**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews for one of three sampled residents, (Resident #1) who was re-admitted with multiple pressure injuries, the Facility failed to ensure nursing staff provided care and services that met professional standards of practice related to timely follow-up on provider recommendations for wound care and accurate transcription of treatment orders.Findings include:Review of the Facility Policy titled Consults: Health Drive, Wound MD, and other outside Consultants, dated as last updated 08/01/25, indicated that residents who have consultants will have recommendations reviewed by attending MD/NP/PA/LIP.The Policy further indicated the staff RN/LPN will review consultation reports and recommendations with the prescriber, prescriber will decide on if recommendations are followed and orders obtained, nursing will document new orders and order supplies if necessary, and nursing will document per house protocol.Review of the Facility Policy titled Verbal Orders, dated as last updated 08/01/23, indicated that the individual receiving the verbal order will read the order back to the practitioner to ensure that the information is clearly understood and correctly transcribed.Resident #1 was admitted to the Facility in March 2025, diagnoses include diabetes mellitus with neuropathy (weakness and numbness due to nerve damage), peripheral vascular disease, and hemiparesis (weakness on one side of the body).Resident #1 had an acute 10-day Hospital stay and was re-admitted to the facility on [DATE].Review of Resident #1's Wound Evaluation and Management Summary, dated 05/29/25 (written by Wound Physician), indicated he/she had 4 separate pressure injuries with 4 recommended treatments as follows;1) Unstageable due to necrosis (dead tissue) sacrum full thickness pressure injury with recommended treatment nursing to apply Calcium Alginate (promotes wound healing forming a gel and absorbs wound fluids) once daily and as needed and Santyl (removes dead tissue from wounds so they can heal) apply one daily and as needed (PRN).However, review of Resident #1's Treatment Administration Record (TAR) dated 05/28/25 through 07/02/25, indicated that nursing was providing a treatment to his/her sacrum according to the original physician's order from 05/13/25, indicating that nursing apply NSW followed by Calcium Alginate and cover with boarder gauze daily and PRN.Further review of Resident #1's Medical Record, including but not limited to the TAR, Medication Administration Record (MAR), Physician's Orders, and Care Plans, indicated that there was no documentation to support a new order had been obtained for Resident #1's Stage 4 sacral pressure injury upon readmission, even after the Wound Physician made new recommendations, and nursing continued to follow an old and incomplete Physician's Order, dated 05/13/25. Review of Resident #1's Physician's Orders, dated 06/03/25, indicated nursing to treat area with normal saline wash (NSW) followed by (F/B) Calcium Alginate and cover with border gauze daily and PRN to sacrum wound.Review of Resident #1's Physician's Orders, dated 07/03/25, indicated nursing to apply Santyl Ointment 250 units per gram (gm) to sacrum topically one time a day for wound care.Further review of Resident #1's Medical Record indicated that there was no documentation to support that the treatment that had been recommended on 05/29/25, had been accurately transcribed until 07/03/25.2) Stage 3 (deep wound that extends through the layers of skin and subcutaneous tissue) pressure injury to the right heel full thickness with recommended treatment for nursing to apply Xeroform (allows hydration in the wound to promote healing) gauze applied once daily and as needed with gauze island border applied once daily and as needed.Review of Resident #1's Physician's Orders, dated 07/03/25, indicated nursing to treat area with a NSW, pat dry, apply Xeroform (cut to fit wound bed) and cover with boarded gauze once daily and as needed to his/her right heel.Review of Resident 1's Medial Record, including but not limited to the MAR, TAR, Physician's Orders, and Care Plans, indicated that there was no documentation to support the dressing that had been recommended by the Wound Physician on 05/29/25, had been obtained until 07/03/25.3) Stage 3 pressure injury to the right buttocks full thickness with recommended treatment for nursing to apply Silver Sulfadiazine (used to prevent wound infections) once daily and as needed, peri (surrounding edges) wound treated with house barrier cream apply once daily and as needed; and4) Stage 3 pressure injury to the left buttocks full thickness with recommended treatment for nursing to apply Silver Sulfadiazine once daily and as needed, peri wound treated with house barrier cream apply once daily and as needed.Review of Resident #1's Physician's Orders, dated 05/29/25, indicated nursing to treat area with Silver Sulfadiazine Cream 1 percent (%) to buttocks topically, on the day shift for wound care and mix with House Barrier Cream.Review of Resident #1's Physician's Orders, dated 06/05/25, indicated nursing to treat area with Silver Sulfadiazine Cream 1 percent (%) to Left buttocks topically, on the day shift for wound care and mix with House Barrier Cream.Review of Resident #1's Medical Record, including but not limited to the TAR, MAR, Physician's Orders, and Care Plans, indicated that there was no documentation to support that each pressure injury, left buttocks and right buttocks, had a specific treatment that had been recommended on 05/29/25 by the Wound Physician and had not been transcribed accurately.Further review of the Wound Summary indicated additional recommendations to include off-load wounds, reposition per Facility Protocol, and Float Heels in bed.Review of Resident #1's Medical Record, including but not limited to the TAR, MAR, Physician's Orders, and Care Plans, that other than one Nurse Entry on 07/13/25, that there was no documentation to support that Resident #1's heels were ever elevated. Review of Resident #1's Wound Evaluation Management Summary, dated 07/10/25, 07/17/25, and 07/24/25 indicated it included a new recommendation, to apply a Pressure Off-Loading Boot to his/her right heel.Review of Resident #1's Medical Record indicated that there was no documentation to support, and pressure off-loading boot was ever applied to help with the healing of Resident #1's right heel pressure injury. During a telephone interview on 09/08/25, Nurse #1 said that on 05/28/25, she had completed the re-admission skin assessment for Resident #1 and said she does not recall obtaining any new orders for his/her wounds. Nurse #1 said that she did remember that Resident #1 had an existing pressure injury to his/her bottom and had a treatment in place before he/she went to the hospital and Nurse #1 said that she thinks the Unit Manager is responsible for obtaining the physician's orders upon a resident's readmission and that nursing should have obtained 4 new Physician's Orders upon admission for his/her wounds. During an interview on 09/02/25 at 2:29 P.M., Nurse #2 said that she remembered Resident #1 had multiple pressure injuries upon his/her return from the hospital, however said she does not recall ever getting recommendations from the Wound Physician for Resident #1.Nurse #2 said that the Wound Physician does not write orders and said he rounds with the Unit Manager weekly and the Unit Manager is responsible for reporting the recommendations to his/her physician and obtaining any treatment orders for the resident. During a telephone interview on 09/08/25 at 12:09 P.M., the Former Unit Manager said that it was her responsibility to round with the Wound Physician weekly and once the Wound Physician uploaded his progress notes (before he leaves the Facility), she would review any recommendations and bring them to the Providers' attention and obtain any new Physician's Orders.The Former Unit Manager said that there should have been separate and accurate physician's orders for each of Resident #1's pressure injuries and does not know what happened.During an interview on 09/02/25 at 4:02 P.M., the Interim Director of Nurses (DON) said that he was not aware that recommendations made by the Wound Physician had not been followed through with or that Resident #1's Physician's orders were not all transcribed accurately.The Interim DON said that it is the Facility's expectation that any recommendation received by a third-party provider, including a Wound Physician, must be reviewed timely with the resident's provider and new and accurate orders are to be obtained.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1) who had severe cognitive impairment, the Facility failed to ensure Resident #1 was free from the use of a physical restraint, when on 05/06/25, Certified Nurse Aide (CNA) #1 used a sheet to restrain Resident #1 in his/her wheelchair to prevent him/her from falling. Findings include: Review of the Facility's Policy, titled, dated as revised 08/01/23, indicated the following: -physical restraints are defined as any manual method of 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, and -restraints shall only be used to treat the resident's medical symptoms and never for discipline, staff convenience, or for the prevention of falls. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated as submitted, 05/12/25, indicated that on 05/06/25, Resident #1 was observed sitting in his/her room in his/her wheelchair with sheet wrapped around his/her waist. The Report indicated that the Facility questioned the inappropriate use of a restraint, and that Resident #1 had no injuries. Review of the Facility's Investigation Report, undated, indicated that on 05/06/25 around 7:00 A.M., staff were completing walking rounds and noticed Resident #1 in his/her room in his/her wheelchair with a restraint (bed sheet) across his/her waist. The Report indicated that the restraint was removed immediately, Resident #1 was assessed, no injuries were noted and he/she was not in distress. Resident #1 was admitted to the Facility in December 2021, diagnoses included dementia and generalized anxiety disorder. Review of Resident #1's Quarterly Minimum Date Set (MDS) assessment, dated 03/22/25, indicated he/she had severe cognitive impairment and was dependent on staff for care and mobility. Review of Resident #1's Falls Care Plan, reviewed and renewed with his/her Quarterly MDS on 03/22/25, indicated Resident #1 required assistance with ambulation to prevent falls. During an interview on 05/22/25 at 10:26 A.M., CNA #1 said during his overnight shift that started on 05/05/25 at 11:00 P.M., and ended on 05/06/25 at 7:00 A.M., Resident #1 did not sleep and made repeated attempts to stand up and walk by him/herself. CNA #1 said Resident #1 was unsteady on his/her feet, and he was afraid he/she would fall, so he stayed with Resident #1 throughout his shift. CNA #1 said that around 6:50 A.M., after he dressed Resident #1, he left him/her in his/her wheelchair while he provided care to Resident #1's roommate. CNA #1 said he was in the room with Resident #1 while he/she had the sheet tied around him/her and only left the room for a brief period of time. CNA #1 said he then returned to Resident #1's room to remove the sheet from around him/her at the end of his shift (7:00 A.M.), when a staff member (CNA #2) noticed the restraint and reported it to the Assistant Director of Nurses (ADON). CNA #1 said he placed the sheet around Resident #1 for his/her safety because he had to provide care to other residents. CNA #1 said he made a bad decision. CNA #1 said he had three residents on his assignment that night that were trying to get up and walk on their own, and he was just trying to keep them safe. During an interview on 05/20/25 at 12:20 P.M., (which included a review of her written witness statement, dated 05/06/25), CNA #2 said she walked into Resident #1's room on 05/06/25 in the morning and saw Resident #1 wheeling him/herself around in his/her wheelchair, when she noticed a sheet around Resident #1's waist, wrapped around the wheelchair armrests, and tied behind his/her wheelchair. CNA #2 said Resident #1 was not in distress, and that she called the ADON (who was on Resident #1's unit at the time), into Resident #1's room so she (ADON) could see the restraint. CNA #2 said the ADON told her to remove the restraint immediately. CNA #1 said he made a bad decision. During an interview on 05/23/25 at 9:56 A.M., the ADON said that on 05/06/25, she was on Resident #1's unit in the early morning (exact time unknown), but said she starts her shift at 7:00 A.M., and begins rounding on the units immediately. The ADON said CNA #2 told her that she saw a sheet tied around Resident #1's waist and wheelchair. The ADON said she went into Resident #1's room and saw him/her (Resident #1) sitting in his/her wheelchair with a sheet in front of his/her waist and tied behind the wheelchair. The ADON said she told CNA #2 to remove the restraint immediately. The ADON said when observed and assessed Resident #1, he/she was not in distress, he/she had not been attempting to stand while the restraint was on, that he/she had no marks on his/her skin and was at his/her baseline. The ADON said she reported the restraint to the Director of Nurses immediately. During an interview on 05/20/25 at 2:54 P.M., the Director of Nurses (DON) said that on 05/06/25, the ADON told her that she and CNA #2 saw a sheet around Resident #1's waist and tied behind his/her wheelchair. The DON said she determined that the sheet was a restraint, and she suspended CNA #1. The DON said Resident #1 had been trying to stand frequently throughout the night and that CNA #1 should have asked other staff for help, but instead he made a bad decision when he used a sheet to restrain Resident #1 in his/her wheelchair to keep him/her from falling. On 05/20/25, the Facility was found to be in Past Non-Compliance and provided the surveyor with a plan of correction which addressed the area of concern as evidenced by: A) 05/06/25, Resident #1 was assessed by nursing, he/she had no visible injuries, was not found to be in any distress, and was at his/her baseline. B) Social Services and Nursing staff continue to monitor Resident #1 for the potential of an adverse reaction to the use of a restraint and will provide emotional support, as needed. C) 05/06/25, CNA #1 was suspended pending a Facility Investigation and subsequently terminated from the Facility. D) 05/06/25, The Assistant Director of Nurses began daily restraint audits on all residents, which continued for two weeks, then transitioned to weekly and will continue for two months. E) 05/06/25 through 05/09/25,The Staff Development Coordinator educated all clinical staff on the use of restraints and the facility's abuse policy's. F) 05/20/25, Quality Assurance Performance Improvement (QAPI) meeting was held with the Facility leadership team to review the incident and their plan of correction. G) Effectiveness of the corrective action plan will be reviewed during Monthly QAPI meetings until further notice. H) Director of Nursing and Executive Director are responsible for overall compliance.

Based on records reviewed and interviews for one of three sampled residents (Resident #1) who, on 05/06/25, had been restrained in his/her wheelchair by Certified Nurse Aide #1, the Facility failed to ensure Administration reported the alleged incident to the Department of Public Health (DPH) within two hours as required, when although the Director of Nurses was aware on 05/06/25, the Facility did not report the use of the restraint to DPH until 05/12/25, (almost a week later). Findings include: Review of the Facility's Policy titled, Abuse Reporting and Investigation, dated as updated 08/01/23, indicated that: - if resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law, and -the administrator or the individual making the allegation immediately reports his or her suspicion to the state licensing/certification agency responsible to surveying/licensing the facility. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated as submitted, 05/12/25, indicated that Resident #1 was observed sitting in his/her room in his/her wheelchair with sheet wrapped around his/her waist. The Report indicated that the Facility questioned if it was an inappropriate use of restraint, and that Resident #1 had no injuries. Review of the Facility's Investigation Report, undated, indicated that on 05/06/25 around 7:00 A.M., staff were completing walking rounds and noticed Resident #1 in his/her room, in his/her wheelchair with a restraint across his/her waist. The Report indicated that the restraint was removed immediately, Resident #1 was assessed, no injuries were noted, and he/she was not in any distress. Resident #1 was admitted to the Facility in December 2021, diagnoses included dementia and generalized anxiety disorder. Review of Resident #1's Quarterly Minimum Date Set (MDS) assessment, dated 03/22/25, indicated he/she had severe cognitive impairment and was dependent on staff for care and mobility. During an interview on 05/22/25 at 10:26 A.M., CNA #1 said on 05/06/25, he placed a fitted sheet across Resident #1's waist, wrapped the sheet around the armrests of the wheelchair, then tied the sheet behind the wheelchair to keep him/her from falling and that it was a bad decision. During an interview on 05/20/25 at 12:20 P.M., (which included a review of her written witness statement, dated 05/06/25), CNA #2 said she walked into Resident #1's room on 05/06/25 in the morning and saw Resident #1 wheeling him/herself around in his/her wheelchair, when she noticed a sheet around Resident #'1's waist, wrapped around the wheelchair armrests, and tied behind his/her wheelchair. CNA #2 said she notified the Assistant Director of Nurses (ADON) immediately. During an interview on 05/23/25 at 9:56 A.M., the Assistant Director of Nurses (ADON) said that on 05/06/25 between 7:00-7:30 A.M., CNA #2 told her that there was a sheet tied around Resident #1's waist and wheelchair, so she (ADON) went into Resident #1's room. The ADON said she saw Resident #1 sitting in his/her wheelchair with a sheet across his/her waist and tied behind the wheelchair. The ADON said she told CNA #2 to remove the sheet, and she (ADON) immediately reported the restraint to the Director of Nurses (DON). During an interview on 05/20/25 at 2:54 P.M., the Director of Nurses (DON) said that on 05/06/25, the ADON told her that she (ADON) and CNA #2 saw a sheet around Resident #1's waist and tied behind Resident #1's wheelchair. The DON said she determined that the sheet wrapped around Resident #1 and tied behind his/her wheelchair was a restraint. The DON said she did not report the restraint incident to DPH immediately, as required. During an interview on 05/20/25 at 3:17 P.M. the Regional Clinical Coordinator said he offered guidance to Facility staff during investigations. The Regional Clinical Coordinator said he did not know why the restraint allegation had not been reported to DPH in a timely manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #109 was admitted to the facility in January 2024 with diagnoses including dementia and history of falling. Review of the Minimum Data Set (MDS) assessment, dated 4/5/25, indicated Resident #109 had one unhealed, unstageable pressure ulcer and was receiving pressure ulcer care. During an interview on 4/24/25 at 8:44 A.M., the wound doctor said Resident #109 had a heel pressure ulcer that he was following. Review of current care plans for Resident #109 failed to indicate the presence of the Resident's heel pressure ulcer, but did indicate the Resident had a pressure ulcer on his/her elbow and buttock. During an interview on 4/29/25 at 12:34 P.M., Unit Manager (UM) #3 reviewed Resident #109's care plan. UM #3 said the care plan indicated the Resident had pressure ulcers on his/her elbow and buttock. UM #3 said the elbow and buttock pressure ulcers had resolved and the Resident only had the heel pressure ulcer which was not indicated in the care plan. UM #3 said Resident #109's care plan should have been updated to reflect the resolved pressure ulcer and the care plan should indicate the current heel pressure ulcer. During an interview on 4/29/25 at 2:37 P.M., the Director of Nursing (DON) said Resident #109's skin care plan should have been updated to reflect the Resident's current skin condition of a heel pressure ulcer. Based on document review, observation, and interview, the facility failed to develop, implement, and individualize comprehensive plans of care for two Residents (#126, #109), out of a total sample of 25 residents. Specifically, the facility failed: 1. For Resident #126, to develop and implement a care plan for the Resident's biliary drains (tubes inserted in the bile ducts to treat a blockage) and portacath (a type of central venous line that is surgically inserted beneath the skin and leads into the heart that is used to administer intravenous (IV) fluids and medications and to take blood samples); and 2. For Resident #109, to ensure the Resident's skin care plan addressed the Resident's current skin condition of a heel pressure ulcer. Findings include: Review of the facility's policy titled Care Plans, Comprehensive Person-Centered, dated 8/1/23, indicated but was not limited to the following: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. -The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS (Minimum Data Set) assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. -The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: (1) services that wound otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; (2) any specialized services to be provided as a result of PASARR (Preadmission Screening and Resident Review) recommendations; and (3) which professional services are responsible for each element of care; c. includes the resident's stated goals upon admission and desired outcomes; d. builds on the resident's strengths; and e. reflects currently recognized standards of practice for problem areas and conditions. -Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. -The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS assessment. 1. Resident #126 was admitted to the facility in March 2025 with diagnoses including gallbladder cancer with metastasis to the liver, duodenum, and peritoneum; protein-calorie malnutrition; bile duct obstruction; and bacteremia (bacterial infection of the bloodstream). Review of Resident #126's hospital Discharge summary, dated [DATE], indicated the Resident underwent portacath placement in February 2025 and left and right biliary drain placements in January 2025. Review of Resident #126's medical record indicated that the Resident's biliary drains were exchanged on 4/9/25. Review of the active Physician's Orders for Resident #126 included but was not limited to: -Flush biliary drain twice daily with 0.9 NaCl (Sodium Chloride) 10ml (milliliters) [order date 3/7/25] -Chlorhexidine Gluconate Cloth External Pad 2% Apply to L and R nephrostomy site topically every evening shift every Fri for Dressing change Biliary tube sites [order date 3/24/25] -Sodium Chloride Solution 0.9% Use 10ml via irrigation every date and evening shift [order date 3/7/25] Review of the current care plans for Resident #126 failed to indicate a care plan was developed reflecting the presence and/or care of the Resident's portacath and biliary drains. Review of the manufacturer's guide indicated it was recommended the portacath be flushed with 5ml of heparinized saline every four weeks when not in use. During an interview on 4/23/25 at 9:09 A.M., Resident #126 said he/she has two drains in his/her abdomen that the nurses at the facility were managing. Resident #126 said he/she had received intravenous fluids through an IV in his/her arm for a few days, but the IV had since been removed. During an interview on 4/29/25 at 8:42 A.M., Unit Manager #2 said she did not know if there were any physician's orders and/or a care plan in place reflecting the presence of and/or maintenance of the portacath that Resident #126 had placed in February 2025. The surveyor showed Unit Manager #2 the portacath information included in the Resident's hospital Discharge Summary. Unit Manager #2 said she would get more information from the Director of Nursing and report back to the surveyor. During a subsequent interview on 4/29/25 at 9:08 A.M., Unit Manager #2 said that Resident #126's chemotherapy was on hold while he/she was at the facility and that the nurses at the facility were not accessing the Resident's portacath to administer medications or maintenance flushes. Unit Manager #2 said that the Resident's portacath and biliary drains should have been included in the Resident's care plan. During an interview on 4/29/25 at 9:29 A.M., Resident #126 showed the surveyor where his/her portacath was located. The Resident said that when he/she was in the hospital in March, the nurses there were administering antibiotics and fluids through the portacath access. The Resident said at the facility, the nurses did not access the Resident's portacath but an additional IV was placed in his/her arm. During an interview on 4/29/25 at 10:24 A.M., the Director of Nursing said that it is her expectation that devices such as biliary drains, IVs, etc. be care planned for all residents. The Director of Nursing said that the facility staff were capable of accessing and caring for Resident #126's portacath, but currently were not performing maintenance to maintain patency.

Based on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to ensure the main kitchen was maintained in a sanitary and safe condition. Findings include: Review of the 2022 Food Code by the Food and Drug Administration (FDA), revised 1/2023, indicated but was not limited to the following: 4-602.13 Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. 6-501.12 (A) Physical facilities shall be cleaned as often as necessary to keep them clean. Review of the facility's policy titled Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices, updated 8/1/23, included but was not limited to the following: Cleaning and Sanitation of Kitchen Surface: -all surfaces in kitchen are to be maintained with cleanliness and sanitation; -all vents shall be clean and free from debris. On 4/23/25 at 7:33 A.M., the surveyor observed, in the main kitchen, a build up of dust on the air handler above clean trays. On 4/28/25 at 11:50 A.M., the surveyor observed the following in the main kitchen: -Large dust clumps throughout the vent grate located in the main kitchen area; -Splotches of dust attached to numerous ceiling tiles located in the main kitchen area; -Yellow/white, raised powdery substance and dust throughout shelving in the walk-in refrigerator; -Black, raised buildup and dust throughout the condenser fan covers in the walk-in refrigerator. During an interview on 4/28/25 at 11:55 A.M., the Food Service Director (FSD) said maintenance would need to remove the walk-in refrigerator condenser fan covers in order to clean them, and she was unsure whether the covers were on the maintenance department's cleaning schedule. The FSD said the fan covers should be free of buildup and debris. During an interview on 4/29/25 at 3:00 P.M., the Director of Maintenance said he did not perform any cleaning or maintenance tasks in the main kitchen other than maintenance requests to fix broken items. During an interview on 4/29/25 at 3:05 P.M., the Director of Housekeeping said his department does not perform any cleaning tasks in the main kitchen. The floor technician, who sometimes performs cleaning tasks, said he has never cleaned in the main kitchen. Review of Weekly Cleaning Assignments for January, February, and March indicated, but was not limited to, the following task: Walk-in refrigerator - Fan and Shelving, Remove fan cover; thoroughly wipe all shelving. All weeks were initialed by staff indicating the task was completed for all weeks in January, February, and March. During an interview on 4/29/25 at 2:15 P.M., the surveyor and FSD observed the buildup and dust in the ceiling vents, on the ceiling tile, and on the walk-in refrigerator shelving. The FSD said vents, ceiling tiles, and shelving should be clean and free of buildup and debris. During an interview on 4/29/25 at 2:50 P.M., the Clinical Coordinator said he expected the main kitchen to be clean and surfaces free of buildup.

Based on record review and interview, the facility failed to ensure for one Resident (#31), out of a total sample of 25 residents, recommended specialist appointments were scheduled. Specifically, the facility failed to ensure specialty eye appointments were scheduled. Findings include: Review of the facility's policy titled Ancillary Services, updated 8/1/23, indicated but was not limited to the following: -Services provided to our residents are performed in accordance with current acceptable standards of clinical practice; -Residents will be offered ancillary services including but not limited to, ophthalmology, audiology, podiatry, and psych services. If resident chooses services outside of ancillary services provided at the facility all efforts will be made to ensure they are seen; -Schedule of services will be provided with as much information as possible, in a timely fashion as possible; -Nursing staff will be responsible for reviewing any and all recommendations from the ancillary services and communicate that to the attending physician/nurse practitioner/physician's assistant for approval or refusal of the recommendation; -Nursing staff will be responsible to ensure that documentation is completed including but not limited to, documentation in nursing note of service provided, recommendations, notification of family and any feedback by the physician regarding orders, changes to plan of care, etc. Resident #31 was admitted to the facility in May 2023, status post corneal transplant surgery, with diagnoses that included major depressive disorder, anxiety disorder, chronic angle-closure glaucoma, corneal edema, corneal transplant status, and encounter for surgical aftercare following surgery on the sense organs. Review of the Minimum Data Set (MDS) assessment, dated 1/18/25, indicated Resident #31 scored 14 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident was cognitively intact. During an interview on 4/28/25 at 9:52 A.M., Resident #31 said he/she would like to know what happened to his/her eye appointments. During an interview on 4/29/25 at 8:21 A.M., Unit Manager (UM) #3 said she was unaware of the Resident wanting to see a specialty eye doctor. On 4/29/25 at 8:27 A.M., Resident #31 told UM #3 and the Clinical Coordinator he/she would like to follow up with his/her eye specialist. During an interview on 4/29/25 at 8:50 A.M., Resident #31 said he/she was blind in the right eye and very impaired in the left eye. He/she was interested in continuing his/her care with the eye specialist because vision is important and that is where he/she had their eye surgery in May 2023. The Resident said his/her vision had worsened over time since the surgery. The Resident said CNA #2 escorted him/her to their last eye appointment, which was sometime in 2023, and he/she missed their last known scheduled appointment in 2023 because he/she was told there was no staff available to escort him/her off campus to the appointment. He/she said they kept asking nursing about scheduling the specialty eye appointments but either there was no one to escort the Resident or the Resident never received follow-up, so the Resident said he/she stopped asking about eye appointments. On 4/29/25 at 9:22 A.M., the surveyor telephoned the eye specialist's office and spoke with a member of the office staff. She said Resident #31 was last seen by the eye specialist in September 2023 and indicated there were several missed and canceled appointments after September 2023. She said he/she was supposed to have repeat surgery which was not scheduled. Review of the Eye specialist records, dated 9/29/23, indicated but were not limited to the following: 5/10/23 - Resident #31 had corneal transplant surgery on 5/10/23. The Resident remained in the hospital several days due to feeling unsafe for discharge. The Resident missed eye appointments on 5/17/23 and 5/18/23. 5/19/23 - Resident stated his/her vision had been improving but became blurry. 5/30/23 - Still at rehab. Reports vision has decreased significantly. 6/28/23 - Resident stated his/her eye was not doing any better, vision still not good. 8/16/23 - Resident stated his/her vision had been wavering with some days better than others. 9/29/23 - Resident stated his/her vision is much worse in the left eye, and he/she had not been getting Latanoprost (an ophthalmic solution used to reduce pressure inside the eye) and he/she ran out of Combigan (a prescription eye drop that lowers pressure inside the eye) the day prior and needs a refill. Review of Resident #31's medical record indicated, but was not limited to, the following: Nurse Practitioner note, dated 9/30/24, stated the Resident's vision remained poor and he/she thought it was getting worse. Assessment and Plan: corneal edema - stable, followed by ancillary eye specialist. He/she has virtually no vision in his/her right eye. He/she is upset that his/her vision seems to be getting worse. Follow up with eye specialist. During an interview on 4/29/25 at 11:39 A.M., Unit Manager (UM) #3 said Resident #31 was admitted to the facility in May 2023 from the eye clinic status post eye surgery. UM #3 reviewed the Resident's medical records and said the last nursing note associated with an eye appointment was on 11/20/23 and stated Resident #31 was scheduled for a specialist eye appointment on 11/21/23 and the ride was booked, but there was no further documentation of the appointment or future appointments. UM #3 said she was unsure of what the plan was for ancillary specialty eye services for Resident #31. During an interview on 4/29/25 at 12:45 P.M., Certified Nursing Assistant (CNA) #2 said she had escorted the Resident to multiple eye appointments and could not recall the date of the last appointment as it was likely over a year ago. Further review of the Resident's medical record indicated, but was not limited to, the following: Nurse Practitioner note, dated 1/3/25, stated Assessment and Plan: Glaucoma stable, followed by eye specialist. Patient with decreased vision in left eye. He/she has virtually no vision in right eye. Continues on multiple eye drops for left eye. Follow up with eye specialist. During an interview on 4/29/25 at 2:45 P.M., the Clinical Coordinator said Resident #31 missed some his/her initial follow-up eye appointments due to emotional struggles regarding his/her vision. The Clinical Coordinator said, other than that, he was unaware of any issues with scheduling or transporting the Resident to ancillary specialty eye care services. During an interview on 4/29/25 at 2:45 P.M., the Director of Nursing (DON) said she expected staff to track residents' ancillary service recommendations, needs, and preferences. She said the UM was responsible for scheduling ancillary appointments and the facility would honor a resident's preference for an escort to assist them to their appointment. The DON said she would expect staff to notify her of any issues scheduling or getting a Resident to ancillary appointments. The DON said Resident #31 should have had a continuation of specialty eye services per recommendation, request, or as needed.

2. Review of the facility's policy titled Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices, updated 8/1/23, included but was not limited to the following: -All employees who handle, prepare, or serve food are trained in the practices of safe food handling and preventing foodborne illness; -Employees must wash their hands after engaging in other activities that contaminate the hands. On 4/23/25 at 8:48 A.M., the surveyor observed, on the Cherrywood Unit, staff serving meals to residents in resident rooms and in the Unit dining room with no hand hygiene performed between residents. The surveyor observed that staff did not offer hand hygiene to the residents prior to the meal. On 4/23/25 at 12:21 P.M., the surveyor observed the following on the Cherrywood Unit: -One staff member checking trays prior to distribution, no hand hygiene performed prior to this task; -Unit staff members not performing hand hygiene prior to passing trays to residents or between passing trays to residents; -clothing protectors delivered with trays to resident rooms. On 4/24/25 at 8:15 A.M., the surveyor observed six residents seated in the Driftwood Unit dining room waiting for breakfast. There was no observation of resident hand hygiene being performed. On 4/24/25 at 8:23 A.M., the surveyor observed staff serving meals to the residents in the Driftwood Unit dining room, still with no hand hygiene offered to or performed on the residents. The surveyor observed three of six residents eating food items with their bare hands. One resident in the dining room said he/she was not offered for his/her hands to be cleaned prior to the meal but that would be nice. During an interview on 4/24/25 at 8:34 A.M., the surveyor observed one Resident eating breakfast in his/her room. The Resident said he/she eats meals in his/her room and in the Driftwood Unit dining room. The Resident said staff does not offer to clean the Resident's hands and he/she usually takes his/her own wipes to the dining room to clean his/her hands prior to meals. The Resident said it would be a good idea if staff offered to clean residents' hands prior to meals. On 4/24/25 at 12:23 P.M., the surveyor observed 13 residents seated in the Cherrywood dining room with no observation of hand hygiene being offered to or performed on residents. On 4/24/25 at 12:31 P.M., the surveyor observed staff serving meals to the residents in the Cherrywood dining room. The surveyor observed staff removing food items from trays, cutting food, and donning clothing protectors on the residents. There was no observation of staff performing hand hygiene between these tasks. On 4/24/25 at 11:55 A.M., the surveyor observed, on the Applewood Unit, CNAs serving meals to residents with no observation of the CNAs practicing hand cleaning or sanitizing between residents. On 4/24/25 at 12:13 P.M., the surveyor observed, on the Cherrywood Unit, staff and CNAs serving meals to Residents in the unit dining room and to resident rooms with no observations of staff cleaning or sanitizing their hands between residents. On 4/24/25 at 12:24 P.M., the surveyor observed 14 residents in the Cherrywood Unit dining room. No hand hygiene had been offered to or performed on residents. On 4/24/25 at 12:33 P.M., the surveyor observed 14 residents in the Cherrywood Unit dining room had received their meals with no observation of staff offering or cleaning the residents' hands. During an interview on 4/24/25 at 12:40 P.M., the Director of Nursing (DON) said staff must sanitize their hands and the Residents' hands prior to meals. Based on observations and interviews, the facility failed to follow infection control prevention practices. Specifically, the facility failed to: 1. Ensure effective hand hygiene practices and appropriate PPE (personal protective equipment) were utilized when entering in and exiting out of resident rooms, including residents on transmission-based precautions; and 2. Ensure resident hand hygiene was implemented during meal service. Findings include: 1. Review of the facility's policy titled Isolation - Initiating Transmission-Based Precautions, dated 8/1/23, indicated, but was not limited to, the following: -Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. -Transmission-based precautions may include contact precautions, droplet precautions, or airborne precautions. -When transmission-based precautions are implemented, the infection preventionist (or designee): a. clearly identifies the type of precautions, anticipated duration, and the personal protective equipment (PPE) that must be used; b. explains to the resident (or representative) the reason(s) for the precautions; c. provides and/or oversees the education of the resident, representative and/or visitors regarding the precautions and use of PPE; d. determines the appropriate notification on the room entrance door and on the front of the resident's chart so that personnel and visitors are aware of the need for and type of precautions: (1) The signage informs the staff of the type of CDC (Centers for Disease Control and Prevention) precaution(s), instructions for use of PPE, and/or instructions to see a nurse before entering the room. (2) Signs and notifications comply with the resident's right to confidentiality or privacy. e. ensures that protective equipment (i.e. gloves, gowns, masks, etc.) is maintained outside the resident's room so that anyone entering the room can apply the appropriate equipment; f. ensures that protective equipment and supplies needed to maintain precautions during care are in the resident's room; and g. ensures that an appropriate linen barrel/hamper and waste container; with appropriate liner, are placed in or near the resident's room. -Transmission-based precautions remain in effect until the attending physician or infection preventionist discontinues them, which occurs after criteria for discontinuation are met. Review of the CDC Contact Precautions sign indicated the following: -Everyone must: Clean their hands, including before entering and when leaving the room. -Providers and staff must also: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. A. Resident #383 was admitted to the facility in April 2025 with diagnoses including Methicillin Resistant Staphylococcus Aureus (MRSA, a type of bacteria that is resistant to many antibiotics). Review of Resident #383's active Physician's Orders indicated, but was not limited to, the following: -Contact Precautions every shift for MRSA in nares (nostrils) + Klebsiella pneumoniae (a type of bacteria that can cause infection and is often resistant to multiple antibiotics) [order date 4/15/25] Review of Resident #383's Care Plans indicated, but was not limited to, the following: -Focus: PRECAUTIONS: [Resident #383] is on contact precautions R/T (related to) MRSA in nares + Klebsiella pneumoniae -Interventions: Institute appropriate precautions as warranted (Contact precautions) Review of Resident #383's MRSA PCR (a laboratory test used to detect the presence of MRSA bacteria) results from a specimen obtained from the Resident's nares on 4/18/25 indicated Resident #383 tested positive for MRSA. Review of the Nurse Practitioner's Progress Note, dated 4/25/25, indicated Resident #383 had tested positive for MRSA of the nares while in the hospital, but it was unclear whether he/she was treated. The Resident was retested at the facility and was again positive for MRSA and was started on Bactroban (a topical antibiotic treatment). On 4/24/25 at approximately 10:17 A.M., the surveyor observed Unit Manager #2 and Nurse #2 assessing Resident #383 after he/she had sustained a fall. A yellow CDC Contact Precautions sign was posted on the wall under the room number plaque outside of the Resident's room and PPE was available in a cart below the sign. On 4/24/25 at 10:21 A.M., the surveyor observed Unit Manager #2 and Nurse #2 leave the Resident's room. A housekeeper then entered Resident #383's room without appropriate PPE on. On 4/24/25 at 10:29 A.M., the surveyor observed Unit Manager #2 and the Director of Nursing entered Resident #383's room without donning (putting on) PPE. On 4/28/25 at 11:59 A.M., the surveyor observed a yellow CDC Contact Precautions sign posted on the wall under the room number plaque outside of the Resident's room and PPE was available in a cart below the sign. The surveyor observed a student volunteer enter the Resident's room with a lunch tray. The student volunteer did not don any PPE before entering the room. On 4/29/25 at 12:24 P.M., the surveyor observed a yellow CDC Contact Precautions sign posted on the wall under the room number plaque outside of the Resident's room and PPE was available in a cart below the sign. The surveyor observed Certified Nursing Assistant (CNA) #1 enter Resident #383's room without donning PPE. During an interview on 4/24/25 at 10:21 A.M., Nurse #2 reviewed Resident #383's electronic health record and said that Resident #383 was not on precautions for an active infection, but because he/she had a Foley catheter. During an interview on 4/29/25 at 9:55 A.M., Nurse #1 said that Resident #383 was on Contact Precautions and that staff should don a gown and gloves when entering the Resident's room, even if care was not being provided. During an interview on 4/29/25 at 12:24 P.M., CNA #1 said that a gown and gloves should be worn when going into Resident #383's room. B. Resident #122 was admitted to the facility in February 2025 with diagnoses including urinary tract infection (UTI) and dementia. Review of Resident #122's active Physician's Orders indicated, but was not limited to, the following: -Contact Precautions every shift for VRE (Vancomycin-resistant Enterococcus, a type of bacteria that is resistant to the antibiotic Vancomycin) in urine [order date 3/27/25] Review of Resident #122's Care Plans indicated, but was not limited to, the following: -Focus: PRECAUTIONS: [Resident #122] is on contact precautions r/t (related to) VRE in his/her urine. 4-3-25 Continues with contact precautions r/t VRE/urine Interventions: Institute appropriate precautions as warranted (Contact precautions) -Focus: INFECTION: Resident has infection and is at risk for complication due to UTI, VRE evidenced by >100,000 vancomycin resistant enterococcus Interventions: Keep resident on isolation precaution as ordered Review of Resident #122's urine culture results from a urine sample obtained on 4/17/25 indicated the Resident tested positive for Vancomycin-resistant enterococcus. On 4/24/25 at 10:53 A.M., the surveyor observed a yellow CDC Contact Precautions sign posted on the wall under the room number plaque outside of the Resident's room and PPE was available in a cart below the sign. The surveyor observed the Director of Nursing standing in the Resident's room. The Director of Nursing stated she was waiting for another staff member to come and assist her to transfer the Resident into bed. The Director of Nursing had no PPE on. C. Resident #390 was admitted to the facility in April 2025 with diagnoses including repeated falls and dementia. On 4/28/25 at 11:59 A.M., the surveyor observed a yellow CDC Contact Precautions sign posted on the wall under the room number plaque outside of the Resident's room and PPE was available in a cart below the sign. A CNA entered the Resident's room without donning PPE and exited without performing hand hygiene. The same CNA reentered the Resident's room on 4/28/25 at 12:02 P.M. without donning PPE and exited the Resident's room without performing hand hygiene. During an interview on 4/28/25 at 1:11 P.M., Nurse #1 said Resident #390 was transferred to the Elmwood Unit from another unit in the facility. Nurse #1 said that Contact Precautions had been implemented for Resident #390 while awaiting the results of his/her urine culture. Nurse #1 said that Resident #390 may have been exposed to a multi-drug resistant organism from his/her former roommate. Review of Resident #390's active Physician's Orders indicated an order was obtained for a UA C&S (urinalysis and urine culture and sensitivity) on 4/28/25. Further review indicated an order for Contact Precautions was entered on 4/29/25. Review of Resident #390's Progress Notes indicated, but was not limited to, the following: -4/28/25 at 11:17 A.M.: Resident #390 was moved to a room on the Elmwood Unit to reduce the risk of house acquired infection and a urine culture would be obtained to rule out UTI. -4/28/25 at 10:08 P.M.: Contact precautions maintained. During an interview on 4/29/25 at 12:29 P.M., the Infection Prevention Nurse said that for residents requiring Contact Precautions, all staff should be wearing at least a gown and gloves upon entry to the resident's room. The Infection Prevention Nurse confirmed that Resident #390 had been moved to another unit and Contact Precautions were initiated while the results of the Resident's urine culture were pending as he/she was possibly exposed to a multi-drug resistant organism.

Based on observation and interview, the facility failed to ensure Resident #70 was provided with a dignified dining experience. Findings include: Review of the facility's policy titled Dignity, dated as last revised 8/1/23, indicated but was not limited to the following: -Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. -Residents are provided with a dignified dining experience. -Demeaning practices and standards of care that compromise dignity are prohibited. -Staff are expected to promote dignity and assist residents. -Staff are expected to treat cognitively impaired residents with dignity and sensitivity. Review of the facility's policy titled Assistance with Meals, dated as last revised 8/1/23, indicated but was not limited to the following: -Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity. Review of the facility's policy titled Assisting the Resident with In-Room Meals, dated as last revised 8/1/23, indicated but was not limited to the following: -Review the resident's care plan and provide for any special care needs of the resident. -Arrange dishes and silverware so that they can be easily reached by the resident. Resident #70 was admitted to the facility in November 2017 with diagnoses which included cerebral infarction (stroke) with hemiparesis and hemiplegia (weakness and paralysis) affecting right dominant side, visuospatial deficit and spatial neglect following intracerebral hemorrhage (brain bleed), and failure to thrive. Review of the Minimum Data Set (MDS) assessment, dated 2/3/24, indicated Resident #70 was rarely or never understood and was unable to complete the Brief Interview for Mental Status (BIMS). Additionally, the Resident's cognitive skills for daily decision making was severely impaired and he/she had impairment on one side and required supervision/touching for eating. The surveyor made the following dining observations: -4/16/24 at 12:30 P.M., Resident #70 was sitting in a reclining Broda chair (specialty wheelchair for positioning) in the corner of the day room alone, slumped over in the chair; their lunch meal was placed on an overbed tray table and staff walked away. Resident then picked up the adaptive lip plate (plate with high edge to contain food) and spilt the entire plate of food on his/her chest and lap, down their legs, and on the floor. Resident was observed to be playing with the food on his/her lap and staff did not intervene to clean up the spilt food, did not call the kitchen for another meal or provide the Resident with assistance to eat anything else. -4/17/24 at 8:05 A.M., Resident #70 was sitting in a reclining Broda chair in the corner of the day room alone. At 8:23 A.M., the nurse cut up the Resident's breakfast, placed the meal on the overbed tray table, and walked away. The Resident was observed self-feeding dry cereal from an adaptive blue bowl which was on the left side. The plate with the main meal was on the right side. Dry cereal was spilt on their clothing protector. No staff offered assistance with feeding or cues to eat anything on the plate. -4/17/24 at 12:42 P.M., Resident #70 was sitting slouched over in a reclining Broda chair in the corner of the day room alone. The Resident's right shoe was off and on the floor in front of the chair. No staff attempted to put the shoe back on. One staff member sat down next to the Resident, however, provided no assistance or verbal cues. The Resident was self-feeding ice cream which was on the left side. The plate with the main meal was on the right side and untouched. The Resident was observed to be leaning forward to reach the table to gather food as the table was not positioned so food was within easy reach. A Certified Nursing Assistant (CNA) was observed standing next to the Resident, offered one bite of food from the main plate (which Resident accepted), and walked away. No further assistance was provided. -4/18/24 at 8:35 A.M., Resident #70 was sitting slouched over in a reclining Broda chair in the corner of the day room alone. The meal was placed on the overbed tray table and the staff walked away. Dry cereal in blue adaptive bowl was on the left side and plate with the main meal was on the right side. Resident fed self the dry cereal; clothing protector had spilt food on it. Staff did not provide assistance or cues with eating. At 8:55 A.M. CNA #10 cleaned up the breakfast trays from the other residents in the day room and removed table linens. She looked at Resident #70 sitting in the reclining Broda chair not eating or being fed and left the room. Resident #70 was left in the day room with their meal still on the overbed tray table, food spilt on the clothing protector and no one to assist him/her with eating. At 9:53 A.M., Resident #70 pushed the overbed tray table away. Resident #70 remained in the day room unsupervised, unassisted, with clothing protector on with food on it until 10:01 A.M. when CNA#10 removed the plate, cups, and clothing protector. The Resident was left in the corner of the day room alone. Review of Resident #70's medical record including physician's orders, progress notes, and flow sheets indicated but were not limited to the following: -HCC (diabetic) Diet lipped plate with all meals (8/26/20). -Dietitian note dated 2/7/24 indicated resident was dependent on nursing staff for eating. Suction bowl and lip plate provided at meals to help with self-feeding. -CNA flow sheet indicated Resident was provided with moderate assistance for eating. Review of the Comprehensive Care Plans for Resident #70 indicated but were not limited to the following: -FOCUS: VISION: Visual Impairment related to CVA (stroke) with right side visual neglect. -INTERVENTIONS: Please place objects in my field of vision-towards my left side. -FOCUS: ACTIVITIES OF DAILY LIVING (ADL): Assist -INTERVENTIONS: Dependent during meals. During an interview on 4/18/24 at 8:55 A.M., CNA #10 said sometimes they help Resident #70 eat, but it depends on his/her mood. She said he/she is not always a feed and doesn't eat much. During an interview on 4/18/24 at 10:15 A.M., Unit Manager #3 said Resident #70 is a mix of supervision, assist, and feed; it depends on the day. She said staff should be providing assistance and allowing him/her to do what they can but still helping as needed. She said he/she has right-sided visual impairment so leaving the plate on the right side is not good. Additionally, she said staff should be promptly cleaning up spills and food as it is not very dignified to sit with food all over one's lap, he/she should not always be left in the corner alone and someone should have fixed his/her sneaker when it was on the floor. She said that is an unacceptable dining experience. During an interview on 4/18/24 at 10:25 A.M., Nurse #6 said Resident #70 likes cereal and tries to eat that independently, but the staff should be offering the other food. During an interview on 4/18/24 at 1:30 P.M., the Assistant Director of Nursing (ADON) said Resident #70 should not be sitting alone with food on their lap during or after meals and should be provided with assistance to eat. Additionally, he/she has right-sided vision concerns so they should be moving plate to the left and helping with meals. During an interview on 4/18/24 at 2:40 P.M., the Director of Nurses (DON) said it is not very dignified to have food on his/her lap and floor surrounding a resident and staff should have provided assistance for a better dining experience.

Based on interviews, review of grievance documentation, and policy review, the facility failed to formulate a grievance timely for concerns brought forward by Resident #6 regarding missing hearing aids. Findings include: Review of the facility's policy titled Loss or Damage to Resident's Dentures, Hearing Aids and/or Eyeglasses, undated, indicated but was not limited to the following: -The Social Worker (SW) for the unit the resident resides in needs to immediately be informed by the resident, responsible party, unit manager (UM) or nurse. -The Social Worker will immediately inform the Administrator and a formal grievance will be written followed by an immediate investigation. Review of the facility's policy titled Lost and Found, dated as last revised 8/1/23, indicated but was not limited to the following: -Facility shall assist all residents in safe-guarding their personal property. -Resident or family complaints of missing items must be reported to the Director of Nursing (DON). Review of the facility's policy titled Grievance/Concern, dated as last revised 10/30/20, indicated but was not limited to the following: -The Grievance Policy refers to documenting and acting on specific complaints or concerns voiced by residents, staff, and families. Listening to concrete needs, addressing them with appropriate team member(s), and resolving them are the principal components and nature of the policy. -All grievances generated in the past 24 hours will be discussed at morning meeting and assigned to the responsible person to do the interview/search and recovery. -The Administrator reviews the grievance and refers appropriate staff members for investigation and timely action is taken. -The Director of Social Services maintains a Grievance Log in the Social Service Director's office. Review of the facility's Grievance Report, dated as last revised 8/22/18, indicated but was not limited to the following: -This form shall be utilized to provide written documentation of any concerns expressed by residents, resident representative or staff member and record the follow up action taken and results thereof. -Documentation of Concern: Type includes but was not limited to: Hearing Aids. -Staff members need to be interviewed starting the shift prior of grievances up to 72 hours prior, both nurses assigned / certified nursing assistant depending on the nature of the grievance. -Grievance should be reported to the Supervisor, DON, and Administrator. -Investigation/Actions of Grievance included but were not limited to interview staff involved, interview resident, Resident property protected from further occurrence. Resident #6 was admitted to the facility in February 2021 with diagnoses which included cerebral infarction (stroke) with hemiparesis and hemiplegia affecting left side (weakness and paralysis). Review of the Minimum Data Set (MDS) assessment, dated 2/10/24, indicated Resident #6 scored a 13 out of 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was cognitively intact and wore hearing aids. Review of the Resident's Comprehensive Care Plan indicated he/she had a communication deficit, was hard of hearing and wore hearing aids. Additionally, the care plan indicated staff should ensure hearing aids were clean and batteries were functioning. During an interview on 4/16/24 at 1:33 P.M., Resident #6 said both of his/her hearing aids were missing. He/she said they were on the table over the weekend and then they were gone. Resident #6 said Nurse #3 was notified yesterday (4/15/24). Review of the grievance book failed to indicate a grievance for the missing hearing aids had been completed. Review of the nursing progress notes failed to indicate the Resident was missing his/her hearing aids. During an interview on 4/17/24 at 3:29 P.M., Nurse #3 said the missing hearing aids were reported to her yesterday, but she had not searched the room yet. Additionally, she said she had not completed a missing item report because she had not looked for them yet. She said usually if they don't find something by the next day or so, they will report it. She said she did not report the missing hearing aids to anyone including the UM, SW, DON, or Administrator yet. During an interview on 4/18/24 at 10:57 A.M., Resident #6 said Nurse #3 found them a few minutes ago (Three days after the Resident said they were reported missing). During an interview on 4/18/24 at 10:57 A.M., UM #2 said she was not notified the hearing aids were missing until yesterday afternoon. She said immediately after a Resident reports a missing item, especially hearing aids, glasses, or dentures, all departments should be notified, including kitchen, laundry, and housekeeping so they can look on trays, laundry and in the trash for them. She said the room should be searched immediately, the UM, SW, DON, and Administrator should be notified, a progress note written, the family should be notified, and the grievance form filled out. She said the grievance was not filed for the missing hearing aids and it should have been done when the nurse was notified by the Resident that the hearing aids were missing. During an interview on 4/18/24 at 2:16 P.M., the Assistant Director of Nurses (ADON) said she was not aware of the missing hearing aids. She said the grievance should be initiated immediately by whomever is notified. She said the room should be immediately searched and all departments should be notified right away. Additionally, she said the investigation should include all staff that took care of the Resident for the 72 hours prior. She said the process should be done right away and not the next day or the day after. During an interview on 4/18/24 at 2:30 P.M, the DON said she was not aware of the missing hearing aids. The DON said the grievance for missing items should be done right away and that would include searching the room, investigating, and notifying all departments. She said it should not wait until the next day or so; people don't understand how important hearing and vision are until they suddenly have it taken away and that is very detrimental to a resident's care. She said the Resident should not have had to wait days before anyone looked for the hearing aids. She said luckily, they found them today, but they could have ended up in the trash or gotten broken going through the laundry because no one was notified to search for them the other day when they should have been.

Based on record review and interview, the facility failed to accurately complete the Minimum Data Set (MDS) assessment for three Residents (#106, #107, and #52), out of 26 sampled residents. Specifically, the facility failed: 1. For Resident #106, to ensure the use of bed and chair alarms were coded on the MDS; 2. For Resident #107, to accurately document the use of chair and bed alarms on the MDS; and 3. For Resident #52, to identify bilateral hand contractures (shortening and hardening of tissues leading to rigidity of joints) on the MDS. Findings include: 1. Resident #106 was admitted to the facility in November 2022 with the following diagnoses: Acute on chronic congestive heart failure, benign prostatic hyperplasia, and frequent falls. Review of the current Physician's Orders for Resident #106, dated 4/17/24, indicated but were not limited to: -Bed alarm: check placement and functioning of alarm every shift (2/17/2023) -Chair alarm: check placement and function of alarm every shift (4/17/2023) During the survey, the surveyor made the following observation of Resident #106: 4/16/24 at 9:28 A.M., Resident alert and awake, lying in bed with head of bed elevated, bed alarm in place. 4/16/24 at 12:20 P.M., Resident alert, lying in bed, with bed alarm in place. 4/17/24 at 8:09 A.M., Resident in bed, bed alarm in place. 4/17/24 at 11:33 A.M., Resident alert, lying in bed, bed alarm in place. Review of the Treatment Administration Record (TAR) for Resident #106 from January 2024 through April 17, 2024, indicated that a licensed nurse verified the placement and function of a bed alarm and chair alarm for the Resident each day. Review of the most recent MDS assessment, dated 1/20/24, failed to indicate under section P, Restraints and Alarms that Resident #106 used a bed or chair alarm. During an interview on 4/17/24 at 3:11 P.M., the MDS Nurse reviewed the medical record and MDS for Resident #106 and said an error was made on the MDS; the Resident does use alarms and a modification of the MDS was required for it to be accurate. 2. Resident #107 was admitted to the facility in October 2022 with the following diagnoses: dementia, difficulty walking, and muscle weakness. Review of the Physician's Orders for Resident #107, dated 4/17/24, indicated but were not limited to the following: -Chair alarm: check placement and function of alarm every shift (4/24/23) -Bed alarm: check placement and function of alarm every shift (4/24/23) During the survey, the surveyor made the following observations of Resident #107: 4/16/24 at 8:12 A.M., Resident alert and awake, sitting in the hallway in his/her wheelchair with chair alarm in place. 4/16/24 at 3:42 P.M., Resident alert, sitting in his/her wheelchair in their room, visiting with family, chair alarm in place. 4/17/24 at 9:04 A.M., Resident alert and awake, sitting in the hallway in his/her wheelchair with chair alarm in place. Review of the TAR for Resident #107 from January 2024 through April 17, 2024, indicated that a licensed nurse verified the placement and function of a chair alarm and bed alarm for the Resident each day. Review of the most recent MDS assessment, dated 3/2/24, failed to indicate under section P, Restraints and Alarms that Resident #107 used a chair or bed alarm. During an interview on 4/17/24 at 3:11 P.M., the MDS Nurse reviewed the medical record and MDS for Resident #107 and said an error was made on the MDS; the Resident does use both a chair and bed alarm daily and modification of the MDS was required for it to be accurate. 3. Resident #52 was admitted to the facility in August 2020 with a diagnosis of Parkinson's disease (disorder of the central nervous system that affects movement). During an interview with observation on 4/18/24 at 12:07 P.M., the surveyor observed Resident #52 lying in bed with his/her arms crossed on their chest with bilateral fingers closed to the palm. Nurse #5 said she was unable to fully extend fingers on either hand of Resident #52. Review of a Physician's Progress Note2, dated 6/22/23, indicated Resident #52 continued to have rigidity likely due to Parkinson's disease and contractures. Review of the Physician's Progress Note, dated 8/14/23, indicated Resident #52 had bilateral hand contractures. Review of the MDS assessment, dated 2/24/24, section GG Functional Abilities and Goals, GG0115 Functional Limitation in Range of Motion indicated Resident #52 had no impairments in the upper extremities. During an interview on 4/19/24 at 1:15 P.M., the MDS Coordinator said she reviewed the medical record and observed Resident #52 and said the MDS was incorrect and should have reflected the Resident's upper extremity limited range of motion.

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 one Resident (#10), in a total sample of 26 residents. Specifically, the facility failed to ensure nail care was performed for Resident #10. Findings include: Review of the facility's policy titled Fingernails/Toenails, Care of, dated 8/1/23, indicated the following: Purpose: to keep nails trimmed; Guidelines: nail care includes daily cleaning and regular trimming; Documentation: the date and time the nail care was given, the condition of resident's nails, any difficulty in cutting the resident's nails, if the resident refused Resident #10 was admitted to the facility in July 2020. Review of the most recent Minimum Data Set (MDS) assessment, dated 3/2/24, indicated the Resident was dependent on one staff person for personal hygiene. On 4/16/24 at 8:45 A.M., the surveyor observed Resident #10 to have long fingernails. The fingernail lengths ranged from 0.1 cm to approximately 1 cm (the width of a standard pen) with the right thumb being the longest. On 4/17/24 at 11:00 A.M., the surveyor observed Resident #10 to continue to have long nails. During an interview on 4/17/24 at 2:39 P.M., the spouse of Resident #10 said the Resident's fingernails were too long. The spouse said the nurse had previously reported that Resident #10 would pull his/her hands away while staff were cutting their nails and now required two staff members to cut their nails. Review of the medical record indicated Resident #10 had their fingernails cut on 2/21/24 (eight weeks prior). During an interview on 4/18/24 at 10:40 A.M., Certified Nursing Assistant (CNA) #2 said she normally cares for Resident #10 and there was no set schedule to cut the Resident's nails. During an interview on 4/18/24 at 10:47 A.M., Unit Manager #4 said the Resident's nails were too long and should be cut periodically. During an interview on 4/18/24 at 10:57 A.M., CNA #3 said she cut the nails of Resident #10 this morning and the nails were too long and needed to be cut. During an interview on 4/18/24 at 11:00 A.M., Unit Manager #4 said she was not sure how the CNAs knew when to cut a resident's nails and after reviewing the Resident's Flow Sheets was unable to see where nail cutting would be documented.

Based on observation, interview, and record review, the facility failed to ensure a resident received proper treatment to maintain hearing and ensure assistive devices to maintain hearing and enhance communication were utilized for one Resident (#86), in a total sample of 26 residents. Findings include: Resident #86 was admitted to the facility in May 2023 with a diagnosis of dementia. Review of the baseline care plan dated May 2023 indicated that the Resident was hearing impaired. Review of the Minimum Data Set (MDS) assessment, dated 1/20/24, indicated Resident #86 had minimal difficulty hearing if hearing devices (hearing aids) were utilized. The MDS indicated that the Resident scored 5 out of 15 on the Brief Interview for Mental Status assessment indicating severe cognitive impairment. Further review of the MDS indicated Resident had an activated health care proxy. During an interview on 4/16/24 at 2:09 P.M., the Resident's representative said the Resident had hearing aids but probably needed new ones and that communication can be difficult without them in. She said she would like him/her to see the audiologist. On 4/17/24 at 8:23 A.M., the surveyor observed the Resident self-propelling in their wheelchair with no hearing aids present. On 4/17/24 at 10:53 A.M., the surveyor attempted to converse with Resident #86 but was not successful. The Resident said, I am deaf, and you must speak loudly. The Resident did not have hearing devices in his/her ears. During an interview on 4/17/24 at 10:53 A.M., Resident #86 had difficulty maintaining a conversation resulting from his/her hearing impairment. The Resident said he/she did not have his/her hearing aids applied. The Resident knew they had a hearing impairment and had hearing aids but could not give further details. The Resident said that he/she would wear the hearing aids if he/she knew the location of the hearing aids. Review of the Facility admission Packet included a Transcare Mobile Health Services Form including the following authorization for services: audiology, that should be reviewed and completed with the Resident/Representative on admission. The services offered are optional as the residents/representatives have the choice to accept the services offered or seek alternate arrangements for these services. Review of the Transcare Mobile Health Services Form indicated that the Resident's representative signed and dated the form on 5/10/23 requesting audiology services. On 4/17/24 at 1:35 P.M., the surveyor observed the Resident sitting at the nurses' station having difficulty holding a conversation with behavioral health staff due to impaired hearing. The Resident misheard multiple words and asked the staff to repeat themselves and still demonstrated he/she did not accurately hear them. The Resident did not have hearing devices in his/her ears. Review of Resident #86's clinical record failed to indicate an impaired communication care plan that identified the Resident had hearing devices to improve their communication. During an interview on 4/17/24 at 2:32 P.M., Unit Manager #4 said the consent should have been faxed over on admission for the Resident to receive audiology services and he/she has not received audiology services during his/her time at the facility. She said he/she should have been referred as the Resident Representative requested to determine if the hearing aids he/she has have been adequate for communication. During an interview on 4/17/24 at 2:58 P.M., Nurse # 4 said the hearing aids are in the top drawer of the medication cart, but she doesn't know how the staff would know to offer them to the Resident since there was no care plan or physician's order. She said that she offers the hearing aids to the Resident when his/her [family member] visits and he/she wears them then. On 4/18/24 at 9:29 A.M., the surveyor observed Resident #86 with hearing aids in, conversing in the dining room with staff and residents. Certified Nursing Assistant #3 said the Resident could hear much better with the hearing aids.

Based on interviews and record review, the facility failed to ensure that one Resident (#28), in a sample of 26 residents, had been seen by a physician every 30 days for the first 90 days of admission. Findings include: Resident #28 was admitted to the facility in December 2023. Review of the Physician Progress Notes indicated Resident #28 was seen for an initial visit on 12/27/23 and subsequent visits on 1/2/24 and 1/5/24. Review of the Physician Progress Notes indicated the next visit occurred on 3/6/24, 60 days after the previous visit. During an interview on 4/19/24 at 11:51 A.M., the Nurse Practitioner said there were no additional visits conducted for Resident #28 between 1/5/24 and 3/6/24. She said Resident #28 was a long-term care resident and only needed to be seen every 60 days. She said she was unaware that all new admissions needed to be seen every 30 days for the first 90 days.

Based on record review, interview, and policy review, the facility failed to act promptly upon recommendations made by the Consultant Pharmacist during the monthly Medication Regimen Reviews (MRR) for one Resident (#20), out of a total sample of 26 residents. Specifically, the facility failed to ensure that the January 2024 and February 2024 consultant pharmacist's recommendations were acted upon in a timely manner to ensure there was a stop date for Bactrim (an antibiotic medication). Findings include: Review of the facility's policy titled Consultant Pharmacist Reports, dated 1/1/21, indicated but was not limited to the following: -The MRR includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and preventing or minimizing adverse consequences related to medication therapy. -The consultant pharmacist reviews the medication regimen of each resident at least monthly. -Resident specific irregularities and/or clinically significant risks resulting from or associated with medications are documented in the medical record and reported to the Director of Nurses (DON), Medical Director, and prescriber as appropriate. -Recommendations are acted upon and documented by the facility staff and/or the prescriber. -Prescriber accepts and acts upon suggestion or rejects and provides an explanation for disagreeing. Resident #20 was admitted to the facility in December 2023 with diagnoses which included urinary tract infection (UTI), chronic kidney disease, and failure to thrive. Review of Resident #20's medical record including physician's orders, Medication Administration Record (MAR), progress notes, and pharmacy recommendation forms indicated but were not limited to the following: -Bactrim 400-80 milligrams (mg) once daily for UTI (1/31/24). -MAR indicated Resident had been administered Bactrim once daily for UTI since 12/30/23. -Pharmacist Progress Note dated 1/30/24 indicated a recommendation was made requesting a stop date for the Bactrim. -Pharmacist Progress Note dated 2/28/24 indicated a recommendation was made again requesting a stop date for the Bactrim. -Pharmacist Progress Note dated 3/26/24 indicated a recommendation was made again requesting a stop date for the Bactrim. Further review of the medical record failed to indicate the recommendation requesting a stop date for the Bactrim had been addressed by the facility from the January or February report. The recommendation was not addressed until 3/27/24 by the Nurse Practitioner (88 days after the Resident started the Bactrim, 57 days after the pharmacist made the initial recommendation and after the pharmacist made a third request for a stop date). During an interview on 4/18/24 at 10:37 A.M., Unit Manager #3 could not speak about the previous recommendations as she was new to the role and said she did not know why they were not addressed or in the medical record. She said they should be completed and then filed under the Pharmacy section of the chart and they were not. During an interview on 4/18/24 at 1:30 P.M., the Assistant Director of Nurses (ADON) said she does not oversee the MRRs. During an interview on 4/18/24 at 2:40 P.M., the Director of Nurses (DON) said the pharmacy recommendation should be addressed and a reason documented if the provider is not in agreement, and they should be filed in the medical record. The DON was unable to speak of these recommendations specifically as she was not employed at the facility at the time but said it should have been addressed when initially recommended back in January.

Based on interviews, record review, and policy review, the facility failed to ensure for one Resident (#20), out of a total sample of 26 residents, that the Resident's drug regimen was free from unnecessary drugs. Specifically, the facility failed to ensure an antibiotic was administered for the appropriate duration and with adequate indications for use. Findings include: Review of the facility's policy titled Antibiotic Stewardship-Orders for Antibiotics, dated as last revised 8/1/23, indicated but was not limited to the following: -Antibiotics will be prescribed and administered under the guidance of the facility's antibiotic stewardship program and in conjunction with the facility's general policy for medication utilization and prescribing. -If an antibiotic is indicated, prescribers will provide complete antibiotic orders including the following elements: Drug name, dose, frequency, duration of treatment (start/stop dates or number of days), route of administration, and indications for use. -Appropriate indications for use of antibiotics include criteria met for clinical definition of active infection or suspected sepsis; and pathogen susceptibility, based on culture and sensitivity, to antimicrobial (or therapy began while culture was pending). -Empirical use of an antibiotic based on clinical criteria of suspected sepsis may be appropriate. The staff and practitioner will document the specific criteria that support the suspicion in the clinical record. Resident #20 was admitted to the facility in December 2023 with diagnoses which included urinary tract infection (UTI), chronic kidney disease, weakness, dehydration, and failure to thrive. Review of the discharge summary from the acute care hospital, dated 12/22/23, indicated but was not limited to the following: -Urine culture was positive for a UTI and was treated with five-day course of antibiotics. -Resident's outpatient Urologist office was contacted and there is NO PLAN for prophylactic antibiotics at this time, although his/her daughter states that is the plan. -Discharge Medication list did not include an antibiotic. Review of the Physician's Progress Note, dated 12/27/23, indicated Resident was admitted after being treated for a UTI, urinary retention and Foley catheter placement. Additionally, the note indicated Resident #20 had completed the course of antibiotics for a UTI. The medication list did not include an antibiotic. Review of the Physician's Progress Note, dated 12/29/23, indicated the Nurse Practitioner (NP) spoke to the daughter, who spoke to the Urologist; Urologist sent over a prescription, and apparently, they do want him/her on Bactrim (antibiotic) daily, prophylactically, to prevent UTIs. Review of the Physician's Progress Note/admission History and Physical for Long Term Placement, dated 2/6/24, indicated the Resident was recently diagnosed and treated for a UTI and was status post antibiotics. Further review of the note failed to indicate the Resident was on prophylactic antibiotics. Review of the Physician's Progress Note, dated 3/15/24, indicated Resident #20, per Urologist, was on prophylactic Bactrim daily. Further review of the note failed to indicate clinical rationale for the prophylactic antibiotic. Further review of the medical record failed to indicate a clinical rationale from any provider (Physician, NP, or Urologist) for the continued use of the Bactrim. Unit Manager #3 was unable to locate any documentation since admission from the Urologist indicating the need for prophylactic antibiotics. Review of the Physician's Orders indicated the following: -Bactrim 400-80 milligrams (mg) once daily for UTI for 7 days (order written and was discontinued on 12/27/23) -Bactrim 400-80 mg once daily for UTI (started 12/30/23 and ended 1/31/24) -Bactrim 400-80 mg once daily for UTI (started 1/31/24) Review of the Medication Administration Record (MAR) indicated Resident #20 had received Bactrim once daily as ordered since December 2023. Further review of the progress notes failed to indicate the need for prophylactic antibiotics or why the stop date was removed from the order. Additionally, the Resident had no documented symptoms of a UTI. Review of the Comprehensive Care Plan failed to indicate Resident #20 was on prophylactic antibiotics. During an interview on 4/18/24 at 1:25 P.M., Nurse #6 said she was not sure why Resident #20 was on the Bactrim but assumed it was because he/she had a history of UTIs. During an interview on 4/18/24 at 10:37 A.M., Unit Manager (UM) #3 said she was unable to get any documentation from the Urologist's office indicating he wanted the Resident on prophylactic antibiotics, if so why, and for how long. UM #3 said she had not spoken to the Urologist's office until today and there was no indication any staff had spoken to the office regarding the prophylactic treatment. She said there were only notes indicating the Resident's daughter said she spoke to the office. UM #3 reviewed the hospital discharge paperwork and confirmed it stated the hospital spoke to the Urologist and there was not a plan for prophylactic treatment despite what the daughter had told the hospital. UM #3 reviewed the NP Progress notes, dated 12/29/23, and confirmed the notes did not indicate facility staff had spoken to the office for confirmation of prophylactic antibiotic use. UM #3 said there should be documentation in the medical record indicating facility staff and Urology discussed the plan regarding the continued use of the Bactrim, how long he/she should be on it and what the indication for long term use was and there was not. During an interview on 4/18/24 at 1:30 P.M., the Assistant Director of Nurses (ADON) said Resident #20 was not on the Bactrim during the previous admission, he/she was discharged home, went to urology and the hospital, and then was re-admitted . She said she thinks the Bactrim order came from the Urologist's office and the physician here just kept it. Additionally, she said she tracks it on the line list but there is no documented clinical indication for use in the record that she could find. During an interview on 4/18/24 at 2:40 P.M., the Director of Nurses (DON) said her expectation for prophylactic antibiotics is that the rationale for long term continued use of antibiotics be documented in the medical record and that there be a trial dose reduction to ensure the medication is needed and at the lowest possible dose. Additionally, she said prophylactic antibiotics should not be dictated by the family; the physicians need to educate the family and document in the medical record accordingly. The DON said the order should be clear, what they are on, for how long, and the reason they need to be on it. Residents should not be on prophylactic antibiotics because the family wants it, with no follow up. Resident #20's daughter initiated this antibiotic order, and it seems like the Urologist's office gave her a script and it was continued here with no re-evaluation. Additionally, she said the facility staff should be in contact with the Urologist's office and it should be documented in the medical record.

Based on record review, policy review, and interview, the facility failed to ensure for one Resident (#15) that their as needed (PRN) psychotropic medication, Ativan, was re-evaluated 14 days after the medication was prescribed to ensure it was beneficial and necessary for the Resident in accordance with the standard of practice. The total sample was 26 residents. Findings include: Review of the facility's policy titled Psychotropic Medication Use, updated 8/1/2023, indicated but was not limited to the following: - psychotropic medications are not prescribed or given on a PRN basis unless that medications is necessary to treat a diagnosed specific condition that is documented in the clinical record - non-pharmacological approaches are used to minimize the need for medications, permit the lowest possible dose, and allow for discontinuation of medications when possible - PRN orders for psychotropic medications are limited to 14 days - if the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use to include the duration of the PRN order Resident #15 was admitted to the facility in June 2023 and has diagnoses including: Failure to thrive, major depressive disorder and dementia. Further review of the medical record indicated the Resident was on hospice services. Review of the most recent Minimum Data Set (MDS) assessment for Resident #15, dated 2/14/24, indicated but was not limited to the following: - Brief Interview for Mental Status (BIMS) score of 5 out of 15, indicating severe cognitive impairment - Section D, Mood, failed to indicate the Resident demonstrated symptoms of depression - Section E, Behaviors, failed to indicate the Resident exhibited any adverse behaviors - Section I, Active diagnosis, failed to indicate the Resident had a diagnosis of anxiety Review of the medical record indicated a handwritten order by the Nurse Practitioner (NP) on 3/29/24 as follows: - Ativan (an anti-anxiety medication) 0.5 milligrams (mg) sublingually (administered under the tongue) every four hours as needed The handwritten order failed to indicate a reason to use the PRN psychotropic medication or a re-evaluation or stop date. Review of the Physician's Orders, dated 4/17/24, for Resident #15, indicated but were not limited to the following: - Lorazepam (Ativan) oral concentrate 2 mg per 1 milliliter (ml) give 0.25 ml by mouth every six hours as needed for anxiety (0.25 ml = 0.5 mg) (initiated: 3/29/24) The current physician's orders failed to indicate a re-evaluation or stop date for the use of the PRN psychotropic medication. During an interview on 4/17/24 at 11:59 A.M., the NP said she wrote an order for the Resident for PRN Ativan on 3/29/24 due to the Resident exhibiting some intermittent restlessness, weeping, and anxiety. She said she did not put a re-evaluation or stop date on the medication because she was unsure of the Resident's need for the medication since the Resident's anxiety did not follow an easily determined pattern. She said she was aware the 14-day re-evaluation date was required for psychotropic medications being used on an as needed basis regardless of the Resident being on hospice and she did not put one in place as she should have. During an interview on 4/17/24 at 12:17 P.M., the Unit Manager said she was aware the original PRN Ativan order for Resident #15 did not have a stop date on it and she did not clarify the order with the NP because the Resident was receiving hospice services. She said the facility policy is to limit PRN psychotropic medications to 14 days and then for them to be re-evaluated and this Resident was past the 14-day mark and the PRN use of the Ativan had not been re-evaluated at this time as it should have been. During an interview on 4/18/24 at 1:17 P.M., the Director of Nurses said the expectation is that the facility follows the regulatory guidelines for use of PRN psychotropic medications and those medications are provided with an initial duration date of 14 days for re-evaluation and then, if necessary, are extended with a documented rationale and a new duration date for evaluation. She said the facility policy for PRN psychotropic medication use was not followed in this instance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, observation, and policy review, the facility failed for five Residents (#109, #37, #106, #52, and #70), out of 26 sampled residents, to develop and implement individualized resident-centered care plans to meet the residents' needs. Specifically, the facility failed: 1. For Resident #109, to implement the care plan for the use of cushioned floor mats at the bedside as a fall intervention; 2. For Resident #37, to consistently implement the care plan for the use of a right-hand Carrot (orthotic device in the shape of a carrot used to prevent worsening hand contracture); 3. For Resident #106, to develop a care plan for the use of long term antibiotics/urinary tract infection (UTI) prophylaxis; 4. For Resident #52, to develop a care plan to include goals and interventions for a Resident with limited range of motion; and 5. For Resident #70, to ensure staff implemented the care plan and placed the Resident's meal in their visual field and provided assistance with feeding during meals. Findings include: Review of the facility's policy titled: Care plans, comprehensive person-centered, updated 8/1/23, indicated but was not limited to the following: -a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident -the comprehensive care plan includes: measurable objectives, describes services that are to be furnished, includes resident's goals, builds on resident's strengths, reflects current recognized standards -care plan interventions are chosen only after data gathering and proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes and relevant clinical decision making -interventions address the underlying source of the problem, when possible, not just symptoms or triggers -assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change 1. Resident #109 was admitted to the facility August 2023 with the following diagnoses: unspecified dementia with other behavioral disturbance, restlessness and agitation, and adjustment disorder with mixed disturbance of emotions and conduct. Review of Resident #109's care plan, as of 4/18/24, indicated but was not limited to the following: Focus: I have the potential for falling due to but not limited to alteration in perception and or cognition with decreased safety awareness and/or impulsivity, cardiac dysfunctions, dementia, diabetes, incontinent, potential medication side effects. Resident had a fall on 10/16/23. Goal: I will not have any fall related injury though my next review. Interventions: mats placed beside bedside to prevent injury (date initiated 9/11/2023) The surveyor made the following observations of Resident #109: -4/16/24 at 3:16 P.M., Resident was in bed with no mats placed at the bedside. -4/17/24 at 8:04 A.M., Resident was in bed with no mats placed at the bedside. -4/18/24 at 10:37 A.M., Resident was in bed with no mats placed at the bedside. -4/22/24 at 7:50 A.M., Resident was in bed with no mats placed at the bedside. During an interview on 4/18/24 at 10:37 A.M., Unit Manager #4 said Resident #109 used to have floor mats because he/she would exhibit a behavior of putting himself on the floor and he/she has a history of falls. She said Resident #109 has a scoop mattress now, but the care plan should have been updated if floor mats are not part of the plan of care. She said she wasn't sure when the maintenance director took the floor mats out of the Resident's room. 2. Review of the facility's policy titled Resident Mobility and Range of Motion, dated 8/01/2023, indicated but was not limited to the following: -Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. -Interventions may include therapies, the provision of necessary equipment and/or exercises and will be based on professional standards of practice and be consistent with state laws and practice acts. Resident #37 was admitted to the facility in May 2018 with diagnoses including but not limited to personal history of transient ischemic attack (TIA) and cerebral infarction without residual deficits. Review of the most recent Brief Interview for Mental Status (BIMS) assessment indicated Resident #7 scored a 3 out of 15 indicating severe cognitive impairment. Review of the current Physician's Orders for Resident #37 as of 4/18/24 indicated but were not limited to the following: -Remove Carot (sic) for right hand during am care. Every day shift for poor skin integrity. Remove Carot (sic) to right hand with A.M. care. -To preserve skin integrity, apply Carot (sic) to right hand with P.M. care. Monitor skin integrity related to contracture. Every evening shift for poor skin integrity on with P.M. care and off with A.M. care. Review of the care plans for Resident #37, as of 4/18/24, indicated but were not limited to the following: Focus: - Skin Breakdown Potential: I have a potential for skin breakdown related to but not limited to right hand contracture Goal: -I will remain without any pressure related areas of skin breakdown through my next review (date initiated 5/27/2020, revised on 12/12/2023, target date 4/19/2024) Interventions: -Please insure (sic) that my Right-hand roll is properly placed as ordered by my MD. Inspect my skin and notify my MD for anything abnormal. Review of the Occupational Therapy Discharge summary dated [DATE], indicated but was not limited to the following: -It is recommended that the patient wear a hand roll to R hand at nighttime daily. [NAME] (apply) with P.M. care, Doff (remove) with A.M. care. Nursing staff is aware and agreeable to splinting schedule currently. In-service completed for splinting schedule to continue following discharge from treatment. On 4/17/24 at 7:55 A.M., the surveyor observed Resident #37 in bed; he/she had not yet received morning care and did not have a carrot in their right hand. The right hand was observed in a clenched fist. On 4/18/24 at 7:08 A.M., the surveyor observed Resident #37 in bed with no carrot in their hand. The surveyor detected a strong, foul sweat-like odor when standing next to the Resident on the right side. During an interview on 4/18/24 at 7:29 A.M., Unit Manager #4 met with the Resident with the surveyor. Unit Manager #4 confirmed there was no orthotic in place, and the Resident had not received morning care. Unit Manager #4 said there shouldn't be an odor coming from the Resident's hand and it is likely a result of moisture collecting from the Resident's tight fist. During an interview on 4/16/24 at 1:42 P.M., the Resident's legal guardian said the facility used to have a roll that would be placed in the Resident's hand to prevent their fingers from digging into the palm and to stretch the fingers, but she had not seen the roll in the room in sometime. During an interview on 4/18/24 at 8:01 A.M., the Director of Nursing (DON) said if the staff couldn't find the Carrot that her expectation would be something is placed in the Resident's hand to prevent further decline in range of motion and maintain skin integrity. She said if a physician's order is on the Treatment Administration Record (TAR) the nurse is responsible for ensuring its completion. Review of the TAR indicated that Nurse #4 signed off on the Carrot being in the Resident's hand and removed 12 out of 17 opportunities in April. During an interview on 4/18/24 at 3:38 P.M., Nurse # 4 said she doesn't personally check to see if the carrot is on or off because the unit gets busy. She said she is aware it is on the TAR but the aides should do it. She was unaware that the carrot was not placed in the Resident's hand during the previous observations. She said she depends on the aides to communicate if a resident refuses or an orthotic is missing. 5. Review of the facility's policy titled Assistance with Meals, dated as last revised 8/1/23, indicated but was not limited to the following: -Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. -Facility staff will serve trays and will help residents who require assistance with eating. -Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, for example not standing over residents while assisting them with meals. -Assistance will be provided to ensure that residents can use and benefit from special eating equipment and utensils. Review of the facility's policy titled Assisting the Resident with In-Room Meals, dated as last revised 8/1/23, indicated but was not limited to the following: -Review the resident's care plan and provide for any special care needs of the resident. -The resident should be positioned so his or her head and upper body are as upright as possible with head tipped slightly forward. -Place tray on serving area. Be sure it is adjusted to comfortable position and height for the resident. -Arrange dishes and silverware so that they can be easily reached by the resident. -If the resident refused the meal or to eat, document the reason why and intervention taken. -Notify the supervisor if the resident refuses the meal or to eat. Resident #70 was admitted to the facility in November 2017 with diagnoses which included cerebral infarction (stroke) with hemiparesis and hemiplegia (weakness and paralysis) affecting right dominant side, visuospatial deficit and spatial neglect following intracerebral hemorrhage (brain bleed), and failure to thrive. Review of the MDS assessment, dated 2/3/24, indicated Resident #70 was rarely or never understood and was unable to complete the BIMS. Additionally, the Resident's cognitive skills for daily decision making was severely impaired and he/she had impairment on one side and required supervision/touching for eating. Review of the Comprehensive Care Plans for Resident #70 indicated but were not limited to the following: -FOCUS: VISION: Visual Impairment related to CVA (stroke) with right side visual neglect. -INTERVENTIONS: Please place objects in my field of vision-towards my left side. -FOCUS: ACTIVITIES OF DAILY LIVING (ADL): Assist -INTERVENTIONS: Dependent during meals. The surveyor made the following observations of Resident #70: -4/16/24 at 12:30 P.M., the Resident was sitting in a reclining Broda chair (specialty wheelchair for positioning) in the corner of the day room alone, slumped over in chair; their lunch meal was placed on an overbed tray table and staff walked away. The Resident then picked up the adaptive lip plate (plate with high edge to contain food) and spilt the entire plate of food on their chest and lap, down legs, and on the floor. The Resident was observed playing with the food on his/her lap and staff did not call the kitchen for another meal or provide the Resident with assistance to eat anything else. -4/17/24 at 8:05 A.M., the Resident was sitting in a reclining Broda chair in the corner of the day room alone. At 8:23 A.M., the nurse cut up breakfast, placed the meal on the overbed tray table and walked away. The Resident was observed self-feeding dry cereal from an adaptive blue bowl which was on the left side. The plate with the main meal was on the right side. No staff offered assistance with feeding or cues to eat anything on the plate. -4/17/24 at 12:42 P.M., the Resident was sitting slouched over in a reclining Broda chair in the corner of the day room alone. One staff member sat down next to the Resident, however provided no assistance or verbal cues. The Resident was self-feeding ice cream which was on the left side. The plate with the main meal was on the right side and untouched. The Resident was observed to be leaning forward to the table to gather food as the table was not positioned so the food was within easy reach. A Certified Nursing Assistant (CNA) was observed standing next to the Resident, offered one bite of food from the main plate (which Resident accepted), and walked away. No further assistance was provided. -4/18/24 at 8:35 A.M., the Resident was sitting slouched over in a reclining Broda chair in the corner of the day room alone. The meal was placed on the overbed tray table and the staff walked away. Dry cereal in a blue adaptive bowl was on the left side and a plate with the main meal was on the right side. Resident fed self the dry cereal. Staff did not provide assistance or cues with eating. At 8:55 A.M., CNA #10 cleaned up the breakfast trays from the other residents in the day room and removed table linens. She looked at Resident #70 sitting in the reclining Broda chair not eating or being fed and left the room. Resident #70 was left in the day room with their meal still on the overbed tray table and no one to assist him/her with eating. At 9:53 A.M., Resident #70 pushed the overbed tray table away. Resident #70 remained in the day room unsupervised, unassisted until 10:01 A.M. when CNA #10 removed the plate and cups. Review of Resident #70's medical record including physician's orders, progress notes, flow sheets, and meal documentation record indicated but were not limited to the following: -HCC (diabetic) Diet lipped plate with all meals (8/26/20). -Dietitian's note, dated 2/7/24, indicated Resident was dependent on nursing staff for eating. Suction bowl and lip plate provided at meals to help with self-feeding. -CNA flow sheet indicated Resident was provided with moderate assistance for eating. -Review of the meal percentage sheet indicated Resident #70 had consumed 25-50% of meals during the observation period. Further review of the medical record failed to indicate Resident #70 had been offered and refused meals. During an interview on 4/18/24 at 8:55 A.M., CNA #10 said sometimes they help Resident #70 eat, but it depends on his/her mood. She said the Resident is not always a feed and doesn't eat much. During an interview on 4/18/24 at 10:15 A.M., Unit Manager #3 said Resident #70 is a mix of supervision, assist, and feed and it depends on the day. She said staff should be providing assistance and allowing him/her to do what they can, but still helping as needed. She said he/she has right-side visual impairment so leaving the plate on the right side is not good and they were not following the care plan. During an interview on 4/18/24 at 10:25 A.M., Nurse #6 said Resident #70 likes cereal and tries to eat that independently, but the staff should be offering the other food. During an interview on 4/18/24 at 1:30 P.M., the ADON said Resident #70 has right-sided vision concerns so they should be moving plate to the left and helping with meals per the care plan. During an interview on 4/18/24 at 2:40 P.M., the DON said the staff should be offering assistance and have the food item on his/her left side per the care plan. 3. Resident #106 was admitted to the facility in November 2022 and has diagnoses including: Acute on chronic congestive heart failure, benign prostatic hyperplasia, dysuria (discomfort with urination) and urinary frequency. Review of the most recent MDS assessment, dated 1/20/24, indicated a BIMS score of 6 out of 15 indicating severe cognitive impairment and the Resident's healthcare proxy (HCP) was activated. Review of the Physician's Orders for Resident #106, dated 4/17/24, indicated but were not limited to the following: -Bactrim (an antibiotic) oral tablet 400-80 milligrams (mg) one tablet one time a day for urinary tract infection (UTI) prophylaxis (11/17/23) Review of the physician's notes from April 2023 to current indicated but were not limited to the following: -Resident was seen by a urologist on 4/11/23 and placed on suppressive antibiotic therapy with Bactrim following a cystoscopy (a procedure used to examine the urethra and bladder lining). -Attending physician examined Resident on 4/14/23 and provided diagnosis of dysuria and indicated per urology recommendations the Resident would be on Bactrim for UTI prophylaxis -4/20/23, MD note indicated use of Bactrim for UTI prophylaxis would be indefinite Review of the current care plans for Resident #106, on 4/18/24, failed to indicate a care plan for long term antibiotic suppressive therapy had been developed or implemented. During an interview on 4/17/24 at 1:13 P.M., Unit Manager #1 reviewed the care plans for Resident #106 and said there should be a care plan in place for long term antibiotic use related to the Resident's urinary issues and was not. During an interview on 4/18/24 at 1:21 P.M., the DON said that the Resident is on a long term antibiotic for suppressive therapy and has a known urinary history and should have a care plan in place, but did not. She said the policy for comprehensive care plans was not followed in this circumstance. 4. Review of the facility's policy titled Resident Mobility and Range of Motion (ROM), dated 8/1/23, indicated but was not limited to the following: -As part of the resident's comprehensive assessment, the nurse will identify the resident's: current range of motion of his/her joints; limitations in movement or mobility; opportunities for improvement; and previous treatment and services for mobility. -The care plan will be developed by the interdisciplinary team based on the comprehensive assessment, and will be revised as needed. -The care plan will include specific interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion. -The care plan will include the type, frequency, and duration of interventions, as well as measurable goals and objectives. Resident #52 was admitted to the facility in August 2020 with a diagnosis of Parkinson's disease (disorder of the central nervous system that affects movement). On 4/16/24 at 11:09 A.M., the surveyor observed Resident #52 lying in bed with their arms crossed on their chest, the left and right hand were observed to have fingers closed to the palm. On 4/17/24 at 2:32 P.M., the surveyor observed Resident #52 lying in bed with their arms crossed on their chest, the left and right hand were observed to have fingers closed to the palm. During an interview with observation on 4/18/24 at 12:07 P.M., the surveyor observed Resident #52 lying in bed with his/her arms crossed on their chest with bilateral fingers closed to the palm. Nurse #5 said she was unable to fully extend fingers on either hand of Resident #52. Review of a Physician's Progress Note, dated 6/22/23, indicated Resident #52 continued to have rigidity likely due to Parkinson's disease and contractures (shortening and hardening of tissues leading to rigidity of joints). Review of the Physician Progress Note dated 3/1/24 indicated Resident #52 had bilateral upper extremity contractures. Review of the care plans indicated Resident #52 had Parkinson's disease with progression of symptoms including rigid muscles (any part of the body-may even be painful and limit my range of motion) with a goal of not experiencing further progression of current symptoms through next review, with an intervention of utilizing Baclofen (a medication used to help relax muscles) to help with stiffness. Review of the medical record, including care plans, failed to indicate the upper extremity limited range of motion and the goal and interventions associated with the limited range of motion. During an interview on 4/18/24 at 3:21 P.M., Unit Manager #4 said she observed Resident #52 and then reviewed the medical record and was unable to find any interventions for the contracted hands. During an interview on 4/19/24 at 1:23 P.M., the Assistant Director of Nurses (ADON) said the process was for the nurses to develop care plans for any newly identified concerns and there were no current care plans for the bilateral upper extremity contractures. Refer to F688

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 properly label and date food products and maintain safe and clean equipment in four of four nourishment kitchenettes. Findings include: Review of the facility's policy titled Food Safety for Your Loved One, undated, indicated but was not limited to: - If you plan to bring food and/or beverages into the facility for your loved one, please make sure that the food is handled safely to prevent the risk of food-borne illness. - Food and beverages should be labeled and dated to monitor food safety. - Food and beverages in unmarked or unlabeled containers should be marked with the name of the resident and date that the food item was prepared. - Food and beverages with a hand-written label should be thrown away three days after the date marked. The date being Day 1. - Food and beverages that have gone beyond the manufacturer's expiration date should be thrown away. - Microwave ovens and food thermometers or similar device will be available on the unit. On 4/16/24 at 2:56 P.M., the surveyor observed the following on the Applewood Unit Kitchenette: - The inside of the microwave had food splatter and food debris on the top, bottom, and sides. - The inside of the microwave had paper towels covering the rotating glass plate. - The refrigerator had an opened package of marshmallow candy without resident identification or opened date. On 4/16/24 at 3:11 P.M., the surveyor observed the following on the Elmwood Unit Kitchenette: - The inside of the microwave had food splatter and food debris on the top, bottom, and sides. - A bottle of nectar thick lemon water in the refrigerator was opened with an open date of 3/29/24. The manufacturer label on the bottle indicated the product should be discarded 10 days after opening. On 4/16/24 at 3:23 P.M., the surveyor observed the following on the Driftwood Unit Kitchenette: - The inside of the microwave had food splatter and food debris on the top and sides. - The glass plate on the inside of the microwave had food residue. - A 12-ounce bottle of Celsius energy drink and a 16-ounce bottle of unsweetened iced tea were located on the top shelf of the refrigerator without a date or resident identification label. - A carton of orange juice was opened in the refrigerator and was not labeled with an open date. On 4/16/24 at 3:31 P.M., the surveyor observed the following on the Cherrywood Unit Kitchenette: - The inside of the microwave had food splatter and food debris on the top and sides. - The top plastic portion of the inside of the microwave had bubbling and was breaking apart. - An opened two-liter Coca Cola Zero bottle was on the top shelf of the refrigerator without date or resident identification. - One carton of orange juice, one carton of apple juice, and one carton of cranberry juice were opened and undated in the refrigerator. - Two pieces of pizza were wrapped in aluminum foil in the freezer without a date or resident identification. On 4/17/24 at 12:31 P.M., the surveyor observed the following on the Applewood Unit Kitchenette: - The inside of the microwave had food splatter and food debris on the top, bottom, and sides. On 4/17/24 at 1:09 P.M., the surveyor observed the following on the Driftwood Unit Kitchenette: - The inside of the microwave had food splatter and food debris on the top and sides. - The glass plate on the inside of the microwave had food residue. - A 12-ounce bottle of Celsius energy drink and a 16-ounce bottle of unsweetened iced tea were located on the top shelf of the refrigerator without a date or resident identification label. - A carton of orange juice and a carton of apple juice were open in the refrigerator and were not labeled with an open date. On 4/17/24 at 1:15 P.M., the surveyor observed the following on the Cherrywood Unit Kitchenette: - The inside of the microwave had food splatter and food debris on the top and sides. - The top plastic portion of the inside of the microwave had bubbling and was breaking apart. - Two pieces of pizza were wrapped in aluminum foil in the freezer without a date or resident identification. During an interview on 4/17/24 at 1:45 P.M., the Food Service Director (FSD) said nourishment kitchenettes on each unit are cleaned and stocked daily. The FSD said a dietary aide stocks the nourishment kitchenettes each morning and cleans the inside of the refrigerator. The FSD said a dietary staff member does a deeper cleaning of the unit refrigerators and freezers on Mondays and Wednesdays each week. The FSD said the housekeeping department is responsible for cleaning and maintaining the rest of the nourishment kitchenettes. The FSD said the dietary aides stocking the nourishment kitchenettes would discard any items in the refrigerators or freezers that were not properly labeled. The FSD said when stock items are opened by staff on the units, they are to be labeled with the open date and a use by date that is three days after opening. The FSD said items specifically for a resident should be labeled with their name and the date the item entered the facility. The FSD and the surveyor reviewed the findings of the nourishment kitchenettes. The FSD said all items in the unit refrigerators should be properly labeled based on the facility's policy. During an interview on 4/17/24 at 3:21 P.M., the Housekeeping Manager and the surveyor reviewed the findings of the nourishment kitchenettes, specifically the unit microwaves. The Housekeeping Manager said his department is responsible for maintaining and cleaning the unit microwaves daily. The Housekeeping Manager said there should be no food residue left on the inside of the microwaves. The Housekeeping Manager said it was not safe for the microwave of the Cherrywood Unit Kitchenette to have inside plastic bubbling or broken.

Based on observation, interview, and policy review, the facility failed: 1. To ensure transmission-based precautions (TBP), specifically contact precautions, were implemented according to Centers for Disease Control and Prevention (CDC) guidance, for one Resident (#44), out of three sampled residents; and 2. To ensure staff implemented infection control practices and performed hand hygiene when performing wound care. Findings include: 1. Review of the facility's policy titled Standard Precautions, dated as last revised 8/1/23, indicated but was not limited to the following: -Standard precautions are used in the care of all residents regardless of their diagnoses, or suspected, or confirmed infection status. Standard precautions presume that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents. -Hand hygiene is performed with alcohol-based hand rub (ABHR) or soap and water before and after resident contact and after contact with items in the resident's room. -Gloves are worn when in direct contact with a resident who is infected or colonized with organisms that are transmitted by direct contact (refer to CDC isolation precaution guidelines). -Gowns (clean, non-sterile) are worn to protect skin and prevent soiling of clothing during procedures and resident care activities. Review of the facility's policy titled Handwashing/Hand Hygiene, dated as last revised 8/1/23, indicated but was not limited to the following: -Hand hygiene is the primary means to prevent the spread of infection. -Use an ABHR or soap and water for the following situations: before and after direct contact with residents, before preparing or handling medications, after contact with objects in the immediate vicinity of the resident, before and after entering isolation precaution setting. -Single use disposable gloves should be used when in contact with a resident, or the equipment, or environment of a resident, who is on contact precautions. Review of the facility's policy titled Isolation-Notices of TBP, dated as last revised 8/1/23, indicated but was not limited to the following: -Notices will be used to alert personnel and visitors of TBP, while protecting the privacy of the resident. -When TBP are implemented, notification is placed on the room entrance, so personnel or visitors are aware of the need for and type of precautions. -Contact Precautions: A sign indicating Contact Precautions on the door to the resident's room. Review of the CDC Contact Precautions Sign being used by the facility, undated, indicated but was not limited to the following: STOP: CONTACT PRECAUTION: EVERYONE MUST: -Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: -Put on gloves before room entry. -Discard gloves before room exit. -Put gown on before room entry. -Discard gown before room exit. Resident #44 was admitted to the facility in August 2023 with diagnoses which included open wound left lower leg, open wound right lower leg, and methicillin resistant staphylococcus aureus (MRSA) infection. The surveyor made the following observations of Resident #44: -4/16/24 at 12:14 P.M., Contact Precautions sign posted at the entrance to Resident #44's room, he/she was walking around the room. -4/17/24 at 12:29 P.M., Contact Precautions sign posted at the entrance to Resident #44's room, he/she was sitting on bed eating lunch; Resident #44's lower extremities from sock to knee were visible with dressings on both. -4/17/24 at 1:11 P.M., CNA #1 entered the room with no gloves or gown on, picked up lunch tray and exited the room. CNA #1 placed the lunch tray in the meal cart and did not perform hand hygiene after. -4/17/24 at 1:12 P.M., Nurse #2 entered the room with no gloves or gown on, stood at bedside talking to Resident #44, he then exited the room, did not perform hand hygiene, walked to the medication cart in the hallway, poured mediations for Resident #44, walked back to room, entered the room, again with no hand hygiene, no gloves, no gown, and administered the medications. Nurse #2 then exited the room with no hand hygiene. Review of Resident #44's medical record including physician orders, treatment administration record (TAR), progress notes, and care plans indicated but were not limited to the following: -Contact Precautions related to MRSA every shift for MRSA to wounds (1/19/24). -Doxycycline 100 milligrams (mg) twice daily for wound infection (4/13/24). -TAR indicated Contact Precautions had been signed off as administered daily as ordered. -Progress note dated 4/5/24 indicated wound culture remains positive for MRSA. -Comprehensive Care Plan indicated that Resident was on Contact Precautions for MRSA to wound. During an interview on 4/17/24 at 1:18 P.M., CNA #1 said Resident #44 is on contact precautions for MRSA and we only need personal protective equipment (PPE) (gloves and gowns) when washing the Resident or doing wound care. During an interview on 4/17/24 at 1:16 P.M., Nurse #2 said the Resident did not have an active infection and he/she was on Enhanced Barrier Precautions (EBP) and did not know why the Contact Precaution sign was there. Additionally, he said the EBP doesn't really mean anything, just that we need PPE for dressing changes, they are not real precautions, and you don't need PPE to enter the room. During an interview on 4/17/24 at 1:20 P.M., Unit Manager #3 said Resident #44 is on Contact Precautions for MRSA in the wounds on both legs. She said the wounds were recently re-cultured and are still positive for infection and he/she is on a course on antibiotics to treat the infection. Additionally, she said there may be some confusion with EBP versus Contact Precautions and who needs what PPE and when, but Resident #44 has an active infection, is on Contact Precautions, and staff should be following the sign which indicates the need for hand hygiene, gloves, and gowns to enter the room. During an interview on 4/18/24 at 1:30 P.M., the Assistant Director of Nurses (ADON) said staff should be following the signs posted on the door and with Contact Precautions they should have full PPE (gloves and gown) per the sign, and they should be performing hand hygiene before entering and after exiting the room. During an interview on 4/18/24 at 2:40 P.M., the Director of Nurses (DON) said with Contact Precautions staff should have full PPE (gloves and gown) per the sign. Additionally, they should be doing hand hygiene before entering and after exiting the room, including picking up a tray and before and after med administration. 2. Review of the facility's policy titled Wound Care, dated as revised 8/1/23, indicated but was not limited to: -Use disposable cloth (paper towel is adequate) to establish clean field on resident's overbed table. Place all items to be used during procedure on the clean field. -Wash and dry your hands thoroughly. -Put on exam glove. Loosen tape and remove dressing. -Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. -Put on gloves. -Apply treatment as indicated. -Remove disposable gloves and discard. Wash and dry your hands thoroughly. Resident #28 was admitted to the facility in December 2023. Review of the medical record indicated Resident #28 had a wound to the third toe on the left foot. On 4/18/24 at 2:11 P.M., the surveyor observed Nurse #4 perform wound care for Resident #28 as follows: -Enter the Resident's room and place treatment supplies on the Resident's overbed table (failed to clean the table) -Remove (with bare hands) the left sock of Resident #28, exposing the wound, which was not covered -Put on gloves (failed to perform hand hygiene prior to putting on gloves) -Provide treatment and remove the gloves Unit Manager #4 entered during the treatment to observe the foot of Resident #28. Unit Manager #4 was observed to put on a pair of gloves and directly touch the foot of Resident #28. Unit Manager #4 then walked to the nightstand and picked up a pair of eyeglasses and attempted to put a lens in the glasses (with the same gloves that had been touching the Resident's foot). During an interview on 4/18/24 at 2:40 P.M., Nurse #4 said she did not clean the overbed table prior to putting the supplies down and she did not perform hand hygiene after removing the sock. During an interview on 4/18/24 at 4:35 P.M., the Director of Nurses said hand hygiene should be performed prior to putting on gloves and gloves should be removed, and hand hygiene performed prior to touching eyeglasses.

Based on policy review, document review, and interview, the facility failed to implement an antibiotic stewardship program which included antibiotic use protocols and monitoring antibiotic use in line with the facility antibiotic stewardship program. Specifically, the facility failed to: 1. Ensure monitoring of antibiotic use that did not meet criteria for antibiotic treatment was completed for three Residents #291, #61, and #78, out of a total sample of 26 residents; and 2. Ensure a stop date or clinical rationale was provided for continued use of an antibiotic for one Resident #20, out of a total sample of 26 residents. Findings include: 1. Review of the facility's policy titled Antibiotic Stewardship, dated as updated 8/1/23, 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 -The purpose of our antibiotic stewardship program is to monitor the use of antibiotics in our residents -Orientation, training and education of staff will emphasize the importance of antibiotic stewardship and will include how inappropriate use of antibiotics affects individual residents and the overall community. -If an antibiotic is indicated, prescribers will provide complete antibiotic orders including the following elements: drug name, dose, frequency of administration, duration of treatment, start and stop date, number of days of therapy, route of administration and indications for use -When a nurse calls a physician/prescriber to communicate a suspected infection, he/she will have the following information available: Signs and symptoms, when symptoms were first observed, resident's hydration status, current medication list, allergy information, infection type, and time of the last antibiotic dose. -When antibiotics are prescribed over the phone, the primary care practitioner will assess the resident within 72 hours of the telephone order. -When a culture and sensitivity (C&S) is ordered lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued. Review of the facility's policy titled Antibiotic Stewardship - Orders for Antibiotics, dated as updated 8/1/23, indicated but was not limited to the following: -Appropriate indications for use of antibiotics include criteria met for clinical definition of active infection or suspected sepsis; and pathogen susceptibility, based on culture and sensitivity, to antimicrobial (or therapy began while culture was pending). -Empirical use of an antibiotic based on clinical criteria of suspected sepsis may be appropriate. The staff and practitioner will document the specific criteria that support the suspicion in the clinical record. Review of the facility's policy titled Surveillance for Infections, dated as updated 8/1/23, indicated, but was not limited to the following: -The infection preventionist (IP) or designated infection control personnel is responsible for gathering and interpreting data. -The surveillance should include a review of any or all of the information to help identify possible indicators of infections: antibiotic review Review of the facility's policy titled Infections - Clinical Protocol, dated as updated 8/1/23, indicated, but was not limited to the following: -Based on review of the clinical situation, the physician or provider and staff will identify whether antibiotics are warranted or whether those that have already been started should continue or change. During an interview with the Director of Nursing (DON) and Staff Development Coordinator (SDC) on 4/22/24 at 9:16 A.M., the DON said she is working as the facility's Infection Preventionist (IP) and the SDC is assisting her. The DON said the facility uses McGeer criteria sheets to determine if an infection meets criteria for antibiotic use. The SDC said she is responsible for tracking, monitoring and reviewing antibiotic use in the facility, and she completes and maintains the tracking documents titled Line Listings, for all antibiotic use in the facility. Review of the facility provided tracking documents titled Line Listings, indicated but were not limited to the following: February 2024 - Resident #291 documented as having a urinary tract infection (UTI) with McGeer criteria not being met but was treated with Cipro (an antibiotic). Review of the medical records for Resident #291 failed to indicate a review of the antibiotic use had been completed by the IP or designee and communicated to the physician or nurse practitioner. March 2024 -Resident #61 documented as having a UTI with McGeer Criteria not being met but was treated with Levaquin (an antibiotic). -Resident #78 documented as having a UTI with McGeer Criteria not being met but was treated with Amoxicillin (an antibiotic). Review of the medical records for Resident #61 and #78 failed to indicate a review of the antibiotic use had been completed by the IP or designee and communicated to the physician or nurse practitioner. During an interview on 4/22/24 at 9:37 A.M., both the DON and SDC reviewed the identified issues with Residents #291, #61, and #78 and said they could not locate any additional information or documentation that would indicate any antibiotic reviews had occurred by the IP or designee. The SDC said she sometimes completes reviews with the MD/NP verbally, but does not recall completing an antibiotic review, and there is no documentation in the medical record. The DON said her expectation is for resident use of antibiotics to be reviewed with the MD/NP shortly after initiation, and the outcome of the review to be documented in the medical record. During an interview on 4/22/24 at 9:51 A.M., the DON said the antibiotic stewardship program is not being followed properly as it should be per the facility's policies. 2. Resident #20 was admitted to the facility in December 2023 with diagnoses which included urinary tract infection (UTI), chronic kidney disease, weakness, dehydration, and failure to thrive. Review of the discharge summary from the acute care hospital, dated 12/22/23 indicated but was not limited to the following: -Urine culture was positive for a UTI and was treated with five-day course of antibiotics. -Resident's outpatient Urologist office was contacted and there is NO PLAN for prophylactic antibiotics at this time. -Discharge Medication list did not include an antibiotic. Review of the Physician's Progress Note, dated 12/27/23, indicated Resident was admitted after being treated for a UTI and the current medication list did not include an antibiotic. Review of the Physician's Progress Note, dated 12/29/23, indicated the Nurse Practitioner (NP) spoke to the daughter, who spoke to the Urologist; Urologist sent over a prescription, and apparently, they do want him/her on Bactrim (antibiotic) daily, prophylactically to prevent UTIs. Review of the Physician's Progress Note/admission History and Physical for Long Term Placement, dated 2/6/24, indicated the Resident was recently diagnosed and treated for a UTI and was status post antibiotics. Further review of the note failed to indicate the Resident was on prophylactic antibiotics. Review of the Physician's Progress Note, dated 3/15/24, indicated Resident #20 per their Urologist was on prophylactic Bactrim daily. Further review of the note failed to indicate a clinical rationale for the prophylactic antibiotic. Further review of the medical record failed to indicate a clinical rationale from any provider (Physician, NP, or Urologist) for the continued use of the Bactrim. Unit Manager #3 was unable to locate any documentation since admission from the Urologist indicating the need for prophylactic antibiotics. Review of the Physician's Orders indicated the following: -Bactrim 400-80mg once daily for UTI for 7 days (order written and was discontinued on 12/27/23) -Bactrim 400-80mg once daily for UTI (started 12/30/23 and ended 1/31/24) -Bactrim 400-80mg once daily for UTI (started 1/31/24) Review of the Medication Administration Record (MAR) indicated Resident #20 had received Bactrim once daily as ordered since December 2023. Further review of the progress notes failed to indicate the need for prophylactic antibiotics or why the stop date was removed from the order. Additionally, the Resident had no documented symptoms of a UTI. Review of the Comprehensive Care Plan failed to indicate Resident #20 was on prophylactic antibiotics. During an interview on 4/18/24 at 1:25 P.M., Nurse #6 said she was not sure why Resident #20 was on the Bactrim but assumed it was because he/she had a history of UTIs. During an interview on 4/18/24 at 10:37 A.M., Unit Manager (UM) #3 said she was unable to get any documentation from the Urologist's office indicating he wanted the Resident on prophylactic antibiotics, if so why, and for how long. UM #3 said she had not spoken to the Urologist's office until today and there was no indication any staff had spoken to the office regarding the prophylactic treatment. UM #3 said there should be documentation in the medical record indicating facility staff and Urology discussed the plan regarding the continued use of the Bactrim, how long he/she should be on it and what the indication for long term use was and there was not. During an interview on 4/18/24 at 1:30 P.M., the Assistant Director of Nurses (ADON) said she thinks the Bactrim order came from the Urologist's office and the physician here just kept it. Additionally, she said she tracks it on the line list but there is no documented clinical indication for use in the record that she could find. During an interview on 4/18/24 at 2:40 P.M., the Director of Nurses (DON) said her expectation for prophylactic antibiotics is that the rationale for long term continued use of antibiotics be documented in the medical record and that there be a trial dose reduction to ensure the medication is needed. The DON said the order should be clear, what they are on, for how long, and the reason they need to be on it and this order is not in line with the Antibiotic Stewardship policy with no rationale for prophylactic treatment.

Based on observation, staff interview, and review of the Centers for Disease Control and Prevention (CDC) guidance, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and potential transmission of communicable diseases and infections within the facility. Specifically, for one Resident (#1), of a total of 7 residents infected with COVID-19, from one of two units with COVID-19 cases, the facility failed to ensure appropriate signage was visible and staff used appropriate Personal Protective Equipment while providing care to a COVID-19 positive resident. Findings include: During an interview on 10/19/23 at 8:00 A.M., the Director of Nursing (DON) said that there was a total of seven residents in the facility who were infected with the COVID-19 virus (four on the Driftwood Unit and three on the Applewood Unit). Review of the CDC guidance titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated May 8, 2023, indicated: -HCP [health care personnel] who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). On the Driftwood Unit on 10/19/23 at 10:45 A.M., the surveyor observed Resident #1 (identified by the DON as COVID-19 positive) lying in bed in his/her room. The surveyor observed that there was no isolation sign visible to alert staff, and/or others, that Resident #1 was infected with the COVID-19 virus. During an interview on 10/19/23 at 10:50 A.M., Nurse #1 said that the Droplet/Contact Precaution sign was not visible as it was posted on the outside of the door, and with the door opened inward, it was not visible. Nurse #1 removed the sign from the door and posted it to the right of the entrance to the Resident's room in an area where it could be seen. During an interview on 10/19/23 at 10:51 A.M., the DON, who was on the unit at that time, said that all isolation/precaution signs should be posted in a visible area at the outside entrance of the Resident's isolation room. Review of the Droplet/Contact Precaution sign indicated for all persons to clean their hands when entering and exiting, wear a mask (N95 when performing aerosol generating procedures), eye protection, gown, and gloves. On the Driftwood Unit on 10/19/23 at 11:00 A.M., the surveyor observed Nurse #1 entering the room of Resident #1. The nurse was wearing a blue surgical mask and donned (put on) a yellow isolation gown, gloves, and a face shield. When finished providing care to Resident #1, Nurse #1 doffed (removed) her contaminated PPE in a trash receptacle inside the room and sanitized her hands. During an interview on 10/19/23 at 11:05 A.M., Nurse #1 said that staff are supposed to wear an N-95 mask into rooms of COVID-19 positive residents. The surveyor explained to Nurse #1 that she was observed wearing a surgical mask while providing care to Resident #1 in an isolation room, and not an N-95 mask. Nurse #1 said, That was my mistake. I should have worn an N-95. The Resident's positive for COVID. During an interview on 10/19/23 at 11:06 A.M., the DON, who was on the unit, said that all staff entering the room of a resident infected with the COVID-19 virus are required to wear an N-95 mask.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), whose Plan of Care indicated he/she was dependent for transfers and required physical assistance of two staff members to complete the task, the Facility failed to ensure nursing staff consistently implemented and followed interventions for two staff members to provide assistance during transfers, when on 08/10/23 Certified Nurse Aide (CNA) #1 transferred Resident #1 without another staff member to assist her, during the transfer, Resident #1 became unsteady on his/her feet, slipped off his/her bed and landed on the floor. Findings include: The Facility Policy, tiled Care Plans and Comprehensive Person-Centered, updated on 08/01/23, indicated a Comprehensive, Person-Centered Care Plan includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Resident #1 was admitted to the Facility in June 2010, diagnoses included psychosis, insomnia, anxiety, depression, muscle weakness, Peripheral Vascular Disease, osteoarthritis and history of falling. Review of Resident #1's Significant Change Minimal Data Set Assessment, dated 07/02/23, indicated Resident #1 was totally dependent for transfers and required a minimum of two staff members to participate with transfers. Review of the Activities of Daily Living Care Plan, dated as revised on 07/03/23, indicated Resident #1 was dependent for transfers and required the assistance of two staff members. During an interview on 08/16/23 at 12:55 P.M., Certified Nurse Aide (CNA) #1 said that on 08/10/23 she was the CNA assigned to provide care to Resident #1. CNA #1 said at approximately 7:30 A.M., she transferred Resident #1 from his/her bed to his/her wheelchair, by herself. CNA #1 said during the transfer, Resident #1 began to lose his/her balance, she was unable to hold onto him/her, so she guided him/her to the floor. CNA #1 said she did not review Resident #1's Care Plan that day, but was aware he/she required two staff members for transfers, but did not ask another staff member for assistance. Review of the Nurse Progress Note, dated 08/10/23 and written by Nurse #1, indicated she was called to Resident #1's room during AM care. The Note indicated Nurse #1 found Resident #1 on the floor, on his/her buttocks in a sitting position, with his/her legs extended outward. The Note indicated CNA #1 reported that she had seated Resident #1 on the edge of the bed and attempted to transfer Resident #1 to his/her wheelchair, when Resident #1 slipped off the bed. During an interview on 08/16/23 at 12:00 P.M., Nurse #1 said CNA #1 reported she needed help, that Resident #1 was on the floor. Nurse #1 said when she entered Resident #1's room, Resident #1 was on the floor in a sitting position, his/her back was against his/her wheelchair and his/her legs were extended outward. Nurse #1 said Resident #1 did not say anything, that he/she is nonverbal at baseline, that she assessed Resident #1 and he/she had no injuries. Nurse #1 said two staff members assisted Resident #1 up off the floor and placed him/her in his/her wheelchair. During an interview on 08/16/23 at 2:00 P.M., the Unit Manager said on 08/10/23 CNA #1 transferred Resident #1 without assistance from another staff member, Resident #1 started to fall and CNA #1 guided him/her to the floor. The Unit Manager said Resident #1 required the assistance of two staff members during transfers. The Unit Manager said Resident #1's Care Plan, indicated that interventions included that Resident #1 required two staff members for assistance with transfers. The Unit Manager said CNA #1 was provided with education related to the importance of following residents Care Plans. During an interview on 08/16/23 at 4:53 P.M. Director of Nursing (DON) said that on 08/10/23 CNA #1 transferred Resident #1 without assistance from another staff member, Resident #1 started to fall and CNA #1 guided Resident #1 to the floor. The DON said after reviewing Resident #1's Care Plan, interventions identified in his/her Care Plan included that Resident #1 required two staff members assistance for transfers. The DON said on 08/10/23, CNA #1 should of had another staff member with her assisting with Resident #1's transfer. The DON said it is his expectation that nursing staff implement interventions from residents Plan of Care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility's policy titled Language policy, undated, indicated but was not limited to the following: - this is our residents' home, and we want to do everything we can to make them feel comfortable, satisfied with the care provided and confident they understand what is being said by all of our staff in their presence - employees are to speak English while on duty and in the presence of residents During an interview on 12/8/22 at 10:21 A.M., the surveyor observed two staff (CNA #1 and Housekeeper #1) in Resident #87's room speaking Spanish while the Resident was being groomed. Nurse #3 approached and said Resident #87 does not speak Spanish and only understands English and proceeded to intervene with the staff. CNA #1 said only caregivers should be within the privacy curtain while care is being provided and she should not have been speaking Spanish in front of the Resident. During an interview on 12/8/22 at 10:24 A.M., Housekeeper #1 said she should not have been within the privacy curtain while CNA #1 was providing care to Resident #87, and they are not supposed to speak a foreign language in front of the residents. During an interview on 12/8/22 at 10:26 A.M., Nurse #3 said only the caregiver should be inside the privacy curtain while care is being provided and staff are not allowed to speak a language the Resident could not understand in front of him/her. She said staff should have provided care in a manner that would maintain Resident #87's dignity. During an interview on 12/14/22 at 4:40 P.M., the Director of Nurses said the staff should not be speaking a foreign language in front of the Resident and the guideline for language and dignity was not followed. Based on observation, interview, and policy review, the facility failed to ensure that dignity was provided for two Residents (#1, #87), out of a total sample of 22 residents. Specifically, the facility failed: 1. For Resident #1, to ensure staff did not stand over or leave the Resident to attend to a personal phone call while assisting him/her to eat; and 2. For Resident #87, to ensure the Resident had privacy during care and that staff spoke only a language understood by the Resident while in the Resident's room. Findings include: 1. Review of the facility's policy titled Assistance with Meals, undated, indicated but was not limited to the following: Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity. For example: -Not standing over residents while assisting them with meals Review of a facility document titled Upcoming Mandatory's-Cell Phone Use, Speaking in English, Name Tags, Resident Privacy, undated, indicated but was not limited to the following: -Cell phones are only to be used during your breaks and only in the employee lounge -Cellular phone usage will be prohibited in all other areas of the building except the employee lounge at employee break times -English is the only language allowed to be spoken in the [NAME] except during your breaks and only in the employee lounge Resident #1 was admitted to the facility with diagnoses including dysphagia (difficulty swallowing) and Alzheimer's disease with late onset. Review of the Minimum Data Set (MDS) assessment, dated 11/9/22, indicated Resident #1 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 0 out of 15. The MDS also indicated Resident #1 required extensive assistance with eating. On 12/8/22 at 8:59 A.M., the surveyor observed Resident #1 lying in bed in his/her room. The head of the bed was elevated at approximately a 35 degree angle. Certified Nursing Assistant (CNA) #2 stood over Resident #1 while feeding him/her their breakfast. A chair was not observed next to the Resident's bed. CNA #2's cellular device was heard ringing while feeding the Resident. CNA #2 stopped feeding the Resident and entered the unit hallway to attend to her device. CNA #2 returned and remained standing alongside the Resident feeding him/her for the duration of the meal. During an interview on 12/8/22 at 9:10 A.M., CNA #2 said the Resident's bed was too low and wanted to stand because it was more comfortable for her. She said she should have been sitting while feeding the Resident but did not. CNA #2 said she hit her phone by accident, which was stored in her front pocket, causing it to ring and had to leave the room to turn it off. On 12/13/22 at 8:17 A.M., the surveyor observed Resident #1 sitting up in bed. CNA #4 stood over Resident #1 while feeding him/her their breakfast. A chair was not observed next to the Resident's bed. During an interview on 12/13/22 at 3:10 P.M., Unit Manager (UM) #4 said Resident #1 needed assistance with meals due to his/her advanced age and dementia. UM #4 said staff should have been sitting down to feed the Resident and should not have been using their cellular device. During an interview on 12/15/22 at 3:02 P.M., the Director of Nursing (DON) and Administrator said staff should be sitting down to feed residents and the facility policy regarding personal cell phone use was not followed by staff.

2. Review of the facility's policy titled Change in a Resident's condition or status, undated, indicated but was not limited to the following: - The nurse will notify the resident's attending physician or on-call physician when there has been a refusal of treatment two or more consecutive times Resident #33 was admitted to the facility in September 2021 with diagnoses including chronic combined systolic and diastolic heart failure, atrial fibrillation, and edema. Review of Resident #33's Interim Physician's Order Sheet, dated 12/7/22, indicated an order to Keep legs elevated. Review of the December 2022 Medication Administration Record (MAR) and Treatment Administration Record (TAR) for Resident #33 failed to indicate the order as being implemented for elevation of the legs. The surveyor observed Resident #33 during the following times without his/her legs elevated as ordered: -12/8/22 at 12:10 P.M. and 4:04 P.M., sitting in bedside chair, legs not elevated -12/9/22 at 1:46 P.M. and 3:21 P.M., sitting in bedside chair, legs not elevated -12/13/22 at 12:44 P.M. and 1:01 P.M., sitting in bedside chair, legs not elevated -12/14/22 at 9:54 A.M., sitting in bedside chair, legs not elevated During an interview on 12/13/22 at 1:01 P.M., Resident #33 said he/she had no way to elevate his/her legs when he/she is out of bed and worries it would be uncomfortable and they could potentially trip over a stool. During an interview on 12/13/22 at 1:47 P.M., Nurse #3 said the Resident refuses to elevate their legs while out of bed. Nurse #3 said she does not know if the physician is aware and could not find any documentation in the medical record of the physician being aware of the consistent refusals. During an interview on 12/14/22 at 10:44 A.M., the Director of Nurses said the physician should be made aware of the Resident's refusals and he could not find any evidence in the medical record that this was done. Based on observations, interview, and record review, the facility failed to ensure a physician was notified of changes for two Residents (#27 and #33) in order to alter the treatment, in a total sample of 22 residents. Specifically, the facility failed: 1. For Resident #27, to notify the physician of a recommendation to change the treatment for a wound on the left heel; and 2. For Resident #33, to notify the physician of the Resident's refusal to elevate their feet in order to change the course of treatment. Findings include: 1. Review of the facility's Skin and Wound Protocol Policy, dated November 2020, indicated the physician would be notified of development of a new treatment plan in conjunction with the wound physician and nursing staff. Resident #27 was admitted to the facility in October 2017 with a diagnosis of atherosclerosis (a buildup of plaque on the arteries, restricting blood flow). Review of the medical record for Resident #27 indicated an arterial wound to the left heel had developed in October 2022. Review of the Wound Evaluation and Management Summary from the physician wound consultant, dated 12/1/22, indicated Resident #27 had an arterial wound to the left heel, measuring 2 centimeters (cm) length by 2 cm width by 0.3 cm depth with moderate serous exudate (clear, thin, watery drainage) and hypergranulated tissue (raised tissue). The wound consultant made a recommendation to discontinue the current treatment of Alginate Calcium with Santyl and to start a treatment of Alginate Calcium with silver (which can be used to treat the hypergranulation). Review of the Treatment Administration Record for December 2022 indicated that as of 12/14/22, the treatment to the arterial wound on the left heel was for Alginate Calcium with Santyl. Review of the Nursing Progress Notes failed to indicate the recommendation was reviewed with the physician to determine if a change to the treatment should be ordered. During an interview on 12/15/22 at 8:30 A.M., Unit Manager #2 said the current order for treatment was for Alginate Calcium with Santyl. She said she was not aware the primary care physician for Resident #27 would need to be notified to make changes to wound treatments. She said the physician should have been notified of the recommendation from the wound consultant to change the treatment.

Based on record review and interview, the facility failed to develop a baseline care plan within 48 hours of the resident's admission that promoted and managed the delivery of safe nursing care in accordance with accepted Standards of Nursing Practice for a peripherally inserted central catheter's (PICC) care needs for one Resident (#214), out of a total sample of 22 residents. Findings include: Resident #214 was admitted to the facility in December 2022 with diagnoses including Type 2 diabetes with right foot ulcer, other acute osteomyelitis right ankle and foot, acquired of another left toe, and legally blind. Review of the medical record indicated Physician's Order for the following: - Change PICC dressing on Fridays every eight hours and as needed for soiled/loose/missing dressing. - Change PICC dressing on Fridays every evening shifts every Friday. Measure external length. (12/5/22) Further review of the medical record indicated that there was no documentation in the medical record that a 48-hour care plan with initial goals, care, and maintenance of the PICC line by the facility had been developed. During an interview on 12/8/22 at 12:50 P.M., Nurse #6 reviewed the medical record for Resident #214 and said there was no baseline care plan in place to address the Resident's PICC line care.

Based on record review and interview, the facility failed to ensure that individualized, comprehensive care plans were developed and consistently implemented for three Residents (#91, #48, and #100), out of 22 sampled residents. Specifically, the facility failed: 1. For Resident #91, to develop a care plan for the use of psychotropic medications that identified target behaviors, non-pharmacological interventions, and measurable goals of treatment; 2. For Resident #48, a. to develop a care plan for the use of psychotropic medications that identified target behaviors, non-pharmacological interventions, and measurable goals of treatment, and b. to develop a care plan for the Resident's diagnosis of dementia; and 3. For Resident #100, to develop a care plan for the provision of private duty care to meet the Resident's needs. Findings include: 1. Resident #91 was admitted to the facility in September 2020 with diagnoses including major depressive disorder. Review of the medical record indicated the following Physician's Orders for psychotropic medications: -Sertraline HCl 25 milligrams (mg), once daily for major depressive disorder (9/29/20) Review of comprehensive care plans included but was not limited to: -Focus: Psychotropic medication- I currently accept psychotropic medications for depression (10/14/20) -Interventions: Administer my medication as ordered by my Physician (10/14/20); contact psychiatric services when ordered by my Physician (10/14/20); encourage me to participate in activities I enjoy (10/14/20); monitor me for, and notify my Physician if any related adverse side effects are observed (10/14/20) -Goal: I will achieve the optimal effect from the lowest possible dose of my psychotropic medication through my next review (revised 3/8/22) Further review of the care plan failed to identify Resident specific targeted signs and symptoms of depression, any Resident specific non-pharmacological approaches, and measurable goals to meet the Resident's needs. 2. Resident #48 was admitted to the facility in April 2018 with diagnoses including depression, anxiety, and dementia. a. Review of the medical record indicated the following Physician's Orders for psychotropic medications: -Quetiapine 100 mg at bedtime for psychosis (6/18/21) -Sertraline HCL 100 mg, two tablets daily for depression (4/25/22) -Trazodone 50 mg, two tablets at bedtime for insomnia (9/18/22) Review of comprehensive care plans included but was not limited to: -Focus: Psychotropic medication- I currently accept medications for anxiety disorders, panic attacks, depression, psychosis, insomnia (6/23/20) -Interventions: Contact psychiatric services when ordered by my Physician (6/23/20); encourage me to participate in activities I enjoy (6/23/20); initiate a behavior tracking when appropriate (6/23/20); monitor me for, and notify my Physician if any related adverse side effects are observed (6/23/20); my Physician and or psychiatric services will review my situation and may consider a dose reduction in my psychotropic medications at least every 90 days unless such a reduction would cause an increase in my symptoms (12/2/20) -Goal: I will achieve the optimal effect from the lowest possible dose of my psychotropic medications through my next review (revised 4/29/22); I will not experience adverse side effects related to my psychotropic medications through my next review (revised 4/29/22); I will establish and maintain an appropriate sleep pattern nightly through my next review (revised 4/29/22) Further review of the care plan failed to identify Resident specific targeted signs and symptoms of depression, any Resident specific non-pharmacological approaches, and measurable goals to meet the Resident's needs. During an interview on 12/15/22 at 12:50 P.M., Nurse #11 said she is not aware of specific behaviors or signs/symptoms that the psychotropic medication is treating. She said there should be resident specific, targeted behaviors identified in the care plan with non-pharmacological approaches with measurable goals. b. Review of interdisciplinary care plans failed to indicate a care plan had been developed to address the Resident's specialized needs as it relates to his/her diagnosis of dementia. During an interview on 12/15/22 at 1:18 P.M., the surveyor and Unit Manager #4 reviewed Resident #48 and #91's medical record. She confirmed a care plan for dementia had not been developed for Resident #48 to meet his/her needs and there were no resident-specific targeted behaviors identified for the use of psychotropic medications for Residents #48 and #91. 3. Resident #100 was admitted to the facility in February 2022 with diagnoses including muscle weakness and a history of falls. On 12/14/22 at 12:30 P.M., the surveyor observed Resident #100 in his/her room with a private caregiver by his/her side. Private Caregiver #1 said that there are three staff from a private agency that come into the facility seven days a week from 10:00 A.M. to 6:00 P.M. to provide supervision and hands-on care including, but not limited to bathing, applying lotion to his/her body, dressing, toileting, and walking. Review of comprehensive care plans failed to indicate a care plan had been developed for the provision of hands-on care by private staff eight hours a day, seven days a week. During an interview on 12/15/22 at 9:54 A.M., Unit Manager #2 said that Resident #100 has received private care staff seven days a week for several months. She said a care plan should have been developed to reflect the private care services and a delineation of services provided by the facility and private caregivers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and interview, the facility failed to review and revise the individual care plans for one Resident (#33) regarding elevation of his/her lower extremities and the refusal of that care. The total sample was 22 residents. Findings include: Review of the facility's policy titled Comprehensive Person-Centered Care, dated October 2020, indicated but was not limited to: - care plans will be reviewed and revised by the interdisciplinary team after each assessment Resident #33 was admitted to the facility in September 2021 with diagnoses including chronic combined systolic and diastolic heart failure, atrial fibrillation, and edema. Review of Resident #33's Interim Physician's Order Sheet, dated 12/7/22, indicated an order to Keep legs elevated. Review of the most recent Minimum Data Set (MDS) for Resident #33 indicated it was dated as completed 12/15/22, eight days after the order to keep the legs elevated. Review of the current care plans in place for Resident #33 failed to indicate a plan for leg elevation or a refusal of care interventions. Review of the current care [NAME] (summary of resident's care and preferences) for Resident #33 failed to identify the need for leg elevation, or a history of refusal of care interventions. During an interview on 12/13/22 at 1:47 P.M., Nurse #3 said there was no information on the care plans that would alert staff Resident #33 required leg elevation, or frequently refused this intervention. During an interview on 12/14/22 at 11:21 A.M., the Director of Nurses said there is no care plan in place indicating the Resident requires leg elevation or declines this intervention. He said this process needed to be improved.

Based on observation, record review, policy review, and interview, the facility failed to ensure that care and treatment of a Peripherally Inserted Central-line Catheter (PICC) was provided in accordance with the facility policy/protocols for one Resident (#214), out a total sample of 22 residents. Specifically, the facility failed to ensure the external length of the PICC line was measured and documented per the physician's order. Findings include: Resident #214 was admitted to the facility in December 2022 with diagnoses including type 2 diabetes with right foot ulcer, other acute osteomyelitis right ankle and foot, and legally blind. The Resident had a double lumen PICC line in the right upper arm for the infusion of intravenous (IV) antibiotics. Review of the facility's policy titled Peripherally Inserted Central Catheter (PICC) Policy, dated November 2020, indicated but was not limited to the following: -Insertion is performed by physician or a specially trained Registered Nurse -Chest X-Ray is required after insertion to confirm placement -Apply extension set at time of insertion; it is considered part of the PICC line -Licensed Nurse administers IV through a PICC -Change dressing twice a week and as needed. Dressing covers insertion site and extension set junction -Flush with (5) cc Heparin (100 units/cc) per doctor's orders -Change infusion cap once a week and PRN (as needed) after blood draw or loss of integrity -Change primary IV tubing every 24 hours. Change secondary IV tubing every 24 hours. Review of the Physician's Orders indicated the following: PICC line: -Change dressing on Fridays every eight hours as needed for soiled/loose/missing dressing. -Change PICC dressing on Fridays every shift, every Friday Measure external length. Review of the Medication Administration Record (MAR) and the Nurse's notes indicated that the PICC line dressing was signed as changed as ordered on 12/9/22. The external length was not measured and documented. Review of a Nursing Progress Note dated 12/9/22 at 1:04 P.M., indicated but was not limited to: Dressing done as ordered, vital signs are stable, no symptoms of infection noted. During an interview on 12/14/22 at 12:51 P.M., Nurse #6 said the external length of the PICC line was not measured during the dressing change as ordered. During an interview on 12/14/22 at 1:01 P.M., Nurse #7 said the external length of the PICC was not measured and documented. During an interview on 12/14/22 at 2:00 P.M., Nurse # 15 said the facility failed to ensure that the external length of the catheter was measured as ordered for migration.

2. Resident #33 was admitted to the facility in September 2021 with diagnoses including malignant neoplasm of the bronchus (lung cancer) and chronic combined systolic and diastolic heart failure. Review of the December 2022 Physician's Orders for Resident #33 indicated the following order: - Give Oxygen (O2) at 2 liters (L) via nasal cannula (NC) as needed to maintain oxygen saturations (sats) greater than 90% on room air every 1 hour as needed (PRN) - O2 sat every shift, if less than 92% see PRN Oxygen order - obtain respirations, O2 sat, and temperature every shift, if temp is 100.0 or greater or sats below 92% call MD Review of the December 2022 Medication Administration Record (MAR) and Treatment Administration Record (TAR) for Resident #33 indicated the following: - 12/1/22 - 12/13/22 - there was no documentation on the MAR or TAR that Oxygen had been administered to the Resident, as no sign off had occurred by a licensed nurse, for the PRN Oxygen order - 12/1/22 - 12/13/22 - O2 sat documented above 92% on all days for each shift of the O2 sat every shift order - 12/1/22 - 12/13/22 - O2 sat documented above 92% on all days for each shift of the O2 sat, respirations and temperature order On the following days of the survey, the surveyor observed Resident #33 utilizing oxygen by way of a NC attached to an oxygen concentrator in the Resident's room: - 12/8/22 at 12:19 P.M., Oxygen at 0.5 L via NC - 12/9/22 at 2:31 P.M., Oxygen at 1.5 L via NC - 12/13/22 at 12:38 P.M., Oxygen at 3 L via NC - 12/13/22 at 4:13 P.M., Oxygen at 2.5 L via NC During an interview on 12/13/22 at 4:13 P.M., the surveyor and Nurse #3 observed Resident #33 on Oxygen at 2.5 L via NC. Nurse #3 said she believed the Resident had an order for 2 L of O2 via NC. She said the Resident wears Oxygen all day and she would have to verify the orders. Upon reviewing the medical record, she said the order for O2 was PRN for O2 sats less than 92%, but the Resident prefers to wear the Oxygen at all times for comfort and that would happen at the nurse's discretion; there was no order for that because she was not aware she needed one. She said the PRN Oxygen order has not been signed off as administered because the Resident does not have any documented O2 sats at or under 92%. During an interview on 12/13/22 at 4:24 P.M., Nurse #5 said there is no order in the medical record for the Resident to use oxygen for comfort and Oxygen should not be administered without an order. During an interview on 12/13/22 at 4:36 P.M., the Director of Nurses said an order is required for the staff to administer Oxygen to a resident. He could not explain why Resident #33 was receiving Oxygen without an order. He said an order would need to be received by the physician if the Resident would like to use Oxygen for comfort and the expectation for Oxygen use was not followed. Based on observations, interview, and record review, the facility failed to follow their policy and professional standards of practice to obtain a physician's order for the administration of Oxygen therapy for two Residents (#413 and #33), in a total sample of 22 residents. Findings include: Review of the facility's Oxygen Administration Policy, dated November 2020, indicated but was not limited to the following: -check physician's order for liter flow and method of administration -set the flow meter to the rate ordered by the physician. 1. Resident #413 was admitted to the facility in December 2022 with a diagnosis of chronic obstructive pulmonary disease (COPD- a lung disease that blocks airflow and makes it difficult to breathe). Review of the Hospital Discharge Summary indicated to continue previous home supplemental Oxygen at 2 to 2.5 liters per minute. Review of the December 2022 admission Resident Assessment indicated Resident #413 used 3 liters of Oxygen per minute and had an oxygen saturation (the fraction of oxygen saturated by hemoglobin in the blood) of 89-90% on room air (normal oxygen saturation for healthy adults is usually between 95-100%). Review of the Baseline Care Plan, dated 12/2022, indicated Resident #413 received Oxygen by nasal cannula (device used to deliver supplemental oxygen) at 3 liters per minute. On 12/08/22 at 3:08 P.M., the surveyor observed Resident #413 in bed, wearing a nasal cannula. The oxygen concentrator was observed to be set at 3 liters. On 12/13/22 at 4:25 P.M., the surveyor observed Resident #413 lying in bed, wearing the nasal cannula and the oxygen concentrator was set at 3 liters. Review of the Physician's Orders as of 12/14/22 indicated there were no active orders for Oxygen therapy from 12/6/22 to 12/14/22. Review of Nursing Progress Notes from 12/06/22 to 12/14/22 for Resident #413 indicated the following: 12/06/22 at 3:28 P.M. Oxygen at 3 liters 12/06/22 at 10:02 P.M. Oxygen at 2 liters 12/07/22 at 4:54 A.M. Oxygen at 3 liters 12/07/22 at 2:34 P.M. Oxygen at 3 liters 12/07/22 at 9:17 P.M. Oxygen at 3 liters 12/08/22 at 5:07 A.M. Oxygen at 3 liters 12/08/22 at 1:59 P.M. Oxygen at 3 liters 12/08/22 at 7:13 P.M. Oxygen at 3 liters 12/09/22 at 4:44 A.M. Oxygen at 3 liters 12/09/22 at 2:02 P.M. Oxygen at 3 liters 12/10/22 at 4:38 A.M. Oxygen at 3 liters 12/12/22 at 2:03 P.M. Oxygen at 2.5 liters 12/12/22 at 9:17 P.M. Oxygen at 3 liters 12/13/22 at 3:56 A.M. Oxygen at 3 liters 12/13/22 at 2:56 P.M. Oxygen at 2.35 liters 12/13/22 at 6:53 P.M. Oxygen at 3 liters 12/14/22 at 6:32 A.M. Oxygen at 3 liters 12/14/22 at 12:27 P.M. Oxygen at 2.35 liters During an interview on 12/14/22 at 11:54 A.M., Unit Manager #2 said she could not find a physician's order for Oxygen in the paper record or the electronic medical record for Resident #413. The Unit Manager and the surveyor reviewed the Hospital Discharge Summary together. The Unit Manager said the discharge summary indicated that Oxygen was recommended for 2 to 2.5 liters per minute. The Unit Manager said an order should have been written when the Resident was admitted to the facility to ensure the appropriate Oxygen liters were administered. The Unit Manager was unable to locate a Physician's progress note in the medical record and requested it be faxed to the facility. The Physician's progress note was obtained by the facility on 12/14/22. Review of the Physician's Progress Note, dated 12/13/22, indicated Resident #413 was to continue the home Oxygen rate of 2 liters per minute.

Based on observations, interviews, policy review, and record review, the facility failed to attempt alternatives prior to installing bed rails (side rails), failed to assess risks and benefits of bed rails, and failed to assess resident risk of entrapment for Resident #413, in a total sample of 22 residents. Findings include: Review of the Food and Drug Administration (FDA) Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, dated 03/10/2006, indicated: The term entrapment describes an event in which a resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Resident entrapments may result in deaths and serious injuries. There are 7 zones of bed entrapment: Zone 1 (within the rail), Zone 2 (under the rail), Zone 3 (between rail and mattress), Zone 4 (Under the rail, at the ends of the rail), Zone 5 (between split bed rails), Zone 6 (between the End of the Rail and the Side Edge of the Head or Foot Board) and Zone 7 (Between the Head or Foot Board and the Mattress End). Review of facility's Side Rail Policy, dated November 2020, indicated the following: -The resident upon admission, change in status, or quarterly will have a side rail screen completed by a licensed nurse. -The facility must attempt appropriate alternatives prior to installing a side rail. -Assess each resident for risk of entrapment from side rail prior to installation. -After a facility has attempted alternative measures to side rail use and determined that these alternatives do not meet the resident's needs, the facility must assess the resident for the risks of entrapment and possible benefit of side rails, in determining whether to use the side rails to meet the need of a resident. -The side rail assessment will have all questions answered. -If side rails are indicated, the nurse will select the type of side rail and put it in the comment section. Resident #413 was admitted to the facility in December 2022 with a diagnosis of muscle weakness. Review of the admission Side Rail Assessment for Resident #413 indicated side rails were currently in use, and the Resident wants them for repositioning. The assessment indicated the Resident had a balance deficit and utilized the assist of one person to transfer between surfaces. The section for other interventions that have been tried did not include any additional interventions. The type of rail requested section was blank. The section list all risks/benefits of the bed rail use was blank. On 12/8/22 at 9:40 A.M., the surveyor observed Resident #413 in bed with bilateral side rails in the active, upright position. The head of the bed was elevated, and the Resident was sitting up. The side rail on the left side of the bed was observed to be horizontal to the ceiling. The side rail on the right side of the bed was tilted with the end closest to the headboard higher than the end closest to the footboard, creating a visible gap between the side rail and the mattress, next to the Resident's arm. During an interview on 12/08/22 at 3:07 P.M., Resident #413 said he/she used the side rails to assist with moving while in bed. The side rail on the right side continued to be tilted and the gap between the mattress and the side rail continued to be visible. On 12/13/22 at 9:40 A.M., the surveyor observed Resident #413 sitting up in bed with the head of the bed elevated. The left side rail continued to be in the horizontal position, while the right side rail continued to be tilted with the end closest to the headboard higher than the end closest to the footboard. There was a visible gap between the side rail and the mattress, larger than the arm of Resident #413. On 12/13/22 at 4:25 P.M., the surveyor observed Resident #413 in bed with the head of the bed elevated. The right side rail continued to be tilted, creating a gap between the bottom of the side rail and the mattress. The gap was observed to be approximately four to five inches. The surveyor touched the side rail, which was loose, and was able to move it towards and away from the mattress. During an interview on 12/14/22 at 2:30 P.M., the Maintenance Director said he did not have any documentation to indicate the inspection of the beds in the facility. When the surveyor inquired if the maintenance department had been checking the entrapment zones of the beds, he replied he had never heard of entrapment zones. During an observation with interview on 12/14/22 at 2:30 P.M., the surveyors, the Maintenance Director, and the Director of Nurses (DON) went to the room of Resident #413. The Resident was not in bed and the bed and side rails were able to be observed fully. The bed was in the flat position and the right side rail was observed to be horizontal. The surveyor was able to move the side rail towards and away from the bed and towards and away from the headboard. The Maintenance Director said the bolt was loose and attempted to tighten the side rail. At this time, the Maintenance Director noted the side rail was not attached to the correct position on the bed. He said the side rail had been attached to the part of the bedframe that bends to sit the head of the bed up. The Maintenance Director said this was why the side rail was tilting when the head of the bed was elevated. The Maintenance Director said the process was for the nursing department to inform him when to remove or add side rails and he did not know if the bed frames and side rails were compatible according to the manufacturer's guidelines as the facility only had two types of side rails and he assumed they were compatible. He said he was not sure who put the side rails on the bed of Resident #413 and the side rails may have already been on the bed when the Resident was admitted the week prior. During an interview on 12/14/22 at 2:30 P.M., the DON said the side rails should not have been on the bed when Resident #413 was admitted , as the assessments to determine the need for their use should have been completed prior to the side rails being installed. During an interview on 12/15/22 at 8:20 A.M., Unit Manager #2 said the process was for a side rail assessment to be completed on admission, quarterly, and as needed. The surveyor and the Unit Manager reviewed the admission Side Rail Assessment for Resident #413. The Unit Manager said when side rails were requested for bed mobility the staff did not attempt alternative interventions, which was why that section of the assessment was not completed for Resident #413. She said all sections of the side rail assessment should have been completed by the nursing department.

Based on record review, document review, and interview, the facility failed to maintain an antibiotic stewardship program that includes current antibiotic use for the residents in the facility, including those on prophylactic antibiotics. Findings include: Review of the facility's policy titled Antibiotic Stewardship, dated November 2020, indicated but was not limited to: The purpose of the Antibiotic stewardship program is to monitor the use of antibiotics in our residents. Review of the facility's policy titled Antibiotic Stewardship: Review and Surveillance of Antibiotics, dated November 2020, indicated but was not limited to the following: - antibiotic usage and outcome data will be collected and documented using a facility approved antibiotic surveillance form - data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility wide antibiotic stewardship - the Infection preventionist (IP) 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 - at the conclusion of the review, the provider will be notified of the review findings Resident #33 was admitted to the facility in September 2021 with diagnoses including malignant neoplasm of the bronchus (lung cancer), chronic combined systolic and diastolic heart failure, and retention of urine. Review of the December 2022 Physician's Orders for Resident #33 indicated an order for Doxycycline Hyclate (an antibiotic) 100 milligrams (mg) one time a day for prophylaxis related to retention of urine and urinary tract infection (UTI), that has been active since April 2022. During an interview on 12/13/22 at 1:48 P.M., Nurse #3 said the Resident receives the medication for urinary retention and a past history of UTI. She said she could not find any documentation in the medical record indicating the need for long term antibiotic usage or a re-evaluation of the antibiotic use. She said she was unaware of what the antibiotic stewardship was for the facility. Review of the facility's December 2022 line listing for antibiotics failed to indicate Resident #33 was on antibiotics. During an interview on 12/14/22 at 10:44 A.M., the Infection preventionist (IP) said the list provided contained all antimicrobials for all residents with current infections and they did not have a list, nor were they aware of any residents on prophylactic antibiotics. He said he would look for further information for Resident #33 and any evaluations and provide them to the surveyor. During a follow up interview on 12/14/22 at 11:21 A.M., the IP said there was no documentation regarding the evaluation of antibiotic use or any information on the prophylactic long term antibiotic use for Resident #33. He said as there is no process in place for prophylactic antibiotics at this time and the antibiotic stewardship was not being followed.

Based on interviews and review of Centers for Medicare and Medicaid Services (CMS) guidance, the facility failed to allow residents to have visitors of their choosing at the time of their choosing. The facility also failed to ensure visitors enjoy full and equal visitation privileges consistent with resident preference. Specifically, visitors unvaccinated from COVID-19 were restricted to scheduled visits on Sunday afternoons in the main dining room. Findings include: Review of the CMS memorandum titled Nursing Home Visitation COVID-19, revised 9/23/22 indicated facilities: -must allow indoor visitation at all times and for all residents as permitted under the regulation -can no longer limit the frequency and length of visits for residents, the number of visitors, or require advanced scheduling of visits -visitors are not required to be tested or vaccinated as a condition of visitation Review of a letter from the Administrator to Residents/Family Members and representatives dated 10/29/2021 indicated: -All outdoor activity and scheduled visits for non-vaccinated families will be brought inside. -Scheduled visits will be held at the dining room solarium. -Scheduled visits are Sunday afternoons from 1:00 P.M. to 2:30 P.M. with the last visit to be completed by 2:30 P.M. On 12/12/22 at 10:30 A.M., the surveyor held a group meeting with five residents in attendance. The residents indicated visitation had gotten better but still had some restrictions. During an interview on 12/13/22 at 9:20 A.M., Activity Assistant #2 said family/visitors who were not vaccinated against COVID-19 had to schedule visits on Sundays. She said vaccinated visitors did not need to schedule visits and could come in the facility at any time. During an interview on 12/14/22 at 9:05 A.M., the Activity Director said there were four or five residents with unvaccinated family members. She said the process was for unvaccinated visitors to schedule the visits for Sundays, starting at 1:30 P.M. and the visits could last for 45 minutes. She said the unvaccinated visitors were to enter through the back door and could only visit residents in the dining room. She said if a visitor who was unvaccinated were to arrive at the facility, without an appointment, they would be asked to leave the facility and would need to call to make an appointment. During an interview on 12/14/22 at 9:26 A.M., Receptionist #1 said unvaccinated visitors were absolutely not allowed to come into the building and would be turned away at the door. During an interview on 12/14/22 at 10:55 A.M., Resident #14 said one of their children was allowed to visit in his/her room, while another child had to make an appointment and could only come on Sunday afternoons, and they could only visit in the dining room. During an interview on 12/14/22 at 7:45 P.M., a family member of Resident #35 said the family had restricted visiting hours due to their vaccination status. She said the process was for her and her spouse to visit on Sunday afternoons for up to one hour in the main dining room. She said the son of Resident #35 would like to visit more frequently in the evenings but had been told he could only visit on Sundays. She said the Sunday afternoon appointments were inconvenient to their family and restricted to only two family members, so the grandchildren had not been able to attend the visits. She said the policy was unfair and ridiculous. During an interview on 12/15/22 at 11:20 A.M., the Administrator said visitors who were unvaccinated from COVID-19 had scheduled visits on Sundays. He said the process was for the unvaccinated person to enter through a separate entrance (main dining room) and the visit would be conducted in the main dining room for about 45 minutes. The Administrator said he thought the process for unvaccinated visitors followed guidance from CMS and the Department of Public Health.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #33 was admitted to the facility in September 2021 with diagnoses including chronic combined systolic and diastolic heart failure, atrial fibrillation, and edema. Review of Resident #33's Interim Physician's Order Sheet, dated 12/7/22, indicated an order to Keep legs elevated. Review of the current care plans and care [NAME] (summary of resident's care and preferences) for Resident #33 failed to indicate a plan for leg elevation or a refusal of care interventions. Review of the December 2022 Medication Administration Record (MAR) and Treatment Administration Record (TAR) for Resident #33 failed to indicate the order as being implemented for elevation of the legs. The surveyor observed Resident #33 during the following times without his/her legs elevated as ordered: -12/8/22 at 12:10 P.M. and 4:04 P.M., sitting in bedside chair, legs not elevated -12/9/22 at 1:46 P.M. and 3:21 P.M., sitting in bedside chair, legs not elevated -12/13/22 at 12:44 P.M. and 1:01 P.M., sitting in bedside chair, legs not elevated -12/14/22 at 9:54 A.M., sitting in bedside chair, legs not elevated The surveyor did not observe a stool or any device to assist with the elevation of the legs in Resident #33's room on any days of the observations of the legs not being elevated. During an interview on 12/13/22 at 1:01 P.M., Resident #33 said he/she had no way to elevate his/her legs when he/she is out of bed. During an interview on 12/13/22 at 1:47 P.M., Nurse #3 said the Resident did not have his/her feet elevated related to refusal of that intervention. She said the order was not monitored on the MAR or TAR and not in the plan of care so it would not be easy for someone who does not know the Resident to know this order needed to be implemented. During an interview on 12/14/22 at 11:21 A.M., the Director of Nurses said the order for leg elevation was not being tracked on the MAR or TAR as it should have been and the process for transcribing & implementing orders would need to be improved upon. 2. Resident #27 was admitted to the facility in October 2017 with a diagnosis of a contracture to the right hand. Review of an Occupational Therapy Discharge summary, dated [DATE], indicated the plan was for a right resting hand roll splint to be applied to the hand/wrist by nursing in the morning and removed by nursing staff in the evening. Review of the Physician's Orders for Resident #27 indicated an order to apply the right hand splint every morning and remove every evening and an additional order to check the placement of the hand splint at noon and at 4:00 P.M. During an interview on 12/9/22 at 8:48 A.M., the surveyor observed Resident #27 in bed with their right hand to have three fingers pressed to the palm. Resident #27 demonstrated that he/she would move the thumb and the index finger, but the three other fingers remained pressed to the palm. Resident #27 said he/she did have a splint that he/she will wear occasionally. The surveyor observed the splint to be on the Resident's nightstand. The surveyor observed on the following days and times Resident #27 not wearing the right hand splint: -12/13/22 at 2:32 P.M., Resident in bed, splint on nightstand -12/14/22 at 11:13 A.M., Resident in reclining wheelchair, not wearing splint -12/14/22 at 3:53 P.M., Resident in reclining wheelchair, not wearing splint; the splint was on a different nightstand. Review of the December 2022 Treatment Administration Record (TAR) indicated nurses applied the splint every morning and removed it every evening. The TAR also indicated the splint was checked for placement at noon and 4:00 P.M., and if it was not in place, it was put in to place. Review of the Behavior Flow Sheet for December 2022 indicated the staff were to monitor for the behavior of removing the hand splint. Review of the documentation indicated the Resident did not have this behavior every day in December 2022. During an interview on 12/15/22 at 8:45 A.M., Unit Manager #2 said the nurses should be following the physician's order to apply the hand splint every day, even if Resident #27 will remove it at times. Unit Manager #2 reviewed all the documentation with the surveyor and said the documentation indicated the hand splint was in place every day and had never been removed or refused by the Resident. She said the nurses should be documenting if the Resident refuses or if the splint needs to be re-applied. Based on observation, interview, record review, and policy review, the facility failed to ensure Residents were provided care in accordance with professional standards of practice for four Residents (#5, #27, #33, and #214), from a total sample of 22 residents. Specifically, the facility failed: 1. For Resident #5, to ensure a physician's order for an air mattress was implemented and accurately documented; 2. For Resident #27, to follow the physician's order for a hand splint; 3. For Resident #33, to follow MD orders to elevate the Resident's legs; and 4. For Resident #214, to administer medications in accordance with professional standards. Findings include: 1. Resident #5 was admitted to the facility in September 2014 with diagnoses including hemiplegia and paresis following a stroke. Review of a Minimum Data Set (MDS) assessment, dated 9/7/22, indicated Resident #5 was dependent on staff for all activities of daily living except eating, had functional limitation in range of motion on one side of his/her upper and lower extremities, and had a pressure relieving device for his/her bed. Review of the medical record indicated a Physician's Order for an air mattress set to the Resident's weight (11/1/22=206.2 pounds (lbs.)), check every shift (initiated 7/20/20). On 12/13/22 at 8:05 A.M., the surveyor observed Resident #5 lying in bed on an air mattress. The air mattress was on and set to 5 (from a range of 1 to 6). The air mattress unit did not indicate a weight range for each number setting. Review of Resident #5's weight record indicated a weight of 212 lbs. measured on 12/13/22. During an interview on 12/14/22 at 9:49 A.M., Nurse #6 and Nurse #15 said that they did not know what the number settings on the air mattress corresponded to in regard to weight settings. They said they did not know if the air mattress was set correctly according to the Resident's weight. Review of the December 2022 Medication/Treatment Administration Record indicated nursing staff signed off on all shifts that Resident #5's air mattress was functioning and set accurately to his/her weight. During an interview on 12/14/22 at 10:30 A.M., the surveyor and the Director of Nursing (DON) examined Resident #5's air mattress. The DON said the unit does not specify weight parameters for each of the six settings, and there is no way to determine if it is set according to the Resident's weight. He said nursing can not validate the accuracy of the setting and should not sign off that it is set according to the Resident's weight. 4. Resident #214 was admitted to the facility in December 2022 with diagnoses including atrial fibrillation, type 2 diabetes with right foot ulcer, other acute osteomyelitis right ankle and foot, and legally blind. On 12/9/22 at 10:30 A.M., the surveyor observed the following at the bedside table in the Resident's room: -Liquid protein 30 milliliters (ML) in a cup Review of the medical record indicated Physician's Order for the following: -Protein Fortifier Liquid, Give 30 ML by mouth two times a day for supplement. Further review of the medical record indicated Resident #214 was administered the Protein Fortifier Liquid as per the physician's order, however the nurse left it on the bedside table. During an interview on 12/9/22 at 10:42 A.M., Nurse #5 said that she administered the medication to the Resident this morning. Nurse #5 said she made a mistake because she left the Resident's protein in the cup to be self-administered. During an interview on 12/9/22 at 3:30 P.M., the Director of Nursing said the Nurse should not have left the protein at the bedside.

Based on observations, interviews, and record review, the facility failed to ensure quality of care was provided, according to the plan of care, facility protocols, and professional standards of practice for two Residents (#67 and #214), out of 22 total sampled residents. Specifically, the facility failed: 1. For Resident #67, to ensure wound care treatments were reflective of recommendations from the physician wound consultant and in line with the primary physician treatment plan; and 2. For Resident #214, to promote and manage the delivery of safe nursing care in accordance with accepted Standards of Nursing Practice by failing to inform the Nurse after observing excessive drainage from the Resident's surgical dressing. Findings include: 1. Resident #67 was admitted to the facility in May 2020 with diagnoses of diabetes, a history of an above the knee amputation of the left leg, and a history of an amputation of two toes on the right foot. Review of the medical record indicated on 9/14/22 Resident #67 returned from the hospital with a deep wound to the third toe of the right foot which was bleeding through the dressing. The Resident was sent back to the hospital where he/she received a hemostatic dressing (used to stop bleeding to traumas) and to follow up with a wound physician or podiatrist. Review of the Wound Evaluation and Management Summary from the wound consultant, dated 9/22/22, indicated a trauma to the right third toe measuring 2.2 centimeters (cm) in length by 1 cm in width by 0.7 cm in depth with 50% necrotic tissue and 50% bone. The wound consultant recommended Mupirocin ointment (an antibiotic ointment) followed by a gauze island with border and a gauze roll, once per day. Review of the Physician's Progress Note, dated 9/22/22, indicated the Resident was seen by the wound doctor and there was a suspicion of infection. Review of the Physician's Progress Note, dated 9/30/22, indicated the new wound recommendations were reviewed with the physician and included Mupirocin ointment. Review of the September 2022 Treatment Administration Record (TAR) indicated the following order initiated on 9/16/22 to the right third toe: wash with normal saline, apply Xeroform (a dressing) followed by ABD pad and wrap securely with gauze, daily. Review of the September and October 2022 TAR indicated this order was not changed until 10/27/22. The order from 9/16/22 through 10/27/22 did not include the Mupirocin ointment. Review of the Physician's Progress Note, dated 10/26/22, indicated the Resident was followed by the wound consultant and treatment with Mupirocin continued. Review of the October 2022 TAR indicated a treatment to the right third toe, dated 10/27/22, to wash with normal saline, apply Xeroform (a dressing) followed by ABD pad and wrap securely with gauze, and do not use stretch gauze, daily. The order did not include Mupirocin ointment. Review of the Wound Evaluation and Management Summary from the wound consultant, dated 11/3/22, indicated to add Xeroform sterile gauze, continue Mupirocin ointment, followed by a gauze roll. Review of the November 2022 TAR indicated the order from 10/27/22 continued. The TAR failed to indicate the physician's order for treatment followed the wound consultant's recommendations, by not including the Mupirocin and having an extra ABD pad. Review of the Wound Evaluation and Management Summary from the wound consultant, dated 12/8/22 indicated the wound physician continued to recommend a treatment of Mupirocin ointment, Xeroform sterile gauze, followed by gauze roll. Review of the December 2022 TAR indicated the physician's order for treatment failed to include the Mupirocin and included an extra ABD pad. Review of the Physician's Progress Note, dated 12/6/22, indicated the right third toe was being treated with Mupirocin ointment and Xeroform. During an interview on 12/15/22 at 8:40 A.M., Unit Manager #2 said the process for wound rounds with the wound consultant was that the Unit Manager would review the wound with the consultant and change the recommendations as indicated. She said she was unaware of the recommendation to use Mupirocin ointment since September 2022. She said she had previously been unaware that the wound consultant's recommendations were written in the Wound Management and Evaluation Summary and had not been reviewing them for accuracy. She said Resident #67 should have been receiving the treatment with the Mupirocin ointment since it was recommended in September 2022, almost three months prior. 2. Resident #214 was admitted to the facility in December 2022 with diagnoses including atrial fibrillation, type 2 diabetes with right foot ulcer, other acute osteomyelitis right ankle and foot, and legally blind. On 12/9/22 at 10:49 A.M., Resident #214's family member told the surveyor that the Resident's plantar surgical dressing came off after the Certified Nursing Assistant (CNA) #6 provided morning care to him/her. The surveyor entered the room and noticed the pad that was placed under the Resident's right foot had large amount of serosanguinous (wound drainage) blood that leaked from the right plantar dressing. During an interview on 12/9/22 at 10:54 A.M., CNA #6 said she did not tell Nurse #5 about her observation of the dressing. CNA #6 said she did not know to report that to the Nurse. During an interview on 12/9/22 at 11:00 A.M., Nurse #5 said the CNA should have called her into the room when she noticed that the dressing was leaking. During an interview on 12/9/22 at 3:30 P.M., the Director of Nursing said the CNA failed to notify the Nurse about her observation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document and policy review, the facility failed to ensure all medications used in the facility were labeled in accordance with currently accepted professional principles. Specifically, the facility failed to ensure staff: 1. Properly labeled all medications stored in 1 out of 2 medication storage room refrigerators reviewed; 2. Properly labeled all medications stored in 1 out of 4 medication carts reviewed; and 3. a) Maintained a temperature log for 1 out of 1 vaccination medication refrigerators to preserve the integrity of the vaccines stored, and b) Stored vaccines separately from other medications and removed expired vaccines from the medication storage area. Findings include: Review of facility's policy titled Medication Use, Medication Storage, dated 2005, indicated but was not limited to the following: -Medications will be stored in a manner that maintains the integrity of the product, ensures the safety of the residents, and is in accordance with State and Federal guidelines -Expired, discontinued and/or contaminated medications will be removed from the medication storage areas and disposed of in accordance with facility policy -Medications requiring refrigeration will be stored in a refrigerator that is maintained between 2 to 8 degrees Celsius (36 to 46 degrees Fahrenheit) 1. On [DATE] at 10:37 A.M., the surveyor reviewed the Cherrywood Unit medication storage room with Nurse #12 and observed the following: -One opened bottle of Atropine Sulfate 1% ophthalmic solution (used to dilate the pupil before eye exams) inside the packaging box, not labeled with the date when opened, not labeled with the expiration date, labeled only with a resident's name During an interview on [DATE] at 10:38 A.M., Nurse #12 said the bottle of Atropine should have been labeled when it was opened and when it expired but was not. 2. On [DATE] at 10:20 A.M., the surveyor reviewed the Driftwood Unit, Cart 2, with Nurse #13 and observed the following: -One opened bottle of Atropine Sulfate 1% ophthalmic solution inside the packaging box, not labeled with the date when opened, not labeled with the expiration date, labeled only with a resident's name -One opened bottle of over the counter (OTC) artificial tears inside the packaging box, not labeled with the date when opened, not labeled with the expiration date, labeled only with a resident's name -One opened bottle of OTC Refresh tears inside the packaging box, not labeled with the date when opened, not labeled with the expiration date, labeled only with a resident's name During an interview on [DATE] at 10:21 A.M., Nurse #13 said the eye medications should have been labeled with open dates and expiration dates but were not. During an interview on [DATE] at 3:42 P.M., the Director of Nursing (DON) said he was not sure how long the Atropine ophthalmic or OTC ophthalmic medications were good for once opened and would provide the surveyor with a list of short-term expiration medications for reference. He said the medications should have had open and expiration dates, and because different medications have different expiration dates, staff need to be aware of this information. During an interview on [DATE] at 4:40 P.M., the DON said he does not have a policy specific to the nursing staff for labeling eye drops. He said it was his expectation that the nursing staff would date these medications upon opening them to ensure they are still good and not expired per the manufacturer. 3. Review of the Center for Disease Control and Prevention (CDC) Vaccine Storage and Handling Toolkit document (Updated [DATE], with COVID-19 Vaccine Storage and Handling Information) indicated but was not limited to the following: -Avoid placing or storing any items other than vaccines, diluents, and water bottles inside storage units. - If other medications and biological products must be stored in the same unit as vaccines, they must be clearly marked and stored in separate containers or bins from vaccines. On [DATE] at 2:00 P.M., the surveyor inspected the vaccine storage refrigerator located in the Director of Nurse's (DON) office. a. Review of the temperature logs for the vaccine storage refrigerator indicated that the temperature of the refrigerator was to be monitored and recorded twice a day with the normal temperatures being from 36 degrees Fahrenheit (F) to 46 degrees F. Review of the temperature logs ([DATE] through [DATE]) indicated that on [DATE], [DATE], and [DATE], the temperature of the vaccine refrigerator had not been obtained twice a day as required. b. Observation of the contents inside of the vaccine refrigerator indicated the following: -An unsealed Insulin E-Kit (Emergency Kit) that contained 2 vials of Insulin (Novolog-N and Humalog 75/25) with the E-Kit expiration date of [DATE] -A resident specific medication (Ozempic-used for Diabetes) who no longer resided in the facility -2 multidose vials of the Moderna booster vaccine that had expired 11/2022. During an interview on [DATE] at 2:40 P.M., the DON stated that he had started at the facility 16 days ago and was unaware of the non-vaccine medications that were present in the refrigerator. He said that the Insulin E- kit and the resident specific medication should not have been stored in the refrigerator and should have been discarded. He stated that the Moderna vaccine had expired and should have been removed/discarded and was not.

Based on interview, record review, and policy review, the facility failed to provide the Pneumococcal and Influenza immunizations as requested/consented for 2 Residents (#6 and #46), out of a total sample of 5 residents. Findings include: Review of the facility's policy titled Influenza and Disease Prevention, dated November 2020, indicated residents should be offered the seasonal Influenza vaccine, regardless of length of stay. Review of the facility's policy titled Pneumococcal Conjugate Vaccine (PCV13) and Pneumococcal Polysaccharide Vaccine (PPV23), dated November 2022, indicated residents that have no history of receiving PCV13 or PPV23 should be offered the vaccines; vaccine administration will be documented in the Immunization section of the electronic medical record. 1. Resident #6 was admitted to the facility in February 2022. Review of the medical record for Resident #6 included a consent of immunizations form, signed by the Health Care Proxy (HCP) on 3/1/22. The form indicated the HCP would like for Resident #6 to receive the influenza vaccine yearly. Review of the paper and electronic immunization record for Resident #6 indicated the Resident had not received the influenza vaccine for the 2022 season. 2. Resident #46 was admitted to the facility in December 2021. Review of the medical record for Resident #46 included a consent of immunizations form, signed by the Resident on 11/15/22. The form indicated the Resident would like to receive the influenza vaccine yearly and would like the Pneumococcal vaccine to be administered. Review of the paper and electronic immunization record for Resident #46 indicated the Resident had not received the influenza vaccine for the 2022 season and had not received the Pneumococcal vaccine. During an interview on 12/15/22 at 1:30 P.M., Nurse #15 said Resident #46 had not received the influenza or Pneumococcal vaccines, per the consent forms. During an interview on 12/15/22 at 2:00 P.M., the Director of Nurses said the facility had not administered all vaccines as consented and the facility would be reviewing the vaccine administration procedures.

5. Review of the Centers for Disease Control and Prevention (CDC) guidance titled Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2 dated: September 2022, indicated criteria to determine when healthcare personnel (HCP) with SARS-CoV-2 infection could return to work and are influenced by severity of symptoms and presence of immunocompromising conditions. It further indicated but was not limited to the following: - HCP with mild to moderate illness could return to work after the following criteria have been met: - At least 7 days have passed since symptoms first appeared, if a negative viral test is obtained within 48 hours prior to returning to work or 10 days if testing is not performed or if a positive test at day 5-7; and - At least 24 hours have passed since last fever without the use of fever-reducing medications, and; - Symptoms (e.g., cough, shortness of breath, etc.) have improved. Review of the facility's Staff COVID-19 Line listing from October to December 2022 indicated but was not limited to the following: - Activity Assistant (AA) #2 was identified to be positive for COVID-19 on 10/22/22 and have cold symptoms, they returned to work on 10/28/22, 6 days following their COVID-19 positive test Further review of the staff COVID-19 line listing failed to indicate whether or not AA #2 had a resolution or improvement in symptoms and whether or not a test had been performed to return to work prior to day 10. Review of the October 2022 staff testing logs failed to indicate a negative COVID-19 test for AA #2 to return to work on 10/28/22. During an interview on 12/15/22 at 1:29 P.M., AA #2 said she had woken up on 10/22/22 with nasal congestion and a headache and took a COVID-19 rapid test at home. She said she tested positive and alerted the facility to that. She said she was told by the Director of Nurses at that time, she had to stay home for 5 days and could then return to work. She said she returned to work on the following Friday (10/28/22). She said no one had asked her if she had any improvement or resolution of her symptoms, and she did not know this was a requirement to return to work. She said she believes the facility did test her prior to her returning to work but she could not explain why there was no documentation of the test. During an interview on 12/15/22 at 1:50 P.M., the Administrator, Director ofNnurses, and Assistant Director of Nurses reviewed the staff COVID-19 line listings with the surveyor and said there was no further information that could be found to indicate resolution or improvement in symptoms for AA #2, or any of the 25 staff listed on the document between October 2022 to current. On review of the testing logs they said there was no evidence or documented proof that AA #2 had been tested prior to returning to work on 10/28/22. They said the guidance for return to work following a COVID-19 infection had not been met. Based on observations, interviews, document review, and policy review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to: 1. Post proper signage for residents on transmission- based precautions (TBP) to ensure staff were aware of precaution need and implement appropriate use of personal protective equipment (PPE) to enter a COVID-19 positive resident's room; 2. Ensure infection control practices were followed per accepted standards of practice during the medication administration task by failing to: a. Disinfect reusable equipment (blood pressure cuff) in between resident uses, and b. Ensure hand hygiene was performed when donning and doffing gloves, while preparing medications, and prior to administering medications; 3. For Resident #88, ensure infection control practices were followed per accepted standards of practice during a wound dressing change; 4. Ensure personal beverages were not stored on top of unit medication carts in use; 5. Implement and utilize a system of surveillance for staff, symptomatic or positive for COVID-19, to include return to work criteria; and 6. Follow the 15-minute exposure guidance, as set by the Centers for Disease Control and Prevention (CDC), to manage an outbreak. Findings include: During the entrance conference on 12/8/22 at 9:20 A.M., the Director of Nursing (DON) said he was also the Infection Preventionist. 1. Review of Centers for Disease Control and Prevention (CDC) guidance titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated September 2022, indicated but was not limited to the following: Personal Protective Equipment -Healthcare Personnel who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to standard precautions and use a NIOSH-approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face) On 12/8/22 at 9:15 A.M., the surveyor observed Certified Nursing Assistant (CNA) #2 enter a COVID-19 positive resident's room wearing a N95 facemask and gown. CNA #2 was not wearing eye protection or gloves. CNA #2 removed the resident's breakfast tray from his/her room, placed the tray on top of the personal protective equipment (PPE) cart located outside the doorway, doffed (remove) her gown, then placed the breakfast tray in the food truck in the hallway. Two signs were observed posted outside the resident's room. One being an isolation sign indicating full PPE was required to enter the room and one a stop sign indicating full PPE was to be used in the room for high-contact care only. During an interview on 12/8/22 at 9:22 A.M., CNA #2 said she was only required to wear a N95 and gown in the COVID-19 positive room because she was only getting the breakfast tray. The surveyor reviewed the posted signage with CNA #2 who said she did not understand the PPE requirement. During an observation with interview on 12/12/22 at 8:22 A.M., the surveyor observed Unit Manager (UM) #4 enter a COVID-19 positive resident's room to deliver a breakfast tray wearing a N95 facemask, eye protection, and gown. UM #4 was not wearing gloves. The PPE cart located directly outside the room did not contain gloves inside the drawers or on top of the cart. No gloves were observed directly inside the resident's room. Two signs were observed outside the resident's room. One being an isolation sign indicating full PPE was required to enter the room and one a stop sign indicating full PPE was to be used in the room for high-contact care only. UM #4 said she should have worn gloves prior to entering the room but there were none available in the PPE cart or in the immediate entry way. UM #4 said the posted PPE signs contradicted each other and there should only have been the isolation sign indicating full PPE upon entering the COVID-19 positive room. During an interview on 12/15/22 at 2:43 P.M., UM #4 said all nursing staff are responsible for restocking the PPE carts to ensure all the necessary supplies are readily available and accessible to staff. 2a. Review of CDC guidance titled Recommendations for Disinfection and Sterilization in Healthcare Facilities: Guideline for Disinfection and Sterilization in Healthcare Facilities (2008) indicated: -Ensure that, at a minimum, noncritical patient-care devices are disinfected when visibly soiled and on a regular basis (such as after use on each patient or once daily or once weekly). On 12/12/22 at 8:50 A.M., the surveyor observed Nurse #9 use a portable automated blood pressure cuff on a resident then place it on top of his medication cart when done. Four minutes later, at 8:54 A.M., Nurse #9 placed the cuff in the bottom drawer of the medication cart without disinfecting it first and did not disinfect the top of his medication cart. During an interview on 12/12/22 at 9:20 A.M., Nurse #9 said he should have disinfected the blood pressure cuff after use and disinfected the top of his medication cart. On 12/12/22 at 9:30 A.M., the surveyor observed Nurse #6 use a vitals sign monitoring device to obtain a resident's blood pressure. Nurse #6 wheeled the device to her medication cart and did not disinfect it immediately after use. At 9:40 A.M., the surveyor observed Nurse #6 wheel the device into another resident's room across the hallway and obtained vital signs without disinfecting the device first. During an interview on 12/12/22 at 10:11 A.M., Nurse #6 said she should have disinfected the equipment in between resident uses. b. Review of the facility's policy titled General Guidelines for the Administration of Medications, dated 2005, indicated but was not limited to the following: -Nurse washes hands or disinfects hands approximately before and after medication administration between each resident On 12/12/22 at 8:50 A.M., the surveyor observed Nurse #9 place one whole medication tablet into a clear plastic pouch to be crushed. Once done, the surveyor observed Nurse #9 touch the inside of the pouch with his right index finger to open it up and pour the medication over applesauce without performing hand hygiene first or donning (to put on) gloves. Nurse #9 administered the resident's medications at 8:58 A.M. without performing hand hygiene first. On 12/12/22 at 9:00 A.M., the surveyor observed Nurse #9 place six whole medication tablets into a clear plastic pouch to be crushed. Once done, the surveyor observed Nurse #9 touch the inside of the pouch with his right index finger to open it up and pour the medications over applesauce. Nurse #9 then donned gloves to open two medication capsules and sprinkled them over applesauce. Nurse #9 doffed (to take off) his gloves then administered the medications to the resident. Nurse #9 did not perform hand hygiene before donning gloves, after doffing the gloves, or prior to administering medications to the resident. During an interview on 12/12/22 at 9:20 A.M., Nurse #9 said he should not have touched the inside of the pouches with his fingers and should have performed hand hygiene before and after glove use as well as prior to administering the medications. On 12/12/22 at 9:40 A.M., the surveyor observed Nurse #6 touch the inside of a medication cup with her right index finger just prior to adding the resident's medication tablets. Nurse #6 was not wearing gloves. During an interview on 12/12/22 at 10:11 A.M., Nurse #6 said she did not know she was not supposed to touch the inside of medication cups with her fingers. 3. On 12/13/22 at 11:07 A.M., the surveyor observed Resident #88's wound dressing changes with Nurse #11 and Unit Manager (UM) #4. The following was observed: -UM #4 used a pair of scissors to remove an old left lower extremity dressing. Nurse #11 used the same scissors to cut a sterile dressing (Xeroform) (type of wound dressing that can help keep the wound clean and promote healing) in half (scissors not disinfected in between); Xeroform applied to right lower extremity wound by Nurse #11. -Prior to applying the Xeroform to the right lower extremity, Nurse #11 cleansed the wound with normal saline and did not doff her gloves, perform hand hygiene, and don a new set of gloves first -Nurse #11 did not remove contaminated items from the top of the treatment cart (open bottle of normal saline to cleanse the wounds, various trash items) located in the resident's room before UM #4 removed the cart from the room entering the nurses' station to the clean utility room. UM #4 removed the contaminated items in the clean utility room and disinfected the cart. During an interview on 12/13/22 at 11:45 A.M., Nurse #11 said the items should have been removed and disposed of in the resident's room upon completion of the wound dressing changes. Nurse #11 said she should have changed her gloves and performed hand hygiene prior to applying the new dressing and the scissors should have been disinfected in between uses. 4. On 12/12/22 at 9:30 A.M., the surveyor observed a Dunkin' Donuts coffee cup on top of a medication cart on the Elmwood Unit. The medication cart was in use by Nurse #6. During an interview on 12/12/22 at 10:11 A.M., Nurse #6 said she should not have had her coffee stored on top of the medication cart. During an interview on 12/12/22 at 1:42 P.M., the Director of Nursing (DON) said the vitals equipment should have been disinfected between resident uses and staff should not be touching the inside of the medication cups or plastic pouches with their fingers. The DON further said hand hygiene should have been performed before and after glove use as well as in between patient encounters. He said staff were required to store personal beverages in break rooms and lockers only. During an interview on 12/15/22 at 2:50 P.M., the DON said there should only have been an isolation sign posted outside the COVID-19 positive resident's room, not the stop sign. He said full PPE was required to enter a COVID-19 positive room and the PPE cart should have contained all the necessary supplies to enter the room. The DON further said standards of practice for infection control during the dressing change observation was not met by staff. 6. Review of the CMS guidance titled: Interim Final Rule (IFC), CMS-3401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements, dated September 2022, indicated but was not limited to the following: - An outbreak investigation is initiated when a single new case of COVID-19 occurs among residents or staff to determine if others have been exposed Review of the CDC Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2, dated September 2022, indicated but was not limited to the following in regard to exposure time guidance: - An exposure of 15 minutes or more is considered prolonged. This could refer to a single 15-minute exposure to one infected individual or several briefer exposures to one or more infected individuals adding up to at least 15 minutes during a 24-hour period - Being within 6 feet of a person with confirmed SARS-CoV-2 (COVID-19) infection, distances of more than 6 feet might also be of concern, particularly when exposures occur over long periods of time in indoor areas with poor ventilation - For individuals with confirmed COVID-19 who developed symptoms, consider the exposure window to be 2 days before symptom onset Review of the Administrator's e-mail correspondence with the facility's epidemiologist indicated that on 12/4/22 at 3:07 P.M., the Administrator alerted her to the following: One of our nurses tested positive yesterday afternoon at approximately 2:00 P.M. Here are the facts leading up to her testing positive. Thursday, December 1st: Worked a double 7:00 A.M. - 3:00 P.M. Applewood unit, and 3:00 P.M.-11:00 P.M., Cherrywood unit. Tested Negative before working this day with no symptoms. Friday, December 2nd: Worked 7:00 A.M. - 11:00P.M. Driftwood unit. Tested Negative before working, no symptoms. Saturday, December 3rd: Worked 7:00 A.M. -3:00P.M. on Cherrywood unit did not test before working shift. At end of shift she said she felt fatigued and decided to test herself and she tested positive. Left the facility. I spoke with her and she's sure she did not have contact with any residents within 6 feet and for 15 minutes of longer on Thursday, Friday and Saturday. She said she might have had close contact with one other nurse. As a reminder, we had an asymptomatic resident on Applewood test positive on Friday but she most likely was exposed while going out to her family on Thanksgiving and had been tested every other day since her return on Thanksgiving. Please advise Review of the Administrator's e-mail correspondence with the facility's epidemiologist indicated that on 12/14/22 at 7:56 A.M., the Administrator alerted her to the following: I received a call last evening from one of our licensed nurses, she tested positive last evening (Tuesday, December 13th). She did not work yesterday or Monday (December 12th or 13th). She worked last Saturday (December 10th), had no symptoms, tested herself as part of standard testing and was negative. She worked Sunday (December 11th) 7:00 A.M. - 3:00 P.M. shift. After checking in and during the morning she began to feel nauseous. She left work at 2:00 P.M., she said she didn't even think she might have COVID-19 until not feeling well yesterday, she tested herself at home and she tested positive. She told me quite clearly that she did not have contact with any residents and/or staff within 6 feet for 15 minutes or more. She said there were two residents that she had to do treatments on but she said she only spent 8-10 minutes with these two residents. To be on the safe side we were going to test these two residents going forward. Please let me know if you agree and have any other suggestions. During an interview on 12/14/22 at 7:57 A.M., the Infection Preventionist (IP) said the 15-minute window for exposure is a staff or person to be within 6 feet of an infected person for 15 minutes in one interaction and they have not had anyone who has met that requirement that he is aware of or that has been reported to the epidemiologist by the Administrator. During an interview on 12/15/22 at 2:04 P.M., the Administrator said the exposure times he was reporting to epidemiology for his notification and request for guidance were based on 15 minutes of exposure to someone in a single instance, not a cumulative 15 minutes over a 24-hour time frame; he said he misunderstood the guidance and therefore the information provided to epidemiology was incorrect. He said this information was gathered for contact tracing purposes, but other than the emails to epidemiology he did not have any contact tracing or investigations completed for review as he thought it was just a matter of asking the questions about 15-minute exposure and they do not document an actual contact tracing at the facility. He said the process needed to be updated and improved upon based on the current guidance.

2. Review of the CMS guidance titled Interim Final Rule (IFC), CMS-3401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements, dated September 2022, indicated but was not limited to the following: - Documentation of Testing: a. Facilities must demonstrate compliance with the testing requirements b. Facilities may document the conducting of tests in a variety of ways, such as a log, schedules of completed testing, and/or staff and resident records. During an observation with interview on 12/8/22 at 7:27 A.M., Staff Member #8 said all staff are required to test for COVID-19 twice a week. She indicated the testing are for staff to self-test was in the copy area to the right of the facility ambulance entrance. The surveyor observed more than 14 used Binax testing cards spread out over the desk with the date and name of person who had tested; there were no times labeled on the cards to indicate when the tests were completed. She said staff self-test and then leave the tests in that area for management to verify the results each day. During an interview on 12/8/22 at 12:38 P.M., Human resources staff member (HR) said she, the receptionist, and the assistant director of nurses (ADON) oversee the staff self-testing process. She said staff screen upon entering the facility then proceed to the testing area, following the posted testing guidelines, label their test with the date and their name, set a timer for 15 minutes and wait in the area to document their results prior to reporting to their assigned area. She said then the results are verified and documentation checked and the tests are disposed of. On review of the test cards currently on the desk, it was identified that Nurse #1, Nurse #2 and Activity assistant (AA) #1's testing cards have been on the desk for an extended period of time and there were no results documented in the testing logs. She said she could not explain why those tests were on the table without results being logged on the staff testing logs, but if the results are missing from the log the process is not being followed. During an interview on 12/8/22 at 12:49 P.M., the ADON said the tests need to be read after 15 minutes and the tests are no good once 30 minutes has passed since the time the test was performed. She said AA #1, Nurse #1, and Nurse #2 did not log the results of their tests for the day and should not have left the area until the process was complete. She said because the staff do not time the test cards she has no way of knowing how long the test cards have been sitting out or what the results of those three tests are. She said the process needed to be updated to include test times to ensure tests are completed and documented timely. Review of the time detail for AA #1 indicated that AA #1 reported to work and punched in at 9:19 A.M. on 12/8/22, but her Binax COVID-19 test results were not documented on the staff testing log and the test card remained on the desk at 12:38 P.M. Review of the time verification form for Nurse #1 indicated she had reported to the facility at 7:00 A.M., on 12/8/22, but her Binax COVID-19 test results were not documented on the staff testing log and the testing card remained on the desk at 12:38 P.M. Review of the time verification form for Nurse #2 indicated she had reported to the facility at 6:45 A.M., on 12/8/22, but her Binax COVID-19 test results were not documented on the staff testing log and the testing card remained on the desk at 12:38 P.M. During an interview on 12/15/22 at 1:33 P.M., the ADON reviewed the testing logs and identified numerous staff who had not documented their results and said it appears the process of staff documenting their test results on the log is not working. Based on observation, interview, and document review, the facility failed to implement a cohesive staff testing procedure for COVID-19 testing. Specifically, the facility failed to: 1. Ensure staff conducted Binax COVID-19 tests accurately, waiting the full 15-minute development time; and 2. Ensure results of staff self-conducted Binax COVID-19 tests were documented on the facility testing logs. Findings include: 1. The BinaxNOW COVID-19 Ag Card is a type of test called an antigen test. Antigen tests are designed to detect proteins from the virus that causes COVID-19 in respiratory specimens, for example nasal swabs. This is considered a form of rapid testing as the results are displayed in 15 minutes. Review of the BinaxNOW COVID-19 Ag instructions for completing the test included but was not limited to the following: Precautions: Wear appropriate personal protection equipment (PPE) and gloves when running each test and handling specimens. Change gloves between handling of specimens suspected of COVID-19. Nasal Swab: To collect a nasal swab sample, carefully insert the swab into the nostril exhibiting the most visible drainage or the nostril that is most congested, if drainage is not visible. Using gentle rotation, push the swab until resistance is met (less than one inch into the nostril). Rotate the swab five times or more against the nasal wall then slowly remove from the nostril. Using the same swab, repeat sample collection in the other nostril. Test procedure Open the test card just prior to use, lay it flat and perform assay as follows. (The test card must be flat when performing testing, do not perform testing with the test card in any other position). Hold extraction Reagent bottle vertically, hovering 1/2 inch above the TOP HOLE, slowly add SIX DROPS to the TOP HOLE of the swab well. DO NOT touch the card with the dropper tip while dispensing reagent. Insert sample into BOTTOM HOLE and firmly push upwards so that the swab tip is visible in the TOP HOLE. Rotate (twirl) swab shaft three times CLOCKWISE (to the right). Do not remove swab. Note: False negative results can occur if the sample swab is not rotated (twirled) prior to closing the card. Peel off adhesive liner from the right edge of the test card. Close and securely seal the card. Read results in the window 15 minutes after closing the card. In order to ensure proper performance, it is important to read the results promptly at 15 minutes, and not before. Results should not be read after 30 minutes. Note: When reading test results, tilt the card to reduce glare on the result window, if necessary. Invalid results are as follows: If no lines are seen. If just the Sample Line is seen. The Blue Control line remains blue. Review of the posted facility process for self Binax testing reads as follows: -Staff member enters the building -The staff member assigned to the desk ensures that a temperature is taken, and the staff sign in -The staff member may proceed to the timeclock located in the basement (do not have to walk through any resident care areas) and then are to proceed to the area where the BinaxNOW is performed. The staff are not to go to their assigned unit until the test is performed and they have waited 15 minutes for their results. -The process on how to perform the BinaxNOW is posted on the wall at the testing area. -All the supplies are in the testing area. -The BinaxNOW supplies (bottle of testing solution, nasal swabs and testing cards) are on the counter within the area and the cards are to be placed on the counter after the process is complete. -The staff member performs the BinaxNOW independently. -The staff member places the completed test with their name and the time the test was performed on the counter in the area. -The staff then wait for the results in the sitting area directly outside of the testing area (15 minutes). On 12/14/22 at 7:00 A.M., the surveyor entered the testing area and observed nine used testing cards on the counter in the testing area. Four of the nine testing cards were completed prior to the 15 minutes of the surveyor's arrival. The remaining five cards had concerns related to waiting the 15 minutes for results, and the specific concerns are as follows: 6:50 A.M. testing card on table, staff member not present (did not wait the 15 minutes-(Nurse #10) 6:50 A.M. testing card on table, staff member, not present (did not wait the 15 minutes-(Nurse #16) 6:56 A.M. testing card on table, staff member present, however read the results without verification from another staff member and disposed of the testing care at 7:05 before the 15 minutes (Nurse #17) 6:48 A.M testing card on table, staff member not present (did not wait the 15 minutes-CNA) Testing card with no time on card-Staff member not present (Nurse #18) Additional observations by the surveyor of the staff not performing testing correctly are as follows: -CNA #8- did not lay the test card flat prior to adding the testing solution drops and added more than six drops -Staff #8-did not lay the card flat, added more than six drops (more than 12 drops) and did not swab her nasal passage correctly -At 7:18 A.M., Nurse #6 told the surveyor that she was now overseeing the testing process and did dispose of the test cards and reviewed the results -CNA #2 did not lay the card flat, held the card at an angle in her hand, and placed more than six drops -Nurse #16 was instructed to come back to retest as the first test performed was inconclusive -Therapist #3 did not wait for Nurse #16 to finish the testing procedure and entered the testing area and began to perform her self-test. She added more than six drops and did not rotate the swab to the right/counterclockwise before sealing/closing the card. -CNA #6 did not rotate the swab to the right/counterclockwise before sealing/closing the card During an interview on 12/14/22 at 7:40 A.M., CNA #2 said that she was downstairs in the basement and had not gone to the unit yet. She said that it is okay to be in the basement area before testing, and again stated she was not working on the Unit yet. Review of the schedule indicated that CNA #2 was scheduled on the Applewood Unit 7:00 A.M. to 3:00 P.M., time punch indicated that she punched in at 6:30 A.M. and tested at 7:25 A.M. During an interview on 12/14/22 at 7:45 A.M., Nurse #16 told the surveyor that he was instructed by Nurse #6 to come back to the testing area as the first test was inclusive. The surveyor asked Nurse #16 why at 7:00 A.M., he was not in the area waiting for the results (15 minutes) when the time indicated was 6:50 A.M. He stated that the time on the test card was incorrect and that he had gone down to punch in and then came back up and realized that there was no time on his card, so he approximated the time. Nurse #16 said that it took him approximately 3 minutes to punch in and come back up. The time punch was 6:59 A.M. The surveyor indicated the time difference and Nurse #16 said that he should have waited the 15 minutes for the results and did not before proceeding to the Unit.

Based on observations, interviews, and policy review, the facility failed to ensure a system was developed to conduct regular maintenance and inspections of all bed frames, mattresses, and bed rails (side rails) as part of a regular maintenance program to identify areas of possible entrapment. Findings include: Review of the Food and Drug Administration (FDA) Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment dated 03/10/2006 indicated: The term entrapment describes an event in which a resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Resident entrapments may result in deaths and serious injuries. There are 7 zones of bed entrapment: Zone 1 (within the rail), Zone 2 (under the rail), Zone 3 (between rail and mattress), Zone 4 (Under the rail, at the ends of the rail), Zone 5 (between split bed rails), Zone 6 (between the End of the Rail and the Side Edge of the Head or Foot Board) and Zone 7 (Between the Head or Foot Board and the Mattress End). Review of guidance from the FDA titled Recommendations for Health Care Providers about Bed Rails dated 07/09/2018 included: -Be aware that not all side rails, mattresses, and bed frames are interchangeable and not all bed rails fit all beds. Check with the manufacturer(s) to make sure the side rails, mattress, and bed frame are compatible. -Inspect and regularly check the mattress and bed rails to make sure they are still installed correctly and for areas of possible entrapment and falls. Regardless of mattress width, length, and/or depth, the bed frame, bed side rail, and mattress should leave no gap wide enough to entrap a patient's head or body. -Inspect, evaluate, maintain, and upgrade equipment (beds/mattresses/bed rails) to identify and remove potential fall and entrapment hazards. On 12/8/22 at 9:40 A.M., the surveyor observed a resident in bed with bilateral bed rails. The right bed rail appeared to be tilted with the end closest to the headboard higher than the end closest to the footboard, creating a large gap between the mattress and the bed rail. During an interview on 12/14/22 at 2:15 P.M., the Maintenance Director said he did not have any documentation to indicate the inspection of the beds in the facility. When the surveyor inquired if the maintenance department had been checking the entrapment zones of the beds, he replied he had never heard of entrapment zones. He said there were only two types of bed rails in the facility, and he assumed they were all appropriate for the type of beds but could not be sure if they were compatible. The Maintenance Director said he periodically conducted inspections of rooms, to ensure call lights were in place and there were no obvious hazards but conducting bed inspections was not part of this.