable face shield, prior to entering the room. B. On 12/27/22 at 9:00 A.M., the surveyor made the following observations on the [NAME] 2 unit: -room [ROOM NUMBER] had three signs posted that included enhanced barrier precautions, contact precautions and droplet precautions. -Rooms 204, 205 and 207 had signs indicating enhanced barrier precautions were required. -room [ROOM NUMBER] had a sign indicating contact precautions were in place -room [ROOM NUMBER] had two signs, one for enhanced barrier precautions and the other for droplet precautions On 12/27/22 from 9:00 A.M. through 11:45 A.M., the surveyor observed staff entering and exiting several of the rooms with posted signs. The staff were observed serving meals, administering medication, and providing care. Staff were not consistently observed implementing the infection control practices during the observation. None of the staff were observed performing hand hygiene and did not consistently put on the required PPE prior to entering resident rooms. Observations included: -On 12/27/22 at 9:15 A.M., a staff member entered room [ROOM NUMBER], which had two signs posted on the door, one for enhanced precautions and the other for droplet precautions. The staff member did not perform handwashing and did not put on any PPE. When the staff member exited no handwashing was performed and she was observed with what appeared to be care items in her hands. The staff member was interviewed about the posted signs, and she said the signs were confusing and they did not help her provide care. She said she did not read the signs before entering a room with a sign. During an interview on 12/27/22 at 11:30 A.M., Unit Manager #3 was unable to state which Resident on her unit had an infection and what the posted signs meant. She said in the top drawer of the PPE cart the type of infection the resident had was identified. The surveyor checked the PPE carts outside of room [ROOM NUMBER] and 216 and no information identifying the infection was available in the drawer. On 12/28/22 at 8:20 A.M., the surveyor observed Nurse #5 approaching room [ROOM NUMBER] with a clipboard in her hand, a cup of water and a cup with medications in it. Nurse #5 stopped outside the door and juggled the items she was carrying and then placed them on top of the PPE cart. The Nurse did not perform hand hygiene before putting on the PPE. She was observed taking a gown out of the cart and tying the neck tie before putting it on. While she was tying the gown the gown was being dragged on the floor. She put the gown over her head and having tied it too tight had to pull and stretched the gown. After putting on the gown the Nurse took out a face shield for eye protection. She did not perform hand hygiene and was observed touching and adjusting the shield and her face mask multiple times without hand hygiene. The Nurse picked up the clipboard, water, and medication cup and entered the room. She put the items she was carrying down on a tray table and took gloves out of a glove container and placed the gloves in her pocket. She gathered the items and went to the Resident where she was observed putting on the gloves without hand hygiene and then administering medication and taking the Resident's blood sugar with a machine she took out of her pocket. During the direct care, the Nurse was observed leaning towards the Resident and her gown was dragging on the floor and on the Resident, as she had not secured the gown in the back. The Nurse was observed walking around the room touching the Resident and other surfaces. She was observed exiting the room without removing her PPE and then re-entering the room several times. When Nurse #5 exited the room, she removed her gown and face mask prior to exiting, but left the soiled gloves on. Nurse #4 was observed cleaning the glucometer and then putting the glucometer in her pocket. Then, the Nurse left the room and returned to the room with tissues for the Resident. The gloves had not been removed and were soiled. Nurse #5 was observed removing her gloves at her medication cart that was located at the nurses' station without performing hand hygiene. During an interview on 12/28/22 at 8:25 A.M., Nurse #5 said she did not know why the Resident in room [ROOM NUMBER] was on precautions and could not identify the infection. Nurse #5 said she did not understand all the signs that were posted on doorways. She said the Assistant Director of Nurses, or the Infection Control Nurse posts the signs and leaves the unit without an explanation. The surveyor observed Nurse #5 ask Nurse #4 if she knew why and what the Resident in room [ROOM NUMBER] had for an infection. Nurse #4 said she did not know. Nurse #4 said she would review the Resident's medical record, but after reviewing said she was unable to determine an infection or what the plan was. Nurse #5 and Nurse #4 were asked if they had received infection control education. Nurse #4 said there had been education earlier that day. She said education was not done frequently and the education received had been reviewing what was written on the signs. Both nurses said they had not learned anything. On 12/29/22 at 10:50 A.M., the surveyor observed a Physical Therapist walking a resident down the hall. The resident had been identified as requiring enhanced barrier precautions. The Physical Therapist walked with the resident around the unit and into a day room, where she had the resident perform exercises. The Physical Therapist was observed providing direct care to the resident and was not wearing a gown or gloves as required for direct care of a Resident that is on enhanced barrier precautions. 3. On 12/28/22 at 4:14 P.M., the surveyor observed Nurse #7 prepare a Binax (COVID-19 test) swab at the nurse's medication cart. Nurse #7 walked to a Resident's room with the Binax swab in her ungloved hand. Nurse #7 did not perform hand hygiene before putting on a pair of gloves and before entering the room. Nurse #7 exited the room with the Binax swab in her hand and placed the Binax swab directly on top of her medication cart. Nurse #7 was wearing the same gloves she entered the room with. When Nurse #7 removed her gloves, she put the soiled gloves directly into the trash container on her medication cart and did not perform hand hygiene. At 4:21 P.M., Nurse #7 announced the test negative and threw the swab directly into the trash container on the medication cart (not a hazard bin per protocol) and did not perform hand hygiene. During an interview on 12/28/22 at 4:22 P.M., Nurse #7 said that the Binax test takes 15 minutes for the results. She said she had not written down the time she took the swab and thought it had been 15 minutes. Nurse #7 said she had implemented the correct infection control practices during the Binax testing and was unaware that she did not follow infection control practices and protocol. During an interview on 12/29/22 at 11:00 A.M., the surveyor informed the Infection Control Preventionist that the staff, on the [NAME] 2 unit, did not have knowledge of what the precautions signs were for and were unable to communicate procedures and protocol for minimizing the spread of infectious diseases. The Infection Control Preventionist said she had done a little education. She said because of the survey she had become aware that staff did not understand the posted signs and how to implement infection control practices. At the time of the interview, the surveyor and the Infection Control Preventionist observed the Physical Therapist in the hallway talking with another staff member. The Resident who had been observed earlier was seated in the day room. The Physical Therapist was telling the other staff member she was not providing direct care and did not need to wear PPE. The surveyor observed the Infection Control Preventionist intervene and explain that a therapist providing treatment is considered a high contact activity and should use gowns and gloves when working with residents on enhanced precautions. The Infection Control Preventionist explained that this was according to the CDC (7/27/22). The Physical Therapist said she did not understand the signs that were posted and disagreed with CDC.