**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement care planned interventions for the prevention of skin breakdown in 2 residents (Resident #20 and #16) out of 10 residents reviewed for comprehensive care plans. Findings: Resident #20 (R20) Review of an admission Record revealed R20 was an [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: stroke and contractures of the left and right hand. Review of a Minimum Data Set (MDS) assessment for R20, with a reference date of 9/8/24 revealed a Brief Interview for Mental Status (BIMS) score of 99, which indicated R20 was severely cognitively impaired. Review of R20's Rehab Order dated 5/12/22 revealed, Palm Protector schedule: Per therapy recommendation, to be worn after breakfast throughout the day, off at night and for hygiene. Review of R20's Order Summary dated 11/24/22 revealed, BUE (bilateral upper extremity) Palm Protector- ON upon rising, OFF at HS and for hygeiene (sic). Special Instructions: Wash hands with warm compress and then apply lotion prior to donning splints. Assess skin integrity with don/doffing- report concerns to PCP (primary care provider) Twice A Day. Upon Rising, (and) At Bedtime. Review of R20's Care Plan revealed, Problem: Resident is at risk for skin breakdown and/or injury r/t (related to) s/p (status post) CVA (cerebral vascular accident/stroke) with left side hemiparesis (paralysis) - requires assistance with repositioning to alleviate pressure .r/t bilateral hand contracture (fingers closing into palm) .r/t use of palm protector bilateral hands. Review of R20's Resident Profile/Care Plan revealed, 05/17/2022 BUE Palm Protector ON upon rising, OFF at HS (bedtime) and for hygiene. Nursing to monitor skin integrity upon application and removal and 01/11/2024 Turn TV on in am upon arising (per family request) Special Instructions: Family request to keep TV on during the day for stimulation. During an observation on 10/14/24 at 10:12 AM, R20 was in bed and did not have bilateral hand splints in place. Her television was not on. During an observation on 10/14/24 at 11:07 AM, R20 was in bed and did not have bilateral hand splints in place. Her television was not on. During an observation on 10/14/24 at 1:55 PM, R20 was up in a recliner and did not have bilateral hand splints in place. During an observation on 10/14/24 at 4:03 PM, R20 was up in a recliner and did not have bilateral hand splints in place. During an observation on 10/15/24 at 8:45 AM, R20 was in bed and did not have bilateral hand splints in place. During an interview on 10/15/24 at 8:52 AM, Registered Nurse (RN) E reported that R20 did not have hand splints in place because she hates them with a passion. During an observation on 10/15/24 at 12:48 PM, R20 was up in a recliner and did not have bilateral hand splints in place. During an observation on 10/16/24 at 8:12 AM, R20 was in bed and did not have bilateral hand splints in place. During an observation on 10/16/24 at 11:00 AM, R20 was in bed and did not have bilateral hand splints in place. Review of R20's Behavior Logs and Electronic Medical Record revealed only 1 entry of R20 removing splint. A note dated 06/19/24 revealed, Observed resident removing palm protectors-she did eventually remove both. An additional note dated 10/15/24 revealed This RN observed resident removing palm protector to right hand. She managed to remove w/o (without) difficulties. This writer did reapply. During an interview on 10/15/24 at 03:44 PM, Responsible Party (RP) G (power of attorney) reported that R20 was to wear splints in both of her hands but it's hit or miss and the splints were not always placed in her hands. RP G reported that the splint placement was to be part of her morning care and R20 needs to start the day with having them. RP G reported that she had informed the last couple DON's (Director of Nursing) that care planned interventions were not implemented and was told that they would ensure staff were aware of interventions that needed to be completed. RP G did not report that R20 would remove the hand splints or that she did not want to wear them. RP G confirmed refusal of hand splints was not part of her care plan. Resident #16 (R16) Review of an admission Record revealed R16 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: Alzheimer's disease, weakness, and need for assistance with personal care. Review of a Minimum Data Set (MDS) assessment for R16, with a reference date of 9/8/24 revealed R16 was severely cognitively impaired. Review of R16's Progress Note dated 10/09/24 revealed, During bed bath with Hospice Aid reddened area noted to coccyx. This RN observed, area is blanchable not open. Measures 7.5cm cm x 3 cm . Review of R16's Progress Note dated 10/11/2024 revealed, .Area is reddened but it is blanchable. Continue to monitor and frequently reposition. Staff education provided. Review of R16's Resident Profile revealed 10/14/2024 provide frequent positional changes and ensure resident is off loading buttocks and 08/20/2024 Soft foam boots on at all times to relieve pressure points BL (bilateral) feet Hospice order. During an observation on 10/15/24 at 7:32 AM, R16 was assisted up to her Broda chair. She did not have foam boots in place. During an observation on 10/15/24 at 9:01 AM, R16 was up in her Broda chair in the dining room. She did not have foam boots in place. During an observation on 10/15/24 at 10:50 AM, R16 was up in her Broda chair in her room. She did not have foam boots in place. During an observation on 10/15/24 at 12:46 PM, R16 was up in her Broda chair in her room. She did not have foam boots in place. During an observation on 10/15/24 at 2:34 PM, R16 was in her bed. She did not have foam boots in place. During an observation on 10/16/24 at 8:10 AM, R16 was up in her Broda chair in the dining During an observation on 10/16/24 at 11:02 AM, R16 was up in her Broda chair in the dining room. She did not have foam boots in place. Review of R16's Behavior Logs and Electronic Medical Record revealed no documentation of behaviors or refusal to wear soft foam boots. During an interview on 10/16/24 at 2:10 PM, Director of Nursing (DON) reported that resident specific care planned interventions should be implemented and followed by the facility staff. Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, A nursing care plan includes nursing diagnoses, goals and/ or expected outcomes, individualized nursing interventions, and a section for evaluation findings (see Chapter 20). The plan promotes continuity of care and better communication because it informs all health care providers about a patient's needs and interventions and reduces the risk for incomplete, incorrect, or inappropriate care measures .The plan gives all nurses a central document that outlines a patient's diagnoses/ problems, the plan of care for each diagnosis/ problem, and the outcomes for monitoring and evaluating patient progress. The plan of care communicates nursing care priorities to nurses and other health care providers. It also identifies and coordinates resources for delivering nursing care. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 249). Elsevier Health Sciences. Kindle Edition. Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, Care plans identify a plan of care based on a patient's appropriate nursing diagnoses, outcomes, and interventions individualized to the patient's unique needs. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 254). Elsevier Health Sciences. Kindle Edition. Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, Care planning is patient centered, taking into consideration the patient's most immediate needs and preferences . be vigilant in monitoring the patient and supervising assistive personnel in carrying out activities to prevent complications and potential injury. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 790). Elsevier Health Sciences. Kindle Edition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow professional standards of nursing practice for comprehensive assessments and medication administration for 2 residents (Resident #25 and #30), out of 10 residents reviewed for the provision of nursing services. Findings: Resident #25 (R25) Review of an admission Record revealed R25 was an [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: lymphedema, urine retention, heart failure, and kidney disease. Review of R25's Progress Note dated 09/25/2024 at 03:00 AM revealed, Resident with episode of confusion-states I think I am a little confused. B/P (blood pressure) 128/50, T (temperature)-98.9, P (pulse)-92, R (respirations)-19 SPO2 (oxygen level) 96%. Urine in Foley cath (catheter) clear dark yellow urine (dark urine is an abnormal finding). Resident also with increased anxiety. Currently sitting in w/c (wheelchair). Resident asked if he wanted to go the hospital and he responded no. Resident respiration even and non-labored. Asked if he wanted to go to the hospital and states no. Encouraged to sit in recliner chair. A comprehensive physical and neurological examination were not completed/documented (including a pain assessment and palpation of the abdomen). There was no documentation that the provider was notified of the change of R25's neurological status (increased confusion/altered mental status). Review of R25's Progress Note dated 09/25/2024 at 07:05 AM revealed, Just after shift change resident heard to be screaming from room. This RN (registered nurse) observed resident in panic state wanting this RN to stop his stationary chair from moving around the room .Increased confusion, and he is very weak. Unable to hold objects in hands w/o (without) dropping them .We called her and girlfriend had concerns with AMS (altered mental status) and immediately called residents daughter. Daughter did speak with resident and encouraged him to go to hospital. Obtained order to send. All paperwork sent with resident. VS (vital signs) (oxygen level) 90% RA (room air) 120 pulse 110/60 (blood pressure) 97.8 (temperature) 17 (respirations) . Approximately 4 hours from the initial documented change in condition. Review of R25's Vitals Report from 7/17/24-9/25/24 revealed no blood pressure assessments or pulse assessments were documented in the report. Review of R25's Hospital Records dated 9/25/24 revealed, .Pt (patient) was brought to the ER (emergency room) today with concerns for fever and hallucinations. He was found to be hypotensive (low blood pressure) and tachycardic (elevated heart rate). Afebrile (no temperature) .Pt denies abdominal pain but does admit to poor appetite and 4-5 days of mid back pain. On exam, he does have RUQ (right upper quadrant abdomen) tenderness to deep palpation. Pt has been given 3 L (liters) of fluids in ER and BP (blood pressure) is improving. He remains tachycardic .Recommend continuation of resuscitation with IV fluids and antibiotics .Upon arrival to the emergency department, patient is afebrile. He is tachycardic with a heart rate in the 110s and hypotensive with a BP as low as 72/58 .Severe sepsis with acute renal failure without septic shock .As evidenced by tachycardia and leukocytosis . During an interview on 10/16/24 at 8:10 AM, Licensed Practical Nurse (LPN) D reported that when a resident is experiencing a change of condition/medical emergency a comprehensive assessment should be completed and documented in the resident's progress notes. Vital signs, physician notification, guardian/emergency contact notification, the comprehensive assessment, and transfer to hospital documentation should be recorded in the resident's Electronic Medical Record. During an interview on 10/16/24 at 2:10 PM, Director of Nursing (DON) reported that she was unable to find any additional vital sign assessments prior to R25's transfer to the hospital on 9/25/24. DON reported that she would have expected vital sign assessments leading up to R25's decline/discharge. DON reported that vital signs should be assessed monthly unless an identified change in condition. Request for documentation that the provider was notified of R25's change in condition as well as additional vitals signs and assessments was requested via email on 10/15/2024 4:43 PM and 10/16/2024 12:35 PM. No additional documentation was received prior to survey exit. Review of the facility policy Notification of Change dated 07/2017 revealed, The residents physician and responsible party must be notified when an event involving the resident occurs or when the resident experiences a change in condition, potential discharge, room transfer or death .INTERVENTIONS: The Licensed nurse will use professional judgment any time that in their opinion the resident requires immediate medical attention. ASSESSMENT: 1. When made aware of a change in condition of a resident the Licensed nurse will perform an assessment based on their professional judgement that may include: *Vital signs *Mental status * Major diagnosis .Monitor and reassess the residents status and response to interventions. The physician should develop a working diagnosis and guide nursing staff in what to look for, what to monitor, and when to re-contact the physician if the residents progress deviates from the anticipated or expected course. Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, It is important to recognize early indicators of acute illness in older adults .A key principle of providing age-appropriate nursing care is timely detection of these cardinal signs of illness so that early treatment can begin. Mental status changes commonly occur as a result of disease and psychological issues. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 178). Elsevier Health Sciences. Kindle Edition. Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, Measurement of vital signs provides data to determine a patient's usual state of health (baseline data). Many factors such as the temperature of the environment, the patient's physical exertion, and the effects of illness cause vital signs to change, sometimes outside an acceptable range. An alteration in vital signs signals a change in physiological function. Assessment of vital signs provides data to identify nursing diagnoses, implement planned interventions, and evaluate outcomes of care . Vital signs are a part of the assessment database. You include them in a complete physical assessment (see Chapter 30), routinely per a health care provider's order, or obtain them individually to assess a patient's condition. Establishing a database of vital signs during a routine physical examination serves as a baseline for future assessments. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 467-468). Elsevier Health Sciences. Kindle Edition. Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, Document the following activities or findings at the time of occurrence: o Vital signs o Pain assessment o Administration of medications and treatments o Preparation for diagnostic tests or surgery, including preoperative checklist o Change in patient's status, treatment provided, and who was notified (e.g., health care provider, manager, patient's family) o Admission, transfer, discharge, or death of a patient o Patient's response to treatment or intervention. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (pp. 371-372). Elsevier Health Sciences. Kindle Edition. Resident #30 (R30) Review of an admission Record revealed R30 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: chronic pain. Review of R30's Order Summary dated 6/1/24 revealed, pregabalin (Lyrica) capsule; 75 mg; amt: 1; oral twice a day (Upon rising and at bedtime). Review of R30's Controlled Substances Proof of Use reviewed on 10/14/24 at 11:40 AM revealed that R30's pregabalin was not signed out as administered the morning of 10/14/24. During an observation on 10/14/2024 at 2:10 PM, LPN F and LPN C were completing a narcotic count on the South Hall medication cart. During the count, LPN C identified that the amount of the controlled drug remaining did not match the number documented in the Controlled Substances Proof of Use form. LPN F reported she had not documented the administration of the medication earlier and signed it out at that time. During an interview on 10/16/24 at 7:53 AM, LPN D reported that the date, time, and nurse signature is documented at the time a controlled medication is removed from the medication cart in order to ensure the correct count of the medication. Review of the Controlled Substance Log on the South Hall medication cart revealed that a nurse removed medication on 10/10/24 and 10/11/24 and did not have a witness signature. During an interview on 10/16/24 at 2:10 PM, DON reported the licensed nurses were expected to follow the facility policy and professional standards of practice when receiving and administering controlled medications. Review of the facility policy Inventory Control of Controlled Substances last revised 8/1/24 revealed, .With respect to Schedule II controlled substances: 1.1 Facility should maintain separate individual controlled substance records on all Schedule II medications and any medication with a potential for abuse or diversion in the form of a declining inventory using the Controlled Substances Declining Inventory Record. These records should include: 1.1.1 Resident name, 1.1.2 Prescription number, 1.1.3 Medication name, strength, dosage form, dosage, 1.1.4 Total quantity received by facility, 1.1.5 Date and time of administration, 1.1.6 Quantity remaining, and 1.1.7 Name and signature of person administering the medication . Facility should ensure that the incoming and outgoing nurses count all Schedule II controlled substances and other medications with a risk of abuse or diversion at the change of each shift or at least once daily and document the results on a Controlled Substance Count Verification/Shift Count Sheet. Facility should: 1.3.1 Reconcile the total number of controlled medications on hand, add newly received medications to the inventory, and remove medications that are completed or discontinued from the inventory, pursuant to the Controlled Substance Verification/Shift Count Sheet; and 1.3.2 Reconcile the number of doses remaining in the package to the number of remaining doses recorded on the Controlled Substance Verification /Shift Count Sheet. 1.3.3 The facility should routinely reconcile the number of doses remaining in the package to the number of doses recorded on the Controlled Substance Verification/ Shift Count Sheet to the medication administration record .

Based on observation, interview, and record review, the facility failed to secure 1 of 2 medication carts (North Hall Medication Cart), resulting in the potential for misappropriation of resident medications. Findings include: During an observation on 10/14/24 at 01:45 PM, the North Hall Medication Cart was left unlocked (the lock was in a pulled out position and the red/orange dot- which would indicate the cart was unlocked- was clearly visible) and unattended in the hallway outside of a resident room. Registered Nurse (RN) B had been observed minutes before partially closing the top drawer of the medication cart, walking away from it, going down the hallway, and turning the corner towards the medication room/nurse's stations. The surveyor was able to pull open the top drawer (which was partially open) of the medication cart without any staff noticing. The medication cart was observed unattended for approximately five minutes and staff were observed walking by the medication cart during this time, but no one locked it. Residents and visitors were also observed in the hallway at the time of the observation. During an observation on 10/14/24 at 01:50 PM, RN B returned to her medication cart. As she was nearing the medication cart, she pulled out the medication cart keys with her right hand. When she approached the cart, she still had the keys in her right hand, but reached out with her left hand and opened the top drawer of the medication cart. She did not gesture towards the lock with the keys in her right hand (this would indicate she knew the medication cart was unlocked). She then grabbed something from the medication cart, locked it, and walked down the hallway to a resident's room. During an interview on 10/14/24 at 01:55 PM when RN B returned back to the medication cart from a resident's room, RN B was asked by the surveyor if her medication cart had been left unlocked not more than five to ten minutes ago. She stated she did not leave her medication cart unlocked and insisted it had not been left unlocked even after the surveyor stated they had seen it unlocked. RN B stated she always locks the medication cart when she walks away from it. She then proceeded to walk away from the surveyor. During an interview on 10/15/24 at 08:40 AM, Licensed Practical Nurse (LPN) C stated she always locks her medication cart when she walks away from it. She stated she does this to keep residents or staff members from stealing meds (medication) from it. During an interview on 10/16/24 09:00 AM, the Director of Nursing (DON) stated she would expect that the nurses lock their medication carts before they walk away from them and leave them unattended. A review of the facility's Storage and Expiration Dating of Medications and Biologicals policy, revised 8/1/24, revealed, 5. Facility 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. A review of the facility's General Dose Preparation and Medication Administration policy and procedure, revised 1/1/22, revealed, 7. Facility should ensure that medication carts are always locked when out of sight or unattended.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement transmission-based precautions and utilize appropriate personal protective equipment for 1 resident (Resident #25) of 10 residents reviewed for transmission-based precautions, resulting in the potential for cross-contamination, disease exposure, and the development and spread of infection to a vulnerable population. Findings: Per the Centers for Disease Control and Prevention (CDC), .Isolate patients with possible C. diff immediately, even if you only suspect CDI (clostridium difficile infection) . https://www.cdc.gov/c-diff/hcp/clinical-overview/index.html (Article dated 3/5/24). Resident #25 (R25) Review of an admission Record revealed R25 was an [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: lymphedema, urine retention, heart failure, and kidney disease. Review of R25's Order Summary dated 10/10/24 revealed, Collect stool sample DX (diagnosis) C diff/diarrhea . Confirming R25 was suspected to have C Diff and was subsequently tested for the infection. Review of R25's Laboratory Result dated 10/11/24 revealed, Negative for C. difficile toxin, however, may represent C difficile colonization. If suspicion for C difficile infection remains high and there is no other explanation for diarrhea, consider empiric treatment and/or consult Infections Diseases for guidance. The laboratory result was not reviewed/signed by the provider until 10/14/24 with an order to test again. Review of R25's Electronic Medical Record revealed no order for R25 to be placed in contact precautions pending the laboratory result for C Diff. Review of R25's Progress Note dated 10/14/2024 at 02:27 PM revealed, Results back from (name omitted) lab for C Difficile interpretation. (Physician assistant) notified and orders received to re-test for C. diff and consult with I&D (Infectious Diseases). Resident will remain in contact precautions until re-test results return as a precaution. Confirming R25 should have been in contact precautions while testing was in progress. Review of R25's Order Summary dated 10/14/24 at 2:09 PM revealed, General Contact Isolation re: positive VRE (vancomycin/antibiotic resistant bacteria) and suspected C-diff. Do not use hand sanitizer-must use soap and water. Use bleach sani-wipes and EPA registered disinfectants for C-diff. Confirming the delay in the implementation of transmission-based precautions/isolation. During an observation and interview on 10/14/24 at 10:11 AM, R25 did not have signage on his door indicating he was in contact precautions/isolation with the PPE required (personal protection equipment utilized when a resident is in transmission-based precautions). A therapy staff member was in his room completing his ordered services and R25 had a visitor in his room. The therapy staff member was not wearing PPE. R25 reported he was unable to complete his therapy at that time due to having diarrhea and the therapy staff member exited his room. R25 reported he had been having diarrhea since returning from the hospital on [DATE]. During the interview, Certified Nursing Assistant (CNA) A entered the room to perform care on R25 and did not don PPE. During an interview on 10/16/24 at 08:21 AM, Director of Nursing (DON)/Infection Control Preventionist (DON) reported that facility staff were to place residents in isolation that had a suspected communicable infection, even if testing was ordered but not yet resulted. DON reported that R25 was being tested for C-diff and the contact isolation sign had been placed on the wrong resident's door. DON reported that she had given the sign to a staff member to put on R25's room door but had not ensured it was placed on the correct door. DON reported R25 had tested negative for C-diff, but the lab result had indicated R25 could be colonized (the bacteria is present but not causing symptoms) with C-diff. DON reported that the provider had ordered an additional stool sample to be collected. During an interview on 10/16/24 at 2:10 PM, DON reported R25 was to be in contact precautions/transmission-based precautions following the laboratory interpretation of his stool sample. DON reported that the laboratory result did not give a definitive result, and she would be reaching out to the local health department for guidance but in the meantime R25 would remain in contact precautions to prevent the potential spread of infection to other residents and staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to develop and implement a meaningful activities program for 4 Residents (R1, R2, R3 and R4) of 4 residents sampled, resulting in residents sitting unsupervised and experiencing boredom without the option for diversional activities to decrease the risk of injury. Findings included: R4 Review of R4' face sheet (no date) revealed she was a [AGE] year-old female admitted on [DATE] and had diagnoses that included: dementia, glaucoma, need for assistance with personal care, repeated falls, and muscle weakness. R4 was not her own responsible party. During an observation on 4/17/24 at 1:37 PM, R4 sat in a wheelchair near the nurse's station. R4's feet were on footrests. R4 was not able to move her wheelchair or answer any questions. R4 grimaced as if she was in pain and rubbed her right leg. Staff moved about the unit. At times, staff were not in sight. There were no activities for the residents sitting near the nurse's station. Other residents in the area also appeared to be confused and had no activities provided. Review of R4's ADL (activities of daily living) care plan dated 1/17/24 revealed approach's that included: 4/15/24, for assistance of 1 person for walking with a 4 wheeled walker. 4/15/24 transfer assist of 1 person. 9/13/23, toileting assistance 1 person. 1/17/21, bed mobility independent. (no interventions were located for bed/chair alarms, 15-minute checks or 1:1, and nothing indicated for need of supervision for safety identified). Review of R4's fall care plan dated 1/17/21 revealed that R4 does not always alert staff to needs and requires one assist with transfer/ambulation related to history of falls with fractures. Approaches listed did not include interventions for supervision or diversional activities to increase supervision for increased safety. During an interview with Regional Clinical Nurse (RCN) A on 4/17/24 at 5:25 PM, she confirmed that R4's care plan did not include the 1:1, 15-minute checks, alarms for her safety, or the need for assistance with ambulation and transfers after a fall on 3/20/24. RCN A stated the team would evaluate R4 upon her return from a medical appointment but did not know what interventions they would implement. Upon survey exit, staff did not put any new interventions into place for R4's safety. RCN A said when R4 fell on 4/6/24 she should have been on 1:1 care and that they educated the nurse that changed R4 to 15-minute checks. (Upon survey exit, the facility did not provide documentation of this education). RCN A was not able to provide any information or documentation of an activities program when asked about activities and supervision for all the facility residents with cognitive impairments and poor safety awareness. The facility currently did not have an activity director or aide on staff. R1 Review of R1's face sheet (no date) revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: fracture of right femur, cerebral infarction (stroke), unsteady on feet, vascular dementia, need for assistance with personal care, difficulty in walking, and altered mental status. No indication of a guardian or durable power of attorney was located. Review of R1's Minimum Data Set (MDS) dated [DATE] revealed she had a Brief Interview of Mental Status (BIMS) score of 6/15 (severely cognitively impaired). During an observation on 4/17/24 at 8:30 AM, R1 was sitting in front of the nurse's station. Staff were not consistently in the area as all staff were busy providing care or doing other tasks. R1 could not recall what activities she liked, and she did not know where she would go if she wanted something fun to do. During an interview with Licensed Practical Nurse (LPN) C on 4/17/24 at 8:37 AM, he named the 4 residents sitting at the nurse's station and responded to questions of whether they were there for any reason by saying they took themselves there and they can move about the facility at will. LPN C said he was not aware of any activities available for the residents at this time but said sometimes staff do provide activities in the main dining area. LPN C was not aware of any safety concerns for R1 or the other 3 residents sitting at the nurses' station. Review of R1's ADL (activities of daily living) care plan dated 3/8/24 revealed, R4 has self-care deficits related to dementia, impaired balance, and right femur fracture. Approaches included: 3/27/24 check and change on or about every 2 hours d/t (due to) incontinence. 3/8/24 needs 1 assist for toileting/elimination, 1 assist for transfers and 1 assist for mobility with a walker, independent with wheelchair mobility. Review of R1's fall care plan dated 1/25/24 revealed she was at risk for falls related to impaired balance, not always aware of safety needs and multiple medical diagnoses. Approaches included: 3/26/24 while awake offer diversional activities - examples magazines, music fiddle objects and television. 3/22/24 reassess toileting needs. 3/1/24 round on resident on or about every hour to ensure nonskid footwear in place, assist with toileting needs if indicated and ensure brief on resident. 1/25/24 assess for residents' participation in bowel and bladder program. 4/17/24, R1 prefers independent activities in her room or to be in the public area; she does not want constant staff oversight. Provide diversional activities of choice such as baby doll, stress balls, snack, or drink. 4/17/24 offer R1 assistance with toileting on or about every 2 hours while awake to promote continence. During an interview with the facility care team for R1 on 4/17/24 at 2:45 PM, the facility Social Worker (SW) J said she met with R1 today and she prefers no supervision. SW J denied any offering of supervision or risk/benefits when asked if the facility offered supervision and risk/benefits or if they discussed them with R1 or her advocate/or guardian. SW J said R1's Brief Interview of Mental Status score was 6 and her physician had determined she was not competent, but the facility requested a second physician review for competency and a second physician has not completed that review yet. SW J had no idea when the second physician would address her competency and could not verify R1 understood the risks when she had the conversation. Regional Director of Operations B directed SW J to contact the second physician to evaluate R1's competency. Upon exit, the facility did not provide a risk benefit statement or any assurance that R1 could understand the risks related to lack of supervision. The facility did not provide any documentation that they changed R1's care plan to reflect supervision needed to ensure her safety. During an interview with the facility care team for R1 on 4/17/24 at 2:45 PM, they were unable to provide any information on how they were supervising R1 when she was awake. They had no documentation to indicate if staff were offering R1 diversional activities and no activity calendar was located for April 2024. R2 Review of R2's face sheet (no date), revealed she was an [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: cerebral infarction (stroke), fracture of left pubis (pelvic bone), unsteady on feet, and muscle weakness. She was not her own responsible party. During an observation on 4/17/24 at 8:30 AM, R2 sat in her wheelchair at the nurse's station. Staff were not always in the area as they were caring for other residents. No activities occurring at that time. R2 could not say what activities she liked or where the facility had activities. During an interview with Licensed Practical Nurse (LPN) C on 4/17/24 at 8:37 AM, he named the 4 residents sitting at the nurse's station and responded to questions of whether they were there for any reason by saying they took themselves there and they can move about the facility at will. LPN C said he was not aware of any activities available for the residents at this time but said sometimes staff do provide activities in the main dining area. LPN C was not aware of any safety concerns for R1 or the other 3 Residents sitting at the nurses' station. Review of R2's fall care plan dated 10/31/23 revealed, R2 is at risk for falls related to impaired balance, weakness and does not always comply with the use of call light to alert staff of needs and will self-transfer/ambulate. The care plan also listed multiple medical diagnoses as risk factors for her falls. Approaches included: 4/2/24, keep alarm box out of reach. 3/27/24, will attempt self-transfers, follow toileting routine as outlined and documented. 3/26/24 toilet before and after meals, upon rising and prior to bed. Also, toilet or check and change on or about 2 AM per bowel and bladder study. 3/22/24 occupy with meaningful distractions music, companion, diversional activity per resident preference, resident enjoys sitting in common area socializing with other residents and staff. 3/22/24 reassess toileting needs. 3/22/24 staff to round on resident on or about hourly when she is in her room related to resident's history of self-transferring. R3 Review of R3's face sheet (no date), revealed she was an [AGE] year-old female admitted on [DATE] and had diagnoses that included: severe protein-calorie malnutrition, need for assistance with personal care, muscle weakness, difficulty in walking, cognitive communication deficit, dementia, and compression fracture of lumbar vertebra. She was not her own responsible party. During an observation on 4/17/24 at 8:30 AM, R3 sat in her wheelchair at the nurse's station. Staff were not always in that area as they were attending to other residents. No activities occurring at that time. R3 could not say what activities she liked or where the facility had activities. During an interview with Licensed Practical Nurse (LPN) C on 4/17/24 at 8:37 AM, he named the 4 residents sitting at the nurse's station and responded to questions of whether they were there for any reason by saying they took themselves there and they can move about the facility at will. LPN C said he was not aware of any activities available for the residents at this time but said sometimes staff do provide activities in the main dining area. LPN C was not aware of any safety concerns for R1 or the other 3 Residents sitting at the nurses' station. Review of R3's ADL (activities of daily living) care plan dated 12/20/23 revealed she requires assistance with ADL's related to dementia, requires cues and assistance to complete ADL/mobility tasks, impaired balance and weakness, Approaches included: 3/22/24 resident is impulsive and will attempt to self-transfer, 12/20/23, toilet/elimination needs 1 assist. 12/20/23, mobility 1 assist to ambulate. 12/20/23, transfers 1 assist. During an interview with the Regional Director of Nursing (RDN) A on 4/17/24 at 2:45 PM, RDN A acknowledged R3's self-transferring and walking without assistance and said the facility trained the husband and that he is safe to assist at this time. RDN A could not say what supervision interventions were in place when R3's husband was not in the room. RDN could not provide any documentation of diversional activities attempted and there was no activity calendar for April. During an interview with the facility treatment team that included the Nursing Home Administrator (NHA), Interim Director of Nursing (IDON), Regional Clinical Nurse A and Regional Director of Operations (RDO) B on 4/17/24 at 2:45 PM., the facility could not provide current information on any activity program designed for their dementia residents that would allow diversional activities, quality of life, or supervision for the residents that wander and have unsafe behaviors. They acknowledged they were making attempts to provide some activities utilizing the Certified Nurse Aides (CNA) and Licensed Nurses. They currently had no activity staff employed. They did not have a calendar or any scheduled activities for the month of April. They were unable to provide documentation for R1, R2, R3 or R4 showing that the facility offered activities. They confirmed that all 4 residents lacked safety awareness and were unpredictable with when they would attempt to self-transfer. Facility staff offered all 4 residents the toilet or having a brief change every 2 hours and staff checked on them every 1 to 2 hours. They were still attempting to self-transfer or take themselves to the bathroom. The facility did not indicate when they would have diversional activities available on a routine basis to ensure dementia residents had supervision and/or assistance when needed to improve their quality of life.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure 1 Resident, (R12) had a legal representative to assist her in making medical decisions, resulting in R12 not having anyone to act in her best interest in making medical decisions. Findings included: Review of R12's face sheet, no date revealed she was a [AGE] year-old female admitted to the facility on [DATE] and diagnoses that included: cerebral infarction (stroke), aphasia (disorder that affects communication), hemiplegia (muscle impairment on one side of the body), and congestive heart failure. No legal decision maker was named. Review of R12's July 2023 Brief Interview of Mental Status (BIMS) score revealed she scored 9/15 (moderately impaired decision making). R12 was observed in the facility main dining room on 10/1/23 @ 11:52 AM. R12 was in a geriatric style wheelchair and was totally dependent on staff for mobility. R12 had her lunch in front of her and was unable to answer questions of if the food was good or what her food preferences were. When she was asked if she wanted food, she would nod her head, yes. At times she would feed herself with a spoon and accepted help when offered. R12's coordination was poor, and her movements were slow. R12 did not verbalize any words. Review of R12's care plan revealed she had a care plan, Psychosocial Well-Being. Resident has participated in Advanced Care Planning and has made wishes known if in the future they are no longer able to do so, dated 7/20/23. Approaches included: Resident has/has not appointed a proxy to make health care decisions when they are no longer able to make decision for themselves. Social Services. If ordered by the physician, honor resident's wishes for medication (s) and pain control, Resident does/does not wish to use hospice care to keep comfortable at the end of life. Licensed Nurse (LPN/RN), Social Services). Review of R12's progress note dated 8/30/23 at 12:25 PM revealed, (Name of Hospice Service), RN (Registered Nurse) visit completed. Pt (patient) sitting in a broda chair in dining room, staff feeding pt 1:1, pt ate about 30% of lunch, staff reported pt coughed several times while eating. LS (lung sounds) have rhonchi throughout. Pt hanging head during assessment. Trace edema in legs and feet b/l (bilateral) Face does not appear to be puffy like last week. Encourage rest as much as possible for comfort. There was no documented indication that R12 had a representative/responsible party notified of resident status and/or changes to care. Review of R12's progress note dated 9/13/23 at 12:17 PM revealed, SSD (Social Services Director) and pharmacist met today to discuss this resident's psychotropic medications. Resident continues on Remeron (antidepressant medication also used to stimulate appetite) recommending GDR (gradual dose reduction) at this time. Physician group to assess. There was no indication that R12 had a representative involved in this decision. During an interview with the Nursing Home Administrator on 10/2/23 at 12 :55 PM, the NHA said they do not currently have a facility Social Worker. The NHA confirmed R12 did not have a legal spokesperson and was no longer able to communicate her needs and wants daily. The NHA said the former facility Social Worker took paperwork to the courthouse for guardianship and informed the family. The NHA said the family did not follow through. A request was made for the documents and the follow up of when the family did not complete the forms. The NHA was not able to locate any documentation of attempts to obtain a legal responsible party for R12.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, the facility failed to provide ADL care per the current plan of care, and/or implement a plan of care for dining, for 2 Residents (R12 and R15), resulting in them not receiving routine showers and assistance required with eating. Findings include: Review of R12's face sheet, no date revealed she was a [AGE] year-old female admitted to the facility on [DATE] and diagnoses that included: cerebral infarction (stroke), aphasia (disorder that affects communication), hemiplegia (muscle impairment on one side of the body), and congestive heart failure. No legal decision maker was named. Review of R12's July 2023 Brief Interview of Mental Status (BIMS) score revealed she scored 9/15 (moderately impaired decision making). R12 was observed in the facility main dining room (MDR) on 10/1/23 at 11:52 AM. R12 was seated at a table with 2 other residents that required feeding assistance. There were 17 residents in the MDR at that time that required some assistance with set up and eating. During R12's time in the MDR for lunch there were between 1-3 staff assisting 17 residents. At times there was only one staff in the room. 2 different staff assisted R12 for about 5 minutes or less with eating. They only physically assisted her eat a few times each. They did cue her to eat. When she fed herself, she was slow and had poor coordination. When she was asked if she wanted food, she generally nodded her head yes. She never responded no. There were times she did not respond. After 45 minutes and less than 10 minutes of assistance R12 ate less than 25% of the food she was provided. Review of R12's weights revealed her last weight was done on 8/7/23 and she weighed 129.5 pounds. She was no longer having weights done because she was in hospice care. Review of R12's ADL (activities of daily living) care plan dated 7/26/22 revealed, an approach dated 8/23/23 for, Eating status: 1:1 feed. During an interview with the Dietary Manager (DM) H and the Director of Nursing (DON) on 10/3/23 at 10:45 AM, they were unable to find any daily food intake records and said they expected staff to document R12's daily food intake in the medical record. Observations that R12 was only receiving intermittent assistance during lunch on 10/1/23 was shared and they said they will look into it. Review of R12's ADL care plan dated 7/26/23 revealed R12's bathing/showering needs were not addressed. During an interview with Certified Nurse Aide (CNA) E on 10/2/23 at 11:25 AM, CNA E said she assisted the Residents with showers. CNA E was aware R12 was a hospice resident. CNA E said she had not been asked to assist with R12's showers and was not aware of what care hospice was providing. During an interview with the Director of Nursing (DON) on 10/2/23 at 11:30 AM, the DON was not able to locate any records that verified facility staff were providing showers for R12. The DON was able to locate some records from hospice indicating the hospice aide was doing some bed baths but R12 was refusing to have her hair washed. The DON was not able to find any documentation that the facility was following up on R12's refusals to have her hair washed. Review of the hospice company records that were faxed to the facility on 9/27/23 at 2:43 PM, revealed a hospice aide provided services for R12 on 9/19/23 and 9/22/23. The services provided were, partial bed bath, dressing, incontinence care and nail care. R12 was documented as refusing a shampoo on both dates. R15 Review of R15's face sheet, no date revealed she was an [AGE] year-old female admitted to the facility on [DATE] had diagnoses that included schizoaffective disorder, chronic respiratory failure, chronic kidney disease, difficulty in walking, and dementia with behavioral disturbances. R15 had a court appointed guardian. R15 was observed in bed on 10/1/23 at 9:26 AM. R15's hair appeared to be very greasy. R15 was in a hospital gown and had ice water and a carton of milk on her bedside table next to her. R15 was not able to say if she ate breakfast or if she needed any care. R15 was observed on 10/2/23 at 8:21 AM in bed receiving her medications. After R15 took her medications, the nurse set up R15's breakfast and handed her the milk carton with a straw and the nurse walked out of the room. R15 was observed in the facility main dining room (MDR) on 10/1/23 at 11:52 AM. R15's tray was set up and she attempted to feed herself independently with a spoon. She had poor coordination and was very slow. After 45 minutes staff did not offer her physical assistance and she had eaten less than 25 % of her food. She did not respond to questions on whether she was hungry or what food she liked. Review of R15's care plan, dated 12/21/20 revealed, Alteration in ADL's (activities of daily living) -self-care deficit r/t (related to) confusion - needs cues/assist to initiate and complete tasks, r/t anxiety, r/t impaired balance with transitions, r/t weakness. The approach dated 12/21/20 for eating revealed, Status of eating ability: set up and supervision, to be sitting up in w/c for all meals. Review of R15's weights revealed she weight 187.5 on 6/15/23 and 181.5 on 7/13/23 and 172.5 on 8/7/23. R15 was on hospice now and did not have any weights documented after 8/7/23. During an interview with the Dietary Manager (DM) H and the Director of Nursing (DON) on 10/3/23 at 10:45 AM, they were unable to find any daily food intake records and said they expected staff to document R15's daily food intake in the medical record. Observations that R15 was in bed daily at breakfast and not being assisted when food was present was shared with DM H and DON. They reported they would look into it. During an interview with Certified Nurse Aide (CNA) E on 10/2/23 at 11:25 AM, CNA E said she assisted residents with showers. CNA E said she did not assist R15 with any showers. CNA E was aware R15 was in hospice care but was not aware of what care hospice was providing. Review of R15's facility hospice book revealed a note for 9/22/23 at 5:30 PM, Care visit, Resident down eating supper upon arrival. Facility staff - CNA said she would do cares when she lays her down in a little while. There was no indication the facility staff did a bed bath or shower. Review of R15's facility hospice book revealed several handwritten notes from hospice staff. The last note in the book was dated 9/29/23 at 7:30 PM, signed by a hospice aide, Care visit - Resident was laying down in bed when I got here. Bed bath and hair wash was given. Review of R15's ADL care plan dated 12/21/23 did not address R15's bathing/showing needs. During an interview with the Director of Nursing (DON) on 10/2/23 at 11:30 AM, the DON was not able to locate any information verifying the facility staff were providing bed baths or showers for R15. The observation of R15's hair being greasy and dirty was shared along with the note that the hospice aide documented she did a bed bath and washed R15's hair on 9/29/23 at 7:30 PM. The DON was not aware of how the hospice aide was doing R15's hair. The DON said she would look into it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide adequate supervision, implementation of meaningful intervention to prevent falls and ensure the fall care plan was followed for 1 Resident (R1), resulting in R1 sustaining multiple falls and the potential for serious injury. Findings include: Review of R1's face sheet, no date revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses that included: Dementia with behavioral disturbance, muscle weakness, lack of coordination, difficulty in walking, and unsteadiness on feet. He was not his own responsible party. Review of the facility timeline of falls revealed R1 had 12 falls from June 4, 2023, to 9/30/23. Most falls were not witnessed, when they were witnessed, staff were too far away to assist in time to prevent the fall. Review of the root cause did not list lack of safety awareness or unsafe transfers. Review of the facility timeline of falls revealed R1's last fall on 9/30/23 at 11:17 AM, R1 was attempting to go to the bathroom and the alarm on the bathroom was not functioning. Review of R1's care plan revealed a care plan dated 9/20/16, Resident can no longer safely care for self at home and requires 24-hour care/supervision and family is unable to provide such. Approaches included: Staff to provide 24-hour care/supervision. Review of R1's ADL (activities of daily living) care plan dated, 4/29/16 revealed, self-care deficit r/t (related to) hydrocephalus s/p (status post) VP (shunt) placement, encephalopathy (brain disease) with impaired cognition/poor safety awareness/impulsivity, altered mental status, disorientation, glaucoma, HOH (hard of hearing) bilaterally, vitamin B deficiency, dysphagia, nystagmus (involuntary eye movements that may blur vision), restlessness/agitation, hx (history) of incontinence, cervical spondylosis, cervical disc degeneration, cervical disc disorder, glaucoma. Approaches did not include amount of assistance needed to use the bathroom or transfers. R1's fall care plan dated 5/9/16 revealed, Resident is at risk for falls and subsequent injury related to: hydrocephalus s/p (status post) VP (shut) placement, encephalopathy (brain disease) with impaired cognition/poor safety awareness/impulsivity, altered mental status, disorientation, glaucoma, HOH (hard of hearing) bilaterally, vitamin B deficiency, dysphagia, nystagmus (involuntary eye movements that may blur vision), restlessness/agitation, hx (history) of incontinence, cervical spondylosis, cervical disc degeneration, cervical disc disorder, glaucoma. Approaches included: Alarm to bathroom door dated 9/7/23, Resident is going to self-transfer, staff should anticipate needs with toileting, redirect when he is fidgety or restless by offering him coffee or snacks, helping him to bed when he is tired and when in bed place wheelchair with brakes locked near bed so when he does self-transfer he can reach for his chair and reduce risk of him falling. During an interview with the Director of Nursing (DON) on 10/3/23 at 8:38 AM, the facility falls timeline was reviewed. The timeline did not include root cause statement. The incident reports were not all complete with the root cause statements and the root cause statements that were listed did not include that R1 was impulsive and had unsafe transfers. The DON did not have documentation or evidence showing that the facility had done a sleep study or any kind of assessments for toileting patterns. The DON could not provide any information as to how staff were to anticipate R1's needs. Interventions included short term increased supervision and no rational for when 1:1 and 15 minutes checks were stopped without putting in place any direct supervision when R1 was awake.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to adequately assess and monitor 3 Residents (R12, R15 and R18) nutritional status and needs, resulting in R15 and R18 resident experiencing weight loss and the potential for R12 to have weight loss. Findings included: Review of R12's face sheet, no date revealed she was a [AGE] year-old female admitted to the facility on [DATE] and diagnoses that included: cerebral infarction (stroke), aphasia (disorder that affects communication), hemiplegia (muscle impairment on one side of the body), and congestive heart failure. No legal decision maker was named. Review of R12's July 2023 Brief Interview of Mental Status (BIMS) score revealed she scored 9/15 (moderately impaired decision making). R12 was observed in the facility main dining room (MDR) on 10/1/23 at 11:52 AM. R12 was seated at a table with 2 other residents that required feeding assistance. There were 17 residents in the MDR at that time that required some assistance with set up and eating. During R12's time in the MDR for lunch there were between 1-3 staff assisting 17 residents. At times there was only one staff in the room. 2 different staff assisted R12 for about 5 minutes or less with eating. They only physically assisted her eat a few times each. They did cue her to eat. When she fed herself, she was slow and had poor coordination. When she was asked if she wanted food, she generally nodded her head yes. She never responded no. There were times she did not respond. After 45 minutes and less than 10 minutes of assistance R12 ate less than 25% of the food she was provided. Review of R12's weights revealed she her last weight was done on 8/7/23 and she weighted 129.5 pounds. She was no longer having weights done because she was in hospice care. Review of R12's ADL (activities of daily living) care plan dated 7/26/22 revealed, an approach dated 8/23/23 for, Eating status: 1:1 feed. During an interview with the Dietary Manager (DM) H and the Director of Nursing (DON) on 10/3/23 at 10:45 AM, they were unable to find any daily food intake records and said they expected staff to document R12's daily food intake in the medical record. Observations that R12 was only receiving intermittent assistance during lunch on 10/1/23 was shared and they said they will look into it. R15 Review of R15's face sheet, no date revealed she was an [AGE] year-old female admitted to the facility on [DATE] had diagnoses that included schizoaffective disorder, chronic respiratory failure, chronic kidney disease, difficulty in walking, and dementia with behavioral disturbances. R15 had a court appointed guardian. R15 was observed in bed on 10/1/23 at 9:26 AM. R15 was in a hospital gown and had ice water and a carton of milk on her bedside table next to her. R15 was not able to say if she ate breakfast or if she needed any care. R15 was observed in the facility main dining room (MDR) on 10/1/23 at 11:52 AM. R15's tray was set up and she attempted to feed herself independently with a spoon. She had poor coordination and was very slow. After 45 minutes staff did not offer her physical assistance and she had eaten less than 25 % of her food. She did not respond to if she was hungry or what food she liked. R15 was observed on 10/2/23 at 8:21 AM in bed receiving her medications. After R15 took her medications, the nurse set up R15's breakfast and handed her the milk carton with a straw and then walked out of the room. Review of R15's care plan, dated 12/21/20 revealed, Alteration in ADL's (activities of daily living) -self care deficit r/t (related to) confusion - needs cues/assist to initiate and complete tasks, r/t anxiety, r/t impaired balance with transitions, r/t weakness. The approach dated 12/21/20 for eating revealed, Status of eating ability: set up and supervision, to be sitting up in w/c for all meals. Review of R15's weights revealed she weighed 187.5 on 6/15/23 and 181.5 on 7/13/23 and 172.5 on 8/7/23. R15 was on hospice now and did not have any weights documented after 8/7/23. During an interview with the Dietary Manager (DM) H and the Director of Nursing (DON) on 10/3/23 at 10:45 AM, they were unable to find any daily food intake records and said they expected staff to document R15's daily food intake in the medical record. Observations that R15 was in bed daily at breakfast and not being assisted when food was present was shared. They reported they would look into it. R18 Review of R18's face sheet, no date revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: dementia, weakness, wheelchair dependent, dysphagia (difficulty swallowing) and cognitive communication deficit. She had a court appointed guardian. R18 was observed in bed on 10/1/23 at 9:25 AM. R18 was asked about breakfast, and she said she had not eaten but would order breakfast soon. No food was observed in the room. R18 was observed in the facility main dining room (MDR) on 10/1/23 at 11:52 AM and was assisted for less than 5 minutes eating after having the tray in front of her for more than 45 minutes. R18 only ate a few bits of food. Review of R18 weight revealed she weighed 191 pounds on July 10, 2023, 183 pounds on 8/7/23 and 172 pounds on 9/7/23. Review of R18's nutritional progress note dated 9/11/23 revealed she lost 10 % of her weight in 180 days and 6 % in 30 days. Mighty shakes were added twice a day to help prevent further weight loss. The plan was to monitor weights, offer alternate food choices when she ate less than 75% of the food offered. There was no indication of any assessment for need of assistance with eating. Review of R18's ADL (activities of daily living) care plan dated 1/16/17 revealed she required set up assistance to eat. The intervention was also dated 1/6/17. During an interview with the Dietary Manager (DM) H and the Director of Nursing (DON) on 10/3/23 at 10:45 AM, they were unable to find any daily food intake records and said they expected staff to document R18's daily food intake in the medical record. Observations that R18 was being left in bed and reporting she still wanted to eat and not eating were shared. The DM H and DON were not able to verify the last time someone assessed R18's ability to feed herself, and they were not able to verify that an assessment was done. They were not sure what foods R18 ate best or liked. They said they would evaluate her nutritional likes and needs for assistance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure all pharmacy recommendations were received and acted on for 2 residents (R11 and R26) reviewed for medication reviews. This deficient practice resulted in R11 and R26 having pharmacy recommendations that were not communicated to the facility and not acknowledged by the physician for suggested changes to be made. Findings include: R11 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R11 admitted to the facility on [DATE] with diagnosis of (but not limited to) congestive heart failure, high blood pressure, kidney failure and diabetes. Brief Interview for Mental Status (BIMS) reflected a score of 13 out of 15 which represented R11 was cognitively intact. R11 required extensive staff assistance of 1-2 with all activities of daily living. Record review of R11's monthly medication regime review reflected that the pharmacy reviewed the medications regime on 8/14/23 and indicated that recommendations were made. A records request was made for all pharmacy recommendations from 8/11/23 to current. The facility provided 2 documents dated 9/13/23 and 9/17/23. There was no recommendation provided for 8/14/23 made available for review. During an interview and record review on 10/3/23 at 1:55 PM, the Director of Nursing (DON) stated she was unaware of any recommendations made on 8/14/23 and the facility did not have a copy of them. The DON was able to obtain a copy of the 8/14/23 pharmacy recommendation report and provided it for review approximately 3:00 PM on 10/3/23. The report reflected, (Name of R11) receives three or more CNS (central nervous system) active medications which can cause an increased risk for falls and fractures: Lorazepam (antianxiety), Buspirone (antianxiety), Escitalopram (antidepressant), Aripiprazole (antipsychotic), Hydrocodone/Acetaminophen (narcotic pain reliever), bupropion (antidepressant). Recommendation: Please reevaluate this combination and reduce the dose of lorazepam to 0.5 mg in the morning and 1 mg at night, with the end goal of discontinuation . There were no signatures on the form and no evidence the recommendation was reviewed by the physician nor acted upon. R26 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R26 admitted to the facility on [DATE]/23 with diagnosis of (but not limited to) liver disease, kidney failure, high blood pressure, and abnormal posture. Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which represented R26 was cognitively intact. R26 required extensive staff assistance of 1-2 with all activities of daily living. Record review of R26's monthly pharmacy medication reviews reflected that the pharmacy reviewed the medications on 4/4/23 and 6/6/23 and indicated that recommendations were made to the facility and physician. A records request was made for all pharmacy recommendations from 3/28/23 to current. There were no reviews provided for 4/4/23 or 6/6/23. On 10/3/23 at approximately 3:30 PM, the DON obtained a copy from the pharmacy and provided a copy of the 4/4/23 and 6/6/23 pharmacy recommendations for review. The recommendations were unsigned by the DON and the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide collaborative hospice care for 2 Residents (R12 and R15), resulting in the potential for services and needs to be unmet. Findings included: Review of R12's face sheet, undated, revealed R12 was a [AGE] year-old female admitted to the facility on [DATE] and diagnoses that included: cerebral infarction (stroke), aphasia (disorder that affects communication), hemiplegia (muscle impairment on one side of the body), and congestive heart failure. No legal decision maker was named. Review of R12's July 2023 Brief Interview of Mental Status (BIMS) score revealed she scored 9/15 (moderately impaired decision making). During an interview with Certified Nurse Aide (CNA) E on 10/2/23 at 11:25 AM, CNA E revealed R12 had a notebook at the nurse's station that should contain information on R12's hospice schedule, what the services were and when hospice planned to provide the services. R12's book had a schedule for October 2023 in the front of the book that indicated the caregiver was scheduled to come every Tuesday and Friday during October at an unknown time. The licensed nurse was schedule to come on Thursdays. There were a few handwritten notes from the hospice social worker and Chaplin in the book. There was no indication what services the hospice caregiver had been providing or when the care was provided. CNA E said she assist other residents with showers in the facility but she does not assist R12 nor had she been approached by R12's hospice to assist with any showers. During an interview with the Director of Nursing (DON) on 10/2/23 at 11:30 AM, the DON revealed the information that showed when and what services the hospice caregiver had been providing for R12 was not in the hospice book. The DON said she would have to call hospice as they do not document in the facility record. The DON provided hospice records for R12 that had been faxed from the hospice company to the facility on 9/27/23 at 2:43 PM, that contained a total of 38 pages. The records were from the hospice electronic record, and you were not able to be filtered by the service being provided. The review revealed a hospice aide provided services for R12 on 9/19/23 and 9/22/23. The services provided were, partial bed bath, dressing, incontinence care and nail care. R12 was documented as refusing a shampoo on both dates. The DON was not able to find any facility documentation that they were aware of R12's refusal for a shampoo or documentation that the facility was providing a shower and shampooing of R12's hair. The DON was not able to locate any documentation showing the facility was meeting or collaborating with R12's care with hospice. R15 Review of R15's face sheet, undated, revealed she was an [AGE] year-old female admitted to the facility on [DATE] had diagnoses that included Schizoaffective disorder, chronic respiratory failure, chronic kidney disease, difficulty in walking, and dementia with behavioral disturbances. R15 had a court appointed guardian. R15 was observed in bed on 10/1/23 at 9:26 AM. R15's hair appeared to be very greasy. R15 was in a hospital gown and had ice water and a carton of milk on her bedside table next to her. R15 was not able to say if she ate breakfast or if she needed any care. During an interview with Certified Nurse Aide (CNA) E on 10/2/23 at 11:25 AM, she revealed R15 had a notebook at the nurse's station that should contain information on R15's hospice schedule and what services and when hospice planned to provide the services. R15's book did not contain any schedule or information on when R15's hospice aide was expected to arrive or what care they planned to provide. CNA E' said she assists the facility residents with showers but she had not been providing any showers for R15 and that hospice had not approached her to assist with showers. Review of R15's facility hospice book revealed several handwritten notes from hospice staff. The last note in the book was dated 9/29/23 at 7:30 PM, signed by a hospice aide, Care visit - Resident was laying down in bed when I got here. Bed bath and hair wash was given. No skin concerns. Bed linens changed. And trash emptied at the end of visit. There was no indication the facility staff assisted or were aware of the services provided. Review of R15's facility hospice book revealed a note for 9/22/23 at 5:30 PM, Care visit, Resident down eating supper upon arrival. Facility staff - CNA said she would do cares when she lays her down in a little while. She was content and eating. There was no indication that the hospice aide provided any care on that day. It appeared that the care the hospice aide was going to do was now going to be done by facility staff due to R15 eating at her normal scheduled time. Review of R15's care plan revealed a care plan for, Resident has DX (diagnosis) of Alzheimer Dementia and has elected to receive Hospice services, dated 6/19/23. Approaches included: Facility staff will assist hospice staff as needed during visits, Facility to continue to conduct routine duties including ADL's (activities of daily living), administration of medication (s), social services support, dietary management, and activities, ect. These approaches all indicated the hospice aide was involved in this service. There were no specific care areas identified for the hospice aide. There was no indication if R15 preferred a bed bath or a shower. There was no indication how often R15 preferred a bed bath or a shower. During an interview with the Director of Nursing (DON) on 10/2/23 at 11:30 AM, the facility hospice book was reviewed, and no schedule was located for when hospice staff were going to provide service for R15 this month. There were handwritten notes that indicated the hospice aide had been providing bed baths and washing R15's hair. The Surveyor reported that R15's hair appeared greasy and dirty. The Surveyor asked who was overseeing R15's hospice care and who was directing them on washing her hair. The DON said hospice staff are to communicate with the facility staff at the time of services. The DON was not able to locate any information that verified hospice staff and facilities staff communicate on the dates of service. There was no indication how the hospice staff were washing R15's hair. The DON was going to check with hospice to see when care was planned and how the staff were washing R15's hair.

Based on observation, interview, and record review the facility failed to: 1. Date mark and discard potentially hazardous foods; 2. Properly cool potentially hazardous foods; 3. Ensure proper concentration of quaternary ammonium sanitizer; 4. Clean food and non-food contact surfaces to sight and tough; and 5. Ensure proper working order of the dish machine. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected 55 residents who consume food from the kitchen. Findings Include: 1. During the initial tour of the kitchen, starting at 9:20 AM on 10/1/23, an interview with [NAME] I found that most foods are date marked for a seven-day discard, but foods made in house would usually be kept for three days. Observation of the two door True cooler found a package of hot dogs dated 9/25 to 10/5, and an open package of hard-boiled eggs with no date. During a tour of the dry storage refrigerator, at 10:50 AM on 10/1/23, the following items were found: yogurt with a best by date of 8/16/23, half and half with a best by date of 8/14/23, an uncovered cookie pudding with no date, and a taco wrapped in tin foil with no date. According to the 2017 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under § 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. (B) Except as specified in (E) -(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety . According to the 2017 FDA Food Code section 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A FOOD specified in 3-501.17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17(A), except time that the product is frozen; (2) Is in a container or PACKAGE that does not bear a date or day; or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in 3501.17(A) . 2. During the initial tour of the kitchen, at 9:25 AM on 10/1/23, observation of the True two door cooler found taco meat tightly wrapped in foil. An interview with [NAME] I found that the taco meat is for taco salad coming up. When asked how the item was cooled, [NAME] I stated she made it around 1:00 PM yesterday, the meat reached 180F when it was finished and over the next two hours it cooled to 155F where [NAME] I stated she covered it up and put it in the reach in cooler. Observation of the pan at this time found heavy accumulation of condensation inside the top cover. When asked if she knew the required time and temperature frequency for cooling, [NAME] I was unsure. According to the 2017 FDA Food Code section 3-501.14 Cooling. (A) Cooked TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cooled: (1) Within 2 hours from 57ºC (135ºF) to 21ºC (70°F); and (2) Within a total of 6 hours from 57ºC (135ºF) to 5ºC (41°F) or less . According to the 2017 FDA Food Code section 3-501.15 Cooling Methods. (A) Cooling shall be accomplished in accordance with the time and temperature criteria specified under § 3-501.14 by using one or more of the following methods based on the type of FOOD being cooled: .(2) Loosely covered, or uncovered if protected from overhead contamination as specified under Subparagraph 3-305.11(A)(2), during the cooling period to facilitate heat transfer from the surface of the FOOD. 3. During the initial tour of the kitchen, at 9:40 AM on 10/1/23, a sanitizer bucket containing quaternary ammonium was tested with Hydrion QT-40 test strips and found to be over 500 parts per million (ppm) when distributed from the pre dispense sanitizer system on the three-compartment sink. An interview with [NAME] I found the concentration is usually around 200-300 ppm. The pre dispense system was tested four times with the facilities test kit and found the concentration was over the 500 ppm (the max that registers on the test strip). Staff were unsure why the concentration was this high, the surveyor asked when the last time the unit was serviced, staff was unsure. According to the 2017 FDA Food Code section 7-204.11Sanitizers, Criteria. Chemical SANITIZERS, including chemical sanitizing solutions generated on-site, and other chemical antimicrobials applied to FOOD-CONTACT SURFACEs shall: (A)Meet the requirements specified in 40 CFR 180.940Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (Food-contact surface sanitizing solutions), or (B)Meet the requirements as specified in 40 CFR180.2020 Pesticide Chemicals Not Requiring a Tolerance or Exemption from Tolerance-Non-food determinations. 4. During a tour of the kitchen, at 9:40 AM on 10/1/23, it was observed that the ice scoop holder on the wall was found with a layer of stagnant water in the bottom of the holder with no holes for proper drainage. When asked how often the ice scoop gets cleaned, [NAME] I stated it gets cleaned once a week. During a tour of the kitchen, at 10:01 AM on 10/1/23, observation of the clean utensil drawers found three mechanical scoops with stuck on food debris, further review found one of the drawers contained excess food and crumb accumulation. When asked if the clean utensil drawers are on a cleaning list, [NAME] I stated yes. According to the 2017 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. 5. During the initial tour of the dish machine area, at 10:16 AM on 10/1/23, it was observed that the dish machine required 155F for the wash cycle and 180F for the rinse water coming out of the manifold. A review of the High Temp Dish Machine Wash and Rinse Temperature Log dated September 2023, found 46 rinse temperatures recorded below the minimum requirement of 180F. According to the 2017 FDA Food Code section 4-501.112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures. (A) Except as specified in (B) of this section, in a mechanical operation, the temperature of the fresh hot water SANITIZING rinse as it enters the manifold may not be more than 90C (194F), or less than: .(2) For all other machines, 82C (180F).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intakes M100131367 and M100 131531 Based on interview and record review, the facility failed to follow policies and procedures for new hires, provide abuse education, and prevent abuse for 2 (Resident #7, Resident #8), resulting in residents feeling threatened and intimidated by staff at the facility. Findings include: Resident #7 (R7) Review of a Face Sheet revealed R7 admitted to the facility on [DATE] with pertinent diagnoses of a cerebral infarction (stroke), hemiplegia and hemiparesis (one sided weakness), and congestive heart failure. Review of the Minimum Data Set (MDS) dated [DATE] for R7 revealed she is cognitively intact and requires extensive assistance of one staff for toileting. Resident #8 (R8) Review of a Face Sheet revealed R8 admitted to the facility on [DATE] and discharged on [DATE]. She had pertinent diagnoses of a cerebral infarction (stroke), hemiplegia and hemiparesis (one sided weakness), and obesity. Review of the MDS dated [DATE] for R8 revealed she was cognitively intact and required extensive assistance of one staff for toileting. Review of a policy titled Abuse Prevention Program revised 9/2022 revealed: Intent: Each resident has the right to be free from abuse, neglect and corporal punishment of any type by staff or anyone. The facility will provide a safe resident environment and protect residents from abuse. POLICY: (Facility) has prevention programs in which policies and procedures safeguard our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint (not required to treat the residents medical symptoms), verbal, mental, and sexual. In addition to the abuse program, (Facility) also has a Grievance Policy, ASAP hotline call program, Management is listening program, General Orientation training, Grand Rounds, resident and family counsel. Review of a complaint reported to the State Agency on [DATE] revealed a concern of a 3rd shift Certified Nursing Assistant (CNA) EE who was verbally abusive, neglectful, and denying care to residents. One individual asked to be changes and (CNA EE) stated (sic) yelling saying, I have already changed you; I'm not doing it again. The complainant reported CNA EE was throwing a tantrum, kicking furniture, and yelled at a different resident who was on hospice who has behaviors she cannot control. When the resident yells out, CNA EE yells back at the resident telling her to shut up. The complainant notified the Director of Nursing and the Nursing Home Administrator. Review of a Grievance Form dated [DATE] at 1:30 PM revealed the Social Worker (who is no longer employed at the facility) documented R8 reported that aide came in at 2 AM and was yelling and sounded like kicking things in our room and yelling at us to be quiet. R7 did not deserve to be treated like that. R7 states aide came in at 2 AM and she yelled at me. She told me to be quiet and she took my call light away from me and threw it across the room and told me I need to be quiet. At the bottom of the form states copy given to admin on [DATE] at 3:30 PM. Review of a Facility Reported Incident (FRI) dated [DATE] revealed an allegation of a 3rd shift CNA who yelled at a resident the night before and moved her call light away from her. R8 reported to the Social Worker that the CNA EE on the 3rd shift was rude to her roommate (R7). R7 told the Social Worker that the CNA had moved her call light on the other side of the bed when she came to check her and that she would have to wait until the next rounds because she had just changed her and provided peri care and treatment. R7 claims she could not reach her call light after this. R7 had complained of a burning sensation in her groin area and was recently treated for a urinary tract infection and vaginitis. Other residents were interviewed, and it was confirmed that it was louder than usual and the NHA was informed. CNA EE was interviewed and stated the call light was left on the table and was still within the residents reach. Other staff members were interviewed and no one recalled having to return the call light to R7. Other residents were interviewed, and one resident reported the only staff member she had a problem with was CNA EE who has a bad attitude and is always loud. R11 reported she had a bad experience with (CNA EE) and never wants that staff member to give her a shower again. A couple more residents reported it was very loud that night. No statements from staff who worked that night were provided and unable to prove they were done. The facility concluded they were unable to substantiate abuse and no education was provided to the staff. CNA EE was terminated for demonstrating poor customer service. The incident was reported to the State Agency on [DATE] at 7:12 PM. No police report provided. Review of an Employee Memorandum document for CNA EE revealed on [DATE] she was suspended pending investigation for Gross negligence in the performance of job duties and discharged on [DATE] for serious customer service concerns that were revealed. During an observation and an interview on [DATE] at 8:55 AM, R7 was in bed eating and was not very talkative. CNA X walked to check on R7 and did not know why she is eating a pureed diet bed alone at this time when asked questions. When CNA X was queried about staff being rude or rough with care or even maybe rushing with care, she said she heard something like that on second shift but it has been reported. The last concern she heard like that was about 2 weeks ago. During an interview on [DATE] at 10:24 AM, the Assistant Director of Nursing (ADON) reported CNA EE was a ball of fire and her approach to resident care came off in a hurried manner and was a rough talker. She was a Lets get it done kind of person and not kind and gentle. She was a no-nonsense kind of person. The ADON did remember hearing something about the incident with R7 and R8 but does not remember seeing that kind of behavior from CNA EE. In an interview on [DATE] at 11:11 AM, the NHA reported that she does provide abuse education to staff but not able to provide documentation showing any staff had received, acknowledged, and understand abuse, neglect, and reporting. The NHA reported that CNA EE just had poor customer service and would use the intercom sometimes to answer the call lights and that is why she is no longer working at the facility. When queried about why the documentation in her employee file shows she was terminated the NHA reiterated that her customer service skills did not meet the facility's standard. Review of the Employee file for CNA EE revealed a Personnel Action Form dated [DATE] revealed that she was terminated due to abuse effective [DATE]. No updated abuse education was received. Review of an Employee file for CNA FF revealed she was eligible for employment on [DATE] and there were no references before hire. Review of an Employee file for CNA W revealed she was eligible for employment on [DATE] and she had no references before hire or trainings that included abuse. Review of an Employee file for CNA A revealed her license expired on [DATE] and her last abuse training was on [DATE]. Review of an Employee file for Social Worker (SW) C revealed she did not have any references before hire and an individual abuse education sign in sheet with only her signature was done on [DATE]. Review of a policy titled Interviewing and Selection effective 01/11 revealed employees are to have a minimum of two references prior to an offer of employment. Review of an Orientation policy effective 11/97 revealed To assure accuracy in completion of all State and Federal mandated new hire documents as well as to orient new employees to Atrium's principals and philosophies. Each new employee will attend department specific orientation as provided by their department director. This may include skills testing as required by state. Department specific training should be completed prior to the employee working in the department.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake M100134991. DPS B Based on observation, interview and record review, the facility failed to follow the care plan and safely transfer 1 (R11), resulting in repeated skin injuries with no investigation to the root cause to prevent repeated injuries. Findings include: Review of a Face Sheet revealed R11 admitted to the facility on [DATE] with pertinent diagnoses of muscle weakness, cognitive communication deficit, mild cognitive impairment, and kidney failure-renal azotemia (elevated nitrogen in blood) primary diagnosis. Review of the MDS dated [DATE] revealed R11 is cognitively intact and requires extensive assistance of 1 staff for transfers and cares. During an observation and an interview on 5/2/23 at 1:35 PM, R11 was sitting in her room in a wheelchair and had a dressing on her left lower leg. R11 reported she got scraped on her leg three times when staff was trying to transfer her to bed. R11 reported the staff were rough with her care and pushed her into the bed. When she told the staff she could not move, they told her they will show her how to move and picked her up and put her in bed. There was a gait belt observed hanging on the back of the residents door. In an interview on 5/2/23 the Director of Nursing (DON) did not have any statements from staff regarding a skin tear on R11's left leg or how it happened but did provide a document that verified an event that involved R11 getting a skin tear. Review of a Skin Integrity Event dated 4/25/23 for R11 revealed she had a skin tear on her left shin that measured 4 cm (centimeters) tall X 3 cm wide X 0.1 cm in depth. A small amount of blood present and pain rated at a 3. No investigation to the root cause or interventions documented. In an interview on 5/3/23 at 3:30 PM, CNA W reported the day R11 scraped her leg was the day that she assisted another CNA to transfer the resident to bed from her wheelchair. When R11 is tired at night she is a 2 person assist because she is heavier when she is tired even though her care plan says she is a one assist. CNA W reported they did transfer the resident without a gait belt by lifting her under her arms from the wheelchair and pivoted the resident to the bed when she heard the resident say ouch and noticed there was blood on her leg. CNA W thinks her leg was twisted when they pivoted her. CNA W reported R11 has fragile skin that got scraped from the bed frame during the transfer. CNA W reported the resident has scraped her leg at least 3 times on the bed frame and suggested to the facility to put a covering over the bed frame. Review of a Skin Integrity Event dated 2/16/23 for R11 revealed a skin tear on the left lower extremity that measured 0.5 cm X 0.3 cm covered with a scab that occurred during a transfer. There is no investigation, conclusion or intervention provided. Review of a Skin Integrity Event dated 3/6/23 for R11 revealed she had a 1 X 1 fluid filled blister on her right knee from an unknown cause. No investigation, conclusion or intervention provided. Review of an Activities of Daily Living (ADL) care plan for R11 revealed on 4/1/22 a transfer status approach started as follows: Staff may offer sit to stand lift as form of transfer. If patient requests Hoyer, it may also be used. Sit to stand lift is to be encouraged. 2 assist for all transfers. In an interview on 5/5/23 at 10:39 AM, the DON reported that her expectation for staff to transfer residents who are at least a one assist to use a gait belt for transfers. The DON was not sure if R11 was transferred with a gait belt when her leg was scratched. When queried if there were any staff statements regarding the incident on 4/25/23 and the root cause, the DON reported the nurse had her written statement at the nurses' station. She later provided the nurses written statement and a written statement from one of the CNAs that transferred R11 to bed that day. The written statement from the CNA who assisted CNA W with transferring R11 on 4/25/23 stated she did use a gait belt to transfer the resident. This citation refers to MI00132223. This citation has 2 DPS DPS A Based on interview and record review, the facility failed to prevent falls for 2 of 3 residents (R10 and R12) reviewed for falls, resulting in R10 sustaining a fracture and minor injuries from falls and R12 sustaining a minor injury from a fall. Findings include: R10 A review of R10's Face Sheet, dated 5/3/23, revealed R10 was an [AGE] year-old resident admitted to the facility on [DATE]. In addition, R10's Face Sheet revealed multiple diagnoses that included dementia, difficulty walking, unsteadiness on feet, generalized muscle weakness, and repeated falls. A review of R10's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 3/12/23, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 10 which revealed R10 was moderately cognitively intact. In addition, R10's MDS revealed they needed limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance) with one person physically assisting them for transfers (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position) and ambulation on the unit. A review of R10's fall risk care plan, dated 3/31/21, revealed multiple interventions that included Wireless sensor alarm to be on when in bed, w/c and recliner to alert staff of self transfer attempts. Check for function and placement q shift- initiated 8-12-21. Fall #1 A review of R10's Fall Risk Assessment, dated 8/23/22, revealed R10 scored a 17 (high risk for falls). A review of R10's progress notes, dated 9/5/22 to 11/5/22, revealed the following: - Licensed Nurse (LPN/RN) note, dated 9/6/22, revealed, Resident alert/confused, pleasant and [NAME] (cooperative) w/care . gets up by self/alarm on and working, enc. resident to call for help. - Registered Nurse (RN) note, dated 9/11/22, revealed, [Name of R10] has made several attempts to self-transfer this far into this shift. Alarm did sound each time. Gait very unsteady. A few times resident stated he needed to use the bathroom, other time he was unsure where he was going. He is currently sitting in WC (wheelchair) at nurses' station for safety reasons. - Registered Nurse (RN) note, dated 9/24/22, revealed, Resident had lunch in dining room, after lunch he was placed on N (North) hall across N nurse's station in WC. This nurse alerted staff not long after resident was in hall that he wasn't in his room. Resident was quickly found by staff in [another resident's room number] bathroom, standing. He was taken back to his room to use bathroom. Alarm was sounding. He is currently in recliner. - Nursing note, dated 10/2/22, revealed, resident self-transferred x 2 (twice) this shift. Sensor alarm is not working. Note left in maintenance book. Chair alarm is not loud enough to hear all the way down the hall. He was educated again to use call light. Within 5 minutes he self-transferred again. - Registered Nurse (RN) note, dated 10/4/22, revealed, Resident was found on floor. When asked what he is was doing he said, I can't remember, I think I was going to bed. He was found on his left side 3 feet in front of his chair facing bathroom door. Fall was not witnessed. Found by [name of a certified nursing assistant]. This nurse asked resident where he hurt. He stated, My left shoulder, left elbow and left hand. Resident was moving arm normally but cradling his Lt (left) hand. He was assisted to bed via [name of mechanical lift]. Lt arm was elevated, and ice was applied. He had been in recliner previous to being found on floor. He was wearing grippy socks. His WC and walker were next to his chair. Pressure sensor alarm did not go off and did seem to be turned on. Left hand, ring finger, is slightly out of alinement (alignment?), and slightly purple like it is bruising. On call [name of on call provider] notified, and Lt hand Xray with phalanges ordered. DON (Director of Nursing) notified, as well as, wife. - Registered Nurse (RN) note, dated 10/5/22, revealed, RN (PRN?- as needed) Tylenol given r/t (related to) pain management to left hand. Swelling/ purple bruising to left hand. Ice also applied for comfort. When asked resident states it only hurst (sp.) when touched. Awaiting x ray tech for ordered x ray to left hand that was faxed this AM (morning) by 3rd shift nurse. - Nursing note, dated 10/05/2022, results from residents xray of left hand shows fracture on the ring finger of left hand. [Name of physician] called and wants PT/OT (physical therapy/occupational therapy) to see if they can splint. Spoke with [name of Director of Therapy (DOT) I] and he said they would splint it. DON contacted and [name of R10's spouse] notified. - Registered Nurse (RN), dated 10/7/22, revealed, PN (PRN?) Tylenol given now for pain management r/t finger fracture. Swelling/bruising still apparent to left hand. Resident is refusing to wear splint on fractured finger. Will monitor medication effectiveness. - Interdisciplinary Team note, dated 10/12/2022, revealed, IDT (Interdisciplinary Team) reviewed fall care plan and added interventions to; ensure bathroom door is closed when not in use to reduce risk of falling or self-injury if resident attempts to grab open door to stabilize self, signage posted on wall and walker for cueing reminder to ask for assistance prior to getting up, offer toileting and to lay down apx (approximately?) 7:45 pm. - Registered Nurse (RN) note, dated 10/19/22, revealed, Resident has self-transferred on several occasions today and did so almost immediately after fall prevention education had taken place by this nurse. 3 self-transfers occurred within 5 mins of each other. He was offered bathroom needs and had just eaten lunch. He was educated on using call light, when asked for teaching feedback he could not verbalize understanding. He did have large incontinent BM (bowel movement). A review of the facility's Maintenance Log, dated 10/3/22, revealed R10's sensor alarm/pad was reported to maintenance as not working on 10/2/22. It also revealed maintenance replaced the pad/alarm on 10/3/22 and noted it was functioning. A review of R10's Safety Events- Fall Events Report, dated 10/5/22, revealed on 10/4/22 at 7:55 PM, R10 was found on the floor and did not remember what he was doing before he fell. R10 stated his left shoulder, left elbow, and left hand hurt. In addition, his ring finger on his left hand was observed being slightly out of alignment and slightly purple like it is bruising. In addition, it was noted that R10's alarm did not sound. A review of R10's October 2022 Medication Administration Record (MAR) revealed R10's alarm function was checked every shift from 10/1/22 to 10/31/22 without any indication there was an issue with the alarm not functioning properly. A review of R10's x-ray of his left hand, dated 10/5/22, revealed R10 had a fracture of his left ring finger. During an interview on 5/3/23 at 12:50 PM, R10 stated he does not remember falling in October 2022. He stated he knows he is supposed to call for assistance before he gets up. Fall #2 A review of R10's Fall Risk Assessment, dated 3/17/23, revealed R10 scored a 18 (high risk for falls). A review of R10's progress notes, dated 4/1//23 to 4/18/23, revealed the following: - Registered Nurse (RN) note, [Recorded as Late Entry on 04/09/2023 12:16 AM] for 4/8/23, revealed, Resident was found on floor of his room, his head at the foot of his recliner with his feet stretching toward his bathroom, on his rt side. He is bleeding from Rt (right) forehead, after cleaning area a 1.5 cm (centimeter) laceration was noted. Laceration is well approximated, so this nurse applied steri strips (steri-strips are small pieces of tape used for cuts that cling to the skin better than ordinary tape). Resident is moving arms and legs well. His LOC (level of consciousness) is at base line. Small bruise noted at apex f (front) elbow. Resident state his elbow hurts. He is moving his arms and legs with difficulty. He is requesting to get in his bed. [Name of mechanical lift device] used to do this. - DON (Director of Nursing) note, dated 4/11/2023, revealed, Root cause analysis regarding event, shows resident got up out of bed to close blind and fell . Resident reports pain to elbow only when pressure is applied. No other discomfort noted. A review of R10's Fall Risk Assessment, dated 4/11/23, revealed R10 continued to be a high risk for falls after this latest fall with a score of 10. A review of R10's Safety Events- Fall Events Report, dated 4/11/23, revealed on 4/9/23 at 9:33 PM, R10 fell while getting up to close his window blinds. R10 sustained a bruise to the left elbow and a laceration to the right side of his forehead. His alarm was used, but did not sound. A review of R10's April 2023 Medication Administration Record (MAR) revealed R10's alarm function was checked every shift from 4/1/23 to 4/30/23 without any indication there was an issue with the alarm not functioning properly. During an interview on 5/3/23 at 12:50 PM, R10 stated he does not remember falling in April 2023. He stated he knows he is supposed to call for assistance before he gets up. R12 A review of R12's Face Sheet, dated 5/4/23, revealed R10 was a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R12's Face Sheet revealed multiple diagnoses that included a right tibia (leg bone) fracture, right fibula (leg bone) fracture, post traumatic stress disorder (PTSD), generalized muscle weakness, unsteadiness on feet, difficulty walking, and abnormal gait and mobility. A review of R12's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 2/28/23, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 13 which revealed R12 was cognitively intact. In addition, R12's MDS revealed they needed extensive physical assistance (resident involved in activity, staff provide weight-bearing support) of two staff members for transfers (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position) and ambulation on the unit. A review of R12's Falls Risk Assessment (located in R12's Critical admission Assessment form), dated 2/23/23, revealed R12 scored a 12 (High Risk). A review of R12's progress notes, dated 3/19/23 to 4/10/23, revealed the following: - Registered Nurse (RN) note, dated 3/26/23, revealed, At 2:40 pm resident heard calling out for help. Resident's door was closed (per her preference) Found sitting on the floor in front of her w/c (wheelchair). C/O (complained of) left knee pain. Assisted from floor into bed per three staff members and [name of mechanical lift]. ROM (range of motion) performed on all extremities without limitations or further c/o pain. Small pinkish area over left knee but skin is intact. Resident denies head strike. All appropriate parties notified. No new orders. Call light is in easy reach. - DON (Director of Nursing) note, dated 4/3/23, revealed, Root cause analysis finds that resident was attempting to transfer to bed from wheelchair. Resident states she landed on her butt because her breaks were not locked. Educated resident on locking wheelchair breaks before any transfers but also to use her call light and wait for staff prior to attempts. Resident verbalized understanding. Staff educated on ensuring call light is within reach at all times. A review of R12's Safety Events- Fall Events Report, dated 4/3/23, revealed on 3/26/23 at 2:40 PM, R12 fell while self-transferring without assistance. Staff heard R12 calling out from behind a closed door and found her sitting up on the floor in front of her wheelchair. R12's call light was not within reach. R12 complained of left knee pain rated at an 8 (severe pain). During an interview on 5/4/23 at 10:20 AM, R12 stated she did not remember falling at the facility on 3/26/23. She stated she did remember falling while trying to get into her wheelchair. However, she was not sure if it happened at the facility or elsewhere.

This citation pertains to intake MI00126209 Based on observation, interview, and record review, the facility failed to adhere to the facility infection control measures and the facility policy on Enhance Barrier Precaution procedures when providing care to two facility residents (R12 and R13), resulting in the potential for the spread of infection to all facility residents. Findings: The facility policy titled Enhanced Barrier Precautions (EBP) dated 10/2022 was reviewed. The facility policy reflected that EBP refers to the use of personal protective equipment (PPE) during high-contact resident care activities for residents known to be colonized or infected with a multi-drug-resistant organism (MDRO) as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). The facility policy section titled Policy Explanation and Compliance Guidelines reflected a. All staff receive training on (EBP) upon hire and at least annually and are expected to comply with all designated precautions. b. All staff receive training on high-risk activities . And c. Clear signage will be posted on the door or wall outside of the resident room indicating the type of precautions, required PPE, and the high-contact resident care activities that require the use of gowns and gloves. The facility policy reflected 2. Initiation of (EBP) .b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds and/or indwelling medical devices .even if the resident is not known to be infected or colonized with a MDRO. And 4 High-contact resident care activities include .f. Changing briefs . h. Wound care . And 7. Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility or until the wound heals . Review of the Electronic Medical Record (EMR) revealed R12 was originally admitted to the facility 2/23/23 and was currently receiving treatment for a Stage II pressure sore. On 5/4/23 at 10:38 AM an observation was conducted at the room of R12. Observed d to the wall outside the door of R12 was a sign that displayed two stop signs and the words Enhanced Barrier Precautions in large block letters. The sign reflected the Providers and Staff must .wear gloves and a gown for the following High-Contact Resident Care Activities .Transferring, Changing briefs or assisting with toileting .Wound Care any skin opening requiring a dressing. Below the sign was a set of drawers that contained gloves, gowns, and eye protection. On 5/4/23 at approximately 10:42 AM while conducting an interview with R12 in her room Registered Nurse (RN) Y and RN CC entered the room to perform a dressing change of an open wound on the coccyx of R12. R12 and the bed she was in were adjusted in preparation for the dressing change. RN Y indicated more gloves were needed for the task and left the room without removing the gloves she was wearing or performing hand hygiene. RN Y returned to the room with a box of gloves still wearing gloves. RN Y reported that R12 had two wounds with one wound requiring a dressing change and the other a topical application. It was observed that the dressing change, wound treatment, and brief change were conducted with neither RN Y or RN CC wearing a gown as the direction of the EBP sign outside the door directed. During the dressing change RN CC was observed holding R12 rolled to her left side. RN CC was observed to remove the soiled dressing with a gloved hand but did not change gloves following the task. RN CC was later observed adjusting bedding, moving the over-the- bed table and providing personal items to R12 while wearing the same gloves worn when removing the soiled dressing. On 5/4/23 at 11:18 AM, outside the room of R12 RN Y was asked when a gown was to be wore when caring for a resident on EBP. RN Y reported that she probably should have gowned up for the dressing change then added probably should have (donned a gown) for the care we just did. RN Y reported that the only reason R12 was on EBP was because the Resident just returned from the hospital and stated, I honestly don't know of any infection she may have. The observations of the care provided R12 and statements by staff did not demonstrate knowledge of the facility EBP policy section titled Policy Explanation and Compliance Guidelines, nor did the staff implement the direction given in facility policy. R13 Review of the medical record reflected R13 was admitted to the facility 3/24/23 with diagnoses that included, Renal failure (on dialysis), Sepsis and Stage 3 Pressure Ulcer of the Sacral Region. Review of the Doctor's Orders reflected R13 was placed on Enhanced Barrier Precautions on the admission date. On 5/4/23 at 12:38 PM R13 was observed in her room being transferred from the wheelchair to the bed by Certified Nurse Aide (CNA) X and the Assistant Director of Nursing (ADON). It was observed that neither staff member wore a gown despite R13 being under EBP. Subsequently, a brief change and dressing change of the sacral pressure ulcer were conducted by the ADON and assisted by CNA without following the guidance of the facility policy on EBP .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure daily weights were obtained as ordered for 1 resident (Resident #88) resulting in the potential for a change in condition to go unrecognized and untreated. Findings: Resident #88 (R88) Review of a facility Face Sheet reflected R88 admitted to the facility on [DATE] with pertinent diagnoses of chronic diastolic (congestive) heart failure, edema, fall, overactive bladder, urinary tract infection, cardiomegaly, chronic obstructive pulmonary disease, type 2 diabetes, high blood pressure, chronic atrial fibrillation, nonrheumatic mitral (valve) insufficiency and sleep apnea. Review of a Care Plan initiated 9/21/2022 reflected R88 had a diagnosis of CHF (Congestive Heart Failure)/Atrial Fibrillation/Aortic Stenosis. The Goal of the care plan was that R88 would not exhibit respiratory distress. Approaches to meet the goal of the care plan included Assess for fluid excess (weight gain, increased blood pressure, full/bounding pulse, jugular vein distention, shortness of breath, moist cough, rales, rhonchi, wheezing, edema, worsening of edema, increased urinary output, nausea/vomiting, liquid stools); Monitor weight, notify MD (physician) and family of significant weight change. Review of a Medication Administration Record (MAR) for the month of September and October 2022 reflected the order Daily Weights to be taken once a morning beginning on 9/23/2022. The MARs indicated staff did not obtain daily weights on 9/24/2022 or 9/29/2022. A daily weight was not obtained on 10/4/2022 due to the resident had already voided and eaten breakfast before staff could take the vital sign. A daily weight was not recorded on 10/5/2022. Review of a Progress Note dated 10/5/2022 at 11:31 AM reflected R88 was c/o (complaining of) not feeling well, some dizziness when open eyes, sob, tachypnea (fast breathing) alternating with periods of apnea (temporary cessation of breathing), 30, bilat (bilateral) lower extremities 4+ pitting edema to just below knees, c/o abdomen feeling bloated, LLL (left lower lobe of the lung) decreased, pulse ox 96% on RA (room air) b/p (blood pressure) 146/90 spoke with (name of physician), ordered stat CBC (complete blood count), BMP (basic metabolic panel), BNP (brain natriuretic peptide) procalcitonin, CXR (chest x-ray) give additional 2 mg bumex (diuretic) x 1 now, increase bumex to 4 mg q (every) am (morning), 2 mg q PM (evening), additional 2 mg given, CXR and labs ordered. During an interview on 10/5/2022 at 12:36 PM, the Director of Nursing (DON) reported that staff should be obtaining daily weights as ordered for R88. Staff may have been alerted to R88's changing condition had a daily weight been obtained.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility failed to ensure interventions were in place as ordered to prevent worsening of contracture's and limitations in Range of Motion for two residents (Resident #2 and Resident #35) reviewed for Range of Motion/Positioning, resulting in the potential for complications and/or avoidable declines. Findings: Resident #2 (R2) Review of a facility Face Sheet reflected R2 originally admitted to the facility in 2017 with diagnoses that included Acute Kidney Failure, muscle weakness, chronic pain and a need for assistance with personal care. Review of a Minimum Data Set (MDS) quarterly assessment indicated R2 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 13/15 and R2 needed extensive assistance from one person for bed mobility, dressing and personal hygiene. R2 was totally dependent on two people for transferring and toilet use and had functional limitations in Range of Motion (ROM) of bilateral upper and lower extremities. Review of the entire Care Plan for R2 did not reflect a care plan was in place for diminished ROM (Range of Motion). A portion of the Care Plan initiated on 3/20/2017 indicated R2 was at risk for skin breakdown/injury related to the use of a left-hand splint. An intervention on the Care Plan initiated on 5/14/2022 reflected that R2 was to wear a left-hand splint ON after breakfast and throughout day, OFF at HS (hour of sleep), monitor skin prior to donning and doffing. During an observation on 10/03/22 at 4:10 PM and following an activity in the dining room, R2 did not have a splint on their left hand. During an observation on 10/04/22 at 11:48 AM R2 did not have the left hand splint in place. Review of a Medication Administration Record (MAR) for the month of October 2022 reflected the order Left hand splint-ON after breakfast and throughout day. Off at HS. The MAR indicated staff did not document the splint was in place as ordered on 10/3/2022 and documented the splint was on as ordered 10/4/2022. Resident #35(R35) Review of a facility Face Sheet indicated that R35 admitted to the facility in 2019 with pertinent diagnosis of postprocedural cerebrovascular infarction (stroke) following cardiac surgery, contraction of the right and left hand and contracture of muscle, multiple sites. Review of a Minimum Data Set (MDS) quarterly assessment dated [DATE] reflected R35 had severely impaired cognitive skills for daily decision making, was totally dependent on two people for activities of daily living and had functional limitations of Range of Motion affecting one side of the upper and lower extremities. Review of the entire Care Plan for R35 did not reflect a care plan was in place specific to her diagnoses of multiple contracture's. A portion of the Care Plan initiated on 1/2/2019 reflected R35 was at risk for skin breakdown and/or injury related to bilateral hand contracture (fingers closing into palm); related to use of palm protector bilateral hands. Interventions included R35 was to have BUE (Bilateral upper extremities) palm protectors on upon rising and off at bedtime and for hygiene. Nursing was to monitor R35's skin integrity upon application and removal of the splints. During an observation and interview on 10/03/22 at 10:27 AM, R35 did not have her palm protectors in place. The Nurse Practitioner (NP) G was asked about R35's contracture's. NP G said she was not sure what staff were doing with her contracted hands and stated, that would be a question for therapy. During an observation on 10/03/22 at 12:24 PM, R35 was up in her recliner chair in room, no palm protectors were in place. During an observation on 10/03/22 at 3:32 PM, R35 did not have palm protectors in place. During an observation on 10/04/22 at 1:17 PM , R35 did not have palm protectors in place. During an interview on 10/04/22 at 1:44 PM, the Director of Rehab (DOR) H reported that donning palm protectors for R35 is possible. DOR H said that facility staff should be reporting when R35 refuses the palm protectors. DOR H stated that if staff were not sure how to place the palm protectors on R35, they should come to therapy staff for assistance and training. During an observation on 10/04/22 at 3:06 PM, R35 did not have palm protectors in place. Review of R35's Medication Administration Record (MAR) for the month of October 2022 reflected the order BUE (bilateral upper extremity) Palm protector-ON upon rising, OFF at HS and for hygiene. Special instructions for the order directed staff to Wash hands with warm compress and then apply lotion prior to donning splints. Assess skin integrity with don/doffing-report concerns to PCP (primary care provider). The MAR indicated staff did not document splints were in place on 10/2/2022 or 10/3/2022 during the day shift. Staff documented the palm protectors were in place on 10/4/2022 despite multiple observations to the contrary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide tube feed care according to best practice guidelines for one resident (Resident #1), out of 2 residents reviewed for tube feed care, resulting in the potential for (a) the administration of spoiled tube feed solution, (b) dehydration, and (c) physician orders to be incorrectly administered. Findings include: Resident #1(R1) Review of a Face Sheet revealed R1 was a [AGE] year old female, last admitted to the facility on [DATE], with pertinent diagnoses of stroke causing paralysis, unresponsiveness and the inability to speak, the inability to take in hydration and nutrition by mouth, and total dependence on staff for all activities of daily living. During an observation on 10/03/22 at 9:30 AM, the tube feed solution for R1 ran at 55 ml/hr (milliliters per hour) and the label on the tube feed bottle read: start date of 10/02/22, no start time was noted on the label and no physician ordered flow rate was noted on the label. The kangaroo flush bag (a bag of fluid used to provide hydration at a specific ordered rate per hour and ran in conjunction with the tube feed solution), did not have any information listed on the bag (resident's name, date and time flush was started, and the physician ordered rate the flush was administered). During an observation on 10/04/22 at 07:56 AM, the tube feed for R1 ran at 55 ml/hr and the kangaroo flush bag ran and did not have any information listed on the bag (resident's name, date and time the flush started, and the physician ordered rate the flush was administered). During an observation on 10/05/22 at 08:07 AM, the tube feed for R1 ran at 55 ml/hr and the kangaroo flush bag was empty. (Resident was not receiving any ordered hydration). During an observation on 10/05/22 at 09:27 AM, the tube feed for R1 ran at 55 ml/hr and the kangaroo flush bag was empty. (Resident was not receiving any ordered hydration). During an interview on 10/05/22 at 11:56 AM Registered Nurse (RN) Q stated that best practice for labeling tube feedings was to label with resident's name, date and time the feed and/or flush was initiated, and the physician ordered rate of flow. Review of all Tube Feed policies and procedures received by the facility revealed no best practice guidelines were included in the policies and procedures related to the labeling of tube feed bottles and flush bags.