2. Review of the facility's policy titled Call Lights: Accessibility and Timely Response, dated as revised, included but was not limited to: -staff will ensure the call light is within reach of resident and is secured, as needed A. Resident #11 was admitted to the facility in March 2025 with diagnoses which included heart failure and urinary tract infection. Review of the MDS assessment, dated 3/5/25, indicated Resident #11 had moderately impaired cognition as evidenced by a BIMS score of 8 out of 15. On 4/6/25 at 8:11 A.M., the surveyor observed Resident #11 in bed with his/her call light button hanging over the headboard not within his/her reach. Resident #11 said he/she needed some water, and he/she was thirsty. Resident #11 said he/she did not know where the call button was. On 4/7/25 at 8:15 A.M. and 1:18 P.M., and on 4/8/25 at 5:02 P.M., the surveyor observed Resident #11 in his/her wheelchair next to the bed, the call light button was on the ground behind the Resident and was not within his/her reach. B. Resident #42 was admitted to the facility in June 2024 with diagnoses which included cerebral vascular accident (stroke) and hemiplegia (paralysis) affecting the left side. Review of the MDS assessment, dated 1/5/25, indicated Resident #42 had severe cognitive impairment as evidenced by a BIMS score of 5 out of 15, and had impaired range of motion on one side of his/her body. On 4/6/25 at 8:41 A.M., the surveyor observed Resident #42 in bed with the call light button not clipped or attached to the bed, on the floor on the left side of his/her bed. The call light button was not within his/her reach. On 4/8/25 at 8:04 A.M. and 9:34 A.M., the surveyor observed Resident #42 in bed with the call light button hanging up and over the side rail, dangling down to the floor on the left side of his/her bed and was not within his/her reach. During an interview on 4/8/25 at 9:34 A.M., Resident #42 said he/she had a stroke and could not use his/her left side and that his/her call light button should be clipped to his bedding so he/she could find it but he/she was unable to find the call light button at the time. During an interview on 4/8/25 at 9:30 A.M., CNA #2 said Residents #11 and #42 both know how to use the call light button. CNA #2 said the call light buttons should be in reach at all times when the residents were in their rooms. During an interview on 4/8/25 at 9:38 A.M., Nurse #1 said the call light buttons should be accessible to residents when they were in their room. During an interview on 4/8/25 at 11:01 A.M., Unit Manager #2 said all residents should have their call light button within reach at all times. During an interview on 4/8/25 at 4:38 P.M., the DON said residents should always have access to the call light button. Based on observations, interviews, and records reviewed, the facility failed to ensure reasonable accommodations were made for three Residents (#35, #11, and #42), of 17 sampled residents. Specifically, the facility failed: 1. For Resident #35, to ensure the Resident's augmentative and alternative communication (AAC) system (an electronic speech-generating device) was offered/utilized to enhance communication, socialization, and independence to control the television; and 2. For Residents #11 and #42, to ensure the call light button was accessible. Findings include: 1. Review of the facility's policy titled Activities of Daily Living (ADLs), undated, indicated but was not limited to the following: -Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: -communication (speech, language, and any functional communication systems); Review of the facility's policy titled Communication, undated, indicated but was not limited to the following: -Having good communication skills is essential to collaborating on teams with your fellow nurses and colleagues from other disciplines. It's also important to resident-centered care. Resident #35 was admitted to the facility in November 2023 with diagnoses which included multiple sclerosis (MS), quadriplegia, contracture of muscle - multiple sites, anxiety disorder, major depressive disorder, and adjustment disorder with depressed mood. Review of the Minimum Data Set (MDS) assessment, dated 2/16/25, indicated Resident #35 had intact cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15, and had impaired range of motion on both sides of his/her body. Review of Resident #35's current Care Plan indicated, but was not limited to, the following: COMMUNICATION: I have a communication problem related to MS. I am nonverbal. I can blink my eyes for once for yes and twice for no. I can participate in in multiple choice questions, answering with my eye movements. I have been given a call light that is flat and will be placed by my neck or hand (family states the hand sometimes is easier but I'm indecisive), to assist in my ability to communicate need for help. BIMS is 15. I may cry or be weepy around care; PRIOR Routine: I like my TV on ABC/Game shows or General Hospital. I was always a BIG Boston sports fan and enjoy watching the games. -I will be able to make basic needs known on a daily basis through the review date; -Anticipate and meet needs; -Assist resident on turning TV on to General Hospital/ABC/ or game shows; -COMMUNICATION: Allow adequate time to respond, Repeat as necessary, Do not rush, Request clarification from the resident to ensure understanding, Face when speaking, make eye contact, Turn off TV/radio to reduce environmental noise, Ask yes/no questions if appropriate, Use simple, brief, consistent words/cues, Use alternative communication tools as needed; -COMMUNICATION: Resident is able to: Blink once for yes, twice for no; -Discuss with resident/family concerns or feelings regarding communication difficulty; -Ensure/provide a safe environment: Call light in reach, Adequate low glare light, Bed in lowest position and wheels locked, Avoid isolation; -Monitor effectiveness of communication strategies; -Refer to speech therapy for evaluation and treatment as ordered. Review of the Resident's medical record indicated, but was not limited to, the following: - 12/16/24 Speech Therapy Progress Note: Reason for skilled services: -to assess and train in patient centered augmentative and alternative communication (AAC) system in order to enhance patient's quality of life by an improved ability to communicate basic wants/needs. -due to the documented physical impairments and associated functional deficits, without skilled therapeutic intervention, the patient is at risk for: decreased participation with functional tasks and social isolation. Further review of the Speech Language Pathologists' (SLP) assessments and notes indicated Resident #35 received Speech Therapy service regularly for several months until he/she was discharged from Speech Therapy services on 12/30/24. - 12/30/24 SLP Discharge Summary: -Highest practical level achieved; Resident able to utilize AAC device with high rate of accuracy with cues; -Short term goal, discontinue on 12/30/24: Patient will communicate needs/wants/desires and social responses/interactions using speech generating AAC system with 80% accuracy and with independence. -Short term goal, met on 12/15/24: Nursing and ancillary staff will participate and learn sequence, maintenance, and positioning of patient and device, and will demonstrate competence with 90% accuracy after 2-3 sessions. During an interview on 4/6/25 at 9:30 A.M., Resident #35 was lying in bed awake, the television was off. A screen attached to a stand was observed to be stowed several feet away from the bedside, not facing the Resident and not powered on. The Resident was observed with bilateral hand contractures and limited ability to move his/her head. The Resident was non-verbal but responded with eye movements, specifically looking upward to answer yes to the surveyor's questions. During an interview on 4/7/25 at 12:45 P.M., the following was discussed with Resident #35 and his/her mother: -Resident #35's mother said the Resident answers yes and no with eye movements. Additionally, she said the main means of communication was a letter board system which involved a laminated paper with several rows of letters used to spell words; for example, the Resident would be asked row one, row two, row three during which he/she would use eye movement to indicate which row of letters he/she selected. If he/she selected row one, then the person would recite the letters in row one during which the Resident would use eye movement to select a letter. This process would be used until a word is spelled and/or the Resident's message is understood. -Resident #35 communicated he/she had an AAC system that was rarely offered or set up for him/her. The Resident's mother said the communication screen allowed the Resident to use his/her eyes to spell words or select phrases in order to communicate with others. Additionally, the AAC system was able to connect to the television which allowed the Resident to independently control the television, including changing channels to select what he/she preferred to watch. -The Resident's mother said regular staff were proficient in using the letter board system, which tended to be the quickest and efficient way to communicate, but there were communication barriers with ancillary staff, agency staff, and other visitors who are not familiar with the Resident. She said these situations were frustrating, and Resident #35 communicated he/she felt upset and isolated when he/she could not communicate with others. -Resident #35 communicated that it had been months since he/she used the AAC system, as it had not been offered or there were connectivity issues. The Resident communicated he/she would like staff to offer the use of the AAC system to communicate and to fix the connectivity issues so he/she could control the television. Review of the Resident's SLP notes and assessments indicated the Resident had completed months of training on the AAC device and did not indicate a disinterest in utilizing the device. During an interview on 4/8/25 at 11:20 A.M., the SLP said she was unsure of how often Resident #35 used the AAC system in recent months. The SLP said her last assessment with the Resident was on 12/30/24 when the Resident was discharged from Speech Services because he/she met his/her level of proficiency on the AAC system. She said family and staff had been trained to set up the AAC system, and the plan was to keep it bedside to use when needed. The SLP said she performs weekly unit rounds and had not been notified of any concerns or issues regarding the Resident's use of the AAC system. During an interview on 4/8/25 at 11:40 A.M., Certified Nursing Assistant (CNA) #3 and CNA #4 said Resident #35 had a television and a screen on a stand in his/her room. Both CNAs said they did not know the purpose of the screen or how to use it. During an interview on 4/8/25 at 12:00 P.M., the Resident's mother said staff had been trained months ago on the AAC system, but due to staff turnover, there were current staff that were not educated on or trained to set up the AAC system. During an interview on 4/8/25 at 12:20 P.M., Unit Manager (UM) #1 said staff were trained on the AAC system in January and should know how to set up and facilitate the system. UM #1 said CNA #4 was the lead CNA and has worked on the unit since February; CNA #3 was still in training. During the same interview on 4/8/25 at 12:20 P.M., UM #1 said the connectivity to the television was inconsistent and kept failing which became frustrating and got to the point where it was easier to use the letterboard system instead. She said the facility's Information Technology (IT) worker had been in once to fix connectivity issues. UM #1 also said in order for Resident #35 to utilize the AAC system, he/she needed to be inclined in bed and he/she did not like to sit up except when eating and receiving medication. UM #1 said the Resident often cried out after being positioned to sit up and the AAC system was in place. During an interview on 4/8/25 at 12:30 P.M., Resident #35 and his/her mother communicated that the Resident needed to be positioned on an incline with a pillow to help with positioning in order to meet the gaze for the AAC system. They said staff would position the Resident to use the screen, but staff would not ask if he/she was comfortable before exiting the room. Resident #35 communicated he/she would speak out/make noise in response to being in an uncomfortable position. During an interview on 4/8/25 at 2:13 P.M., the Director of Nurses (DON) said Resident #35 was generally assigned regular staff who were familiar with him/her but he/she did get ancillary visitors including activities and their guests. The DON said she expected staff, especially the CNAs, to know about the AAC system, how to set it up and how to use it. The DON said her impression was that the Resident became frustrated by the process of using the AAC system, and she was unaware of connectivity issues which should be addressed if the Resident wanted to use the AAC system. The DON said she expected staff to offer the AAC system to the Resident to promote independence and communication and to confirm he/she is comfortable before leaving his/her room.

Based on observation, interview, and record review, the facility failed to provide services that met professional standards of practice for one Resident (#42), out of a 17 sampled residents. Specifically, the facility failed to follow physician's orders for a resting hand splint. Findings include: Resident #42 was admitted to the facility in June 2024 with diagnoses which included cerebral vascular accident (stroke) and hemiplegia (paralysis) affecting the left side. Review of the Minimum Data Set (MDS) assessment, dated 1/5/25, indicated Resident #42 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 5 out of 15, and had impaired range of motion on one side. Review of Resident #42's Physician's Orders indicated but was not limited to: -L resting hand splint on daily, at all times, except for activity of daily living (ADL) cares and meals, dated 4/3/24 Review of Resident #42's care plans indicated but were not limited to: -Focus: I have Hemiplegia/Hemiparesis related to CVA, date initiated: 3/5/24 -Interventions: [NAME] (put on) resting hand splint as ordered, date initiated 4/16/24 Review of Resident #42's Occupational Discharge Summary, completed by Occupational Therapist (OT) #1 on 7/3/24, indicated but was not limited to: -discharge recommendations and status: Splint and Brace Program Established/Trained: Left upper extremity hand splint with palm roll. Don/doff, wearing schedule written and in person teaching completed. On the following dates and times of survey, the surveyor observed Resident #42 not wearing his/her left hand splint: -4/6/25 at 8:41 A.M., he/she was in bed and was not receiving ADL care or consuming a meal -4/7/25 at 11:53 A.M., he/she was in bed and was not receiving ADL care or consuming a meal -4/7/25 at 1:18 P.M., he/she was sitting in his/her wheelchair in the family room was not receiving ADL care or consuming a meal -4/8/25 at 8:04 A.M. and 9:34 A.M., he/she was in bed and was not receiving ADL care or consuming a meal During an interview on 4/8/25 at 9:34 A.M., Resident #42 said he/she used to use a splint for his/her left hand but it had not been put on in a while. Resident #42 said every once in a while, a rolled-up cloth would be used but no brace or splint had been used in quite some time. During an interview on 4/8/25 at 9:30 A.M., Certified Nursing Assistant (CNA) #2 said Resident #42 did not have a splint for his/her left hand but sometimes the facility staff used a rolled washcloth. During an interview on 4/8/25 at 9:38 A.M., Nurse #1 said Resident #42 did not utilize a brace or splint for his/her left hand. Nurse #1 said on occasion a rolled-up face cloth was applied. During an interview on 4/8/25 at 10:55 A.M., OT #1 said Resident #42 was discharged from services in July 2024 and had not been seen since. OT #1 said the discharge recommendations included a left resting hand splint to be worn at all times except when bathing or eating. During an interview on 4/8/25 at 11:05 A.M., Unit Manager #2 said Resident #42 had a left hand contracture and was followed by therapy in the past. Unit Manager #2 said there was a left hand splint at some point. The surveyor and Unit Manager #2 reviewed Resident #42's physician's orders and Unit Manager #2 said there was an active order for a hand splint to be worn at all times except when receiving care or meals. Unit Manager #2 said the order did not carryover onto the Treatment Administration Record because of the way it was entered and that was probably why the hand splint was not being applied. During an interview on 4/8/25 at 4:38 P.M., the Director of Nurses (DON) said orders should be followed.

Based on observations, interviews, and record review, the facility failed to implement safe smoking for two Residents (#212 and #57), out of three sampled residents who smoked cigarettes. Specifically, the facility failed: 1. For Resident #212, to ensure a smoking assessment was completed prior to the Resident smoking at the facility, the Resident was provided the smoking policy, the smoking safety apron was worn as indicated on the care plan, and the Resident did not possess lighting materials (lighter); and 2. For Resident #57, to ensure a smoking assessment was completed prior to the Resident smoking at the facility and the Resident was provided and educated on the smoking policy. Findings include: Review of the facility's policy titled Smoking Policy and Procedures, dated as revised in May 2023, indicated but was not limited to the following: -it is the policy to provide a safe environment for residents, staff and visitors through the enforcement of a smoking policy designed to reduce risks to residents who smoke tobacco products -the smoking policy will be introduced by the admitting nurse; all residents expressing a desire to smoke will be assessed upon admission, when there is a change in status and quarterly -Once the facility has assessed the resident, safety interventions will be implemented and added to the resident's plan of care -residents will not share cigarettes -no residents will be allowed to keep lighters, matches, or other lighting materials on their person or in their rooms -a specific care plan will be designed to meet individual needs and all appropriate safety interventions will be included such as smoking apron -the {Facility} policy and procedure will be reviewed with all residents expressing the desire to smoke tobacco products and signed as acknowledgment that they have received and understand the policy 1. Resident #212 was admitted to the facility in April 2025 with a diagnosis of tobacco use. On 4/6/25 at 9:01 A.M., the surveyor observed Resident #212 tell staff he/she wanted to go outside to smoke and that he/she did not know what the smoking times were. On 4/6/25 at 10:25 A.M., the surveyor observed Resident #212 outside with the Scheduler smoking a cigarette. The Resident was observed wearing a smoking apron. The Resident was observed to ask another Resident if they would like a hit off of their cigarette, the Scheduler informed the Resident that this was not permitted. Review of the medical record indicated the Smoking and Safety assessment for Resident #212 was completed on 4/6/25 at 1:37 P.M., after the Resident had gone outside to smoke with the scheduler that morning. Review of the assessment indicated Resident #212 did not display any of the predetermined safety concerns (poor vision, balance problems, etc.). The safety note indicated the Resident was able to light their own tobacco products. The Smoking Care Planning section was not completed and the Clinical Suggestions section did not have any designations (apply smoking apron, set-up cigarette holder, staff to extinguish cigarette, etc.). Review of the care plan indicated Resident #212 utilized tobacco and would use a safety vest (a bright orange vest related to safety near a parking lot) and a smoking apron (a protective, fire-resistant apron designed to shield individuals, from burns caused by smoking materials) with a goal of adhering to the smoking policies at the facility. Review of the electronic and paper medical record failed to indicate Resident #212 had been provided and signed the facility Smoking Policy and Procedures. On 4/7/25 at 2:42 P.M., the surveyor observed Resident #212 go outside to the smoking area with Nursing Aide (NA) #1. The surveyor observed the NA holding a smoking apron in his hand, did not attempt to put it on Resident #212 and then hand Resident #212 a red lighter to light their cigarette. Resident #212 was smoking without wearing the smoking apron. During an interview on 4/7/25 at 2:45 P.M., NA #1 said the smoking apron wasn't really for Resident #212, it was more for a different resident who was in a wheelchair, but that resident was not outside at this time. He said the smoking apron was for smoke or something, that it was thick and that he really was not sure what it was for. On 4/7/25 at 3:54 P.M., the surveyor observed Resident #212 lying in bed with a red lighter next to them. During an interview on 4/7/25 at 4:05 P.M., Unit Manager #1 said Resident #212 had been admitted to the facility in the evening and then had gone out with family the next day. She said she could not be sure when the Resident first went outside for smoking but that the assessment had been completed in the afternoon on 4/6/25, after the surveyor observed the Resident smoking. She said Resident #212 had been verbally educated on the policy when the smoking assessment was completed and that the facility no longer had residents sign the policy and procedure. She said the policy was for every resident who smoked to wear a smoking apron and Resident #212 should have been wearing the smoking apron while smoking. She said the NA knows that the Resident should wear the apron. She said the NA should have taken the lighter back from Resident #212 and the Resident should not have a lighter in their room. During an interview on 4/8/25 at 11:00 A.M., the Director of Nurses said Resident #212 should have been assessed for smoking safety the first time they had gone out to smoke. She said the assessment should guide the nurses to determine which safety devices, if any, are needed and the smoking apron did not have to be worn for all residents, but should be based on the assessment. She said the NA should have followed the recommendation for the smoking apron and had the Resident wear it if it was indicated on the care plan. She said the staff should have reviewed the policy and procedures with the Resident and had the Resident sign it. 2. Resident #57 was admitted to the facility in February 2025 with diagnoses including but not limited to nicotine dependence, chronic obstructive pulmonary disease, and epilepsy. Review of the Minimum Data Set (MDS) assessment, dated 2/27/25, indicated Resident #57 had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 which indicated the Resident was cognitively intact. During an interview on 4/6/25 at 9:55 A.M., Unit Manager #1 said Resident #57 has decided to decline smoking cessation options and resume smoking. She said the Resident had been out smoking previously but decided he/she wanted to stop smoking and accepted a nicotine patch but as of yesterday he/she desired to smoke cigarettes again. During an interview on 4/6/25 at 10:05 A.M., Resident #57 said he/she desired to begin smoking again since the weather was improving and said the nurses have his/her cigarettes behind the nursing station. He/She said they planned to go out smoking two out of the three available smoking times today. On 4/6/25 at 10:35 A.M., the surveyor observed Resident #57 outside in the smoking area smoking a cigarette. During an interview on 4/6/25 at 10:36 A.M., Resident #57 said this was the smoking area and he/she had been out to this area before. Review of progress notes indicated a smoking and safety evaluation was completed on 4/8/25 two days after the Resident was observed smoking. Review of the plan of care related to Smoking Care Plan, date initiated 2/21/25, indicated the Resident will adhere to the smoking policies of the facility. Review of the medical record indicated on 4/7/25, one day after Resident #57 was observed outside smoking, the Resident had reviewed and signed the {Facility} Smoking Policy and Procedure which indicated but was not limited to: -All residents expressing the desire to smoke tobacco or e-cigarettes will be assessed upon admission to the center, when there is a change in status and quarterly. Once the facility has assessed the resident, safety interventions will be implemented and added to the resident's plan of care. During an interview on 4/8/25 at 11:39 A.M., Unit Manager #1 said the Resident decided they wanted to resume smoking. She said she was aware of the Resident smoking in the evening previously. She said the smoking evaluation was not completed prior to the Resident smoking. During an interview on 4/8/25 at 12:13 P.M., the Director of Nurses (DON) said the smoking and safety evaluation should be completed prior to smoking, and the policy should have been reviewed with Resident #57 prior to the Resident smoking.

Based on observations, interviews, and records reviewed, the facility failed to ensure one Resident (#56), out of 17 sampled residents, received care and treatment to promote healing of a pressure ulcer. Specifically, the facility failed to implement a treatment that included an antimicrobial wash to a Stage 4 pressure ulcer (full-thickness skin and tissue loss) on the sacrum (bone located at the base of the spine). Findings include: Resident #56 was admitted to the facility in December 2024 with diagnoses which included pressure ulcer of sacral region. Review of the Minimum Data Set (MDS) assessment, dated 3/16/25, indicated Resident #56 had one unhealed Stage 4 pressure ulcer that was present on admission. Review of Resident #56's Physician's Orders indicated but was not limited to: -wash sacral wound with normal saline, pat dry, apply Santyl and pack with calcium alginate then cover with foam dressing, initiated on 12/17/24 and discontinued on 2/7/25 Review of Resident #56's Treatment Administration Record (TAR) from December 2024 through February 2025 indicated his/her sacral wound treatment order had been completed as ordered. Review of Resident #56's Wound Evaluation and Management Summary report, dated 12/17/24, indicated the Wound Consultant recommended sacrum wound treatment included: -Wash with hypochlorous acid solution (Vashe, a wound cleanser that prevents bacterial growth) daily for 15 minutes, normal saline followed by calcium alginate and Santyl Review of the subsequent Wound Evaluation and Management Summary reports, with the following dates, indicated that the Wound Consultant's recommended sacral wound treatment did not change: -12/23/24 -12/31/24 -1/7/25 -1/14/25 -1/21/25 -1/28/25 -2/4/25 Further review of Resident #56's December 2024 through February 2025 TARs failed to indicate his/her sacral wound had been cleansed with hypochlorous acid solution (Vashe) as recommended by the wound consultant. Review of Resident #56's progress notes failed to indicate the provider was aware of and declined the Wound Consultant recommendation for Vashe. On 4/8/25 at 11:44 A.M., the surveyor left a message for the Wound Consultant with no return call. During an interview on 4/8/25 at 11:08 A.M., Unit Manager #2 said the Wound Consultant comes in weekly and completes a Wound Evaluation & Management Summary report which includes an assessment of the wound and the recommended treatment plan. Unit Manager #2 said the Wound Nurse and the Unit Manager review the Wound Evaluation & Management Summary report to make sure the recommended orders were in place. Unit Manager #2 said if the recommendation did not match the order the facility would get the recommendation approved by the physician and implement the orders. During an interview 4/8/25 at 11:47 A.M., Physician #1 said the facility had a wound specialist consultant who assesses the wounds weekly. Physician #1 said the Wound Consultant completes a report and provides the facility with his recommendations. Physician #1 said that because the Wound Consultant was the specialist the recommendations were generally approved and ordered. Physician #1 said if the recommendations were not approved there should be documentation in the record. During an interview on 4/8/25 at 2:53 P.M., Unit Manager #1 said the Wound Consultant comes in weekly and completes a Wound Evaluation & Management Summary report. Unit Manager #1 said the Wound Consultant includes his recommendations for the wound on the report. Unit Manager #1 said she goes in and reviews the reports to make sure accurate orders have been implemented. Unit Manager #1 said she did not recall the resident ever receiving Vashe and that part of the recommendation had never been implemented. Unit Manager #1 reviewed the medical record and said there was no evidence the provider had declined the Wound Consultant's recommendations. During an interview on 4/8/25 at 1:27 P.M., the Clinical Care Coordinator (Wound Nurse) said the Wound Consultant comes in weekly and assesses the wounds and determines the treatment plan. The Wound Nurse said the Wound Consultant completes the Wound Evaluation & Management Summary report and sends it to the facility. The Wound Nurse said once the facility receives the Wound Evaluation & Management Summary report the unit managers review it and ensure the recommendations have been implemented. The Wound Nurse said if the wound consultant recommendations were not implemented a note should be included in the medical record. During an interview on 4/8/25 at 4:38 P.M., the Director of Nurses said the Wound Consultant recommendations should be implemented.

Based on observation, interview, and record review, the facility failed to treat the Resident's clothing items with respect. Specifically, the facility failed to label the Resident's clothing to ensure prompt return of the clean laundry, for one Resident (#35), out of a total sample of 17 residents. Findings include: Review of the facility's policy titled Personal Property, undated, included but was not limited to the following: -The resident's personal belongings and clothing shall be inventoried and documented upon admission and as such items are replenished. -The facility will promptly investigate any complaints of misappropriation or mistreatment of resident's property. Resident #35 was admitted to the facility in April 2024 with diagnoses including: cellulitis (infection of skin) of the left leg, muscle weakness, and difficulty in walking. Review of the Minimum Data Set (MDS) assessment, dated 5/4/24, indicated that Resident #35 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Further review indicated Resident #35 required substantial to maximum assistance for upper body dressing and was dependent for lower body dressing. During an interview on 5/21/24 at 4:30 P.M., Resident #35 said all his/her clothes have been down in the laundry for at least a week and he/she has no clean clothes. Resident #35 said he/she has been wearing the same clothes for days. On 5/21/24 at 4:35 P.M., the surveyor, with Resident #35's permission, observed the closet and dresser, the closet had no clothes and the dresser had multiple unlabeled new white boxer shorts and pairs of socks. The surveyor observed Resident #35 to be wearing khaki shorts and gray top. During an interview on 5/23/24 at 10:28 A.M., Resident #35 said they finally brought back some of his/her clothes. Resident #35 was observed wearing the same clothes he/she was wearing on 5/21/24. Resident #35 said he/she had complained to the Aides (Certified nursing assistants-CNAs) multiple times about the missing clothing and nothing was done. On 5/23/24 at 10:30 A.M., the surveyor, with Resident #35's permission, observed the closet and dresser. There were three pairs of shorts and one shirt hanging in the closet and two shirts in the dresser. The clothes were not labeled with the Resident's name. On 5/23/24 at 10:35 A.M., the Director of Laundry came into Resident #35's room and looked at the clothes hanging in the closet and the dresser and said the clothes were not labeled and should have been. During an interview on 5/23/24 at 10:43 A.M., in the laundry room the Director of Laundry said all resident's clothes come down in a bin in the morning, they are washed and hung on the rack, and then delivered to the residents the following morning. The surveyor observed laundry personnel completing the process and when a garment was not labeled, it was brought to the back room and hung on a separate rack. The Director of Laundry said all residents' dirty clothes are put in one bin on the unit, so if they are not labeled, we have no idea whose clothes they are until someone comes looking for them. The surveyor viewed the back room and there were two racks of unlabeled resident clothing. He said laundry staff, or the nurses are supposed to label all the residents' clothing. During an interview on 5/23/24 at 10:58 A.M., Nurse #6 said laundry has been a problem for a long time, the clothes go down, but they don't come back for a long time. She said the families get really frustrated and you end up having to bring them down to the basement to look on the rack for the missing clothes. During an interview on 5/23/24 at 11:05 A.M., Unit Manager #1 said laundry has been a problem, the clothes go down and they take a while to come back. She said Resident #35's clothes were delivered by his/her Assisted Living Facility and she personally gave the clothes to laundry staff in a bag to be labeled. During an interview on 5/23/24 at 11:16 A.M., with the Director of Laundry and Unit Manager #1 present, Unit Manager #1 said Resident #35's clothes were given to laundry staff for labeling. The Director of Laundry said he doesn't know why the staff didn't label them; it delays the clothes getting back to the Resident.

Based on observation, interview, record review, and policy review, the facility failed to follow professional standards of practice for three Residents (#27, #216, and #35), out of a total sample of 17 residents. Specifically, the facility failed: 1. For Resident #27, to ensure medications were administered under direct supervision and not left at the bedside; 2. For Resident #216, to ensure medications were administered under direct supervision and not left at the bedside; and 3. For Resident #35, to ensure medications were administered in accordance with physician's orders. Findings include: Review of the facility's policy titled Administering Medications, dated December 2023, indicated but was not limited to the following: -Medications are administered in accordance with prescriber orders, including any required time frame. -The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. -Residents may self-administer their own medications only if the attending physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. Review of Lippincott Nursing Procedures, 8th edition. [Philadelphia: Wolters Kluwer, [2019], indicated but was not limited to the following: Safe Medication Administration Practices, General: -To promote a culture of safety and prevent medication errors, nurses must adhere to the five rights of medication administration; identify the right patient by using at least two patient-specific identifiers; select the right medication; administer the right dose; administer the medication at the right time; and administer the medication by the right route. -Address concerns about the order with the practitioner, pharmacist, or your supervisor if needed. -Document all medications administered in the patient's medication administration record (MAR) or treatment administration record (TAR) including the medication strength, dose, route of administration, and date and time of administration. If a medication wasn't administered, document the reason why, and interventions taken, practitioner notification, and the patient's response to interventions. -Handle medications brought by the patient from home as directed by your facility. 1. Resident #27 was admitted to the facility in September 2023 and had diagnoses including venous thrombosis and embolism, major depressive disorder, chronic kidney disease, congestive heart failure, atrial fibrillation, chronic obstructive pulmonary disease (COPD) (group of lung diseases that block airflow and make it difficult to breathe), hyperlipidemia, anxiety, neuropathy, gastro-esophageal reflux disease (GERD), and asthma. Review of the Minimum Data Set (MDS) assessment, dated 5/19/24, indicated Resident #27 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. During an observation with interview on 5/21/24 at 10:56 A.M., the surveyor observed a plastic medication cup on top of the Resident's overbed tray table with approximately 15 various whole pills inside. A nurse was not present in the room or in the immediate vicinity. Resident #27 said there were 17 pills inside the cup and forgot to take them that morning. Resident #27 said the nurse left them there for him/her to take, per his/her preference, and said, I think they're my nine o'clock pills. Review of current Physician's Orders indicated the following 9:00 A.M. scheduled medications: -Eliquis oral tablet (anticoagulant), give 2.5 milligrams (mg) by mouth, two times a day related to atrial fibrillation, 11/9/23 -Sertraline HCL (antidepressant) oral tablet 25 mg, give 3 tablets by mouth (total dose 75 mg) one time a day for depression, 9/12/23 -Lasix (furosemide) (diuretic) oral table 40 mg, give 1 tablet by mouth one time a day related to acute on chronic diastolic (congestive) heart failure, 10/10/23 -Amiodarone HCL (antiarrhythmic) oral tablet, give 200 mg by mouth one time a day related to atrial fibrillation, 9/29/23 -Aspirin 81 mg oral table chewable, give 1 tablet by mouth in the morning for blood thinner, 3/15/23 -Clopidogrel Bisulfate (Plavix) (blood thinner) oral tablet 75 mg, give 1 tablet by mouth one time a day related to hyperlipidemia, 11/18/23 -Colace Capsule (docusate sodium) (stool softener) 100 mg, give 1 capsule by mouth two times a day for constipation, 9/10/23 -Depakote (divalproex sodium) (anticonvulsant and treats mood disorder) tablet delayed release 125 mg, give 1 tablet by mouth one time a day for diagnosis of mood disorder, 3/15/23 -diltiazem HCL (calcium channel blocker) oral tablet 120 mg, give 1 tablet by mouth two times a day related to atrial fibrillation, 9/28/23 -gabapentin oral capsule 100 mg, give 1 capsule by mouth three times a day for neuropathy, 10/9/23 -iron (Ferrous Sulfate) tablet 325 mg (65 Fe) mg, give 1 tablet by mouth one time a day for supplement for iron deficiency, 9/10/23 -Magnesium oral capsule 400 mg, give 1 capsule by mouth one time a day related to COPD with acute exacerbation: chronic respiratory failure with hypoxia, 8/15/23 -Multivitamin oral tablet, give 1 tablet by mouth one time a day related to muscle weakness, 8/14/23 -pantoprazole sodium tablet delayed release 40 mg, give 1 tablet by mouth in the morning for GERD, 11/27/21 -Potassium Chloride ER oral tablet extended release, give 10 milliequivalent (mEq) by mouth one time a day for supplement, heart failure, 10/27/23 -theophylline (bronchodilator) ER tablet extended release 12-hour 300 mg, give 0.5 mg tablet by mouth one time a day for antiasthmatic and bronchodilator agents, total dose 150 mg, 10/12/21 Review of the May 2024 Medication Administration Record (MAR) indicated the above 5/21/24 medications were prepared and documented as being administered by Nurse #1. During an observation with interview on 5/22/24 at 4:13 P.M., the surveyor observed a plastic medication cup on top of the Resident's overbed tray table with one whole capsule inside. The Resident said it was gabapentin for tingles in his/her feet. No nurse was present inside the room or in the immediate vicinity. The Resident said it was his/her 2:00 P.M. medication and Nurse #6 left it with him/her to take on his/her own. Review of current Physician's Orders indicated the following: -gabapentin oral capsule 100 mg, give 1 capsule by mouth three times a day for neuropathy, 10/9/23 Review of the May 2024 MAR indicated the 5/22/24 2:00 P.M. gabapentin medication was prepared and documented as being administered by Nurse #6. Nurse #6 was not available for interview. Review of Resident #27's most recent Self-Administration of Medications assessment, dated 5/14/24, indicated the Resident was not approved for self-administration of medications and was not approved to keep medications at the bedside. During an interview on 5/23/24 at 11:22 A.M., Nurse #1 said Resident #27 was very independent and took their pills on his/her own. Nurse #1 said she left the pills with the Resident on 5/21/24 to take them on his/her own. Nurse #1 said the policy is to stay with the patient until all the medications are taken unless approved to self-administer them. She said she should have stayed with Resident #27 as the Resident was not approved to take them on his/her own. During an interview on 5/23/24 at 11:33 A.M., the Staff Development Coordinator (SDC) said the 5/14/24 self-administration evaluation indicated Resident #27 was not approved to self-administer medications. She said Nurse #1 should have stayed with the Resident until all the medications were administered. During an interview with the Administrator and SDC on 5/23/24 at 3:48 P.M., the SDC said the nurses should have stayed with Resident #27 to ensure the medications were all taken. She said if an assessment approves of self-administration, then the order would follow and, if approved, be specific for the types of medications that are approved for self-administration, but this was not the case for this Resident. 2. Resident #216 was admitted to the facility in May 2024 and had diagnoses including diabetes mellitus type II, hypertension, and GERD. Review of the MDS assessment, dated 5/9/24, indicated Resident #216 was cognitively intact as evidenced by a BIMS score of 15 out of 15. During an observation with interview on 5/21/24 at 9:27 A.M., the surveyor observed a plastic medication cup on top of the Resident's overbed tray table with three whole small white round tablets, one whole large white oval tablet, one whole yellow round tablet, and one whole green round tablet inside (six tablets total). No nurse was present inside the room or in the immediate vicinity. Resident #216 said nursing staff usually leave them with him/her to take by his/herself and preferred it that way. Review of current Physician's Orders indicated the following 8:00 A.M. and 9:00 A.M. scheduled medications: -desmopressin acetate (antidiuretic) oral tablet 0.2 mg, give 1 tablet by mouth two times a day for diabetes mellitus, 5/4/24 -Ferrous sulfate oral tablet 325 mg (65 Fe) mg, give 1 tablet by mouth one time a day for anemia, 5/4/24 -hydrocortisone oral tablet (steroid) 10 mg, give 1 tablet by mouth two times a day for colitis, 5/4/24 -metformin HCl (antidiabetic) oral tablet 1000 mg, give 1 tablet by mouth one time a day for diabetes mellitus, 5/4/24 -pantoprazole sodium oral tablet delayed release 40 mg, give 1 tablet by mouth two times a day for GERD, 5/4/24 Review of the May 2024 MAR indicated the above 5/21/24 medications were prepared and documented as being administered by Unit Manager (UM) #1. During an observation with interview on 5/23/24 at 8:35 A.M., the surveyor observed Resident #216 sitting at the side of the bed eating his/her breakfast meal. A plastic medication cup was observed on top of the Resident's overbed tray table with 1 whole large white oval tablet, 2 whole small white round tablets, 1 whole small green round tablet, and 1 whole small yellow round tablet inside (5 tablets total). No nurse was present inside the room or in the immediate vicinity. Resident #216 said UM #1 left them there for him/her to take on his/her own because he/she liked to take them after breakfast. Review of Resident #216's medical record failed to indicate a consent/request to self-administer medications, a completed admission Self-Administration of Medications assessment, or a physician's order to self-administer medications. During an interview on 5/23/24 at 10:40 A.M., UM #1 said she brought the Resident their pills that morning then left the room because the Resident had his/her hand out. UM #1 said she should have stayed with the Resident to ensure all the pills were swallowed. She said she assumed he/she took them, so she left the room. UM #1 said residents who wish to self-administer need to be assessed to determine if they know what the pills are, which is which, what they're for, when they need to take them, side effects if they miss them, and if they're able to swallow them safely. At 10:44 A.M., the surveyor reviewed Resident #216's medical record with UM #1 who said there was no consent or assessment completed upon admission to self-administer medications and no physician's order for it, but there should be if the Resident wished to self-administer. During an interview with the Administrator and SDC on 5/23/24 at 3:48 P.M., the SDC said the nurses should have stayed with Resident #216 to ensure the medications were all taken. She said if an assessment approves of self-administration, then the order would follow and, if approved, be specific for the types of medications that are approved for self-administration, but this was not the case for this Resident. 3. Resident #35 was admitted to the facility in April 2024 and had diagnoses including aortic valve disorder, transient ischemic attack (TIA), and cerebral infarction. On 5/23/24 at 9:00 A.M., the surveyor observed Nurse #4 prepare Resident #35's 9:00 A.M. medications as follows: 9:00 A.M. - Nurse #4 opened an over-the-counter (OTC) bottle of chewable aspirin 81 mg from the top drawer of her medication cart and added one whole tablet into a medication cup along with nine other medication tablets. Nurse #4 did not separate the chewable aspirin from the rest. Nurse #4 said the order wasn't for an enteric coated tablet as indicated on the label of a different OTC bottle she had first looked at, just a regular aspirin, so she gave a chewable tablet instead. 9:17 A.M. - Nurse #4 administered the medications to the Resident. Resident #35 swallowed all the tablets whole except for a Tums tablet which had been separated from the rest and chewed. Resident #35 swallowed the chewable aspirin whole. Review of current Physician's Orders indicated the following: -aspirin low dose oral tablet delayed release 81 mg, give 1 tablet by mouth one time a day for analgesics, 4/28/24 During an interview on 5/23/24 at 9:31 A.M., the surveyor reviewed the physician's orders with Nurse #4 who said the order was for a delayed release aspirin tablet. She said the Resident would have swallowed a delayed release tablet whole and, if given a chewable tablet instead, then the Resident should have chewed it, not swallowed it. She said the other aspirin bottle said enteric coated, not delayed release, so she gave the chewable instead. Nurse #4 said she should have clarified the order with the physician prior to giving the chewable tablet, which was an immediate release, not a delayed release tablet per physician's orders. During an interview with the Administrator and SDC on 5/23/24 at 3:32 P.M., the SDC said medications should be administered per physician's orders and if clarification was needed, then the nurse should have asked the physician. The SDC said medications should be administered per the 5 rights: right medication, right dose, right time, right patient, and right route.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review, the facility failed to ensure staff stored all drugs and biologicals used in the facility in accordance with currently accepted professional principles. Specifically, the facility failed: 1. For Resident #27, to ensure a bottle of Echinacea Complex (used for healthy immune function) tablets, Breztri Aerosphere inhaler, albuterol inhaler, and nasal spray bottle were stored in the medication cart and not left at the bedside; and 2. To ensure a schedule-IV controlled substance medication was maintained in a separately locked, permanently affixed compartment. Findings include: Review of the facility's policy titled Storage of Medications, revised [DATE], indicated but was not limited to the following: -Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light, and humidity controls. -The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Review of the facility's policy titled Administering Medications, dated [DATE], indicated but was not limited to the following: -Medications are administered in accordance with prescriber orders, including any required time frame. -Residents may self-administer their own medications only if the attending physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. 1. Resident #27 was admitted to the facility in [DATE] and had diagnoses including chronic obstructive pulmonary disease (COPD) (group of lung diseases that block airflow and make it difficult to breathe). Review of the Minimum Data Set (MDS) assessment, dated [DATE], indicated Resident #27 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. During an observation with interview on [DATE] at 10:56 A.M., the surveyor observed one large bottle of Echinacea Complex, 100 tablets, stored inside a wire container that was visible on the floor next to his/her bed. Resident #27 said it was his/hers from home and took one tablet in the morning and one tablet in the evening. On [DATE] at 11:07 A.M., the surveyor observed the following: -One large bottle of Echinacea Complex, 100 tablets, stored inside a wire container that was visible on the floor next to Resident #27's bed -One Bretztri Aerosphere (budesonide/glycopyrrolate/formoterol fumarate) aerosol inhaler, 160 micrograms (mcg)/9 mcg/4.8 mcg per inhalation with 110 inhalations remaining, stored on the Resident's overbed tray table. The inhaler was not stored in the packaging box. -One albuterol sulfate inhaler, 90 mcg/inhalation with 160 inhalations remaining stored on the Resident's overbed tray table. The inhaler was not stored in the packaging box. -One bottle of saline nasal spray, 1.5 fluid ounces, seal broken, stored on the Resident's overbed tray table. During an interview on [DATE] at 11:07 A.M., Resident #27 said he/she took the medications on their own and preferred it that way. The Resident said he/she used the Bretztri inhaler twice a day and the Albuterol as needed for COPD and asthma. The Resident said he/she had last used the Albuterol the day before and said staff knew. Resident #27 said the saline nasal spray was for a dry nose from the weather and the Oxygen and the nurses gave it to him/her a month or so ago. Review of current Physician's Orders indicated the following: -albuterol sulfate (bronchodilator) HFA aerosol solution 108 (90 base) mcg/act, 2 puff inhale orally every 4 hours as needed for shortness of breath or wheezing, [DATE] -Bretztri Aerosphere aerosol (budesomide-glycopyrrol-fumoterol), 160-9-4.8 mcg/act, 2 puffs inhale orally two times a day for COPD, use spacer, rinse mouth after each use, [DATE] Further review of physician's orders failed to indicate an order for the Echinacea tablets or saline nasal spray and failed to indicate an order for Resident #27 to store the medications at the bedside. Review of Resident #27's most recent Self-Administration of Medications assessment, dated [DATE], indicated the Resident was not approved for self-administration of medications and was not approved to store medications at the bedside. During an interview on [DATE] at 11:22 A.M., Nurse #1 said the Resident was very independent and takes medications on his/her own. She said she was aware the Resident kept inhalers in the room but was not aware of the bottle of Echinacea. Unit Manager (UM) #2 said there wasn't an order to keep medications at the bedside but should be if the Resident was approved to do so. During an interview on [DATE] at 11:33 A.M., the Staff Development Coordinator (SDC) said the [DATE] self-administration evaluation indicated Resident #27 was not approved to self-administer medications or keep medications at the bedside. She said there wasn't an order to store medications at the Resident's bedside. UM #2 said the Resident goes out of the facility with friends and sometimes purchases his/her own medications without telling staff. 2. During the 2nd floor medication storage room review on [DATE] at 7:57 A.M. with Unit Manager (UM) #2, the surveyor observed a locked metal box stored inside the medication refrigerator on the upper shelf. There was no lock on the refrigerator and the surveyor was able to easily remove the box from the refrigerator. The box was not permanently affixed to the shelf. Contents were heard inside. UM #2 said it was a narcotic box, but she didn't think there was anything stored inside of it and was unable to open it for surveyor review. Nurse #3 was present and was also unable to open the box. During an interview on [DATE] at 8:12 A.M., the Staff Development Coordinator (SDC) arrived at the medication storage room and opened the narcotic box alongside UM #2. Stored inside was one opened bottle of lorazepam (Ativan) oral concentrate 2 milligram (mg)/milliliter (ml), 30 ml, stored inside its packaging box. A pharmacy label for Resident #1A was affixed to the packaging box. The SDC and UM #2 said the Resident had expired a while ago and didn't know the lorazepam was still stored in the box. The SDC said the narcotic box should have been permanently affixed inside the medication refrigerator or the idea would be to have a locked refrigerator but there was no lock on it. The SDC said Resident #1A's liquid Ativan should have been accounted for then destroyed when the Resident expired but wasn't.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, document review, and policy review, the facility failed to ensure an accurate account of all controlled medications was maintained. Specifically, the facility failed to ensure an accurate account of lorazepam (Ativan) (schedule IV-controlled drug with low potential for abuse, treats anxiety) oral concentrate was maintained in the controlled substance accountability record book, as required. Findings include: Review of the facility's policy titled Controlled Substances, undated, indicated but was not limited to the following: -The facility shall comply with all laws, regulations, and other requirements related to the handling, storage, disposal, and documentation of Schedule II and other controlled substances. -Controlled substances must be counted upon delivery. The nurse receiving the medication, along with the person delivering the medication, must verify that correct amount is received. -If the count is correct, an individual resident-controlled substance record must be made for each resident who will be receiving a controlled substance. -Nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services/designee. Review of the facility's policy titled Discontinued Medications, undated, indicated but was not limited to the following: -Staff shall destroy discontinued medications or shall return them to the dispensing pharmacy in accordance with facility policy. During the 2nd floor medication storage room review on [DATE] at 7:57 A.M. with Unit Manager (UM) #2, the surveyor observed a locked metal box stored inside the medication refrigerator on the upper shelf. Contents were heard inside. UM #2 said it was a narcotic box, but she didn't think there was anything stored inside of it and was unable to open it for surveyor review. Nurse #3 was present and was also unable to open the box. During an interview on [DATE] at 8:12 A.M., the Staff Development Coordinator (SDC) arrived at the medication storage room and opened the narcotic box alongside UM #2. Stored inside was one opened bottle of lorazepam (Ativan) oral concentrate 2 milligram (mg)/milliliter (ml), 30 ml, stored inside its packaging box. A pharmacy label for Resident #1A was affixed to the packaging box. The SDC and UM #2 said the Resident had expired a while ago and didn't know the lorazepam was still stored in the box. The surveyor reviewed the controlled substance accountability record book, page 143, for Resident #1A's lorazepam 2 mg/ml oral concentrate with the SDC who said the book was not transcribed properly. She said there was a page change, and the medication did not follow so there was no account for the medication since [DATE], therefore, they didn't know the drug was still in the box. The SDC said the nurse who was responsible for carrying over the medication to another page no longer worked at the facility and the other nursing signature documented was illegible. The SDC said Resident #1A's liquid Ativan should have been accounted for then destroyed when the Resident expired but wasn't. During an interview on [DATE] at 3:51 PM., the SDC said on [DATE] Resident #1A's liquid Ativan was discontinued and the Resident was started on PO (by mouth) Ativan. She said the same day the Resident had been transferred to another room, switched nurses, and had a different narcotic book record. She said the liquid Ativan got lost in transition, but the discontinued date should have been transcribed in the narcotic book and the medication destroyed. She said the last dose was given on [DATE]. The SDC said there was not an accurate account of all controlled substances maintained in the facility.

Based on observation, policy review, and interview, the facility failed to follow their policy and 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 that one of two resident kitchenette refrigerators maintained a safe temperature of below 41 degrees Fahrenheit (°F). Findings include: Review of the facility's policy titled Food Receiving and Storage, undated, indicated but was not limited to the following: -Food shall be received and stored in a manner that complies with safe federal handling practices. -Food items and snacks kept on the nursing units must be maintained as indicated below: -All food items to be kept below 41°F must be placed in the refrigerator located at the nurse's station and labeled with a use by date. -Refrigerators must have working thermometers and be monitored for temperature according to state specific guidelines. Review of the 2022 Food Code by the U.S. Food and Drug Administration (FDA), revised 1/2023, indicated but was not limited to the following: FDA continues to recommend that food establishments limit the cold storage of time/temperature control for safety foods, ready-to-eat foods to a maximum temperature of 41°F. On 5/22/24 at 11:32 A.M., the surveyor observed the second-floor resident kitchenette and observed the internal temperature of the refrigerator to be 48°F. On 5/22/24 at 3:32 P.M., the surveyor and Food Service Manager (FSM) observed the second-floor resident kitchenette and made the following observations: -Internal temperature of the refrigerator was observed to be 45°F. -Internal temperature of carton of milk in the lower right drawer was 50.4°F. -Internal temperature of can of ginger ale on the second shelf was 48.2°F. During an interview on 5/22/24 at 3:35 P.M., the FSM said the refrigerator must be below 41°F and the product inside maintained below 41°F.

Based on record review, observations, and interviews, the facility failed to ensure a restraint assessment, with an evaluation for the least restrictive interventions, was completed for one Resident (#41), in a total sample of 18 residents. Specifically, the facility failed to assess and re-evaluate the use of a one-piece jumpsuit, which zippered up the back, and was unable to be removed by the Resident. Findings include: Review of the facility's policy titled Use of Restraints (undated) indicated the following: -Physical restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. -Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptom and to determine if there are less restrictive interventions that may improve the symptoms. -Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative. -Resident/sponsor shall be informed about the potential risks and benefits of all options under consideration, including the use of restraints, not using restraints, and the alternatives to restraint use. -Documentation regarding the use of restraints shall include: a) A description of the resident's medical symptoms that warrants the use of restraints. b) How the restraint use benefits the resident by addressing the medical symptom. c) The type of the physical restraint used. Resident #41 was admitted to the facility in May 2022 with a diagnosis of dementia with behavior disturbance. On 1/24/23 at 12:40 P.M., the surveyor observed Resident #41 wearing a light blue, one-piece jumpsuit with a back zipper and a snap flap covering the zipper pull. Review of the care plans indicated Resident #41 had a Focus of Behaviors including consuming and smearing feces. Review of the Interventions included to intervene as necessary to protect others, approach in a calm manner, divert attention, and remove from situation. There was no indication the one-piece jumpsuit was being used as an intervention. Review of the Social Services Progress Notes indicated on 7/22/22 the Social Worker spoke to the family member of Resident #41 regarding the Resident's behaviors and the family member agreed to buy one-piece jumpsuits. Review of the Nursing Progress Notes indicated the family member of Resident #41 brought in two one-piece jumpsuits on 8/3/22. Review of the paper and electronic medical record failed to indicate a restraint assessment had been completed to include the least restrictive interventions, alternatives utilized prior to the use of the jumpsuit, when the jumpsuit should be worn, or when to re-evaluate the use of the one-piece jumpsuit. Review of the medical record including Nursing and Social Service Progress Notes, Physician Progress Notes, Psychiatric Nurse Practitioner visits, and Behavior Monitoring Chart failed to indicate any behaviors of feces smearing and eating since 9/3/22, over four months prior. On 1/25/23 at 1:15 P.M., the surveyor observed Resident #41 wearing a regular shirt and a pair of pants. On 1/26/23 at 3:05 P.M., the surveyor observed Resident #41 wearing a regular shirt and a pair of pants. On 1/27/23 at 9:10 A.M., the surveyor observed Resident #41 sitting in a chair in his/her room wearing a light blue, one-piece jumpsuit with a back zipper and a snap flap covering the zipper pull. During an interview on 1/27/23 at 9:15 A.M., Unit Manager #2 said Resident #41 is unable to remove the one-piece jumpsuit and the jumpsuit keeps the Resident from picking and smearing feces by not allowing access to his/her body. Unit Manager #2 said the family had purchased two one-piece jumpsuits. Unit Manager #2 said the plan was for Resident #41 to wear the jumpsuits when they were available from the laundry. Unit Manager #2 said a restraint assessment was not completed for Resident #41.

Based on policy review, interview, and record review, the facility failed to develop and implement a person-centered plan of care for the use of glasses for Resident #49, out of a total sample of 18 residents. Findings include: Review of the facility's policy titled Comprehensive Person-Centered Care Plan, undated, indicated but was not limited to the following: - a comprehensive person-centered care plan that includes measurable objectives, to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident - the care planning process will facilitate the resident and/or family involvement, include an assessment of the resident strengths and needs, and incorporate the resident's personal preferences - the care plan will incorporate identified problem and express the resident's expressed wishes - identify problem areas and their causes and develop interventions that are targeted and meaningful to the resident Resident #49 was admitted to the facility in October 2021 with diagnoses that included metabolic encephalopathy. On 1/24/23 at 10:47 A.M., the surveyor observed that Resident #49 appeared distressed while saying he/she was looking for his/her glasses. He/she then held up a pair of green glasses frames that had no arms and said this is the broken pair and he/she was looking for the good pair. Nurse #2 intervened and verbally calmed and redirected the Resident, and said the Resident had numerous pairs of glasses because he/she breaks and loses them frequently. Review of the most current Minimum Data Set assessment, dated 1/8/23, indicated under Section B, Vision that Resident #49 had adequate vision with corrective lenses. During the following days and times, the surveyor observed the Resident without his/her glasses on: 01/25/23 at 7:28 A.M. - no glasses on his/her person and no glasses observed in the room 01/26/23 at 7:45 A.M. - no glasses on his/her person and no glasses observed in the room 01/26/23 at 3:11 P.M. - no glasses on his/her person, but glasses sitting on the overbed table next to a word search paper During an interview on 1/26/23 at 3:00 P.M., Nurse #2 said Resident #49 has numerous pairs of glasses that are not prescription, but cheaters (glasses bought over the counter). She said the Resident typically does not wear his/her glasses but carries them around with them and becomes distressed when he/she cannot find them. She said the family provides the Resident with numerous pairs for this reason. During an interview on 1/26/23 at 3:04 P.M., Unit Manager #1 said Resident #49 has numerous pairs of glasses that he/she frequently misplaces or breaks. She said the Resident has a very specific routine and carries the glasses with him/her throughout the day. On review of the current care plans, Unit Manager #1 said the Resident does not have a care plan indicating that he/she has glasses but that they should.

Based on observations, interviews, and record review, the facility failed to ensure activity of daily living (ADL) care was provided to maintain good personal grooming for two Residents (#48 and #51), in a total sample of 18 residents. Specifically, the facility failed to ensure: 1. Showers were provided to Resident #48; and 2. Nail care was performed for Resident #51. Findings include: 1. Resident #48 was admitted to the facility in October 2022 with a diagnosis of quadriplegia. A review of the most recent Minimum Data Set (MDS) assessment, dated 10/28/22, indicated the Resident was cognitively intact with a score of 15 out of 15 on the Brief Interview for Mental Status (BIMS). The MDS indicated the Resident was totally dependent of one staff for physical assist with bathing. During an interview on 1/24/23 at 2:20 P.M., Resident #48 said he/she had not had a shower in over a month. He/she said the showers were supposed to happen on Fridays and he/she was not sure why they had not gotten a shower. The surveyor observed Resident #48 to have oily looking hair. Review of the December 2022 and the January 2023 ADL Flow Sheets (documentation of ADL care by Certified Nursing Assistants) indicated Resident #48 had received a bed bath every day in December 2022 and January 2023 (through 1/24/23). Review of the Unit Shower Schedule indicated Resident #48 was scheduled to have showers on Fridays during the 3:00 P.M. to 11:00 P.M. shift. Review of the Certified Nursing Assistant (CNA) Assignment sheets indicated CNA #5 was assigned to care for Resident #48 on the following Fridays: 12/16/22, 12/30/22, 1/13/23, and 1/20/23. During an interview on 1/26/23 at 5:35 P.M., CNA #5 said Resident #48 was not scheduled to get showers on the 3:00 P.M. to 11:00 P.M. shift. The CNA and the surveyor reviewed the shower schedule, which indicated Resident #48 was scheduled to receive showers on Fridays during the 3:00 P.M. to 11:00 P.M. shift. CNA #5 said she had not given Resident #48 a shower in the two months she had worked at the facility and was unaware of the posted shower schedule. She said the process was for the word shower to be written next to a resident's name on the CNA Assignment sheets to indicate a shower was to be given during that shift. Review of the 3:00 P.M. to 11:00 P.M. CNA Assignment sheets for December 2022 and January 2023 failed to indicate the word shower next to Resident #48's name. 2. Review of the facility's policy titled Care of Fingernails/Toenails, undated, indicated nail care included daily cleaning and regular trimming. Resident #51 was admitted to the facility in October 2022. Review of the most recent Minimum Data Set (MDS) assessment, dated 10/17/22, indicated the Resident needed extensive assist of one staff person for personal hygiene. During an interview on 1/24/23 at 12:30 P.M., the surveyor observed Resident #51 to have long, jagged fingernails varying in length and the Resident said the staff keep saying they will cut his/her nails and then no one does. The surveyor observed some of the nails to have a brown substance under the nails. During an observation with interview on 1/25/23 at 3:22 P.M., the surveyor and Unit Manager #2 observed Resident #51 to have long, jagged fingernails with a brown substance under two nails on the left hand. Resident #51 said he/she would be okay with staff cutting his/her nails, but no one ever does. During an interview on 1/25/23 at 3:23 P.M., Unit Manager #2 said the nails of Resident #51 were too long. She said the staff usually file nails down, but the nails of Resident #51 looked as though they had not been filed down. During an observation with interview on 1/26/23 at 10:00 A.M., the surveyor observed Resident #51 to be in his/her room and continued to have long nails. Resident #51 said he/she was still waiting for someone to cut their nails.

Based on observation, record review, and interview, the facility failed to arrange for an audiology appointment for one Resident (#54), out of 18 sampled residents, to address the Resident's hearing loss. Findings include: Resident #54 was admitted to the facility in September 2022. Review of the Minimum Data Set (MDS) assessment, dated 12/18/22, indicated for Resident #54 the ability to hear was moderately difficult- the speaker has to increase volume and speak distinctly. During an attempt to interview on 1/24/23 at 10:14 A.M., Resident #54 was unable to hear the surveyor and continued to repeat the word what. When the surveyor pointed to the Resident's ears and repeatedly said the word hearing aid the Resident said he/she did not have any. Review of the HealthDrive Request for Services indicated an audiology consult request was completed on 9/22/22. Review of the Care Plans for Resident #54 indicated a focus of having a communication problem related to a hearing deficit with interventions of refer to audiology for hearing consult as ordered, dated 9/27/22. Review of a Nursing Progress Note, dated 9/22/22, indicated Resident #54 was hard of hearing and the Physician ordered for the Resident to have a hearing consult for possible hearing aids. Review of the medical record for Resident #54 failed to indicate the Resident had been seen by an audiologist in the four months since the Physician's request. During an interview on 1/27/23 at 9:05 A.M., the Director of Nurses said the staff had been able to communicate with Resident #54, despite the hearing loss, so they had not referred the Resident to the audiologist since the Physician's request for services four months prior.

Based on record review and interview, the facility failed to ensure that services were coordinated with the Hospice provider to implement the resident's plan of care as required in the provider contract agreement for two Residents (#12 and #26), out of a total sample of 18 residents. Specifically, the facility failed to ensure: 1. For Resident #12: a. an integrated care plan was developed to reflect services provided by both the Hospice provider and facility staff, and b. the Hospice provider's plan of care for Home Health Aide services was implemented and documented in the clinical record; and 2. For Resident #26: a. to ensure an integrated care plan was developed to reflect services provided by both the Hospice provider and facility staff, and b. the Hospice provider's plan of care for Home Health Aide services was implemented and documented in the clinical record. Findings include: Review of the Nursing Facility Services and Preferred Provider Agreement, dated January 15, 2018, included but was not limited to: - Hospice shall coordinate with the facility for ensuring the continuity of care for Hospices residents, upon admission. - Hospice and Facility will jointly develop and agree upon a coordinated Plan of Care. - The parties will collaborate in jointly coordinating the implementation, evaluation, and modification, as needed of the Plan of Care on an ongoing basis - Will identify which provider is responsible for performing the respective functions that have been agreed upon and included in the Plan of Care. Review of the facility's policy titled Royal Group Hospice Program, last revised July 2017, included but was not limited to: - The facility is responsible for ensuring coordinated plans of care for residents receiving Hospice services will include the most recent Hospice plan of care as well as the care and services provided by our facility (including the responsible provider and discipline assigned to specific tasks) to maintain the resident's highest practicable physical, mental, and psychosocial well-being. 1. Resident #12 was admitted to the facility in November 2022 with diagnoses including metastatic stage 4 breast cancer and respiratory failure. Review of Resident #12's clinical record indicated the Resident was admitted to Hospice care on 11/07/22. Review of the Resident's Hospice binder included an initial certification and frequency of Hospice services dated 11/07/22 through 2/3/23. -Skilled Nursing one to two times a week -Home Health Aide (HHA) two times a week -Social Work initial/determine frequency -Chaplain- Initial visit/determine frequency a. Review of the Interdisciplinary Care Plans included but was not limited to: -Focus: Resident requires hospice services related to metastatic stage 4 breast cancer, respiratory failure; admitted to Hospice services on 11/07/22 (CP initiated 11/15/22) -Interventions/Tasks: Air mattress in place check for placement and function every shift (11/21/22) -Allow resident/family to express feelings, concerns, and fears (11/15/22) -Be available for resident/family. Assure resident/family as needed (11/15/22) -Coordinate/communicate POC with hospice agency. Notify hospice of any change in condition (11/15/22) -Provide basic comfort measures (food/fluid/massage/pillows). Manage pain and other uncomfortable symptoms. Administer needs as needed for palliation. (11/15/22) -Resident's advanced directive wishes will be honored. -Goal: Resident/family or HCP will actively participate in decision making related to end stage disease. (11/15/22) b. Review of the Hospice provider's Facility Care Coordination document indicated a Notice to Facility Staff including but not limited to: -Hospice staff will make regular visits to the resident and will coordinate with your staff during each visit -Hospice staff will review and document in the resident's facility clinical record The Hospice care plan failed to identify the care and services that are needed, and specifically identify which provider is responsible for performing the respective functions that have been agreed upon to maintain the Resident's highest practicable physical, mental, and psychosocial well-being. 2.Resident #26 was admitted to the facility in September 2022 with diagnoses including Unspecified fracture of left femur, subsequent encounter for closed fracture, Pain in left hip, Muscle weakness (generalized), Other reduced mobility, and Personal history of COVID-19. Review of Resident #26's clinical record indicated the Resident was admitted to Hospice care on 09/14/22. Review of the Resident's Hospice binder included an initial certification and frequency of Hospice services dated 9/14/22 through 12/12/22. Hospice services were last recertified on 12/13/22 and signed by the Physician on 12/7/22 for the period 12/13/22 to 3/12/23 and indicated the following Hospice services: -Skilled Nursing one to two time a week and as needed -Home Health Aide (HHA) two times a week -Social Work initial/determine frequency -Chaplain- Initial visit/determine frequency a. Review of the Interdisciplinary Care Plans included but was not limited to: -Focus: Resident require hospice services related to fracture of the left femur; admitted to Hospice services on 09/14/22 (CP initiated 9/15/22) -Allow resident/family to express feelings, concerns, and fears (9/15/22) -Be available for resident/family. Assure resident/family as needed (9/15/22) -Coordinate/communicate POC with hospice agency. Notify hospice of any change in condition (9/15/22) -Provide basic comfort measures (food/fluid/massage/pillows). Manage pain and other uncomfortable symptoms. Administer needs as needed for palliation. (9/15/22) -Resident's advanced directive wishes will be honored. (9/15/22) -Goal: Resident/family or HCP will actively participate in decision making related to end stage disease. (9/15/22) b. Review of the Hospice provider's Facility Care Coordination document indicated a Notice to Facility Staff including but not limited to: -Hospice staff will make regular visits to the resident and will coordinate with your staff during each visit -Hospice staff will review and document in the resident's facility clinical record Review of the clinical record failed to include the Hospice Home Health Aide made any visits to Resident #26. The Hospice care plan failed to identify the care and services that are needed, and specifically identify which provider is responsible for performing the respective functions that have been agreed upon to maintain the Resident's highest practicable physical, mental, and psychosocial well-being. During an interview on 1/26/23 at 08:30 A.M., Unit Manager #1 said the facility did not develop an integrated care plan that outlines services provided by the Hospice staff such as nursing, HHA, and social work for Residents #12 and #26. She could not verify the Hospice HHA had come to provide service to Resident #12 from 1/23/23 to 1/27/23 and from 1/16/23 to 1/22/23. The Unit Manager said she did not know why there was no HHA documentation in either Resident #12 or Resident #26's clinical record to reflect implementation of the plan of care.

Based on interviews, record review, and policy review, the Consultant Pharmacist failed to identify and report any irregularities (use of a medication that is inconsistent with accepted standards of practice) for two Residents (#19 and #21) who were receiving prophylactic antibiotics. The total sample was 18 residents. Findings include: Review of the Antibiotic Stewardship Policy Interpretation and Implementation, undated, indicated the following: -If an antibiotic was indicated prescribers would include the following: drug name, dose, frequency, duration of treatment, start and stop date, number of days of therapy, route of administration and indication for use -During the drug regimen review, the Consultant Pharmacist will identify, and flag orders for antibiotics that are not consistent with antibiotic stewardship practices 1. Resident #21 was admitted to the facility in September 2011. Review of the care plans for Resident #21 indicated the Resident had a history of urinary tract infections (UTI) and included an intervention, initiated on 6/15/21, of taking Keflex (an antibiotic) prophylactically. Review of the Medication Administration Record (MAR) indicated Resident #21 had an order for Keflex 250 mg (milligrams) to be given one time per day for prophylactic UTI. The order was initiated on 1/16/21 (two years prior) and did not have an end date. Review of the monthly Medication Regimen Reviews by the Consultant Pharmacist indicated on 1/27/21 the Resident had a new order that month for Keflex, every day, prophylactically. Review of all following monthly Medication Regimen Reviews failed to include the reporting of irregularities related to the continued use of an antibiotic, without duration. 2. Resident #19 was admitted to the facility in July 2020. Review of the care plans for Resident #19 indicated the Resident had a history of recurrent urinary tract infections (UTI) and received antibiotic therapy for prevention. Review of the Medication Administration Record (MAR) indicated Resident #19 had an order for Keflex 500 mg, to be given one time per day prophylactically for cystitis (infection or inflammation of the bladder.) The order was initiated on 10/20/20 (2 years and 3 months prior) and did not have an end date. Review of the monthly Medication Regimen Reviews by the Consultant Pharmacist indicated all monthly Medication Regimen Reviews since 10/22/20 failed to include the reporting of irregularities related to the continued use of an antibiotic, without duration. During an interview on 1/27/23 at 10:42 A.M., the Consultant Pharmacist said during the medication regimen review for antibiotic use she will review the diagnosis for use to ensure the appropriate antibiotic is being used and ensure the duration of treatment is appropriate. She said for prophylactic antibiotics there is no research to indicate a benefit of continued use after one year, so she would recommend a review of the antibiotic at that time. She said she would like to review the records for Resident #19 and Resident #21 and would follow up. During an interview on 1/27/23 at 11:38 A.M., the Consultant Pharmacist said the use of Keflex for Resident #19 and Resident #21 was a preference by the physician. She said she had not made any recommendations to the prescribing physician regarding the continued use of antibiotics for both residents for two years.

Based on interviews, record review, and policy review, the facility failed to ensure that for two Residents (#19 and #21), out of a total sample of 18 residents, that each Resident's drug regimen was free from unnecessary drugs. Specifically, the facility failed to ensure antibiotics were administered for the appropriate duration and with adequate indications for use. Review of the Antibiotic Stewardship Policy Interpretation and Implementation, undated, indicated the following: -If an antibiotic was indicated prescribers would include the following: drug name, dose, frequency, duration of treatment, start and stop date, number of days of therapy, route of administration and indication for use -During the drug regimen review, the Consultant Pharmacist will identify, and flag orders for antibiotics that are not consistent with antibiotic stewardship practices 1. Resident #19 was admitted to the facility in July 2020. Review of the care plans for Resident #19 indicated the Resident had a history of recurrent urinary tract infections (UTI) and received antibiotic therapy for prevention. Review of the Medication Administration Record (MAR) indicated Resident #19 had an order for Keflex 500 milligrams (mg) to be given one time per day prophylactically for cystitis (infection or inflammation of the bladder.) The order was initiated on 10/20/20 (2 years and 3 months prior) and did not include an end date. During an interview on 1/26/23 at 2:20 P.M., Unit Manager #2 said Resident #19 had continued on an antibiotic for a history of UTIs, the Resident had not seen a Urologist, and she was not sure who would re-evaluate the use of the prophylactic antibiotic. 2. Resident #21 was admitted to the facility in September 2011. Review of the care plans for Resident #21 indicated the Resident had a history of urinary tract infections (UTI) and included an intervention, initiated on 6/15/21, of taking Keflex (an antibiotic) prophylactically. Review of the Medication Administration Record (MAR) indicated Resident #21 had an order for Keflex 250 mg to be given one time per day for prophylactic UTI. The order was initiated on 1/16/21 (two years prior) and did not have an end date. During an interview on 1/27/23 at 10:42 A.M., the Consultant Pharmacist said for antibiotic use she will review the diagnosis for use to ensure the appropriate antibiotic is being used and ensure the duration of treatment is appropriate. She said for prophylactic antibiotics for UTIs there is no research to indicate a benefit of continued use after one year. During an interview on 1/26/23 at 4:20 P.M., the Infection Control Preventionist said for prophylactic use of antibiotics the primary physician would usually defer to a specialist (Urologist or Infectious Disease). She said neither Resident #21 nor Resident #19 were seeing specialists related to their chronic UTIs or use of prophylactic antibiotics. She said she had not discussed the continued use of the antibiotics with the Physician and the medications had not been re-evaluated to determine the need for their continued use.

Based on interview and record review, the facility failed to ensure as needed (PRN) psychotropic medications had a documented rationale in the medical record indicating the need for the duration of the medication to continue beyond 14 days for one Resident (#44), out of a total sample of 18 residents. Findings include: Resident #44 was admitted to the facility in March 2022 with diagnoses including anxiety, obsessive compulsive disorder, and functional quadriplegia. Review of the January 2023 Physician's Orders for Resident #44 indicated but was not limited to the following: - Ativan (an anti-anxiety psychotropic medication) 1 milligram (mg) by mouth every eight hours PRN for increase agitation and anxiety with a start date of 11/15/22 and a discontinue date of 1/19/23 - Ativan 1 mg by mouth every eight hours PRN for increase agitation and anxiety until 1/31/23, with a start date of 1/19/23 Review of Resident #44's Medication Administration Record (MAR) for 1/1/23 through 1/25/23 indicated the Resident only received one dose of the PRN Ativan on 1/19/23 prior to the original order being discontinued. Review of the Pharmacy Recommendations for Resident #44 indicated a recommendation was made on 12/12/22 and 1/10/23 that indicated but was not limited to the following: - this Resident has an order for a psychoactive PRN Ativan which has been in place for greater than 14 days, without a stop date - guidelines require a 14-day initial review of all psychoactive agents being used PRN - after 14 days the use of this psychoactive PRN medication may be continued if it is determined that the benefit of treatment outweighs the potential/actual risks - please consider discontinuing this medication or scheduling this medication if necessary - if continuation of the PRN is necessary, please conduct a risk versus (vs.) benefit analysis to ensure the facility stays in compliance with the regulation Further review of the 12/12/22 Pharmacy Recommendation included a notation by the attending physician indicating continue indefinitely and was signed on 12/14/22. Review of the Physician's Progress Notes failed to indicate a risk vs. benefit analysis or rationale for the psychotropic PRN medication was completed. During an interview on 1/25/23 at 12:55 P.M., Unit Manager #1 reviewed Resident #44's medical record and said the December pharmacy recommendation was signed by the physician to continue indefinitely, but the follow up documentation was not in place, and the January 2023 pharmacy recommendation is a duplicate of the December 2022 recommendation regarding the use of the PRN Ativan. She said the facility practice is to re-evaluate the order with the physician and continue the PRN psychotropic medications for 30 days at a time. She reviewed the physician's progress notes and said there is no risk vs. benefit or rationale documented in the Resident's record that would indicate why the Resident needed to continue the medication on a PRN basis. During an interview on 1/25/23 at 2:11 P.M., the Director of Nurses said the expectation is for the physician to document a rationale and risk vs benefit analysis in the progress notes and then for the unit managers or a nurse to follow that up with a nurse's note in the medical record. She said if the documentation was not in place as it should be, then the expectations were not met.

Based on observations, interviews, and policy review, the facility failed to ensure two of two nourishment kitchenette refrigerators and one refrigerator in the first-floor dining room, were maintained in a safe and sanitary manner to prevent potential foodborne illness. Specifically, the facility failed to: a. Ensure three of three refrigerators were clean, and b. Ensure food brought in from family was labeled appropriately and staff foods were not stored in the residents' refrigerator. Findings include: Review of the posted Kitchen Policy sign, undated, indicated the following: Before storing any item in the refrigerator, please make sure that All of the following regulations have been met: 1. Resident's Name is clearly written on the item 2. Resident's Room number is written on the item 3. The date is clearly marked on the item No items are to be stored in the refrigerator for more than three days. All items that are mislabeled and/or stored incorrectly will be discarded. This refrigerator is for Resident items only. Therefore, any personal food, drink, etc., belonging to staff are to be kept in the breakroom only. These items will also be confiscated if they are found in this refrigerator. a. On 1/26/23 at 1:50 P.M., the surveyor observed the first-floor residents' refrigerator located in the kitchenette to be visibly stained on the door and the inside bottom. The inside top and bottom door had juice and food spilled, and it appeared rusted. Thereafter, the dining room refrigerator on the first floor was observed to have the same issues. On 1/26/23 at 2:05 P.M., the surveyor observed the second-floor resident refrigerator located in the kitchenette room to be stained on the inside bottom. During an interview on 1/26/23 at 02:30 P.M., Dietary Assistant #1, who reviewed all three refrigerators with the surveyor, agreed the refrigerators needed to be cleaned. b. On 1/26/23 at 1:50 P.M. on the first floor, the surveyor observed the following in the Kitchenette refrigerator: One bowl of chicken salad with no name, date, and room number One half gallon thickened Orange Juice (OJ) appeared decolorated and not labeled One bottle of natural concord grape syrup, opened and not labeled One Italian salad dressing, opened and not labeled One cocktail sauce and one Ensure Plus (nutritional supplement), opened and not labeled One half gallon of fruit punch juice, opened and not labeled On 1/26/23 at 2:10 P.M. on the second floor, the surveyor observed the following in the bottom of the refrigerator: One thickened OJ, opened and not labeled One bottle of natural concord grape syrup, opened and not labeled One Italian salad dressing, opened and not labeled One cocktail sauce and 1 Ensure Plus, opened and not labeled One half gallon of fruit juice, opened and not labeled Three bowls of garlic chicken, one opened and two unopened, had resident's name and room number, but were not dated In the freezer observed: One meat loaf dinner and one lasagna dinner, not labeled with resident's name and room number On 1/26/23 at 2:05 P.M., the surveyor inspected the First Floor Dining Room Refrigerator and observed: 1 zipper bag of shrimp, dated 1/20/23 (policy says discard after 3 days). On 01/26/23 at 02:24 P.M., the surveyor inspected the Second Floor Nourishment refrigerator in the Kitchenette and observed the following: Chicken Broth Classic, labeled with Resident's name, but no date or room number Half gallon of OJ, opened not labeled Two Greek yogurts, dated 1/25/23, but not labeled with Resident's name or room number. During an interview on 1/26/23 at 02:30 P.M., the Dietary Assistant said the residents' food brought from family/visitors should be verified and approved by staff. The Dietary Assistant said staff should follow the sign posted on the board in the Kitchenette. The Dietary Aide said after reviewing the refrigerators staff did not write the Resident's name, the Room numbers, and the Date the foods were stored in the refrigerators. During an interview on 1/26/23 at 2:40 P.M., Nurse #2 said the nourishment refrigerator in the dining room is always dirty. She said some of the staff stored their foods in there also.

Based on document review and interview, the facility failed to fully inform residents of their right to not enter into an arbitration agreement as a condition of becoming a resident for three Residents (#213, #211, and #212), out of a total of four sampled residents. Findings include: Review of the facility's Royal Health Group admission agreement, undated, indicated but was not limited to the following: The health care facility and the Resident agree that arbitration is the fairest and often quickest way to resolve a dispute using a neutral arbitrator agreed to by the parties in a convenient venue and without involving the court system. Although we will explain the agreement to you, you are encouraged to read Appendix E carefully, to ask any questions you have, and to consult with your attorney, family, or friends before choosing to accept the terms and conditions of the agreement to arbitrate. As a resident of the health care facility, you agree upon admission to execute the arbitration agreement found in Appendix E, which means that all disputes related to this agreement (with the exception of collections matters as described in the arbitration agreement), shall be resolved by binding arbitration and not by a judge or jury as more fully detailed in Appendix E. During the entrance conference on 1/24/23 at 8:05 A.M., the Administrator said the facility does have numerous residents who have signed arbitration agreements. During an interview on 1/27/23 at 9:50 A.M., Resident #213 said he/she signed so many forms the first few days of admission that he/she cannot recall any specific details, but an arbitration agreement does sound familiar. He/She said they could not recall having an arbitration agreement explained or whether or not it was a condition of admission to the facility. He/She said they do not have a copy of the arbitration agreement for review. During an interview on 1/27/23 at 10:01 A.M., Resident #211 said he/she does not remember discussing any type of arbitration agreement with the facility during the first few days of admission. He/she said no one explained what a binding arbitration agreement would entail, but he/she does know what the meaning of arbitration is. He/she said they would like to review the information but did not receive a copy. During an interview on 1/27/23 at 10:10 A.M., Resident #212 said he/she signed many forms and agreed to many things on the first few days of admission and recalls the word arbitration, however, does not remember anything specifically being discussed. He/She said they cannot review the information because they were not provided a copy. During an interview on 1/27/23 at 10:15 A.M., the admission Coordinator said admission packets are electronic and signed electronically by the residents or their representatives. She said she completed a readmission agreement with Resident #213 that is one page that indicates the Resident continues to agree to the agreement signed prior, as long as the agreement was completed within the last 30 days. She said they do not review the full admission agreement or any pieces of it at that time. She said the admission agreement was recently amended and she received an addendum to the arbitration section of the agreement on 1/25/23. She said she has not completed any admission agreements or discussed arbitration with anyone since the new agreement was updated on 1/25/23. She said to her knowledge since the documents are electronically signed the residents do not receive a copy of the agreement, but it is maintained electronically should they want to view it. Review of the medical record for Residents #213 indicated he/she was admitted to the facility in December 2022, and then re-admitted in January 2023 before the arbitration agreement was updated on 1/25/23. Review of the medical records for Residents #211 and #212 indicated they were admitted to the facility in January 2023 before the arbitration agreement was updated on 1/25/23. During an interview on 1/27/23 at 1:02 P.M., the Administrator reviewed the admission agreement with the surveyor and said the verbiage indicating as a resident of the health care facility you agree upon admission to execute the arbitration agreement could be confusing, but she does not remember ever having the arbitration agreement being a condition of admission. She said any clarification stating signing an arbitration agreement is not documented anywhere for Residents #211, #212, or #213, and therefore in her experience if something isn't documented it didn't occur. She said she was unaware the residents were not receiving copies of the information for their own review and use, and they should. She said the process was recently updated to include a clause that explicitly tells the residents they do not need to sign the arbitration agreement, but that information was not in place prior to the update the facility received on 1/25/23 and therefore it was fair to say that the residents and or their responsible parties may not have been aware that they were not required to sign the facility's arbitration agreement as a condition of admission.

2. Review of the facility's policy titled Dry/Clean Dressings, undated, indicated but was not limited to the following: - wash and dry hands thoroughly, put on clean gloves, remove soiled dressing - pull glove off over soiled dressing and discard - wash and dry hands thoroughly, open clean dressing supplies, wash hands thoroughly and put on clean gloves - assess the wound, cleanse with ordered cleanser and apply clean dressing, remove gloves, wash and dry hands On 1/25/23 at 1:10 P.M., the surveyor observed Nurse #3 perform a dressing change. Nurse #3 was observed to perform hand hygiene put on gloves and have her clean treatment ready in her hand while removing the disposable incontinence brief of Resident #44. Nurse #3 then proceeded to clean and place the new dressing over the wound. She was not observed to remove her gloves and perform hand hygiene after handling the Resident's incontinence brief which was observed to be soiled with urine. During an interview on 1/25/23 at 1:17 P.M., Nurse #3 said she should have changed her gloves and performed hand hygiene in between managing the soiled brief and cleansing the wound but did not. During an interview on 1/25/23 at 3:21 P.M., the Infection Preventionist said that her expectation of the nurses during a dressing change is to follow good infection control techniques including multiple instances of hand hygiene and glove changes. She was made aware of the surveyor observations and said Nurse #3 did not meet the facility policy or expectation of maintaining infection prevention practices during the dressing change process. 3. Review of the Centers for Disease Control and Prevention (CDC) guidance titled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDROs), dated July 12, 2022, indicated but was not limited to the following: - Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. - EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with wounds or indwelling medical devices, regardless of MDRO colonization status - in the majority of situations, EBP are to be continued for the duration of a resident's admission Review of the facility's policy titled COVID 2.0, undated, included but was not limited to the following: - precaution signs, which include required PPE, will be posted on residents' doors. Signs include enhanced, quarantine, and isolation. On 1/27/23 at 11:12 A.M., the surveyor observed an enhanced barrier precautions sign posted on the door of Resident #48's room. The sign included but was not limited to the following information: - 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 care activities On 1/27/23 at 11:22 A.M., the surveyor observed Nurse #5 and certified nurse assistant (CNA) #7 position Resident #48 for a wound dressing change. CNA #7 was holding Resident #48 on his/her right side leaning against CNA #7 for the 14 minute duration of the treatment, CNA #7 was not wearing an isolation gown. During an interview on 1/27/23 at 11:36 A.M., CNA #7 said she was not wearing a gown and that she was aware Resident #48 was on EBP and simply forgot to put on a new gown. She said repositioning the Resident and holding him/her to her was high contact care and she should have had a gown on but did not. During an interview on 1/27/23 at 11:39 A.M., Unit Manager #2 said that repositioning Resident #48 and holding him/her over for wound care to be completed by the nurse was high contact care and CNA #7 should have had a gown on since the Resident is on EBP, and the policy was not followed. Based on observations, interviews, and record review, the facility failed to follow infection control prevention practices. Specifically, the facility failed to: 1. Ensure all Personal Protective Equipment (PPE) was removed when leaving the room of COVID-19 positive residents; 2. Ensure effective hand hygiene practices were used throughout the dressing change process for Resident #44; and 3. Ensure staff used appropriate PPE when providing direct care to Resident #48, who was on enhanced barrier precautions. Findings include: 1. Review of the Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated 9/23/22, indicated when used solely for source control, any of the options listed above could be used for an entire shift unless they become soiled, damaged, or hard to breathe through. If they are used during the care of a patient for which a NIOSH-approved respirator or facemask is indicated for personal protective equipment (PPE) (e.g., NIOSH-approved particulate respirators with N95 filters or higher during the care of a patient with SARS-CoV-2 infection, facemask during a surgical procedure or during care of a patient on Droplet Precautions), they should be removed and discarded after the patient care encounter and a new one should be donned. During an interview on 1/24/23 at 8:35 A.M., the Infection Control Preventionist said the facility currently had 14 COVID-19 positive residents and the current protocol was for staff to wear an N95 mask throughout the unit, don (put on) a gown, gloves, and eye protection when entering the room of a COVID-19 positive resident and to doff (remove) the gown, gloves, and eye protection when exiting the room of the COVID-19 positive resident. She said the staff were keeping the N95s on throughout the unit, until they exited the unit. On 1/25/23 at 7:58 A.M., the surveyor observed Unit Manager #2 to exit the room of Resident #54, who tested positive for COVID-19 on 1/23/23. The Unit Manager was observed to doff the gown, gloves and goggles. She did not remove the N95 mask after leaving the COVID-19 positive room. During an interview on 1/25/23 at 8:03 A.M., Unit Manager #2 said the staff do not need to remove their N95 mask when leaving a COVID-19 positive room. She said the staff could wear the same N95 throughout the unit and into all resident rooms, regardless of their infection status. On 1/26/23 at 10:24 A.M., the surveyor observed Nurse #6 leave the room of Resident #11, who tested positive for COVID-19 on 1/19/23 and remained on isolation precautions. The surveyor observed Nurse #6 remove gown, gloves, goggles and then look in the PPE cart outside the room for a new N95 mask. The PPE precaution cart was observed to not have any N95 masks. The surveyor observed Nurse #6 walk through the unit, to the stairwell to get a new N95 mask. During an interview on 1/26/23 at 2:26 P.M., Nurse #6 said she had been told by the Infection Control Preventionist that she did not need to change her N95 mask leaving the COVID-19 positive room and that was why the masks were not in the PPE cart. On 1/26/23 at 11:05 A.M., the surveyor observed Certified Nursing Assistant (CNA) #4 exit the room of COVID-19 positive Resident #11 and remove her gown, gloves, and goggles. The CNA was then observed to walk down the hall to a room of a COVID-19 negative resident. During an interview on 1/26/23 at 3:40 P.M., the Clinical Coordinator said the facility did not have a shortage of PPE or N95 masks. During an interview on 1/26/23 at 4:00 P.M., the Infection Control Preventionist said she thought the N95 masks did not have to be changed because the facility was using them for source control.

Based on interview, record review, and policy review, the facility failed to implement their Antibiotic Stewardship program and ensure antimicrobial medications were used for an acceptable and prescribed indication and duration of time for two Residents (#19 and #21), in a total sample of 18 residents. Findings include: Review of the facility's policy titled Antibiotic Stewardship, undated, indicated but was not limited to the following: -Antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program -Prescribers will provide complete antibiotic orders including: drug name, dose, frequency, duration of treatment, start and stop date (or number of days of therapy) and indications for use -The DON (Director of Nurses) will monitor individual resident antibiotic regimens, including reviewing clinical documentation supporting antibiotic orders and compliance with start/stop dates and/or days of therapy. - The Infection Preventionist will audit, and the DON will provide feedback to providers on antibiotic prescribing practices - The Infection Preventionist will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics. Therapy may require further review and possible changes if: therapy was ordered for prolonged surgical prophylaxis. 1. Resident #21 was admitted to the facility in September 2011. Review of the care plans for Resident #21 indicated the Resident had a history of urinary tract infections (UTI) and included an intervention, initiated on 6/15/21, of taking Keflex (an antibiotic) prophylactically. Review of the Medication Administration Record (MAR) indicated Resident #21 had an order for Keflex 250 mg (milligrams) to be given one time per day for prophylactic UTI. The order was initiated on 1/16/21 (two years prior) and did not have an end date. 2. Resident #19 was admitted to the facility in July 2020. Review of the care plans for Resident #19 indicated the Resident had a history of recurrent urinary tract infections (UTI) and received antibiotic therapy for prevention. Review of the Medication Administration Record (MAR) indicated Resident #19 had an order for Keflex 500 mg, to be given one time per day prophylactically for cystitis (infection or inflammation of the bladder.) The order was initiated on 10/20/20 (2 years and 3 months prior) and did not have an end date. During an interview on 1/26/23 at 2:20 P.M., Unit Manager #2 said Resident #19 had continued on an antibiotic for a history of UTIs, the Resident had not seen a Urologist and she was not sure who would re-evaluate the use of the prophylactic antibiotic. During an interview on 1/27/23 at 10:42 A.M., the Consultant Pharmacist said for antibiotic use she will review the diagnosis for use to ensure the appropriate antibiotic is being used and ensure the duration of treatment is appropriate. She said for prophylactic antibiotics for UTIs there is no research to indicate a benefit of continued use after one year. Review of the manufacturer's guidelines for use indicated prolonged use of Keflex may result in the overgrowth of non-susceptible organisms. During an interview on 1/26/23 at 4:20 P.M., the Infection Control Preventionist said for prophylactic use of antibiotics the primary physician would usually defer to a specialist (Urologist or Infectious Disease). She said neither Resident #21 nor Resident #19 were seeing specialists related to their chronic UTIs or use of prophylactic antibiotics. She said she had not discussed the continued use of the antibiotics with the Physician and the medications had not been re-evaluated to determine their appropriate use, per the facility Antibiotic Stewardship program.