**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the physician documented the clinical rationale and duration of use in the medical record for a PRN (as needed) psychotropic medication for one Resident (#6) of five residents reviewed for unnecessary medications. Findings include: Resident #6 (R6) was admitted to the facility 6/23/25. A Minimum Data Set (MDS) assessment dated [DATE] documented R6 had severe cognitive impairment and received psychotropic medications. There were no behaviors coded in the MDS.The Electronic Medical Record (EMR) of R6 contained a physician's order dated 7/9/25 for alprazolam (an antianxiety medication) 0.25 mg (milligrams) every 24 hours PRN for anxiety. A medication history review revealed the PRN alprazolam was initially ordered on 6/24/25.A pharmacist medication regimen review (MRR) for R6 dated 6/24/25 read, in part: .Note to attending physician/prescriber.This resident has an order for PRN alprazolam. Please evaluate current diagnosis, behaviors and usage patterns and evaluate continued need. PRN psychotropic orders cannot exceed 14 days with the exception that the prescriber documents their rationale [sic] in the resident's medical record and indicate the duration for the PRN order [sic]. Review of the EMR on 7/31/25 revealed no documentation by the physician regarding the PRN alprazolam, including the clinical rationale or duration of use for the PRN antianxiety medication for R6. A nurse's progress note dated 7/9/25 at 8:56 PM documented, PRN Xanax [brand name of alprazolam] reviewed with Dr. [physician's name redacted]. Orders received to continue current order and review in 2 weeks. There were no further nurse progress notes regarding the alprazolam.The Director of Nursing (DON) was interviewed on 7/31/25 at 8:33 AM. The DON said the use of PRN psychotropic medications was limited to 14 days before the physician was required to re-examine and evaluate the continued use of the medication. The DON was asked if the physician had evaluated the PRN alprazolam for R6 and if the physician documented the duration of use and clinical rationale for the continued use of the antianxiety medication. The DON said she would review the EMR.On 7/31/25 at 10:34 AM, the DON reported the physician of R6 did not document on the alprazolam including the continued need for the medication or duration of use. The policy Medication - Psychotropic dated as reviewed/revised 10/30/23 documented, in part: .PRN orders for psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e. 14 days). a. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she shall document their rationale in the resident's medical record and indicate the duration for the PRN order.

Based on interview and record review, the facility failed to ensure one Resident (#2) of one resident reviewed for PASARR (Preadmission screening/Annual Resident Review) had a Level one (1) OBRA (Omnibus Budget Reconciliation Act) screening sent to the Community Mental Health Services Program (CMHSP) for a level two (2) OBRA evaluation. Findings include:The Electronic Medical Record (EMR) of Resident #2 (R2) revealed an admission date of 6/19/25. R2's diagnoses included but were not limited to: Bipolar Disorder and Major Depressive Disorder. A Level 1 screening dated 6/11/25 documented R2 had a diagnosis of mental illness and had received treatment for mental illness, including psychotropic medications within the last 14 days. The EMR did not contain a Level 2 OBRA evaluation, and no documentation was in the EMR indicating a Level 1 had been referred to the CMHSP for evaluation.The MDS Nurse (Registered Nurse (RN) C) was interviewed on 7/30/25 at 1:41 PM. RN C confirmed she was the staff member responsible for completing the PASARR. RN C said there was not a Level 2 for R2 because a Level 1 assessment for R2 was not sent to the CMHSP for evaluation for services that may be needed for R2. RN C said R2 had transferred to the facility from a different nursing facility and the person in the company responsible for admissions did not transfer the OBRA from the facility from which she was transferred to the current facility, so RN C did not receive a notification to follow-up with the local CMHSP. The Social Services Coordinator (SSC) was interviewed on 7/30/25 at 2:11 PM. The SSC confirmed R2 was not receiving services for mental illness. The SSC was asked regarding R2 receiving services for mental illness. The SSC said the Resident Representative (RR) of R2 would need to approve the services. The SSC was asked if the RR of R2 was provided with the option to accept or decline services for R2. The SSC confirmed the RR was not approached regarding mental health services for R2. The SSC said, [R2] fell through the cracks.The policy PASARR - Pre-admission Screen and Resident Review dated as reviewed/revised 10/30/23 documented, in part: . All residents are required to have a level 1 PASRR [sic]screen prior to or upon admission the facility [sic]. When indicated on the level 1 screen that a level 2 is required, the facility will complete notification to the State's PASRR [sic] program notice for the level 2 screen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews, the facility failed to maintain a safe, functional, sanitary, and comfortable environment. This resulted in an increased potential for contamination and a possible decrease in satisfaction of living among all residents. Findings Include:On 07/30/2025 at 10:27 AM, it was noted that the drain line on the ice machine in the main dining room off the kitchen had black slime growing on end of the pipe. Maintenance Director F observed the drain pipe, and stated he cleans the ice machine and the drain tray weekly, but not the drain line that hangs above the floor drain.On 7/29/25 at 10:31 AM, the register cover in room [ROOM NUMBER] was observed dirty with brown splatters on the wall and had been re-enforced to hold the front and the top of the unit together. On 7/29/25 at 12:42 PM, during an interview with Guardian/Conservator G she was asked about the heater/register in room [ROOM NUMBER] and stated that it looks terrible, but functions fine. She stated the register was beat up and could be replaced.On 7/30/2025 at 8:05 AM, a follow-up observation found that the heating register cover in room six was damaged.On 07/30/2025 at 8:25 AM, during a tour of the soiled utility room with the Senior Maintenance Director E , an interview found that the facility flushes water fixtures weekly to prevent stagnate lines and Legionella from growing and spreading. The hopper was observed full of clear water. When the over hopper fill faucet was turned on, the water coming from that fixture was noted brown and discolored. Senior Maintenance Director E continued to run it for approximately a minute until a small clog dislodged, and the water ran clear. Senior Maintenance Director E stated that this fixture would now be added to the fixture flushing schedule.On 7/30/2025 at 8:40 AM during a tour of the A Wing with Maintenance Director F, it was observed that the heat register covers were damaged, or loose in Rooms 1, 5, 6 and 8. The cover in room [ROOM NUMBER] was loose in several places. The cover in room [ROOM NUMBER] was not attached completely. The cover in room [ROOM NUMBER] was observed to be damaged and pried up, exposing the heating coils inside. The wall behind the heat register in room [ROOM NUMBER] was noted soiled and splattered with brown and black debris. The heating register cover in room [ROOM NUMBER] was pulled away slightly, partially exposing the heating coil underneath.On 7/30/25 at 8:58 AM, the Maintenance Director F stated that he has been trying to order parts to repair these registers, but the parts have not been available.

Based on observation, interview, and record review, the facility failed to ensure medications were safely administered in an environment of a residents choosing for one Resident (R191) of twelve residents reviewed for Residents' Rights. Findings include: During medication administration observation on 8/7/24 at 7:24 a.m., Registered Nurse (RN) E provided Resident #191 (R191) her prescribed medications while R191 was eating breakfast in the dining room with other residents. RN E placed the medications directly on the table next to R191 and exited the dining room without observing R191 take the medications. The Director of Nursing (DON) was interviewed on 8/7/24 at 10:30 a.m. The DON agreed medications should not be provided in the dining room unless a resident prefers to take his or her medications in the dining room. The DON said the resident preference for administration locale would be in the care plan if a resident wants medications administered in a public area such as the dining room. R191 was interviewed on 8/7/24 at 11:51 a.m. When asked about receiving medication while in the dining room, R191 said the nurses usually provide her with medications in her room. When asked how she felt about receiving medications while in the dining room, R191 replied, I don't want them in the dining room. I never want them in there. I want to get them in here [resident's room]. The policy Promoting/Maintaining Resident Dignity dated 10/26/23 read, in part: .It is the practice of the facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment that maintains or enhances residents' quality of life by recognizing each resident's individuality . An undated, attached addendum for Residents' Rights read, in part: .(d) a patient or resident is entitled to privacy, to the extent feasible in treatment and in care for personal needs with consideration, respect, and full recognition of his or her dignity and individuality .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure assistance was provided with donning a back brace for one Resident (R20) of four residents reviewed for range-of-motion and mobility. Findings include: Resident #20 (R20) On 8/5/24 at approximately 9:15 a.m., a Thoracolumbosacral orthosis (TLSO - a type of back brace) was observed on a chair in R20's room. R20 was sitting in a wheelchair talking on the phone and was not visibly wearing a different brace or device to stabilize or support the spine. On 8/5/24 at 12:47 p.m., the TLSO remained in the chair in R20's room. When asked about the TLSO, R20 said, I broke my back and I'm supposed to wear that when I'm out of bed, but I can't put it on by myself. R20 indicated she was admitted to the facility for skilled rehabilitation services after experiencing a fall at home that resulted in a spinal fracture. R20 was asked if the staff assisted with donning the brace. R20 said the therapist was assisting with the brace but skilled therapy had ended in July, and no one helped her put on the TLSO since. On 8/6/24 at 10:22 a.m., R20 was observed in her room using a walker to ambulate. R20 was not wearing the TLSO. R20 said, No one helps me put it on since therapy stopped. I'm supposed to wear it when I'm not in bed, but I can't buckle it by myself. On 8/6/24 at 10:26 a.m., the nurse manager, Registered Nurse D (RN D) was asked if R20 should be wearing her TLSO every day when out of bed. RN D said R20 always refuses to wear it [the TLSO]. RN D accompanied the surveyor to R20's room and asked R20 if she would like help with placing her back brace. R20 responded, yes - it's about time! Resident #20 (R20) was admitted to the facility on [DATE] with a spinal fracture. A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14 indicating R20 was cognitively intact. Section E did not code any behavioral concerns. Section E0800 of the MDS documented R20 did not exhibit rejection or refusal of care necessary to achieve R20's goals for health and well-being. R20 had a physician's order for TLSO brace with activity every shift. Transfer records from the hospital documented the need for R20 to wear the TLSO when out of bed. R20's care plans included an intervention for TLSO as ordered. There was no documentation of refusing to wear the TLSO in the care plan or in behavior tracking tasks. The Physical Therapist Assistant (PTA) and Occupational Therapist (OT) were interviewed on 8/06/24 at 10:53 AM. The OT reviewed R20's record and said skilled therapy did not have any documentation on R20's TLSO. The PTA said he worked with R20 for the duration of her skilled therapy, and confirmed he assisted her each day with applying the TLSO. The PTA said R20 wore the brace willingly and never refused to wear it for him. The PTA said R20 was unable to apply the brace independently and required assistance with placing the brace. When asked who was supposed to be aiding with the brace, the PTA said, nursing. The PTA and OT confirmed R20 should be wearing the brace every day when out of bed. The OT said occupational therapy and physical therapy ended on 7/23/24 and 7/26/24 so nursing should have been applying the brace each day since skilled therapy services ended. The Treatment Administration Record (TAR) revealed the order for the TLSO. The brace was signed out as being applied every day, each shift in August including 8/5/24 and 8/6/24 when the observations were made of R20 not wearing the brace. There were no documented refusals by R20 to wear the brace. RN A, the nurse who initialed the TAR indicating the TLSO had been applied on 8/5/24 and 8/6/24, was interviewed on 8/6/24 at 12:52 p.m. RN A confirmed he had not assisted R20 with applying the TLSO. RN A said, I've never assisted (R20) with application of the brace. When asked why he signed the TAR with his initials indicating the brace was applied, RN A said the Certified Nursing Assistants (CNAs) applied the TLSO. The tasks in R20's medical record did not include documentation by CNAs indicating R20 was assisted with placing the TLSO when out of bed. Progress notes in R20's record did not document the daily donning and doffing of the brace. A physician's progress note on 6/17/24 read, in part: .Generalized weakness. To wear TLSO brace when up . The Director of Nursing (DON) was interviewed on 8/7/24 at 10:38 a.m. The DON said the expectation is for staff to assist R20 with placement and removal of the TLSO. The policy Use of Assistive Devices dated 10/26/23 read, in part: .The purpose of this policy is to provide a reliable process for the proper and consistent use of assistive devices for those residents requiring equipment to maintain or improve function .facility staff will provide appropriate assistance .set up assistance, supervision, or physical assistance as needed .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: 1. Document the rationale for declining gradual dose reductions for an antipsychotic medication for one Resident (R1) of five residents reviewed for unnecessary medications, and 2. Document the rationale and duration of PRN use of a psychotropic medication for one Resident (R6) of five residents reviewed for unnecessary medications. Findings include: Resident #1 (R1) A review of the physician's orders for R1 included an order for Abilify (an antipsychotic medication) 10 milligrams (mg) daily. A review of R1's medical record did not reveal any attempts at Gradual Dose Reduction (GDR) of the Abilify since R1 was admitted to the facility on [DATE]. A form Antipsychotic Gradual Dose Reduction Form dated 11/23/23 was in R1's record. The form documented the Antipsychotic medication to be addressed was Abilify for Bipolar disorder and hallucinations. A box was checked that read: a gradual dose reduction is contraindicated for the following reason: . but no documentation followed - the area to document the response was blank. R1's physician did not provide a written response documenting the reason for declining a GDR attempt for Abilify. Staff F was interviewed on 8/6/24 at 1:37 p.m. Staff F confirmed she was the social services designee and oversaw GDR of psychotropic medications. When asked when the last GDR of Abilify was attempted for R1, Staff F said a dose reduction had not taken place since she assumed the social services designee position in January 2023. Staff F was asked if the physician had attempted a GDR of the Abilify since R1 was admitted to the facility. Staff F replied, No, I don't think so. Staff F was asked if the physician had documented any rationale for not attempting a GDR or if there was documentation of clinical contraindication of a GDR. Staff F reviewed R1's medical record and said, I can't find any documentation. Staff F said a GDR for Abilify was submitted to the physician on 11/23/23 but the physician had declined the GDR request. Staff F was asked for the documented reasoning for declination. Staff F reviewed R1's medical record and confirmed there was no physician documentation indicating the physician's reason for not attempting a GDR. Staff F was asked if the facility's contracted provider of psychiatric services was involved with R1's psychiatric needs and psychotropic medication. Staff F said contracted psychiatric services were not involved because R1 is followed by Community Mental Health (CMH). Staff F was asked the location of CMH documentation, facility communication, and collaboration with the facility regarding R1's Abilify and GDR history. Staff F reviewed R1's medical record and confirmed there was no documentation in the medical record from CMH. Staff F confirmed the medical record was the only place documented reasoning for declination of GDR attempts would be located. On 8/6/24 at 3:34 p.m., the Corporate Regional Nurse (CRN) provided a medication history for Abilify. The CRN said, No GDR's have been tried since (R1) was admitted in 2021 - (R1) has been on 10 milligrams [of Abilify] since (R1) has been here. The Director of Nursing (DON) was interviewed on 8/7/24 at 10:34 a.m. The DON said GDRs should be attempted every 6 months the first year of admission, then annually. The DON said physician documention of reasoning is required if a physician determines a GDR would be detrimental for a resident. The DON was asked where the physician documented a reason for declining a GDR for R1. The DON replied, He [the physician] didn't document a reason. The policy Use of Psychotropic Drugs and Gradual Dose Reductions dated 10/24/22 read, in part: .Residents who use psychotropic drugs receive gradual dose reductions .unless clinically contraindicated .The physician has documented the clinical rationale for why .attempted dose reduction at that time would be likely to impair the resident's function or increase distressed behavior . Resident #6 (R6) R6 was prescribed lorazepam (an antianxiety medication) every 8 hours PRN (as needed) for anxiety for 14 days. The most recent admission date of R6 was 8/18/23. A review of the lorazepam order history revealed R6 was prescribed the lorazepam PRN since readmission to the facility at varying time intervals and varying durations of therapy without adequate indications for use or rationale provided by a physician. A Medication Regimen Review (MRR) by the consultant pharmacist dated 7/8/24 read, in part: .This resident currently has an order for lorazepam PRN .PRN psychotropic orders cannot exceed 14 days with the exception that the prescriber documents their rationale in the residents medical record and indicates the duration for the PRN order. Please consider ( )discontinue PRN lorazepam or ( ) If PRN lorazepam is to be continued, please write a new PRN order and include the duration of therapy and rationale for continued use . The physician response on the July MRR read in chart. Physician notes in R6's medical record from 8/18/23 through 8/7/24 did not reveal documented rationale by the physician for the PRN lorazepam nor did the documentation contain an indication of the duration of use for the PRN lorazepam. The Director of Nursing (DON) was interviewed on 8/7/24 at 10:21 a.m. The DON said R6's anxiety increased at bedtime. The DON stated, We've tried melatonin [a hormone that regulates the sleep cycle] and things like that, but it wasn't effective. (R6) can't sleep because of anxiety so we are using lorazepam to help her sleep. The DON was told R6 was currently being administered melatonin at night. The DON said the melatonin is not effective with assisting R6 with sleeping. When asked why R6 was being administered melatonin if it wasn't working, the DON responded, Good question! When asked why an antianxiety medication was being utilized in lieu of a hypnotic medication to assist with sleep, the DON did not provide an answer. The policy Use of Psychotropic Drugs and Gradual Dose Reductions dated 10/24/22 read, in part: .PRN orders for psychotropic drugs shall be used only when the medication is necessary .and for a limited duration i.e., 14 days. A. If the attending physician or prescribing practitioner believes it is appropriate for the PRN order to be extended beyond 14 days, he or she shall document their rationale in the resident's medical record and indicate the duration for the PRN order .

Based on observation, interview, and record review, the facility failed to ensure medications were appropriately administered for two Residents (R4 and R17) of four residents reviewed for infection control practices during medication administration. Findings include: During medication administration observation on 8/6/24 at 7:41 a.m., Registered Nurse (RN) A was preparing medications for Resident #4 (R4) at the medication cart. RN A picked up a plastic water cup by the lip of the cup with ungloved hands to set the cup on the med cart. RN A poured water into the cup they had just touched with bare fingers and gathered the medications and cup of water and entered R4's room. RN A placed the cup of water, a medication cup containing R4's medications, and an insulin syringe on R4's bedside table without a barrier. RN A handed R4 the medication cup containing the medication. When R4 attempted to place the medications from the cup into his mouth, three medications fell from the cup onto R4's bed. RN A picked up the medications with bare, ungloved fingers and placed the three medications back into the medication cup. RN A provided R4 the cup of water. R4 placed the rim of the cup RN A had touched with bare fingers to his mouth to swallow the medications including the three medications RN A had touched with his bare fingers. RN A administered medications to Resident #17 (R17). RN A obtained a water cup containing a flexible straw then adjusted the straw by bending the top of the straw (the portion that is placed in the mouth when drinking from a straw) with bare hands. RN A placed the portion of the straw they had just touched with bare, ungloved fingers into R17's mouth for the resident to drink. The Director of Nursing (DON) was interviewed on 8/7/24 at 10:30 a.m. When the medication administration observations were conveyed to the DON, the DON confirmed the actions by RN A were unacceptable. The DON said, It's not ok - it's an infection control issue. The policy Infection Prevention and Control Program dated 12/27/23 read, in part: .Licensed staff shall adhere to safe infection and medication administration practices . The policies Administration Procedures for All Medications and Oral Medication Administration, both dated 8/2020, read in part: .Medications will be administered in a safe and effective manner .Use a barrier to carry medication containers into the resident's room and to separate the supplies and the over-the-bed table or other surface .taking care to avoid touching the tablet or capsule .

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent, for two Residents (#2 & #7) of five residents reviewed for medication administration. This deficient practice resulted in lack of assessments to determine efficacy of respiratory medications and the potential for undesirable therapeutic effects from inaccurate insulin administration. Findings include: Resident #2 (R2) Medication administration for R2 on 9/20/23 at 12:10 PM, was observed performed by Registered Nurse (RN) H. This included the administration of Albuterol Sulfate Inhalation Nebulizer Solution 2.5 mg (milligrams) / 3 ml (milliliters), 3 ml inhale orally via nebulizer (machine that turns liquid medication into a fine mist and inhaled though the mouth into the lungs). RN H did not have a stethoscope with her. RN H failed to listen to R2's lung sounds, check heart rate and respiration rate, and obtain a pulse ox (oxygen saturation level in the blood) prior to treatment. On 9/20/23 at 12:30 PM, an interview was conducted with RN H who was asked if she had a stethoscope and replied, Yes. It is in my medication cart. RN H confirmed she failed to assess the vital signs and lung sounds of R2 prior to and post nebulizer treatment. Review of R2's active Physician Orders, as of 9/20/23, revealed the following: Albuterol Sulfate Inhalation Nebulizer Solution 2.5 mg / 3 ml, 3 ml inhale orally via nebulizer, Start Date 5/16/23. On 9/20/23 at 12:50 PM, an interview was conducted with the Director of Nursing (DON). The DON was asked about the nebulizer policy for medication administration. The DON confirmed all residents required a respiratory assessment prior to and following treatment and stated no resident was exempt from this policy. Resident #7 (R7) Medication administration for R7 on 9/20/23 at approximately 11:35 AM, was observed performed by RN H. This included administration of Insulin Glargine injection 25 units subcutaneously. RN H administered the injection by pushing down on the syringe plunger and then immediately pulled out the needle. RN H failed to hold the needle in the subcutaneous tissue following the injection site for ten seconds after pushing the plunger down and administering the insulin to R7. On 9/20/23 at 12:35 PM, an interview was conducted with RN H regarding the administration of insulin for R7 earlier that day. RN H confirmed she did not hold the needle in the injection site for ten seconds. RN H replied, I thought I just had to do that with the insulin pens. Review of R7's active Physician Orders, as of 9/20/23, revealed the following: Insulin Glargine injection 25 units subcutaneously, Start Date 8/30/23. On 9/20/23 at 2:43 PM, an interview was conducted with Regional Director of Operations J who confirmed medication administration by licensed staff should follow the manufacturer's guidelines. Review of the manufacturer's guidelines for insulin glargine, provided by Regional Director of Operations J, read in part, Injecting insulin glargine with a vial and syringe .Step 4: Complete the injection - administer insulin - slowly push in the plunger of the syringe all the way, making sure you have injected all the insulin. Leave the needle in the skin for 10 seconds . Review of facility policy titled, Medication Administration, dated 1/1/22, read in part, Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines: .8. Obtain and record vital signs, when applicable .14. Administer medication as ordered in accordance with manufacturer specifications . Review of facility policy titled, Nebulizer Therapy, dated 1/1/22, read in part, Policy: It is the policy of this facility for nebulizer treatments, once ordered, to be administered by nursing staff as directed using proper technique and standard precautions. Policy Explanation and Compliance Guidelines: 1. Care of the Resident .f. Obtain resident's vital signs and perform respiratory assessment to establish a baseline . Two medication administration errors out of 31 opportunities, resulted in a medication error rate of 6.25 percent.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 9/19/23 at 10:20 AM, an observation was made of the B-hall. The B-hall double doors were both shut, and no signs were on the outside of the door to alert staff, residents, or visitors of the COVID-19 positive cases on the other side of the doors. On 9/19/23 at 10:22 AM, an interview was conducted with Registered Nurse (RN) I. RN I was asked how many COVID-19 positive residents she was caring for and when the outbreak started. RN I replied, This past Friday or Saturday is when the outbreak started. I came back into work on Monday (9/18/23) morning and there were six and then we retested yesterday and now there are eight, but one went home. RN I was asked what kind of precautions were being taken to protect the other residents and staff from contracting COVID-19. RN I replied, We have the signs on their doors indicating airborne precautions, we are gowning, wearing N-95's, gloving, and wearing eye protection. We don and doff personal protective equipment (PPE) as necessary and hand hygiene. On 9/19/23 at 10:35 AM, an observation was made of B-hall and there were seven rooms that indicated droplet precautions with instructions on how to don and doff PPE. B-hall contained three PPE carts with surgical masks, N-95 masks, gloves, gowns, eye protection, red bags, disposable vital signs equipment, and three different kinds of sanitizing wipes (one sanitizing wipe canister for hands only and 70% alcohol based, one with a disinfection time of two minutes and one with a disinfection time of four minutes and with bleach). On 9/19/23 facility staff were observed on B-hall and the following observations were made: a.) At 12:09 PM, an observation was made of Certified Nurse Aide (CNA) L who exited room [ROOM NUMBER], a COVID-19 positive room with her prescription glasses with side shields on her face. CNA L failed to sanitize her eye wear off and then proceeded to enter room [ROOM NUMBER] a non-COVID-19 positive room. On 9/19/23 at 12:15 PM, an interview was conducted with CNA L. CNA L was asked if she sanitized her eye wear off when she exited room [ROOM NUMBER] and replied, Am I supposed to? b.) At 12:20 PM, an observation was made of CNA L who entered room [ROOM NUMBER], a COVID-19 positive room with goggles on and had removed her prescription glasses. CNA L exited room [ROOM NUMBER] and removed her goggles from her prescription glasses and placed them on top of the table of the PPE cart with her bare hands and left them sitting there. CNA L failed to sanitize her hands or the goggles. c.) At 12:21 PM, an observation was made of Housekeeper N who removed a lunch tray from room [ROOM NUMBER], a COVID-19 positive room. Housekeeper N failed to cover the lunch tray which was already consumed, with a red bag, walked down B-hall approximately 48 feet to the tray cart, walked past non-CVOVID-19 resident rooms, and placed the lunch tray on the tray cart. On 9/19/23 at 12:22 PM, an interview was conducted with RN I who was asked if trays should be removed from COVID-19 positive rooms without a red bag covering them after they had been eaten from. RN I replied, No. Why? RN I was made aware of the observation and confirmed Housekeeper N should have covered the lunch tray from room [ROOM NUMBER] before placing it back on the tray cart. d.) At 12:25 PM, an observation was made of the tray cart located in the middle of B-hall on the left (East) side of the hall, there were two COVID-19 resident's lunch trays in red bags. The bags were both open on the ends and did not 100% cover the trays. e.) At 12:31 PM, an observation was made of room [ROOM NUMBER], a COVID-19 positive room, where the door was wide open for approximately five minutes until CNA M came by and closed the door. f.) At 12:40 PM, an observation was made of RN / Infection Preventionist C walking down B-hall, stopped at the PPE cart, picked up the goggles that were on top of the cart, opened the top drawer of the PPE cart, put the goggles in the top drawer, and closed the drawer (the same PPE cart where CNA L doffed her eye protection earlier without sanitizing the eye wear when she exited room [ROOM NUMBER], a COVID-19 positive room). g.) At 12:43 PM, an observation was made of RN I who exited room [ROOM NUMBER], a COVID-19 positive room, improperly wearing her eye wear on top of her head. RN I failed to sanitize her eye wear and proceeded to the medication cart to dispense another resident's medication. RN I then completed her task, and entered room [ROOM NUMBER] a non-COVID-19 positive room to pass medications at 12:53 PM. h.) At 12:47 PM, an observation was made of CNA K who entered room [ROOM NUMBER], a COVID-19 positive room. CNA K exited room [ROOM NUMBER] at 1:00 PM. CNA K then entered room [ROOM NUMBER] a non-COVID-19 positive room at 1:02 PM. No sanitization of the eyewear was observed which CNA K used when she exited room [ROOM NUMBER], a COVID-19 positive room before she entered room [ROOM NUMBER] a non-COVID-19 positive room. i.) At 12:56 PM, an observation was made of CNA O who entered room [ROOM NUMBER], a COVID-19 positive room. CNA O had her prescription eyeglasses on without side shields and wore a surgical mask. CNA O exited room [ROOM NUMBER] at 1:01 PM and failed to sanitize her eyeglasses. On 9/20/23 facility staff were observed on B-hall and the following observations were made: a.) At 7:57AM, an observation was made of room [ROOM NUMBER], a COVID-19 positive room. room [ROOM NUMBER]'s door was wide open. At 8:11 AM, an interview was conducted with RN I. RN I confirmed that room [ROOM NUMBER] was COVID-19 positive, on droplet precautions, and the resident was in her room with the door wide open. At 8:28 AM, an observation was made of room [ROOM NUMBER] with the door wide open, and a coughing noise coming from the room was heard while this Surveyor was observing staff on B-hall. At 8:39 AM, an observation was made of CNA K shutting the door of room [ROOM NUMBER]. room [ROOM NUMBER]'s door remained wide open for 42 minutes. b.) At 8:18 AM, an observation was made of RN I who entered through the B-hall double doors. RN I adjusted her face mask with her hands, pulling the surgical mask over her nose, and failed to sanitize her hands after she touched her surgical mask. RN I then entered room [ROOM NUMBER] a non-COVID-19 positive room and shut the door behind her to provide direct resident cares. c.) At 8:04 AM, an observation was made of CNA L who exited room [ROOM NUMBER], a COVID-19 positive room, doffed her goggles on top of the PPE cart without sanitizing her hands, and went to assist CNA K. At 8:06 AM, CNA L was observed back at the PPE cart, picked up the goggles with her bare hands, sanitized the goggles by wiping them off with a purple sanitizing wipe, placed the goggles back in the top draw of the PPE cart, and failed to sanitize her hands after cleaning the goggles (disinfection time on the purple wipes is two minutes per manufacturer instructions). d.) At 8:08 AM, an observation was made of CNA K who exited room [ROOM NUMBER], a COVID-19 positive room, sanitized her eye protection with bare hands, placed eye protection back on the top of her head, and failed to sanitize her hands after sanitizing the eye protection (disinfection time on the orange wipes is four minutes per manufacturer instructions). e.) At 8:28 AM, an observation was made of CNA O transporting resident from room [ROOM NUMBER], a COVID-19 positive room, in a wheelchair. CNA O was carrying shampoo and shower gel which came from room [ROOM NUMBER] with the resident and was located next to her body under her arm. f.) At 8:31 AM, an observation was made of CNA L who exited room [ROOM NUMBER], a COVID-19 positive room, doffed goggles by placing them on top of the PPE cart and wiped the googles off with bare hands (disinfection time on the purple wipes is two minutes per manufacturing instructions). g.) At 8:42 AM, an observation was made of RN I who exited room [ROOM NUMBER], a COVID-19 positive room, wearing an N-95 and did not replace her mask. RN I returned to the medication cart to prepare medications, then proceeded to room [ROOM NUMBER] a non-COVID-19 room to deliver medication, and then exited and proceeded to room [ROOM NUMBER] again. RN I was asked if she had changed her mask and replied, No. I did not. I guess I forgot. On 9/20/23 at 9:30 AM, and interview was conducted with Minimum Data Set / Infection Control / RN B who was made aware of the infection control concerns observed by this Surveyor. RN B confirmed she had done a couple of infection control audits yesterday on proper PPE usage with CNA L and CNA K. RN B was asked about the audit results and replied, They both did fine. RN B confirmed goggles needed to be sanitized when exiting COVID-19 positive rooms and should be allowed to dwell for either two or four minutes depending on the sanitizing wipes being used. RN B also confirmed gloves should be worn during the sanitization process and eye protection should not be worn on the top of a staff member's head. RN B was asked what kind of mask should be worn in a COVID-19 positive room. RN B replied, An N-95, and these should be discarded in the room just prior to exiting and a new mask should be applied after the staff exit and can be a new surgical mask. RN B was asked about the room trays that were inside the COVID-19 positive rooms. RN B replied, When they are brought out of the COVID-19 positive rooms they need to be in a red bag and should be entirely covered and then placed on the tray cart, so kitchen staff are aware the tray was removed from a COVID-19 positive room. RN B confirmed COVID-19 positive doors need to be always closed unless staff are entering and exiting the room. Based on observation, interview, and record review, the facility failed to implement a comprehensive, facility-wide Infection Control Program as evidenced by failure to: 1. Don, doff, and disinfect PPE (personal protective equipment) for residents with confirmed or suspected of COVID-19 infection. 2. Assess for COVID-19 symptoms and implement transmission-base precautions timely. 3. Complete infection control analysis, correlation, and trending of resident and staff infections. 4. Maintain timely and accurate infection control line listings and surveillance mapping. 5. Properly retrieve meal room trays from COVID-19 positive rooms. 6. Ensure disinfectant chemicals used to clean and disinfect transmission based precaution (TBP) rooms met the minimum concentration specified by the vendor of the chemical. This deficient practice has the potential to result in the transmission of pathogens between residents rooms and the spread of infectious organisms to all 32 vulnerable residents. Findings include: On 9/19/23 at approximately 9:00 AM, upon entering the facility, an observation was made of the facility entry door indicating there were COVID-19 positive residents within the building. On 9/19/23 at approximately 9:15 AM, an entry introduction was made with the Nursing Home Administrator (NHA) during the screening of the Surveyor Team. The NHA guided the Surveyor Team into his office and provided a list of facility residents who were COVID-19 positive. The list revealed COVID-19 positive residents down the B-hall located in rooms: 16, 17, 19, 20, 21, 23, and 28 (a total of seven residents). The list also revealed a COVID-19 positive resident down the A-hall located in room [ROOM NUMBER] who no longer remained in the facility because they were sent to the local hospital. Further review of the resident list revealed one other resident who was located down the B-hall in room [ROOM NUMBER] (grayed out on the list) who returned home on 9/18/23 per the NHA. During the above interview on 9/19/23 with the Nursing Home Administrator (NHA), the survey team was informed the facility had a total of eight COVID-19 positive residents and one staff member. The NHA said the first identified resident case of COVID-19 was identified on Saturday, 9/16/23. During an interview on 9/19/23 at 12:20 p.m., The facility provided an Infection Control (IC) line listing of residents who had tested positive for COVID-19 since the first case identified on 9/16/23. Two Residents (R35 and R32) were not on the list of residents who were identified as positive for COVID-19. When asked about why R35 and R32 were missing from those identified as COVID-19 positive, IP C stated, They (IC line list and IC tracking map) are not completed yet because we do them at the end of the month. Documentation of all Resident COVID-19 testing during September 2023 was requested at that time. During an interview on 9/20/23 at 8:55 a.m., COVID-19 Resident testing documentation for September 2023 was again requested from the Director of Nursing (DON), who also performed IC tasks in the facility, but no documentation was provided. During an observation and interview on 9/19/23 at 10:50 a.m., two survey team members entered R35's room. The room door was open, no transmission-based precaution (TBP) signage was on the door, and no personal protective equipment (PPE) was positioned in a wheeled cart outside of the room door. This indicated R35's room should not have had any COVID-19 symptomatic or positive residents. When R35 was asked if they routinely got up into their wheelchair during the day, R35 said they had been sleeping the past couple of days because they did not feel well. R35 said they had a sore throat and a fever for the last several days. Facility staff were observed to enter R35's room wearing surgical masks with no other PPE. During an interview on 9/19/23 at approximately 10:55 a.m., Registered Nurse (RN) H was asked about R35's self-report malaise, sore throat, and increased temperatures. RN H confirmed R35 was experiencing increased temperatures and fatigue. R35 was subsequently tested for COVID-19 on 9/19/23 following the above observation and tested positive. Record review of R35's documented temperatures in the Electronic Medical Record (EMR) revealed R35 had an increased temperatures of 100.3 F (Fahrenheit) on 9/17/23 with continued elevated temperatures through 9/20/23. During an interview on 9/20/23 at 1:06 p.m., IP C was asked about R35's increased temperature, in the midst of the COVID-19 outbreak. IP C said facility nursing staff would usually test a resident when they were symptomatic (such as an increased fever). IP C reported being unaware of the elevated temperature until Monday morning 9/18/23. IP C acknowledged R35 was not placed in TBP until 9/19/23, even though she had an increased temperature, and self-reported sore throat and malaise. Review of the Centers For Disease Control, Infection Control: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 [COVID-19]), updated 5/8/23, revealed the following, in part: HCP (Health Care Personnel) who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). Review of the facility COVID-19 Prevention, Response, and Reporting policy, implemented 8/20/20 and updated on 5/26/23, revealed the following, in part: HCP who enter the room of a resident with suspected or confirmed SARS-CoV-2 infection should adhere to standard precautions and use a NIOSH-approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection. Record Review of the facility's Monthly Infection Prevention and Control Binder was conducted on 9/20/23 at 9:00 a.m. The review revealed the facility experienced an outbreak of COVID-19 in February of 2023, with 16 residents identified as positive for COVID-19 infection. The facility Infection Control Mapping tool which was used to track and trend infections did not contain all of the 16 Residents with COVID-19 in February. Review of the monthly Infection Control line listings from March 2023 through August 2023, did not document the symptoms identified for each resident infection. The Infection Control Line listing only included Residents on antibiotics - no residents with symptoms indicative of a potential infection were identified on any line listing unless an antibiotic was prescribed. During an interview on 9/20/23 at 1:06 p.m, Infection Preventionist (IP) C was asked to verify the discrepancy between the February 2023 Infection Control Line listing and the February 2023 Infection Control Mapping tool. IP C confirmed the infection mapping did not show 16 residents were tracked for COVID-19 during February 2023. Review of the Monthly Infection Prevention and Control Binder for the month of March 2023 was reviewed and revealed an outbreak of a gastrointestinal illness affecting 16 residents. The organism was identified on the line listing as Norovirus for all 16 affected residents. According to The Monthly Infection Prevention and Control Binder, Norovirus continued into the month of April 2023 with at least 10 more identified cases of Norovirus. Review of the Centers for Disease Control and Prevention (CDC) Reporting and Surveillance for Norovirus, last reviewed May 24, 2023, revealed the following, in part: Healthcare providers should report all outbreaks of acute gastroenteritis, including suspected outbreaks of norovirus, to the appropriate state, local, or territorial health department. During an interview on 9/21/23 at 10:41 a.m., documentation of sign-in sheets and education provided for dietary and housekeeping staff was requested from IP C. IP C stated, I don't have any proof that I did any Norovirus education with dietary staff or the housekeeping staff. IP C, RN B, and the DON all confirmed no staff education was documented on sign-in sheets during the Norovirus outbreak of the February 2023 COVID-19 outbreak. IP C also confirmed no dietary or housekeeping audits were performed during the outbreaks of illness in February and March of 2023. The facility IC Monthly Analysis and Summary documented handwashing observations with on the spot corrections but did not indicate what concerns were identified or what corrections were needed. The line listing for April 2023 reflected 10 cases of Norovirus in April 2023, and the April 2023 mapping showed 18 gastrointestinal illnesses. IP C again confirmed the discrepancy between the line listing and the infection mapping in April 2023. Review of an employee call-in log for March 2023 showed an employee call-in on March 13, 2023 (onset date) for a gastrointestinal illness. Documentation indicated the illness lasted for seven days and was resolved on 3/20/23. This employee call-in on March 13th was the first documented indication of gastrointestinal illness in the facility. Review of April 2023 documentation reflected three employee call-ins for gastrointestinal infections which lasted five days, four days, and six days according to onset and resolution dates. The infectious organism was not reflected on any of the employee tracking logs for any of the three employees. The number of illness related employee absences was documented as zero (0) on the March 2023 Monthly Analysis and Summary and documented in April as 2 employee illnesses. There was no indication the facility correlated resident illnesses with employee illnesses. During an interview on 9/20/23 at approximately 1:15 p.m., IP C, RN B and the DON were queried regarding the facility line listing for infections. IP C said the line listing was for tracking antibiotic usage. When asked about the lack of signs and symptoms of infection on the line listing, IP C said the symptoms were entered into an external Infection Control program, but not necessarily into the medical records of each resident experiencing an infection. 6. On 9/20/23 at approximately 8:50 AM, an interview was conducted with the regional director of Housekeeping and laundry services (RDH) A. It was learned during this interview the facility utilized a peroxide based chemical for the disinfection of surfaces in Transmission Based Precaution (TBP) rooms (isolation) with COVID-19 positive residents. Observations were made with RDH A while tests were conducted of the dispensing unit of the peroxide based disinfectant and the testing of the concentration of the chemical. RDH A filled a small bucket with the solution discharged from the dispenser, then using the appropriate test strips and measured the concentration of the peroxide. The test strip indicated a concentration below 2350 ppm (parts per million) in the solution being discharged from the dispenser and being used by staff in resident rooms. A review of the instructions provided by the vendor of the chemicals was conducted with RDH A and confirmed the minimum concentration of the peroxide chemical was 3500 PPM, well above the measured and demonstrated level shown by the test strips. At 9:30 AM RDH A was requested to produce any documentation demonstrating the last time the solution from the dispenser was tested and showed the minimum concentration required for proper disinfection of COVID-19 was met. RDH A stated the facility did not have any documentation to show the solutions had been tested to determine the solution was dispensed at the appropriate concentration for the disinfecting chemical. Review of the Infection Prevention and Control Program policy, revised 5/22/23, revealed the following, in part: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines . The designated Infection preventionist is responsible for oversight of the program and serves as a consultant to our staff on infectious diseases, resident room placement, implementing isolation precautions, staff and resident exposures, surveillance, and epidemiological investigations of exposures of infectious diseases . Surveillance: a. A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon a facility assessment and accepted national standards . COVID-19 Testing: . If healthcare-associated transmission is suspected or identified, the facility may consider expanded testing of HCP and residents as determined by the distribution and number of cases throughout the facility and ability to identify close contacts . Review of facility policy titled, Transmission-Based (Isolation) Precautions, dated 5/22/23, read in part, Policy: It is our policy to take appropriate precautions to prevent transmission of pathogens, based on the pathogens' modes of transmission .Definitions: Airborne precautions refers to actions taken to prevent or minimize the transmission of infectious agents/organisms that remain infectious over long distances when suspended in the air .Policy Explanation and Compliance Guidelines: 1. Facility staff will apply Transmission-Based Precautions, in addition to standard precautions, to residents who are known or suspected to be infected or colonized with certain infectious agents requiring additional controls to prevent transmission .11. Airborne Precautions .d .staff will wear a fit-tested N-95 or higher-level respirator and other appropriate PPE while delivering care to the resident . Review of facility handout titled, Sequence for Removing Personal Protective Equipment (PPE), undated, read in part, Except for respirator, remove PPE at doorway or in anteroom. Remove respirator after leaving patient room and closing door .2. Goggles or face shield - outside of goggles or face shield is contaminated! To remove, handle by head band or earpieces. Place in designated receptacle for reprocessing or in waste container .4. Mask or respirator - Front of mask/respirator is contaminated - DO NOT TOUCH! Grasp bottom, then top ties or elastic and remove. Discard in waste container. Perform hand hygiene between steps if hands become contaminated and immediately after removing all PPE. On 9/25/23 the disinfectant products manufacturer instructions were reviewed online using website: SuperSaniCloth_EnglishFrench_LCan_.pdf (pdihc.com), read in part, .Directions for use: .To disinfect and deodorize: To disinfect nonfood contact surface only: Unfold a clean wipe and thoroughly wet surface. Allow treated surface to remain wet for two (2) minutes. Let air dry . On 9/25/23 the disinfectant products manufacture instructions were reviewed online using website: SaniClothBleachEnglish-French_LgCan.pdf (pdihc.com), read in part, .Directions for use: .To clean, disinfect and deodorize: Use a wipe to remove heavy soil. Unfold a clean wipe and thoroughly wet surface. Treated surface must remain viably wet for 4 minutes. Use additional wipes if needed to assure continues 4-minute wet contact time .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the proper incontinence care products to ensure the highest possible practicable physical, mental, and psychosocial well-being was achieved for three (Resident #104, Resident #101, and Resident #102) of five residents reviewed. This deficient practice resulted in the potential for impaired self esteem and reduced level of confidence. Findings include: Resident #104 Resident #104's Electronic Medical Record (EMR) revealed an admission date of 12/19/22 and medical diagnoses which included Chronic Obstructive Pulmonary Disease (COPD), atrial fibrillation, and falls. Resident #104's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14/15, indicating Resident #104 was cognitively intact. During an interview on 1/18/23 at 10:53 a.m., Resident #104 was observed holding onto a pull up incontinent brief. Resident #104 said this was the only large sized one left and she was saving it for night time. Resident #104 reported the facility frequently did not have the correct size and they put an extra extra large brief on her instead. A package of extra extra large size incontinent pull up briefs was observed at Resident #104's bedside. Resident #104 said the extra extra large briefs leaked and did not feel comfortable. Resident #104 said she had tried wearing shorts over the briefs in an attempt to make them more snug but it had not worked. When Resident #104 has had to wear the extra extra large briefs to bed, her bed became soaked because they leaked. When asked how wearing a leaking brief made her feel, Resident #104 said, No wonder a baby cries whey they are wet. I do not like sitting in wet briefs. Resident #101 Resident #101's EMR contained an admission date of 4/12/16 and indicated medical diagnoses which included multiple sclerosis, morbid obesity, and urinary tract infections. Resident #101's MDS assessment dated [DATE] included a BIMS score of 15/15 which indicated Resident #101 was cognitively intact. On 1/18/23 at 9:45 a.m. Resident #101 said there had been several times when there were not the correct size incontinent briefs available. Resident #101 reported the facility had the blue briefs and the pull ups, but not the bariatric large size that she required. Resident #101 said, I pay money to be here, the last thing I expected would be they [the facility] would run out of briefs .I find it ridiculous, briefs need to be available. Resident #101 said she had been placed in the yellow briefs which cut into her groin area. She reported she has had multiple urinary tract infections and identified the incorrect brief size as a contributing factor. Resident #101 said wearing the wrong size brief was uncomfortable and worried about the brief leaking because it was too small. Resident #102 Resident #102's MDS assessment dated [DATE] included an admission date of 4/13/22, a BIMS score of 13/15, which indicated Resident #102 was mildly cognitively impaired. Resident #102's Medication assessment revealed Resident #102 was receiving a diuretic (a medication which works be removing excess fluid in the body through the kidneys) daily. Resident #102's medical diagnoses included morbid obesity, depression, and anxiety. During an interview with Resident #102 on 1/18/23 at 10:37 a.m., Resident #102 said the facility often ran out of incontinence briefs. When this happened, there was approximately a 3-4 day waiting period to get the correct briefs back in stock. Resident #102 reported that when the briefs were not available for her, the staff placed an incontinence pad in her underwear instead. Resident #102 voiced concerns around wearing a pad instead of the proper brief because she felt as though the pad would leak and said she would be very embarrassed if this happened during an activity. On 1/18/23 at 11:12 a.m., Certified Nurse Aide (CNA)/Central Supply Staff F and this Surveyor observed the supply closet, the closet contained included blue briefs and large briefs. Staff F and This surveyor then observed the basement storage supply area. Five boxes of small/medium briefs were observed and four boxes of large briefs were observed. Staff F said the facility was currently out of bariatric briefs and pull ups. Staff F was said there had been a mishap with the order and the incontinant supplies had been delayed. Staff F said she was not aware of residents not having the correct incontinent supplies and was not able to offer any further explanation as to why this would happen. Staff F' said each resident was measured to ensure they would be placed in the correct incontinent materials per their preference and this is what the orders were based from. On 1/18/23 at 11:51 a.m., CNA D said she the facility was out of bariatric briefs. CNA D said she had to place a bariatric pull on Resident #102 after she was showered this morning. CNA D said when she put the pull up on Resident #102, it looked like it fit her a little too snug. CNA D said the incontinent pads were not effective and leaked. CNA D said the bariatric briefs were better for Resident #102 because the tabs allowed room for it to shift. CNA D reported it seemed like they had been running out of the correct pull ups for Resident #104 frequently. CNA D said Resident #104 is on diuretics and goes through a lot of pull up briefs. The blue briefs did not work on Resident #104 because she was so active. On 1/18/23 at 12:10 p.m., CNA C reported the facility was out of bariatric briefs. CNA C said several residents wore the bariatric briefs and when there were not any available, they have to substitute them for something different. Resident #101 had to be placed in a yellow incontinence brief which are a little bit smaller and may be a little snug. CNA C explained it was difficult to keep some sizes in stock because certain residents wanted to be changed even when their briefs were barely damp. On 1/18/23 at 3:03 p.m. CNA E said there were times when the correct sizes of incontinent supplies were not available to residents. CNA E said they had to use a bigger or smaller size than what the resident had been measured for or what they preferred. CNA E said residents often complained the incontinence supplies were either to big and slid off or too snug and were uncomfortable. CNA E said Resident #104 urinated often and overflowed her pull up briefs when she went. A review of the Resident's Pull-Up & Brief Size which was updated 1/17/22 indicated Resident #101 required bariatric sized briefs and she did not wear pull ups. Resident #102 required extra extra large pull ups or bariatric briefs, and Resident #104's information on the size list indicated she wore the yellow briefs and pull ups were not indicated. In an interview with the Director of Nursing (DON) on 1/18/22 at 3:12 p.m., the DON said the expectation was for residents to be placed in the proper sized incontinent supplies. The DON voiced concerns over potential problems with dignity, and preferences and choices not being honored if they improper briefs were placed on residents. Generally they borrow from other facilities or go to the store to get more. Last CNA meeting they were asked to resize the bariatric and the oversize bariatric size. DON confirmed problems with dignity, preferences, and choices and residents should have the proper fitting briefs. The facility's Promoting/Maintaining Resident Self-Determination policy with the most recent revision date of 2/6/22 contained the following information, in part, It is the practice of this facility to protect and promote resident rights by promoting and facilitating resident self-determination through the support of resident choice. The facility will ensure that each resident has the opportunity to exercise his/her self autonomy regarding those things that are important in his/her life such as opportunity and preferences .1. All staff members involved in providing care to residents will promote and facilitate resident self-determination .3. Each resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident .9. The facility will accommodate the resident preferences to the extent possible and as agreed upon by the resident sponsor and physician.