Based on records reviewed and interviews for one of three sampled residents (Resident #1), the Facility failed to ensure his/her Minimum Data Set (MDS) Assessment accurately reflected his/her behaviors of wandering and repeated requests to go home, which contributed to a delay in developing a plan of care and implementing interventions to address these behaviors. Findings include: Review of the Facility Policy titled, Resident Assessment Instrument (RAI) and Care Plan Development, dated as last revised 08/22/2023, indicated the following; -The MDS Assessment uses patient observation, staff, family, and patient interviews to form the foundation of the comprehensive assessment; -The Care Area Triggers are derived from the information coded on the MDS that identify patient who have or at risk for developing specific functional problems that require further assessment; and -The information identified using the MDS and Care Area Assessment process is used to develop an individualized person-centered care plan that includes the patient's voice, the patients' goals while residing in the Facility and for discharge that assists the patient to attain and/or maintain their highest practicable level of well-being. Resident #1 was admitted to the Facility in March 2024, diagnoses include neurocognitive disorder with Lewy Body Dementia (problems with thinking, unpredictable changes in attention and alertness), atrial fibrillation, depression and Parkinson's Disease (disorder of the central nervous system that affects movement, often includes tremors). Review of Resident #1's admission Nursing Progress Notes (located within the admission Collection Tool), dated 03/12/24, indicated he/she had been looking for his/her coat to go out and had been continuously asking to go home. Review of Resident #1's Nurse Progress Note, dated from 03/13/24 through 03/30/24, indicated the following; -On 03/13/24, he/she had been looking for his/her coat to go out and was continuously asking to go home; -On 03/17/24, he/she had been wandering, was intrusive at times going into other resident rooms, and rummaging through trash; -On 03/18/24, he/she had been wandering frequently, intrusive at times, rummaging through other resident belongings and trash; -On 03/21/24, he/she had been wandering, intrusive at times, packing his/her bags and stated that he/she was leaving; -On 03/23/24, he/she had been wandering on unit; -On 03/24/24, he/she had been agitated, anxious, restless, pacing, screaming at others and refusing care; and -On 03/25/24, he/she had been wandering and intrusive at times, attended activities, however, wanders away and attempts to distract him/her works short term only. Review of Resident #1's admission MDS Assessment, section E (Behaviors), dated 03/18/24, indicated he/she had not exhibited any types of behaviors, including wandering, intrusiveness, rummaging, and pacing during the Assessment Reference Period (ARD) 03/12/24 through 03/18/24. However, this was not consistent with Nurse Progress Notes, dated 03/13/24, 03/17/24, and 03/18/24, which documented Resident #1 had exhibited those types of behaviors. Per the Facility's Investigation, on 4/01/24 at approximately 3:30 P.M., Resident #1 walked to the door at the main entrance, a staff member disengaged the lock that opened the front door and Resident #1 proceed to walk out of the entrance and away from the Facility. During an interview on 04/16/24 at 12:16 P.M., the Social Worker (SW) said she had missed Resident #1's nursing notes describing his/her behaviors and realized that she had not captured that information in Section E on Resident #1's MDS. The SW said if she had captured those behaviors within the admission MDS, a Behavior Care Area Assessment (CAA) would have triggered and a wandering and/or behavior care plan with interventions and goals, would have been developed. During an interview on 04/16/24 at 12:48 P.M., the Director of Social Services said he had not realized that Section E, on Resident #1's MDS, had not been completed correctly and said if Section E had been completed correctly, a care plan would have been developed for wandering and/or exit seeking behaviors for Resident #1. During an interview on 04/16/24 at 3:47 P.M., the Director of Nurses said that the coding error on Resident #1's MDS led him/her to not being triggered for wandering and exit seeking behaviors, so no care plan was initiated. The DON said it is the Facility's expectation to complete all sections of the MDS accurately in order to properly care for each resident and develop care plans that are appropriate for each individual resident.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who upon admission wandered, verbalized to staff that he/she wanted to go home and had physician's orders for psychotropic medication for anxiety and depression, the Facility failed to ensure that upon admission, nursing developed and implemented a baseline care plan with interventions, treatments, goals, and outcomes that addressed the residents overall immediate care needs. Findings include: Review of the Facility Policy titled, Baseline Care Plan, dated as last revised 08/11/23, indicated that a baseline care plan will be developed for every resident within 48 hours of admission to provide an initial set of instructions needed to provided effective and person-centered care of the resident that meet professional standards of care. Resident #1 was admitted to the Facility in March 2024, diagnoses include neurocognitive disorder with Lewy Body Dementia (problems with thinking, unpredictable changes in attention and alertness), atrial fibrillation (irregular, often rapid heart rate that commonly causes poor blood flow), depression and Parkinson's Disease (disorder of the central nervous system that affects movement, often includes tremors). Review of Resident #1's admission Nursing Assessment, dated 03/12/24, indicated he/she was noted with the following; -verbalizing wanting to go home with wandering; -exhibited agitation, restlessness, anger and sadness; -taking multiple psychotropic medications; and -risk for falls; Review of Resident #1's Medical Record indicated there was no documentation to support Baseline Care Plans were developed or implemented for Resident #1 within 48 hours of admission addressing his/her immediate needs, with the exception of Advanced Directives. The Baseline Care Plan Form for potential problems and/or areas of concern, including behaviors was left blank. Per the Facility's Investigation, on 4/01/24 at approximately 3:30 P.M., Resident #1 walked to the door at the main entrance, a staff member disengaged the lock that opened the door and Resident #1 proceed to walk out of the Facility. During an interview on 04/16/24 at 12:48 P.M., the Director of Social Services said he was not able to provide any documentation to support that baseline care plans were completed for Resident #1. During an interview on 04/25/24 at 4:18 P.M., the Case Manager said she had no documentation to support that the baseline care plans were ever completed for Resident #1, and said she did not know how Resident #1's Baseline Care Plans slipped through the cracks. During an interview on 04/16/24, the Director of Nurses said she was unaware that Resident #1 had no baseline care plans in place within 48 hours of admission. The DON said that it is the Facility's expectation that all residents have a baseline care plans developed and implemented within 48 hours of admission, that addresses the immediate needs for each resident until the comprehensive assessment is completed.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who upon admission exhibited wandering behavior and verbalized to staff that he/she wanted to go home, the Facility failed to ensure that the Interdisciplinary Team developed and implemented a person-centered comprehensive care plan with interventions, treatments, goals, and outcomes that addressed the resident's risk for wandering and/or elopement. Findings include: Based on the Facility Policy titled Comprehensive Care Plans and Conferences, dated as last revised 08/22/2023, indicated that the facility is required to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and time frames to meet a residents medical nursing, and mental psychosocial needs that are identified in the comprehensive assessment. The Policy also indicated the following; -The Comprehensive Care Plan cannot be completed until the MDS, the Care Area Triggers are addressed through the CAA Assessment Process; and -Identify and collect information that is needed to identify an individual's condition that enables proper definitions of their conditions, strengths, needs, risks, problems, and prognosis. Resident #1 was admitted to the Facility in March 2024, diagnoses include neurocognitive disorder with Lewy Body Dementia (problems with thinking, unpredictable changes in attention and alertness), atrial fibrillation, depression and Parkinson's Disease (disorder of the central nervous system that affects movement, often includes tremors). Review of Resident #1's admission Nursing Progress Note (located within the admission Collection Tool), dated 03/12/24, indicated he/she had been looking for his/her coat to go out and was continuously asking to go home. Review of Resident #1's Nurse Progress Note, dated from 03/13/24 through 03/30/24, indicated the following; -On 03/13/24, he/she had been looking for his/her coat to go out and continuously asking to go home; -On 03/17/24, he/she had been wandering and intrusive at times going into other resident rooms and rummaging through trash; -On 03/18/24, he/she had been wandering frequently and intrusive at times, rummaging through other resident belongings and trash; -On 03/21/24, he/she had been wandering, intrusive at times, and packing his/her bags and stated that he/she was leaving; -On 03/23/24, he/she had been wandering on unit; -On 03/24/24, he/she had been agitated, anxious, restless, pacing, screaming at others and refusing care; and -On 03/25/24, he/she had been wandering and intrusive at times, attends activities, however, wanders away and attempts to distract works short term only. Review of Resident #1's admission MDS Assessment, section E (Behaviors), dated 03/18/24, indicated he/she had not exhibited any types of behaviors, including wandering, intrusiveness, rummaging, and pacing during the Assessment Reference Period (ARD) 03/12/24 through 03/18/24. However this was not consistent with Nurse Progress Notes during the same reference period of time, in which staff documented Resident #1 had wandering and exit seeking behaviors. Review of Resident #1's Comprehensive Care Plan, dated 03/20/24, indicated that there was no documentation to support that a person-centered care plan was developed or implemented for his/her risk for wandering and/or exit seeking (elopement risk) until 04/02/24, the day after Resident #1 actually eloped from the Facility. Review of the Facility Report submitted via the Health Care Facility Reporting System (HCFRS), dated 04/01/24, indicated that Resident #1 got out of the Facility. The Report indicated that on 4/01/24 at approximately 3:30 P.M., Resident #1 walked to the door at the main entrance, a staff member disengaged the lock that opened the door and Resident #1 proceed to walk out of the Facility. During an interview on 04/16/24 at 12:16 P.M., the Social Worker (SW) said she must have missed Resident #1's nursing notes describing his/her behaviors and realized that she had not captured the information in Section E of Resident #1's MDS. The SW said if she had captured those behaviors on the admission MDS a Behavior Care Area Assessment would have triggered and a wandering/elopement and/or behavior care plan would have been triggered to proceed to develop an at-risk care plan. During an interview on 04/16/24 at 12:48 P.M., the Director of Social Services said he had not known that section E was not completed correctly and said if section E had been completed correctly, a care plan would have been developed for a risk for wandering and/or behaviors for Resident #1. During an interview on 04/16/24 at 3:47 P.M., the Director of Nurses said that the coding error on Resident #1's MDS led to him/her not triggering for wandering and therefore no care plan was developed for his/her risk status. The DON said it is the Facility's expectation to complete all sections of the MDS accurately so a complete and accurate care plan is developed for each resident.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who upon admission exhibited wandering behaviors and had verbalized to staff that he/she wanted to go home, the Facility failed to ensure he/she was provided an adequate level of staff supervision to prevent an incident of elopement, when on 04/01/24 at approximately 3:30 P.M., despite his/her photograph being placed at the reception desk alerting staff to the fact he/she was identified as an elopement risk, he/she successfully eloped from the facility when the receptionist on duty let him/her out of the facility. Resident #1 was found at the home of a family member in another town. Findings include: Review of the Facility Policy, titled Unsafe Wandering and Elopement Prevention, dated as last revised 08/10/21, indicated the Facility would promote safety and reduce unsafe wandering and elopements by proactively identifying, care planning and monitoring of Resident wandering and elopement indicators. The Policy further indicated the following; -Residents will be assessed for unsafe wandering and elopement indicators upon admission, readmission, change in condition, quarterly, and with any unsafe wandering or elopement event; and -During the admission and readmission process, a care plan will be initiated by the admitting nurse on any resident assessed with unsafe wandering or elopement behaviors. Review of the Facility Report submitted via the Health Care Facility Reporting System (HCFRS), dated 04/01/24, indicated that Resident #1 got out of the Facility. The Report indicated the facility received a call from a family member who notified them that Resident #1 was at his/her home (previous address prior to admission to the facility). The Report indicated, after walking away from the facility, Resident #1 had been picked up by a good Samaritan and driven to an address provided by Resident #1, but after dropping him/her off, the Samaritan became concerned and notified police in that community (a neighboring town). The Report indicated Resident #1 was unharmed and was brought back to the facility by his/her spouse. Resident #1 was admitted to the Facility in March 2024, diagnoses include neurocognitive disorder with Lewy Body Dementia (problems with thinking, unpredictable changes in attention and alertness), atrial fibrillation, depression and Parkinson's Disease (disorder of the central nervous system that affects movement, often includes tremors). Review of resident #1's Physician's Orders, dated 03/12/24, indicated his/her Health Care Proxy had been activated. Review of Resident #1's admission Minimum Data Set (MDS) Assessment, dated 03/18/24, indicated he/she scored an 8 out of 15 on his/her Brief Interview for Mental Status (BIMS) Assessment (0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired cognition, and 12-15 suggests a resident is cognitively intact). The MDS, Section GG (baseline mobility) indicated Resident #1 required supervision or touch assist with ambulating 10 feet and with ambulation of 50 feet, including making two turns. Review of Resident #1's Physician Progress Note, dated 03/12/24, indicated he/she scored a 3 out of 30 points (indicating severe cognitive impairment) on the Mini-Mental State Exam (MMSE, mild severity is greater than or equal to 20, mild to moderate cognitive impairment is 10-26, moderate to severe cognitive impairment is less than 14, and severe cognitive impairment is less than 10). Review of Resident #1's admission Nursing Progress Note, (located within the admission Collection Tool), dated 03/12/24, indicated he/she had been looking for his/her coat to go out and continuously asking to go home. Review of Resident #1's Nurse Progress Note, dated from 03/13/24 through 03/30/24, indicated the following; -On 03/13/24, he/she had been looking for his/her coat to go out and continuously asking to go home; -On 03/17/24, he/she had been wandering, was intrusive at times going into other resident rooms and rummaging through trash; -On 03/18/24, he/she had been wandering frequently, was intrusive at times, rummaging through other resident belongings and trash. -On 03/21/24, he/she had been wandering, was intrusive at times, had been packing his/her bags and stated that he/she was leaving; -On 03/23/24, he/she had been wandering on unit; -On 03/24/24, he/she had been agitated, anxious, restless, pacing, screaming at others and refusing care; and -On 03/25/24, he/she had been wandering, was intrusive at times, attended activities, however wanders away, attempts by staff to distract him/her worked short term only. Review of the Facility Surveillance Video Footage, dated 04/01/24 at 3:30 P.M., clearly showed Resident #1 exiting the Facility through the main entrance once a staff member (receptionist seat at desk) unlocked the door via a release/locking device behind the reception desk. The Video also showed that Resident #1 had approached the main entrance door alone and that there were no visitors, staff members, or other residents seen with him/her. During an observation on 04/16/24 at approximately 8:00 A.M., the Surveyor observed the Facility Reception Desk, directly upon entrance to the Facility. The Surveyor had to be let in by the receptionist sitting behind the front desk, who must hit a button to allow visitors in and out. The reception desk was surrounded by a wall of Plexiglas and no staff, visitors, or residents would be able to access the release / unlock feature for the main entrance door unless they were behind the desk. During an interview on 04/16/24 at 2:03 P.M., Receptionist #2 said that Resident #1's photograph had been hanging at the front desk for some time and said he/she would often go to the front desk on the evening shift (4:00 P.M.-8:00 P.M.) and she would have to call the Nurse to help get him/her back to the unit. During an interview on 04/16/24 at 2:24 P.M., Certified Nurse Aide (CNA) #2 said that Resident #1 was always wandering and that he/she would go to the front desk a lot and the receptionist would have to send him/her back to the unit. During a telephone interview on 04/23/24 at 12:05 P.M., Nurse #1 said she thought Resident #1 was at risk for elopement and said she had assumed his/her elopement assessment was completed correctly and that he/she had a wandering/elopement risk care plan in place. During a telephone interview on 04/24/24 at 2:03 P.M., the Unit Manager said that she had not read Resident #1's admission Nurse Progress Note and had not realized he/she had been looking to go home upon admission. The Unit Manager said she was not aware of his/her elopement assessment results or that Baseline and Comprehensive Care Plans were never developed for Resident #1 as being at risk for wandering/elopement. During an interview on 04/16/24 at 3:15 P.M., the Assistant Director of Nurses (ADON) said at first they had not identified Resident #1 at risk for elopement, but said as time went on they had identified his/her to be at risk for elopement. The ADON said she had not read Resident #1's admission Nurse Progress Note indicating he/she was asking to go home and wandering. The ADON said that a photograph of Resident #1 was placed at the front desk (exact date unknown) but acknowledged that it was done so prior his/her elopement. The ADON said that as soon as they identified Resident #1 was at risk for elopement a new elopement assessment and care plan should have been developed. During an interview on 04/16/24 at 3:47 P.M., the Director of Nurses (DON) said that the Unit Manager had placed a picture of Resident #1 at the reception/front desk because he/she was very ambulatory, wandered frequently and looked like a visitor. During an interview on 04/16/24 at 3:35 P.M., the Administrator said that the only way to exit the front door was to be buzzed out by a staff member who is behind the front desk. The Administrator said that Receptionist #1 had been working at the time of the elopement and said Receptionist #1 continued to repeat that Resident #1 had looked like a visitor. The Administrator said Resident #1's picture had been hanging at the reception desk and that Receptionist #1 had not noticed that she had let Resident #1 out the front entrance.

Based on observation, interview, and policy review, the facility failed to maintain and consistently implement an infection prevention and control program to provide a safe, sanitary, and comfortable environment and to help prevent the development and potential transmission of communicable diseases and infections for one Resident (#7), out of a total sample of 18 residents. Specifically, the facility failed to ensure Enhanced Barrier Precautions (EBP), including a gown, was consistently implemented during care. Findings include: Review of the facility's policy titled Enhanced Barrier Precautions, revised 6/12/23, included but was not limited to: -The facility may use Enhanced Barrier Precautions (EBP) as an additional MDRO (multi drug resistant organism) mitigation strategy for residents that meet the following criteria, during high-contact resident care activities. -Indwelling medical devices (e.g., central line, urinary catheter, feeding tube, trach, ventilator) regardless of MDRO colonization status. -Post clear signage on the door or wall outside of the resident room indicating Resident is on Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that require the use of a gown and gloves. Examples of high-contact resident care activities requiring gown and glove use include device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator. Resident #7 was admitted to the facility in March 2022 with diagnoses including dysphagia (swallowing difficulties) and presence of a gastrostomy tube (also called a G-tube- is a tube inserted through the belly that brings nutrition directly to the stomach). Review of the Physician's Orders for Resident #7 included but was not limited to: -Enteral Feed Order every shift Jevity 1.5 liters at 70 milliliters (ml)/hour for 16 hours via pump. Flush with 200 ml purified water every 4 hours (1/18/24) -Enhanced Barrier Precautions (7/10/24) -Morphine Sulfate (narcotic pain reliever) Concentrate Oral Solution 20 milligrams (mg)/ml two times a day (1/18/24) On 1/31/24 at 8:14 A.M., the surveyor observed a three-tiered plastic cart outside of Resident #7's room. Two of the three drawers contained disposable gowns. EBP signage was posted on the doorframe of Resident #7's room. On 1/31/24 at 8:16 A.M., the surveyor observed an enteral feeding pump (a medical device that is used to deliver nutrients directly into the gastrointestinal (GI) tract) with tubing connected to the pump at Resident #7's bedside. The pump was not in use and had unsecured tubing hanging down to the floor with the uncapped transition connector tip (end of the tubing that connects directly to the G-tube) lying directly on the floor. On 1/31/24 at 8:47 A.M., the surveyor observed Unit Manager #1 enter Resident #7's room and place a small syringe of medication and a cup on the overbed table, sanitize her hands, and put gloves on. Unit Manager #1 did not put a gown on. She poured water and liquid medication into an oral feeding syringe (used to deliver feeding or medication) connected to the G-tube and administered the medication. Upon completion of the medication administration, she took the feeding tube with the uncapped transition connector that was lying on the floor and told the surveyor she was going to attach the feeding tube to the port. Prior to the Unit Manager connecting the contaminated connector to the G-tube, the surveyor intervened and asked her to explain the process for G-tube tubing and uncapped connector that is lying on the floor. She inspected the connector and said she mistakenly thought it had a cap on it, and she needs to change the entire tubing set because it is contaminated. During an observation with interview on 1/31/24 at 9:00 A.M., the surveyor observed Unit Manager #1 enter Resident #7's room with a new tubing set, sanitize her hands, and put gloves on. Unit Manager #1 did not put a gown on. Unit Manager #1 then attached the new tubing to the pump and to Resident #7's G-tube port. Although the EBP sign was posted at Resident #7's doorway, Unit Manager #1 said she only needed to wear gloves to administer medications and feeding through a G-tube. During an interview on 1/31/24 at 11:03 A.M., Unit Manager #1 said she read the enhanced precautions sign posted at the Resident's door again and said she should have worn a gown when administering care to Resident #7's G-tube. During an interview on 1/31/24 at 2:00 P.M., the Staff Development Coordinator said Unit Manager #1 last completed training on infection control precautions, including EBP, on 5/7/23 and should have known to wear both a gown and gloves while providing care to Resident #7.

Based on interviews, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service. Specifically, the facility failed to designate a person who met the minimum qualifications to serve as the Director of Food and Nutrition Services. Findings include: During an interview with the Dietitian and the Food Service Manager (FSM) on 1/29/24 at 10:40 A.M., the Dietitian said she is employed 32 hours per week and is in the building four days a week. The FSM said he has been employed since September 2023 and currently is not certified as a Food Service Director. He said he is enrolled in an online class starting in February. During an interview on 1/31/24 at 1:00 P.M., the Dietitian said most of the time when she is in the building, she is in meetings. She said she has tried to help in the kitchen and provide some education and support to the Food Service Manager, but it has been tough. During an interview on 1/31/24 at 2:15 P.M., the Administrator said he understands the FSM does not currently meet the qualifications to be the Food Service Director and the Dietitian needs to work 35 hours (full-time) and she is working only 32 hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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: 1. Ensure milk cartons stored in the milk chest and served to the residents were not expired; 2. Handle ready-to-eat food (food which does not require cooking or further preparation prior to consumption) utilizing proper hand hygiene to prevent cross contamination. In addition, ensure the use of gloves was limited to a single use task; 3. Ensure the floor in front of the food service line was maintained in a sanitary condition when food service operation was occurring; 4. Service the main kitchen ice machine per the facility policy; 5. Ensure food items designated as emergency supply were stored in a clean environment and were not expired; and 6. Ensure the clean side of the dishwasher in the dish room was maintained in a clean, sanitary condition to prevent cross contamination to the clean dishes exiting the dish machine. Findings include: Review of the facility's policy titled Resident Dining Services, dated 4/26/23, indicated but was not limited to the following: -Store, prepare, distribute, and serve food in accordance with professional standards for food service safety. -Flatware will be wrapped, and food, desserts, salads, and beverages will be covered before being transported throughout the facility. Review of the facility's policy titled Food Safety, dated 4/26/23, indicated but was not limited to the following: -Cross-contamination- means the transfer of harmful substances or disease-causing microorganisms to food by hands, food contact surfaces, sponges, cloth towels, or utensils which are not cleaned after touching raw food, and then touch ready-to-eat foods. -Food will not be stored in the locker room, bathroom, dressing room, garbage room, mechanical room, under sewer lines, sprinkler heads, or water lines under which water has condensed, and under open stairwells. -The first in, first out (FIFO) method is used in food storage or according to state regulation. -Foods are prepared and served with clean tongs, scoops, forks, spoons spatulas, or other suitable implements so as to avoid manual contact with prepared foods. -Tongs must be used when serving rolls, pickles, etc., cakes and pies must be placed on a plate with a spatula. Review of the 2022 Food Code by the U.S. Food and Drug Administration (FDA) indicated but was not limited to: -4-602.11 Equipment Food-Contact Surfaces and Utensils. (E)(4) In EQUIPMENT such as ice bins and BEVERAGE dispensing nozzles and enclosed components of EQUIPMENT such as ice makers, cooking oil storage tanks and distribution lines, BEVERAGE and syrup dispensing lines or tubes, coffee bean grinders, and water vending EQUIPMENT: (a) At a frequency specified by the manufacturer, or (b) Absent manufacturer specifications, at a frequency necessary to preclude accumulation of soil or mold. -3-304.15 Gloves, Use Limitation. (A) If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. 1. On 1/31/24 at 8:25 A.M., the surveyor observed the main kitchen's milk chest and there were two crates filled with a mixture of whole milk and 1% milk cartons, all with various dates. In both crates, there were observed numerous 1% milk cartons dated 1/30/24. The surveyor then observed the breakfast tray line ice bath of milk cartons and observed numerous cartons of milk dated 1/30/24. During an interview on 1/31/24 at 8:30 A.M., the Food Service Director (FSD) said the milk dated 1/30/24 should not have been in the milk chest or on the tray line for morning's breakfast service. He said after a meal service the dietary staff has been putting the cartons of milk back into the crates in the milk chest and they should not be doing that. On 1/31/24 at 9:00 A.M., the surveyor observed milk cartons, dated 1/30/24, on residents' breakfast trays in the following rooms: -room [ROOM NUMBER] -room [ROOM NUMBER] -room [ROOM NUMBER] -room [ROOM NUMBER] -room [ROOM NUMBER] -room [ROOM NUMBER] During an interview on 1/31/24 at 9:18 A.M., the Director of Nurses (DON) and the surveyor observed a milk carton on a breakfast tray in room [ROOM NUMBER], dated 1/30/24. The DON said the milk cartons dated 1/30/24 should not have been served during breakfast service today. During an interview on 1/31/24 at 11:50 A.M., the Administrator said he was made aware of the milk served during this mornings breakfast service was dated 1/30/24. He said there should have been an immediate action plan to correct the problem. 2. On 1/31/24 at 7:30 A.M., the surveyor made the following observation during breakfast service tray line: -Cook #1 started the breakfast service tray line plating the French toast, English muffins, and toast with gloved hands. [NAME] #1 was observed wearing the same gloves during the observed breakfast service, leaving the tray line to obtain supplies, handling the plates, insulated dome covers and bottoms, which were received from the dietary staff not wearing gloves, and touching the oven doors. [NAME] #1 was not observed to change his gloves. -Dietary Staff #2 was observed handling the silverware with no gloves, touching the food-contact ends during breakfast tray line service. During tray line service, Dietary Staff #2 was observed preparing breakfast trays, reaching into ice baths for milk cartons, juice containers, and the silverware. On 1/31/24 at 12:30 P.M., the surveyor observed [NAME] #1 plating the dinner rolls with gloved hands. [NAME] #1 was observed wearing the same gloves during lunch service leaving the tray line to obtain supplies, handling the plates, insulated dome covers and bottoms which were received from the dietary staff not wearing gloves. [NAME] #1 was not observed to change his gloves. -Dietary Staff #2 was observed handling the flatware with no gloves, touching the food-contact ends during lunch tray line service. During tray line service, Dietary Staff #2 was observed preparing lunch trays, reaching into ice baths for milk cartons, juice containers, desserts, and the silverware. During an interview on 1/31/24 at 12:30 P.M., the Dietitian said [NAME] #1 should not be handling the rolls, French toast, English muffins, or toast with gloves that have touched other surfaces. She said Dietary Staff #2 should not be handling the food-contact ends of the silverware with no gloves. During an interview on 1/31/24 at 12:40 P.M., the Corporate Food Service Manager (FSM) said the silverware should be pre-rolled prior to meal service. 3. On 1/31/24 at 12:45 P.M., the surveyor observed a plastic mat in front of the tray line service area which had a saturated wet cardboard box underneath the plastic mat. The top of the perforated plastic mat was observed to be wet and dirty with a black substance. During an interview on 1/31/24 at 1:15 P.M., the Dietitian said there is a drainpipe broken underneath the floor by the tray service line and the facility had initiated the repair process. The Dietitian and the surveyor observed the mat, the standing black colored water, and a saturated wet cardboard box that had areas of a buildup of a black substance. The Dietitian said the kitchen staff should have been keeping this area clean until the pipe was repaired. During an interview on 1/31/24 at 2:15 P.M., the Administrator and the surveyor viewed the plastic mat in front of the tray service line, he said he does not know why there is a cardboard box under the mat or why it was wet and dirty. The Administrator said the kitchen staff should have maintained the area of the broken pipe and it should have been cleaned and sanitized using bleach until it could be fixed. 4. Review of the facility's policy titled Dietary Service Ice Making Machine, undated, indicated but was not limited to the following: -It is the policy of this facility that the ice machine will be maintained in a clean and sanitary manner. -Quarterly: every 90 days clean the evaporator and water filled tubes. An outside vendor may be called for this service. On 1/31/24 at 1:18 P.M., review of the main kitchen ice machine cleaning log indicated the last time the ice machine was cleaned was 7/14/23. During an interview on 1/31/24 at 1:20 P.M., the Dietitian viewed the side of the ice machine and said the last time the ice machine was cleaned was July 2023. She said the ice machine was due to be cleaned in October 2023 and was not. During an interview on 1/31/24 at 2:00 P.M., the Administrator said the ice machine should have been cleaned quarterly and it was not. He said maintenance does not have any documentation of the ice machine being serviced. 5. On 1/31/24 at 1:30 P.M., the Dietitian and the surveyor observed the facility's mechanical room for the emergency water and food supply and observed the following: -Four Boxes of pancake mix, dated 5/18/22. -One case of B&M Baked beans, dated August 2023. -Two bags of powdered milk, no date observed. During an interview on 1/31/24 at 2:00 P.M., the Administrator said there should be no food stored in the Mechanical room. He said the Food Service Manager was supposed to remove all the food stored in this room and he did not. 6. On 1/31/24 at 8:19 A.M., the surveyor observed the main kitchen dish room and made the following observations: -The right side of dish machine, where clean dishes exit the machine onto the metal countertop, had a buildup of food particles around the opening. -The top of the dish machine and the wall to the right of dish machine had a large amount of food particles dried to the surfaces. -The metal countertop to the right of the dish machine had visible food particles along the sides of the counter and at the end of the counter. During an interview on 1/31/24 at 1:00 P.M., the Dietitian said the dishwasher should be maintained clean and there should not be food particles on the side where the clean dishes exit the machine. During an interview on 1/31/24 at 2:20 P.M., the Administrator and the surveyor viewed the dish machine, the walls, and metal countertop to the right of the dish machine. He said the dishwasher, the walls, and the counter should be kept clean.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff developed and implemented a comprehensive person centered care plan for three Residents (#328, #71, #228) out of a total sample of 20 residents. Findings Include: 1.) For Resident #328 the facility failed to ensure that staff developed a comprehensive care plan for the care and treatment of a pressure ulcer. Additionally the facility failed to follow physician orders for the application of Prevalon Boots. Resident #328 was admitted to the facility in April 2022 with diagnoses that included end stage Heart Failure, Chronic Obstructive Pulmonary Disorder (COPD), Diabetes, and Cellulitis (infection of the skin) of the right lower limb. Review of the medical record indicated Resident #328 had a physician order to apply a Xerofrom Dressing (a dressing used to protect wounds) every day shift to the pressure area. Review of the May 2022 Treatment Administration Record (TAR) indicated a treatment was completed daily between 5/12/22-5/17/22 on the 7-3 shift. Review of Resident #328's physician orders, dated May 2022, indicated the following: - Prevalon Boot to right foot at all times, may remove for care and to check skin integrity every shift. On 5/12/22 at 11:00 A.M. the surveyor observed the Resident lying in bed on his/her right side with the right foot exposed over the blanket. The Resident did not have the Prevalon boot on to the right foot. On 5/16/22 at 9:35 A.M. the surveyor observed the Resident lying in bed with his/her right foot hanging off the right side of the bed. The Resident did not have the Prevalon boot on the right foot. During an interview on 5/18/22 at 11:30 A.M. the DON said the Resident should be wearing the boot if there is a physician order for the boot to be worn. Review of Resident #328's interdisciplinary care plans indicated there was no documented evidence that the facility developed a care pan that addressed the care and treatment of the pressure ulcer. 2.) For Resident #71 the facility failed to ensure that staff developed a comprehensive care plan for the monitoring of a left hip bruise and bruising to bilateral extremities. Resident #71 was admitted to the facility in October 2021 with diagnoses that include Lewy Body Dementia, Cirrhosis, Renal Failure, and Anemia. Review of the Minimum Data Set ( MDS) Assessment, dated 4/27/22, indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 14 out of a total score of 15, indicating the Resident is cognitively intact. During an interview on 5/17/22 at 9:30 A.M. Resident #71 was observed with multiple bruises to his/her bilateral extremities. When asked about the bruising the Resident proceeded to show the surveyor a large bruise he/she had on their left hip. He/she said that they were pretty sure the bruise happened during a fall they sustained. The Resident said it had been there a while and just wouldn't go away. Review of the medical record indicated Resident #71 had two skin assessments completed by staff on 5/6/22 and 5/15/22. The skin assessments did not provide any documented evidence that the Resident had bruising to the left hip or bilateral extremities. During an interview on 5/17/22 at 3:15 P.M. Nurse #3 said the bruise to Resident #71's hip was not new and that everyone was aware of the bruise. Review of the interdisciplinary care plans indicated there was no documented evidence that addressed the monitoring of the bruising or that Resident #71 had an alteration in skin integrity.3. Resident #228 was admitted to the facility in April 2021 with the following diagnoses: Atrial Fibrillation, macular degeneration and knee pain. Review of the most recent Minimum Data Set (MDS), dated [DATE] indicated that Resident #228 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating that he/she was cognitively intact. Review of the nursing progress notes and fall incident report, dated 5/4/22 indicated that Resident #228 had a witnessed fall resulting in a nondisplaced vertical fracture of the fifth cervical spinous (fracture of the neck) and a comminuted depressed fracture of nasal bone tip. Further review of the medical record indicated that Resident #228 had complaints of loose teeth following the fall. During an interview on 5/11/22 at 3:01 P.M., Resident #228 said he/she recently had a fall resulting in his/her teeth feeling loose. Resident said the loose teeth make it more difficult for him/her to eat foods and is very embarrassing. The Resident said he/she has been eating softer foods and has plans to see the dentist. Review of the medical record for Resident #228 failed to indicate a care plan had been developed for the concerns related to oral/dental health. During an interview on 5/18/22 at 12:43, Cooperate Nurse #1 said she could not locate a dental care plan for Resident #228.

Based on observation, record review and interviews, the facility failed to implement and revise individual care plans for three Residents (#51,#71, and #47) out of total sample of 20 residents. Specifically, the facility failed to: 1. For Resident #51 the facility failed to revise the plan of care to ensure care approaches were effective, individualized and appropriate for Resident at risk for falls. 2. For Resident #71 the facility failed to revise the plan of care to ensure care approaches were individualized and appropriate for Resident at risk for falls. 3. For Resident #47 the facility failed to revise the plan of care to accurately reflect the Resident was no longer wearing Prevalon boots or using a Broda chair while out of bed. Findings include: Review of the facility policy, titled Fall Management (revised 4/7/22), indicated but is not limited to the following: - Each resident receives adequate supervision and assistance devices to prevent accidents - The interdisciplinary team will review any additional fall risk indicators and revise the resident's care plan as indicated - The interdisciplinary team will review and revise the care plan, if indicated, upon completion of each comprehensive, significant change and quarterly MDS, upon a fall event and as needed thereafter 1.) Resident #71 was admitted to the facility in October 2021 with diagnoses that include Lewy Body Dementia and falls. Review of the Minimum Data Set (MDS) Assessment, dated 4/27/22, indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 14 out of a total score of 15, indicating the Resident is cognitively intact. Further review of the MDS indicated the Resident has had two or more falls since admission. During an observation on 5/11/22 at 12:00 P.M. the surveyor observed a bed alarm box sitting on the bedside table for Resident #71. The Resident was observed standing up from the bed. The bed alarm did not sound. Upon inspection of the bed alarm the surveyor noted that the alarm cord was not attached to the alarm box. The Resident said to the surveyor that he/she disconnects the cord because it is to loud when it goes off. During an observation on 5/12/22 at 9:59 A.M. the surveyor observed Resident #71 stand from the bed. The bed alarm did not sound. During an interview on 5/17/22 at 9:49 A.M. with Resident #71 the surveyor observed the Resident move from a lying position to a sitting position. The bed alarm sounded and remained sounding for approximately one minute. No staff responded to the alarm in that time. The Resident then proceeded to pick up the alarm box that was located on the bed side table and pull the cord out of the box causing it to stop sounding. The Resident said to the surveyor that the noise drives him/her crazy. On 5/17/22 at 10:08 A.M. the Resident was observed standing in the doorway of his/her room. The alarm was not sounding Review of the physician orders indicated the Resident had the following orders: - bed sensor alarm when in bed at all times, check function and placement each shift. (5/5/22) - chair sensor alarm while in chair. Check function and placement each shift. (5/5/22) Review of the care plan, initiated 10/21/21, indicated Resident #71's fall risk was related to history of falls, Lewy Body Dementia, antidepressant medication use, and unsteadiness due to fatigue, anemia. The goal identified was that the Resident will not sustain serious injury requiring hospitalization. Interventions included but were not limited to the following: - anticipate and meet resident's needs ( 2/11/22) - call light within reach (10/21/21) - keep locked wheelchair next to bed (3/29/22) - slipper socks as tolerated ( 1/31/22) - medication regime review (2/8/22) - offer resident room change ( 3/30/22) - PT evaluate and treat as ordered (5/5/22) Further review of the fall care plan (revised 5/5/22) , did not provide documented evidence of the bed or chair sensor alarms. During an interview on 5/17/22 at 2:58 P.M. Nurse #3 said she was aware the Resident was a fall risk. She said staff are aware the Resident shuts off the alarms but feels that it is still a good intervention as it alerts them to when he/she is moving around. Although the plan of care, revised 5/5/22, for the risk of falls included approaches to prevent falls, there was no documented evidence that the interdisciplinary team reviewed the effectiveness of the interventions being put in place to prevent the falls.2.) Resident #47 was admitted to the facility April 2019 with diagnoses of Parkinson's disease, muscle weakness, diabetes and a mild cognitive impairment. Resident required a mechanical lift using a lift pad to transfer from bed to wheelchair and wheelchair to bed. Review of Resident #47's current care plan indicated the following, but was not limited to: Resident #47 is at risk for break in skin integrity related to non-ambulatory/chair bound, urinary incontinence, requires assist with activities of daily living, and Parkinson's. -Pressure reducing mattress to bed alternate pressure set on 3 and cushion to the Broda chair. -Prevalon boots on both feet when up in chair. On 05/12/22 at 12:15 P.M., Resident #47 was observed sitting in a high back wheel chair with a blue seat cushion. Both Resident's legs were supported with a pillow on the calf rests and he/she was wearing sneakers. On 05/13/22 at 02:16 P.M., Resident #47 observed sitting in high back wheelchair with a blue cushion and legs elevated on pillows. Resident #47 was wearing sneakers. During an interview on 05/17/22 at 12:15 P.M., the Rehabilitation Director viewed Resident #47's wheelchair and said this is a high back reclining wheelchair with a Posture Works seat cushion. Resident #47 said he/she used to be in a Broda chair but they switched my chair last year to this wheelchair. Resident #47 also said he/she does not wear the padded boots (Prevalon boots) because he/she wants to wear sneakers. 3.) Resident #51 was admitted to the facility December 2019 with the diagnoses of history of falls, bipolar, severe depression with severe psychotic features, mood disorder, muscle weakness, mild cognitive disorder. Review of current care plan indicated the following interventions in place to prevent falls: -Resident is at risk for falls related to fall history, psychotropic medication use, and muscle weakness. Interventions: -1/27/21 Resident educated to keep shoes and socks on when ambulating with rolling walker at all times. -10/8/20 Resident independent in room and on unit with rolling walker -11/10/21 Resident received new slippers and is wearing them -11/3/21 Resident to get new pair of slippers -12/26/21 Educated to observe environment while ambulating -Extra belongings removed from walker basket -3/16/22 educated to have only one light item in walker basket -3/16/22 Rehab issued new rolling walker -3/16/22 Rehab screen placed -4/1/22 Educated on safety awareness, encouraged not to put a lot of items in walker bin -4/14/22 No alarms needed -7/7/20 Encouraged to wear non-skid socks while in bed -12/29/21 Resident has been educated to decrease speed of movement and be more observant of his/her environment -7/2/19 Anticipate and meet the resident's needs -7/2/19 Assist with activities of daily living as needed -7/2/19 Call light within reach -7/2/19 Complete fall assessment risk -7/2/19 Educate Resident/family/caregivers about safety reminders and what do do if a fall occurs -1/23/22 Educated on proper footwear when up -3/4/22 Fall no injury -1/23/22 Medication regime review -7/2/19 Orient resident to room -7/2/2019 Provide activities that minimize the potential for falls while providing diversion and distraction -7/2/2019 Provide adaptive equipment or devices as needed -7/2/2019 Physical therapy evaluate and treat as ordered or as needed -1/23/2022 Rehab screen -4/4/2022 Rehab screen for safety and fall recovery -3/28/2022 Resident educated on 3/4/22 and reminded to request assistance from staff rather than reaching for items. Encouraged to to utilize call bell -7/2/2019 bilateral side rails up as ordered -10/21/2020 Sign placed on walker facing resident that states Resident #51 keep walker with you at all times During an interview on 05/18/22 at 09:54 A.M., the Director of Nurses (DON) reviewed Resident #51's current care plan and said she agrees the care plan has a lot of interventions and many of them are doubles or not effective interventions. The DON said she was not aware Resident #51's walker no longer has a sign on it to remind him/her to use the walker at all times or he/she no longer has a basket on the walker. The DON said the current care plan needs to be looked at.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and staff and family interview, the facility failed to provide treatment and services to adhere to professional standards of practice for 3 Residents (#328, #47, #12) out of a total sample of 20 residents. Specifically: 1.) For Resident #328 the facility failed to ensure that the physician and hospice services were notified of a change in condition resulting in a delay in change of care for the Resident 2.) For Resident #12 the facility failed to monitor Resident's self scratching behavior resulting in worsening wounds to the legs, back, stomach and chest. 3.) For Resident #47 the facility failed follow physician orders for air mattress settings and turning resident every two hours to promote healing of the skin. In addition, the facility failed to provide optimal seating position in the wheelchair by leaving the lift pad under the resident while sitting in the wheelchair, the missing left foot plate and leaving the right leg rest in the shortest position resulting in both feet dangling having to support to assist Resident in repositioning. Findings Include: 1.) Resident #328 was admitted to the facility in April 2022 with diagnoses that included end stage heart failure and chronic obstructive pulmonary disease (COPD). The Resident was receiving hospice services. On 5/11/22 at 11:00 A.M. the surveyor observed the Resident lying in bed. The Resident was noted to be on oxygen via nasal cannula at 10 liters and appeared comfortable. The Resident was observed to have dirty finger nails and hands. He/she had dried food on their face. A pressure relieving bootie was noted on the floor next to the bed. The Resident was observed with a large bandage to his/her right foot. During an interview on 5/11/22 at 11:00 A.M. the Resident said he/she was doing fine. The Resident denied pain or discomfort. He/she said said they wanted to go home to be with their family but had to get stronger first. The Resident was alert and able to make needs known. On 5/16/22 at 8:30 A.M. the surveyor observed the Resident lying in bed on his/her right side with the lower half of his/her body hanging out of the bed. The Resident's right foot was on the floor and the bandage was observed to be covered in blood. The surveyor observed the sheets on the bed to be covered in blood. The Resident was observed breathing heavily with his/her eyes rolled in the back of their head. The surveyor notified the Director of Nurses (DON) immediately. Upon arrival to the room the DON said the condition the Resident was in was unacceptable and she would have staff take care of him/her right away. The DON had staff come in and assist the Resident. Review of the nurse progress notes, dated 5/13/22, indicated the Resident had dusky toes and was seen by hospice. Further review of the progress notes failed to indicate any documented evidence that any new interventions were implemented for the plan of care for the change in the Resident's condition. The Resident was also seen by the MD/NP and the only new order put in place was to add a diagnosis of right foot diabetic ulcer. Review of the hospice communication book failed to provide any documented evidence that the Resident was seen on 5/13/22 as indicated in the nurses note or that any new interventions were put in place for the plan of care. Further review of the nurse progress notes indicated the following: - on 5/14/22 the Resident had increased shortness of breath and had restlessness. The Resident was unable to be redirected and he/she kept pulling off his/her oxygen. - on 5/15/22 the Resident was unable to swallow medications due to a decline in his/her condition Review of the physician orders, dated May 2022, indicated the following: - Morphine Sulfate Solution 20 mg/ml (milligrams/milliliters)- give one ml every six hours for palliative care - Morphine Sulfate Solution 20 mg/ml- give 1.5 ml every two hours as needed for pain, shortness of breath, tachypnea related to palliative care Review of the Medication Administration Record (MAR) indicated the Resident received the scheduled Morphine Sulfate as prescribed every six hours as ordered. Further review indicated on 5/14/22 the Resident received Morphine Sulfate 1.5 ml as needed 7 times and on 5/15/22 the Resident received Morphine Sulfate 1.5 ml as needed 10 times, which was an increase from days prior, indicating the Resident was having increased pain, shortness of breath, or tachypnea. Further review of the nurse progress notes, dated 5/14/22 and 5/15/22, failed to indicate any documented evidence that the physician or the hospice team were notified of the Resident's change of condition. During an interview on 5/16/22 at 9:00 A.M. the DON said she notified hospice to come and see the Resident for the change in condition. Hospice staff #1 came in and saw the Resident on 5/16/22 at approximately 10:00 A.M. The following interventions were put in place: - Clonazepam (antianxiety medication) 0.5 mg (milligrams) -give two tabs by four times a day for anxiety - Fentanyl Patch (narcotic pain patch) 75 mcg (micrograms)- apply one patch every 72 hours for pain - Hycoscyamine Sulfate Solution 0.125 mg ( medication to dry up excess secretions)- give 0.25 mg by mouth every four hours for increased secretions During a observation on 5/16/22 at 3:00 P.M. the surveyor observed the Resident lying in bed sleeping. The Resident was noted to be calm without shortness of breath or restlessness. During an interview on 5/17/22 at 2:00 P.M. Family Member #2 said that she was at the facility all weekend with the Resident. She said that the weekend was tough for the Resident. She said the Resident was restless and agitated and that staff tried the best they could to keep him/her comfortable. Family member #2 said she had no conversations with hospice or the physician over the weekend. She said hospice did not come in to see the Resident over the weekend.2. Resident #12 was admitted to the facility November 2019 with diagnosis Alzheimer's, dementia with behavioral disturbances, obsessive-compulsive disorder and excoriation (skin picking) disorder. Review of the Minimum Data Set (MDS) dated [DATE] indicated Resident #12 scored a 6 out of 15 on the Brief Interview for Mental Status, indicating he/she had severe cognitive impairment. During an interview on 05/12/22 at 01:15 P.M., Resident #12 said he/she has sores on her legs that he/she scratches and they bleed. Resident #12 while lying in bed, pulled back the blanket and the sheet and showed the surveyor his/her legs. The surveyor observed the bottom and top sheet to heavily stained with small spots of blood. In addition, the surveyor observed multiple areas of red, raw skin that appeared to be scratched resulting in bleeding on the front and back of the lower legs, front of both thighs, left hip and right upper chest area. Resident #12 said sometimes the nurses give him/her cream for the scratching, but he/she feels like a forgotten person. On 05/13/22 at 10:30 A.M., the surveyor observed Resident #12 get out of bed and walk into the bathroom. The surveyor observed both lower extremities to red, raw with multiple areas having visible blood. Resident #12's bed was observed and again the sheets were heavily stained with small spots of blood. During an interview on 05/13/22 at 02:10 P.M., Resident #12 was sitting at the edge of his/her bed and said he/she made a mess with the blood on his/her legs and maybe he/she should see someone. The surveyor informed Nurse #7 that Resident #12 had blood on both hands and legs from scratching and was requesting to see a nurse. Nurse #7 went to the treatment cart and was observed to get gauze pads and bottle of saline water and go to Resident #12's room. During an interview on 05/17/22 at 04:50 P.M., Nurse #6 said Resident #12's Health Care Proxy wanted us to encourage Resident #12 to wear long sleeve shirt and pants. Nurse #6 said they are not putting any cream on his/her legs at this time, but said Resident #12 has his/her own cream to put on. The surveyor and Nurse #6 went to Resident #12's room and Nurse #6 visualized Resident #12's skin in the bathroom. Nurse #6 said Resident #12 has some open areas and she will call the physician and let him know. Review of Wound Observation Tool dated 5/18/2022 indicated the following -Worsening, Acquired during residents stay on 11/16/2021 -Location: areas back, legs, arms, stomach and chest. -Type: Wound listed as other -Overall Impression: Worsening - Describe Other: Areas are scabbed and surrounding tissue is red. -Drainage: None -Additional comments: Resident will be seen by dermatology -Current treatment plan: Triamcinolone cream, Resident to see Nurse Practitioner today. Review of Resident #12's current orders indicated the following: - Activate Healthcare proxy - Weekly Skin Check on Shower Day , every day shift every Mon - Luvox 100 mg by mouth twice daily for obsessive compulsive disorder - Claritin Tablet 10 MG (Loratadine), Give 1 tablet by mouth one time a day for itching - Encourage long sleeves and pants when out of bed every day and evening shift Review of Behavior/Intervention Monthly Flow Sheet for compulsory skin picking of arms and legs May 1 through May 17, 2022 (total of 17 days) indicated the following: -Day shift: seven days documentation blank , nine days recorded no skin picking, one day of skin picking times two occasions. -Evening shift: One day documentation blank, sixteen days documented no skin picking -Night Shift: two days documentation blank, fifteen days documented no skin picking -Only the day shift on May 14, 2022 has documentation of Resident exhibiting scratching behavior. Review of Driftwood Unit weekly non-pressure ulcer tracking report dated 5/11/2022 did not have Resident #12 being followed for his/her skin condition. Review of May 2022 nursing notes indicated the only documentation of Residents skin condition was on the following dates: 5/13/2022- Patient picking at lower extremities causing bleeding. Patient legs cleaned with normal saline solution. Patient educated about infection control. 5/13/2022- Patient seen by Psyche nurse practitioner (NP) regarding scratching/picking at skin and order received to increase Luvox. See MD orders. 5/17/2022 - Resident noted to be scratching legs, arms and back. Red areas noted. New orders for Triamcinolone acetonide cream 0.025% topically twice daily for 14 days. Review of the Nurse Practitioner progress noted dated 4/18/2022 indicated the following, but was not limited to: -Chief complaint: Resident was noted to have scratches on his/her lower extremities. -Assessment/Plan: Resident was noted to have increased itching. He/She is also scratching and was recently treated with hydroxyzine 25 mg every 6 hours as needed for 14 days which did not have the expected outcome. Resident continues to scratch both legs so the medication was not renewed. Ordered to start Clobetasal 0.5% to be applied to lower extremities twice daily for 14 days. The staff will continue to monitor the patient for increased itch. Review of Psychiatric Nurse Practitioner note dated 5/13/2022, indicated the following but was not limited to: -Chief Complaint: Generalized emotional distress, psychotic ideation, depression, anxiety, isolation, skin picking, sleep disturbances, and poor appetite. -Diagnosis: Dementia, obsessive compulsive disorder, anxiety, and depression. -Psychiatric medication: Risperdal .25 mg at bedtime, and Lovox 100 mg twice daily. -Skin: History of skin picking. Multiple scabbed areas on both lower legs and right arm. Resident #12 says the scabbed areas are uncomfortable and burn. -Other: Staff report he/she has ben presenting with increased skin picking/scratching and multiple red/scabbed areas are noted. Resident endorses feeling frustrated and irritable. Given skin picking/compulsive behavior, recommend increase in Luvox. -Discontinue Luvox 100 mg twice daily and start Luvox 150 mg AM and 100 mg at bedtime. Review of Wound Observation Tool dated 5/18/2022 indicated the following -Worsening, Acquired during residents stay on 11/16/2021 -Location: areas back, legs, arms, stomach and chest. -Type: Wound listed as other -Overall Impression: Worsening - Describe Other: Areas are scabbed and surrounding tissue is red. -Drainage: None -Additional comments: Resident will be seen by dermatology -Current treatment plan: Triamcinolone cream, Resident to see Nurse Practitioner today. During an Interview on 05/18/22 at 09:41 A.M., Nurse #1 and Nurse #3 said someone requested they see Resident #12 in wound rounds today to look at his/her skin. Nurse #3 said she has not seen Resident #12's scratching wounds this bad, especially the ones on his/her back, she doesn't know how the Resident can reach the areas to scratch. The surveyor reviewed Resident 12's behavior logs for Scratching for May 1, 2022 through May 18, 2022 and the logs only indicated Resident had the behavior one time during the day shift on May 14, 2022. Both Nurse #1 and Nurse #3 said they don't know why the nurse weren't documenting the Resident was scratching his/her skin. Nurse #3 said if you read the nursing notes you would never know his/her skin was this bad and we wouldn't know to see the Resident in wound rounds unless someone told us. During an interview on 05/18/22 at 09:54 A.M. the Director of Nurses (DON) said she was not aware nor was the wound team aware that Resident #12's skin was getting worse, therefore the Resident was not followed by the wound team. In addition, she said she does not know why the nurses were not documenting the changing skin condition in their notes or why the nurses were documenting on all three shifts the Resident was not exhibiting scratching behavior except one shift. During an interview on 05/18/22 at 12:56 P.M., Nurse #1 and Nurse #3 said after seeing Resident's skin condition today, they made an appointment with a dermatologist (skin doctor) to see if they can recommend a treatment to help to help resolve the Resident's skin condition. During an interview on 05/18/22 at 12:56 P.M., the Psychiatric Nurse Practitioner said we were treating Resident #12 with Luvox for his/her obsessive compulsive disorder to help stop the scratching, but clearly its not working but she was not made aware. 3. Resident #47 was admitted to the facility April 2019 with diagnoses of Parkinson's disease, muscle weakness, diabetes and a mild cognitive impairment. Resident required a mechanical lift using a lift pad to transfer from bed to wheelchair and wheelchair to bed. Resident #47's healthcare proxy (HCP) has been invoked with Family Member #3 the acting HCP. Review of the Minimum Data Set (MDS) dated [DATE] indicated Resident #47 scored a 15 out of 15 on the Brief Interview for Mental Status, indicating he/she was cognitively intact. In addition, the MDS indicated Resident was not on a toileting program and was always incontinent of urine, has moisture associated skin damage, and is using a pressure reducing bed and chair. 05/17/20022 at 10:56 A.M., the surveyor observed Nurse #6 provide skin care to Resident #47 and the following observations were made: - Air mattress was comfort level set on 5 (highest setting) and on the float setting. - Right buttocks scabbed with two slits in the skin and was observed to be red raw with bright red skin. - Left buttocks was excoriated. -Back of both thighs red and discolored. -Observed fresh blood on the Resident's brief. -Both buttocks had dried paste like ointment on affected skin areas making wounds hard to assess. On 5/11/22 at 10:30 A.M., the surveyor observed Resident #47 lying on his/her back in bed with air mattress comfort level set on 5 and on float position. During an interview on 05/11/22 at 05:00 P.M., Resident #47 said if he/she can only sit up in the wheelchair for part of the day because his/her bottom hurts. The Resident said when they lift him/her out of bed to the wheelchair, they lift the lift pad under him/her in the wheelchair and it causes pain. Family Member #3 said he/she agrees sitting on the lift pad when he/she is in the wheelchair causes Resident #47 pain and if he/she stays in the wheelchair it causes the Resident's bottom to bleed. The Resident was observed lying on his/her back with head elevated and the air mattress comfort setting was 5 on float position. On 05/12/22 at 12:15 P.M., Resident #47 was observed sitting in his/her recline back wheelchair in the dining room, sacral sitting (poor seating posture with rounding of the upper back and the hips shifted forward), the right leg rest foot plate was too short and the left leg rest did not have a foot plate. The Resident's lower legs were supported with two pillows resting on leg rests with both feet hanging over the edge not supported. The Resident was observed to be sitting on the lift pad. 05/13/22 12:16 PM Resident #47 was observed in bed lying on his/her back, working with the Speech Therapist. Air mattress set on 5 in the float position. On 05/13/22 at 02:16 P.M., Resident #47 was observed in bed all morning lying on his/her back with the head elevated through lunch. The Resident now observed in activities, sitting in the wheelchair, hips shifted forward, both legs elevated on pillows with both feet dangling over the end. The left leg rest did not have a foot plate and the right leg rest foot plate was in the shortest position resulting in back of the right lower leg resting on top of the foot plate on the pillow. The Resident was sitting on the lift pad. During an interview on 05/17/22 at 09:55 A.M., Nurse #6 said Resident #47's bottom does not look good, he/she was just seen by rehab and put on an out of bed schedule. Nurse #6 prior to rehab implementing the out of bed schedule, Resident #47 would tell staff when his/her bum hurt and they would transfer the Resident back to bed. Resident #47 was observed lying in bed on his/her back with the head of the bed elevated. Air mattress comfort setting was on 5 in the float position. On 05/17/22 at 12:15 P.M., Director of Rehabilitation (DOR) said the Occupational Therapist did a rehab screen on Friday and a full wheelchair assessment on Sunday and found Resident #47's wheelchair positioning was good. The DOR and surveyor went and viewed Resident #47's wheelchair and visualized the right leg foot plate was in the shortest position and there was no foot plate on the left leg rest. The DOR said she has no explanation for short right foot rest or the missing foot plate. The DOR also observed Resident #47's air mattress on comfort setting #5 in the float position. Resident #47 said they put him/her in a wheelchair and put pillows under his legs and lifts both legs up. The Resident said he/she prefers to have legs down and feet resting on the ground with his/her sneakers on. During an interview on 05/17/22 at 05:41 P.M., Family Member #3 said he/she received a call yesterday from Rehab staff #1 and he told her the lift pad should never be left under Resident#47 when he/she is sitting up in the wheelchair because it can irritate the skin. In addition, he told Family Member #3 that he just put Resident #47 on an out of bed schedule to limit the time he/she is sitting in the wheelchair to help the skin heel. Family Member #3 asked the surveyor why it took so long for them to figure out sitting for too long on the lift pad was a cause of pain? He/She said we already knew that. During an interview on 05/18/22 at 11:32 A.M., Rehab staff #1 said he is part of the wound team and Resident #47 has significant incontinent dermatitis. He said he/she should be on a regular changing schedule, but he is not aware if that is occurring because it was a nursing thing. Additionally, Rehab Staff #1 said the nursing staff should be removing the lift pad from underneath the Resident once he/she is sitting in the wheelchair to avoid added pressure to the damaged skin. During an interview on 05/17/22 at 11:30 A.M., the Director of Nurses (DON) said the facility does not have a wound physician, they have a team of two nurses and Occupational Therapist that do the weekly wound rounds and document on paper. The DON said when she arrived in building a few weeks ago it was identified the wound documentation was not working as you can see showing the surveyor the old forms which consisted of three check offs and did not include a description, measurements, or current treatments or outcomes. She said the new forms document more thoroughly allowing the facility to track the wound, current treatments and the outcomes of the the treatments. The DON said she is aware Resident #47 has significant skin breakdown and the documentation is lacking. The surveyor informed the DON of the observations made during survey including the air mattress has been set on the wrong settings consistently set on comfort setting 5 in the float position, the Resident has only been observed lying on his/her back with the head of the bed elevated, never lying on right or left side. In addition, Resident #47 has been observed with poor sitting positioning in wheelchair, sitting with the hips shifted forward, the feet dangling off of the end of the leg rest, and sitting on the lift pad when in the wheelchair. The DON said she was not aware of these observations but would look into them.

Based on obervation, interview, and documentation review, the facility failed to ensure the care and treatment of residents with catheters was provided per standards of practice. Specifically, the facility failed to keep catheter bags off the floor at all times to prevent the risk for infection for one Resident (#75), out of a total sample of 13 residents. Findings include: Review of the Agency for Healthcare Research and Quality (AHRQ) website, drainage bags should be kept below the level of the bladder and off the floor at all times to avoid the risk of infection (March 2017). Resident #75 was admitted to the facility in January 2022 with diagnoses which included neuromuscular dysfunction of the bladder. Review of the most recent Minimum Data Set (MDS) assessment, dated 4/27/22, indicated Resident #75 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating that he/she was cognitively intact. On 6/29/22 at 3:00 P.M., the surveyor observed Resident #75 lying in bed. A urinary catheter drainage bag was observed to be on the floor to the right side of the bed. On 6/29/22 at 4:20 P.M., the surveyor observed Resident #75 lying in bed. A urinary catheter drainage bag was again observed to be on the floor to the right side of the bed. During an interview on 6/29/22 at 4:22 P.M., Nurse #2 said all catheter drainage bags should not be on the floor.

Based on policy review, observation, medical record review, and interview, the facility failed to ensure that respiratory equipment was managed in accordance with professional standards of practice for one resident (#328) out of a total sample of 20 residents. Findings Include: Review of the facility policy, titled Oxygen Administration Safety/Storage/Maintenance, (revised 8/2/21), includes but is not limited to: - Humidifiers are required on NC (nasal cannula) with liter flows 4 liters or greater - Equipment should be labeled with patient name and dated when set up or changed Resident #328 was admitted to the facility in April 2022 with a diagnosis of end stage heart failure. Review of the medical record indicated the following physician orders: - Oxygen at 6 liters/minute continually per nasal cannula. Document every shift. (4/28/22) - Change oxygen tubing and nebulizer circuit every night shift every Sunday (4/28/22) On 5/11/22 at 10:00 A.M. Resident #328 was observed lying in bed. The oxygen tubing was noted to be connected to the concentrator, with a nasal cannula (NC) (small flexible tube that contains two open prongs that sit inside the nostrils to deliver oxygen). The concentrator was on and set to a flow rate of 10 liters/minute, 4 liters higher than what was ordered by the physician. The surveyor inspected the oxygen tubing and noted that there was no label fastened to it indicating when it was last changed. Upon further inspection of the oxygen concentrator the surveyor noted the humidification bottle ( a bottle that is filled with water and connected to the oxygen concentrator to help alleviate dryness or discomfort of the upper airway) was empty. The humidifier bottle was not labeled to indicate when it was last changed. On 5/12/22 at 9:45 A.M. Resident #328 was observed lying in bed. The oxygen tubing was noted to be connected to the concentrator with the NC in place. The concentrator was on and set to a flow rate of 10 liters/minute, 4 liters higher than what was ordered by the physician. There was no label fastened to it to indicate when the tubing was last changed. Inspection the humidification bottle connected to the oxygen concentrator was empty and had no label to indicate when it was last changed. On 5/16/22 at 9:10 A.M. Resident #328 was observed lying in bed. The oxygen tubing was noted to be connected to the concentrator with the NC in place. The concentrator was on and set to a flow rate of 6 liters/minute. There was no label fastened to it to indicate when the tubing was last changed. Inspection of the humidification bottle connected to the oxygen concentrator was empty and had no label to indicate when it was last changed. During an interview on 5/17/22 at 9:00 A.M., Nurse #3 said that the tubing should be changed weekly on the night shift and should be labeled and dated. She said that any Resident on oxygen greater than 3 liters should have humidification attached. She said she would check the Resident's oxygen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) On 5/11/22 at 8:23 A.M., the surveyor observed breakfast service in the Driftwood Unit dining room and the following observations were made: -Approximately 8-10 residents were being served in the dining room, breakfast trays were placed in front of the residents on tables or over bed tray tables. -There were no observations of table clothes on the tables or breakfast meals being served without the use of a tray in front of the residents. -Two Certified Nurses Assistants (CNAs) were observed to be standing next to residents assisting them with meals. -The two CNAs were walking around the dinning room assisting residents to eat, as needed. -At no point during the observation did the CNAs sit down next to the residents, to assist the residents at a seated eye level. On 05/12/22 at 12:15 P.M., the surveyor observed lunch service in the Driftwood Unit dining room and the following observations were made: -There were 12 residents eating lunch in the dining room. - Two residents were eating in Reclining chairs, reclined back approximately 30 degrees with an over bed tray table about one foot in front of them. -Two residents, one in reclining wheelchair with legs extended and second resident in a reclining chair were angled off to the side of the table, making it challenging to eat off their plates. -No table cloths were on the tables. - Five of five tables had activity busy boards, gadgets and other activity items left on the tables from the morning activity while they were eating lunch. -Eleven of the twelve residents were served their food on trays, with the insulated dome covers left on the tables. - A CNA #1 and PCA #1 (personal care assistant) were observed walking from one resident to another, standing to assist them with their meal. -During part of the meal, they had on both the music and the television. On 05/16/22 at 12:15 P.M., the surveyor observed lunch service in the Driftwood Unit dining room and the following observations were made: -All residents had small white towels draped across the front of them for clothing protectors. -All residents were served food on their trays, covers were left on the tables. -PCA #1 was observed walking around the dining room assisting multiple residents at the same time eat their meal, always in a standing position. -CNA #3 was observed assisting one resident with meal while standing and a second she sat down to assist with the meal. -Observed large pieces of scrambled eggs on the floor under two tables, leftover from breakfast meal. During an interview on 05/16/22 at 12:35 P.M., CNA #3 said they are behind in the wash and there are no clothing protectors available so we used towels today. During an interview on 05/16/22 at 12:41 P.M., the Administrator said they should not be using towels for clothing protectors, she would have to check with the Laundry Director why they don't have them available. During an interview on 05/16/22 at 12:50 P.M., the Director of Laundry said there should be clothing protectors in the clean linen room. The surveyor and Director of Laundry checked the unit, there were no clothing protectors on the unit. We observed the laundry room and there were plenty of clean clothing protectors. The Director of Laundry said the staff just did not go get the clean clothing protectors and used towels instead. During an interview on 05/17/22 at 11:30 A.M., the Director of Nurses (DON) was made aware of the dining observations. The DON said said the dining experience on Driftwood should be the same dining experience the residents receive in the main dining room. She said the staff should be sitting down when assisting residents to eat and the food should be served off the trays whenever possible. Based on observations, interviews and record review, the facility failed to: 1. Ensure that residents maintained the right to a dignified existence by having a catheter bag visible and without a privacy cover for one Resident (#75), in a total sample of 20 residents; and 2. The facility failed to provide a dignified dining experience in one of three dining rooms. specifically, the facility served the residents in the Driftwood dining room their food on service trays, left the insulated dome's on the table, used towels for clothing protectors, residents wheelchairs poorly aligned with the tables, over bed tray tables were used instead of bringing residents to a table and they were poorly aligned when used, and the staff routinely walked from resident to resident standing to assist with feeding. Findings include: 1.) Resident #75 was admitted to the facility in January 2022 with the following diagnoses: neuromuscular dysfunction of the bladder, and Diabetes Mellitus. Review of the most recent Minimum Data Set (MDS), dated [DATE] indicated that Resident #75 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating that he/she was cognitively intact. Throughout the Recertification survey, the surveyor made the following observations: - 5/11/22 at 11:23 A.M.: Resident #75 was laying in bed. A urinary catheter drainage bag was observed to be on the floor to the left side of the bed, urine was observed in the bag. - 5/17/22 at 9:36 A.M.: Resident #75 was laying in bed. A urinary catheter drainage bag was observed to be hanging on the left side of the bed, urine was observed in the bag. There was no observation of a privacy bag being used. - 5/17/22 at 2:25 P.M.: Resident #75 was observed in the Main Dinning Room, participating in a group activity. A urinary catheter drainage bag was observed hanging from the Resident's chair. There was no observation of a privacy bag being used. During an interview on 5/18/22 at 9:48 A.M., Resident #75 said the catheter bag is often just hanging on the side of the bed exposed. Resident #75 said he/she did not know that privacy bags could be used. During an interview on 05/17/22 at 05:01 P.M., Corporate Nurse #1 said all catheter drainage bags should be placed in a privacy bag and not exposed or on the floor. On 5/18/22 at 9:48 A.M., the surveyor entered Resident #75's room. The Resident was laying in bed. The urinary drainage catheter bag was again hanging on the left side of the bed exposed. There was no observation of a privacy bag being used to maintain a dignified existence for Resident #75.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) Resident #23 was admitted to the facility in [DATE] with diagnoses that include diabetes with foot ulcer, muscle weakness, abnormal posture, and UTI's (urinary tract infection) Review of the most recent Minimum Data Set (MDS) Assessment, dated [DATE], indicates the Resident has a Brief Interview For Mental Status (BIMS) score of 10 out of a total score of 15 indicating the Resident is moderately cognitively impaired. Further review of the MDS indicates the Resident is at risk for developing pressure ulcers and has a pressure reducing device for the bed. Review of Resident #23's physician orders, dated [DATE], indicated the following: - elevate both feet on Heelz Cloud heel suspension cushion at all times when in bed every shift. On [DATE] at 12:28 P.M. the surveyor observed the Resident lying in bed. The Heelz Cloud cushion was not being used and the Resident's heels were lying flat on the bed. On [DATE] at 8:47 A.M. the surveyor observed the Resident lying in bed. The Heelz Cloud cushion was at the bottom of the bed and not being used. The Resident's heels were lying flat on the bed. On [DATE] at 8:30 A.M. the surveyor observed the Resident lying in bed. The Heelz Cloud cushion was not being used. The Resident's heels were lying flat on the bed. Review of the Treatment Administration Record (TAR) for [DATE] indicated that the nursing staff were documenting that the Heelz Cloud cushion was in place and being used on [DATE], [DATE], and [DATE]. During an interview on [DATE] at 11:30 A.M. the Director of Nurses (DON) said if a resident has an order to use a Heelz up cushion then the order should be followed and the resident should have his/her heels elevated. 3.) Resident #71 was admitted to the facility in [DATE] with diagnoses that include Lewy Body Dementia and falls. Review of the MDS Assessment, dated [DATE], indicate the Resident had a BIMS of 14 out of a total score of 15 indicating the Resident is cognitively intact. Further review of the MDS indicated the Resident has had falls since admission to the facility. Review of the facility policy, titled Neurological Assessment, (revised [DATE]), indicated the following but is not limited to: - the assessing nurse initials the neurological check list in PCC ( Electronic Medical Record) and completes as indicated - the nurse must initial/sign each documentation entry Review of the fall progress incident notes indicated Resident #71 had falls on [DATE], [DATE], [DATE], and [DATE] The fall incident notes indicated the following: - on [DATE] the Resident was found on the floor behind the door to the room. Review of the neurological assessment indicated the assessment was initiated at 2:20 P.M. Further review of the assessment indicated no documented evidence that the assessment was completed for the last two checks of the assessment per the protocol. - on [DATE] (no exact time documented but nurses note was written at 12:37 P.M.) the Resident was found near the bed in a sitting position on the floor. Review of the neurological assessment indicated the assessment was initiated at 5:25 P.M. Further review of the assessment indicated no documented evidence that the assessment was completed for the scheduled check on [DATE] at 12:00 A.M. per the facility protocol. - On [DATE] (no exact time documented for all but nurses note written at 8:15 A.M.) was found lying on the floor. Review of the neurological assessment indicated the assessment was initiated at 12:00 A.M. but was not started till 7:00 A.M. on [DATE]. Further review of the assessment indicated there was no documented evidence that the assessment was completed for 9:30 A.M. on [DATE] per the facility protocol. - on [DATE] the Resident was found at 1:15 P.M. on the floor in the bedroom. Review of the neurological assessment indicated it was initiated at 1:15 P.M Further review indicated that the assessment was not completed for the last three checks on [DATE] per the facility protocol. During an interview on [DATE] at 2:58 P.M. Nurse #3 said that neurological signs should be completed when a resident has had an unwitnessed fall. Based on record review, observations, and interviews, the facility failed to: 1). destroy controlled substances per facility policy and applicable law. Specifically, the facility failed to document the appropriate signatures for narcotic destruction in the Controlled Substance Registrar and the Narcotic and Sedative Destruction Log. and 2). the facility failed to ensure services provided by the facility met professional standards of practice for four Residents (#23, #328,#71,) out of a total sample of 20 residents. Specifically the facility failed to: 1.) Follow their policy for narcotic destruction. 2.) For Resident #23 the facility failed to follow physician orders to apply Heelz Up cushion (a cushion used to elevate and relieve pressure off of heels) while the Resident was in bed 3.) For Resident #71 the facility failed to accurately document neurological vital signs after a resident fall. 4.) For Resident #47 the facility failed to follow physician orders to apply Prevalon Boots while out of bed and failed to accurately document on the Treatment Administration Record (TAR) the application of the Prevalon Boots, the monitoring of the air mattress settings and the turning of the resident every two hours while in bed when the treatments were not implemented. Findings Include: 1.) Review of facility policy titled Disposal/Destruction of Expired of Discontinued Medications, revised [DATE], indicated but was not limited to the following: - Facility should destroy controlled substances in the presence of a registered nurse and a licensed professional in accordance with facility policy or applicable law. - Destruction of controlled medications should be documented on controlled medication count sheet and signed by the registered nurse and witnessing licensed professional which should record: Quantity destroyed, date of destruction and signature of registered nurse and licensed professional. - In Massachusetts, the drugs should be destroyed with two of the following authorized individuals: the Administrator, the Director of Nursing, the Assistant Director of Nursing, or the pharmacy consultant. Staff nurses and supervisors are not authorized to destroy any controlled substances. Upon completion of the destruction, the Disposal Record should be signed by the two authorized individuals who destroyed the drugs, as well as both signatures present on the specified page of the narcotic book. Review of facility policy titled Routine Reconciliation of Controlled Substances, dated [DATE] indicated the following: - Before destruction or disposal of controlled substances the assigned nurse and witness should count the number of doses to be destroyed to each declining inventory sheet and document the doses being destroyed as correct. On [DATE] at 3:46 P.M., the surveyors observed the a Controlled Substance Registrar book located in the Staff Development/Infection Control office closet. The closet was unsecured and unlocked. Resident's personal information including the residents name, medication being taken, the dose and time of administration were indicated within the book. On further observation, two surveyors observed the book was no longer in use at the facility, however many of the narcotics documented within the book could not be identified as a medication being discontinued, transferred to another page or destroyed. There were no nurses' signatures of the releasing nurse, the receiving nurse or the quantity of narcotic medications being destroyed. Review of the Narcotic and Sedative Disposal Record from [DATE] through [DATE] failed to indicate on 14 occasions that the narcotic and sedative destruction was signed by the authorized individuals required per facility policy and applicable law. During an interview on [DATE] at 6:15 P.M., Cooperate Nurse #1 and the Administrator were shown the Narcotic and Sedative Disposal Record. Cooperate Nurse #1 said the narcotic destruction should have been signed by at least two Registered Nurses. The Administrator said she has typically been signing off on narcotic destruction but if she didn't sign the page then she was unaware the narcotics were being destroyed. During an interview on [DATE] at 11:40 P.M., The Director of Nurses said she since she came into this building, she realized the nurses did not know the process to remove narcotics from count (removing/destroying discontinued medications from the Controlled Substance Registrar) and education was needed. She said the nurses were unaware that they should be signing the narcotic book to release the narcotics to the Director of Nurses or Administrator for destruction. Additionally, the Director of Nurses also said there was no real process within the building for the maintenance and storage of old narcotic records.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the medical records were accurately documented in accordance with professional standards of practice for one Resident (#47) out of a total sample of 20 residents. Resident #47 was admitted to the facility April 2019 with diagnosis of Parkinson's disease, muscle weakness, diabetes and a mild cognitive impairment. Resident required a mechanical lift using a lift pad to transfer from bed to wheelchair and wheelchair to bed. Review of the Minimum Data Set (MDS) dated [DATE] indicated Resident #47 scored a 15 out of 15 on the Brief Interview for Mental Status, indicating he/she was cognitively intact. In addition, the MDS indicated Resident was not on a toileting program and was always incontinent of urine, has moisture associated skin damage, and is using a pressure reducing bed and chair. Review of current physician orders indicated the following: -Air mattress to bed alternate pressure/set at #3. Check placement and function every shift. -Resident to be turned every two hours, every shift. -Prevalon boots on both feet when up in chair. Review of the Treatment Administration Record 5/1/2022 through 5/16/2022 indicated the following the following treatments were provided every shift: -Air mattress to set set on alternate pressure/Set at 3#3 check every shift -Resident turned every two hours -Prevalon boots on both feet when out of bed During the survey the surveyor consistently found Resident #47's air mattress set on comfort level 5 in the float position. All observations of the Resident out of bed in his/her wheel chair, the Resident was wearing sneakers. All observations of the Resident lying in bed, the Resident was lying on his/her back with the head of the bed elevated approximately 30 degrees. At no time was Resident 47 observed lying on either side while in bed. On 5/11/22 at 10:30 A.M., the surveyor observed Resident #47 lying on his/her back in bed with air mattress comfort level set on 5 and on float position. On 05/11/22 at 05:00 P.M., the surveyor observed Resident #47 lying on his/her back with head elevated and the air mattress comfort setting was 5 on float position. On 05/12/22 at 12:15 P.M., the surveyor observed Resident #47 was observed sitting in his/her recline back wheelchair in the dining room, sacral sitting ( poor seating posture with rounding of the upper back and the hips shifted forward), the right leg rest foot plate was to short and the left leg rest did not have a foot plate. The Residents lower legs were supported with two pillows resting on leg rests with both feet hanging over the edge not supported wearing sneakers. On 05/13/22 12:30 P.M., the surveyor observed Resident #47 multiple times this morning in bed, lying on his/her back with the air mattress set on #5 in the float position. Resident #47 now lying on back in bed working with speech therapy. On 05/13/22 at 02:16 P.M., the surveyor observed Resident #47 in activities sitting in wheelchair wearing sneakers. On 05/17/20022 at 10:56 A.M., the surveyor observed Nurse # 6 provide skin care to Resident #47 and the following observations were made: - Air mattress was comfort level set on 5 (highest setting) and on the float setting. On 05/17/22 at 12:15 P.M., the surveyor and the Director of Rehabilitation (DOR) observed Resident #47 lying on his/her back and the air mattress set on comfort setting #5 in the float position. During an interview on 05/17/22 at 09:55 A.M., Resident #47 said he/she only wears his/her sneakers when in the wheelchair and he/she does not lie on his/her side, and stays on his/her back while in bed with the head up. Resident #47 was observed currently lying in bed on his/her back with the head of the bed elevated., and the air mattress set on comfort setting #5 in the float position. Review of the Treatment Administration Record indicated that during the duration of the survey the nursing staff had signed off, inaccurately, that all treatments were being completed as ordered, every shift. During an interview on 05/17/22 at 11:30 A.M., the Director of Nurses (DON) said Resident #47 refused to wear the Prevalon boots and the order was discontinued and she was not aware the air mattress settings have been set on the wrong settings and she was not sure if Resident #47 was being turned while in bed. The surveyor informed the DON of the above observations and reviewed the Treatment Administration Record, which indicated the nursing staff has checked off all treatments as being completed, inaccurately, every shift during the duration of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and policy review, the facility failed to maintain a clean, sanitary, and homelike environment for all residents residing on two of two units. Findings include: Review of the facility policy titled Daily Room Cleaning, revision date of 2/24/22, indicated but was not limited to the following: - The cleanliness of each resident's room is maintained on a daily basis by the housekeeping staff to provide a fresh, clean, and sanitary environment and reduce the potential for nosocomial infections. - Using a damp rag (Hospital Grade EPA Registered Disinfectant List N and water) damp dust the room starting with the resident's area (overbed table, bedside table and phone) and move to the rest of the items in the room. This includes windowsills, doorframes, shelves, walls, and doors. - Clean and disinfect restrooms. Using a Hospital Grade EPA Registered Disinfectant List N solution and a clean rag, wipe counters, shelves, shower, horizontal, and vertical surfaces. - Pull furniture away from the wall and clean weekly Observations of environmental cleanliness concerns on resident units included dirty wall surfaces, wall surfaces in disrepair, broken heating baseboards, dirty air vents, missing tiles, furniture with missing pieces and flooring in need of sweeping and washing in rooms #128, 122, 106, 112, 115, 203, 210, 201, 209, 203 and 212. [NAME] Unit: 1. On 5/11/22, at 11:23 A.M., in room [ROOM NUMBER] the flooring was dirty and sticky to the touch. A large yellow dried spill was observed next to the bed. Food crumbs and debris was observed between the beds. A black build-up was observed between the floor tiles. Dust and black debris was observed behind the beds, bedside table and in the corners of the room. There was a strong smell of urine observed upon entry to the room. On 5/12/22 at 1:33 P.M., in room [ROOM NUMBER] the flooring remained dirty behind the beds and bedside table, in the corner of the rooms and the floors had not thoroughly cleaned. The floor was sticky to the touch and the odor of urine was present. The black-buildup between the tiles was still present. The flooring in this room remained uncleaned on 5/18/22. The floor remained sticky and the build-up and debris was still observed. 2. On 5/11/ 22 in room [ROOM NUMBER], the flooring was dirty with a brownish-black build-up observed where the trim and floor meet. Dust and debris was observed under the beds and behind the bedside table. The bedside table was cluttered with a suction machine, oral hygiene swabs, magazines, incontinent pads and writing materials. The tubing to the suction machine was hanging behind the bedside table, where dirt and debris was observed. On 5/18/22, the flooring, under the bed and behind the bedside table were all still in need of cleaning. The suction tubing remained hanging behind the bedside table. 3. Observations on 5/18/22 at 1:03 P.M. in rooms #112 and #115, revealed that the flooring was in need of cleaning, a black build-up was observed in the corner of the rooms. The heating baseboard had black dirt build-up in the corners which extended to the wall, trim and floor. A brown splatter was observed throughout the walls. Scuff marks were also observed on the walls and paint was chipping from the doorways of each room. The closet doors had dirt build-up, scuff marks and dents. The closet floors had a thick black build-up of hardened debris where the closet door rests, which extended to the perimeter of the closet. room [ROOM NUMBER] has a missing tile from the windowsill. room [ROOM NUMBER] has a bedside table which was missing a draw handle. The baseboard heater in the bathroom of room [ROOM NUMBER] was broken and the strike plate on the door jamb to the bedroom door was broken, with missing pieces of the metal and sharp edges exposed. Ceiling tiles were stained and black debris was observed in the lighting fixtures on the ceiling. In room [ROOM NUMBER] and #115 a Welcome, this room is ready sign was observed on both beds. During an interview on on 5/18/22 at 1:18 P.M., Housekeeper #1, who identified himself as plant services and the person responsible for cleaning the two rooms said the sign placed on the beds in the two rooms means the room had been cleaned, sanitized and ready for admission. He said there should be nothing more that is needed prior to an admission entering those rooms. 4. On 5/18/22 at 1:03 P.M., in room [ROOM NUMBER] the flooring was dirty with dried black build-up along the edges and in corners of the floor, as well as under the bed. The closet door had scuffs, dried dirt and dents. The edges of the doorway had chipping paint and black dirt build-up. Driftwood Unit: 5. During an interview on 05/17/22 at 05:41 P.M., Family Member #3 said the floors are dirty and you can see old food on the floor. The surveyor observed the floor under the bed and it was visibly dirty and had small pieces of old food scattered on the ground. In the left corner of the room, in-between the wall and bedside table there was a large amount of brown crumbs on the ground. The surveyor observed the crumbs. Family Member #3 said the floors need a good cleaning. On 05/18/22 at 2:09 P.M., the surveyor observed room [ROOM NUMBER] and found the same food debris on the floor that was present the prior evening. During an interview on 05/18/22 at 02:15 P.M., the Administrator and the surveyor observed the food on the floor. 6. On 5/18/2022 at 1:52 P.M., in room [ROOM NUMBER] the floor was observed to be dirty with build up of dirt along the wall. The top left dresser drawer panel was missing. 7. On 5/18/22 at 1:55 P.M., in room [ROOM NUMBER] the floor was observed to be dirty in front of the chair where the resident sits and there was black debris build up along the wall behind the chair. 8. On 5/18/22 at 1:57 P.M., in room [ROOM NUMBER] the floor and the bathroom floor were observed to be visibly dirty and had increase in dirt build up along the walls and under the heater panel by the window. 9. On 5/18/22 at 12:41 P.M., in room [ROOM NUMBER] the corner wall next to the bathroom door was chipped and a hole was present. Black build-up was observed on the floor along the edges of the wall and the trim was dirty. Dried black dirt spots were scattered on the floor. Scuff marks were observed throughout the walls. The doorways were scuffed, dented and paint was chipped. A brown dried stain was observed behind the resident's bed along with debris and dust. 10. On 5/18/22 at 12:44 P.M., in room [ROOM NUMBER] the corner wall next to the bathroom was chipped and a large area of plaster was missing. The walls were splattered with dried debris on several walls and behind the trash can. Scuff marks were present on the walls, doors and closet doors. Food products were observed smashed into the floor under the resident's chair. Black dirt, and dried stains were observed on the floor in several areas and behind the bed. Fecal matter was observed on the bathroom floor. On 5/18/22 at 2:12 P.M., the room remained uncleaned. 11. In the hallways on the Driftwood Unit, food splatter was observed dried to the carpeted walls and chair rail trim in multiple locations. The heating baseboard at the end of the hallway was broken and removed from the base. The vent located above the baseboard heater at the end of the hallway was covered in dust. During an interview on 5/18/22 at 11:18 A.M., the Administrator said she could not locate a cleaning schedule, and there is no formal cleaning checklist to monitor for thoroughness. She said she spoke with the Housekeeping/Maintenance Director who was not in the building that day, and he confirmed there was no cleaning schedule which would include a deep clean of the rooms, including stripping and waxing the floors. During an interview on 5/18/22 at 1:18 P.M., the Administrator walked the [NAME] Unit with the surveyor to review the observations. The Administrator said the rooms needed to be cleaned better and the broken fixtures, including the heating baseboards need to fixed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, policy review, and interviews, the facility failed to ensure adequate supervision and safety interventions were developed and consistently implemented to maintain each Residents' safety to prevent additional falls in two Resident's (#51 and #71) out of total sample size of 20 residents. Additionally, the facility failed to ensure that medications, biologicals, sharps, and chemicals were stored according to facility policy to prevent accidents and hazards and maintain the safety of all residents, staff and visitors for one unit ([NAME] Unit) out of two units. Specifically: 1.) For Resident #71, provide adequate supervision, monitor the effectiveness of fall interventions, and revise the plan of care as per the facility policy, in an attempt to prevent falls 2.) For Resident #51, the facility failed to follow recommendations of the pharmacist medication review due to Resident history of falls with complaints of dizziness to obtain postural blood pressures ( Blood pressure taken lying down, sitting and standing) and to implement effective interventions rather than repeating interventions already in place or attempted. 3.) The facility failed secure medications, biologicals, sharps, and chemicals leaving them in an unsecured room that was not monitored. Findings include: Review of the facility policy, titled Fall Management, last revised 4/7/22, indicated the purpose was to promote patient safety and reduce patient falls by proactively identifying, care planning, and monitoring of patients fall indicators. The policy included but is not limited to: -The facility will assess the resident upon admission, readmission, quarterly, with change of condition, and with any fall event for any fall risks and will identify appropriate interventions to minimize the risk for injury related to falls. -The interdisciplinary team will review the care plan, if indicated, upon completion of each comprehensive assessment, significant change, quarterly MDS, upon a fall event an as needed thereafter. 1. Resident #71 was admitted to the facility in October 2021 with diagnoses that include Lewy Body Dementia. Review of the Minimum Data Set (MDS) assessment, dated 4/27/22, indicated the Resident required supervision with transfers and ambulation. Further review indicated the Resident has had falls since admission documenting two or more with injuries. Review of the falls care plan, initiated on 10/21/21 and last revised on 5/5/22, indicated Resident #71 was at risk for falls related to history of falls, Lewy Body Dementia, antidepressant medication use, and unsteadiness due to fatigue, anemia. The goal was Resident #71 will not sustain serious injury requiring hospitalization. The interventions to achieve this were as follows but not limited to: -Anticipate and meet needs (2/11/22) -Resident Call light within reach (10/21/21) -Educate resident/family/caregiver about safety reminders and what to do if falls occur (2/11/22) -Excess packed belongings to be removed from the room (1/31/22) -Frequently used items and snacks to be placed within reach (above the level of the waist) in bed (3/30/22) -Keep locked wheelchair next to bed when in bed (3/29/22) -Medication regime review (2/8/22) -Offer resident room change (10/21/21) -PT evaluate and treat as indicated (5/5/22) -Speech screen to assess resident's cognitive status regarding new info/education and frequent falls Review of the medical record indicated Resident #71 sustained 10 falls between January 2022 and April 2022. Nine of the 10 falls were unwitnessed falls. Review of the clinical record and Interdisciplinary Team (IDT) notes indicated the facility failed to follow their policy and procedures for falls. The facility failed to implement measures to evaluate why the Resident may have fallen and failed to implement and revise effective interventions to prevent reoccurrence. Review of the nurse progress note, dated 1/28/22, indicated the Resident was found on the floor behind the door. The Resident said he/she was trying to get something. The Resident's walker was across the room. The Resident said he/she hurt his/her back and hit their head. A bruise was noted to the right forearm. The IDT note, dated 1/31/22, indicated a sign was placed on the bathroom wall on the side of the Resident's bed to remind the Resident to use the walker. Review of the nurse progress note, dated 1/31/22, indicated the Resident was found in the hallway laying on his/her back under the Hoyer lift (mechanical lift to move residents from one place to another). The Resident said he/she hit their head. The Resident did not have the walker with them. Resident presented with increased confusion and was sent to the hospital for an evaluation. The IDT note, dated 2/1/221, indicated the Resident was confused and agitated at time of the fall. There was no documented evidence that upon return from the hospital that the team implemented or re-evaluated the cause of the fall. Review of the nurse progress note, dated 2/7/22, indicated the Resident was found sitting on the floor with their face near the bed. The Resident said he/she felt dizzy and slid off the bed. The IDT note, dated 2/8/22, indicated a therapy screen and a medication regime review was put in place. The therapy screen documented that an evaluation would be done for strength and balance. There was no documented evidence a medication regime review was completed. Review of the nurse progress note, dated 2/11/22, indicated the Resident was found lying on the floor. The Resident said he/she fell because of the pain in his/her right leg. The IDT note, dated 2/14/22, indicated an x-ray was done of the right knee and a medication regime review would be done. Review of the nurse progress note, dated 2/25/22, indicated the Resident was on the floor in a supine position. Review of the nurse progress note, dated 2/17/22, indicated a chair and bed alarm were in place for safety. Review of the nurse progress note, dated 3/28/22, indicated the Resident was found on the floor along the side of the bed with their face down. Review of the therapy screen, dated 3/28/22, indicated the Resident was on skilled services for general strength with transfer. No new interventions were documented. The IDT note, dated 3/29/22, indicated a speech screen would be implemented to assess the Resident's ability to understand re-education. The Resident was offered a room change. Review of the therapy screen, dated 3/29/22, indicated the Resident was working with therapy for safety and balance and recommended that the wheelchair stay at the bedside and locked in case the Resident tries to transfer themselves Review of the nurse progress notes for falls sustained on 3/28/22 and 3/29/22 did not indicate any documented evidence that the bed or chair alarms were sounding. Review of the nurse progress note, dated 3/31/22, indicated the bed alarm was found disconnected and sitting at the foot of the bed. Review of the nurse progress note, dated 4/8/22, indicated the Resident was found lying on the floor on his/her back. The Resident said he/she was trying to straighten out their bed and hit their head on the wall. Further review of the progress notes, dated 4/15/22, indicated that an order for a bed alarm and chair alarm were put in place. Per previous nurse progress notes the alarms had already been in place since 3/31/22. Review of the nurse progress note, dated 4/26/22, indicated the Resident was on the floor at the end of the bed between the wheelchair and walker. The progress note did not provide documented evidence that the alarm was sounding. Review of the therapy screen, dated 4/27/22, recommended the Resident engage in activities and stay of the room Review of the nurse progress notes, dated 4/27/22, indicated the Resident was found at the foot of the bed. The Resident was at that time moved to a room closer to the nursing station for close monitoring due to recent falls. This intervention was put in place after the Resident had already sustained 10 falls over a period of two months. Review of the nurse progress notes, dated 4/28/22, indicated the nurse observed the Resident lose his/her balance while he/she was attempting to go into the closet. The Resident stumbled to the floor landing on their buttocks. The alarm was not sounding and upon investigation the alarm was noted to be disconnected. Further review of the nurse progress notes indicated that on 4/29/22 the Resident was transferred to the hospital for evaluation related to a mental status change. Upon return to the facility on 5/4/22 the facility continued the use of the bed and chair alarms for safety. Review of an IDT Care Plan note, dated 2/24/22, indicated that a meeting was held with the team, including nursing, the Director of Nurses, Social Services, Therapy. The note did not have any documented evidence that the Resident's repeated falls were discussed or that the effectiveness of the interventions for the falls were discussed. Review of a pharmacy note, dated 4/23/22, indicated that a medication review was completed and no irregularities were found. Review of the pharmacy consultant Report, dated 5/9/22, indicated the Resident was at moderate to high risk for falls due to having repeated falls, and receiving the psychotropic medication Seroquel (medication that decreased hallucinations and improves concentration) daily. The recommendation was to review the continued use of the Seroquel at its current dose. Report indicated if the medication was to be continued the facility should ensure the IDT should ensure ongoing monitoring for effectiveness and potential adverse consequences (new onset of falls, dizziness, lethargy). Further review of the report indicated the physician declined the recommendations and did not wish to implement any changes due to it being a new medication for behavioral escalation. On 5/11/22 at 12:00 P.M. the surveyor observed the Resident sit up on the side of the bed. No alarm sounded. The alarm box was observed on the nightstand. The wire was disconnected. On 5/12/22 at 9:59 A.M. the surveyor observed the Resident stand from the bed. No alarm sounded. The alarm box was observed on the nightstand. The wire was disconnected. On 5/17/22 at 9:49 A.M. the surveyor observed the Resident move from a lying position to a sitting position on the side of the bed. The alarm sounded for approximately one minute. The surveyor observed the Resident disconnect the wire from the alarm box and shut it off. No staff responded to the alarm. During an interview on 5/11/22 at 12:00 P.M. the Resident said he/she shuts off the alarm and the staff don't know the [NAME]. He/she said it's too loud when it goes off. During an interview on 5/17/22 at 2:58 P.M. Nurse #3 said staff is aware the Resident shuts off the alarm but that the staff feel it is a good intervention because it can alert them to when the Resident is trying to get up on their own. Although the plan of care for the risk for falls is identified in the care plan and progress notes, there is no documented evidence that the IDT reviewed the effectiveness of the interventions that were put in place for the falls allowing ineffective interventions to remain in place while the Resident continued to have falls. 2. Resident #51 was admitted to the facility December 2019 with the diagnoses of history of falls, bipolar, severe depression with severe psychotic features, mood disorder, muscle weakness, mild cognitive disorder. Review of the Minimum Data Set (MDS) dated [DATE] indicated Resident #51 scored a 15 out of 15 on the Brief Interview for Mental Status, indicating he/she is cognitively intact. Resident requires physical assist of one for toileting, dressing, walking in corridors on the unit. In addition, Resident received antipsychotic, antianxiety, antidepressant, diuretic and opoid medication seven of the previous seven days. Review of the Fall Packets received from the Director of Nurses (DON) dated December 28, 2021 to April 15, 20022, indicated Resident #51 had six falls, two of which the resident complained of being dizzy. The Fall Packets indicated the following circumstances of the falls and the interventions put into place: 1. 12/28/2021-Resident #51 reported to Certified Nursing Assistant (CNA), he/she was walking to the bathroom lost his/her balance and fell. interventions: Rehab screen dated 12/28/2021-Resident educated to decrease speed of movement and increase attention to environment. Physical therapy to evaluate to train rehab aide for maintenance program. 2. 1//24/2022- Resident found sitting on her buttocks in front of the bathroom door with feet facing the bed. resident stated he/she was moving a pillow from the chair to the bed when she got dizzy, grabbed her walker and fell. Interventions: -Rehab screen dated 1/24/2022- Resident stated she felt light headed reached and grabbed rolling walker, but pulled it over. Resident already on occupational caseload for strength and flexibility. -Request for medication review dated 1/23/2022 for Resident #51 due to falls, dizziness, or evidence of impaired coordination. 3. 3/4/2022- Resident was found sitting on the floor in front of his/her closet. Resident said she was reaching into his/her closet for under garments and slid to his/her buttocks Interventions: Rehab screen dated 3/7/2022- Resident reports he/she does not recall how she fell, per nursing resident was reaching to the ground. Resident will benefit from continued reminders to use reacher. 4. 3/16/2022- Resident walking with Activity Staff and the Resident's walker tip over and resident lost his/her balance falling to the floor. Resident said My walker tipped and pocketbook was on the right side and I fell landing on my buttocks. Interventions: Rehab screen 3/16/2022 Staff and Resident educated that resident should only have one light item in basket. 5. 4/1/2022- Resident self reported fall to certified nursing assistant, he/she was on the toilet and got dizzy. Resident said he/she pulled the call button, but while for help he/she slid off the toilet. interventions: -Rehab referral for cognitive evaluation. -Remind her not to put so much in his/her walker basket. -Requires no alarms at this time. 6. 4/15/2022- Resident was found sitting on the floor in front of his/her closet. Resident said I was trying to help, picking out my own cloths Interventions: -Rehab referral, advise resident to call for assistance, Resident #51 stated she has do things for herself. -Rehab Screen dated 4/19/2022. Rehab recommended frequent checks on resident. Review of current physician orders indicated Resident #51 was taking the following medications: Bupropion HCI extended release give 150 mg one time day for depression. Carbamazepine chewable 100 mg give two tablets one time a day for bipolar. Clonazepam 0.5 mg give one tablet three times ad ay for anxiety disorder Fluoxetine HCL 40 mg , give one capsule one time day for major depression disorder. Oxycodone HCL 5 mg, give one tablet every 12 hours as needed for pain. Oxycodone HCL 5 mg, give two times a day for pain right shoulder. Quetiapine Fumarate 100 mg, give two tablets at bedtime for bipolar disorder Seroquel 25 mg ( Quetiapine Fumarate), give one time a day for bipolar Tegretol 200 mg(Carbamazepine) , give two tablets one time a day for bipolar Review of Pharmacy consultant medication review dated 2/21/2022 indicated the following: - Repeated recommendation from 1/25/2022. -Resident #51 has experienced a recent fall with dizziness. Carbamazepine level elevated on 1/10/22. 1. Please consider reducing carbamazepine dose 2. Please consider avoiding the combination of clonazepam and quetiapine with oxycodone since boxed warning for this combination potentiating opoid adverse advents, including falls. -Postural blood pressures (taken lying, sitting and standing) should be monitored with quetiapine use. -If this therapy is to continue, the facility interdisciplinary team should ensure ongoing monitoring for effectiveness and potential adverse consequences. Review of medical record weights and vital summary indicated blood pressure monitoring 1/9/22 through 5/18/22 were recorded 15 times in a sitting or lying down position. There was no record of postural static (Lying, sitting and standing) blood pressure taken. Review of the nursing notes including the interdisciplinary team notes 1/1/2022 through 5/18/2022, there was no documentation that Resident #51 had any postural blood pressures recorded. Review of current care plan indicated the following interventions as read in the order they were listed in the care plan: -Resident is at risk for falls related to fall history, use psychotropic medication use, and muscle weakness. Interventions: -1/27/21 Resident educated to keep shoes and socks on when ambulating with rolling walker at all times. -10/8/20 Resident independent in room and on unit with rolling walker -11/10/21 Resident received new slippers and is wearing them -11/3/21 Resident to get new pair of slippers -12/26/21 Educated to observe environment while ambulating - Extra belongings removed from walker basket -3/16/22 educated to have only one light item in walker basket -3/16/22 Rehab issued new rolling walker -3/16/22 Rehab screen placed -4/1/22 Educated on safety awareness, encouraged not to put a lot of items in walker bin -4/14/22 No alarms needed -7/7/20 Encouraged to wear non-skid socks while in bed -12/29/21 Resident has been educated to decrease speed of movement and be more observant of her environment -7/2/19 Anticipate and meet the resident's needs -7/2/19 Assist with activities of daily living as needed -7/2/19 Call light within reach -7/2/19 Complete fall assessment risk -7/2/19 Educate Resident/family/caregivers about safety reminders and what do do if a fall occurs -1/23/22 Educated on proper footwear when up -3/4/22 Fall no injury -1/23/22 Medication regime review -7/2/19 Orient resident to room -7/2/2019 Provide activities that minimize the potential for falls while providing diversion and distraction -7/2/2019 Provide adaptive equipment or devices as needed -7/2/2019 Physical therapy evaluate and treat as ordered or as needed -1/23/2022 Rehab screen -4/4/2022 Rehab screen for safety and fall recovery -3/28/2022 Resident educated on 3/4/22 and reminded to request assistance from staff rather than reaching for items. Encouraged to to utilize call bell -7/2/2019 bilateral side rails up as ordered -10/21/2020 Sign placed on walker facing resident that states Resident #51 keep walker with you at all times During an interview on 05/18/22 at 09:54 A.M., the DON said Resident #51 did not have any postural blood pressures taken as recommend by the pharmacist medication review in February. In addition, we reviewed Resident #51 care plan and interventions put in place after his/her falls dating back to December 28, 2021. The DON agreed the care plan has a lot of interventions and many of them are doubles or not effective interventions. The DON said she was not aware Resident #51's walker no longer has a sign on it to remind him/her to use the walker at all times or he/she no longer has a basket on the walker. The DON said the current care plan needs to be looked at. 3.) Review of facility's policy titled 5.3 Storage and Expiration Dating of Medications, Biologicals, revision date 1/1/22 included but was not limited to the following: - Facilities should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. Review of facility's policy titled Handling and/or Disposing of Contaminated Sharps, dated 3/6/19, indicated the following: - When the sharps disposal container is 3/4 full, lock it and replace it. - Store the locked container in the appropriate area for disposal by a licensed vendor. On 5/17/22 at 3:40 P.M., the Staff Development/Infection Control office was observed to be opened and unattended by any staff personnel. The office is located on the [NAME] Unit, directly across from the active nurses station and in close proximity to the entrance of the resident's day room where activities are held. The office is easily accessible to residents, visitors and all staff. Throughout the recertification survey 5/11/22 through 5/18/22, the surveyors observed the office door to be opened daily and many times unattended by a staff member. Residents were observed ambulating the hallways or self-propelling themselves, unattended in close proximity to the office. The [NAME] Unit had a resident census of 38 residents and 12 of those residents had a diagnosis of Dementia/Alzheimer's according to facility documentation. On 5/17/22 at 3:42 P.M., two surveyors observed the closet in the Staff Development/Infection Control office to be opened and accessible. The closet did not have a door, and was only using a curtain to provide privacy when closed. There was no lock on the closet. The two surveyors observed six large boxes piled from floor to ceiling. Behind the six boxes, an additional three smaller boxes, and two cloth shopping bags were observed. Multiple prescription, and over the counter medications were observed within the boxes, bags and scattered throughout the closet shelves. On 5/17/22 at 3:46 P.M., the Infection Preventionist (IP) returned to the office at the request of the surveyors, and in the presence of the IP the surveyors removed the six large boxes to make closer observations. The surveyors observed the following: - 4 large boxes filled with prescription medications - 2 smaller boxes filled with prescription medications and over the counter medications - 2 cloth shopping bags filled with prescription medications - 3 plastic bags filled with over-the counter medications - 2 plastic bags filled with intravenous (IV) medications and IV solutions (normal saline) - 1 plastic bag filled with 4 small nip size bottles unopened and labeled vodka - 5 containers of pharmaceutical destroyer (a chemical used to destroy medications) - 2 filled sharps containers with used sharps and syringes - IV supplies, Lovenox syringes (anticoagulant medication) The medications and supplies were in large quantities and too numerous to count. During an interview on 5/17/22 at 3:46 P.M., the Infection Preventionist said she recently moved into this office, about two weeks ago. She said the medications have been in that closet since she moved in and have not been locked or secured. During an interview on 5/17/22 at 4:06 P.M., Cooperate Nurse #1 said the medications were recently discovered in this closet. She said medications should be kept in a secure location and sharps should be collected by the maintenance department and kept secure until removed from the facility. During an interview on 5/18/22 at 10:17 A.M., the Administrator said she was aware of the medications being kept in the SDC closet for about three weeks at most. She said her and the Director of Nurses have been coming up with a plan to destroy the medications but since the discovery, the medications have remained in the closet which was unlocked and unsecured. During an interview on 5/18/22 at 11:40 A.M., the Director of Nurses said she was made aware of the medications being stored in the SDC closet about two weeks ago. She said they have been coming up with a plan to finish destroying them, but since the discovery of the medications they have remained stored in that closet. She further said some of the medications were dated as far back as 2015.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The following observations were made on the Driftwood Unit: d.) On [DATE] at 2:20 P.M., the surveyor observed the medication cart, located on the B side, unlocked and unsupervised. The nurse assigned to the medication cart was unavailable at the time of the observation. During an interview on [DATE] at 2:25 P.M., Nurse #6 said the medication carts should not be unlocked when the nurse is away from the cart. She said they should remain locked. e.) On [DATE] at 2:30 P.M. on the Driftwood Unit Hallway B, the surveyor observed the treatment cart to be unsecured and unsupervised in the hall outside the unit dining room. The surveyor could open the treatment cart where resident prescription creams and ointments were accessible. Nurse #1 said that she had left it unlocked because she was planning on cleaning out the drawer. She said it should have been locked until then. 4.) On [DATE] at 2:15 P.M. the surveyor inspected the Driftwood Unit Medication Room with Nurse #1. Three boxes of the Pneumococcal polysaccharide vaccine were observed in the refrigerator. Review of the refrigerator temperature log indicated the temperature is checked twice a day, once on the 7-3 shift and once on the 3-11 shift. Review of the temperature log indicated the temperature had not been checked on the 3-11 shift from [DATE]-[DATE]. During an interview on [DATE] at 2:20 P.M., Nurse #1 said the temperature logs should be checked twice a day. 5) On [DATE] at 2:15 P.M. the surveyor inspected the Driftwood Unit Medication Room with Nurse #1. The counter tops were dirty and covered with a white powder substance that had been spilled on it. The inside of the sink had rust built up inside of it and was in need of cleaning. Nurse #1 said that the counter tops needed to be cleaned and that the sink had been that way for a while. The medication cabinets were disorganized with over the counter medications stocked inside. There was a large amount of resident medication packs stacked up in the cabinets. These medications were either medications that had been discontinued for residents or medications for residents who had been discharged from the facility. Nurse #1 said she was unsure why the medications had not been removed from the medication room and discarded. She said that they should have been removed and destroyed once the medication was no longer needed. Based on observation and interview, the facility failed to: (1) Store all expired or discontinued medications in a secured location, inaccessible by residents and visitors on one out of two units; (2) Label medications and biologicals in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable; (3) Store all drugs and biologicals in locked compartments, and permit only authorized personnel to have access on two out of two units; (4) Ensure refrigerators housing vaccines had temperature monitoring two times per day for one out of two medication rooms and; (5) Ensure medications and biologicals are stored in an orderly manner in cabinets, drawers, and carts. Findings include: Review of facility's policy titled 5.3 Storage and Expiration Dating of Medications, Biologicals, revision date [DATE] included but was not limited to the following: - Facilities should ensure that medications and biologicals are stored in an orderly manner in cabinets, drawers, carts, refrigerators/freezers of sufficient size to prevent crowding. - Facilities should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. -Once any medication or biological package is opened, facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facilities staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened. - If a multi--dose vial of an injectable medication has been opened or accessed, the vial should be dated and discarded within 28 days unless the manufacturer specifics a different (shorter or longer) date for that opened vial. - Facility should ensure that medications and biologicals are stored at their appropriate temperatures according to United States Pharmacopeia guidelines for temperature ranges. Facility staff should monitor temperature of vaccines twice a day. - Facility should ensure that medications and biologicals for expired or discharged or hospitalized residents are stored separately, away from use, until destroyed or returned to provider. - Facility should destroy or return all discontinued, outdated/expired, or deteriorated medications or biologicals in accordance with pharmacy return/destruction guidelines and other applicable law, and in accordance with Policy 8.2 (Disposal/Destruction of Expired or Discontinued Medication). Review of facility's policy titled 8.2 Disposal/Destruction of Expired or Discontinued Medication, revision date [DATE], included but was not limited to the following: - Facility staff should destroy and dispose of medications in accordance with facility's policy and applicable law, and applicable environmental regulations. - Facility should place all discontinued or outdated medications in a designated, secure location which is solely for discontinued medications or marked to identify the medications are discontinued and subject to destruction. - Facility should dispose of discontinued medication, outdated medications, or medications left in facility after a resident has been discharged in a timely fashion and no more than 90 days of the date the medication was discontinued by Physician/Prescriber, or sooner per applicable law 1.) On [DATE] at 3:40 P.M., the Staff Development/Infection Control office was observed to be opened and unattended by any staff personnel. The office is located on the [NAME] Unit, directly across from the nurses station and in close proximity to the entrance of the resident's day room. The office is easily accessible to residents, visitors and all staff. On [DATE] at 3:42 P.M., two surveyors observed the closet to be opened and accessible. The closet did not have a door, and was only using a curtain to provide privacy when closed. There was no lock on the closet. The two surveyors observed six large boxes piled from floor to ceiling. Behind the six boxes, an additional three smaller boxes, and two cloth shopping bags were observed. Multiple prescription, and over the counter medications were observed within the boxes, bags and scattered throughout the closet shelves. On [DATE] at 3:46 P.M., the Infection Preventionist (IP) returned to the office at the request of the surveyors, and in the presence of the IP the surveyors removed the six large boxes to make closer observations. The surveyors observed the following: - 4 large boxes filled with prescription medications - 2 smaller boxes filled with prescription medications and over the counter medications - 2 cloth shopping bags filled with prescription medications - 3 plastic bags filled with over-the counter medications - 2 plastic bags filled with intravenous (IV) medications and IV solutions (normal saline) - 1 plastic bag filled with 4 small nip size bottles unopened and labeled vodka - 5 containers of pharmaceutical destroyer (a chemical used to destroy medications) - 2 filled sharps containers with used sharps and syringes - IV supplies, Lovenox syringes (anticoagulant medication) The medications and supplies were in large quantities and too numerous to count. During an interview on [DATE] at 3:46 P.M., the Infection Preventionist said she recently moved into this office, about two weeks ago. She said the medications have been in that closet since she moved in and have not been locked or secured. During an interview on [DATE] at 3:58 P.M., the Staff Development Coordinator (SDC), said she has been working in the building for 11 years. She said prior to the current Director of Nurses (DON), the nurses were asked to give the previous DON all medications that needed to be destroyed. She said each unit had a box in the medication room and when the medication box was full, the nurses would hand them to the DON and she always assumed they were being destroyed. The SDC said prior to office changes, this office was the DON's for many years. During an interview on [DATE] at 4:05 P.M., the Cooperate Nurse #1 with the Administrator present said the boxes of medications were recently discovered. She said the building did not have the scanners to destroy the medications. The Administrator said she was aware that the pill crusher has also been out of commission for sometime. During an interview on [DATE] at 10:17 A.M., the Administrator said she was aware of the medications being kept in the SDC closet for about three weeks at most. She said her and the current Director of Nurses have been coming up with a plan to destroy the medications. During an interview on [DATE] at 11:40 A.M., the Director of Nurses said she was made aware of the medications being stored in the SDC closet about two weeks ago. She said they have been coming up with a plan to finish destroying them, but since the discovery of the medications they have remained stored in that closet. She further said some of the medications were dated as far back as 2015. 2.) On [DATE] at 10:46 A.M., the [NAME] Unit, A-South medication cart was inspected by the surveyor with Nurse #4. On inspection of the top draw of the medication cart, an Insulin Glargine Solution Pen (a long-acting insulin used to treat Diabetes Mellitus) was observed in the back left corner of the medication cart. The insulin was opened and dated [DATE]. According to the manufacturers guidelines for Insulin Glargine Solution Pen-Injector, unrefridgerated pens should be discarded after 28 days of initial use. Nurse #4 said the pens are usually good for 28 days but she wasn't completely sure. She said if it was only good for 28 days then the pen would be expired. Further inspection of the top draw of the medication cart indicated an undated Insulin Lispro Solution Pen (a short-acting insulin used to treat Diabetes Mellitus). According to the manufacturers guidelines for Insulin Lispro Solution, unrefridgerated pens should be discarded after 28 days of initial use. Nurse #4 said she could not tell the surveyor how long the insulin pen had been opened for or if it was past the date of expiration. During an interview on [DATE] at 10:45 AM, the Director of Nurses said the insulin pen was labeled incorrectly. She said all insulins should be dated when opened and the nurses should know when the medications expire. 3.) The following observations were made on the [NAME] Unit. a.) On [DATE] 9:40 A.M., the surveyor entered [NAME] Unit. The medication cart (identified as the south medication cart) was observed to be unsupervised and unlocked, parked against the nurses station. Nurse #4 was observed sitting at the nurses station and on several occasions would walk down the hallway, into patient rooms leaving the medication cart unsupervised. At 10:35 A.M., a second nurse was observed to locked the medication cart and leave the area. Nurse #4 returned to her medication cart and said she thought her medication cart had been locked that entire time. She said the cart should be locked when it is not in use. b.) On [DATE] at 9:45 A.M., the treatment cart on the [NAME] Unit was observed to be unlocked, and unsupervised parked to the left of the nurses station. At 9:48 A.M., Nurse #5 was observed trying to lock the treatment cart but was having difficulties. She said the treatment cart can be very difficult to lock, and eventually left the treatment cart unattended and unsecured. At 10:54 A.M., the surveyor was still able to open the unsupervised treatment cart. The surveyor was able to open the treatment cart draws and observed several prescription and over the counter creams, ointments and powders labeled with resident information. During an interview on [DATE] at 10:58 A.M., Nurse #4 said the treatment cart has been very difficult to lock. She said it should be locked at all times when not in use. c.) On [DATE] at 8:47 A.M., the surveyor entered the [NAME] Unit. The medication cart (identified as the south medication cart) was again unlocked and unsupervised. The surveyor waited at the cart for the nurse to return. Nurse #4 returned to the medication cart a few minutes later and said, the cart is locked, I locked it. The surveyor was able to open the medication cart draws without the use of a key. Nurse #4 then said she was unsure why the cart was unlocked. During an interview on [DATE] at 8:50 A.M., the Staff Development Coordinator said all medication and treatment carts should be locked anytime they are not in use. 6.) On [DATE] at 8:28 A.M., the surveyor observed Nurse #2's medication cart, located on the Driftwood Unit. When Nurse #2 unlocked the cart, both her and the surveyor observed that there were several loose pills of various sizes, shapes and colors in the bottom of the drawer. Nurse #2 pulled out 38 tablets and placed in a cup on top of the medication cart. The medications were not stored and/or labeled properly. Many of the blister packs (medication cards send from the pharmacy with resident specific prescription medications) were jammed in tight as there was not sufficient room for all the blister packs to be stored/spaced appropriately. The surveyor further observed a pre-poured medication in a medication cup, unlabeled and undated. Nurse #2 said is was a sodium tablet for a resident. During an interview on [DATE] at 8:28 A.M., Nurse #2 could not verbalize what the facility's protocol would entail in regards to what she should do with the loose pills or pre-poured medications. Some of the pills were in pieces and broken. During an interview on [DATE] at 8:39 A.M., the DON said that nursing staff needs to clean the carts regularly and this should not be happening.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Review of the facility policy titled Indwelling Urinary Catheter (Foley) Management, dated 4/1/22 indicated the following: - Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor. Resident #75 was admitted to the facility in January 2022 with the following diagnoses: neuromuscular dysfunction of the bladder, and Diabetes Mellitus. Review of the most recent Minimum Data Set (MDS), dated [DATE] indicated that Resident #75 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating that he/she was cognitively intact. On 5/11/22 at 11:23 A.M., the surveyor observed Resident #75 laying in bed. A urinary catheter drainage bag was observed to be on the floor to the left side of the bed, urine was observed in the bag. During an interview on 05/17/22 at 05:01 P.M., Corporate Nurse #1 said all catheter drainage bags should be placed in a privacy bag and not on the floor. Based on observations, interview and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to: (1) Ensure that for 1 of 1 staff nurses (Nurse #2) from total sample of 1 staff observed, performed hand hygiene consistently before and after medication preparation and/or administration and adhered to basic infection control practices and; (2) Keep catheter bags off the floor at all times to prevent the risk for infection for one Resident (#75) out a total sample of 20 residents. Findings include: 1) Review of the facility policy titled, Hand Hygiene, revised 12/4/2020, indicated the following: - Handwashing/hand hygiene is considered the most important single procedure for preventing nosocomial infections - Purpose is to decrease the risk of transmission of infection by appropriate hand hygiene - Alcohol-based hand rubs (ABHR) is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. ABHR effectively reduces the number of pathogens that may be present on the hands of healthcare providers after brief interactions with residents or the care environment. - CDC recommends ABHR with a 60-95% alcohol in healthcare settings. Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. CDC does not have recommended alternative to ABHR. - The facility should provide education to associates on hand hygiene routinely, and this education should include but is not limited to: - Before and after all resident contact - After contact with potentially infectious material Resident #328 was admitted to the facility in April 2022, on hospice due to congestive heart failure. Resident has diabetic ulcers on both feet. Resident #328 had his/her foot wrapped with gauze and there was visible blood soaking through the top of the dressing. The blood was visible on the sheets as well. There was a precaution cart outside the room and a sign posted on the door indicating Aerosol Generating Procedure and the personal protective equipment (PPE) to be worn upon entering included: face mask, face shield, gown and gloves. On 5/16/22 at 8:54 A.M., during the medication administration observation, Nurse #2 prepared the medications for Resident #328, which included klonopin 0.5 mg PO (by mouth), gerikot 1 tab PO and liquid morphine sulfate 30 mg PO and a nitroglycerin 0.4% patch to be applied transdermally. Nurse #2 did not perform hand hygiene prior to the start of preparing the medications. She crushed the klonopin and gerikot tabs together and added yogurt. Nurse #2 drew up the liquid morphine in a needlelessss syringe to administer by mouth to the Resident, and prepared the nitroglycerin patch. Nurse #2 entered the Resident's room wearing a face mask, with liquid morphine held in the one gloved hand, and the remaining medications in her other ungloved hand. Nurse #2, while administering the medications, leaned her thighs against the side of the bed where there was visible blood on the sheet. She reached across the Resident to remove the old nitroglycerin patch apply the new nitroglycerin patch on the Resident's arm, which was the furthest from her. She then removed the one glove. She administered the the remaining oral medications which were crushed in yogurt and assisted the Resident by holding the cup of water for him/her to sip while swallowing. She then administered the liquid morphine into the Resident's mouth. She took the empty needleless syringe to the bathroom to rinse it out with no gloves donned (to put on). Nurse #2 exited the Resident's room and did not perform hand hygiene. She then proceeded back to the medication cart, and continued to have contact with the medications in the drawer, items on top of the cart, and used the computer. Nurse #2 unlocked the cart with the key, unlocked the narcotic box within the cart and then placed the syringe back in the box for reuse. She then performed hand hygiene and moved the cart onto the next room. During an interview on 5/16/22 at 9:11 A.M., the surveyor inquired about the reason for not wearing full PPE, lack of hand hygiene and as to not documenting in the narcotic book the klonopin and morphine. Nurse #2 said that the Resident has end stage Chronic Obstructive Pulmonary Disease, we only need to wear full PPE if we are doing a nebulizer treatment. She did not mention the visible blood. In response to the lack of hand hygiene, Nurse#2 said that she was very nervous. Nurse #2 then said oh, I forgot to document the narcotics. During an interview on 5/16/22 at 1:25 P.M., the Director of Nurses (DON) said that she enforces with staff to wear full PPE due to the visible blood with Resident #328. Staff need to protect themselves and other residents from unknown pathogens.

Based on interview, policy review, and record review, the facility failed to conduct testing in a manner consistent with professional standards of practice for COVID-19 testing. Specifically, the facility failed to conduct outbreak testing in accordance with facility policy for five out of five staff personnel and five out of five residents reviewed. Findings include: Review of the facility's policy titled COVID-19 Outbreak Investigation, reviewed 6/28/22, indicated the following: - The facility will perform COVID-19 outbreak investigations in accordance with local, state, and federal regulations to mitigate the spread of COVID-19 within the facility. Review of the Department of Public Health (DPH) Memorandum titled Update to Caring for Long-Term Care Residents during the COVID-19 Response, including Visitation Conditions, Communal Dining, and Congregate Activities, dated 6/10/22, indicated the following: - Once a new case is identified in a facility, following the requisite outbreak testing, long-term care facilities should test all residents and staff at least every three days on the affected unit until the facility goes seven days without a new case and then once per week until the facility goes 14 days without a new case unless a DPH epidemiologist directs otherwise. Review of the facility's most recent outbreak documentation for May/June 2022 indicated a facility staff personnel was identified as being positive for COVID-19 on 5/1/22. Since that time a total of 14 additional staff members tested positive for COVID-19, with the most recent case identified on 6/28/22. Further review of the most recent outbreak documentation indicated from 6/20/22 through 6/28/22, a total of 12 residents had tested positive for COVID-19 and remained positive as of 6/29/22. During an interview on 6/29/22 at 10:56 A.M., the Infection Preventionist said staff and resident testing should be completed every three days until no cases are identified for seven days. She said all residents were receiving rapid Binax antigen testing since the outbreak and testing was documented in the medical record. She further said staff was receiving weekly PCR (polymearse chain reaction) testing and Binax antigen testing two times per week in order to fulfill every three day requirements. The Infection Preventionist said they have remained in outbreak mode since the initial positive case on 5/1/22. Review of the facility's Staff Binax Testing Logs for June 2022 failed to indicate testing was completed for all working staff as required. Additionally, the logs had missing data for staff Binax testing from 6/4/22 through 6/24/22. The Infection Preventionist could provide no documentation that Binax testing was completed for the staff or that testing was completed every three days per facility policy. A sample of five staff personnel were reviewed for compliance with the facility's policy of every three day testing. For five out of five staff members, the facility failed to provide testing during a COVID-19 outbreak per facility policy. Review of the medical record for five out of five residents reviewed failed to indicated testing was completed and documented every three days during a facility outbreak per facility policy. During an interview on 6/29/22 at 3:40 P.M., the Director of Nurses said it was the expectation that testing of all staff and residents would have been completed every three days until no new positive cases were identified.