**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure toileting and personal care were provided in a dignified manner for R1 who was left exposed and nude on the toilet while facing a window to facility courtyard. The window was not closed for privacy. In addition, the facility failed to ensure dignity was maintained for 1 of 1 resident (R18) who utilized an indwelling catheter. Findings include: R1 R1's quarterly Minimum Data Set (MDS), dated [DATE] identified R1 with intact cognition, impairment of one side for upper extremities and required partial to moderate assistance with toileting and upper body dressing. In addition, R1 had diagnoses of spinal stenosis (narrowed space around the spinal cord causing irritation and compression of the spinal cord), heart failure, and arthritis. During observation on 2/4/25 at 8:08 a.m., R1 was sitting on the toilet naked. R1 was left alone by nursing assistant (NA)-C while NA-C left room to obtain supplies. The bathroom had a shower curtain as a separator between the bathroom and resident's bedroom which was left opened. The window of bedroom faced facility courtyard, and the window blinds were not closed for privacy. R1 faced the courtyard and shrugged, reaching for a small towel to cover her breasts. Trained medication aide (TMA)-A walked into room and saw R1 on the toilet, walked to the window, and closed the blinds to the courtyard. I closed the curtains[blinds] because [R1] was being exposed. I would be super embarrassed. TMA-A stated, I could tell [R1] was uncomfortable. During interview with NA-C on 2/4/25 at 8:13 a.m., NA-C stated she had worked for an agency and that I left the window shade open. I left to get wipes. Yes, I left her on the toilet naked. Also, the window blinds were open enough for anyone outside the window to see inside the room. During interview with R1 on 2/4/25 at 8:20 a.m., R1 stated, there was a curtain. I usually ask to have the blinds closed. It is not a pleasant thing being left alone on the toilet naked and feeling exposed here. R1 stated NA-C was new and was not prepared to assist with bathing. R1 stated, I have given up a lot of my dignity while being here. It does bother me when I am left exposed but don't say anything because it doesn't change. During interview with DON on 2/4/25 at 12:41 p.m., DON stated, That is unacceptable. We want [R1] to be comfortable. I would offer a drape or something to cover her body before leaving the room. During interview with NA-E on 2/4/25 at 1:07 p.m., NA-E stated, I would not leave anyone naked on the toilet and leave the room. I would cover them and shut the blinds for privacy and dignity. I would be very upset if someone did that to me. R18 R18's quarterly (MDS) dated [DATE], identified R18 had moderate cognitive impairment, was dependent on staff for toileting and lower body dressing and had an indwelling catheter (tube to drain urine from the bladder into a collection bag). During observation and interview on 2/3/25 at 6:03 p.m., R26 was in wheelchair while nursing assistant (NA)-A transported him to his room. NA-A wheeled R26 down the hall past another resident and staff member into R26's room. A large urine drainage bag was visible from under R26's wheelchair and was uncovered. NA-A stated he had been assigned to assist R26 from facility's dining room to his bedroom. NA-A stated the drainage bag should be covered and was unable to locate a privacy cover in the residents' room. NA-A stated importance of covering the bag was privacy. During interview with director of nursing (DON) on 2/4/25 at 12:47 p.m., DON stated urine drainage bags, should always be covered. We have dignity covers and pillowcases to cover up the urine drainage bags. Undated facility policy titled Quality of Life-Dignity stated, Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. And Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by: Helping the resident to keep urinary catheter bags covered.

Based on interview and document review, the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) to 1 of 3 residents (R30) reviewed whose Medicare Part A coverage ended and they remained in the facility. Findings include: R30's Notice of Medicare Non-Coverage (CMS-10123) dated 10/22/24, indicated R30's last covered day of Medicare A would be 10/22/24, and was signed by family member (FM)-B on 10/17/24. R30's SNF Beneficiary Protection Notification Review form dated 10/22/24, indicated R30 had not been provided a SNFABN as resident won appeal. R30's Notice of Medicare Non-Coverage (CMS-10123) dated 11/7/24, identified R30's last covered day of Medicare A would be 11/7/24, and was signed by family member (FM)-B on 11/4/24. R30's Census record dated 2/1/25, indicated R30's primary payer source switched from Medicare A to private pay on 11/8/24, and they stayed in the facility until current. R30's medical record was reviewed and did not indicate a SNFABN had been given prior to R30's Medicare Part A coverage ending. During an interview on 2/4/25 at 11:38 a.m., licensed social worker (LSW)-A confirmed she had reviewed R30's medical record and found that a SNFABN had not been given to R30 prior to his Medicare Part A coverage ending. LSW-A stated she oversaw giving SNFABNs to residents and thought it had been missed for R30. A policy regarding SNFABNs was not received.

During observation and interview, the facility failed to ensure 3 of 3 (R14, R19, R149) resident records that contained private, medical, and personal information were not accessible to unauthorized personnel. Findings include: During observation on 2/3/25 at 7:25 p.m., an unattended laptop identified three residents and their care sheet information. The care sheet information contained their names, diagnoses, assistance needs for dressing and showering, oxygen status, diet, toileting, repositioning, and special instructions such as preferences. Two staff walked past the unattended laptop. During interview with nursing assistant (NA)-B on 2/3/25 at 7:29 a.m., NA-B stated, that should not be open for anyone to see. Privacy is why. During interview with NA-A on 2/3/25 at 7:33 p.m., NA-A stated he was responsible for the unattended laptop. NA-A stated unattended laptop contained visible, patient confidentiality [information] and it should not be left open for everyone to see. During interview with Trained Medication Aide (TMA)-A on 2/4/25 at 7:55 a.m., TMA-A pointed to laptop and stated, It has their [resident] information on the screen and people can walk by and look at the information. We always must close the screen for privacy. During interview with director of nursing (DON) on 2/4/25 at 12:39 p.m., DON stated, that should not occur due to a HIPPA (Health Insurance Portability and Accountability Act) violation. Someone could walk by and see the private information. During interview with NA-E on 2/4/25 at 1:07 p.m., NA-E stated, patient information should not be visible to stop [others] from being nosey. Undated facility policy titled HIPAA Privacy Policies and Procedures state all staff and associates act in an appropriate and compliant manner to protect patient information under the HIPAA privacy regulations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure an individualized comprehensive care plan was developed and maintained to ensure appropriate care was provided for 1 of 2 residents (R42) who required staff assistance with activities of daily living (ADLs) including prevention of pressure ulcers and care needs. Findings include: R42's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated R42 had intact cognition. R42 required moderate staff assistance with personal hygiene and oral hygiene, maximum assistance from staff for upper body dressing, and was dependent on staff for bed mobility, sit to lying, lying to sitting on side of bed, footwear, lower body dressing and toileting. MDS indicated no behaviors present or rejection of care exhibited. R42's pertinent diagnoses included: displaced intertrochanteric fracture of right femur (a broken hip bone that has shifted or separated), atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular beating of the heart), Parkinson's disease (a progressive neurodegenerative disorder that affects movement, balance and coordination) and weakness. Section M Skin Conditions indicated R42 was at risk for developing pressure ulcers and had one or more unstaged pressure ulcer at Stage 1 or higher. Furthermore, M0300 Current Number of Unhealed Pressure ulcers at Each Stage under section G; Unstageable-Deep tissues: suspected deep tissue injury in evolution, indicated one unstageable pressure ulcer with suspected deep tissue injury in evolution that was present upon admission/entry or reentry. R42's care plan, printed 2/3/25, indicated the following: - NURSING: The resident has potential for pressure ulcer development r/t [related to] advanced age, pain, weakness, immobility, use of anticoagulant, Foley catheter. Braden = 15 with the following interventions - Administer treatments as ordered and monitor for effectiveness. - Follow facility policies/protocols for the prevention/treatment of skin breakdown. - Obtain and monitor lab/diagnostic work as ordered. Report results to MD [medical doctor] and follow up as indicated. - Staff to assist with routine toileting and skincare for incontinence. - Treat pain as per orders prior to treatment/turning etc. to ensure The resident's comfort. - NURSING: The resident has indwelling Foley [urinary] catheter R/T urinary retention. Foley catheter to be removed on 11/22/24 for voiding trial, he F/U [follow up] with Urology on 12/4/24. - CATHETER: Catheter - Change catheter bag, and cath kit (syringe & basin) once weekly, initial and date new supplies Q [every] Friday. - CATHETER: last changed: (SPECIFY Date). Change catheter (FREQ). (SPECIFY Size) (SPECIFY Type) -CATHETER: The resident has (SPECIFY Size) (SPECIFY Type of Catheter). Position catheter bag and tubing below the level of the bladder and away from entrance room door. - Check tubing for kinks [# TIMES] each shift. -NURSING: The resident has an ADL selfcare and mobility deficits r/t R hip FX S/P IM nailing [right hip fracture after surgical repair], weakness, difficulty in walking, pain, Parkinson's disease, orthostatic hypotension, Foley catheter, precaution for WBAT RLE (weight bearing as tolerated right lower extremity). -TOILET USE: The resident requires is dependent on mechanical stand lift Ax2 [assist of 2] to transfer on/off toilet and dependent on staff to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. He has Foley Catheter, that will be removed on 11/22/24 for voiding trial. He F/U with Urology on 12/4/24. -TRANSFER: The resident requires Mechanical Lift Ax2 with 3rd staff on standby assistance for transfers. R42's care plan lacked identification of history of pressure injury, resident specific interventions for prevention of pressure ulcers, removal of catheter and possible fluctuating ability to transfer. R42's care sheet, printed 2/5/25, identified the following: -Repo[reposition]: Q 2 hours from side to side-encourage [R42] to stay off back, has open area to coccyx -Toilet: Toilet upon waking, after meals, before bed and NOC [night] as tolerated. Wheelchair to Bathroom assist of 2 with walker to toilet -Transfer Method: Assist of 1 with [NAME] for all transfers. R42's care sheet lacked need for air mattress, cushion in wheelchair or other interventions to prevent reoccurrence of deep tissue injury or pressure ulcer. Furthermore, lacked evidence that R42's deep tissue injury/pressure ulcer had healed on coccyx. On 2/03/25 at 2:11 p.m., R42 was observed seated in his wheelchair with a cushion on the chair. R42 stated he had a sore on his bottom, and was unsure when it started but knew he had it at the hospital. R42 indicated the staff were doing wound care on it. R42 stated he was unsure of if it was getting better or worse as he was unable to see it. R42's Order Recap Report, printed 2/4/25, indicated the following order: -1. Cleanse with NS (nasal saline), pat dry 2. Apply skin prep to surrounding tissue and allow to dry. 3. Cover with a foam dressing 4. Change 3x week and PRN (as needed), D/C (discontinue) when healed as needed for DTI [deep tissue injury] sacrum and in the morning every Mon, Wed, Fri with a start stated of 12/16/24 with and end date of 1/14/25. R42's February's Medication Administration and Treatment Record (MAR/TAR), printed 2/5/25, indicated the following: -Complete weekly skin check and bath (according to shower schedule) every day shift every Friday with a progress note with findings R42's January 2025 MAR/TAR, printed 2/5/25, indicated the following: -Complete weekly skin check and bath (according to shower schedule) every day shift every Friday with a progress note with findings -On 1/3/25, 1/17/25, 1/31/25 indicated it was completed by a check mark. -On 1/10/25, the box was left blank -On 1//24/25, the box was marked with a 9 which indicates other/see progress notes R42's January MAR/TAR lacked evidence of wound care order for listed above which was started on 12/16/14, and discontinued on 1/14/25. R42's progress notes, dated 12/16/24 to 2/5/25, revealed the following: -1/31/25 at 11:04 a.m.: skin check completed with no new skin issues. -1/29/25 at 1:03 p.m.: uses the urinal and tolerates well -1/25/25 at 11:05 p.m.: continent of bowel and bladder -1/24/25 at 1:48 p.m.: shower was not done today. -1/23/25 at 9:11 a.m., [R42] scored 22 on Braden, which is not at risk for skin impairment. His appetite is improved and he is much stronger moving more and is able to lift himself off the bed and up off the wheelchair. His continence is improved, though he does wear a brief for dribbling or possible accidents. His skin is intact, incision to rt [right] upper chest healed and steri strips are peeling off. His RT hip incision is healed and no redness noted. His bottom is pink and he still is having barrier cream applied. -1/20/25 at 1:12 p.m.: is voiding well following removal of Foley catheter. -1/19/25 at 12:13 p.m.: continent of bowel and bladder -1/17/25 at 12:29 a.m.: : shower not given today .shower to be done tomorrow. -1/9/25 at 11:02 a.m.: Resident has appointment with Urology today regarding his urinary retention and Foley catheter use. Catheter removed at 0940 [9:40 a.m.,] per order. -12/30/24: [R42] scored 15 on Braden he is at risk for skin breakdown related to his inability to independently move in bed or reposition himself without sliding in bed is not able to lift clear of mattress and chair surfaces. Has redness to bottom/coccyx area and redness to groin which is treated with nystatin powder and Barrier cream to bottom. -12/20/24 at 2:25 p.m.: Coccyx/perineal area MASD [moisture associated skin damage], 1 x 0.5 cm slough appearing area to right gluteal cleft. Foam dressing applied and barrier cream applied. -12/16/24 at 8:02 p.m.: He has an open area to sacrum/coccyx are[a] .he is chairfast and non ambulatory at this time and moves feebly on his own, he will root around in the bed to get off his side to his bed and to move around in bed with friction possible, He scored 12 on his Braden which he is high risk for Skin impairment. At this time there are orders for wound care daily and 3 times weekly .Care Plan updated. R42's progress notes lacked ongoing assessment of pressure ulcer and interventions placed to prevent further development of pressure ulcers. R42's Weekly Wound Tool, dated 12/16/24, identified a suspected deep tissue injury (SDTI) located on sacrum with slough tissue present which was described as 100% thin white slough with a serous scan amount of drainage with no odor measuring at 25 millimeter (mm) in length by 8 mm in width with no tunneling or undermining. The peri-wound (tissue surrounding the wound) was described as red but blanching with defined edges with the treatment (listed above) being started. R42's electronic medical record (EMR) lacked any further weekly wound tool assessment completed. On 2/04/25 at 10:17 a.m., licensed practical nurse (LPN)-B stated she was responsible for the wound assessments. LPN-B stated skin checks are to be completed weekly by nurses on the floor and a progress note entered in the EMR. LPN-B stated if a skin issue was identified, they put it on the 24-hour sheet, let her know along with the clinical coordinators for follow up. LPN-B stated she does a Weekly Wound Tool assessment weekly on residents with wounds which is the expectation. LPN-B stated she does not update the care plan as the care coordinators update the care plan. On 2/05/25 at 10:35 a.m., registered nurse (RN)-C stated if a wound was identified during a skin check, the wound nurse, family and provider would be notified. Furthermore, they would initiate interventions needed. RN-C stated floor nurses did not update the care plan. On 2/05/25 at 10:41 a.m., RN-F stated they did not remember doing any wound cares with R42 since he had returned from the hospital and stated they worked with RN-F numerous times. RN-F stated the only wound that they had known of was a healed incision on his hip. RN-F stated, I was not aware of that one, when asked about a wound on his coccyx when returning from the hospital. RN-F indicated R42 did have some moisture related issues in his groin area but not his coccyx of sacrum. R42 was assessed by RN-F at 10:53 a.m., and did not have a pressure sore on his coccyx. On 2/05/25 at 11:01 a.m., nursing assistant (NA)-F stated nursing assistants got their information from the care plan. NA-F stated they pulled up a document on the computer that pulls resident information from the care plan for their care guide/sheet. NA-F reviewed R42's sheet and stated R42 care sheet indicated that R42 did not have a cushion in wheelchair or air mattress. Furthermore, indicated had an open area to coccyx. On 2/04/25 at 9:28 a.m., LPN-A indicated when any skin issue was noted on a skin assessment, the wound nurse was notified after documenting anything found in a progress note. LPN-A stated they (clinical coordinators) updated the care plan. During a follow up interview on 2/05/25 at 9:55 a.m., LPN-B she was able to review R42's EMR and stated R42's care plan had not been updated to reflect identification of DTSI on 12/16/24. LPN-B stated no wound assessments had been completed except for the initial assessment on 12/16/24, and no progress notes indicated the sacrum wound was monitored. LPN-B stated the progress notes lacked documentation of details of skin assessments the MAR indicated were completed. LPN-B stated the clinical care coordinators updated the care plans. On 2/05/25 at 12:20 p.m., director of nursing (DON) stated she would expect care plans to reflect residents' care. DON reviewed R42's care plan and stated R42's care plan lacked specific interventions for pressure ulcer prevention such as turning and repositioning, type of mattress, history of pressure injury, etc. A facility policy titled Person-centered Care Planning, dated 4/2024, indicated person-centered care plan will be sued by al personnel involved in the care of the resident. Furthermore, comprehensive care plans must be reviewed and revised quarterly and as needed by the interdisciplinary team.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure routine bathing was completed in accordance with identified wishes for 1 of 4 residents (R7) reviewed for activities of daily living (ADLs) and who was dependent on staff for their bathing care. Findings include: R7's quarterly Minimum Data Set (MDS), dated [DATE], identified R7 had severe cognitive impairment but demonstrated no delusional or rejection of care behaviors. Further, the MDS identified R7 was dependent on staff for personal hygiene care. On 2/3/25 at 5:31 p.m., R7 was asked about her baths at the care center. R7 stated aloud, I'm missing those, while making a back and forth motion using her hands. R7 struggled with word-finding but reiterated, when pointedly asked, she was not getting her baths every week adding aloud, Yea [affirm]. R7's care plan, dated 9/16/24, identified R7 had a self-care deficit and needed assistance with ADLs due to weakness and other past medical history or conditions. The plan listed a goal which read, Will be clean and neatly dressed with assistance, along with multiple interventions including, Bathing: Assist X1. The care plan lacked information on how often bathing was scheduled or preferred. On 2/4/25 at 9:41 a.m., nursing assistant (NA)-D was interviewed. NA-D explained they had worked with R7 prior, including for bathing, and stated the staff followed a shower list which was on their internal computer system. NA-D stated R7 was scheduled for a twice-a-week shower and preferred only female caregivers with it. NA-D verified R7 was supposed to be getting a twice weekly shower and stated she (R7) had been scheduled with that for many months now. NA-D stated they always strived to get R7's shower done but added doing so could be more challenging in the Summer months with staffing. NA-D stated all showers or baths would be charted in the medical record and the nurse's do a corresponding skin check but only one of the two days. NA-D stated the care center had recently adjusted to only five NA working on the morning shift and, as a result, there were times when they'd be on the unit by myself and residents would then get only quick bed baths and no showers. NA-D stated if baths or showers weren't completed, they could try to re-schedule them but with the workload, it would be tough adding aloud, We don't have time to do an additional shower. NA-D stated they felt R7 was consistently getting her second evening-shift shower but then expressed aloud, I don't always know if they do it. R7's POC (Point of Care) Response History, dated 2/4/25, identified a 14-day look-back period. The data provided space to record what level of bathing assistance R7 needed (i.e., independent, supervision, dependent) along with a date and time for each episode. The data had two recorded data points, on 1/22/25 and 1/29/25, however, both of these were recorded as, Not applicable. R7's progress notes, dated 1/1/25 to 2/3/25, identified the following note(s) recorded under a label, Nurse's Note. On 1/13/25, R7 was recorded as having received a shower and skin check. R7 was recorded as having 1+ edema to her foot. On 1/20/25, R7 was recorded as having received a shower and skin check. On 1/27/25, R7 was recorded as not having a shower. The note had dictation which read, Shower not completed today. The note lacked any rationale or reason why the shower was not done. The completed progress note(s) and medical record both lacked any further evidence R7 was receiving a twice weekly shower and/or bath as was scheduled per the direct care staff. On 2/4/25 at 2:32 p.m., registered nurse manager (RN)-A was interviewed. RN-A reviewed R7's medical record and verified R7 was scheduled to receive a twice weekly shower. RN-A stated they were unsure why the nurse' charted the shower was not completed on 1/27/25, and verified the NA should be charting all completed showers or baths in the record (i.e., POC). RN-A acknowledged the lack of charting or documentation to show the second shower was being completed and expressed staff typically didn't chart a second skin check note when multiple baths are scheduled. RN-A stated staff had not consistently reported issues with getting showers or baths completed but expressed some days were very challenged with workload and call-ins. RN-A stated they were not personally checking or auditing charting to ensure it was completed but expressed showers and baths should be done and recorded as the lack of them can cause all kinds of skin problems. A provided Standard ADL Protocol, undated, identified a procedure for each respective discipline to complete ADLs. This included for the NA, Offer weekly bath or shower per individual preferences, [NA] to be present during tub bath or shower. The policy lacked information on how completed baths or showers would be recorded or tracked.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to assess potential signs of constipation to determine what, if any, proactive interventions were needed to promote comfort and reduce the risk of complication (i.e., impaction) for 1 of 1 residents (R41) who reported being constipated. Findings include: R41's admission Minimum Data Set (MDS), dated [DATE], identified R41 had intact cognition and demonstrated no delusional thinking during the review period. Further, the MDS identified R41 did not have constipation. On 2/3/25 at 1:51 p.m., R41 was interviewed and stated she had recently moved into the care center from the hospital. R41 stated her bowels were not too good and complained of feeling constipated adding, I get stuffed up a lot. R41 stated staff were aware of this and, when she'd ask, they would give her medication to have a bowel movement. R41 stated she didn't recall anyone ever talking with her about what proactive interventions could be done such as prune juice or fiber supplements. R41 stated she'd be willing to hear what options she had as her usual pattern for a movement was every-other-day. R41's most recent Continence Evaluation, dated 1/9/25, identified a section labeled, Bowel Continence Evaluation, which outlined R41 had no history of bowel incontinence or fecal impaction, and she was able to sense the urge to defecate. The evaluation a subsection labeled, Elimination Assist, had spaces to mark what, if any, assist item (i.e., laxatives, prune juice/fiber) was used. These were all left unchecked and only a single check was placed next to the option, f. None. The evaluation continued and identified R41 remained on antibiotics and had evidence of diverticulitis (inflammation of small pouches [diverticula] that form in the wall of the large intestine). The evaluation concluded with a section labeled, Plan, which placed a checkmark next to the option, h. Other, and outlined R41 was able to participate in a bowel and bladder program with dictation, Usually continent, toilet per her request and PRN [as needed]. R41's elimination care plan, dated 1/15/25, identified R41 had urge incontinence of bladder. The care plan listed multiple interventions including barrier cream as ordered, encourage fluids during the day, laxatives as ordered, and monitor bowel pattern/consistency. The listed interventions were all last implemented or revised on 1/15/25. When interviewed on 2/4/25 at 9:41 a.m., nursing assistant (NA)-D stated they had worked with R41 only a few times but recalled the overnight nurse reporting R41 had been asking for a suppository. NA-D stated they last heard this about a week and a half ago adding they had last helped R41 to the toilet with a bowel movement the same morning the suppository was given. NA-D stated R41's stool then was putty consistency. NA-D stated R41 would, at times, still toilet herself so staff always asked her if she had a bowel movement, too. Further, NA-D stated all bowel movements were charted in the electronic system (i.e., Point Of Care). R41's POC (Point Of Care) Response History, dated 2/4/25, identified a 20-day look back period and listed the consistency staff had recorded for each bowel movement R41 had on their respective shift including: On 1/20/25, R41 had a recorded formed bowel movement. On 1/24/25 (four days later), R41 had two recorded bowel movements with one being labeled, Loose/Diarrhea. On 1/26/25, R41 had two recorded formed bowel movements. On 1/29/25 (three days later), R41 had a formed bowel movement. R41's Medication Administration Record (MAR), dated 1/2025, identified R41's provided and recorded medications for the period. This identified R41 received the following: On 1/23/25, R41 received Biscolax suppository (used for constipation) at 6:08 a.m. and the results were recorded, I [ineffective]. Later, on 1/23/25, R41 was given a dose of Sorbitol (can be used as a laxative) which was recorded, E [effective]. On 1/30/25, R41 received another Biscolax suppository with results listed, E. The MAR lacked any ongoing medications to promote regualar bowel movements (i.e., Senna). Further, R41's medical record was reviewed and lacked evidence R41 had been reassessed to determine what, if any, proactive interventions were needed (i.e., medication, prune juice, fiber) to promote more regular bowel movements and reduce the need for ongoing PRN use despite multiple as-needed laxatives being given over the past few weeks. On 2/4/25 at 2:37 p.m., registered nurse manager (RN)-A was interviewed and verified they had reviewed R41's medical record. RN-A explained R41 was mostly independent within her room and could, if she wanted, take herself to the bathroom. RN-A acknowledged R41's charted bowel movements (via POC) had some periods with multiple days between and R41 had been given as-needed laxatives. RN-A stated a comprehensive assessment of R41's bowel patterns and needs would be done initially [by] the floor nurse. RN-A stated they had just spoke with the nurse prior who was going to be looking into that [R41's bowels]. RN-A stated any re-assessment would be in the progress notes or on a subsequently completed Continence Evaluation, however, expressed the new charting system was more limited on spacing to record items such as interventions or dictation. RN-A stated nobody had reported any concerns to them about R41's bowels or potential constipation and expressed it was important to ensure it was evaluated as constipation could cause a lot of health issues. A facility' provided Protocol For Bowel Management, undated, listed a purpose to ensure each resident had a bowel movement at least every 72 hours (three days). A procedure was listed which outlined how as-needed medications would be provided and listed, Should the same resident require nursing intervention for bowel evacuation 3 or more times in one month, the nurse will inform the resident's primary physician. However, the policy lacked direction on how a comprehensive bowel management program would be assessed or documented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, facility failed to provide 2 of 2 residents (R5, R37) with care consistent with professional standards of practice to prevent pressure ulcers (localized damage to the skin and underlying soft tissue) who were identified as risk for pressure ulcers/pressure injuries. Findings include: R5 R5's annual Minimum Data Set (MDS) dated [DATE] identified R5 with intact cognition, was dependent on staff for all toileting, bathing, and dressing and did not reject care. In addition, R5 was identified as at risk of developing a pressure ulcer/pressure injury. R5's electronic medical record (EMR) nursing assistant task form titled TRANSFER: SELF PERFORMANCE-How resident moves between surfaces including to or from: bed, chair, wheelchair, standing position (excludes to/from bath/toilet) and documented from 1/22/25, to 2/4/25, identified R5 as requiring, TOTAL DEPENDENCE-Full staff performance. R5's EMR nursing assistant task for titled, BED MOBILITY: SUPPORT PROVIDED-How resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture and documented from 1/22/25, to 2/4/25, identified R5 as requiring One person physical assist. R5's nursing assistant care sheet identified R5 as requiring Repo[repositioning]: Q 2 hours and PRN-AVOID lying on RT side. During observation on 2/3/25 at 2:47 p.m., R5 lying in bed on her back watching television. During observation and interview with R5 on 2/3/25 at 5:44 p.m., R5 laying in bed on her back watching television. R5 stated, I don't recall when they asked me to turn or get off my back. It hasn't been since lunch time today. I am pretty stiff. During observation and interview with R5 on 2/3/25 at 7:20 p.m., R5 lying on bed on her back. They don't move or turn me. Haven't done it all day. They don't even ask me. During interview with nursing assistant (NA)-A on 2/3/25 at 7:26 p.m., NA-A stated he was R5's nursing assistant for the evening shift from 2:30 p.m. to 11:00 p.m., I don't know when [R5] was last turned. NA-A stated [R5] can get pressure sores so she needs to turn. NA-A stated expectation of nursing assistants to follow the nursing assistant care sheet to inform them of what the residents require with cares including turning and repositioning. NA-A stated expectation of nursing assistants to document cares and refusals in the EMR under Tasks. During interview with licensed practical nurse (LPN)-A on 2/4/25 at 8:27 a.m., LPN-A stated she was familiar with R5. LPN-A stated, [R5] moves a little in the bed but not completely. LPN-A stated expectation of nursing assistants to follow the nursing assistant care sheet to inform them of what the residents requires with cares including turning and repositioning. LPN-A stated R5 required assistance to turn and reposition at least every 2-3 hours. LPN-A stated she was not aware of when R5 was turned or repositioned last. R37 R37's quarterly MDS dated [DATE] identified R37 with significant impairment to cognition, impairment to lower extremities, was dependent on staff for all efforts of self-care, had diagnoses of Alzheimer's, dementia, depression, and bipolar and did not reject care. In addition, R37 identified as a risk of developing a pressure ulcer/pressure injury. R5's nursing assistant care sheet identified R37 as requiring Repo: Q 2 hours and PRN. Offer/enc to lay down in bed for at least short period of time after breakfast & lunch bathroom. During observation on 2/3/25 at 1:38 p.m., 2:13 p.m., 2:20 p.m., R37 sleeping on recliner lying on her back. At 5:42 p.m., R37 still sitting in recliner sleeping lying on her back but the lights to the room were turned off. During interview with NA-E on 2/4/25 at 1:07 p.m., NA-E stated expectation of nursing assistants to use the nursing assistant care sheet to inform them of what the residents requires with cares including turning and repositioning. NA-E stated R37 is not on turning repositioning program. Usually, we wait about 2 hours to try to get them [residents] to shift weight because if they are in the same spot too long the skin can break down. Also, we [aides] don't document it anywhere. During interview with registered nurse (RN)-B on 2/5/25 at 12:36 p.m., RN-B stated expectation of staff to reposition residents per care sheet. RN-B stated progress note from nurses should reflect refusals. RN-B verified EMR lacked documentation for both R5 and R37 were turned, repositioned, or provided range of motion exercises. If it is not documented then we cannot be sure that the ROM or turning or repositioning was done. In addition, RN-B stated both R5 and R37 were high risk for skin breakdown if not turned or repositioned regularly. During interview with director of nursing (DON) on 2/4/25 at 10:03 a.m., DON stated expectation of nursing assistants to document in the Task section of EMR on what they do for the resident like turning, toileting, etcetera. During interview with DON on 2/5/25 at 1:57 p.m., DON stated, expectation is we should still be offering to offload[sic] should be documented in progress note for refusals. DON stated, [residents] are dependent on staff for turning and repositioning and transfers. We do not have a system in place to actually see if [residents] are being turned and repositioned every 2-3 hours. DON stated R5 and R37 were considered high risk for pressure ulcers and their EMRs lacked documentation of refusals. Facility policy requested for pressure ulcer prevention and not received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to comprehensively reassess and, if needed, develop proactive interventions to reduce the risk of further falls and injury for 2 of 2 residents (R44, R26) reviewed who had sustained falls at the care center. Findings include: R44 R44's admission Minimum Data Set (MDS), dated [DATE], identified R44 had severe cognitive impairment, demonstrated no behavioral symptoms (i.e., physical, verbal, rejection of care) and required assistance for nearly all activities of daily living (ADLs). Further, the MDS outlined R44 had sustained a fall within the month prior to admission, however, sustained no falls since she admitted to the care center. R44's care plan, revised 12/20/24, identified R44 was at risk for falls with dictation, NURSING: The resident is at risk for falls [related to] weakness, impaired mobility . [as evidenced by] H/O [history of] fall prior to admission. The plan listed a goal which read, The resident will be free of falls through the review date, along with several interventions including anticipating/meeting R44's needs, ensure the call light is within reach, encouraging participation is activities which promote exercise, and ambulating R44 twice daily. The care plan interventions each listed a date implemented and, if applicable, revision. This identified only one revision to a single intervention on 12/20/24, the remainder of interventions being listed as having the same start-date as the problem statement. On 2/3/25 at 3:53 p.m., R44's family member (FM)-A was interviewed. FM-A stated R44 had sustained a few falls since she admitted to the care center from her prior assisted-living setting. FM-A stated they were not sure exactly what, if any, new interventions were being done between the falls. Later, on 2/5/25 at 8:54 a.m., R44 was observed seated in a standard wheelchair which had metallic anti-roll brakes installed. R44 was in the television room by the central nursing station and she appeared calm and responded aloud, Good, when asked about her day so far. R44 was unsure how long she had lived at the care center and responded again aloud, Pretty good. R44's medical record was reviewed which identified R44 had sustained multiple falls since the care plan had last been revised (12/20/24), and these included: R44's progress note, dated 12/23/24 at 11:44 p.m., identified R44 had been found on the floor at 11:20 p.m. when R44 turned on their call light to alert staff. The note outlined, Resident found on floor sitting on buttocks next to her bed. Gripper sock on right foot, left foot bare. R44 denied pain and had confusion per baseline. The note continued, First[,] resident stated she was getting up to use the toilet, then stated she was getting up to get a drink of water. The note identified R44 was assisted to the restroom and provided water, along with a voicemail left for R44's family member and the provider adding, Will continue to monitor. The note lacked any further information on what, if any, future interventions would be done to reduce R44's risk of falls. R44's corresponding incident report titled, #20 Unwitnessed Fall, dated 12/23/24, identified text from the completed progress note and outlined R44 was oriented to person only. The report listed multiple sections to record various data points including pre-disposing factors, environmental factors, and statements from staff about the event. The report included spacing to record what, if any, actions (i.e., interventions) were assessed or implemented after the event; however, this was left blank with no new interventions being listed or rationale for the lack thereof. A subsequent Fall Risk Evaluation, dated 12/26/24, identified R44 scored 19.0 which was labeled, At Risk. The evaluation identified a total of nine (9) questions to be answered by the evaluator including level of consciousness, history of falls, vision status, and medication (changes). However, the completed evaluation lacked information on what, if any, proactive interventions had been assessed or implemented to reduce R44's risk of continued falls. R44's progress note, dated 1/2/25 at 10:30 p.m., identified R44 was again found sitting on the floor. The note outlined, Noted to be sitting on floor next to wheel chair near locked exit door in hallway. No injury noted. Later stated that she wanted to go outside. The note identified R44's family member and provider were contacted. However, again, the note lacked information to identify what, if any, additional interventions were determined or assessed to reduce R44's risk of continued falls and injury. R44's corresponding incident report titled, #23 Unwitnessed Fall, dated 1/2/24, identified text from the completed progress note and the space to record R44's mental status was left blank and not completed. The report placed a checkmark next to a pre-disposing environmental factor of, Other (Describe). However, the report lacked further information on what this factor had been or was. The report, again, listed multiple sections to record various data points but, again, lacked information on what, if any, actions (i.e., interventions) were assessed or implemented after the event. A subsequent Fall Risk Evaluation, dated 1/8/24, identified R44 scored 18.0 which was labeled, At Risk. The evaluation, again, identified nine (9) questions to be answered by the evaluator including level of consciousness, history of falls, vision status, and medication (changes). However, the completed evaluation lacked information on what, if any, proactive interventions had been assessed or implemented to reduce R44's risk of continued falls. On 2/5/25 at 10:31 a.m., registered nurse manager (RN)-B was interviewed, and they explained when a fall happens, the floor staff respond and assess them for pain or injury then help them back to a surface. The staff ask the resident several questions, such as what happened, and then document them on the incident reports located in the system's risk management section. The report then is uploaded to the system for others, including management and leadership, to see and update. RN-B stated a Fall Risk Evaluation is also triggered and completed by the floor staff in the record. RN-B stated the report should then be reviewed by the interdisciplinary team (IDT) as soon as possible to help determine what, if any, new ideas or interventions are needed. RN-B then reviewed R44's reports in the system (dated 12/23/24, and 1/2/25), and verified the section labeled, Action, would be where new interventions or rationale would be recorded. RN-B then expressed aloud, I am just going to be honest with you, and stated they were not sure if all R44's fall reports had been brought to IDT for review. RN-B reviewed R44's fall on 12/23/24, and verified it lacked any new interventions being recorded or outlined. RN-B stated the lack of completion with the report could possibly be related to being pulled to the floor so much due to staff call-ins, adding aloud, Often, I don't [get them done]. RN-B stated it was a chore and a struggle to get all assigned things, such as fall reports and admissions, done timely, adding they felt at times new interventions had been done but just not been documented. RN-B verified both of R44's reviewed falls, dated 12/23/24, and 1/2/25, did not have the report completed and lacked documentation to support what, if any, new interventions had been assessed or implemented but reiterated they felt things were discussed but not formally in IDT. RN-B verified they didn't recall reviewing R44's falls with IDT but expressed they recalled adding the wheelchair brakes at some point. RN-B reviewed R44's fall care plan and verified it had not been revised since 12/20/24, despite R44 having two falls since then. RN-B again attributed the lack of updated care plan to being pulled repeatedly to the floor but verified it should be updated with any new interventions adding, We're supposed to review that on a regular basis and update it. RN-B stated it was important to ensure falls were assessed and new interventions developed and recorded as, We want to keep our residents safe. R26 R26's quarterly MDS dated [DATE], indicated R26 had severely impaired cognition and required assistance for nearly all ADLs. The MDS indicated R26 had no falls since the prior MDS assessment. R26's progress note dated 8/11/24 at 1:00 p.m., indicated R26 was found lying on the floor next to his bed and could not communicate to staff what had happened. R26's quarterly fall risk assessment dated [DATE], indicated R26 was at a high risk for falls based on an assessment of factors such as mental state, history of past falls, ambulation status, medications, and predisposing diseases. R26's care plan dated 12/12/24, indicated R26 was at risk for falls related to dementia, heart failure, and a previous stroke. The care plan included multiple fall interventions such as Anti-rollback breaks and a dropped wheelchair seat, encouraging proper footwear, keeping the wheelchair by the bed/recliner when R26 was not using it, encouraging R26 to use a call light to call for assistance, etc. The care plan did not indicate any fall interventions had been added or revised since 9/11/24. R26's Fall Scene Investigation Form dated 1/16/25 at 11:50 p.m., indicated R26 had an unwitnessed fall from his bed. The form included possible environmental factors or causes that staff had assessed such as R26's call light was in reach, bed wheels were locked, glasses were off, and R26 was wearing gripper socks. The form indicated that R26 was unable to account for his fall. The form indicated R26's new/immediate fall interventions that were implemented were a wheelchair placed close to the bed, doing safety checks, and reminding R26 to call for help. The form included a section for IDT Team Review Notes which was left blank. R26's progress note dated 1/17/25 at 12:23 a.m., indicated R26 was found lying on the floor of his room with his bedding partially on the floor. The note indicated that R26 was unable to account for his fall. During an interview on 2/4/25 at 1:12 p.m., RN-F stated she was R26's and R44's nurse today. RN-F stated she was unsure if either resident had fallen recently but if they had she would expect these new fall interventions to be put on their care plan as that is how they communicate changes from shift to shift. During an interview on 2/5/25 at 12:33 p.m., RN-B stated she thought a fall investigation form had been filled out for R26's fall on 8/11/24, and given to the director of nursing (DON) but was unsure if the fall had been reviewed by IDT. The 8/11/24, fall scene investigation form was requested and not received. RN-B stated after reviewing the 1/17/25, Fall Scene Investigation Form, she did not think IDT had reviewed the fall as that part of the form was left blank. RN-B stated the expectation was that R26's care plan and nursing assistant care sheet be updated to reflect each fall and new interventions and that was not completed for R26. A facility' provided Accident: Managing Resident Falls policy, reviewed 4/2024, identified the center would evaluate and analyze hazards and/or risks for potential resident' falls on admission, quarterly and as needed. The policy outlined, The IDT will monitor for accidents and recommend modifications to improve accident interventions. A section labeled, Resident Fall Guideline, listed a procedure for a fall including providing first aid (if needed) and documenting it within the medical record. The policy directed, IDT will review all falls including the fall scene investigation form and immediate interventions implemented. Interventions may be changed or added to further reduce the risk of additional falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to comprehensively assess for entrapment risk and attempt alternatives before installation of grab bars for 1 of 3 residents (R15) reviewed who were observed to have grab bars affixed to their beds. Findings include: R15's quarterly Minimum Data Set (MDS) dated [DATE], indicated that R15 had moderately impaired cognition and required substantial assistance with transferring out of bed. The MDS indicated in section, P0100. Physical Restraints, that R15 had bed rails that were used as restraints daily. R15's Grab Bar assessment dated [DATE], indicated the assessment was done on the resident's admission to the facility, and bilateral grab bars were used to assist the resident with moving side to side. The assessment included a section Identify alternative methods/products attempted prior to the use of grab bars which was left blank. The assessment indicated the risks and benefits of grab bar use had been explained to R15/her representative and consent was received. R15's order summary dated 8/5/24, included an order for bilateral mobility bars on the bed for turning, repositioning, and bed mobility. The medical record was reviewed and did not indicate appropriate alternatives to grab bars had been attempted before installation and how these alternatives failed to meet the R15's needs. The medical record also did not indicate R15 had been reviewed for risk factors for possible entrapment such as medical diagnosis, medications, cognition, or fall risk when considering grab bar use. During an interview and observation on 2/4/25 at 9:59 a.m., R15 stated she used the grab bars to pull herself out of bed and confirmed she didn't feel they were restrictive or stopped her from moving in any way. Bilateral grab bars were observed affixed to R15's bed. During an interview on 2/4/25 at 1:55 p.m., registered nurse (RN)-B, the unit manager, stated grab bars had been applied to R15's bed on admission and they had not attempted alternatives due to the resident's weight and R15 requiring two staff members to turn in bed. At 2:54 p.m., RN-B stated she had reviewed R15's medical record and found that the risk for entrapment associated with grab bar use had been reviewed with R15 when consent was received but she did not find that individualized entrapment risk factors had been reviewed for R15's grab bar use. RN-B stated that R15's history of right-sided weakness and being at risk for falls could make her a greater risk for entrapment but did not see that these had been assessed as entrapment risks. During an interview on 2/05/25 at 12:28 p.m., director of nursing (DON) stated a nursing assessment was completed to determine if a bedrail was appropriate for a resident prior to be applied along with a reviewing a pamphlet that reviews risks involved with the resident and/or family. DON stated the resident was assessed annually and if there was a significant change with the resident. The Bed Rail Use policy dated 4/24, indicated upon admission, readmission, or change of condition, residents will be screened to determine the need for special equipment or accessories (side rails, for example.) Staff will assess the resident to identify appropriate alternatives and assess for risk of entrapment, review the risks and benefits with the resident and representative, obtain informed consent, and obtain a physician order, before installing bed rails.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure use of an as-needed (i.e., PRN) psychotropic medication was limited to a 14-day period and/or re-evaluated by the provider to ensure ongoing need and efficacy of the medication for 1 of 5 residents (R44) reviewed for unnecessary medication use. Findings include: R44's admission Minimum Data Set (MDS), dated [DATE], identified R44 had severe cognitive impairment but demonstrated no behavioral symptoms (i.e., physical, verbal, rejection of care). Further, the MDS identified R44 had depression, anxiety disorder, but consumed only anti-depressant medication (i.e., high-risk medication) during the review period. On 2/5/25 at 8:54 a.m., R44 was observed seated in a standard wheelchair in the television room by the central nursing station. R44 appeared calm and responded aloud, Good, when asked about her day so far. R44 was unsure how long she had lived at the care center and responded again aloud, Pretty good. R44 had no obvious physical symptoms of anxiety at this time (i.e., crying, worried expression). R44's Ridgeview Home Health Hospice Orders For Facility, dated 1/13/25, identified R44's name and listed an admitting diagnosis of senile degeneration of the brain. R44 was listed as being admitted to hospice the same day (1/13/25), and included a section labeled, Above orders per hospice, with two orders written below this. These included an order for morphine as needed and, 2 [circled] Ativan [an anti-anxiety medication . every 4 hours as needed for anxiety. Update hospice if ineffective. However, the completed order lacked any identified stop date for the medication. R44's Medication Administration Record (MAR), dated 1/2025 and 2/2025, respectively, were reviewed and identified the transcribed order for the PRN Ativan (ordered 1/13/25). R44 was recorded as receiving the medication two (2) times with doses recorded on 1/13/25 at 3:24 p.m., and the other on 1/17/25 at 12:03 p.m. For both administrations, the results were recorded as effective. R44's corresponding progress note, dated 1/13/25 at 3:24 p.m., identified the medication was provided and listed rationale, Crying and very agitated. The note lacked what, if any, non-pharmacological interventions had been attempted prior to the medication being give. R44's other corresponding progress note, dated 1/17/25 at 12:03 p.m., identified the medication was provided and listed no rationale or record information on why the medication was provided; nor any information on what, if any, non-pharmacological interventions were attempted prior. R44's care plan, dated 1/31/25, identified R44 consumed anti-anxiety medication and wrote out, NURSING: The resident uses anti-anxiety medications (lorazepam [Ativan] PRN per hospice order) r/t [related to] Anxiety. The care plan directed to administer the medication as ordered, monitor for effectiveness or side effects, and monitor and record occurrence for target behaviors and document per protocol. On 2/5/25 at 8:59 a.m., registered nurse (RN)-F was interviewed and reviewed R44's medical record. RN-F explained R44 had most cares completed by the nursing assistant (NA) staff and needed help with most activities of daily living (ADLs). RN-F verified R44 was on hospice care and explained R44 used to cry a lot and, as a result, they had recently increased her anti-depressant medication and she seems to be better. RN-F denied ever seeing physical or verbal behaviors from R44 and reiterated she just used to have just like sad statements. RN-F verified R44 had an active order for PRN Ativan and expressed many people on hospice have the same order. RN-F stated the ordered PRN Ativan typically had a date listed when it drops off [stop date] and then it should be renewed by the provider. However, RN-F verified R44's current order for PRN Ativan lacked a stop date and remained active. RN-F reviewed R44's signed hospice order (dated 1/13/25) and verified they had co-signed it but did not request a stop date adding, I should have probably checked for an end-date. RN-F reviewed R44's medical record and verified it lacked evidence of a stop-date being identified, nor evidence the provider had reviewed it since the medication had been ordered on 1/13/25 (over 14 days prior). When interviewed on 2/5/25 at 10:01 a.m., the consulting pharmacist (CP) verified they had reviewed R44's medical record and it had lacked a stop-date until that day when they obtained a six month extension of the medication. CP stated they were working with hospice providers to ensure stop-dates get listed and verified the medication needed a 14-day re-evaluation without a stop-date established. CP stated the order for the PRN Ativan happened between their reviews of R44's medications so they were not aware of it. On 2/5/25 at 10:55 a.m., registered nurse manager (RN)-B was interviewed. RN-B stated the hospice agency should be ensuring a stop-date is listed, however, there had been some examples where it didn't happen and then they (hospice) wanted the care center's provider to write out a stop date which RN-B stated their provider doesn't like that. RN-B verified the PRN Ativan should have had a two week stop date or been re-evaluated. RN-B stated it was important to ensure this happened as we don't want a gap in their medications and patient could suffer if the re-evaluation wasn't completed timely. A facility' policy on PRN psychotropic medication use was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure recommended pneumococcal vaccinations, as outlined by the Centers for Disease Control (CDC), were offered and/or provided in a timely manner to reduce the risk of severe disease for 1 of 5 residents (R37) reviewed for immunizations. Findings include: A CDC Pneumococcal Vaccine Timing for Adults feature, dated 3/2023, identified several tables with corresponding recommendations when to receive various versions (i.e., PPSV23, PCV13, PCV20) of the pneumococcal vaccine. The graph labeled, Adults [at or older than] [AGE] years old, outlined persons with a complete series of pneumococcal vaccination (i.e., PCV13 at any age, PPSV23 at or above [AGE] years old) should have shared clinical decision-making between the resident and healthcare provider to determine if PCV20 was appropriate. R37's quarterly Minimum Data Set (MDS), dated [DATE], identified R37 admitted to the care center in August 2024, and had several medical conditions including dementia and high blood pressure. R37's electronic medical record (EMR) was reviewed which identified a section labeled, Immunizations, along with R37's received immunizations or, if applicable, their refusal. This identified R37 as being [AGE] years old and having had received the PCV13 in 12/2017, and the PPSV23 in 3/2019 (over five years prior). However, it lacked evidence R37 had been offered or received the PCV20 as recommended by the CDC. On 2/4/25 at 12:58 p.m., a telephone call was placed to R37's family member to discuss what, if any, discussion the care center had with them about R37's immunization using PCV20. A message was left, however, a return call was not received. R37's medical record was reviewed and lacked evidence R37 or their representative had been offered or provided the PCV20 vaccination despite being admitted to the care center multiple months prior. On 2/5/25 at 10:25 a.m., licensed practical nurse (LPN)-B was interviewed. LPN-B verified they were the campus' infection preventionist (IP) and had reviewed R37's medical record. LPN-B stated R37 had not yet received the PCV20 and expressed her family member always likes to sign the paperwork so there was not a signed consent or refusal to show. LPN-B stated they last spoke with R37's family member back in December 2024 about another vaccine series (i.e., RSV), however, at that time LPN-B did not have the PCV20 form for them to sign so, as a result, it had not been done. LPN-B stated they recalled R37's family member did not want R37 to get the vaccine, however, acknowledged the record lacked any documentation to support that conversation had happened. LPN-B verified all listed immunizations on R37's EMR were correct and current and expressed they would follow-up with R37's family member soon, adding, I will make it a point to meet up with [them]. Further, LPN-B stated part of the reason for the delay in follow-up was possibly due to themselves repeatedly being pulled to work on the floor due to call-ins and other reasons adding such was, The way it is now-a-days. However, LPN-B verified R37 should have been offered the vaccination and expressed it was important as pneumonia could be a heft disease process and impair the elderly. A facility provided Pneumococcal Immunization policy, last reviewed 4/2024, identified the care center would offer pneumococcal immunizations in accordance with MDH (Minnesota Department of Health) guidelines. The policy added, The [immunization] will be administered per professional standards of practice and standing orders for administering pneumococcal vaccines to adults, adding further, Document administration in the resident's medical record.

During observation on 2/5/25 at 9:35 a.m., an unattended and unlocked medication cart was observed in the hallway of the unit named, Cardinal Lane. The unattended and unlocked cart was in the hallway against the wall between two resident rooms. During interview with registered nurse (RN)-C on 2/5/25 at 9:37 a.m., RN-C stated, it is unlocked because I forgot to lock it when I walked away. [It is] important to be locked and we have important medications that are deadly in there and we don't want anyone to get into there and take whatever they want. During an interview on 2/05/25 at 12:30 p.m., director of nursing (DON) stated all unattended medications carts should be kept locked at all times, to prevent people from getting into them that shouldn't as it could have ill effects. A facility policy titled Storage and Expiration Dating of Medications and Biologicals, revision date 8/1/24, section 5.3 indicates Facility should ensure 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. Based on observation and interview and policy review, the facility failed to ensure medications were securely stored safely and under direct observation of authorized staff in areas where residents, staff and guests could access medications in 3 of 5 medication carts affecting 3 of 4 units of the facility. Findings include: During observation on 2/03/25 at 7:36 p.m., an unattended and unlocked medication cart was observed outside in the hallway of the unit named, Eagle Lane. The unattended and unlocked cart was in the hallway against the wall between two resident rooms. At 7:40 p.m., registered nurse (RN)-E returned to medication cart. RN-E indicated they left the medication cart unlocked and unattended. RN-E stated a resident was hollering and they went to help them. RN-E stated it unattended medication carts should always be locked so residents couldn't get into it. During a continual observation on 2/05/25 at 11:08 a.m., an unattended and unlocked medication cart was observed in the hallway of the unit named, Bluejay Lane. The cart was placed between the doors of resident rooms. During observation, numerous residents and family members walked past the unattended and unlocked medication cart. At 11:39 a.m., licensed practical nurse (LPN)-B verified the medication cart was unlocked and unattended. LPN-B locked the medication cart. LPN-B state medication carts should be locked at all times when not in use, so resident's do not get in there and overdose and staff don't steal medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure sufficient nursing staff and leadership to meet assessed resident needs and facility processes for 2 of 2 residents (R5, R37) reviewed for pressure ulcer prevention, for R7, R42 reviewed for activities of daily living who were dependent on staff for their care, for R1 who was left exposed and nude on the toilet, and R18 who utilized an indwelling catheter reviewed for dignity. In addition, the facility failed to reassess and implement proactive interventions to reduce the risk of falls and injuries for R26 and R44 who sustained falls at the facility. Additionally, the facility failed to address ongoing staffing and long call light concerns identified during resident council meeting minutes. Also, during survey, one family (FM-A) and four residents (R4, R5, R14, and R33) expressed ongoing concerns with not enough staff and significant wait times for cares. These findings contributed to several associated deficiencies and the lack of sufficient and/or competent staff had the potential to affect all 45 residents within the care center. Findings include: Refer to F550. Based on observation, interview and document review, the facility failed to ensure toileting and personal care were provided in a dignified manner for R1 who was left exposed and nude on the toilet facing window to facility courtyard. The window was not closed for privacy. In addition, the facility failed to ensure dignity was maintained for 1 of 1 resident (R18) who utilized an indwelling catheter. Refer to F656. Based on interview and document review, the facility failed to ensure an individualized comprehensive care plan was developed and maintained to ensure appropriate care was provided for 1 of 2 residents (R42) who required staff assistance with activities of daily living (ADLs) including prevention of pressure ulcers and care needs. Refer to F677. Based on interview and document review, the facility failed to ensure routine bathing was completed in accordance with identified wishes for 1 of 4 residents (R7) reviewed for activities of daily living (ADLs) and who was dependent on staff for their bathing care. Refer to F686. Based on observation, interview and document review, facility failed to provide 2 of 2 residents (R5, R37) with care, consistent with professional standards of practice to prevent pressure ulcers (localized damage to the skin and underlying soft tissue) who were identified as risk for pressure ulcers/pressure injuries. Refer to F689. Based on observation, interview, and document review, the facility failed to comprehensively reassess and, if needed or able, develop proactive interventions to reduce the risk of falls and injury for 2 of 2 residents (R44, R26) reviewed who had sustained falls at the care center. R1 R1's quarterly Minimum Data Set (MDS), dated [DATE] identified R1 with intact cognition, impairment of one side for upper extremities and required partial to moderate assistance with toileting and upper body dressing. In addition, R1 medical diagnoses include spinal stenosis (narrowed space around the spinal cord causing irritation and compression of the spinal cord), heart failure, and arthritis. R4 R4's admission MDS assessment, dated 1/6/25, indicated R4 had moderately impaired cognition. R4 required maximal staff assistance for dressing, bathing, toileting and bed mobility. R4 required moderate staff assistance for transfers and personal hygiene. In addition, R4's medical diagnoses include osteoporosis, seizures, muscle weakness, and history of breast cancer. R5 R5's quarterly Minimum Data Set (MDS) dated [DATE] identified R5 with intact cognition, was dependent on staff for all toileting, bathing, and dressing and did not reject care. In addition, R5 identified as a risk of developing a pressure ulcer/pressure injury. R5's medical diagnoses include bipolar, anxiety, depression, and chronic pain. R7 R7's quarterly MDS, dated [DATE], identified R7 with severe cognitive impairment, was dependent on staff for personal hygiene care and did not reject care. R7's medical diagnoses include stroke, peripheral vascular disease, diabetes, arthritis, aphasia (impairment in speaking), hemiplegia (paralysis on one side of body), and depression. R14 R14's quarterly MDS dated [DATE], identified R14's with intact cognition, was dependent on staff for all toileting and dressing and required substantial assistance with personal hygiene and bathing. In addition, R14 did not reject cares. In addition, R14 medical diagnoses include spinal cord compression, neurogenic bladder, diabetes, arthritis, paraplegia (paralysis on one side of the body), and depression. R18 R18's quarterly MDS dated [DATE] identified R18 with moderate cognitive impairment, was dependent on staff for toileting hygiene and lower body dressing, and did not reject care. In addition, R18 with indwelling catheter (tube to drain urine from bladder to a bag outside of the body). In addition, R18 medical diagnoses include diabetes, peripheral vascular disease, arthritis, and depression. R26 R26's quarterly MDS dated [DATE], identified R26 had severely impaired cognition and required assistance for nearly all ADLs. In addition, R26 did not reject cares. In addition, R26 medical diagnoses include dementia, heart failure, kidney disease, diabetes, aphasia (difficulty speaking), seizures, anxiety and depression. R33 R33's admission MDS dated [DATE] identified R33 with intact cognition, required substantial assistance with dressing, bathing, and mobility such as rolling from side to side in bed, lying to sitting, sitting to stand and transferring from bed to chair. In addition, R33 did not reject cares. R33's medical diagnoses include hip fracture, and Parkinson's Disease. R37 R37's quarterly MDS dated [DATE] identified R37 with significant impairment to cognition, impairment to lower extremities, was dependent on staff for all efforts of self-care. Also, R37 identified as a risk of developing a pressure ulcer/pressure injury. In addition, R37's medical diagnoses include Alzheimer's, dementia, depression, and bipolar and did not reject care. R42 R42's Significant change in status MDS dated [DATE] identified intact cognition, no impairment in upper and lower extremity range of movements, was dependent on staff for mobility, toileting, and lower body dressing and required assistance with personal hygiene. R42's medical diagnoses include hip fracture, coronary artery disease, heart failure, urinary tract infection, and Parkinson's disease. R44 R44's admission Minimum Data Set (MDS), dated [DATE], identified R44 had severe cognitive impairment, demonstrated no behavioral symptoms (i.e., physical, verbal, rejection of care) and required assistance for nearly all activities of daily living (ADLs). In addition, R44's medical diagnoses include dementia, hypertension, kidney disease, anxiety and depression. Resident and family interview: During interview with family member (FM)-A of R44 on 2/3/25 at 3:51 p.m., FM-A stated R44 had sustained a few falls since she admitted to the care center from her prior assisted-living setting, and the falls led him to believe the facility did not have enough staff to provide R44 with adequate supervision. During interview with R4 on 2/3/25 at 5:12 p.m., R4 stated she, feels the facility [sic] understaffed and it takes a long time and sometimes they don't come. R4 expressed frustration as when she admitted to the facility she needed more assistance from staff and wasn't receiving it. During interview with R33 on 2/3/25 at 2:22 p.m., R33 stated she got very frustrated when she put her call light on for staff assistance as it just takes forever. R33 stated she used her call light for staff assistance to get in and out of bed, any transfers, and to go to the bathroom. R33 stated the time of day did not impact how fast the call lights were answered. R33 stated it could take up to an hour for her call light to be answered. R33 stated facility's lack of call light response has caused her to have an accident [incontinent of urine] and added, what if I fall and no one comes for how long? During interview with R5 on 2/3/25 at 2:44 p.m., R5 stated, not enough help to answer call lights. Staff interviews: During interview with trained medication aide (TMA)-A on 2/4/25 at 7:31 a.m., TMA-A stated I don't feel there is enough staff to meet the needs of the residents. I have twenty-five residents. If aides show up it is four to five aides per morning shift. They recently reduced staffing to 'cut costs' apparently and people have missed showers and answering call lights has been delayed. During interview with licensed practical nurse (LPN)-A on 2/4/25 at 7:46 a.m., LPN-A stated, I have twenty-one residents. They need help today. Normally I have more than that. Some days I don't have time to get my work done. Range of motion exercises (ROM's), sometimes I don't get to it. LPN-A stated they were not surprised if showers weren't done due to staffing. During interview with licensed practical nurse (LPN)-B who was also the facility infection control/wound nurse, stated she was responsible to complete weekly wound assessments and document results in the resident electronic medical record (EMR). LPN-B stated an initial Weekly Wound Tool assessment had been completed for R42's wound on 12/16/24, and should have been completed weekly thereafter until healed. LPN-B stated she was out sick for thirteen days in December (2024) and it fell off my radar. Furthermore, LPN-B stated, I get pulled to the floor a lot. During interview with registered nurse (RN)-B on 2/5/25 at 12:36 p.m., RN-B stated, Staffing is always a concern here. If we have five aides working on a shift and three are agency aides, then the two facility aides have to chart on all of the residents because we don't allow the agency aides to document. It is too much. Also, RN-B stated, due to staffing, the range of motion exercises and other personal cares won't be done. RN-B stated she had seen aides in the past have a tendency to leave residents in their beds to eat meals instead of assisting them up out of bed and transporting them to the dining room. During interview with RN-B on 2/5/25 at 10:31 a.m., (RN)-B reviewed R44's fall reports dated 12/23/24, and 1/2/25, and stated, I am just going to be honest with you, and stated she was not sure if all of R44's fall reports had been brought to IDT for review. RN-B reviewed R44's fall on 12/23/24, and verified it lacked any new interventions being recorded or outlined. RN-B stated the lack of completion with the report could possibly be related to being pulled to the floor so much due to staff call-ins adding, Often, I don't [get them done]. RN-B stated it was a chore and a struggle to get all assigned things such as fall reports and admissions done timely, adding they felt, at times, new interventions had been done but just not been documented. During interview with staffing coordinator (SC) on 2/5/25 at 10:09 a.m., SC stated she worked in the position for ten to eleven years. SC stated she directed staff concerns regarding low staffing to the DON. SC stated call lights should be answered within ten to fifteen minutes. No more than fifteen minutes. SC stated she was expected to follow guidance from management to staff nursing assistants with one aide per 10 residents and, it used to be one aide per 8 residents. SC stated she recently was informed that she was responsible for staffing both the skilled nursing facility and the assisted living facility portion of the building. During interview with director of nursing (DON) on 2/5/25 at 10:45 a.m., DON stated expectation of, Call lights are to be answered as soon as the staff are able to answer them. Everybody should answer call lights. Not just one role. Time range acceptable ideally within half an hour to forty-five minutes. Half an hour is common. Things happen and we want to answer them right away. Sometimes we cannot. It is frustrating. DON stated staffing for 2/5/25, was impacted due to a call in from a nurse so the DON had to fill in for the empty shift and administer morning medications and treatments until a nurse from the evening shift agreed to come in early to relieve her. DON stated the facility did not have access to call light logs and did not do call light audits to determine length of time call lights were on. Call lights: During continuous observation and interview on 2/5/25 starting at 9:20 a.m., the call light was illuminated outside room of R14. -At 9:39 a.m., registered nurse (RN)-D stood outside of room and did not answer it. RN-D entered another resident room. -At 9:40 a.m., RN-C walked past the room and entered another resident room. -At 9:41 a.m., Another staff member walked past the room. -At 9:43 a.m., RN-C walked to medication cart outside of R14's room and typed into computer and walked away. -At 9:44 a.m., RN-D obtained hand sanitizer from outside R14's room and walked across the hall to another resident room. -At 9:46 a.m., RN-D obtained surgical gloves from medication cart outside R14's room and walked back across the hall to another room. -At 9:46 a.m., a laundry staff person knocked on the door and brought in clean clothes to R14 room and said, Oh I don't do that. Did you get your light on? Staff walked outside of R14 room and saw the illuminated call light on above R14's door. Staff walked back into the room and spoke a few words and walked down the hall toward the nursing station. -At 9:48 a.m., laundry staff entered room again and brought in more clothes. Call light was still illuminated. At this time an activities staff member walked past R14's room. -At 9:50 a.m., RN-D walked past R14's room and entered another resident room. -At 9:51 a.m. nursing assistant (NA)-G walked out of another resident room and obtained an EZ stand from the hall and entered R14's room. NA-G stated, Sorry I didn't know your light was on. During interview with NA-G on 2/5/25 at 10:00 a.m., NA-G stated, I don't know how long it was on. I help with answering call lights. NA-G stated R14 had choir practice in activities. Since we are short staffed, I am working on another unit and part of this one. I have an agency aide with me so this is slowing things down and we can't answer all the lights when we should. There is no one to help us. NA-G stated, I have to prioritize. That was unacceptable for her to wait that long. We are responsible for answering call lights. The nurses can answer but don't really. During interview with R14 on 2/5/25 at 10:02 a.m., R14 stated, my light was on for almost an hour. I need them [staff] to get me up. I can't do it by myself. It is frustrating for me. I am late for my activity and am mad about it. They need more help here to get us all up and ready. During interview with NA-D on 2/5/25 at 10:04 a.m., NA-D stated, we don't have enough to help with this floor so we have to ask for help from other units which takes a long time. The call light times are very long. Resident Council: Review of facility's Resident Council meeting minutes for January 2025, December 2024, October 2024, August 2024 and June 2024 identified concerns were verbalized from residents about inadequate staffing. During interview with resident council member attendees (R1, R13, R20 and R25) on 2/4/25 at 1:12 p.m., R1 stated, on a lane (hall) with only one aide, [we are] bound to wait. It is like Christmas out here when the lights are going. R13 stated, Mornings are bad. Facility has not been responding real well. Nothing has really changed. R1 stated, facility staff[sic] their hands are tied. Management are the ones who call the shots. Facility Assessment: The Facility Assessment (FA) reviewed 10/29/2024, identifies the facility is licensed for 60 beds with an average census of 48. The FA identified 80% of residents are totally dependent on staff for mobility needs and receive skilled nursing level care such as range of motion exercises, transfers, ambulation, dressing, feeding, including bed mobility assistance. The staffing plan includes direct care staff ratios of: -Day Shift: 4-6 nursing assistants with one to two RN or LPN Charge nurse -Evening Shift: 4-6 nursing assistants with one to two RN or LPN Charge nurse -Night shift: 3 nursing assistants with one RN or LPN Charge nurse. No other information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure privacy was maintained for 1 of 2 residents (R146) reviewed for dignity. Findings include: R146's face sheet undated, indicated R146 admitted [DATE] and had diagnoses of nondisplaced intertrochanteric fracture of right femur, unspecified fall, weakness, essential tremor, and depression. R146's baseline care plan observation dated 5/28/24, identified R146 was oriented to person and time and had forgetfulness and intermittent confusion. R146 required assistance of one with bed mobility, toileting, dressing, and grooming/hygiene. R146 transferred with a standing mechanical device with assistance of two and did not walk. R146 had a history of falls with fracture prior to admission and was incontinent of bladder and bowel. R146's paper baseline care plan dated 5/28/24, identified R146 had a foley catheter and occasional, accidental incontinence. During observation on 5/30/24 at 8:59 a.m., nursing assistant (NA)-B uncovered R146, stated R146 had a catheter, and walked out of the room to place on personal protective equipment (PPE). NA-B left R146's personal and shared room door opened, and R146 was seen from the hallway with a shirt, incontinent product, wound dressing on right thigh, and gripper socks. R146 resided on a transitional care unit in which residents were assisted to and from their rooms for meals and therapy. R146 stated they were bare naked and did not like that. During interview on 5/30/24 at 9:25 a.m., NA-B stated they ensured residents' privacy by shutting room doors and keeping residents covered as much as possible throughout cares. NA-B stated some residents were more conservative than others, and they cared for residents based on their preferences to ensure residents were comfortable. NA-B learned about residents and what cares and assistance they required from the care plans and other information on OneNote. NA-B was surprised and stated they should have shut R146's door when they placed on PPE outside the room. During interview on 5/31/24 at 11:03 a.m., NA-G stated they ensured residents' privacy and dignity by closing doors and curtains, giving residents time to complete tasks themselves and assisting with tasks residents needed such as shaving, showering, changing incontinent products. During interview on 5/31/24 at 11:47 a.m., registered nurse (RN)-A stated they provided residents privacy by knocking on residents' door prior to entering, not giving medication during activities or dining without asking the resident first, and assisting lab to find private space to draw blood. During interview on 5/31/24 at 1:50 p.m., RN-B stated staff closed doors or pulled curtains shut to provide privacy for residents during cares. Staff were not to leave residents uncovered with the door open. During interview on 5/31/24 at 5:12 p.m., the director of nursing (DON) expected staff to keep residents covered or have the door closed when residents exposed. DON stated having a resident uncovered with the door open was a dignity issue and did not respect resident's modesty. The facility policy Resident Rights dated 11/16, directed staff to protect and promote the rights of each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure residents were free from accident hazards for 1 of 1 residents (R13) who used a remote-controlled recliner. In addition the faility failed to comprehensively assess resident falls to ensure appropriate interventions were implemented to reduce the risk of falls for 2 of 4 residents (R13, R99) reviewed for falls. Findings include: R13's quarterly Minimum Data Set (MDS) dated [DATE], indicated mild cognitive impairment with no exhibited verbal or physical behaviors, no rejection of care, and no hallucinations or delusions. The MDS also indicated R13 had hemiplegia and hemiparesis (one-sided weakness and immobility) due to a stroke, depression, high blood pressure, and restless leg syndrome. R13's Care Area Assessment (CAA) dated 8/4/23, for functional status indicated he had right-sided weakness from a stroke with decrease range of motion to the affected side. The CAA indicated R13 had reached his baseline and declined restorative programs historically. R13's CAA for falls dated 8/4/23, indicated he had a non-skid pad in his recliner. The CAA reported R13 was dependent on staff assistance for total lift transfer as he was unable to bear weight or stand on his own. A fall risk assessment dated [DATE] indicated R13 was a risk for falls related to his impaired mobility, dementia, weakness and immobility from a stroke, incontinence, and obesity. The assessment indicated R13 had frequent confusion related to his dementia. The assessment identified additional risk factors including his dependence on staff for total lift transfer, medication regimen, toileting hygiene assistance requirement, and reported episodes of dizziness upon standing. The assessment identified an intervention to continue with non-skid on top of soaker pad in recliner. R13's physician orders identified in the fall assessment included the following: - lorazepam (Ativan) 0.25 milligrams (mg) tablet, Give 0.25mg oral three times a day for anxiety, dated 12/16/23. - bupropion hydrochloride (HCl) (Wellbutrin) 100mg tablet, Give 100mg oral three times a day for depression, dated 6/15/23. - lisinopril 20mg tablet, Give 20mg oral once daily in the morning for high blood pressure. - mirtazapine (Remeron) 30mg tablet, Give 30mg oral at bedtime daily for anxiety, dated 6/6/23. - sennosides-docusate sodium (Senna-S) 8.6-50mg tablet, Give 1 tablet as needed for constipation, dated 6/6/23. - sertraline (Zoloft) 100mg tablet; Give 150mg once in the morning for anxiety, dated 6/15/23. R13's care plan last updated 11/3/23, identified he was at risk for falls related to his weakness, poor balance, obesity, history of stroke, swelling, vitamin D and other vitamin deficiencies, and history of falls. The care plan identified interventions of a non-skid mat on top of his recliner, use of a mechanical lift and assist of two staff for transfers, and use of a wheelchair and assist of one staff for locomotion. R13's care plan identified his impaired mobility related to his right-side hemiplegia and hemiparesis from the stroke, obesity, and history of falling. R13's care plan lacked documentation of assessment of his safety with a remote-controlled recliner. An event report for an unwitnessed fall dated 2/11/24, indicated R13 was found by staff laying on the floor in front his recliner in his room. The recliner was found in the max raised position. The event report indicated R13 was alert and conscious with no observed injury. The event report indicated R13 was checked on 30 min prior, call light in reach, remote control for recliner in reach. Was reclined and denied needs/complaints at that time. A fall scene investigation report dated 2/11/24, indicated staff commented it appeared R13 raise the recliner to a vertical position using the remote and slid off onto the floor. The interdisciplinary team (IDT) reviewed the incident and wrote on the report encourage/recommend store remote in pocket of chair. The nursing assistant (NA) care sheet indicated under the Safety/Position header for R13, encourage and recommend to store remote to chair in pocket of chair. A review of R13's electronic health record (EHR) lacked documentation of assessment for his safety to use a remote-controlled recliner, or documentation of discussion of risk versus benefits of having remote-controlled recliner and safety risks involved. During interview on 5/30/24 at 7:46 a.m., R13 was unable to recall being assessed for his safety using the remote-controlled recliner. During interview on 5/31/24 at 9:43 a.m., NA-D stated fall interventions could be found in a resident's care plan and was unsure of what specific fall interventions R13 had in place. NA-D stated R13 did not attempt to self-transfer and was not aware of recent falls for him. During interview on 5/31/24 at 9:53 a.m., licensed practical nurse (LPN)-A stated fall interventions were listed on a resident's care plan and care sheets for NAs. LPN-A stated R13 was off and on for his risk for falls due to his restlessness. LPN-A identified keeping his door open as one way to keep a better eye on R13. LPN-A was not able to identify any specific interventions for R13. During interview on 5/31/24 at 3:07 p.m., registered nurse (RN)-B verbalized being aware of R13's fall from the recliner on 2/11/24. RN-B was unaware of any formal safety assessment for a remote-controlled recliner but stated if an issue was identified, the family and resident might be interviewed to determine their understanding of the issue. RN-B stated if the resident was safe and understood the recliner and the remote control, it may have been care planned and then the remote control should stay in the pocket of the recliner. RN-B stated if safety was a concern and the resident and family still wanted the recliner despite of the safety issues, they would still have that choice and education could be provided on the risks. RN-B stated that would be documented in a progress note. RN-B was unable to locate documentation of safety assessment of R13 and his remote-controlled recliner or documentation of a risk versus benefits conversation. During interview on 5/13/24 at 4:28 p.m., the director of nursing (DON) stated if a resident has a fall, staff were expected to implement immediate interventions to provide for that resident's safety as needed. Falls were discussed during IDT meetings to determine root cause analysis and if further interventions are needed. The DON stated fall interventions are updated on the NA care sheets and on the resident's care plan once they are developed. A safety assessment for R13 and the remote-controlled recliner was requested but not received. A request for a resident risk assessment related to resident equipment was requested but not received. A facility policy titled Accident: Managing Resident Falls policy dated, 8/15/18, included evaluation and analyzing hazards and risks for potential resident falls will occur upon admission, quarterly, annually and as needed. The nursing staff in conjunction with the IDT, resident, and/or resident representative will implement the residents plan of care with interventions to reduce the risk of falls if appropriate. R99's admission Minimum Data Set (MDS) record had not been completed. R99's Clinical admission Documentation dated 5/22/24, included R99 was alert and oriented, took antidepressant medications (which can cause dizziness and drowsiness), required supervision for bed mobility and assist of one staff with transfers and toileting, and indicated R99 did not have a history of falls in the past 6 months. The documentation included R99 had a stroke two months before admission and a diagnosis of weakness. R99's PT (physical therapy) Evaluation and Plan of Treatment dated 5/22/24, included R99 was on fall precautions, and had unknown falls win the past year. R99's baseline care plan dated 5/22/24, included R99 did not have a history of falls, however lacked interventions related to PT evaluation determination of fall risk. R99's medical record lacked documentation of R99's nursing fall risk assessment. A progress note dated 5/26/24, indicate R99 had an unwitnessed fall with head strike and was found on the floor in their room next to the bed after trying to self-transfer from the wheelchair to the bed. R99's Event Report dated 5/26/24, indicated R99 was lifted from the floor using a mechanical lift and assessed for injury. The form included a section labeled INTERVENTIONS - Immediate measures taken which lacked documentation. Further, the section labeled Outcome of interventions was documented as No Interventions Used. R99's Fall Scene Investigation Form dated 5/26/24, outlined the details and some potential contributing factors of the fall, and indicated the care plan was reviewed, however no interventions were added to the care plan. During interview on 5/28/24 at 3:10 p.m., R99 stated they fell two days ago because they tried to self-transfer from the bed to go to the bathroom. R99's family member (FM)-A stated R99 sometimes had poor judgement and decision-making and lacked impulse control, and they weren't sure what kind of interventions the facility put in place to help prevent it from happening again. During interview on 5/31/24 at 10:12 a.m., nursing assistant (NA)-A stated they knew who was at risk for falls by reviewing the care plan, or if therapy informed them. They indicated R99 felt he could do everything and had a fall over the weekend but was not aware of any resident-specific interventions to reduce risk of falls. During interview on 5/31/24 at 10:51 a.m., registered nurse (RN)-A stated clinical coordinators assessed for fall risk at admission and reviewed medications and other risk factors, and then briefed the nursing staff on the results. If a resident fell the nurse assessed the resident for pain, started a fall form, and handed the fall form to the clinical coordinators to review, identify, and document any interventions in the record. During interview on 5/31/24 at 11:06 a.m., registered nurse (RN)-B/clinical coordinator stated they completed the baseline care plan on the day of admission and determined fall risk at that time by asking the resident or the family about their fall history. The official fall risk assessment was completed within seven or eight days after admission with the MDS timing requirements. If a resident fell staff completed a fall form and the interdisciplinary team (IDT) would discuss the fall and the need for any interventions at their next meeting, however immediate interventions were not generally implemented beyond an initial resident condition assessment. Upon review of R99's medial record, RN-B confirmed the facility did not have any initial or additional fall interventions care planned for R99, however it was important to do what they could to decrease risk of falls and injuries. During interview on 5/31/24 at 12:05 p.m., director of nursing (DON) stated the initial falls risk assessment was completed within the first week to 10 days after admission, based on MDS guidelines, otherwise they relied on the therapy evaluation to determine risk. Staff implemented immediate interventions after a fall if the care plan had not been followed or if something needed to be corrected, and if the care plan was not followed staff should report it to the on-call nurse. The staff nurses completed a fall event form and submitted it to the nurse manager, and it would be reviewed at the next IDT meeting which met three days per week. The IDT team would determine what, if any, interventions would be implemented to prevent future falls, and/or, prevent injury. If there was an issue needing immediate correction, such as a maintenance concern or wet floor, it should be dealt with immediately, otherwise, typically, interventions were added when the IDT team met. Upon review of R99's record, DON confirmed they did not see any fall interventions after the PT evaluation on 5/22/24, or any additional interventions after the fall on 5/26/24. The Accident: Managing Resident Falls policy dated 8/15/18, included evaluation and analyzing hazards and risks for potential resident falls will occur upon admission, quarterly, annually and as needed. The nursing staff in conjunction with the IDT, resident, and/or resident representative will implement the residents plan of care with interventions to reduce the risk of falls if appropriate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Findings include: R146's face sheet undated, indicated R146 admitted [DATE] and had diagnoses of nondisplaced intertrochanteric fracture of right femur, unspecified fall, weakness, essential tremor, and depression. R146's baseline care plan observation dated 5/28/24, identified R146 was oriented to person and time and had forgetfulness and intermittent confusion. R146 required assistance of one with bed mobility, toileting, dressing, and grooming/hygiene. R146 transferred with a standing mechanical device with assistance of two and did not walk. R146 had a history of falls with fracture prior to admission and did not use grab bars and was incontinent of bladder and bowel. R146's paper baseline care plan dated 5/28/24, identified R146 used a left and right mobility bar and had a foley catheter and occasional, accidental incontinence. R146's progress note dated 5/29/24, indicated staff reviewed R146's baseline care plan with resident; however, the note lacked evidence of discussion of bed rail risks, benefits, and consent. R146's order started 6/1/24, identified OK to use bilateral mobility bars on bed to assist with turning, repositioning and bed mobility. R146's Physical Therapy PT Evaluation and Plan of Treatment dated 5/28/24, identified an equipment during tasks assessment was added to the document 6/4/24, and R146 was able to safely utilize bilateral mobility bars on bed to allow greater independence with bed mobility; however, the document lacked comprehensive nursing assessment. During observation on 5/30/24 at 8:59 a.m., nursing assistant (NA)-B assisted R146 with changing incontinent brief and repositioning while R146 was in bed. NA-B instructed R146 to turn by using the bed rail and directed R146's hand to the bed rail. During interview on 5/31/24 at 10:51 a.m., registered nurse (RN)-A stated the clinical coordinators assessed residents along with therapy to determine if the application of bedrails was appropriate. The grab bars were then added to the resident care plan. During interview on 5/31/24 at 11:06 a.m., RN-B/clinical coordinator stated they reviewed the residents record upon admission to see if the resident could benefit from grab bars and maintenance applied them. They completed the grab bar observation assessment documentation including risk and benefits, alternatives, and informed consent approximately one week later when the MDS assessments were due and then get an order for the grab bars from the provider. RN-B stated it was important to complete the assessments to prevent possible injuries, including entrapment, and to ensure the family it aware of the potential risks prior to installation. During interview on 5/31/24 at 11:24 a.m., therapy department staff (TS) stated they recommended grab bars when needed, maintenance applied them, and nursing completed the assessments and paperwork. During interview on 5/31/24 at 12:05 p.m., director of nursing (DON) stated therapy will determine the need for bed rails and then staff obtained an order from the provider. Maintenance then installed the grab bars, and the resident was re-evaluated at least quarterly to ensure they were still appropriate. The nurse managers were responsible for discussing risks and benefits with the resident and/or family and obtaining consent for the grab bars and they completed the observation in the electronic record. DON confirmed the observations were often completed several days after the bars were already installed, and they relied on the therapist's recommendation to ensure safety. If nursing or the family requested them, nursing completed the observation/assessment prior to installation. DON stated they did not attempt or document any alternatives prior to use of grab bars, as they were installed to assist in maximizing independence and bed mobility and there were no alternatives. They indicated sometimes the admitting nurse talked with the resident or family and another nurse might have completed the documentation pertaining to the bed rails several days later and would not have knowledge of any discussion which may or may not have taken place at admission, however residents needed to be comprehensively assessed prior to installation to minimize likelihood of injury from the rails. During interview on 5/31/24 at 1:12 p.m., NA-C confirmed R146 had grab bars and stated R146 did not use the bed grab bars during cares and repositioning that morning. During interview on 5/31/24 at 1:45 p.m., RN-B/clinical coordinator confirmed they did not have a nursing assessment for R146's grab bars. Therapy had given an okay for grab bars on the day of R146's admission, and R146's grab bars were noted on the paper baseline care plan. The Bed Rail Use policy dated 10/27/21, included upon admission, readmission, or change of condition, residents will be screened to determine the need for special equipment or accessories (side rails, for example.) Staff will assess the resident to identify appropriate alternatives and assess for risk of entrapment, review the risks and benefits with resident and representative, obtain informed consent, and obtain a physician order, prior to installing bed rails. Staff will update the resident's care plan to reflect the use of the bedrails. Based on observation, interview, and document review, the facility failed to comprehensively assess, discuss risks and benefits, obtain informed consent, and attempt alternatives prior to installation of grab bars for 2 of 2 residents (R96, R146) reviewed who were observed to have grab bars affixed to their beds. Findings include: R96's admission Minimum Data Set (MDS) dated [DATE], indicated they were severely cognitively impaired, required partial/moderate assistance with bed mobility and transfers, and had diagnoses of fractures, heart failure, and anxiety. The MDS indicated R96 did not use a bed rail. R96's admission Observation Detail Report dated 5/7/24, included R96 required extensive assistance of one staff for transfers, was occasionally incontinent of bladder and bowel, had a fall in the previous 31-180 days, and did not use bed rails. R96's progress note dated 5/7/24, indicated staff completed admission paperwork with R96's family member and power of attorney, however, the note lacked evidence of discussion of bed rail risks, benefits, and consent. R96's Physical Therapy PT Evaluation and Plan of Treatment dated 5/8/24, included R96 was able to safely use bilateral mobility bars on bed to allow greater bed mobility, however, the document lacked comprehensive nursing assessment. R96's care plan dated 5/8/24, included R96 was at risk for falls and had bilateral grab bars on the bed to aid in turning, repositioning, and bed mobility per physical therapy recommendation. R96's admission Fall Risk Screen dated 5/14/24, indicated R96 was at risk for falls and fell on 4/30/24, and had another fall the month prior. R96's progress note dated 5/14/24 at 11:17 p.m., indicated R96 was found on the floor with bleeding from one side of their head and sent to the hospital for evaluation. R96's Orders printed 5/30/24, included OK to use bilateral mobility bars on bed for turning, repositioning, and bed mobility starting 5/24/24. R96's medical record lacked evidence of comprehensive nursing assessment, discussion of risks/benefits, alternatives, and consent for bedrails prior to installation. During observation on 5/28/24 at 4:32 p.m., R96 was seated in their wheelchair in their room and had a large bruise on the right side of their cheek and forehead. Grab bars were affixed to both side of R96's bed. During observation on 5/31/24 at 10:00 a.m., R96's bed had grab bars affixed to both side of the bed as before. During interview on 5/31/24 at 10:12 a.m., nursing assistant (NA)-A stated R96 was confused and unable to use the bed rails to turn themselves, however, could use them to steady themselves during cares. During interview on 5/31/24 at 10:51 a.m., registered nurse (RN)-A stated the clinical coordinators assessed residents along with therapy to determine if the application of bedrails was appropriate. The grab bars were then added to the resident care plan. During interview on 5/31/24 at 11:06 a.m., RN-B / clinical coordinator stated they reviewed the residents record upon admission to see if the resident could benefit from grab bars and maintenance applied them. They completed the grab bar observation assessment documentation including risk and benefits, alternatives, and informed consent approximately one week later when the MDS assessments were due and then get an order for the grab bars from the provider. Upon review of R96's medical record RN-B stated they were unable to find the safety observation documentation, evidence of risk/benefit education, alternatives, and consent. RN-B confirmed the grab bars were placed on the bed before the required elements were completed, and it was important to complete the assessments to prevent possible injuries, including entrapment, and to ensure the family is aware of the potential risks prior to installation. During interview on 5/31/24 at 11:24 a.m., therapy department staff (TS) stated they recommended grab bars when needed, maintenance applied them, and nursing completed the assessments and paperwork. During interview on 5/31/24 at 12:05 p.m., director of nursing (DON) stated therapy will determine the need for bed rails and then staff obtained an order from the provider. Maintenance then installed the grab bars, and the resident was re-evaluated at least quarterly to ensure they were still appropriate. The nurse managers were responsible for discussing risks and benefits with the resident and/or family and obtaining consent for the grab bars and they completed the observation in the electronic record. DON confirmed the observations were often completed several days after the bars were already installed, and they relied on the therapist's recommendation to ensure safety. If nursing or the family requested them, nursing completed the observation/assessment prior to installation. DON stated they did not attempt or document any alternatives prior to use of grab bars, as they were installed to assist in maximizing independence and bed mobility and there were no alternatives. They indicated sometimes the admitting nurse talked with the resident or family and another nurse might have completed the documentation pertaining to the bed rails several days later and would not have knowledge of any discussion which may or may not have taken place at admission, however residents needed to be comprehensively assessed prior to installation to minimize likelihood of injury from the rails. The Bed Rail Use policy dated 10/27/21, included upon admission, readmission, or change of condition, residents will be screened to determine the need for special equipment or accessories (side rails, for example.) Staff will assess the resident to identify appropriate alternatives and assess for risk of entrapment, review the risks and benefits with resident and representative, obtain informed consent, and obtain a physician order, prior to installing bed rails. Staff will update the resident's care plan to reflect the use of the bedrails.

Based on observation, interview, and document review, the facility failed to ensure dishware was maintained in a safe and sanitary manner by failing to remove chipped and cracked dishware from use within the facility. Findings include: During interview on 5/31/24 at 7:48 a.m., an unidentified resident stated the facility had a lot of chipped ceramic dishware, including bowls and cups. They stated they had sent them back and let the staff know, it bothered them, and they would not want to use chipped and cracked dishes at home, however the facility had not corrected the concern. During observation on 5/30/24 from 8:05 a.m., - 8:36 a.m., a.m., three bowls containing various amounts of leftover oatmeal were observed on the tables in the dining room after the residents finished breakfast, each with at least one chip in the outer lip of the bowl, exposing the material under the glossy coating. One nursing assistant was assisting a resident to eat oatmeal from another chipped bowl. One additional chipped bowl was in the clean pile to be used for the next resident who requested oatmeal. During observation and interview on 5/30/24 at 12:52 a.m., an unidentified resident was observed eating salad out of a bowl with a crack running from the lip down the inside of the bowl. The resident indicated they were served food in a chipped bowl the previous day as well. During interview on 5/30/24 at 12:52 p.m., dietary aide (DA)-B stated dishes with chips and cracks were thrown away when they were identified during dishwashing or when handling. DA-B was shown the resident's bowl with the crack and stated the staff needed to go through each one to remove those with cracks and chips. DA-B went to the kitchen to inform the dietary manager (DM). During interview on 5/30/24 at 1:04 p.m., DA-A stated when they did dishes, they would remove any broken dishware from service and throw them away, but if there were small chips out of them, they were still usable and placed back in the stack. During interview on 5/30/24 at 1:07 p.m., DM stated staff threw away and dishware when they were chipped or cracked to ensure residents did not get cut, and to ensure they were still able to be sanitized since the exposed area would be porous. During interview on 5/31/24 at 10:38 a.m., administrator stated they expected dishware to be clean and sanitized, with no chips or cracks. Staff should be looking at dishware when putting items in the dishware or on the shelves and discarding any with damage for sanitation purposes and minimize risk of foodborne illness. The Dishware and Glassware policy (undated) indicated chipped or cracked drinking glasses or china are discarded immediately.

Based on interview and document review, the facility failed to implement a Quality Assurance and Performance Improvement (QAPI) plan assuring care and services were identified to maintain acceptable levels of performance and continual improvement, and failed to conduct ongoing quality assessment and assurance activities, develop, and implement appropriate plans of action to correct repeated quality deficiencies identified during the survey the facility was aware of or should have been aware of which had the potential to adversely affect all 50 residents which resided in the facility. Findings include: Refer to F883 During document review, the quality assurance and performance improvement (QAPI) quarterly meeting minutes for 7/26/23, 1/30/24, 4/23/24, all indicate a section titled survey results and plan of correction (POC), with an agenda item, survey between 3/27 - 3/30/23 Results: Issues with Pharmacy Review, PPSC 23/PCV13/ Influenza vaccinations, COVID Vaccine Information Sheets, Vaccination offerings and Policy and TB testing. During an interview with the direction of nursing (DON) on 5/31/24 at 2:48 p.m., she stated the facility held quarterly QAPI meetings but had not developed performance improvement projects and did not have any formal documentation relating to the correction of previously and repeated quality deficiencies. She stated since the organization was under new management, QAPI activities are on hold and waiting for further instruction from new management on processes. A facility plan titled Quality Assurance/ Assessment and Performance Improvement Plan, undated, indicated the quality assurance/ assessment and performance improvement (QAPI) program is to utilize an on-going, data driven, pro-active approach to advance the quality of life and quality of care for all residents at ABC facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review the facility failed to adhere to evidence based practices and assure resident catheter bags & ports were maintained in an appropriately placement for 2 of 2 resident (R7 & R146) whos catheter bags were on the the ground. The facility failed to ensure proper personal protective equipment (PPE) & hand hygiene was used for 2 of 2 residents (R146, R198) when providing care for residents on enhanced barrier precautions (EBP) & contact precautions. Furthermore the facility failed to identify and track potential infections for 1 of 1 resident (R198) reviewed for antibiotics use. Additionally, the facility failed to develop a written policy/procedure of infection surveillance and maintain a policy, procedure or water management plan to reduce the likelihood of Legionella and other serious bacterial diseases, which had the potential to affect all 50 residents. Findings Include: ENHANCED BARRIER, CONTACT PRECAUTIONS AND HAND HYGIENE R198's admission Minimum Data Set (MDS) dated [DATE], indicated impaired cognition. R198's undated face sheet indicated he had diagnoses including history of falls, diarrhea, a stage 3 pressure ulcer (a wound that breaks down skin and underlying tissue) of the sacral (tailbone) region, unspecified stage pressure ulcer to the left buttock, muscle weakness, depression, and anxiety. The face sheet also indicated the resident admitted to the facility on [DATE]. R198's Care Area Assessments (CAA) dated 5/21/24, for activities of daily living (ADLs) and functional status indicated he had a decline in ADL status related to a history of falls prior to his recent admission to the facility and fracture to his right lower extremity. R198's CAA for urinary incontinence for indwelling catheter dated 5/21/24, indicated he had an indwelling catheter related to his inability to void and urinary retention. R198's CAA for pressure ulcer and injury dated 5/21/24, indicated he had the potential for alteration in skin integrity related to his admission diagnosis. The CAA indicated R198 was frequently incontinent of bowel required staff assistance with ADLs and toileting hygiene. The CAA identified R198 had intrinsic risk factors for pressure injury including immobility, cognitive loss, incontinence, and poor nutrition. The CAA deferred to the care plan for further consideration. R198's order summary included the following orders: - Monitor resident for loose watery stools and update provider as needed every shift, dated 5/28/24. - Rest period after breakfast and lunch, side to side positioning only every, dated 5/20/24. - stool culture for Clostridium Difficile (bacteria that can cause inflammation of the colon and severe diarrhea) special instructions: discontinue when collected, every shift, dated 6/1/24. - Apply barrier cream to reddened areas after each dressing change every shift, dated 5/28/24. - Wound clinic referral (sacral ulcer/left gluteal fold), dated 5/20/24. - Treat midline coccyx-right unstageable wound: 1. Wash hands with soap and water prior to changing dressing. Cleanse wound using normal saline and gauze. Pat dry with gauze and gently wipe away any loose drainage or tissue. 2. Apply skin barrier film to wound perimeter and to the site of dressing adhesive and allow to dry prior to placing dressing. 3. Cut Adaptic or similar product and apply a small amount of Medihoney gel. Place Adaptic over wound with the Medihoney gel-side down. 4. Cover wound with a silicone border foam dressing. 5. Change Monday/Wednesday/Friday and as needed, dated 5/30/24. - Treat left ischial tuberosity unstageable wound: 1. Wash hands with soap and water prior to changing dressing. Cleanse wound using normal saline and gauze. Pat dry with gauze and gently wipe away any loose drainage or tissue. 2. Apply skin barrier film to wound perimeter and to the site of dressing adhesive and allow to dry prior to placing dressing. 3. Cut Adaptic or similar product and apply a small amount of Medihoney gel. Place Adaptic over wound with the Medihoney gel-side down. 4. Cover wound with a silicone border foam dressing. 5. Change Monday/Wednesday/Friday and as needed, dated 5/30/24. - Treat left buttock stage 3 wound: 1. Wash hands with soap and water prior to changing dressing. Cleanse wound using normal saline and gauze. Pat dry with gauze and gently wipe away any loose drainage or tissue. 2. Apply skin barrier film to wound perimeter and to the site of dressing adhesive and allow to dry prior to placing dressing. 3. Santyl: Apply a nickel-thick layer of Santyl onto a piece of Adaptic and place into depth of wound with the Santyl-side down. 4. Cover each wound with a silicone border foam dressing. 5. Change Monday/Wednesday/Friday and as needed, dated 6/1/24. R198's orders lacked documentation of enhanced barrier precautions (EBP) or updated transmission-based precautions (TBP). R198's care plan dated 6/3/24, indicated he had impaired skin integrity related to three different wounds on his bottom upon his admission. The care plan identified interventions of monitoring for signs and symptoms of infection daily, treatment per nursing and provider orders, redistribution mattress in bed, wheelchair cushion, and turning and repositioning every two hours while sitting and every two hours while laying. The care plan also identified R198's self-care deficit evidenced by his inability to toilet himself and incontinence of bowel and bladder. The care plan identified R198 required staff assistance with bed mobility, toileting, and transfers. R198's care plan lacked documentation of his indwelling urinary catheter and requirement of enhanced barrier precautions. A progress note dated 5/15/24 indicated R198 was admitted on [DATE] and had, three broken areas to bottom that were present when he arrived. A progress note dated 5/20/24 indicated an indwelling catheter was inserted per orders. A progress note dated 5/28/24 at 2:40 p.m., indicated new orders were received for the antibiotic Keflex and R198's family was updated. A progress note dated 5/28/24 at 10: 46 p.m. (22:46), indicated R198 had multiple soft/mushy stools that evening. The progress note indicated orders were received to monitor for loose/watery stools and update his provider. A progress note dated 5/30/24 at 10:45 p.m. (22:45), indicated after his return from wound clinic appointment, new orders were received to discontinue the Keflex and collect a stool sample to rule out a Clostridium Difficile infection due to R198's continuous loose stools the entire afternoon visit there. The progress note indicated R198 had no stools after he returned to the facility. R198's progress notes lacked documentation of his requirement for enhanced barrier precautions or need for transmission-based precautions. During observation on 5/28/24 at 4:51 p.m., there was no signage on R198's door to indicate he was on enhanced barrier precautions. There was a chair outside of his room with a bag of disposable plastic gowns on the seat. During interview on 5/28/24 at 7:21 p.m., registered nurse (RN)-E stated enhanced barrier precautions were for residents with an opening to the body, like wounds, catheters, or fistulas. RN-E stated a resident who was on EBP should have a sign on the door telling staff what PPE to wear and when, gowns, gloves, and sanitizer available. RN-E also stated the resident's care plan would be updated as well. RN-E stated R198 would meet the criteria for EBP. RN-E verified there was no signage outside his room indicating R198 required EBP and stated, we should definitely get that set up. During observation on 5/29/24 at 2:11 p.m., there was no signage on R198's door indicating R198 was on enhanced barrier precautions. The chair outside his room had a bag of plastic gowns and a box of gloves on the seat. During continuous observation on 5/30/24 between 8:08 a.m. and 9:06 a.m., there was no signage on R198's door indicating he required EBP. The chair outside of his room had a box of gloves and bag of plastic gowns on the seat. At 8:16 a.m., nursing assistant (NA)-E approached R198's door to answer his call light. She performed hand hygiene, donned a gown and gloves, and stated R198 was on contact precautions because of his open wound. NA-E stated staff assisting with cares would need to wear personal protective equipment (PPE) and normally there's a sign on the door that explains what PPE and when staff need to wear it. NA-E gestured to a room across the hall that had an EBP sign on the door. NA-E entered R198's room and introduced self and surveyor and began assisting R198 with morning cares. At 8:33 a.m., licensed practical nurse (LPN)-B knocked on the door and entered the room with PPE in hand and no gown or gloves on. LPN-B set gown and gloves down on the bedside, brought paper towels from the bathroom and set them down on the foot of R198's bed. LPN-B set gloves and container of liquid solution on the paper towels, sanitized hands, and donned gown and gloves. NA-E asked R198 to help turn himself onto his left side and assisted him to turn over. LPN-B gathered wound supply basin from R198's closed closet with gloved hands and moved items on the bedside table. LPN-B doffed gloves in the bathroom and washed hands at the sink before donning new gloves. LPN-B assessed R198 for pain prior to starting wound cares, then removed the sacral dressing, then removed the dressing near thigh/groin. LPN-B doffed gloves, gathered clean supplies over the clean work area, did not perform hand hygiene, and donned new gloves. LPN-B cleansed the wounds from a head-to-toe laterality with the liquid solution and gauze and continued to ask R198's pain level. LPN-B doffed gloves, did not perform hand hygiene, donned new gloves, and measured his sacral wound. Using the same gloved hands, LPN-B cut a piece of foam and packed R198's sacral wound with the cut foam piece. LPN-B continued to wear the same gloves and re-measured the wound before using a pen to write down the measurements. LPN-B put the pen down and used the same gloved hand to remove a new dressing from the package and write the date on the dressing. While writing the date on the dressing, LPN-B's same gloved left thumb touched the inner gauze of the clean dressing. LPN-B applied Medihoney gel to the gauze pad before applying the dressing over R198's sacral wound with the same gloved hands. LPN-B doffed gloves, performed hand hygiene, donned new gloves, and used the liquid solution to clean the thigh/groin wound. LPN-B measured the second wound and continued with the same gloved hands to apply the Medihoney gel to the backside of the clean dressing before applying it to the wound. LPN-B doffed gloves and performed hand hygiene after wound cares were completed and exited the room. At 8:55 a.m., RN-D knocked and entered R198's room to assist with his transfer from bed to the wheelchair. RN-D verbalized hand hygiene was completed prior to entering his room and had on gloves but no gown. RN-D asked NA-E if there was a need for further PPE and NA-E stated there was not. NA-E and RN-D used a mechanical standing lift to assist in R198's transfer out of bed. After he transferred into his wheelchair with the assistance of two staff, RN-D doffed her gloves and performed hand hygiene at the sink in the bathroom and donned new gloves to apply a lidocaine patch (a type of over-the-counter medicated pain patch) to R198's hip. RN-D doffs gloves and performs hand hygiene before exiting his room. During interview at 9:06 a.m., RN-D stated the reasoning for PPE in R198's room is for infection prevention but was unaware of any precautions. RN-D stated, I don't think he's on any precautions, he just has that wound and we wouldn't want to spread whatever might be there. During observation on 5/30/24 at 11:46 a.m., the sign on the door across the hall from R198's room NA-E gestured to read, Providers and Staff Must Also: Wear gloves and a gown for the following high-contact resident care activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use: central line, catheter, feeding tube, tracheostomy, wound care - any skin opening requiring a dressing change. During continuous observation on 5/31/24 between 9:09 a.m. and 9:30 a.m., there was no signage outside R198's door indicating he required transmission-based precautions. The chair outside his room had a box of gloves on the seat. Trained medication assistant (TMA)-A entered his room at 9:17 a.m. without PPE on and exited the room at 9:19 a.m. No hand washing with soap and water was observed. During interview, TMA-A stated no report was received about his appointment the previous day. TMA-A stated R198 was on precautions for his open wounds, which is why TMA-A did not wear any PPE before when entering the room because I was just in there to check on him, I didn't need any PPE. TMA-A stated when applying his lidocaine patch and working closely with him, PPE of gown and gloves would be required. TMA-A stated the precautions were in place to ensure residents are safe from outside infections and to keep staff safe from any infections. TMA-A stated staff should sanitize their hands before going into the room and make sure they perform hand hygiene after performing cares with him. TMA-A re-entered R198's room and exited the room at 9:30 a.m. without performing hand washing with soap and water, walked to the medication cart to return something to the cart, then walked to the soiled utility room to wash hands with soap and water. During interview on 5/30/24 at 12:31 p.m., LPN-B, who also served as the facility's Infection Prevention Manager (IPPM) and wound nurse, stated staff were expected to perform hand hygiene prior to entering a resident's room and should be wearing whatever appropriate PPE is required for wound care. The IPM stated staff were expected to perform hand hygiene between glove changes and staff should change gloves any time they go from dirty to clean, like if staff take a dressing off and after cleaning the wound, staff would be expected to remove gloves and perform hand hygiene before donning new gloves and applying treatments or new dressings. If staff touched something that was not part of the clean supplies, the IPPM stated staff would be expected to change gloves and perform hand hygiene. The IPM stated staff were expected to doff PPE and perform hand hygiene before exiting a resident's room. The IPPM stated R198 was on enhanced barrier precautions because of his wound and catheter and staff were expected to wear appropriate PPE for transfers or boosts in bed. The IPM stated, as soon as you touch the patient, any of those high-contact cares, you should be dressed in PPE. The IPPM stated an in-house educational in-service was provided for staff about EBP. The IPPM verified missed opportunity for hand washing during wound cares when measuring the wounds and packing his wound and applying a new dressing. During interview on 5/31/24 at 9:43 a.m., NA-D verbalized being unaware of any changes to R198's condition. During interview on 5/31/24 at 9:48 a.m., LPN-A stated they were still processing R198's orders from his wound appointment yesterday. LPN-A reviewed his hard chart for the new orders and found the order to discontinue is Keflex. LPN-A stated the clinic called to discontinue that because R198 had loose stools while at the appointment. LPN-A stated R198 was on contact precautions that required gown and gloves for his wound care and his catheter cares. LPN-A stated his precautions have not changed since his appointment. LPN-A stated hand washing should occur before and after wound care and if hands are visibly soiled, LPN-A stated hand sanitizer would be appropriate for other opportunities for hand hygiene when working with R198. During subsequent interview on 5/31/24 at 9:59 a.m., the IPM stated R198 had an order to collect a stool sample and send that out to rule out Clostridium difficile infection and staff still needed to collect the sample to send in. The IPM stated R198 should be on enteric precautions because of this and expected staff to wear gown and gloves according to what the enteric process was. The IPM stated hand washing with soap and water was expected of staff because that is what kills the virus so you have to wash with soap and water. The IPM stated R198 was previously on EBP and expected there to be signage on the door and an isolation or supplies cart outside his room. The IPM verified contact precautions (or enteric precautions) had not been implemented in addition to EBP because I haven't gotten there, but stated the nurse managers and charge nurses were able to set up TBP. The IPM verified at R198's room that there was no signage and no isolation or PPE supplies cart outside his room. A facility policy titled Hand Hygiene Policy and Procedure dated 3/2021, indicated the facility followed current Centers for Disease Control and Prevention (CDC) guidelines for hand hygiene recommendations. The policy indicated handwashing with soap and water was indicated when hands were visibly dirty or were visibly soiled with blood or other bodily fluids, before eating and after using a restroom, after caring for a person with known or suspected infectious diarrhea, and after known or suspected exposure to spores (e.g., B. anthracis, C. difficile outbreaks). Furthermore, the policy indicated hand hygiene with alcohol-based hand sanitizer was indicated before having direct contact with a resident, before inserting indwelling urinary catheters, peripheral vascular catheters, or other invasive devices that do not require a surgical procedure, after contact with a resident's intact skin, after contact with bodily fluids or excretions, mucous membranes, non-intact skin, and wound dressings, only if hands are not visibly soiled, when moving from a contaminated body site to a clean body site during resident care, after contact with inanimate objects (including medical equipment) in the immediate vicinity of a resident, and after removing gloves. An undated facility policy titled Enhanced Barrier Precautions indicated the organization would promote decreased transmission of Centers for Disease Control (CDC)-targeted and epidemiologically important multidrug-resistant organisms (MDRO) by utilizing enhanced barrier precautions (EBP). The policy indicated EBP were used in addition to standard precautions and expanded the use of PPE to donning of gown and gloves during high-contact resident care activities. EBP were indicated for residents with any of the following: infection or colonization with a CDC-targeted MDRO when contact precautions do not otherwise apply or wounds and/or indwelling medical devices even when a resident is known to not be infected or colonized with a MDRO. The policy indicated for residents on EBP, high-contact care activities include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, and wound care. A facility policy titled Contact Precautions (including Enteric) dated 2/2020, indicated employee would use standard/universal precautions in addition to contact precautions for residents/clients known or suspected to have serious illnesses easily transmitted by direct resident/client contact by contact with items in the environment. The policy indicated hand washing should be completed prior to donning gloves, gloves should be worn when entering the room and while providing cares and should be changed after having contact with infective material. The policy indicated gloves should be removed before leaving the resident/client's room and hand washing performed immediately and hands should not touch potentially contaminated environment surfaces or items and should wash hands again after exiting the room. The policy indicated precaution signage for all would be placed on the resident's door/apartment and additional information would be kept in the infection control cart. The policy indicated contact precautions may be considered for Clostridium difficile and diarrhea. During interview on 5/31/24 at 5:12 p.m., the director of nursing (DON) expected staff to wear proper PPE when in close contact with a resident who was on enhanced barrier precautions. Staff who did not wear proper PPE had potential to spread MDROs (multi-drug resistant organisms). R146's face sheet undated, indicated R146 admitted [DATE] and had diagnoses of nondisplaced intertrochanteric fracture of right femur, unspecified fall, weakness, essential tremor, constipation, and depression. R146's baseline care plan observation dated 5/28/24, identified R146 was oriented to person and time and had forgetfulness and intermittent confusion. R146 required assistance of one with bed mobility, toileting, dressing, and grooming/hygiene. R146 transferred with a standing mechanical device with assistance of two and did not walk. R146 had a history of falls with fracture prior to admission and was incontinent of bladder and bowel and did not indicate EBP. R146's paper baseline care plan dated 5/28/24, identified R146 had a foley catheter and occasional, accidental incontinence and did not indicate EBP. R146's progress note dated 5/30/24 at 10:36 p.m., identified R146's foley catheter was discontinued. During observation on 5/29/24 at 2:41 p.m., R146 had a sign which indicated R146 was on enhanced barrier precautions and directed providers and staff to wear gloves and gown during high-contact resident care activities such as transferring, providing hygiene, changing briefs, wound care (any skin opening requiring a dressing). During observation on 5/30/24 at 8:59 a.m., NA-B had gown and gloves on to assist R146 with peri-cares and placed a clean incontinent brief on R146. NA-B removed the gloves used for peri-cares and used hand sanitizer. Unidentified staff entered R146's room with gown and gloves, and NA-B and unidentified staff boosted R146 up in bed while NA-B was not wearing new gloves NA-B adjusted R146 to eat breakfast in bed, exited the room with gown on, dropped an item off at the cart with breakfast trays, and went into the utility room about halfway down the hallway. NA-B removed the gown in the utility room and washed hands. During interview on 5/30/24 at 9:25 a.m., NA-B stated staff needed to use gown and gloves when residents have catheters, open wounds, and ostomy bags to keep residents safe. NA-B stated staff did not need to wear gowns and gloves when giving residents water or medication but needed gown and gloves to assist residents with transfers, personal cares, and anytime close to residents for extended time. NA-B stated they should have had gloves on when they repositioned R146 and slipped their mind. During interview on 5/30/24 at 12:31 p.m., infection prevention manager (IPPM) expected to wear appropriate PPE for transfers or boosts in bed for residents who had enhanced barrier precautions. IPPM stated, as soon as you touch the patient, any of those high-contact cares, you should be dressed in PPE. The IPPM stated an in-house educational in-service was provided for staff about EBP. During interview on 5/31/24 at 11:49 a.m., registered nurse (RN)-A stated staff wore gown and gloves during direct cares and when in residents' personal space for residents on enhanced barrier precautions. RN-A consulted the sign on residents' doors for directions on PPE. During interview on 5/31/24 at 5:12 p.m., the director of nursing (DON) expected staff to wear gloves when boosting a resident who had enhanced barrier precautions. Staff had close contact to resident and their bed linen and clothing and had potential to spread MDROs (multi-drug resistant organisms). An undated facility policy titled Enhanced Barrier Precautions indicated the organization would promote decreased transmission of Centers for Disease Control (CDC)-targeted and epidemiologically important multidrug-resistant organisms (MDRO) by utilizing enhanced barrier precautions (EBP). The policy indicated EBP were used in addition to standard precautions and expanded the use of PPE to donning of gown and gloves during high-contact resident care activities. EBP were indicated for residents with any of the following: infection or colonization with a CDC-targeted MDRO when contact precautions do not otherwise apply or wounds and/or indwelling medical devices even when a resident is known to not be infected or colonized with a MDRO. The policy indicated for residents on EBP, high-contact care activities include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, and wound care. ILLNESS TRACKING R198's face sheet undated, indicated R198 had diagnoses which included diarrhea, a stage 3 pressure ulcer (a wound that breaks down skin and underlying tissue) of the sacral (tailbone) region, unspecified stage pressure ulcer to the left buttock, muscle weakness, depression, and anxiety. The face sheet also indicated the resident admitted to the facility on [DATE]. R198's face sheet did not indicate infectious disease diagnoses. R198's order summary included the following orders: - amoxicillin-pot clavulanate (Augmentin) 875-125 mg twice a day 5/15/24 to 5/22/24. - cephalexin 500 mg twice a day 5/28/24 to 5/30/24. - Monitor resident for loose watery stools and update provider as needed every shift, dated 5/28/24. - stool culture for Clostridium difficile (bacteria that can cause inflammation of the colon and severe diarrhea, often due to antibiotic use) special instructions: discontinue when collected, every shift, dated 6/1/24. - Wound clinic referral (sacral ulcer/left gluteal fold), dated 5/20/24. R198's orders did not indicate transmission-based precautions. R198's medication administration record (MAR) indicated the following: - vital signs were monitored 5/15/24, 5/16/24, 5/19/24, and 5/26/24 and temperature 5/15/24 to 5/29/24. - monitor resident for potential allergic reaction while resident on cephalexin due to penicillin allergy with start day of 5/28/2024 until discontinued on 5/30/24. - wound care at least daily or twice a day since admission. R198's medication administration record (MAR) included the following regarding the order to monitor loose stools: - soft stools on evening shift of 5/28/24 and day shift of 5/31/24. - loose stools on day and evening shift of 5/29/24. R198's progress notes included the following: - 5/15/24 to 5/22/24 notes described the wounds as foul odor a couple times. Loose stools were not mentioned. - 5/28/24 at 10:46 p.m., R198 had multiple soft/mushy stools causing dressing to become soiled. Stool consistency was reported to nurse practitioner and order for Imodium given and to monitor resident for loose/watery stools and update nurse practitioner as needed. The Imodium was given once in the evening and results were somewhat effective. - 5/30/24 at 10:45 p.m., indicated R198 was seen by wound clinic and provided with orders to discontinue Keflex and send stool specimen for culture for Clostridium difficile. Clinic stated R198 had continuous loose stools the entire afternoon visit at the clinic. R198's progress notes did not indicate transmission-based precautions. R198's bowel movement documentation indicated R198 had loose bowel movements 5/20, 5/21, 5/22, 5/28, 5/29 and soft/formed bowel movements 5/18, 5/20, 5/29 and other dates did not indicate bowel movement consistency or no bowel movements documented. R198's wound/ostomy progress note dated 5/30/24, indicated R198 had watery stool with a sweet odor and no signs or symptoms of infection. During interview on 5/30/24 at 12:37 p.m., infection prevention manager (IPPM) acknowledged R198's orders for Imodium for loose and watery stools with increased incontinence. During observation on 5/31/24 at between 9:09 a.m. and 9:30 a.m., there was no signage outside R198's door indicating R198 required transmission-based precautions. The chair outside his room had a box of gloves on the seat. During interview, TMA-A stated no report was received about his appointment the previous day. During interview on 5/31/24 at 9:43 a.m., NA-D verbalized being unaware of any changes to R198's condition. During interview on 5/31/24 at 9:48 a.m., licensed practical nurse (LPN)-A stated they were still processing R198's orders from R198's wound appointment yesterday. LPN-A reviewed R198's hard chart for the new orders and found the order to discontinue Keflex. LPN-A stated the clinic called to discontinue Keflex because R198 had loose stools while at the appointment. LPN-A stated R198 was on contact precautions which required gown and gloves for his wound care and his catheter cares. LPN-A stated his precautions have not changed since his appointment. During interview on 5/31/24 at 9:59 a.m., IPPM stated R198 had an order to collect a stool sample and send that out to rule out Clostridium difficile infection and staff still needed to collect the sample to send in. The IPM expected there to be signage on the door and an isolation or supplies cart outside his room. The IPM verified contact precautions (or enteric precautions) had not been implemented in addition to EBP because I haven't gotten there, but stated the nurse managers and charge nurses were able to set up TBP. The IPM verified at R198's room that there was no signage and no isolation or PPE supplies cart outside his room. During interview on 5/31/24 at 10:34 a.m., registered nurse (RN)-A stated residents who did not present as themselves were assessed, kept in room if seemed contagious such as with temperature, and staff reached out to provider. Providers may then order x-rays, labs, urine specimens. Staff completed additional follow-up assessments such as vitals and lung sounds depending on the infection. RN-A documented in progress notes and had a book with a shift report. During interview on 5/31/24 at 1:21 p.m., IPPM stated weekly or every few days they pulled a report from the electronic medical record system, Matrix, which listed residents who had antibiotic orders with start and end dates and other order information. The report of antibiotics did not include resident signs or symptoms of infection. Staff called IPPM when antibiotics started. IPPM used information from the report to track antibiotic use and then placed in a tracking form on the computer which included information such as resident name, infection type, if resident had device, whether surveillance criteria met or not, diagnostic tests performed and results, antibiotic medication information, who started the antibiotic, if a time out was completed, if transmission-based precautions were needed. During interview on 5/31/24 at 3:55 p.m., registered nurse (RN)-C stated nurses assessed and monitored residents who had a change of condition or new symptoms which could indicate illness, such as loose stools. Nurses reported assessment, which included vital signs, and signs and/or symptoms of illness or infection to the provider and processed labs, diagnostic tests, or any other order given. Nurses placed general orders to flag oncoming shifts to monitor resident condition and could monitor vital signs, push fluids, or initiate standing orders if related to suspected illness or infection. Nurses documented in progress notes and a 24-hour communication report and had verbal reports between shifts. RN-C alerted IPPM right away if they were in the facility or left a voicemail or let the next shift know to communicate with IPPM. RN-C stated they could alert the care coordinator or director of nursing if IPPM not available. During follow-up interview on 5/31/24 at 4:33 p.m., IPPM stated they did not have a process for tracking illnesses not related to antibiotic use. IPPM had become [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to develop and implement a facility wide system to monitor the use of antibiotics and reduce unnecessary or inappropriate antibiotic use, which reduces risk of adverse effects, for 1 of 1 resident (R198) reviewed for antibiotic use. This had the potential to affect all 50 residents residing in the facility. Findings include: R198's face sheet undated, indicated R198 had diagnoses which included diarrhea, a stage 3 pressure ulcer (a wound that breaks down skin and underlying tissue) of the sacral (tailbone) region, unspecified stage pressure ulcer to the left buttock, muscle weakness, depression, and anxiety. The face sheet also indicated the resident admitted to the facility on [DATE]. R198's order summary included the following orders: - Monitor resident for loose watery stools and update provider as needed every shift, dated 5/28/24. - stool culture for Clostridium difficile (bacteria that can cause inflammation of the colon and severe diarrhea, often due to antibiotic use) special instructions: discontinue when collected, every shift, dated 6/1/24. - Wound clinic referral (sacral ulcer/left gluteal fold), dated 5/20/24. R198's medication administration record (MAR) indicated the following: - amoxicillin-pot clavulanate (Augmentin) 875-125 mg twice a day 5/15/24 to 5/22/24. - cephalexin 500 mg twice a day 5/28/24 to 5/30/24 when discontinued. - vital signs were monitored 5/15/24, 5/16/24, 5/19/24, and 5/26/24 and temperature 5/15/24 to 5/29/24. - monitor resident for potential allergic reaction while resident on cephalexin due to penicillin allergy with start day of 5/28/2024 until discontinued on 5/30/24. R198's MAR included the following regarding the order to monitor loose stools: - soft stools on evening shift of 5/28/24 and day shift of 5/31/24. - loose stools on day and evening shift of 5/29/24. R198's progress notes included the following: - 5/15/24 to 5/22/24 notes described the wounds and foul odor a couple times. Antibiotic use and loose stools were not mentioned. - 5/23/24 notes identified a wound had foul odor, another wound slough, and another wound no signs and/or symptoms of infection. The note indicated antibiotic course would finish. - 5/28/24 at 11:25 a.m., R198's wound on bottom had redness, foul smelling drainage, normal temperature. Primary nurse practitioner was called per family member (FM)-E and clinical coordinator for antibiotic orders. - 5/28/24 at 2:40 p.m., new orders for Keflex were given and FM-E spoke with primary nurse practitioner about the order. - 5/28/24 at 10:46 p.m., R198 had multiple soft/mushy stools causing dressing to become soiled. Stool consistency was reported to nurse practitioner and order for Imodium given and to monitor resident for loose/watery stools and update nurse practitioner as needed. The Imodium was given once in the evening and results were somewhat effective. - 5/30/24 at 10:45 p.m., indicated R198 was seen by wound clinic and provided with orders to discontinue Keflex and send stool specimen for culture for Clostridium difficile. Clinic stated R198 had continuous loose stools the entire afternoon visit at the clinic. R198's bowel movement documentation indicated R198 had loose bowel movements 5/20, 5/21, 5/22, 5/28, 5/29 and soft/formed bowel movements 5/18, 5/20, 5/29 and other dates did not indicate bowel movement consistency or no bowel movements documented. R198's wound/ostomy progress note dated 5/30/24, indicated R198 had watery stool with a sweet odor and no signs or symptoms of infection. The note indicated to discontinue Keflex as the wound was not infected and information was discussed with FM-E. Antibiotic stewardship log for March 2024 was reviewed and April and May 2024 were blank. The facility was asked for the last three months of antibiotic stewardship logs, but the logs were not provided. The facility was asked for the last three months of antibiotic time outs and did not provide. The facility was asked for their policy and procedure about antibiotic time outs and did not provide. During interview on 5/29/24 at 2:51 p.m., FM-E stated R198's wounds were getting worse and asked the facility about the antibiotic which was stopped a week prior, and the facility restarted the antibiotic. FM-E stated R198 had an appointment with a wound team at a clinic 5/30/24 which the facility recommended. During interview on 5/30/24 at 12:53 p.m., infection prevention manager (IPPM) stated R198's wound looked better compared to when first seen. IPPM stated FM-E was adamant about R198 being on an antibiotic and demanded the facility restart an antibiotic prior to the wound clinic. IPPM stated R198's wound had a slight odor and explained to FM-E the odor was part of the wound process and would be best if R198 was not on an antibiotic. IPPM stated they discussed risk versus benefits with FM-E but did not have documentation. During interview on 5/31/24 at 10:34 a.m., registered nurse (RN)-A stated residents who did not present as themselves were assessed, kept in room if seemed contagious such as with temperature, and staff reached out to provider. Providers may then order x-rays, labs, urine specimens. If provider ordered an antibiotic, staff completed additional follow-up assessments such as vitals and lung sounds depending on the infection. RN-A documented in progress notes and had a book with a shift report which contained when antibiotics started. RN-A stated infections such as a urinary tract infection required more than a fever to start an antibiotic, but IPM completed the behind the scenes documentation to ensure proper protocols were followed. RN-A alerted IPM when antibiotics were started. During interview on 5/31/24 at 3:55 p.m., licensed practical nurse (LPN)-A stated IPPM completed antibiotic 72-hour time outs and followed up on antibiotic stewardship. During interview on 5/31/24 at 1:21 p.m., IPPM stated they weekly or every few days pulled a report from their electronic medical record system, Matrix, which listed residents who had antibiotic orders with start and end dates and other order information. The report of antibiotics did not include resident signs or symptoms of infection. Staff called IPPM when antibiotics started. IPPM used information from the report to track antibiotic use and then placed in a tracking form on the computer which included information such as resident name, infection type, if resident had device, whether surveillance criteria met or not, diagnostic tests performed and results, antibiotic medication information, who started the antibiotic, if a time out was completed, if transmission-based precautions were needed. January through March 2024 was filled out in the tracking log, but April and May 2024 were blank. Most of the 72-hour antibiotic time outs were marked as no on the log. IPPM stated they had been away from the facility some of May 2024 so was reviewing the past weeks of antibiotics via the report from Matrix. IPPM stated no one looked over antibiotics or time outs when they were gone and was catching up and had not come across any concerns with prescribed antibiotics or infections from their time away. IPPM worked with providers to ensure antibiotics met minimum criteria for use, but some providers and family members were harder to educate. The nurses also had access to the minimum criteria information for starting antibiotics. IPPM had a form for 72-hour antibiotic time outs but stated they were often not completed, because they were on the floor working and not in the office. IPPM stated other nurses did not have the 72-hour time out form and one time out was completed in April and one completed in May. Antibiotic time outs may also be in progress notes. IPPM checked on residents at the end of their antibiotic regimen to assess residents; otherwise, nursing notes regarding resident symptoms throughout treatment were a hit or miss. IPPM was not sure why the facility did not have a process for daily documentation regarding antibiotic treatment and resident symptoms. During interview on 5/31/24 at 5:16 p.m., DON stated IPPM oversaw the antibiotic time out process and communicated to providers regarding antibiotics continuing or stopping. DON stated time outs were important to prevent superbugs and unnecessary medication. DON expected staff to monitor resident symptoms and temperatures and chart in progress notes. DON stated they were talking about putting in an order set list for residents on antibiotics or with viral infections to alert nurses to assess and chart once a day or once a shift. DON stated nurse monitoring was important to know if resident's illness was improving and how illness progressed. DON expected staff to monitor resident symptoms and temperatures and chart in progress notes. DON stated they were talking about putting in an order set list for residents on antibiotics or with viral infections to alert nurses to assess and chart once a day or once a shift. DON stated nurse monitoring was important to know if resident's illness was improving and how illness progressed. The facility's policy Antibiotic Stewardship Program dated 2/20, indicated the facility's tracking will monitor antibiotic use and outcomes from antibiotic use and directed to the facility's Infection Control policy section Infection Surveillance. Further, the policy directed the facility to make resources available to clinicians, nursing staff, residents, and families about antibiotic resistance and appropriate antibiotic use. The facility's policy Infection Control Program dated 2/23, indicated the infection control preventionist or designee did surveillance of healthcare-associated infections and antibiotic use by the following: -Implementing policies and procedures for infection prevention and systems for recognition of an increase in infection and identification of clusters and outbreaks for residents/clients and personnel. -Monitoring effective use of antibiotics and make recommendations for changes. -Utilizing the recommended minimum criteria for initiating antibiotics.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure the sound levels of the dining room were conducive to a pleasant dining experience. This affected three of three residents (R3, R34, R48) and their visitors (FAM-A, FAM-B) who identified concerns about the noise level of the ice machine in the dining room. Findings include: During observation on [DATE], at 12:13 p.m. R3, R34, R48, family member (FAM)-A, FAM-B, nursing assistant (NA)-B and NA-C were observed seated at the dining table in the dining room. The residents and family were all seated within 8-12 feet of the ice machine, which made a loud, continuous grinding hum heard throughout the dining room. During interview on [DATE], at 12:15 p.m. FAM-A was seated approximately 10 feet from the ice machine at the dining table with R34. She stated the ice machine was very loud and had been that way for a couple of months, and when it shut off even the staff were relieved. On [DATE], at 12:26 p.m. the ice machine continued to make a loud, grinding noise and had not shut off throughout the meal. During interview on [DATE], at 11:59 a.m. FAM-B was observed seated at the dining table approximately 12 feet from the ice machine next to R48. He stated R48 had been at the facility for a couple of months and noted there was a drone in the dining room, and if it was in his house, he would not like it. During interview on [DATE], at 12:03 p.m. FAM-A was observed seated next to R34 approximately 10 feet from the ice machine. She was unable to have a conversation with other residents or family because of the ice machine noise made it difficult to hear. She stated it sounded like it may conk out any minute. On [DATE], at 12:10 p.m. R3 was seated at the dining table approximately eight feet from the ice machine which was making a loud, grinding noise. NA-B was observed asking R3 three times if he wanted mashed potatoes, and twice if wanted green beans or vegetable blend. R3 indicated each time he was unable to hear her. R3 was wearing bilateral hearing aids. During interview on [DATE], at 12:16 p.m. NA-B stated R3 was hard of hearing and wore hearing aids, but she had to talk a little louder in the dining room because it was noisy in there. She stated the ice machine was loud and might interfere with his ability to hear in the dining room. During interview on [DATE], at 12:41 p.m. NA-C stated she often assists residents with eating at the table closest to the ice machine and it had always been noisy. On [DATE], at 12:42 p.m. NA-B was seated at the dining table next to R3 approximately 8 feet from the ice machine. She repeated it's a napkin three times in response to a question from R3. When R3 was asked a question a moment later, R3 repeated what four times. He was wearing bilateral hearing aids. During interview on [DATE], at 12:47 p.m. dietary aide (DA)-A stated the ice machine had always been noisy and described it as its standard state, although maintenance looked at it once. She stated staff had gotten used to it, and she would probably not want that noise in her own home. During interview on [DATE], at 1:16 p.m. culinary director stated the compressor on the ice machine was really, really loud and indicated it had been that way for many months. He stated many of the residents were hard of hearing, it needed to be fixed, and he was unaware of any maintenance requests. During interview on [DATE], at 1:21 p.m. the current maintenance director stated the facility had someone out to look at it approximately 8 months prior because it was so noisy and were told it would cost approximately $2000.00 to fix. He stated the cost of a new one was estimated at approximately $4000.00. The previous director of maintenance recommended leaving it until it died and then replacing it. He stated the loud noise was annoying, and he did not consider it home-like. During interview on [DATE], at 12:57 p.m. administrator was standing in the dining room approximately 10 feet from the ice machine. Administrator confirmed the ice machine was a little noisy and stated as a new resident it would be distracting at first, but they would probably get used to it and would become background noise. She stated they had someone out to try to fix it and talked about adding a door in front of it but would look into some way to decrease the noise in the future. She stated this was the residents' home, and they should be able to be comfortable there. A policy related to the ice machine/sound levels of the facility was requested and not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure consulting pharmacist recommendations were addressed or acted upon for 3 of 5 residents (R4, R28, and R14) reviewed for unnecessary medications. Findings include: R4's quarterly Minimum Data Set (MDS) dated [DATE], indicated R4 had intact cognition and had not experienced a fall since admission to the facility. R4's diagnoses included drug induced constipation. R4's physician's orders printed 3/30/23, indicated R4 received Senna Plus (laxative) 8.6-50mg 2 tablets twice a day: once between 7:00 a.m. - 11:00 a.m. and again between 4:00 p.m. - 6:00 p.m. R4's care plan dated 5/19/20, instructed to administer bowel medication(s) as ordered. R4's monthly medication review (MRR) pharmacy report dated 12/9/22, included a recommendation to consider moving the afternoon dose of Senna Plus to bedtime to reduce R4's fall risk. R4's medical record lacked evidence the recommendation from the December MRR had been reviewed or addressed by R4's medical provider. There was no change in R4's Senna Plus administration times. R28's quarterly MDS dated [DATE], indicated R28 had severely impaired cognition. R28's diagnoses included dementia without behavioral disturbance and delusional disorders. R28's physician's orders printed 3/30/23, indicated R28 received haloperidol (antipsychotic medication) 0.25 mg twice daily. R28's MRR pharmacy report dated 12/9/22, included a recommendation to consider a trail dose reduction of haloperidol to ensure R28 was receiving the lowest effective dose of the medication and to minimize potential risks. R28's medical record lacked evidence the recommendation from the December MRR had been reviewed or addressed by R28's medical provider. There was no change in R28's dose of haloperidol. R14's significant change MDS dated [DATE], indication R14 had intact cognition. R14's diagnoses included gastro-esophageal reflux disease with esophagitis. R14's physician's orders printed 3/30/23, indicated R14 received pantoprazole (a medication to treat acid reflux) 40 mg daily. R14's care plan dated 6/13/19, instructed to administered medications for stomach discomfort as ordered. R14's MRR pharmacy report dated 12/9/22, included a recommendation to decrease pantoprazole to 20 mg daily to minimize risk of negative side effects. R14's medical record lacked evidence the recommendation from the December pharmacy report had been reviewed or addressed by R14's medical provider. There was no change in R14's pantoprazole dosage. During an interview on 3/30/23, at 8:26 a.m. the director of nursing (DON) stated the pharmacist completed a MRR for each resident at the facility to ensure residents are on the lowest effective dose of medications, to minimize potential side effects, and reduce the risk of polypharmacy. After the pharmacist completes the monthly review, he sends a report with recommendations to the facility for distribution to the appropriate medical providers for follow-up. The DON stated she was unable to find documentation of MRR reports from the consulting pharmacist for the month of December. Although the facility should receive MRR reports monthly the DON stated she was unable to find evidence the MRR recommendations from the pharmacist's December reviews for R4, R28, and R14 had been received by the facility or addressed by the residents' medical providers. During interview on 3/30/23, at 12:00 p.m. the nurse practitioner (NP)-A, who served as the medical provider for R4, R28, and R14, stated she had not received MRR reports from the consulting pharmacist in the month of December. During interview on 3/30/23, at 12:18 p.m. the consulting pharmacist (CP-A) indicated he had completed MRRs onsite at the facility in the month of December. CP-A stated these recommendations from the medication reviews were sent to the DON via email prior to CP-A leaving the facility. CP-A was unable to provide documentation to show the reports had been sent as discribed. The facility policy, Consultation by Pharmacist, dated 10/19/17, included, The Pharmacy Consultant will perform a monthly drug regimen review on each resident unless the resident condition/risk will indicate a more frequent schedule that is individualized and communicated between the facility clinical staff and the Pharmacy Consultant. Irregularities identified will be documented on a separate, written report and sent to the attending physician, medical director, and director of nursing, listing the resident name, relevant drug, and irregularity the pharmacist has identified. The attending physician will document on the recommendation document that the identified irregularity has been reviewed and what, if any action has been taken to address it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F883 Pneumo Based on interview and document review, the facility failed to ensure 1 of 5 residents (R34) were offered or received the pneumococcal pneumonia vaccine in accordance with the Center for Disease Control (CDC) recommendations. Findings include: R34's annual MDS dated [DATE], indicated R34 was admitted to the facility on 3/22. R34's Physician Order Report dated 3/30/23, included facility's standing house orders starting 3/10/22. The facility Standing House Orders for [NAME] Manor (undated) included an order for PPSV23 or pneumovax is recommended for all adults 65 years and older, unless contraindicated. Prevnar 13 is also recommended for adults 65 years and older, unless contraindicated. Administer these at least on year apart; following verbal/signed consent. R34's medical record lacked evidence of pneumococcal immunization, education, contraindication, and/or documentation of refusal by the resident or resident representative. During interview on 3/30/23, at 12:20 p.m. infection preventionist (IP) stated she reviewed resident vaccination records and if they did not have the appropriate pneumococcal immunizations, she usually waited awhile before giving it. She stated she received individual orders from the provider, but the immunization was not on the house standing orders. She stated the resident (or representative) signed a declination form if they did not want to receive it. IP confirmed R34's medical record lacked a consent or declination form and indicated he most likely did not get the immunization but was not sure. IP stated the immunization was important to the safety of the residents due to being in a communal living environment. During interview on 3/30/23, at 1:45 p.m. director of nursing (DON) stated if a resident was not up to date with pneumococcal immunizations, they were educated and offered the immunization, and she expected the form to be completed whether given or declined. She stated the residents were part of a high-risk population and pneumonia could be a critical illness for them, and the immunization could mean the difference between a mild case treated in the facility or a severe case requiring hospitalization. The facility policy Pneumococcal Immunization dated 9/4/2018, indicated the facility will off the pneumococcal immunization to all residents, and refusal will be documented on the Resident Pneumococcal Immunization Consent or Refusal Form and maintained in the resident's record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure 1 of 5 residents (R9) reviewed for COVID-19 vaccination status were offered the COVID-19 vaccine, and/or provided education regarding the risks, benefits, and potential side effects of COVID-19 vaccinations in accordance the Centers for Disease Control and Prevention (CDC) recommendations. Findings include: R9's significant change Minimum Data Set (MDS) dated [DATE], indicated R9 was admitted to the facility on 10//22. The facility resident COVID-19 vaccination tracking document (undated) indicated R9 had not received any COVID-19 vaccinations and/or refused the COVID-19 vaccinations. R9's medical record lacked evidence R9 was offered the COVID-19 vaccination on or after admission and educated about its risk and/or benefits. In addition, the medical records lacked documentation of COVID-19 administration, refusal, or contraindication. During interview on 3/30/23, at 9:27 a.m. R9 stated she did not get the COVID-19 vaccine and did not recall receiving education or an offer to get the vaccine at admission, but would like to talk with her family to determine if she should get one or not. During interview on 3/30/23, at 12:09 p.m. registered nurse (RN)-A stated she did not educate or offer the COVID-19 vaccine to residents on admission, and if needed, it would be done by the infection preventionist (IP). During interview on 3/30/23, at 12:20 p.m. IP stated if a resident request a COVID-19 vaccination she recommended they go to the pharmacy to get it, but it was not offered on site unless a large vaccine clinic was held. She stated they did not document education or refusals and did not have a form to use for it. IP stated she did not recall if COVID-19 vaccination education was provided to R9 and verified R9's record lacked documentation of education, consent, refusals, or contraindications. During interview on 3/30/23, at 1:45 p.m. director of nursing (DON) stated if a resident was not vaccinated for COVID-19 staff provided education and encouraged them to go to the pharmacy to get it because the population in the facility was at high risk of complications from COVID-19 and the residents and staff needed to be protected. She was not sure why there was no documentation in the medical record for R9 and confirmed the facility did not have a form to document the education, refusals, or contraindications for the first series of immunizations. A policy pertaining to COVID-19 vaccinations for residents was requested but not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure 1 of 3 residents (R1) reviewed for accidents remained free of injury when R1 was transferred using a mechanical lift and fell to the ground. Findings include: R1's Face Sheet indicated diagnoses included a fracture to the pelvis and lumbosacral spine, dementia, and heart failure. R1's admission Minimum Data Set (MDS) dated [DATE] indicated R1 was non-ambulatory and dependent on two staff for all transfers. R1 had a mild cognitive impairment. R1's care plan undated indicated R1 was to be transferred with a full body mechanical lift and assist of two staff. The facility Fall Scene Investigation form dated 3/7/23, indicated R1 fell from mechanical lift, transferring from wheelchair to bed, using medium sling. The director of nursing (DON) determined the care plan was followed at the time of the incident. No obstructions were observed by the DON. The mechanical lift and sling were inspected following the incident. No [NAME] or mechanical issues noted. R1's progress note dated 3/7/2,3 indicated R1 had witnessed fall at 9:25 a.m. while being transferred with a mechanical lift from her wheelchair to her bed. R1 had a laceration left side of forehead, skin tear to left temple, and skin tear on left arm. Pressure and an ice pack were applied to the laceration and skin tear areas. Steri-strips were applied to her left forearm. A bandage was applied to the left forehead and left temple. Nurse Practitioner (NP)-A assessed R1 at the facility. On 3/13/23, at 11:32 a.m. R1 was observed with bandages covering her left temple area and above her left eyebrow. Steri-strips covered R1's left forearm wound. R1 stated she had fallen to the floor, but did not remember the incident. On 3/13/23, at 11:38 a.m. nursing assistant (NA)-A was interviewed and stated she involved with R1's fall from the mechanical lift on 3/7/23, along with NA-B. NA-A stated R1 was in her wheelchair, the sling was under R1 and crossed between the legs, with the loops hooked onto the hanger bar. NA-A stated she confrimed all loops were positioned correctly. NA-B was pushing the machine and had the controls. When R1 was positioned parallel to the bed, the left upper strap of the sling gave out. NA-A stated they thought it had broke, but it had not broke. NA-A stated R1 head fell to the base frame of the mechanical lift. NA-A stated she called the nurse for assistance. NA-A stated nurses assessed R1, then R1 was lowered to the floor, and then lifted into the bed. On 3/13/23, at 12:31 p.m. licensed practical nurse (LPN)-A stated she responded to the call for a nurse on 3/7/23, when R1 fell from the mechanical lift. LPN-A stated R1 had a skin tear to her left temple, a skin tear above her left eyebrow, and skin tear to her left forearm. LPN-A stated four staff assisted R1 back into bed. LPN-A stated the DON and NP-A were advised of fall immediately. LPN-A stated family and hospice were notified. LPN-A stated there were no concerns with the equipment involved with the incident. On 3/13/23, at 12:45 p.m. registered nurse (RN)-A was interviewed and stated she responded to the call for a nurse on 3/7/23 at 9:25 a.m. when R1 fell from the mechanical lift. RN-A stated NA-A and NA-B were transferring R1 from wheelchair to bed when the fall occurred. R1 was described to have her head resting on the leg of the machine, with the left strap of the sling intact, but off of the hanger bar. RN-A stated R1 had a left side forehead injury and left forearm injury. R1 was lowered and an ice pack was applied. NP-A arrived to the room to complete the assessment. On 3/13/23, at 1:45 p.m. staffing coordinator (SC)-A was interviewed and stated she inspects all 15 mechanical lift slings monthly. SC-A stated all straps, handles and slings are visualized to inspect for any worn or torn areas. If concerns were identified, the sling was taken out of service, thrown away, and replaced with a new one. On 3/13/23, at 1:54 p.m. the director of maintenance (DM)-A stated all mechanical lifts were routinely inspected and maintenance was provided every six months. On 3/13/23, at 2:25 p.m. NA-B stated he was involved with R1's fall from the mechanical lift on 3/7/23, along with NA-A. NA-B stated he was called into R1's room to assist with the mechanical transfer from the wheelchair to bed. NA-B stated he confirmed all loops were in place. NA-B stated as R1's bottom touched the bed, the sling became unattached at the left upper strap. NA-B called for a nurse while R1 fell to the left. R1's head contacted the frame of the mechanical lift. R1's lower body was still suspended with the sling attached to the lift, approximately 3-4 feet from the floor. NA-B stated he began to lower the boom of the lift. NA-B stated R1 sustained an abrasion to left side of her forehead at the time of the incident. NA-B stated there were no concerns with the mechanical lift or sling. NA-B stated if they had concerns, he would advise maintenance and remove the equipment from use immediately. On 3/13/23, at 3:28 p.m. the DON stated NA-A and NA-B were following the care plan at the time R1 fell from the mechanical lift on 3/7/23. The DON stated staff were transferring R1 from the wheelchair to the bed with the mechanical lift. When the fall occurred, staff called for a nurse to come to R1's room, and R1 was lowered to the floor and assessed. The DON stated R1 sustained a laceration above her left eyebrow,an abrasion to the left temple of her head, and a skin tear to her left forearm. The DON stated her investigation of the fall concluded the sling appeared to have been applied and secured correctly. The DON stated the sling and mechanical lift were inspected with no [NAME] or defects observed. On 3/14/23, at 9:04 a.m. the EZ Way brand representative (R)-A was interviewed. R-A stated if the sling was correctly applied to the mechanical lift, it would be held in place by gravity with the resident's weight. R-A stated if the sling was applied correctly, it could not come off of the hanger bar on the mechanical lift. On 3/14/23, at 9:34 a.m. NP-A was interviewed and stated she assessed R1 within five minutes of the fall on 3/7/23. NP-A stated injuries included an abrasion above the eyebrow and a laceration to the left forearm. Ice was applied to R1's head injury and was then bandaged. Steri-strips were applied to her left forearm. On 3/14/23, at 11:34 a.m. the DON measured R1's injuries. R1's left temple wound was 3.5 centimeters (cm) x 2.75 cm, the laceration above her left eyebrow was 1.25 cm x 0.5 cm, and her left forearm wound was 4.5 cm x 5.0 cm. Mechanical lift inspections revealed inspection of all eight mechanical lifts occurred 11/18/22, without concerns. The Mechanical Lift Procedure undated directed staff to make sure a final check of all four loop attachment points to ensure each loop is sufficiently attached to the respective hook of the hanger bars.

Based on interview and document review the facility failed to report an allegation of abuse timely to the State Agency (SA) for 1 of 4 resident (R1) reviewed for allegations of abuse. Findings include A Facility Reported Incident (FRI) submitted to the State Agency on 11/17/22, at 1:35 p.m., alleged caregiver abuse when certified nursing assistant (CNA)-E reported to registered nurse (RN)-A that she heard CNA-A slap R1. CNA-E reported the alleged event on 11/17/22 at approximately 12:30 a.m. During an interview on 12/8/22, at 8:10 a.m. RN-A stated she worked the night shift on 11/16/22 into 11/17/22. RN-A stated at approximately midnight CNA-E reported that she thought CNA-A had hit R1 after she heard a slap when CNA-A was in the room doing cares for R1. RN-A stated she did call the on-call nurse and was instructed to assure that CNA-A did not enter R1's room for the rest of the night and assure R1 was paired up with another CNA until they could investigate further in the morning. RN-A indicated she had not reported to the SA. During an interview on 12/7/22, at 3:20 p.m., the director of nursing (DON) stated RN-A called the on-call nurse informing her of the allegation at approximately 12:30 a.m. and indicated there was not enough information gathered and/or reported to the on-call nurse to ascertain what had occurred between CNA-A and R1. After further discussion and information in the morning, it was determined it should be reported to the state agency within 2 hours. The Abuse, Neglect, or Exploitation Response, Reporting, and Investigation Policy last reviewed 11/2021 indicated after witnessing, suspecting abuse, neglect, or exploitation of a resident staff are to ensure the safety of the residents in immediate danger; report immediately to any department leader; document the facts that cause suspicion. Further indicates designated facility staff members are responsible for receiving alleged violations, conducting alleged violation investigations, and initiating reporting obligations to the State Agency and law enforcement if there is a suspicion of a crime.