**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure resident-specific resuscitation wishes were clear and evident throughout the electronic medical record (EMR) and physical paper chart for 1 of 1 resident (R22) reviewed for advance directives. Findings include: R22's admission Minimum Data Set (MDS) dated [DATE], indicated R22 had short- and long-term memory problems, severely impaired cognitive skills for daily decision making, and continuous inattention and disorganized thinking. R22's diagnoses included hypertension, renal failure, hip fracture, osteoporosis, depression, Alzheimer's disease, and dementia. During record review on [DATE] at 6:00 p.m., R22 did not have an order for code status. R22's banner in the EMR had a link to Advance Directives which was blank and did not have a POLST (a medical order indicating treatments a person would like to receive in case of serious illness and/or cardiac arrest) uploaded in the EMR. Progress notes and care conference summaries indicated R22's code status was reviewed but did not specify R22's wishes. R22's Physician Discharge Orders/Instructions dated [DATE], indicated R22's code status as DNAR/DNI (do not attempt resuscitation/do not intubate). R22's Statutory Short Form Power of Attorney document dated [DATE], indicated R22 agreed to be kept comfortable and allow natural death to occur under the section of Terminal Condition/Life-Prolonging Treatment section. When interviewed on [DATE] at 6:11 p.m., nursing assistant (NA)-G indicated they would notify a charge nurse if they found a resident unconscious. When interviewed on [DATE] at 6:12 p.m., licensed practical nurse (LPN)-I indicated they would activate a code to get help right away if they found a resident unresponsive and would check resident's paper chart first to review their code status. LPN-I stated they would assume resident as a full code and start CPR (cardiopulmonary resuscitation) if there were no POLST in the resident's chart. LPN-I reviewed R22's paper chart and face sheet and confirmed the face sheet did not indicate R22's code status and there was no POLST. R22's Statutory Short Form Power of Attorney document was in R22's physical, paper chart. LPN-I stated the director of nursing (DON), floor managers, and social worker (SW) assisted with admissions and verified residents' code status and related paperwork. LPN-I stated they would check with the floor manager. During subsequent interview, LPN-I reviewed R22's Medication Administration Record (MAR), and the MAR indicated DNR/DNI under the Special Instruction section of the banner. LPN-I stated most residents have a POLST, but staff looked in the MAR when a POLST was not in the resident chart. When interviewed on [DATE] at 6:23 p.m., LPN-B stated R22 was not capable of making their own decisions and had called R22's family member (FM)-A to confirm R22's code status when R22 first admitted . LPN-B stated they mailed R22's POLST to FM-A for them to sign and forgot to make a copy for R22's chart. LPN-B stated the physician would sign the POLST after the family signed the POLST. LPN-B reviewed R22's Care Conference Summary dated [DATE] and confirmed the summary indicated R22's code status was reviewed but did not specify what R22's code status was. LPN-B stated R22 came from the hospital with orders for code status, and staff used the hospital ordered code status until they confirmed code status with resident or family within 48 hours of admission. LPN-B stated they or the director of nursing entered in admission orders, which included code status, and verified R22 did not have a code status in the EMR's orders. When interviewed on [DATE] at 7:32 p.m., LPN-K stated they would check resident's code status in the paper chart or EMR prior to initiating CPR or not if they found a resident pulseless and not breathing. LPN-K stated the director of nursing or other managers reviewed and entered residents' orders and POLST during admissions. During additional interview on [DATE] at 7:40 p.m., LPN-B stated code status orders were part of ancillary orders when residents first admitted . Staff used the template to add in the code status and another nurse verified the admission orders. The code status showed up in the EMR banner when the orders were entered using the template. LPN-B stated the process was missed for R22, and the facility did not use an admission checklist. LPN-B reviewed R22's Statutory Short Form Power of Attorney document and reviewed the section which described to keep R22 comfortable and allow natural death to occur but stated the statement still was not a POLST. When interviewed on [DATE] at 7:49 p.m., LPN-J stated they checked resident's code status under the advance directives section in the EMR's miscellaneous section and the paper chart before initiating CPR on a resident who was pulseless and not breathing. LPN-J stated the health unit coordinator scanned in the POLSTs into the miscellaneous section of the EMR. LPN-J stated they would initiate CPR if a POLST or code status was not in place. When interviewed on [DATE] at 9:23 a.m., FM-A stated they verbally spoke with staff to confirm R22's code status as DNR and did not receive a POLST in the mail to sign. When interviewed on [DATE] at 9:26 a.m., LPN-D stated they would initiate CPR if they found a resident pulseless and not breathing and would call a second nurse to check the resident's code status. LPN-D stated residents' code status was listed in the banner of the MAR and in the front tab of residents' paper charts. When interviewed on [DATE] at 9:32 a.m., LPN-L stated they would call a second nurse to check if a resident was pulseless and not breathing and would verify the resident's code status in their paper chart or EMR on the face sheet or miscellaneous section where POLSTs were scanned. When interviewed on [DATE] at 9:45 a.m., registered nurse (RN)-C stated they would first check resident's code status if they were pulseless and not breathing. RN-C checked for resident code status in the paper chart or checked the EMR, such as the resident face sheet, if not in the paper chart. When further interviewed on [DATE] at 9:54 a.m., LPN-B stated they reviewed resident POLSTs when first admitted and at quarterly care conferences. When interviewed on [DATE] at 10:05 a.m., SW stated they facilitated conversations about code status with nursing on admission, quarterly, annually, and with hospitalizations or other changes. SW updated code status in resident care plans if nursing had other tasks to complete. SW stated the facility did not have a medical records person right now, so SW helped with scanning POLSTs into EMRs or sent out POLSTs for family members to sign if they were out of state and then notified the provider to sign the POLST or have a conversation with the resident's family. SW stated R22 had a health care directive which indicated DNR/DNI. When interviewed on [DATE] at 1:20 p.m., DON expected staff to call for help if a resident was unresponsive and verify code status immediately and assess the resident. DON stated code status was indicated on POLST found in residents' paper charts or the EMR had a banner which reflected residents' code status. DON stated they had monthly code status drills, and code statuses were in the EMR if not in the paper chart. DON stated staff reviewed POLST and code status when residents first admitted and quarterly at care conferences. DON expected a code status to be entered into residents' orders immediately during the admission process and reviewed by or at the 48-hour admission care conference. DON or floor managers entered residents' orders in a que, and a second nurse checked and confirmed the orders into the EMR. DON stated they emailed or faxed POLSTs for family to sign. DON expected a chart to have a copy of a POLST with verbal confirmation until a signed POLST returned. DON expected the resident or guardian preferred provider to review and sign POLST within 72 hours. When interviewed on [DATE] at 1:59 p.m., the vice president of success stated the facility did not have a POLST policy and procedure and followed state guidance. The CPR policy dated [DATE], directed staff to provide basic life support, including CPR, prior to the arrival of emergency medical services, and: a. In accordance with the resident's advance directives, or b. In the absence of advance directives or a Do Not Resuscitate order; and c. If the resident does not show obvious sings of clinical death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to notify providers about a resident's weight status while on a prescribed diuretic (water pill) for 1 of 1 residents reviewed for edema (swelling). Findings include: R5's significant change Minimum Data Set (MDS) dated [DATE], indicated she had severe cognitive impairment with diagnoses of heart failure, kidney failure, respiratory failure, anxiety, depression, and lymphedema (a chronic condition causing swelling from lymph or protein-rich fluid in the body's tissues). The MDS further indicated R5 received hospice care. R5's Care Area Assessment (CAA) for functional abilities dated 11/5/24, identified her need for assistance with all activities of daily living (ADLs) and mobility, directing staff to provide max assist with all cares and dependent assistance with toileting and transfer cares. The CAA directed staff to proceed to the plan of care with goal of comfort and dignity with end of life cares. R5's unsigned order summary was reviewed 12/13/24, and included the following orders: - furosemide oral tablet, Give 40 milligrams (mg) by mouth one time a day for pulmonary edema (fluid buildup the lungs), heart failure with chronic kidney disease and failure, dated 3/12/24. - weight and vitals weekly (obtain re-weight if change of 5 lbs (pounds) since last weight every Thursday, dated 5/28/24. R5's treatment administration record (TAR) dated 8/2024, reflected the following documented weights: - 8/8/24: 170 [lbs]. - 8/15/24: 171 [lbs]. - 8/22/24: 165 [lbs]. - 8/28/24: lacked documentation of weight and referred to the progress notes. R5's TAR dated 9/2024 reflected the following documented weights: - 9/5/24: NA. -9/12/24: 164 [lbs]. 9/19/24: 164.3 [lbs]. 9/26/24: lacked documentation of weight with rationale refused. R5's TAR dated 10/2024 reflected the following documented weights: - 10/17/24: NA. - 10/31/24: 164.2 [lbs]. The dates of 10/3/24, 10/10/24, and 10/24/24, lacked documentation of weights and referred to the progress notes. R5's TAR dated 11/2024 reflected the following documented weights: - 11/14/24: NA. - 11/28/24: NA. The dates of 11/7/24, and 11/21/24, lacked documentation of weights and referred to the progress notes. R5's TAR dated 12/2024 reflected the following documented weights: - 12/5/24: 162.5 [lbs]. - 12/12/24: NA. R5's care plan dated 7/28/23 identified she was on diuretic therapy to treat her lower extremity edema. The care plan guided staff to report signs and symptoms of dehydration, hypotension, dizziness, etc. to meet her goal of having no adverse effects. Additionally, the care plan identified her risk for excess fluid volume due to her lower extremity swelling (edema) and directed staff to report signs and symptoms edema or fluid overload, including weight gain. Per progress note dated 8/1/24 at 1:07 p.m., for the order to weight and vitals - weekly obtain re-weight if change of 5 lbs since last weight), two attempts were made to collect R5's weight and/or vital signs and would be attempted again later. The progress note lacked documentation on provider notification of refusals. Per progress note dated 8/13/24 at 11:43 a.m., the interdisciplinary team (IDT) discussed R5's weight loss of approx. 25 lbs over last 4 months and potential causative factors. The progress note lacked documentation if her provider was updated on her weight loss. A progress note dated 8/29/24 at 9:47 a.m., indicated R5 refused her weekly weight three times. The progress note lacked documentation on provider notification of refusals. A progress note dated 10/17/24 at 9:44 a.m., lacked documentation regarding why weight was not documented in R5's TAR as ordered. The progress note lacked documentation on provider notification. A progress note dated 10/24/24 at 9:32 a.m., indicated R5 refused weekly weight but other vitals completed. The progress note lacked documentation on provider notification of refusals. Per a nutrition assessment note dated 11/5/24 at 3:02 p.m., R5 was at risk for fluid shifts and weight fluctuations related to diuretic use. The note directed staff to continue the current nutrition plan of care. Per progress note dated 11/7/24 at 9:41 a.m., R5 refused to get out of bed for her ordered weekly weight check. The progress note lacked documentation on provider notification. Per progress note dated 11/21/24 at 9:41 a.m., R5 refused to get out of bed for her ordered weekly weight check. The progress note lacked documentation on provider notification. A provider progress note dated 9/20/24, identified R5's abnormal weight loss with her self-reported anorexia (medical term for loss of appetite) and weight loss for a few months. The provider progress note indicated under the Assessment and Plan for abnormal weight loss staff should continue to trend weight. A request for further primary care provider visit documentation or provider progress notes was requested but not received. R5's electronic medical record (EMR) was reviewed on 12/12/24, and lacked documentation on provider notification of her refusal to be weighed. Per observation on 12/10/24 at 9:08 p.m., R5 was laying in her bed on her back. She had mild swelling to both legs and did not have any stockings or wraps on her legs. Per interview on 12/12/24 at 10:00 a.m., with the registered dietitian (RD), R5 was being followed because she was a high-risk for her weight. RD reviewed her weights in R5's EMR and stated she followed her monthly and confirmed weight loss. RD verified she was due for another risk charting note soon and stated R5's weight had been stable for about a month, but was unsure what was currently going on. RD identified her diuretic use could affect her weight but stated she was on hospice and did not like to demand things when a resident was on hospice care. RD expected documentation of a resident's refusals of weights and stated it would be preferable for monthly weights to be obtained. RD identified a weight on 12/5/24, and stated, She's down a couple of pounds but expected this for a resident on hospice cares. RD denied concern for R5's weight loss. Per interview on 12/12/24 at 10:14 a.m. with R5's hospice registered nurse (HRN), R5 appeared well-cared for during hospice visits and assessments at the facility. HRN reported assessing R5's respiratory status and fluid retention/edema during visits and denied concern beyond R5's baseline. HRN stated R5 was really short of breath with exertion and even in conversation and her legs have always been very swollen. HRN verified a lack of notification regarding R5's refusals to be weight and a lack of documented weekly weights. HRN stated, it is something I am monitoring but not necessarily something I expect to be updated on, however, endorsed concern for staff not monitoring weights because if they are not monitoring weights, then I wouldn't be able to monitor them either. HRN deferred to R5's primary care provider (PCP) for management of her weights and diuretic orders. Per interview on 12/12/24 at 4:23 p.m., R5's primary care provider and nurse practitioner (NP) confirmed not receiving updates on R5's lack of documented weights and her refusals to be weighed. NP expected to be updated and stated if staff had provided updates, I would have reassessed the orders and the need for the Lasix, particularly because she's on hospice. NP indicated there had not been any observed changes to R5's baseline edema and denied concern regarding R5's weights, stating they seem stable for her baseline. Per interview on 12/13/24 at 9:50 a.m., with licensed practical nurse (LPN)-D, R5's edema in her legs were much improved now with a decrease in her fluid retention. LPN-D explained for residents at risk for fluid retention and/or on a diuretic, staff should watch for respiratory changes, edema, and weight changes. LPN-D stated, If I saw those things, I would notify the unit manager, update the doctor and request they assess the resident. LPN-D stated if a resident was weighed and it looked off, we would encourage a reweigh, and if a resident was consistently refusing, staff were expected to reapproach, distraction and if the refusals continued, staff were expected to update the provider about the refusals. During interview on 12/16/24 at 9:50 a.m., with LPN-A, also the unit manager, R5's EMR was reviewed for notification of change to the provider regarding her refusal to be weighed and lack of documented weekly weights. LPN-A verified there was no documentation in the EMR or provider portal on her refusals and lack of weights. LPN-A expected staff to report refusals to the nurse and expected nurses to reapproach the resident. If a resident continued to refuse the treatment or order, LPN-A expected staff to update the provider and resident's representative. During interview on 12/16/24 at 12:01 p.m., the director of nursing (DON) hoped staff would bring concerns with residents refusing to be weight to IDT to be discussed. The DON expected staff to report R5's refusals to both her hospice provider and her primary provider teams so we can make a better plan for that resident. Per facility policy titled Change in Condition of the Resident revised 9/20/22, the facility should immediately inform the resident; consult with the resident's physician; and notify , consistent with his or her authority, the resident representative(s) when there is a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment). The policy explained when a resident presented with a possible change of condition, staff should notify a resident's physician and for non-immediate notifications, staff were guided to provide the notification via the phone, fax, or method preferred by the physician being contact. Additionally, the policy directed staff to ensure the resident's change in condition was included on the 24-hour report to be reviewed later by the IDT and to updated the plan of care as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to provided Notice of Medicare Non-Coverage (NOMNC) in the required time frame for 1 of 3 residents (R143) reviewed for beneficiary notices. Findings include: R143 admission minimum data set (MDS) dated [DATE], included R143 had moderate cognitive impairment and diagnosis of dementia. Facility progress note dated 10/7/24, included R143's power of attorney (POA) discussed a discharge for resident on 10/9/24. R143's NOMNC dated 10/9/24, included skilled nursing/therapy services will end 10/8/24. Handwritten note on document read resident elects early discharge with benefit days remaining. NOMNC was signed by resident. No evidence of POA reviewing or signing document. During interview on 12/12/24 at 11:17 a.m., family member (FM)-B stated she did not remember ever being informed about a notice of Medicare non-coverage, but was updated that therapy would be ending. During interview on 12/13/24 at 10:45 a.m., registered nurse (RN)-D confirmed the discharge NOMNC was signed the day R143 was discharged by R143 himself. RN-D confirmed R143 did have a POA but stated sometimes she had the resident sign the form even if there was a POA if she felt they were cognitively intact. She stated she did not do any formal assessment to determine cognitive status other than observation. RN-D confirmed there was discussion with R143's POA two days prior to discharge but the form was not discussed at that time. During interview on 12/13/24 at 11:19 a.m., the administrator stated there are no exceptions for the NOMNC being given two days prior to discharge. The administrator stated the POA should be given the notice to sign. Facility denied having a policy on NOMNC and stated they follow Medicare regulations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and documentation review, the facility failed to ensure a safe, clean, comfortable homelike environment when the facility failed to address maintenance issues identified in the dining areas, resident rooms, and throughout the building for 2 of 8 residents (R30, R36) reviewed for homelike environment. Findings include: R30's admission record printed 12/16/24, indicated he admitted to the facility on [DATE]. A complaint/incident investigation reported by R30 and dated 9/16/24, was reviewed and indicated the facility itself is very unsanitary. The report included, one part of the walls at the facility is currently missing, and staff did not appear to be doing anything to fix this. A complaint/incident investigation reported by R30 and dated 10/8/24, was reviewed and indicated the facility had environmental issues but lacked specificity on where the alleged mold was. A complaint/incident investigation reported by R30 and dated 11/27/24, was reviewed and identified a fire hazard and electrical hazard in the facility. A TELS closed work orders report printed 12/13/24 for the dates of 3/1/24 - 12/12/24 identified the following closed work orders: - the dining room baseboard trims fell off in the dining, created 4/8/24, completed 4/9/24. - walls behind bed are scratched/gauged (needs repair-puttying) for R30's room, created 8/22/24, completed 9/4/24. - LTC [sic, long-term care] dining room in second floor dining, created 2/16/24, completed 3/11/24. Per observation on 12/9/24 at 2:18 p.m. of the second-floor dining room, the following environmental concerns were identified: - the corner of the wall near the dining room entrance had gouge marks with large parts of the wall missing as well as a loose baseboard. - across from the wall with the gouge marks and missing wall, there was a wall with baseboards missing. - at the serving line in front of the steam table, there was another missing baseboard. - multiple ceiling tiles with large tan-to-light brown stains that covered approximately half of the ceiling tile's surface area. - the wall on the opposite side of the room's doorway had a long, dark black and gray scuff mark that ran along the side of the wall. - throughout the dining room, multiple baseboards had black and green taped areas. - the first window across from the steamtable and serving line had brown blinds and had thick white, web-like material on the blinds and above them onto the wall. - the second window's bottom ledge showed dried white chips and dark brown flecks coming off the ledge of the wall. On one spot of the window ledge, there was an area approximately 8-inches across and 2-inches down, that had long dried white and brown chips and was nearly coming off the wall entirely. - white, web-like material was in the corner of dining room by the two windows, as well as dried white chips flaked off the walls. - the baseboard and tile on the floor across from window in the back of the dining room was warped. - the ice and water machine behind the steam table had thick white buildup around the ice dispenser, and dried white buildup in the drain area and gates. Per interview on 12/9/24 at 2:46 p.m. with dietary aide (DA)-A, the areas noted during the second-floor dining room observation had been present for the duration of DA-A's employment. DA-A reported working in the facility for two weeks. During dining observation on 12/9/24 at 5:54 p.m., R30 was eating supper in the dining room with two other unidentified residents. During observation on 12/10/24 at 3:34 p.m., the baseboard on the wall outside the door of the second-floor dining room was falling off the wall. There were dried white chips flaking off the wall underneath where the baseboard once was. The baseboard was attached only at the corner of the wall and the rest of the slab of baseboard rested on the floor. It spanned the entire wall length, which was approximately 6-feet in length. During observation on 12/11/24 at 11:09 a.m., the dining room and baseboard outside the dining room remained unchanged. During observation and interview on 12/9/24 at 5:58 p.m., R30 confirmed filing the complaint/incident investigation reports and stated he reported these grievances in resident council. He pointed to the wall behind his bed and nightstand and observed were 9 scuff marks and an electrical outlet that was coming out/detached from the wall. R30 ate his meals in the second-floor dining room and confirmed the various scuff marks, gouges in the walls, black marks, and baseboards falling off. He stated the dining room had been like that since I've been here. R30 said the overall condition of his room and the dining room made him think the building isn't healthy and safe. Per interview on 12/10/24 at 1:37 p.m. with family member (FM)-C, the facility's maintenance department was really lacking and the facility only repaired something when it was broken. FM-C reported a privacy curtain was falling off the tracks in a resident room and stated it was reported before, but the facility had not done anything to repair it. Additionally, FM-C reported I've seen mold around the dining room area. FM-C did not believe the second-floor dining room, R3's room, or the facility itself felt homelike. Per interview on 12/11/24 at 7:24 a.m. with housekeeper (H)-B, any staff were able to enter a maintenance request through the facility's TELS system if they identified a concern. Per interview on 12/11/24 at 7:31 a.m., nursing assistant (NA)-D confirmed the dining room was something staff had been working on. NA-D stated the administrator made daily rounds in the morning to assess the facility for things that might be wrong. During interview on 12/13/24 at 10:03 a.m., licensed practical nurse (LPN)-C confirmed staff reported their environmental concerns and submitted TELS requests for the second-floor dining room and staff did not do anything about them. LPN-C was unable to recall how long ago the requests were made, however, stated they were submitted when the previous maintenance director was still in the facility, in September, and now, we do not have a maintenance person at all, so you can imagine how that works. During interview on 12/13/24 at 10:31 a.m., housekeeper (H)-A stated they had a checklist for cleaning rooms but not the dining areas and did not wipe down ice machines, walls, or windows. During interview and environmental tour on 12/13/24 at 1:19 p.m., the administrator and housekeeping director (HD), verified the second-floor dining room needed improvement. The administrator stated the dining room needs a good look and was a project for the facility. The environmental tour continued, and the administrator verified the gouges in the wall behind R18's head of bed and stated staff have been running the bed into that. In R30's room, the administrator stated the whole wall needs to be looked at and verified being aware of the scuff marks and headboard. The administrator confirmed the electrical outlet was detached/coming out of the wall and stated it was discussed during the LifeSafety survey. R36 R36 ' s Minimum Data Set (MDS) dated [DATE], indicated intact cognitive function, and included diagnosis of mechanical complication of internal fixation device of right humerus (surgery to repair a right broken shoulder). The MDS indicated R36 was ambulatory with use of rolling walker with seat. The record review on 12/13/24 at 2:24 p.m., on 11/8/24 a deep clean of room check off sheet completed. It did not state unstable cabinetry. During an observation and interview of R36's room on 12/9/24 at 3:35 p.m., R36 stated there was no heat vent in the bathroom and they needed to leave bathroom door open for heat. Four bath blankets were rolled up on the windowsill next to the glass. R36 stated they were there to prevent cold air from entering the room. The wall adjacent from window had 2 large gouges out of it, approximately 4 inches wide, 24 inches long and two inches deep, it had unpainted patchwork around the area. A privacy curtain hung with missing hooks and unable to fully close. The dull blue/gray curtain was covered in brown splotchy areas of unknown substance ranging in size from 1 inch by 1 inch to 4 inches by 3 inches. The floor to ceiling cabinetry was not securely affixed to the wall. It was very unstable, wiggled and moved with any activity. R36 stated they did not consider it a homelike environment, that the place is falling down, and no one cares. During an interview on 12/12/24 at 9:51 a.m., licensed practical nurse (LPN)-D stated the process for a concern in a resident ' s room was to discuss concern(s) with administrator. There was not a maintenance department in the facility. LPN-D observed the cabinetry and confirmed there was a safety concern and reported that to administrator. During an interview on 12/12/24 at 2:49 p.m., registered nurse (RN)-A stated any concern with a resident ' s room was brought to the administrator. RN-A stated that safety of the residents was the number one concern, and verbalized the cabinetry would be shown to the management. During an interview on 12/13/24 at 11:48 a.m., administrator discussed the maintenance policy and procedure of rooms and facility. He verified there was not a maintenance department in the facility. A corporate maintenance person came to facility once a month. The facility policy on Safe and Homelike Environment Policy dated 6/16/22 stated Policy: In accordance with residents' rights, the facility will provide a safe and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure a Level II Pre-admission Screening and Resident Review (PASARR) was completed to screen for mental health needs for 1 of 1 residents (R8) reviewed for PASARR. Findings include: R8 admission Minimum Data Set (MDS) dated [DATE], included diagnosis of schizophrenia. R8's order summary report dated 4/3/24, included diagnoses of mild cognitive impairment, schizoaffective disorder (a mental health disorder with symptoms of both schizophrenia and a mood disorder), depression, bipolar disorder (extreme mood swings), and hoarding disorder. R8's preadmission screening results (PAS) dated 1/11/24, included the R8 would need a Level II assessment for mental illness. During interview on 12/11/24 at 9:11 a.m., social services (SS)-A stated she did an audit of all PAS results when she was hired and R8's previous PAS was unclear, but she thought she may have needed a Level II. SS-A resubmitted R8's PAS information at that time. SS-A stated she did not realize the PAS results indicated a Level II assessment was needed. SS-A confirmed upon review of PAS results dated 1/11/24, a Level II assessment was required. During interview on 12/12/24 at 1:50 p.m., SS-A state it was important to know if there was a mental health or developmental disorder so the facility would know how to care of them. Facility policy requested and not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure a shower was offered or provided for 1 of 3 residents (R30) reviewed for bathing. Findings include: R30's quarterly Minimum Data Set (MDS) dated [DATE], indicated he had moderately impaired cognition with a memory deficit following a cerebrovascular accident (CVA, or a stroke), weakness and paralysis or inability to move his left dominant side after a stroke, depression, and dementia (a condition causing a decline in cognitive function, memory, and behavior). His MDS indicated he displayed no rejection of cares and required substantial to maximal staff assistance for bathing/showering cares and mobility and transfers. R30's annual MDS dated [DATE], identified bathing preferences were very important to him. R30's functional abilities Care Area Assessment (CAA) dated 6/24/24, was triggered due to his need for assistance with ADL cares and identified he was at risk for ADL decline and directed staff to the plan of care. R30's care plan revised 7/5/24, identified his self-care deficit and directed staff to provide assist of 1 with bathing and showering cares to meet his goal of receiving assistance necessary to meet his ADL needs. R30's [NAME] indicated his shower was scheduled for Tuesday mornings. R30's PointOfCare (POC) ADL - Shower on Tuesday Am's Task was reviewed 12/13/24, and lacked documentation of showering/bathing cares for the last 30 days. R30's progress notes were reviewed on 12/16/24, and lacked documentation of shower refusals. During interview on 12/09/24 at 6:36 p.m., R30 stated he was last offered a shower a couple months back, but it was during a time when the facility had turned off the hot water, so he declined. R30 reported this was the last time he could recall staff offering him a shower, and he believed that to be sometime in October 2024. R30 vocalized a wish to be offered a shower at least monthly. During interview on 12/13/24 at 3:09 p.m., nursing assistant (NA)-B was unable to find documentation of R30's last shower. During interview on 12/13/24 at 3:15 p.m., licensed practical nurse (LPN)-J reviewed R30's skin assessments and explained weekly skin assessments coincided with resident's scheduled showers. LPN-J stated R30's last skin assessment was done on 12/5/24, and his most recent was completed 12/13/24. LPN-J used the skin assessment to report R30's last shower was today. During interview and observation on 12/16/24 at 8:16 a.m., R30, sat in his wheelchair in his room. His hair appeared shiny and slick. R30 stated he did not take and was not offered a shower throughout the survey week of 12/9/24 - 12/16/24. Per interview on 12/16/24 at 9:16 a.m., with nursing assistant (NA)-A, resident showers were documented in POC and if a resident refused, NAs should document the refusal in addition to reporting it to the nurse. Per interview on 12/16/24 at 9:33 a.m., with licensed practical nurse (LPN)-D, R30's shower day was Tuesday. LPN-D reviewed his electronic medical record (EMR) and was unable to locate R30's last documented shower. LPN-D verified there was no documentation in the progress notes about him refusing a shower. LPN-D expected NAs to report any concerns identified during a bath or shower, including a refusal, to the nurse. LPN-D stated if the NAs reported anything of concern or a refusal, I'll document that. During interview on 12/16/24 at 9:20 a.m., LPN-C stated the resident shower schedule was posted in the nurse's station and verified the posted schedule. LPN-C expected NAs to notify the nurse on duty if a resident refused a shower and stated the nurse should document the refusal as well. During interview on 12/16/24 at 9:43 a.m., LPN-A (also the unit manager) stated NAs were expected to document in POC under the tasks section if a resident had a shower and if a resident refused, NAs were expected to report to the nurse on duty and the nurse expected to document in the progress notes. LPN-A stated NAs should be aware of scheduled showers/baths because the schedule was printed and posted at the nurse's station, the schedule as discussed during shift report, and it was on their POC tasks. LPN-A expected R30's last shower date to be 12/10/24 and expected to see documentation in POC or a refusal documented in the progress notes. LPN-A confirmed there were no documented refusals in the progress notes. LPN-A was unable to provide documentation of R30's last shower in POC. Per interview on 12/16/24 at 12:01 p.m., with the director of nursing (DON), NAs were expected to offer a shower on resident's scheduled shower/bathing day and document in POC. If the resident refused a shower, NAs were expected to report to the nurse on duty, and the nurse was expected to document in progress notes. The DON reviewed R30's EMR and confirmed there was no documentation of a shower or of a refusal. The DON explained staff may have offered his shower as a part of his morning cares and if he refused, it may not be reflected as a true refusal because the skin check may or may not be done. The DON endorsed staff may not be the greatest at documenting when a bed bath was performed. The DON stated it was important to offer showering to residents to promote dignity and overall health. Per facility policy titled Resident Rights last revised 7/2022, residents would be treated with respect and dignity and care. The policy identified the resident's right to request, refuse and/or discontinue treatment, and the right to make choices about aspects of his/her life in the facility that are significant to the resident including the choice of healthcare consistent with the resident's interests, assessments, plan of care and other choices. Per facility policy titled NSG - Activities of Daily Living (ADLS) dated 7/26/22, the facility would, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless avoidable. The policy identified care and services would be provided for ADLs including bathing, dressing, grooming and oral care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure a resident's preferred activities for individual entertainment were offered for 1 of 1 residents (R26) reviewed for activities. Findings include: R26's quarterly Minimum Data Set (MDS) dated [DATE], indicated she had severely impaired cognition and was marked not applicable for transfers. The MDS identified diagnoses of muscle weakness, depression, and high blood pressure. R26's significant change MDS dated [DATE], indicated it was very important to R5 to participate in her favorite activities and to go outside and get fresh air when the weather is good. R26's Care Area Assessment (CAA) for communication dated 1/3/24, indicated R5 was usually understood and usually understands. The CAA identified she was at risk for missed information and unmet needs as her primary language was Russian, but she did know some English. The CAA indicated she was able to make her needs known and guided staff to proceed the plan of care. An activity participation review dated 9/26/24, indicated R5 did not attend any small or large group activities, rather preferred 1:1's and attended those 2-3 x a week. The review indicated R5 spends much of her time in bed, and watched TV, read books, had visits from a family friend and daughter. Furthermore, the review indicated life enrichment or activities staff visited 2-3 times per week and because R5 spoke Russian, she was able to socialize some when visited by staff and she smiles and giggles at times and appears to enjoy the visits. The review indicated R5 participated in individual activities daily and included family and friend visits and identified her favorite activities as cognitive (reads Russian books); Entertainment (Russian television); Spiritual (Jewish faith); Social (1:1, snack, socials and visits with staff, Family friend visits), and pet visits. The review lacked documentation of her preference to go outdoors for fresh air. The review identified R5's progress towards her activity goals were not met and had been revised in the care plan. Additionally, the review identified her activity-related IDT interventions/approaches had not been effective towards reaching her goals and new approaches were added to the care plan. R26's undated and unsigned order summary was reviewed 12/11/24 and reflected the following orders: - up in w/c [sic, wheelchair] one time per day for core strengthening in the afternoon for muscle wasting (a loss of muscle mass and strength), dated 9/9/24. R26's care plan last revised 9/26/24, indicated she preferred not to attend group activities due to her primary language being Russian, although she did speak and understand some English. The care plan identified she preferred to spend time in her room resting and watching television. The care plan included her meaningful interests last revised 3/18/23, of 1:1 visits with life enrichment or activities staff, television, and reading. The care plan identified interventions including the following: - Provide 1;1 activity visit of potential interest (i.e. discussion of family, books) 2 - 3 x per week. - Will respect choice in regard to limited/no activity participation. - Will visit to offer leisure supplies/materials as able. DTR [sic, daughter] to bring Russian specific supplies. Conversely, R5's care plan identified her difficulty communicating as she spoke Russian and little English. The goal was to use an alternative method to communicate needs/wants, including a translator. Additional goals included demonstrate understanding by completing task when requested and needs would be met with comfort and dignity. The care plan directed staff to call an interpreter for translation and provided a contact number with instructions, and to involve R5 in activities that did not rely on her ability to communicate or hear, such as parties, crafts, or movies. The care plan lacked resident preference for going outside to get fresh air when the weather was good as identified in her significant change MDS dated [DATE]. A PointOfCare (POC) task record printed 12/10/24, to make sure resident is up in wheelchair every day for one hour during lunch. Inform nurse if resident refuses to get up, with a lookback period of 30 days reflected, No Data Found. The record lacked documentation staff attempted or offered to get resident up in wheelchair every day. A POC task record printed 12/10/24, for ADL - transferring Hoyer with two staff, with a look-back period of 30 days indicated out of 84 opportunities, R5 required limited assistance (resident highly involved in activity, staff provide guidance maneuvering of limbs or other non-weight-bearing assistance) on 8 instances; total-dependence (full staff performance) on 11 instances; required extensive assistance (resident involved activity, staff provide weight-bearing assistance) on 3 instances; and staff documented not applicable on 61 instances. A POC task record printed 12/10/24, for ADL [sic, Activities of Daily Living]- Activity Participation, Which Activity?, with a look-back period of 30 days indicated R5 participated in move/TV activities on 5 instances and a family/friend visit on 1 instance. The record lacked documentation of R5's preferred activity of going outside for fresh air. A POC task record printed 12/10/24, for ADL - Activity Participation - Activity, with a look-back period of 30 days indicated R5 was independent for 6 out of the 7 instances and a 1:1 for 1 of the 7 instances on the record. R5's [NAME], printed on 12/16/24, lacked documentation of her preferred activity of going outside for fresh air. The [NAME] included directions to staff to make sure resident is up in wheelchair every day for one hour during lunch. Inform nurse if resident refuses to get up. During observation on 12/9/24 at 2:58 p.m., R5 was lying in bed wearing a hospital gown. R5 stated she wished staff would bring her outside more often. Her family member (FM)-D was at bedside visiting and R5 said something in Russian to FM-D, and FM-D translated back, she said, 'they do not take me outside.' During observation on 12/10/24 at 8:27 a.m., R5 was lying in bed wearing a hospital gown with the television on. During observation on 12/11/24 at 7:34 a.m., nursing assistant (NA)-D performed morning ADL cares and stated R5 was able to listen clearly and could point to things she wanted if she did not know the word for it. NA-D stated R5 knew a little English and was able to make her basic needs known. NA-D stated, we offer sometimes to get her up for a meal or if she wants to get up, but R5's family says if she doesn't want to, we don't need to push it. We were in the meeting, some of the nurses, and that's what they want us to do. NA-D stated R5 got out of bed once or twice a week, and if she refused, NAs were expected to report the refusal to the nurse. NA-D exited the room after morning cares without offer to reposition, get R5 up in the wheelchair, or offer of activity. There was a calendar taped to R5's closet door for September and it listed some speech eval dates but no activities identified. There was no activities calendar in R5's room. During follow-up interview on 12/11/24 at 7:54 a.m., NA-D stated R5's family brought her outside for activities and thought activities (A)-A sometimes brought her around the unit to look at things, but stated R5 was not someone who goes to other activities and would tell staff if she wanted to go. During observation on 12/13/24 at 9:53 a.m., R5 was lying in bed wearing a hospital gown with the television on. Per interview on 12/13/24 at 9:11 a.m. with A-A, residents were assessed for their activity preferences quarterly, annually, and with significant changes, and those preferences were documented in the care plan. A-A stated R5 slept at intervals throughout the day and didn't want to wake her if she was asleep. A-A indicated R5 had a history of refusing to get up and refusing activities. A-A stated for special occasions, like parties or Bingo, staff offered to get R5 out of bed for the activity, but she refuses. A-A identified R5 liked 1:1 visits and used to like reading Russian books, but stated that went in streaks. A-A confirmed, the language barrier can be an issue, but I try and articulate in English, and I will comment about her Russian television programs, and added, R5 sure likes the visits, as evidenced by her smiles during the visit. A-A stated during warmer months when R5's family visited, they would bring her outside and verified staff would notify activities if she was up in her wheelchair. A-A could not recall R5 asking to go outside directly but confirmed being unable to meet R5's activity preferences stating, I have not been able to get her up and in the wheelchair to go seeing the building. A-A believed activities helped with resident engagement, potentially reducing accidents like falls, improve resident satisfaction and helped residents feel good. A-A confirmed being the only activities staff in the facility and stated, when I'm not here, its independent activities adding having more staff in the department would definitely be helpful. A-A indicated on scheduled days off, the staff pretty much know what I do from seeing what I do, they know what the residents like from seeing what I do, and stated there was a basket of puzzles, coloring sheets, card games, and magazines in the unit manager's office on the memory care unit. A-A stated the residents off the memory care unit were more independent and some preferred to stay in bed and were not engaged. Per interview on 12/13/24 at 10:24 a.m. with the administrator, also acting as the interim co-scheduler with the director of nursing (DON), confirmed the facility's activities department could be more robust, but believed residents overall were enjoying themselves. They verified A-A was the only activities staff and stated there was capability for other staff to provide activities for residents to do when A-A was not scheduled. The administrator stated A-A visited the residents and did not believe the facility had lonely residents. The administrator believed, you can always use more resources around activities and believed this to be true for all facilities throughout the system. During interview on 12/16/24 at 12:01 p.m., the DON stated activities were super important because it helped residents feel like they were a part of something and was good for their mental health. The DON wished the facility could provide more activities and believed A-A was pushed past her limit. The DON was not aware of R5's request to go outdoors for fresh air and stated, if she's communicating, I've never heard she's communicated that to staff. The DON stated, it's difficult to know how much R5 knows about activities. The DON stated R5 could be agreeable to get up in the wheelchair for a good reason like an appointment but could decline to get up for a party. The DON expected staff to offer activities and opportunities to get up out of bed and document refusals but was unsure of nursing staff were documenting R5's refusals as they should be. Per facility policy titled Activities last revised 7/11/22, the facility would provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Per the policy, each resident's interests and needs would be assessed on a routine basis and would include an activity assessment to include a resident's interests, preferences and needed adaptations. Furthermore, the policy identified activities could include indoor and outdoor activities and directed staff to assist residents to and from activities when necessary. Additionally, the policy indicated the facility would consider accommodations in schedules, supplies and timing in order to optimize a resident's ability to participate in an activity of choice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure a resident was comprehensively assessed for appropriate treatment and services to prevent urinary tract infections (UTIs) and to restore continence to the extent possible for 1 of 1 residents (R3) reviewed for toileting programs. Findings include: R3's quarterly Minimum Data Set (MDS) dated [DATE], reported she had intact cognition, no hallucinations, delusions, or verbal, physical or other behavioral symptoms towards herself or others. The MDS identified R3 was dependent on staff for toileting hygiene and transfers, required substantial to maximal assist for mobility and all other transfers, had no urinary catheters, had not trialed a urinary or bowel toileting training program and was frequently incontinent of urine and bowel. Additionally, the MDS identified R3 was at risk for pressure injury wound. R3's Care Area Assessment (CAA) for urinary incontinence dated 11/8/24, confirmed the risk for skin breakdown and stated, she is at risk for MSAD [sic, moisture associated skin dermatitis] and infection. Furthermore, the CAA identified R3's history of urinary tract infections and listed preventative interventions staff implemented, including thorough peri care [sic, perineal] provided and barrier cream applied by staff as needed. R3's diagnosis report dated 12/12/24, indicated she had arthritis (inflammation of the joints causing pain, stiffness, and impaired mobility), muscle weakness, reduced mobility, right hip replacement, unsteadiness on feet, history of UTIs, depression, unspecified psychosis (a cluster of symptoms causing a person to lose touch or have a break with reality) not due to a substance or known physiological condition, anxiety, sleep apnea (a disorder that can cause people to stop breathing when they are asleep), and chronic pain syndrome. A bladder/incontinence evaluation dated 10/16/24, identified R3 took a narcotic/sedative/hypnotic medication that might have contributed to her bladder dysfunction. The evaluation summary reported, resident stable. The evaluation was otherwise blank, and lacked further documentation of other potential risk factors contributing to her bladder incontinence. A bladder/incontinence evaluation dated 11/5/24, identified R3's risk factors for incontinence included impaired mobility and her dependence on 2 persons for transfers. The evaluation identified R3 was currently incontinent of bladder and the signs and symptoms exhibited included urgency, daytime frequency, and nocturia (a medical term for waking up at night to urinate, in this evaluation, it means greater than 2 times per night). Additional risk factors identified included polypharmacy (taking many medications), a history of UTIs, and taking antidepressant and antianxiety medications. The evaluation indicated a physical examination had not been performed, no post void residual (PVR) studies had been attempted, and no treatment program initiated. The evaluation cited R3's impaired cognition and mobility in determining her mixed incontinence (stress and urge) but lacked documented treatment programs and/or interventions that may promote R3's continence or improve her current level of function. The evaluation summarized the assessment, incontinence both bowel and bladder. R3's care plan revised on 11/15/24, identified R3's activities of daily living (ADL) self-care deficit and directed staff to provide 2 staff assist with toileting, bed mobility, and transfers. Additionally, the care plan indicated staff should use a hoyer large sling for transfers to meet R3's goal to improve current level of function in ADLs. R3's care plan also identified her urinary and bowel incontinence related to deconditioning secondary to UTI lasted revised 11/15/24. The care plan outlined her goal to have no complications due to incontinence and directed staff to provide assistance with toileting and incontinence cares, use absorbent products as needed, and report signs and symptoms of UTI and skin breakdown. The care plan lacked interventions to promote R3's continence or improve current level of function. R3's care plan furthermore identified her risk for alteration in skin integrity related to her impaired mobility and incontinence. The goal, last revised 11/15/24, was to decrease and/or minimalize skin breakdown risks and resolve yeast (fungal) infection. The care plan guided staff to apply barrier cream as needed, encourage her to reposition as needed, float heels as able, observe for and report skin changes and utilize pressure redistributing devices in her bed and chair. The care plan focus lacked interventions to promote continence and/or improve her current level of functioning to reduce her risk of skin breakdown. R3's hard chart was reviewed on 12/11/24 and included the following orders: - Diflucan (antifungal) for vaginitis (inflammation of the vagina), dated 12/10/24. - cefuroxime (antibiotic) for UTI, dated 12/7/24. - urinalysis/urine culture (UA/UC, a lab test performed to diagnose and treat a UTI), dated 12/6/24. - UA (a urine lab test to preliminarily diagnose a UTI), dated 12/4/24. Per a lab report dated 12/6/24, the urine culture showed an abnormal growth of greater than 100,000 colony forming units (CFU)/milliliter (mL) Klebsiella pneumoniae (a bacteria). Copies of these orders and lab reports were requested but not received. A provider note dated 12/10/24, confirmed the hard chart orders and lab report and indicated she was seen for urinary tract infection and indicated she was started on Bactrim. Later UC resulted to be UC +> 1000,000 [sic] CFU/mL Klebsiella pneumoniae. The provider note indicated an improvement of symptoms of dysuria (painful urination), urgency, and increased incontinence. Additionally, the provider note indicated, the patient's unspecified urinary incontinence is reportedly stable. Under the Assessment and Plan:, the provider issued new orders, including the Diflucan 150 milligrams (mg) by mouth (po) x 1 dose, may repeat in 72 hours if remains symptomatic (vaginal itching). A PlanOfCare (POC) for R3's task sign-off for transferring with a lookback period of 30 days, dated 11/12/24 - 12/11/24, indicated staff documented R3 required 2 person assistance with transfers on 33 instances, 1 person assisstance on 4 instances, response not required on 44 instances, and required no physical help or set-up on 1 instance out of 85 opportunities. Per physical therapy PT evaluation and plan of treatment note dated 11/22/24, R3 was referred to physical therapy for evaluation and treatment of a decline in her functional mobility per her provider. Per a physical therapy PT progress report dated 11/22/24 - 12/9/24, R3 met her goals of improved ability to transfer to a standing position from sitting with partial to moderate assistance with a front wheeled walker (FWW); to improve her ability to safely transfer and efficiently transfer to and from a bed to a chair (or wheelchair) with substantial to maximal assistance; and to safely ambulate on level surfaces 10 feet using two-wheeled walker with partial/moderate assistance to increase independence within the facility and to facilitate participation in functional activity. The progress report identified new goals, included ambulation goals at longer distances and less staff assistance with transfers. The report indicated R3 was making consistent progress towards reaching short-term and long-term goals and her condition has potential to improve as a result of skilled rehab and patient's functional performance is progressing as a result of exercises. Per physical therapy treatment encounter note(s) dated 12/12/24, staff and R3 were trained on safe transfers using the EZ stand from the edge of her bed to the wheelchair and back again using 2 staff assistance. The note reported it was okay to downgrade the transfers to hoyer and notify therapy if R3 was deemed unsafe for any reason with the transfers. The note indicated R3 and staff confirmed they have not had safety concerns with EZ stand transfers, but confirm knowledge of ability to downgrade to ensure patient safety if concern were to arise. Made repeat rehab communication form to confirm continued EZ stand transfer status of assist of 2 staff for nursing staff. During observation on 12/9/24 at 2:59 p.m., R3 was in her bed and appeared asleep. During observation on 12/10/24 at 8:29 a.m., R3's room was dark, and the shades were pulled. She was in bed with the covers over her and her eyes were closed. A continuous observation on 12/11/24 between 10:48 a.m. and 11:37 a.m. included: 10:48 a.m.: R3's call light was put on. 10:49 a.m.: nursing assistant (NA)-A entered R3's room to answer the call light and was heard stating she would be back to help her. Per interview at 10:49 a.m., R3 verified NA-A stated she would be back to help clean her up. 11:09 a.m.: the director of nursing (DON) walked down the hallway and asked where NA-A was. Within 2 minutes, the DON left the unit and was observed walking onto the elevator leaving the second floor. 11:13 a.m.: NA-A was not back to assist. An overhead page was heard announcing, 2 west, you have a resident call. 11:14 a.m.: There were no staff observed on the 2 East of the unit. An overhead page was heard announcing, 2 west nurse please call and a call-back number was read aloud. 11:18 a.m.: No staff were present on the 2 east unit. 11:20 a.m.: Licensed practical nurse (LPN)-H walked onto the 2 east unit to the medication cart. 11:22 a.m.: LPN-H left the medication cart and walked off the 2 east unit. No staff have attempted to enter R3's room. 11:26 a.m.: Activities-(A) pushed another resident into his room and walked back out and off the 2 east unit without addressing other residents within a minute. 11:30 a.m.: NA-A walked off the elevator, walked through the nurse's station and into the nurse manager's office. No visible staff observed down the 2 west hallway or the 2 east hallway. 11:38: a.m.: An unidentified staff walked off the elevator and back to the nurse manager's office. 11: 41 a.m.: LPN-H and NA-A walk back to the 2 east unit and hallway. 11:42 a.m.: LPN-H and NA-A entered R3's room to assist with cares requested from call light request at start of observation. During interview on 12/10/24 at 1:37 p.m., R3's family member (FM)-C verbalized concerns about the staffing in the facility and stated, I think they're understaffed, and they don't have the time to respond to call lights or calls. FM-C identified evenings and mealtimes as the longest wait times when R3 puts her call light on for assistance. FM-C stated on numerous occasions while visiting during mealtimes, R3 put her call light on and staff won't respond at all and FM-C would have to go and find someone to talk to get help. FM-C reported during the evening, if R3 put her call light on and waited an extended period, she would call FM-C at home. FM-C would then call the facility using a personal phone to get staff to assist with R3's toileting cares. During interview on 12/11/24 at 9:13 a.m., R3 reported the call light wait times were just horrible, weekends are the worst. R3 believed the longest she waited was an hour and was unable to recall any times where she had waited for her call light to be answered and become incontinent or had fallen. R3 stated she was not aware of her urge to void. During follow-up interview at 10:45 a.m., R3 stated she did mind the bedpan, and had not attempted to use the bedside commode since her admission because it just doesn't work. R3 stated felt like she needs to have a bowel movement. During interview on 12/11/24 at 2:22 p.m., physical therapist (PT) verified R3 was working with physical therapy and was picked back up on 11/21/24 for decline in strength with transfers. PT stated R3 was working on transfers and gait during their sessions and she made a big jump in her progress. PT confirmed R3 could safely transfer with moderate to maximal assistance with 2 staff and a FWW, but expected NAs to use an EZ stand for transfers. PT verified R3's goals were to transfer without the EZ stand and to ambulate with staff safely. PT stated the obstacles for R3 in attaining her goals included her forgetting the sequencing side of things, for example, the confusion in what she can do and in what order. PT stated the recommendations to nursing staff were to provide verbal cueing on what steps to perform and in what order and for R3 to call for help in getting out of bed. Per interview on 12/12/24 at 4:14 p.m., R3's nurse practitioner (NP) explained that Klebsiella pneumoniae, the bacteria found growing in her UC, was a common bacteria in the gut and verified the UTI diagnosis on 12/10 with the Ceftin antibiotic order on 12/7/24. NP further explained that Klebsiella pneumoniae was a common bacterium that could cause UTIs, stating it could be common with poor hygiene. She has told me takes awhile to get cleaned up at the facility. Incontinence and poor hygiene could contribute to developing a UTI that showed Klebsiella growth. NP elaborated it could be difficult for her to be entirely dry, being incontinent and with her mobility issues. I think she has had a delay in care due to her restricted mobility with not being able to get up and out of bed or move much. Per interview on 12/16/24 at 9:57 a.m. with LPN-A, R3 had not trialed and was not currently on a bowel or bladder toileting program. LPN-A stated occupational therapy initiated those programs and would only do so if a resident had awareness of their urge to use the bathroom, stating occupational therapy usually assessed a resident's awareness of continence during admission, and if they did not identify that as a goal, then we do not start a toileting program. LPN-A stated if a resident was in the facility long-term and staff observed they were unable to do daily tasks they were once able to do for themselves but were currently unable to perform and the resident verbalized a desire to perform those ADLs, staff could request an occupational therapy evaluation. LPN-A stated R3 would not be a candidate for a toileting program because she could not stand and because she admitted incontinent of both bowel and bladder. LPN-A confirmed she was working with physical therapy and stated, they've been trying to stand with her but we have not been. Per interview on 12/16/24 at 12:01 p.m. with the DON, a bowel and/or bladder toileting program can be initiated with an assessment or screener. The biggest things reviewed during the assessment include a resident's therapy status, transfer abilities, and skills. The DON stated it was definitely an IDT discussion and contradicted LPN-A, stating any staff person was able to bring up a concern or recommendation for a toileting program. The DON agreed occupational therapy could be responsible for guiding the program, but indicated the facility did not have an occupational therapist. The DON stated the benefits of a toileting program for residents included increased self-esteem and self-worth, decreased risk of UTIs and skin breakdown, and the potential for increased mobility for residents, and task and workload reduction for staff. The DON stated R3 could be someone we could consider for a toileting program at first glance, but digging deeper, she might not be. The DON reported R3's cognitive issues, stating she has hallucinations, and her unawareness of her urge to void as the reasons a toileting program would not appropriate. The DON believed R3 would need therapy involved directly for a toileting program to be effective, stating, saying the words 'therapy ending' to her stopped her standing with nursing staff. The DON confirmed toileting a resident at the same time every day is a good thing, and believed R3 could use a bedside commode with the EZ stand. The DON verified the facility's staffing was not ideal. The DON verified resident needs were exceeding staffing levels and agreed resident outcomes were suffering. The DON stated, our staffing is not meeting the needs of our residents. If we're only meeting bare minimum, that's not good customer service. A facility assessment dated [DATE], indicated it evaluated the facility's resident population and identified resources needed to provide the necessary care and services to residents during day-to-day operations and emergencies. The assessment tool identified itself as a resource for the facility's leadership to use when making decisions for purposes regarding sufficient staffing numbers, competent staff, recruitment, and retention of staff, and continency planning for emergency events. The assessment indicated input form residents, their representatives, staff, and resident council meeting minutes were reviewed for applicable input. The assessment identified other pertinent facts or descriptions of the resident population to be considered when determining staffing and resource needs which included the following: - require a Hoyer or Sit-to-Stand lift (2-person transfer). - are on increased monitoring for behaviors or are Cares in Pairs. - require hands-on transfer assistance. - have mixed preferences for eating in the dining room, versus resident room. - needs of ancillary staff (readying those residents who receive therapy by a certain time each, for instance). The assessment indicated physical therapy and specific rehabilitation services provided services such as ADL cares to support a resident's independence in doing as much of the ADLs by himself/herself. Furthermore, the assessment indicated it provided bowel and bladder care, including incontinence prevention and care and responding to requests for assistance to the bathroom or toilet promptly in order to maintain continence and promote dignity. A request for policies pertaining to toileting programs, incontinence, and staffing were requested but not received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure prescription topical medications were applied and documented in accordance with professional standards of practice for 1 of 2 residents (R26) observed during morning activities of daily living (ADL) cares. Findings include: R26's quarterly Minimum Data Set (MDS) dated [DATE], indicated severely impaired cognition and substantial to moderate staff assistance with personal and toileting hygiene cares. The MDS identified diagnoses of muscle weakness, depression, and high blood pressure. R26's undated and unsigned order summary was reviewed 12/11/24, and reflected the following active physician orders: - Nystatin external powder 100000 unit/gm (gram) (Nystatin (Topical)) Apply to skin folds topically as needed for rash under breasts, dated 9/9/24. - Nystatin powder (Nystatin (Bulk)) Apply to groin topically every 12 hours as needed for groin, dated 10/8/24 A request for R26's most recently signed order summary was requested but not received. R26's medication administration record (MAR) dated 10/2024, lacked documentation of as needed (PRN) Nystatin powder administration for rash under breasts, as well as groin. R26's MAR dated 11/2024, lacked documentation of as needed (PRN) Nystatin powder administration for rash under breasts, as well as groin. R26's MAR dated 12/2024, lacked documentation of as needed (PRN) Nystatin powder administration for rash under breasts, as well as groin. R26's treatment administration record (TAR) dated 10/2024, indicated an order for, weekly skin review every evening shift every Fri [sic, Friday] if new area is identified follow protocol . This order was marked as completed on 10/3/24, 10/11/24, 10/18/24, and 10/25/24. R26's TAR dated 11/2024, indicated an order for, weekly skin review every evening shift every Fri [sic, Friday] if new area is identified follow protocol . This order was marked as completed on 11/1/24, 11/8/24, 11/15/24, 11/22/24, and 11/29/24. R26's TAR dated 12/2024, indicated an order for, weekly skin review every evening shift every Fri [sic, Friday] if new area is identified follow protocol . This order was marked as completed on 12/6/24. R26's care plan dated 9/9/24, identified her self-care deficit and guided staff to provide assistance with personal hygiene and bathing cares. Additionally, the care plan identified a risk for skin integrity concerns and indicated a head-to-toe assessment would be performed by a licensed nurse. During observation on 12/11/24 at 7:34 a.m., nursing assistant (NA)-D performed morning cares with R26. NA-D washed under R26's underarms and breasts and patted the areas dry with a clean hand towel. NA-D stated R26 had dry skin and every morning NA-D applied lotion and the doctor ordered this powder for under R26's arms and breasts. NA-D showed the surveyor a bottle with a prescription label affixed to it that read, Kaylesta (Nystatin) powder. NA-D stated they gave me this to put on for the dry skin and NA-D applied the powder from the bottle under R26's arms and breasts. NA-D further explained R26 had issues with her skin intermittently because she's a large woman with a lot of skin there. NA-D stated NAs monitored the skin and would report when the areas were improving or worsening to the nurses as well if NAs used the powder on R26. Per interview on 12/13/24 at 9:46 a.m., licensed practical nurse (LPN)-D expected prescription medications, including topical powders like Nystatin, be applied by nurses because nurses were responsible for the assessment piece and to determine if a resident had reactions to the medication. Per interview on 12/13/24 at 9:53 a.m. with LPN-C, prescription topical medications, like Nystatin powder, should be kept in the locked medication cart and should be applied by a nurse unless a resident had been assessed to safely administer their own medications and had the order in place. LPN-C reviewed R26's MAR and confirmed there were no documented administrations of Nystatin powder on 12/11/24, or for the MAR dated 12/2024. LPN-C was unaware of any skin concerns for R26. LPN-C was unable to locate a skin assessment for R26 identifying any current skin concerns for R26. LPN-C stated a NA applying a prescription topical powder without a nurse's knowledge and keeping it at bedside sounds like an educational piece. LPN-C verified the prescription bottle of Nystatin powder in R26's room before locking the bottle in the medication cart. Per interview on 12/16/24 at 12:01 p.m., with director of nursing (DON), only the nurse should apply medications that are prescribed unless a resident had been assessed to administer them safely themselves and had an order to do so. The DON stated this was important because nurses needed to follow the rights of medication administration. The DON stated prescription medications, including topical powders like Nystatin, should be kept in the nurse's cart. Per facility policy titled Medication Administration dated 1/2024, medications were expected to be administered in accordance with manufacturer's specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. The policy directed staff to have medications prepared only by licensed nursing, medical, pharmacy or other personnel authorized by state regulations to prepare medications. Further, the policy directed the individual who administered the medication to record the administration on the resident's MAR immediately following the medication being given and if administer a PRN (as needed) medication, the individual administering the medication should also document the date and time, dose, route of administration, complaints or symptoms for which the medication was given, results achieved from giving the dose and the time the results were noted, and a signature or initials of person recording the administration and/or of the person recording effects.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to provide appropriate side effect monitoring (including vital and orthostatic blood pressure monitoring) and obtain informed consent for psychotropic medication and ensure a PRN (as needed) psychotropic medication order included an end date for 1 of 5 resident (R1) reviewed for unnecessary medication use. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 had severe cognitive impairment, inattention and disorganized thinking which fluctuated, did not have physical, verbal, or other behavioral symptoms, did not reject cares, had diagnoses of heart failure, hypertension (high blood pressure), thyroid disorder, arthritis (conditions which cause inflammation of the joints), osteoarthritis (chronic disease when cartilage which lines joints are worn down and bones rub against each other), and adjustment disorder with mixed anxiety and depressed mood. Further R1 took an antipsychotic and antidepressant. R1's Order Summary Report dated 12/12/24 indicated the following orders: - 11/27/24, Depakote (anticonvulsant used to treat seizure and bipolar disorders) oral tablet delayed release 500 mg. Give one tablet by mouth at bedtime related to adjustment disorder with mixed anxiety and depressed mood. - 11/27/24, trazodone HCL [hydrochloride] (antidepressant used to treat depressed mood and other depression-related symptoms) oral tablet 150 mg. Give 75 mg by mouth at bedtime for trouble sleeping. - 11/27/24, trazodone HCL oral tablet 50 mg. Give 25 mg by mouth as needed for trouble sleeping, with no end date noted. - 11/30/24, Seroquel (quetiapine fumarate; antipsychotic used to treat schizophrenia, bipolar disorder, and depression) oral tablet 25 mg. Give one tablet by mouth as needed TID (three times a day) for anxiety, restlessness and agitation related to adjustment disorder with mixed anxiety and depressed mood, with end date of 12/13/24. - 12/10/24, Seroquel oral tablet 100 mg. Give one tablet by mouth at bedtime for insomnia. - 12/10/24, quetiapine fumarate oral tablet 25 mg. Give 12.5 mg by mouth two times a day for agitation and/or impulsiveness. - 12/11/24, Neurontin (gabapentin; anticonvulsant used to treat seizures and nerve pain) oral capsule 300 mg. Give one capsule by mouth three times a daily for anxiety and/or pain. R1's care plan printed on 12/16/24, indicated R1 was at risk for adverse effects related to use of psychotropic medications, which was initiated 10/29/24. The care plan included an intervention revised on 10/20/24 to evaluate effectiveness and side effects of medications for possible decrease and/or elimination of psychotropic drugs. The care plan did not indicate vital or orthostatic blood pressure monitoring. R1's MAR/TAR (medication administration record; treatment administration record) dated November and December 2024, indicated R1 received trazodone PRN on 11/27/24, 12/2/24, and 12/7/24. R1's MAR/TAR for November 2024, directed staff to enter R1's vital signs weekly every Tuesday PM [evening] with start date of 11/5/24 and end date of 11/27/24. Vitals were recorded on 11/5/24, 11/12/24, 11/19/24, and 11/26/24 indicated R1 was hospitalized . R1's medical record had no indication of vital monitoring after 11/27/24. Further, R1's medical record had no indication of orthostatic blood pressure monitoring. R1's medical record had no indication of consent by the resident, family, or guardian for use of gabapentin. When interviewed on 12/13/24 at 10:57 a.m., licensed practical nurse (LPN)-A stated nursing spoke with resident or family member to give education about psychotropic medications and obtained consent and signed a form placed in residents' paper chart. LPN-A stated orthostatic blood pressures were taken every few months and scheduled in the MAR/TAR. LPN-A stated nursing wrote progress notes if residents refused orthostatic blood pressure monitoring. LPN-A stated they monitored residents' vitals daily when first admitted and then weekly vitals with bathing and skin assessment unless resident acutely ill. LPN-A stated vitals were recorded in the MAR/TAR and transferred over to the medical record's vitals tab. LPN-A stated they observed for side effects of psychotropic medications daily per the MAR and TAR. LPN-A stated trazodone prn should be scheduled for 14 days, and prn trazodone use would be evaluated after the set time frame to see if still needed and document a reason to uphold the order. When interviewed on 12/13/24 at 2:26 p.m., LPN-B stated R1 entered the facility on psychotropic medications, and they reviewed R1's medications with R1's family member and filled out the consent form for R1. LPN-B confirmed they did not get a consent for gabapentin and was not sure if they needed to and stated nursing needed to monitor for side effects of gabapentin such as drowsiness, dry mouth, and tremors. LPN-B stated not all psychotropics required orthostatic blood pressure monitoring and were scheduled once a month if needed on the TAR. LPN-B confirmed R1 did not have orthostatic blood pressure monitoring, and R1 may need orthostatic blood pressure monitoring for use of Seroquel. LPN-B stated resident vitals were checked once a week with their shower and skin assessment. LPN-B stated vitals were entered into the MAR/TAR and automatically went to the vitals tab. LPN-B confirmed R1 did not have weekly vital monitoring scheduled. LPN-B stated they placed in orders to monitoring for psychotropic medication side effects every shift per the medical record order set. LPN-B confirmed R1 did not have psychotropic monitoring in the MAR/TAR or vital or orthostatic blood pressure monitoring in the care plan. LPN-B confirmed R1's order for prn trazodone did not have an end date and did not have a provider documented reason for the indefinite order. DON expected prn trazodone to have a 14 day stop date. DON stated it was important for prn psychotropics to have a stop date to ensure the providers were evaluating the medications use and side effect monitoring. When interviewed on 12/16/24 at 11:01 a.m., the director of nursing (DON) expected nursing to obtain consent for psychotropic medication, which included gabapentin depending on if used for a psychological change. DON agreed gabapentin used for anxiety and/or pain needed a consent for administration. DON stated obtaining consents were important to ensure resident or responsible party were aware of side effects, which included irreversible side effects. DON expected nursing to have orthostatic blood pressures recorded monthly for R1, unless R1 had issues with blood pressure. DON expected residents' vitals to be taken at least once a week. DON stated R1 was noncompliant and expected to see notes of refusals. DON expected R1 to have three days of vital monitoring when returned from hospital on [DATE]. DON expected nursing to monitor for psychotropic side effects according to pharmacist recommendations. When interviewed on 12/16/24 at 11:11 a.m., the consulting pharmacist (CP) CP expected nursing to obtain consent for R1's gabapentin use after a risk and benefit education. CP verified R1's prn trazodone did not have a stop date and an end date was important to have to ensure the medication was re-evaluated per regulations. CP expected staff to monitoring for orthostatic blood pressures for antipsychotics and confirmed R1 should have psychotropic medication side effect monitoring in place but did not. The Psychotropic Medications policy dated 10/24/22, indicated a psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs included but were not limited to antipsychotics, antidepressant, anti-anxiety, and hypnotics. The policy directed staff to educate residents and/or representative on the risks and benefits of psychotropic drug use. Further, the policy indicated prn orders for all psychotropic drugs would be used only when the medication was necessary to treat a diagnosed specific condition, which was documented in the clinical record, and for a limited duration, such as 14 days. Additionally, the policy directed staff to monitor effects of psychotropic medications on residents' physical, mental, and psychosocial well-being on an ongoing basis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure a bed remote control was monitored and kept in safe condition for 1 of 1 resident (R16) reviewed for bed controls. Findings include: R16's quarterly Minimum Data Set (MDS) dated [DATE], indicated R16 had severely impaired cognition and diagnoses of heart failure, diabetes mellitus, depression, and dementia. R16 had no impairment to upper and lower extremity and was independent with mobility, such as rolling left and right, sit to lying, and lying to sitting on side of bed and required more assistance with transfers and dressing. During observation and interview on 12/9/24 at 2:42 p.m., R16 laid in bed with the bed controller within reach. The bed controller cord had a black covering which had a half inch or less gap between the controller with the buttons and insulated wires were visible and not frayed. R16 stated they used their bed controller independently. When interviewed on 12/13/24 at 2:12 p.m., nursing assistant (NA)-G stated R16 required extensive assistance for most ADLs but was able to turn herself side to side in bed and used the bed controller independently. NA-G did not notice wires on R16's bed controller but would report to nursing and maintenance if observed. NA-G stated the facility had a TELS (a building management platform) system to report concerns to maintenance. When interviewed on 12/13/24 at 2:16 p.m., licensed practical nurse (LPN)-I stated they had not heard about any bed controller concerns recently but would report to maintenance or director of nursing if such a concern occurred. LPN-I stated electrical concerns caused risk of shock and at times have needed to disconnect residents' bed and move them to another room to ensure safety. When interviewed on 12/13/24 at 2:18 p.m., LPN-B expected staff to place a maintenance request in TELS if they saw exposed wires to protect resident safety. LPN-B observed R16's bed controller and ensured it worked. LPN-B stated there were exposed wires but were not frayed so would let the administrator know the controller needed to be replaced. The TELS Work Orders dated 3/1/24 to 12/12/24, did not indicate R16's bed controller needed repair. When interviewed on 12/16/24 at 10:02 a.m., the administrator stated they saw the bed controller and replaced it. Administrator expected staff to enter a TELS request if a bed controller needed replacement. The Work History Report dated January to October 2024, indicated Bed-Electric audits were completed 8/10/24 and described as not good. The report described the beds as shortage of good beds on 8/17/24, very short on 8/24/24, short on good beds on 8/31/24, beds are poor condition, and we are low on 9/7/24. The task was indicated as skipped with description no maintenance director at this time on 9/14/24. The Perform Bed Inventory Check for Beds-Electric indicated no action recorded on 9/21/24 and 9/28/24. Bed safety audits were completed on 9/30/24. The task did not record any action on 10/5/24. The task indicated no maintenance director at this time and action skipped on 10/12/24. The task did not record any action on 10/19/24 and 10/26/24. The Physical Environment: Electrical Equipment Policy dated 6/16/22, indicated the maintenance director would maintain schedules for routine inspection and maintenance of all machinal, electrical, and patient care equipment. The policy directed inspection, testing, and maintenance of electrical equipment to be tracked in the TELs building management platform.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure consultant pharmacist recommendations were acted upon timely for 4 of 5 residents (R1, R5, R8, R14) reviewed for unnecessary medications. Findings include: R1 R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 had severe cognitive impairment, inattention and disorganized thinking which fluctuated, did not have physical, verbal, or other behavioral symptoms, did not reject cares, had diagnoses of heart failure, hypertension (high blood pressure), thyroid disorder, arthritis (conditions which cause inflammation of the joints), osteoarthritis (chronic disease when cartilage which lines joints are worn down and bones rub against each other), and adjustment disorder with mixed anxiety and depressed mood. Further, R1 took an antipsychotic and antidepressant. R1's Order Summary Report dated 12/12/24, indicated the following orders: - 11/27/24, Depakote oral tablet delayed release 500 mg (used for manic depression). Give one tablet by mouth at bedtime. - 11/27/24, trazodone HCL [hydrochloride] oral tablet 150 mg (an antidepressant often used for sleep). Give 75 mg by mouth at bedtime . - 11/27/24, trazodone HCL oral tablet 50 mg. Give 25 mg by mouth as needed, with no end date noted. - 11/30/24, Seroquel oral tablet 25 mg (quetiapine fumarate) (an antipsychotic). Give one tablet by mouth as needed TID (three times a day), with end date of 12/13/24. - 12/10/24, Seroquel oral tablet 100 mg (quetiapine fumarate). Give one tablet by mouth at bedtime. - 12/10/24, quetiapine fumarate oral tablet 25 mg. Give 12.5 mg by mouth two times a day. - 12/11/24, Neurontin oral capsule 300 mg (gabapentin) (often used for pain). Give one capsule by mouth three times a daily. R1 did not have side effect and/or adverse effect monitoring in place. R1's Pharmacy Review assessment dated [DATE], indicated recommendations were made and to view Clinical Pharmacy Report. The section New Medications/General/Recommendation notes indicated: Memory; migraines, chronic pain; HLD, HF, adjustment disorder 11/24 PRN. R1's Clinical Pharmacy Report dated 11/4/24, was reviewed onsite and directed nursing to identify an end date for trazodone or provider rationale and documentation for extended end date, and add in psychotropic side effect monitoring. A copy was not provided. R1's Pharmacy Review assessment dated [DATE], indicated recommendations were made and to view Clinical Pharmacy Report. The section New Medications/General/Recommendation notes indicated: Memory; migraines, chronic pain; HLD, HF, adjustment disorder 12/24 REC: clarifications 11/24 PRN. R1's Clinical Pharmacy Report dated 12/2/24, was reviewed onsite and noted to have repeated both recommendations from 11/4/24. A copy was not provided. R5 R5's significant change Minimum Data Set (MDS) dated [DATE], indicated she had severe cognitive impairment with diagnoses of heart failure, kidney failure, respiratory failure, anxiety, depression, and lymphedema (a chronic condition causing swelling from lymph or protein-rich fluid in the body's tissues). The MDS further indicated R5 received hospice care. R5's unsigned order summary was reviewed 12/13/24, and included the following orders: - albuterol-budesonide inhalation 90-80 micrograms (mcg) / actuation (ACT), 2 puff inhale orally every 6 hours as needed for shortness of breath, dated 10/29/24. - furosemide oral tablet, Give 40 milligrams (mg) by mouth one time a day for pulmonary edema (fluid buildup the lungs), heart failure with chronic kidney disease and failure, dated 3/12/24. - lorazepam oral concentrate 0.125 milligrams (mg) / milliliter (mL), Give 0.25mL every 4 hours as needed for agitation 0.5mg=0.25mL, dated 11/05/24. - lorazepam oral tablet 0.5mg, Give 1 tablet sublingually every 3 hours as needed for anxiety, dated 10/29/24. - morphine sulfate (concentrate) oral solution 20 mg/mL, Give 0.25mL by mouth every 4 hours as needed for shortness of breath/pain, dated 12/13/24. - quetiapine fumarate oral tablet, Give 150mg by mouth at bedtime, for anxiety, depression, dated 2/29/24. - sertraline hydrochloride (HCl) oral tablet 50mg, Give 50mg by mouth one time a day for depression, dated 10/14/24. A request R5's most recent signed order summary was requested during survey and not received. R5's care plan last revised 11/18/24, identified her use of psychotropic medications (antidepressants, antianxiety, and antipsychotics) and diuretic therapy to treat her lower extremity therapy. The care plan directed staff to perform medication regimen reviews (MRRs) as needed, identify available resources and needs for treatment, and attempt GDRs per orders. A pharmacy review notes dated 9/5/24, 10/14/24, and 11/4/24, indicated recommendations were made. The notes referred to the clinical recommendations reports. A PharMerica note to attending Physician/Prescriber MRR dated 9/5/24, provided a recommendation for periodic lipid panel for R5's medications. The provider signed the MRR on 10/31/24 and deferred to R5's hospice team. A PharMerica note to attending Physician/Prescriber MRR dated 11/4/24, provided a recommendation regarding duplicative therapy. The MRR lacked provider signature or follow-up. A PharMerica note to attending Physician/Prescriber MRR dated 11/4/24, provided a recommendation regarding R5's lorazepam order. The note stated as needed (PRN) psychotropic orders required no more than 14 days duration or, if deemed necessary beyond, a clinical rationale and specific duration documented by provider. The MRR lacked provider signature or follow-up. A PharMerica nursing recommendations for the recommendations created between 11/4/24 and 11/6/24, indicated R5's albuterol-budesonide inhalation aerosol order should NOT be a combination product and directed staff to review data entry. The MRR lacked nursing signature or follow-up. A PharMerica note to attending Physician/Prescriber MRR dated 12/3/24, provided a recommendation regarding R5's lorazepam orders. The note requested the provider add parameters for when to use the lorazepam tablets versus the concentrate. Additionally, the note repeated the request for the PRN lorazpem order to include an end date of no more than 14 days, and if deemed necessary to include a clinical rationale and a specific duration. The MRR lacked provider signature and follow-up. R5's EMR was reviewed and lacked documentation of MRR follow-up. A request was made for provider response and/or documentation of MRR follow-up and was not received. R8 R8 admission Minimum Data Set (MDS) dated [DATE], included an admission date of 2/20/13. R8's diagnosis included schizophrenia. R8's order summary report dated 4/3/24, included diagnosis of mild cognitive impairment, schizoaffective disorder (a mental health disorder with symptoms of both schizophrenia and a mood disorder), depression, bipolar disorder (extreme mood swings), and hording disorder. PharMerica Nursing Recommendations dated 8/9/24, included a recommendation to complete labs that were ordered in May but not completed and to place results in the chart. No facility notes were placed in the follow-Through section of the form. PharMerica Nursing Recommendations dated 10/11/24, again recommended completion of labs ordered in May that were never completed. Again, the facility failed to place notes in the follow-through section of the form. When interviewed on 12/16/24 at 11:11 a.m., the consulting pharmacist (CP) stated they were unsure if R8 declined the labs or the provider did not order. CP stated they needed to be able to see the provider's follow-up to their recommendations or labs drawn on residents. R14 R14's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition and reported no behaviors, hallucinations, or delusions. The MDS indicated R14 had heart failure, high blood pressure, kidney failure, obstructive sleep apnea (sleep disorder causing your breathing to repeatedly stop or be reduced while you sleep), respiratory failure, anxiety, depression, bipolar disorder, and dementia (a neurological condition causing a decline in thinking, memory, and behavior). The MDS indicated she was diabetic and received insulin injections over the lookback period, in addition to antidepressants and antianxiety medications. The MDS lacked documentation on if a drug regimen review was assessed and if issues were found. Furthermore, the MDS confirmed medication follow-up was not assessed/no information and the MDS lacked documentation on medication intervention assessment. R14's Care Area Assessment (CAA) for psychotropic drug use dated 8/13/24, indicated the consultant pharmacist (CP) reviewed her medications and made recommendations to the interdisciplinary team (IDT) monthly and as needed. A signed order summary dated 6/6/24, identified the following orders: - carvedilol oral tablet milligram (mg), Give 6.25mg by mouth two times a day, for heart failure, dated 2/12/24. - doxepin hydrochloride (HCl) oral capsule 10mg, Give 20mg by mouth at bedtime for insomnia related to obstructive sleep apnea, dated 2/12/24. - fluoxetine HCl oral capsule 20mg, Give 20mg by mouth in the morning for depression, dated 2/12/24. - furosemide oral tablet, Give 40mg by mouth one time a day dated 2/12/24. - novolog injection solution 100 unit/milliliter (mL) (Insulin Aspart), Inject 17 unit subcutaneously before meals for diabetes, dated 4/8/24. - Remeron tablet (Mirtazapine) Give 7.5mg by mouth at bedtime for depression, dated 2/12/24. - Wellbutrin Sustained-Release (SR) oral tablet Extended Release (ER) 12 Hour 100mg (bupropion HCl), Give 100mg by mouth one time a day for depression, dated 2/12/24. A request for R14's most recent signed order summary prior to survey entrance was requested but not received. R14's medication administration record (MAR) dated 12/2024 reflected the following active and administered medication orders: - carvedilol oral tablet milligram (mg), Give 6.25mg by mouth two times a day, for heart failure, dated 9/13/24. - fluoxetine HCl oral capsule 20mg, Give 20mg by mouth in the morning for depression, dated 6/19/24. - furosemide oral tablet 20mg, Give 3 tablet orally one time a day, for heart failure, give 3 tablets (60mg), dated 11/14/24. - isosorbide mononitrate ER 24 Hour oral tablet, Give 60mg by mouth one time a day, for high blood pressure and chronic kidney disease, dated 11/16/24. - lidocaine external gel 4%, Apply to right shoulder topically every 12 hours for shoulder pain, dated 11/25/24. - mirtazapine oral tablet 7.5mg, Give 1 tablet my mouth at bedtime for depression, dated 11/19/24. - novolog FlexPen Subcutaneous Solution Pen-injector 100 unit/mL (Insulin Aspart), Inject 14 unit subcutaneously with meals for diabetes with chronic kidney disease, dated 10/31/24. - Wellbutrin SR oral tablet Extended Release 12 Hour 100mg (bupropion HCl), Give 100mg by mouth one time a day for depression, dated 6/19/24. R14's care plan, last revised on 8/21/24, identified her use of antidepressants and dependence on insulin and risks associated with each medication. The care plan included goals to be free of complications related to the use of the medications and directed staff to administer medications per orders. The care plan lacked documentation or guidance for staff related to R14's use of furosemide, a diuretic (water pill). A pharmacy review note dated 10/11/24 indicated recommendations were made. The review indicated R14 had previous gradual dose reductions (GDRs) of her doxepin on 10/4/24 and mirtazapine on 9/25/24. The note referred to the clinical recommendations report. R14's progress notes were reviewed and lacked documentation of medication regimen review (MRR) follow-up by provider and/or nursing staff. A pharmacy review note dated 12/3/24, indicated recommendations were made. The review indicated an increase to R14's mirtazapine on 11/19/24, and referred to the clinical recommendations report. The progress notes were review and lacked documentation of MRR follow-up by provider and/or nursing staff. A PharMerica Nursing Recommendations report dated 10/11/24, identified three recommendations or clarifications pertaining to R14's carvediolol medication administration instructions, isosorbide medication formulation, and a clarification regarding the lidocaine formulation. The nursing recommendation lacked documentation of MRR follow-up by provider and/or nursing staff. A PharMerica MRR Recommendation Summary: Medical Director and Director of Nuring (DON) dated 10/11/24, identified three recommendations or clarifications pertaining to R14's carvediolol medication administration instructions, isosorbide medication formulation, and a clarification regarding the lidocaine formulation. The MRR summary lacked documentation of MRR follow-up by provider and/or nursing staff. A PharMerica Nursing Recommendations report dated 11/4/24, was received and indicated the resident was out of the facility during the MRR and requested staff evaluated the need for MRR. The report lacked documentation of follow-up. A request for R14's MRRs, clinical recommendations and related follow-up for 6 months were requested but not received. When interviewed on 12/13/24 at 10:57 a.m., licensed practical nurse (LPN)-A stated they received recommendations from the pharmacist and followed up with the primary care physicians to ask if they approved of the pharmacy recommendations or not. LPN-A followed through with what the primary care physician approved. When interviewed on 12/13/24 at 2:26 p.m., LPN-B stated they sometimes received emails from the pharmacist about recommendations they had after order review and followed up on the recommendations right away. LPN-B stated the director of nursing (DON) received the pharmacist recommendation forms, then the managers followed up on the recommendations and returned the pharmacist form to the DON after completion. LPN-B confirmed R1's trazodone did not have an end date and did not have side effect monitoring in place for psychotropic medication. When interviewed on 12/16/24 at 11:01 a.m., the DON stated they printed out the pharmacist recommendation forms and made copies in green. DON gave the original copy to the doctors and nurses to address and placed the green copy in a binder, so they knew the recommendation still needed to be followed up on. DON stated if providers do not follow up on pharmacy recommendations within one month, they asked the provider again. DON received emails and followed up immediately on anything dire. When interviewed on 12/16/24 at 11:11 a.m., the consulting pharmacist (CP) expected pharmacist recommendations to be followed up on within 30 days or by the next visit. CP gave recommendations again when not completed, but the timing on when to give the second reminder depended on what the initial recommendation was, since the providers liked to see the residents before acting or not on some recommendations. CP confirmed the facility had not placed in an end date for R1's trazodone and would have expected them to complete after the recommendation in November of 2024, since they needed to know why trazodone was administered and needed to re-evaluate the use per regulations. CP also confirmed R1 did not have side effect monitoring for psychotropic medication in place as was recommended previously. Per facility policy titled Medication Reconciliation last revised 10/24/22, the facility reconciled medication throughout a resident's stay to ensure the resident was free of any significant medication errors. The policy indicated the monthly process was the provide the consultant pharmacist access to all medication areas and records for completion of pharmacy services activities. Furthermore, the policy directed staff to respond to any medication irregularities reported by the pharmacist within relevant time frames.

Based on interview and document review, the facility failed to ensure required in-service training based on annual performance reviews was completed for 5 of 5 nursing assistants (NA-B, NA-C, NA-D, NA-H, NA-H) whose employee files were reviewed. This had the potential to affect all 37 residents who resided at the facility. Findings include: A review of employee records on 12/12/24 between 1:24 p.m. and 2:37 p.m., lacked documentation of completed annual performance reviews. Furthermore, the employee records lacked documentation of in-service training that addressed areas of weakness determined by performance reviews. All 5 sampled employees were employed at the facility for greater than one year. Per interview on 12/12/24 at 2:11 p.m. with the administrator, it was believed the previous director of nursing (DON) completed competencies with annual reviews. The administrator stated, I'm looking through file cabinets and if I can't find them, I can't say that we have them without them. Per interview on 12/16/24 at 12:01 p.m., the DON had no luck locating the performance reviews, completed in-service trainings based on weaknesses determined by reviews, or competences for the sampled NAs. The DON stated the facility would be restarting those reviews beginning January 1st and indicated it was important because staff needed to be aware of what they were doing well and what could be improved upon. Additionally, the DON stated annual reviews were a good way to build rapport with staff and helped build the team. A policy pertaining to annual reviews or in-service trainings was requested but not received. The facility assessment last reviewed 8/8/24, indicated the facility's training program included was based on the facility's resident population and was an ongoing training for all new and existing staff including managers, nursing, and other direct care staff. The assessment identified annual reviews were a part of the training sessions and would be completed to meet regulatory requirements. Furthermore, the assessment indicated, skills and competencies were completed on hire and annually to test continued competence in assessment, safe patient handling, infection control, medication administration, wound care, feeding and bathing; skills competencies testing is based on the usual and customary duties performed by each staff member.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident as determined by the resident assessments, plans of care, and facility assessment. This had the potential to affect all residents residing in the facility. Bowel and Bladder - See F690 - R3 Findings include: R3's quarterly Minimum Data Set (MDS) dated [DATE], reported she had intact cognition, had no hallucinations, delusions, rejections of care, and no verbal, physical or other behavioral symptoms towards herself or others. The MDS identified R3 was dependent on staff for toileting hygiene and transfers, required substantial to maximal assist for mobility and all other transfers, had no urinary catheters, had not trialed a urinary or bowel toileting training program and was frequently incontinent of urine and bowel. Additionally, the MDS identified R3 was at risk for pressure injury wound. During a continuous observation on 12/11/24 between 10:48 a.m. and 11:37 a.m., the following was observed: - 10:48 a.m.: R3's call light was put on. - 10:49 a.m.: nursing assistant (NA)-A entered R3's room to answer the call light and was heard stating she would be back to help her. Per interview at 10:49 a.m., R3 verified NA-A stated she would be back to help clean her up. - 11:09 a.m.: the director of nursing (DON) walked down the hallway and asked where NA-A was. Within 2 minutes, the DON left the unit and was observed walking onto the elevator leaving the second floor. - 11:13 a.m.: NA-A was not back to assist. An overhead page was heard announcing, 2 west, you have a resident call. - 11:14 a.m.: There were no staff observed on the 2 East of the unit. An overhead page was heard announcing, 2 west nurse please call and a call-back number was read aloud. - 11:18 a.m.: No staff were present on the 2 east unit. - 11:20 a.m.: Licensed practical nurse (LPN)-H walked onto the 2 east unit to the medication cart. - 11:22 a.m.: LPN-H left the medication cart and walked off the 2 east unit. No staff have attempted to enter R3's room. - 11:26 a.m.: Activities-(A) pushed another resident into his room and walked back out and off the 2 east unit without addressing other residents within a minute. - 11:30 a.m.: NA-A walked off the elevator, walked through the nurse's station and into the nurse manager's office. No visible staff observed down the 2 west hallway or the 2 east hallway. - 11:38: a.m.: An unidentified staff walked off the elevator and into to the nurse manager's office. There were no nursing staff on either the 2 west hallway or 2 east hallway. - 11: 41 a.m.: LPN-H and NA-A walk back to the 2 east unit and hallway. - 11:42 a.m.: LPN-H and NA-A entered R3's room to assist with cares requested from call light request at start of observation. Per interview on 12/9/24 at 3:19 p.m. with nursing assistant (NA)-F, there was no staffing, no management and no one to do the scheduling right now. NA-F stated if someone called out of their shift, they normally find a replacement by asking nurses to overlap and help with the NA work. NA-F stated, it happens that we [are] short but not often. R23 The quarterly Minimum Data Set (MDS) dated [DATE], for R23 indicated moderately impaired cognition. MDS indicated on 10/12/24 cognitive loss, dementia, with decrease of functional abilities, falls, nutritional status, pressure ulcer/injury, and pain. R23 diagnosis on 1/25/24 peripheral vascular disease, absence of other left toes acquired absence of other right toes. R23 is full assist of two, non-weight bearing, has an air mat, reposition every 2 to 3 hours. Heel boot and float heels. During an observation of R23 on 12/11/24 at 8:11 a.m., nursing assistant (NA)-A completed hand hygiene, donned enhanced barrier precautions (EBP) and cleaned face and arms of R23. NA-A doffed EBP, left room, found another staff member to do peri cares and reposition. NA-D was in the dining room assisting residents with breakfast. The licensed practical nurse (LPN)-A was interrupted during a medication pass, washed hands, donned EBP performed cares and repositioned resident. During a continuous observation of R23 on 12/11/24 between 10:48 a.m. and 11:37 a.m.: - 10:48 a.m., call light on, no staff were observed in hallways - 11:10 a.m., no staff observed in hallway, call light remained on. - 11:20 a.m., no staff observed in hallway, call light remained on. - 11:36 a.m., a staff member was observed walking to the medicine cart and within one minute, walked away and off the unit. - 11:37 a.m., a staff member was observed walking in room and able to assist with cares per her call light request initiated at 10:48 a.m. Grievance/complaints A grievance/complaint report on 5/21/24, indicated R36 reported they were wet for 2.5 hours. They put on their call light at approximately 4:30 a.m., nursing assistant (NA)-A told R36 that they were the only NA on the floor, and they were taking a 2.5-hour break because of a 16-hour shift. R36 stated they were still wet at 6:00 a.m., and could not be changed as the day shift wasn't on yet. The follow up indicated the concern was discussed with staff their responsibility to provide cares. A grievance/complaint report on 6/4/24, R19 told licensed practical nurse (LPN)-A that nursing assistant (NA)-A did not finish changing resident, NA-A walked out of room and left R19 unattended for 35 minutes without coming back or saying anything to resident. The follow up indicated LPN-A found nursing assistants (NA)-D and NA A, on break together. The staff were brought back to the floor and completed the cares for R19. A group meeting was held with registered nurse (RN)-B, LPN-A, LPN-D, NA-A and NA-D. The result of actions where two NAs were verbally counseled. The resolution of grievance included R19 was very upset, and staff explained R19 was able to report situations at any time. A grievance/complaint report on 6/28/24, identified the interdisciplinary team (IDT) held a quarterly meeting, and R19 reported she was upset that she was not being assisted up in wheelchair due to being short staffed. The report indicated nursing confirmed staffing was insufficient. The follow up for R19 included the administration discussed care plan, observed staffing on the floor, and provided the ability to transfer R19 into wheelchair. A grievance/complaint report on 7/31/24, included R19 informed the facility they were not changed after a bowel movement. They indicated they waited for 3 hours because there was not enough staff to provide cares. R19 put on call light at least two times an hour, and was repeatedly told by staff, they were not able to provide cares. The follow up was a staff meeting, and R19 should notify the manager each time this type of incident happens. Staff involved were unnamed. A grievance/complaint report on 8/21/24, indicated R37 stated they put on their call light at 12:30 a.m. for a brief change. A staff member came into room, turned off call light, and told R37 it will get done. The staff did not return, and R37 reported they did not get changed until 6:15 a.m. The facility follow up included providing coaching for staff members. A grievance/complaint report on 8/30/24, indicated at approximately 2:00 a.m., R37 put on their call light to request a brief change and water. Licensed practical nurse (LPN)-G answered the call light, left, and did not come back for approximately 2 hours to change him. R37 put call light on, requested to sit in chair, and a staff member told him they aren't going to get him up. The follow up included a staff meeting to explain requirement to provide cares, answer call lights promptly, and honor resident wishes. A grievance/complaint report on 9/19/24, indicated R37 put their call light on at 7:30 p.m. to request a brief change for bowel movement. R37 was banging on the foot of bed to get help. Licensed practical nurse (LPN)-I told R37 that the nursing assistant (NA) left at 8:30 pm, and R37 needed to wait to be changed. R37 asked LPN-I to change him. LPN-I turned off call light and did not change him. R37 put light on again, was changed at 11:30 pm. The facility follow up was to remind staff to answer call lights and resolve the issue. Resident council meetings minutes 10/20/24, were reviewed on 12/16/24, and identified call light wait times were brought up as a concern. Resident council meeting minutes dated 9/18/24, were reviewed on 12/16/24, and identified call light wait times was discussed. Resident council meeting minutes dated 10/20/24, were reviewed on 12/16/24, and identified call light wait times were brought up as a concern. A resident council meeting was held on 12/10/24 at 10:00 a.m., R36 reported call lights take a long time to answer. R37 stated call lights wait times take the longest to be answered in the evening and at night. R30 reported the facility had been without a maintenance worker and the facility needs so much work because the place is falling down. R30 verbalized they did not feel the facility had enough staff to take care of the building or to take care of residents. During an interview on 12/11/24 at 8:34 a.m., nursing assistant (NA)-A stated, when the cares are difficult to complete when residents are an assist of two. The staff were interrupted during medication passes, and during meals. One staff member was in the dining room. There was not enough staff to complete morning cares on time. During an interview on 12/12/24 at 2:19 p.m., licensed practical nurse (LPN)- D confirmed there was 9 out of 18 residents on 2 east and 2 west hallways required assist of two to provide safe cares. It is difficult to complete cares when interrupted with phone calls, mealtimes, and medication pass. During an interview on 12/13/24 at 10:21 a.m., administrator, stated the staff schedule has double shifts built in. In case of a no show/sick call or emergencies, bonuses were offered to other staff. The management and ancillary staff assisted with tasks that were necessary for the residents. He verbalized the staffing for cares in pairs was a concern. The staff, residents and families brought workload concerns to facility by email, phone number, able to submit anonymously. The system to address concerns were quality assurance and performance improvement (QUAPI), interdisciplinary team (IDT) and meetings. During an interview on 12/16/24 at 10:10 a.m., director of nursing (DON) verified insufficient staffing. The DON stated the resident needs outweigh the staff available. DON stated, lack of support from corporate, and being a new DON, mentorship was needed but fell by the wayside. The DON confirmed the acuity for the residents is high, 9 out of 18 residents required assist of two staff for cares. Staffing and management were working with corporate to get staffing numbers up. The facility was actively recruiting for a health unit coordinator or receptionist to assist in tasks in the facility. This facility did not utilize pool, contract or agency nursing. The maintenance director resigned; no daily maintenance is completed. Corporate sent someone out once a month to do repairs. The system was in place for workload concerns are phone number for grievances, and email, anonymously if desired. During interview on 12/13/24 at 10:24 a.m., the administrator verified being responsible for the scheduling with the DON. The administrator reflected on the facility's recent self-reported investigations and requirement to remove staff from the schedule and verified it had not been easy to schedule around their absences but stated we've been able to provide cares. The administrator stated the levels of care were assessed during interdisciplinary team (IDT) meetings every day, including resident behaviors. The administrator believed the staffing approaches covered the acuity needs of the residents. When asked about the continuous observation on 12/11/24, and if that was a demonstration of appropriate staffing, the administrator stated, I expect a call light to be answered ideally within 10-15 minutes, and stated the expectation was to provide cares in an appropriate and safe manner. The administrator stated they discuss resident acuity and case mix daily but stated residents requiring cares in pairs are not always considered in their case mix or acuity count. The DON verified the facility's staffing was not ideal and stated the administrator had received the short end of the stick. The DON stated they both were taking hits and had received discipline by corporate management for staffing the way we do and we're still not meeting the acuity needs. The DON stated they are urging families to file formal grievances to aid in their efforts to support their staffing needs. The DON stated they did not have employees to call on as back-ups for instances of no-call/no-shows and did not have the permission to set that up. The DON verified resident needs were exceeding staffing levels and agreed resident outcomes were suffering. The DON stated, Our staffing is not meeting the needs of our residents. If we're only meeting bare minimum, that's not good customer service. A facility assessment dated [DATE], indicated it evaluated the facility's resident population and identified resources needed to provide the necessary care and services to residents during day-to-day operations and emergencies. The assessment tool identified itself as a resource for the facility's leadership to use when making decisions for purposes regarding sufficient staffing numbers, competent staff, recruitment, and retention of staff, and continency planning for emergency events. The assessment indicated input from residents, their representatives, staff, and resident council meeting minutes were reviewed for applicable input. The assessment identified other pertinent facts or descriptions of the resident population to be considered when determining staffing and resource needs which included the following: - require a Hoyer or Sit-to-Stand lift (2-person transfer). - are on increased monitoring for behaviors or are Cares in Pairs. - require hands-on transfer assistance. - Have mixed preferences for eating in the dining room, versus resident room. - needs of ancillary staff (readying those residents who receive therapy by a certain time each, for instance). The assessment indicated physical therapy and specific rehabilitation services provided services such as ADL cares to support a resident's independence in doing as much of the ADLs by himself/herself. Furthermore, the assessment indicated it provided bowel and bladder care, including incontinence prevention and care and responding to requests for assistance to the bathroom or toilet promptly in order to maintain continence and promote dignity. The assessment concluded the staffing level process was to consider the corporate staffing requirements and identified the facility-specific requirements at a census of 43 residents or more, the staffing levels should be 3 licensed nurses on the day and evening shifts and 2 nurses on the overnight shift; 4 NAs on the day and evening shifts and 2 NAs overnight with 2 nurse managers at least 8 hours per day Monday through Friday. Additionally, the assessment indicated an acuity consideration of over one third of our residents require two-person assistance with transfers, either stand-by assist or Hoyer or EZ stand lifts and due to behavioral issues, one third of our residents are care planned to be Cares in Pairs and require two individuals to be present during all cares. Additionally, the assessment always included memory care's requirement of 2 staff on the floor at all times for safety with wandering residents. Meal Service The facility assessment dated [DATE], indicated meals are served from the same dining room at the same time for all units, delivering meals that are hot and palatable is best done with full staff. The assessment also indicated meals were delivered in a space preferred by the resident, either in their room or in the dining room and staff must accommodate both preferences and deliver meals in a timely manner to ensure food safety be maintained. During observation and interview on 12/10/24 at 8:15 a.m., residents were seated in the memory care dining area, and a resident asked where breakfast was at. The resident stated breakfast was supposed to start at 8 a.m. and stated the current time. At 8:17 a.m., another resident asked when the food was going to arrive. Nursing assistant (NA)-G stated breakfast was coming soon and gave the resident some drinks. At 8:19 a.m., the nurse stated the food would arrive in a few minutes. At 8:24 a.m., dietary aide (DA)-A entered the memory care area with breakfast in a closed container and a cart of juice and coffee. When interviewed on 12/11/24 at 8:56 a.m., NA-G stated breakfast was usually served around 8:10 and 8:15 a.m. and was an improvement. During meal observation and interviews on 12/11/24 at 11:59 a.m., cook (C)-A brought a serving cart with food and items to serve from the main kitchen on the first floor to the second floor. C-A placed food in the transitional care unit (TCU) and long-term care (LTC) dining room steamer and completed other tasks for meal service. At 12:07 p.m., dietary aid (DA)-A prepared silverware on meal trays and other tasks. Two residents were served in the dining area. At 12:11, culinary district manager (DM) stated they were waiting for nursing staff to be ready to serve before dishing up the plates. At 12:17 p.m., registered nurse (RN)-C entered the dining area from the memory care area, and DM stated they were waiting for staff to start meal service. At 12:22 p.m., licensed practical nurse (LPN)-B entered the dining area from the memory care area, and DM stated they were waiting for staff to start meal service. Then C-A started to plate lunch, and DA-A placed completed meal trays into an enclosed cart. At 12:31 p.m., multiple residents were sitting in the memory care area dining room and only a few residents had drinks in front of them. At 12:33 p.m., DA-A entered with the drink cart. At 12:37, nursing assistant (NA)-E entered the memory care area with the food cart. At 12:47 p.m., social worker (SW) was in the dining area between the TCU and LTC care area standing next to an enclosed cart filled with room trays and stated they were waiting for a juice cup. At 12:52 p.m., SW pushed the cart into the LTC hallway and served the first person their meal tray and continued serving the rest of the residents in the hallway room by room. Medication administration During medication observation and interview on 12/11/24 at 7:15 a.m., licensed practical nurse (LPN)-H had two medication cups with medications on the medication cart and then placed into the top drawer of the medication cart. LPN-H prepared medication for R2 and then added the prepared medications to one of the medication cups from the top drawer. LPN-H stated they were preparing medications for R2 now and for R2's next medication pass time when surveyor approached and panicked so checked the medications due now as given already and saved the medications to give R2 at the next medication pass in the top drawer. LPN-H stated they usually labeled the prepped medication cup with the resident's name and room number. LPN-H stated they often prepped residents' medications early or else they would not have their work completed until 4:00 p.m. each day. LPN-H stated the long-term care and transitional care units had a total of two nurses and two nursing assistants, but about twice a week had one nurse and one to two nursing assistants. LPN-H assisted with resident ADLs and other tasks when there was one nursing assistant for the transitional care unit and long-term care area. LPN-H felt pressured to find ways to save time when there was only one nurse and had appointments, labs, new orders, wounds, and intravenous medications to manage. LPN-H stated they spoke with management before, and management staffed according to resident census. When interviewed on 12/9/24 at 3:19 p.m., nursing assistant (NA)-F stated sometimes there were not enough staff, and there was no staffing coordinator and a lack of management in general.

Based on interview and document review, the facility failed to complete annual performance reviews for 5 of 5 nursing assistants (NA-B, NA-C, NA-D, NA-H, NA-M) whose employee files were reviewed. This had the potential to affect all 37 residents who resided at the facility. Findings include: A review of employee records on 12/12/24 between 1:24 p.m., and 2:37 p.m., lacked documentation of completed annual performance reviews. All 5 sampled employees were employed at the facility for greater than one year. Per interview on 12/12/24 at 2:11 p.m., the administrator stated it was their understanding the previous director of nursing (DON) completed competencies with annual reviews. The administrator stated, I'm looking through file cabinets and if I can't find them, I can't say that we have them without them. Per interview on 12/16/24 at 12:01 p.m., the DON had no luck locating the annual performance reviews or recent completed competencies for the sampled NA's. The DON stated the facility would be restarting those reviews beginning January 1st and indicated it was important because staff needed to be aware of what they were doing well and what could be improved upon. Additionally, the DON stated annual reviews were a good way to build rapport with staff and helped build the team. The facility assessment last reviewed 8/8/24, indicated the facility's training program was based on the facility's resident population and was an ongoing training for all new and existing staff including managers, nursing, and other direct care staff. The assessment identified annual reviews were a part of the training sessions and would be completed to meet regulatory requirements. Furthermore, the assessment indicated, skills and competencies were completed on hire and annually to test continued competence in assessment, safe patient handling, infection control, medication administration, wound care, feeding and bathing; skills competencies testing is based on the usual and customary duties performed by each staff member. The assessment also included the annual review process in staff recruitment and retention section. A policy pertaining to annual reviews was requested but not received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Legionella The facility is not required to do testing unless a concern is identified. They are required to have a schematic of the water system and a program to mitigate growth of legionella. During entrance conference on [DATE] at 1:52 p.m., administrator was asked to provide a copy of the facility Legionella risk assessment and plan to mitigate the growth of Legionella. A plan was not provided. On [DATE], a 2nd request was placed to the administrator for a copy of the Legionella plan and evidence of implementation. No documentation was provided. On [DATE] at 8:49 a.m., a requested for information on the Legionella water management plan was sent to the director of nursing (DON). No documentation was provided. O [DATE] at 2:30 p.m., the administrator requested clarification on what was needed for evidence of Legionella plan. The administrator stated, we flush toilets and run the water on first floor weekly. The administrator was unable to provide a schematic of the buildings water flow and no additional documentation was provided. Facility document titled Legionella Surveillance Policy dated [DATE], included the facility would establish a primary and secondary strategy to prevent and control Legionella infections. Based on observation, interview, and document review, the facility failed to ensure staff performed appropriate hand hygiene during medication administration for 2 of 3 residents (R2, R6) observed during medication administration, and failed to implement enhanced barrier precautions (EBP) for 6 of 7 residents (R4, R9, R14, R18, R26, R29) reviewed for precautions. Further, the facility failed to develop and implement a Legionella risk assessment and plan to mitigate the growth of Legionella. This had the potential to affect all 37 residents, staff and visitors. Findings include: Hand Hygiene R2's quarterly Minimum Data Set (MDS) dated [DATE], indicated R2 was cognitively intact with diagnoses of coronary artery disease (arteries which supply blood to the heart become narrowed or blocked), heart failure, hypertension, and diabetes mellitus. R6's quarterly MDS dated [DATE], indicated R6 was cognitively intact with diagnoses of hypertension, urinary tract infection, diabetes mellitus, dementia, anxiety, and depression. During a medication observation and interview on [DATE] at 7:15 a.m., licensed practical nurse (LPN)-H prepared medication for R2 at the medication cart outside of R2's room. LPN-H entered R2's room and took R2's temperature and oxygen saturation level. LPN-H exited the room and did not perform hand hygiene and typed information into the computer, then LPN-H locked the cart and gave medication cup to R2. R2 took medication independently. LPN-H returned to the medication cart, did not perform hand hygiene, and prepared medication for R6. LPN-H found a tray to place R6's medication on, placed on gloves to clean the tray, removed gloves, and performed hand hygiene. LPN-H brought medication to R6 and observed R6 take medication independently. R6 stated they had a cream LPN-H to apply. LPN-H exited the room, did not perform hand hygiene, and looked at R6's orders on the computer. LPN-H returned to R6's room and touched and looked at the tube of cream in R6's room. LPN-H stated they would confirm and apply the appropriate cream later and left R6's room. LPN-H returned to the medication cart to chart the medications given to R6 and did not perform hand hygiene. LPN-H started to look at another resident's medication list and readied a new medication cup. LPN-H confirmed they performed hand hygiene after cleaning the tray and removing gloves but missed opportunities to perform hand hygiene between giving medications to one resident and preparing medications for a different resident. When interview on [DATE] at 2:25 p.m., LPN-B stated staff should perform hand hygiene when leaving a resident room before preparing another resident's medications. LPN-B stated staff did not want to transfer germs from one resident to another. When interviewed on [DATE] at 11:01 a.m., the director of nursing (DON) expected staff to perform hand hygiene in between medication passes to lessen the risk of germs spreading from one resident to another. The Hand Hygiene policy dated [DATE], directed staff to perform hand hygiene when indicated, using proper techniques consistent with accepted standards of practice. The policy included a Hand Hygiene Table which directed staff to perform hand hygiene before preparing or handling medications. EBP R4's admission record printed [DATE], included an admission date of [DATE]. R4's care plan printed [DATE], included R4 had a pressure ulcer (wound caused by pressure) on his coccyx (tailbone). The care plan failed to include interventions for EBP. Observation of R4's room did now show evidence of signage or personal protective equipment (PPE) for EBP on [DATE], and [DATE]. R9's admission record printed [DATE], included an admission date of [DATE], and a diagnosis of pressure ulcer of the right heel. R9's care plan printed [DATE], failed to include interventions for EBP. Observation of R9's room did now show evidence of signage or personal protective equipment (PPE) for EBP on [DATE], and [DATE]. R14's admission record printed [DATE], included an admission date of [DATE], and a diagnosis of neuromuscular dysfunction of bladder (causes a person to not be able to control their bladder emptying). R14's care plan printed [DATE], included R14 had a Foley catheter. R14's care plan failed to include interventions for EBP. Observation of R14's room did now show evidence of signage or personal protective equipment (PPE) for EBP on [DATE], and [DATE]. R18's significant change Minimum Data Set (MDS) dated [DATE], included an admission date of [DATE], and an active diagnosis of benign prostatic hyperplasia (enlargement of the prostate gland). R18's MDS included he had an indwelling catheter. Observation of R18's room did now show evidence of signage or personal protective equipment (PPE) for EBP on [DATE], and [DATE]. R26's admission record dated [DATE], included an admission date of [DATE]. R26's care plan printed [DATE], included R26 has a urostomy (an opening in her stomach for urine to leave the body). R26's care plan failed to include interventions for EBP. Observation of R26's room did now show evidence of signage or personal protective equipment (PPE) for EBP on [DATE], and [DATE]. R29's admission record printed [DATE], included an admission date of [DATE], and diagnosis of neuromuscular dysfunction of the bladder. R29's care plan printed [DATE], included R29 had an indwelling catheter. R29's care plan failed to include interventions for EBP. Observation of R29's room did now show evidence of signage or personal protective equipment (PPE) for EBP on [DATE], and [DATE]. When interviewed on [DATE] at 9:49 a.m., nursing assistant (NA)-D stated nursing assistants did not follow enhanced barrier precautions, and enhanced barrier precautions were for nurses. During interview on [DATE] at 2:00 p.m., director of nursing (DON) was unable to state when a resident should be placed on EBP. She states she would follow the CDC guidelines. When the DON referred to the printout of CDC guideline in the infection control binder, she confirmed the guidelines were to implement EBP whenever a resident had an open wound are an indwelling medical device, such as a catheter. The DON confirmed they were not following EBP correctly in the facility and provided a list of residents who had either an indwelling medical device or an open wound. Facility policy titled Enhanced Barrier Precautions dated [DATE], included the facility would initiate EBP for residents with wounds and/or indwelling medical devices.

Based on observation, interview and document review, the facility failed to ensure structural issues and items in disrepair throughout the facility were addressed to help promote a functional, sanitary, and safe environment. Additionally, the facility failed to ensure an ice and water dispensing machine in the second floor TCU and LTC (transitional care unit and long-term care) dining room was clean and free of excess mineral build up and properly functioning. This had the potential to affect all 37 residents residing in, visitors, and staff working in the facility. Findings include: A resident council meeting was held on 12/10/24 at 10:00 a.m., and residents in attendance reported the condition of the facility was a shithole. The residents stated they were aware there was no maintenance in the building to fix the multiple problems in resident rooms, dining rooms, hallways, and the holes in the walls. MAIN KITCHEN During observation on 12/11/24 at 11:37 a.m., the wall across from the main kitchen refrigerator had multiple blackish-brownish colored speckles. The area under the three-compartment sink had multiple crumbs on the floor and the wall below the sanitizer end of the three-compartment sink had brownish colored speckles. The wall next to an oven-like compartment used keep food at holding temperature had streaks of tannish colored substance down the wall. When interviewed on 12/13/24 at 10:01 a.m., a.m., dietary manager (DM) stated staff have daily cleaning assignments. Account manager (AM - serving as director of culinary services) and DM verified the wall across from the refrigerator with the blackish-brownish colored speckles, and DM stated black colored serving carts must bump against the wall. The speckles on the wall were throughout an area of approximately five feet across and two feet vertical. MEMORY CARE DINING AREA When interviewed on 12/10/24 at 8:37 a.m., family member (FM)-A stated the memory care dining area had missing appliances, cabinet pieces missing, and other mismatched items. FM-A stated the dining area did not feel like a home, and the whole interior of the building appeared tired. During observation and interview on 12/11/24 at 9:03 a.m., the memory care dining area had orange-yellow-colored splotches about the size of a quarter at the entrance to the right on the wall. About six air vents lined the wall near the ceiling on both sides of the dining room and had grayish-blackish colored fuzzy substance speckled throughout various areas of each vent. One vent near one corner of the dining room had brownish-black speckled color particles and streaks extending on the wall from each of the four corners of the vent. The valance which hung above the window next to the vent was darker colored by brownish-black speckles. The other corner of the dining area had another valance above a window and had thick, grayish colored particles covering the side of the valance closest to a vent. There was a sink on top of a brown cabinet. One side of the cabinet had a missing brown area about one and a quarter foot by one inch and a circular area of cabinet missing the outer brown area about one inch by one and half inches and two other similar missing areas. Two sides of a blue wall had various white scuff marks, with one spot eight inches by one inch and others were similar in size or less. A spot of cabinetry near the refrigerator was missing and a yellowish tan area with areas of white plaster shown on the wall about three feet down and two feet across. A spot of the cabinetry liner was missing. Other various parts of the walls had faint tannish color streaks down them. When interviewed on 12/11/24 at 9:32 a.m., nursing assistant (NA)-G stated the area missing in between cabinets near the refrigerator used to be an oven and had been so for a year or more. NA-G confirmed the condition of the wall where the oven used to be and stated they would not want their home looking that way. NA-G confirmed the other memory care area dining observations and stated they focused attention to the residents so had not noticed the dining room appearance but would not want their home to have the appearance of the dining room. During environmental tour on 12/13/24 at 1:17 p.m. with the administrator and housekeeping director (HD), the administrator stated there was a stove which was removed from the memory care dining area and had been that way a couple months or more. The administrator verified the area needed repainting or to be blocked. Administrator and HD verified the other conditions of the memory care dining area, and the administrator stated the scuffs on the wall were most likely from food carts or wheelchairs. The administrator stated the dining room was not horrible but needed a make-over. Upon review of the main kitchen on the first floor, the administrator and HD confirmed the wall looked like it had splatter, grime, or evidence of rubbing from a caret, and stated the wall needed to be wiped down. When interview on 12/13/24 at 2:56 p.m., licensed practical nurse (LPN)-B stated they have seen the HD steam clean the valances before. LPN-B stated the memory care residents were calm and conversed as able in the dining area so in that sense was homelike, but family members and staff had concerns about the appearance of the dining area for at least two years. LPN-B stated housekeeping cleaned in the dining room after meals but not much of other actions were taken to fix the appearance of the dining area. ICE MACHINE During interview on 12/10/24 at 1:37 p.m., family member (FM)-C reported getting water and ice from the machine behind the steamtable in the second-floor dining room independently without staff assistance. FM-C stated the machine was malfunctioning and stated, the ice machine needs maintenance, it sprays everywhere, and it goes everywhere. During observation on 12/11/24 at 12:11 p.m., dietary aide (DA)-A raised one water pitcher, which was already nearly full, to the water dispenser in the second-floor TCU and LTC dining area and held the pitcher so the mouth of the pitcher almost touched the water dispenser. After a second, DA-A stopped and moved the pitcher to the ice machine to add ice which raised the water line to fill the rest of the pitcher. DA-A used the ice machine to fill up two more water pitchers in this manner. [NAME] sediment was around the ice spout, on the grate, and speckled on the back splash. When interviewed on 12/13/24 at 10:08 a.m., DM stated staff tried to wipe down the ice and water dispensing machine as much as possible to keep clean. The machine had preventative maintenance, but the facility needed a new maintenance director. DM stated the facility had hard water and the grate and other areas of the ice machine needed to be broken down for a deep cleaning. DM attempted to fill a cup with water, and the water dispenser spurted water in different directions and filled the cup when the cup was held closer to the spout. DM stated the nozzle needed to be cleaned or placed correctly, so one stream of water could fill the cup. During interview on 12/13/24 at 10:31 a.m., housekeeper (H)-A stated they had a checklist for cleaning rooms but not the dining areas and they did not wipe down ice machine. The Work History Report created 12/12/24 with due date timeframe of 1/24 to 10/24, indicated the ice machine and/or ice bins task was completed on 8/26/24 and included check filter, clean coils, sanitize interior, delime as necessary. The same task was marked as completed on 3/8/24. The report lacked indication the exterior surfaces were cleaned. Per interview on 12/12/24 at 2:11 p.m. with the administrator, the facility was without a maintenance director since 9/2024. The administrator stated, I hear about things, and I just go fix them, and was unsure how comprehensive the maintenance reports were. The administrator explained the facility received help from a corporate maintenance person every two weeks. The Physical Environment: Electrical Equipment Policy dated 6/16/22, indicated the maintenance director shall maintain schedules for routine inspection and maintenance of all mechanical, electrical, and patient care equipment. The policy indicated essential equipment shall be repaired or replaced as soon as practicable. The facility assessment last reviewed 8/8/24, indicated the process to ensure adequate supply, appropriate maintenance of or replacement of building and/or other physical structures and equipment was the TELS maintenance program and activities. The assessment identified the administrator was responsible for reviewing the TELS program and activity daily, weekly, and monthly for preventative maintenance, Life Safety monitoring, and reporting along with daily work-order tracking. The assessment identified examples, including, bathroom safety bars, sinks for residents and for staff, lifts, lift slings, room and common space furniture, steam table, waste management, sliding doors, nurse call system, and emergency power. Per facility policy titled Resident Rights last revised 7/2022, residents would be treated with respect and dignity and care for each resident would be given in a manner and in an environment that promotes maintenance or enhancement of his/her quality of life.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure an allegation of physical staff to resident abuse was reported timely, within two hours, as required to the State Agency (SA) and to the administrator for 1 of 1 residents (R1) reviewed for abuse. Findings include: R1's significant change Minimal Data Set (MDS) dated [DATE], indicated R1's diagnoses included dementia and personality disorder. R1's cognition was not impaired. Review of facility report number 358043 submitted to the SA on 9/24/24 at 5:41 p.m., identified R1 had reported a nursing assistant (NA) while providing cares was angry and telling R1 not to use the call light and it made her angry. R1 reported NA pinched her in the left leg and grabbed her hair with water on her hands. R1 was able to identify the staff as NA-A. On 10/2/24 at 10:32 a.m., licensed practical nurse (LPN)-A stated staff were expected to report allegations of abuse to the nurse manager, director of nursing (DON) and administrator immediately. On 10/2/24 at 10:41 a.m., LPN-B stated the facility's abuse policy required staff to report allegations of abuse right away to their immediate supervisor and the allegation would need to be reported to the SA within two hours. Further, LPN-B stated they were notified by LPN-C at approximately 1:00 p.m. on 9/24/24, R1 had reported a NA had pinched her. LPN-B stated they notified DON and administrator. On 10/2/24 at 10:57 a.m., social services (SS)-A stated staff were expected to report allegations of abuse immediately and report to the administrator and DON who were then required to report to the SA within two hours. SS-A stated they were informed on 9/24/24 at approximately 2:00 p.m., by LPN-C who reported R1 made an allegation she was hit and pinched by NA-A. SS-A stated they notified the administrator and they both went to interview R1. Further, SS stated LPN-C was made aware of R1's allegation at approximately 11:30 a.m., and LPN-C had reported the allegation to LPN-B as required however, LPN-B directed LPN-C to report the allegation to the administrator and SS-A. SS-A stated she was unsure why LPN-C waited until 2:00 p.m., to report R1's allegation to SS-A however assumed due to medication administration and meal service LPN-C was busy. SS-A stated she was unsure if LPN-C had been re-educated regarding reporting requirements as the administrator would have addressed that. On 10/2/24 at 11:14 a.m., administrator stated staff were trained annually regarding the facility's abuse policy and staff were required to report an allegation of abuse immediately, but within two hours, to the administrator. Administrator stated he then had to investigate if the allegation of abuse was expected to be reported to the SA within two or 24 hours based on if there was actual harm or injury. Administrator stated he was notified by SS-A of R1's allegation at approximately 2:00 p.m. on 9/24/24. Further, administrator stated he educated LPN-C verbally regarding reporting immediately however did not have evidence of addressing reporting requirement. On 10/2/24 at 11:31 a.m., LPN-C stated staff were provided abuse training but could not recall how often. LPN-C stated staff were expected to report allegations of abuse to their supervisors immediately. Further, LPN-C stated at approximately 11:30 a.m. on 9/24/24, LPN-C was administering R1's medications when R1 reported staff had pinched and hit her. LPN-C stated she reported this allegation to LPN-B after exiting R1's room. LPN-C stated she was directed by LPN-B to report the allegation to SS-A however SS-A was in a care conference and it was a busy day so LPN-C was not able to connect with SS-A until after lunch. In addition, LPN-C stated she was aware allegations of abuse were to be reported right away. LPN-C confirmed the administrator had not re-educated her regarding reporting requirements and had not spoken to the administrator since 9/24/24. On 10/2/24 at 11:42 a.m. administrator confirmed he did not report R1's allegation to the SA until 5:41 p.m., due to there was a lot going on and by the time administrator interviewed NA-A it was close to the two-hour timeframe, I don't know. Review of facility policy titled Abuse, Neglect and Exploitation revised 7/15/22, indicated staff were expected to report all alleged violations to the administrator, SA and to all other required agencies within specified timeframes: immediately, but not later than two hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to immediately implement an intervention to protect 1 of 1 residents (R1) following an allegation of physical staff to resident abuse. This deficient practice had the potential to affect all other residents currently residing in the facility. Findings include: R1's significant changes Minimal Data Set (MDS) dated [DATE], indicated R1's diagnoses included dementia and personality disorder. R1's cognition was not impaired. Review of facility report number 358043 submitted to the SA on 9/24/24 at 5:41 p.m. R1 had reported a nursing assistant (NA) while providing cares was angry and telling R1 not to use the call light and it made her angry. R1 reported NA pinched her in the left leg and grabbed her hair with water on her hands. R1 was able to identify the staff as NA-A. Review of NA-A's timecard dated 10/2/24, indicated NA-A had clocked in for work at 5:31 a.m. and clocked out at 3:34 p.m., on the day of the alleged incident 9/24/24. On 10/2/24 at 10:41 a.m., licensed practical nurse (LPN)-B stated following an allegation of staff to resident abuse, the alleged perpetrator would need to be removed from direct care and building pending the investigation to protect the residents. On 10/2/24 at 10:57 a.m., social services (SS)-A stated she was made are of R1's allegation at approximately 2:00 p.m. on 9/24/24, and SS-A stated the investigation started NA-A had already left the building as her shift was completed. SS-A stated she interviewed R1 regarding the allegation and R1 had reported she now felt safe in the facility knowing NA-A was no longer in the building. On 10/2/24 at 11:14 a.m., administrator stated he was notified of R1's allegation at approximately 2:00 p.m. on 9/24/24. Administrator stated he interviewed R1 at approximately 2:05 p.m., and R1 had reported she did not feel safe in the facility because NA-A was still in the building. Administrator stated he had not interviewed NA-A yet however ensured R1 that NA-A was going to be suspended immediately which R1 then reported she felt safe. On 10/2/24 at 11:31 a.m., LPN-C stated at approximately 11:30 a.m. on 9/24/24, LPN-C was administering R1's medications when R1 reported staff had pinched and hit her. LPN-C stated NA-A was R1's caregiver that day assisting R1 as needed and requested. LPN-C stated she was not aware of any incidents between R1 and NA-A, and LPN-C stated NA-A appeared fine that day no unusual behaviors. On 10/2/24 at 11:46 a.m., NA-A stated R1 had reported to LPN-C while NA-A was assisting R1 with cares NA-A pinched her. NA-A confirmed she had assisted R1 with cares on the day of the allegation, and NA-A was suspended for three days while the facility completed an investigation, however NA-A could not recall when she left the building on 9/24/24. Review of facility policy titled Abuse, Neglect and Exploitation revised 7/15/22, indicated the facility would make efforts to ensure all residents were protected from physical and psychosocial harm during and after the investigation. Examples included but were not limited to responding immediately to protect the alleged victim and integrity of the investigation and room or staffing changes to protect the resident(s) from the alleged perpetrator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure urinary catheter drainage bags were covered to maintain dignity for 1 of 1 residents (R32) reviewed for dignity. Findings include: R32's annual Minimum Data Set (MDS) dated [DATE], indicated she was rarely understood and had diagnoses of alcohol-induced dementia (loss of memory, language, problem-solving and other thinking abilities) and obstructive uropathy (disorder of the urinary tract caused by urinary flow obstruction). Furthermore, R32's MDS indicated she had an indwelling urinary catheter. R32's Care Area Assessment (CAA) for urinary incontinence and indwelling catheter was triggered and indicated R32 required staff assistance with toileting and had an indwelling catheter in place due to her obstructive uropathy. The CAA indicated staff would assist with catheter cares and provide interventions per R32's plan of care. R32's care plan dated 10/25/22, indicated her catheter bag should be in a dignity bag attached to her wheelchair or bed. During observation on 2/27/24 at 11:36 a.m., R32 was laying in bed in a shared room. Her catheter drainage bag hung on the bed frame and a clear plastic bag was tied around it. At 1:57 p.m., the catheter bag containing clear yellow liquid continued to be inside a clear plastic bag At 3:00 p.m., R32's catheter bag remained unchanged. During observation on 2/28/24 at 7:28 a.m., R32 was in the dining room with two other unidentified residents. Her catheter bag was hanging from her wheelchair and a clear plastic bag was tied around it. At 8:06 a.m., there were six unidentified residents in the dining room with R32 and R32's catheter bag remained unchanged. At 8:11 a.m., nursing assistant (NA)-A pushed R32 out of the dining room and into the TV lounge area. NA-A stated the bags they normally used to cover R32's catheter bag was unavailable and acknowledged the clear plastic bag did not provide dignity for R32. At 8:16 a.m., licensed practical nurse (LPN)-A stated there was a pouch attached to R32's wheelchair that could be used, however, the catheter bag itself was too large to fit. LPN-A stated it is not facility policy to use a plastic bag to cover catheter bags and explained there is storage room with extra cloth bags where one could be retrieved. LPN-A also acknowledged the plastic bag did not provide for R32's dignity. LPN-A found a cloth cover inside the wheelchair's pouch and attempted to put it over R32's catheter bag that remained inside the clear plastic bag. The cloth cover slipped over the catheter bag and hung loosely around the catheter tubing, leaving the catheter bag exposed. LPN-A stated there was a more appropriate catheter cover for R32 and walked away to find it at 8:18 a.m. At 8:31 a.m., LPN-A returned to the TV lounge area where R32 remained and asked how she was feeling. LPN-A left the area within a minute without providing for R32's dignity by covering her catheter bag. At 8:44 a.m., NA-A entered the TV lounge area and exited without offering to provide for R32's dignity. During interview on 2/28/24 at 8:46 a.m., the director of nursing (DON) stated the facility has specific catheter bags and covers that go with them and those were expected to be used. The DON stated a clear plastic bag tied around a catheter bag did not provide for a resident's dignity. A facility policy titled Resident Rights dated 7/2022, indicated residents will be treated with respect and dignity and care for each resident will be given in a manner and in an environment that promotes maintenance or enhancement of her quality of life.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a self-administration of medication assessment was completed to allow a resident to safely administer their own medication for 1 of 1 residents (R11) observed self-administrating a nebulizer treatment. Findings include: R11's quarterly Minimum Data Set, dated [DATE], indicated R11 had intact cognition and diagnoses of hypertension, respiratory failure, chronic obstructive pulmonary disease (COPD; lung disease which blocks airflow and makes it difficult to breathe), and malnutrition. R11 had impairments to both upper and lower extremities, was independent with bed mobility and eating, and required partial/moderate and/or dependent assistance with activities of daily living (ADLs) such as dressing and personal hygiene. R11's MDS indicated they received hospice services. R11's annual MDS dated [DATE] did not indicate R11 had impairment to upper or lower extremities. R11's care plan dated 3/1/24, indicated an alteration in respiratory status and directed staff to administer medications as ordered. R11's care plan lacked documentation to indicate R11 was able to self-administer medications. R11's care plan indicated 10/26/22 R11 recently signed onto hospice services. R11's orders included budesonide inhalation suspension 0.5 mg/2 mL 1 vial inhale orally one time a day related to COPD with start date of 10/19/23, ipratropium-albuterol 0.5-2.5 (3) mg/3 mL solution 3 mL inhale orally four times a day for shortness of breath and/or wheezing with start date of 2/22/21 and two times a day as needed with start date of 11/13/19. Orders for these medications did not specify self-administration. R11's Medication Self Administration assessment dated [DATE], directed for licensed staff to dispense the nebulizer medication and allow R11 to administer after dispensing. During observation on 2/26/24 at 12:50 p.m., R11 was in their room alone and had their nebulizer on but not up to their face. Nursing assistant-E entered R11's room, spoke with R11 and then exited. No other staff were observed in the hallway. R11 held up the nebulizer to their mouth. During observation on 2/26/24 at 12:57 p.m., R11 turned the nebulizer off. During interview on 2/26/24 at 2:40 p.m., R11 stated staff put the medication in the nebulizer vial, and R11 turned the nebulizer on when needed. R11 stated staff did not stay with in the room while the nebulizer was being taken, and R11 shut off the nebulizer themselves if staff did not. During observation on 2/27/24 at 11:34 a.m., R11 was in their room with nebulizer up to their mouth. No nursing staff were observed near or in R11's room. Registered nurse (RN)-B affirmed R11 was in the room alone with the nebulizer running and staff were supposed to be with R11 during the nebulizer treatment. RN-B stated the nurse who administered the nebulizer would be back and went to grab something. RN-B stated R11 had arthritis in joints so was unable to administer some medications themselves. RN-B stated R11 needed an order for self-administration of the nebulizer and did not mention the need for a self-administration assessment. At 11:45 a.m., RN-B asked licensed practical nurse (LPN)-B to go to R11's room. During interview on 2/27/24 at 11:47 a.m., LPN-B stated they usually set up the nebulizer for R11, and R11 was able to turn on the nebulizer themselves. LPN-B stated they needed an order for self-administration and did not mention the need for an assessment. LPN-B stated staff turn off the nebulizer, or R11 also turned off the nebulizer. LPN-B stated they had set-up the nebulizer around 10 a.m. when R11 was almost done with breakfast. During interview on 2/27/24 at 11:58 a.m., R11 stated they turned on and off the nebulizer themselves, and LPN-B checked the nebulizer was off. During interview on 2/28/24 at 2:15 p.m., LPN-A stated staff should not leave R11 alone during nebulizer administration. LPN-A stated staff were to turn on and off R11's nebulizer, and staff were able to stand by the door as R11 held the nebulizer to their mouth. LPN-A reviewed R11's Self-Administration Assessment for nebulizer from 6/22/21 and stated R11 needed a more recent assessment as R11 went onto hospice and had a change of condition. LPN-A stated R11 could have inadequate use of medication and not take the whole dose without having a self-administration assessment completed. During interview on 3/1/24 at 11:50 a.m., the director of nursing (DON) stated staff asked residents if they wanted to self-administer medications upon admission and during care conferences. DON expected an assessment to be completed before residents self-administered medications. The facility's policy Medication Self Administration dated 6/1/17, indicated residents were not permitted to administer any medication in their room unless their attending physician writes an order for self-administration of the medication, and resident was assessed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R4's quarterly Minimum Data Set (MDS) dated [DATE], indicated severe cognitive impairment and R4 was totally dependent on staff assistance for transfers and bed mobility. MDS also indicated diagnoses of right-sided weakness and immobility due to a stroke, dementia (loss of memory, language, problem-solving and other thinking abilities), depression, anxiety, dysarthria (condition causing facial immobility or tongue or throat muscle weakness), and glaucoma of both eyes (disease that damages the eyes' optic nerve, causing visual disturbances). R4's Care Area Assessment (CAA) dated 6/19/23, triggered for activities of daily living (ADL) functional and rehabilitation potential. The CAA indicated R4 required extensive to total assistance with most of his ADLs related to his weakness and immobility. The CAA identified a goal to ensure R4's safety and meeting his needs by following his care plan. R4's care plan dated 3/24/20, identified a fall reduction intervention of pinning the call light to R4's clothing and instructing him to use it. Additionally, the care plan identified placing R4's personal items within his reach as a way to reduce falls. An undated [NAME] identified a safety intervention of pinning R4's call light to his clothing to help reduce falls. During observation on 2/26/24 at 5:22 p.m., R4 was in his Broda chair in his room facing the television. His call light was tucked in the upper nightstand drawer, out of his reach. During observation on 2/27/24 at 10:49 a.m., R4 was in his Broda chair in his room facing the television. He had his remote control for the television in his hand. The call light was clipped to the bed, out of his reach. At 11:11 a.m., nursing assistant (NA)-A entered R4's room and exited the room within a minute. The call light was still clipped to the bed, out of R4's reach. At 11: 21 a.m., NA-A stated R4 had fallen a month or two ago but was unsure about specific fall interventions. NA-A reported using the [NAME] to identify interventions and stated the call light should be accessible for residents. NA-A verified R4 was unable to reach his call light and stated he should have it within his reach in case he needed to call for help. NA-A pinned the call light to R4's shirt before exiting the room. During observation and interview on 2/28/24 at 12:43 p.m., R4 was sitting in his Broda chair in his room facing the television. The call light was pinned to his bed, out of his reach. At 12:50 p.m., licensed practical nurse (LPN)-A verified the call light was not in a place that R4 could reach. LPN-A stated R4 should have his call light within reach because he should have a way to call for someone. During interview on 2/29/24 at 2:49 p.m., the director of nursing stated fall prevention interventions included ensuring the call light is within reach. The DON verified a call light within reach is an appropriate intervention for all long-term care residents. Furthermore, the DON stated all care planned interventions NAs are expected to implement would be listed on the [NAME]. Additionally, the DON stated the NAs had training and provided return demonstrations on how to access and read the [NAME]. A facility policy titled NSG - Call lights: Accessibility and Timely Response dated 7/26/22, indicated all staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light. The policy also indicated special accommodations will be identified on the resident's person-centered plan of care, and provided accordingly. Furthermore, the policy indicated staff will ensure the call light is within reach of resident and secured, as needed. Based on observation, interview, and document review, the facility failed to ensure R33 had access to the bathroom in their room. In addition, the facility failed to ensure R4 had access to their call light for two of two residents (R4 and R33) reviewed for reasonable accomodation of needs and preferences. Findings include: R33's quarterly Minimum Data Set, dated [DATE], identified R33 was cognitively intact, had diagnoses of stroke with left sided weakness and dementia, required set-up for oral care, substantial assistance with toilet transfers, was independent with using their wheelchair for short distances, and incontinent of bowel and bladder. R33's quarterly Bladder/Bowel assessment dated [DATE], indicated he was incontinent of bladder and continent of bowel. R33's care plan dated 12/29/23, included R33 required assist of one staff for toileting due to left sided weakness and directed staff to offer to stand pivot transfer to toilet before breakfast, after lunch, and at bedtime. R33's [NAME] (nursing assistant care sheet) printed 2/27/24, indicated R33 used the communal toilet/shower room toilet for their toileting needs. R33's Hopkins Health Services Notice of Room Relocation dated 12/14/23, and signed by the social worker 12/20/23, indicated R33 was moved to their current room to allow for more accessibility with bathroom to meet maximum potential, more room/space for resident to get around. During observation and interview on 2/27/24 at 1:46 p.m., R33 stated they were unable to get into their bathroom to use the toilet, brush their teeth, or wash themselves because there was too much stuff in the way to get into it. They stated they wanted to use the toilet in their bathroom, but staff told them R33 needed to use the one in the shower room because R33 needed assistance with transfers and there wasn't room. R33 stated the shower room was often occupied, or the shower chair was in the way of the toilet preventing him from using it when he needed to. A floor fan, nightstand, and R33's roommate's wheelchair was positioned in front of R33's bathroom door preventing full access. The bathroom contained a tall bedside table which held a large cardboard box of items covered in a sling for a mechanical lift, and a tall floor fan. The sink counter had two large pink bins of medical supplies, one on each side of the sink, and two emesis basins with oral care supplies behind the faucet. Three boxes of additional medical supplies were on the floor in front of the sink. During observation on 2/29/24 at 11:16 a.m., R33's bathroom continued to contain the boxes, table, and oscillating floor fan as previously described. Another floor fan and a nightstand were located behind the bathroom door preventing it from fully opening. Additionally, R33's roommate's wheelchair was parked directly in front of the toilet. During interview on 2/29/24 at 12:29 p.m., nursing assistant (NA)-A stated R33 was sometimes continent and let them know when they needed to use the toilet, and stated they usually used the one in the shower room during the day, but sometimes there was already someone using it. Upon observation of R33's bathroom, NA-A stated the supplies and equipment were not supposed to be stored in the bathroom and they prevented R33 from using it. During interview on 2/29/24 at 12:34 p.m., licensed practical nurse (LPN)-E stated they were not sure why R33 needed to use the toilet in the shower room but thought it might be easier to grab the bars on the wall for pivot transfers due to weakness on one side of their body. During interview on 2/29/24 at 12:36 p.m., LPN-A stated occupational therapy (OT) evaluated R33 and R33 had a difficult time transferring in the bathroom because it was too small, and used the toilet in the communal shower room because it was large and had a grab bar R33 could use. LPN-A stated R33 had several room changes in the past two months but never used the bathroom in their own room, and indicated, It's a mess, I'm sure, as supplies were being stored in the room. During interview on 2/29/24 at 1:48 p.m., certified occupational therapist assistant (COTA) stated they previously worked with R33 on transfers, and R33 needed one staff for stabilization. R33 was moved to their current room so they could more easily access the larger bathroom, but there was a lot of stuff in there which prevented R33 from using it. During interview on 2/29/24 at 1:54 p.m., director of nursing stated they were not aware of the therapy recommendation, however they expected R33 to have access and be able to use the bathroom in their room if they were evaluated and safe to do so. The Safe and Homelike Environment Policy dated 6/16/22, included the facility will provide a safe, clean, comfortable, and homelike environment, which includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. Environment refers to any environment in the facility frequented by residents, including resident's rooms and bathrooms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure 1 of 1 resident (R12) had a vision appointment for decreased vision. Findings include: R12's annual Minimum Data Set (MDS) dated [DATE], indicated R12 had short-term and long-term memory problems and moderately impaired daily decision-making cognitive skills. The MDS did not indicate rejection of cares. The MDS indicated R12 had schizophrenia, hypertension, and moderately impaired vision. R12's Care Area assessment dated [DATE], indicated R12 had diagnosis of myopia (condition in which close objects appear clearly, but far ones don't), did not wear glasses, and was at risk for further loss of vision and falls. During record review on 2/29/24, R12's careplan lacked interventions for vision impairment. R12's admission Record dated 3/1/24, indicated R12 had partial retinal artery occlusion of the right eye and retinal artery branch occlusion of the left eye with onset date of 10/6/21. On 2/26/24 at 5:13 p.m., R12 laid in their bed and stated they lost their eyesight in the left eye and was not sure if the facility offered eye exams. On 2/27/24 at 2:37 p.m., R12 laid in their bed and stated they used to like to read but now do very little because of their eyesight. During interview on 2/28/24 at 11:11 a.m., nursing assistant (NA)-A stated about a month ago R12 asked for assistance with reading her mail, so NA-A notified the social worker to assist R12. NA-A had not heard of any concerns with R12's eyesight. During interview on 2/29/24 at 11:24 a.m., the medical records coordinator (MRC) stated Health Drive was at the facility today for eye appointments and R12 was not on the list for today's appointments and was not sure when she was last seen or when she would be seen next. MRC stated residents have annual exams but were seen sooner as needed. MRC stated they schedule appointments if residents requested or nursing alerted them. Residents were sent to appointments with a clinic form in an envelope and the doctor was to write on the form and send it back to the facility with the resident. Nursing would see if a resident needed a follow up appointment from the form described or after visit summary and would let MRC know to schedule an appointment. Paperwork from appointments were scanned into the electronic medical record. During interview on 2/29/24 at 11:56 a.m., MRC communicated R12 had her eye appointments through the VA (Veterans Affairs) and not Health Drive. During interview on 2/29/24 at 2:19 p.m., MRC stated they called the VA and found out R12's last eye appointment was 10/24/22, and R12's 10/23/23 appointment was cancelled by the clinic. MRC stated R12 now had an appointment scheduled for 3/8/24. During interview on 2/29/24 at 3:42 p.m., LPN-A stated R12 complained about her vision approximately three to four months ago and could see straight ahead but peripheral eyesight was gone. LPN-A stated R12 sometimes did not comply with going to appointments and thought R12 mentioned having a bad experience with the VA but should check if she had an eye appointment since the change in eyesight. LPN-A verified R12's care plan did not mention vision. During interview on 2/29/24 at 12:00 p.m., the director of nursing (DON) stated R12 had been offered onsite vision services in the past but declined. DON stated sometimes R12 called the VA to set up their own appointments, and then the VA would call the facility to confirm the appointment. DON did not know about R12's vision concerns. DON thought the VA would have rescheduled R12's appoitnment since they cancelled the appointment. The facility did not have a policy about vision or appointments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R144's 5-day admission Minimum Data Set (MDS) dated [DATE], indicated R144 had severe cognitive impairment and diagnoses of chronic kidney disease, heart disease and dementia. R144's admission skin assessment dated [DATE], indicated R144 had no skin impairments present, was warm to touch with good circulation. Furthermore, R144's admission skin assessment lacked indication R144 was at risk for skin alterations. R144's nursing assistant (NA) [NAME] printed 2/29/24, lacked indication R144 required repositioning assistance. R144's care plan dated 2/23/24, lacked indication R144 was at risk for pressure injury or required interventions to prevent skin injury. R144's nursing daily skilled observation note dated 2/24/24, indicated R144 had no skin impairments. R144's emergency department provider note dated 2/24/24, indicated R144 had blanching erythema (skin redness that is caused by injury, inflamation or infection) of the left heel and left lower leg skin excoriation with erythema that was outlined. When interviewed on 2/29/24 at 11:46 a.m. family member (FM)-A stated R144 was in the facility for three days before returning to the emergency room. FM-A further stated the emergency room found pressure sores on R144's heels that included a blister. FM-B stated the day R144 went back to the emergency room, they called the facility to check on R144 at approximately 10:30 a.m., and R144 was still in bed. Furthermore, FM-A was concerned with how R144 was moved at the facility as these sores were not present during the prior hospitalization. When interviewed on 2/29/24 at 12:56 p.m. registered nurse (RN)-A stated R144 had no skin issues upon admission, and the coccyx skin was intact and not open. Furthermore, RN-A stated the few days of being at the facility, R144 was assisted out of bed for breakfast around 10:00 a.m. and would sit out by the nurse's desk. RN-A was not aware of any skin concerns when R144 was sent to the hospital. Furthermore, RN-A stated residents had a skin assessment was completed right away upon admission. The admission assessment would then trigger interventions to be included in the care plan. RN-A verified R144 was at risk for pressure injury due to poor mobility and unable to reposition themselves and the admission assessment did not include that risk. When interviewed on 3/1/24. The Director of Nursing (DON) stated a skin assessment were part of the admission assessment and risks for pressure injury would then be included on the care plan. DON verified R144's admission skin assessment showed no pressure areas or other skin concerns. The DON verified R144 was very frail and at risk for skin breakdown and acknowledged the assessment did not show that and there was no care planned interventions in place. After review of R144's emergency room skin pictures, DON stated she expected staff to have knowledge and awareness of the skin concerns identified in the emergency room. Based on observation, interview, and record review the facility failed to ensure provider orders for pressure relieving devices were in place for 1 of 5 residents (R23) reviewed for pressure injury. Furthermore, the facility failed to ensure assessment and monitoring for pressure injury was provided for 1 of 5 (R144) residents reviewed for pressure injury. Finding include: R23's significant change Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnoses of Alzheimer's disease, type II diabetes and did not have a history of refusing care. It further indicated R23 required moderate assistance with rolling side to side and was dependent on staff for mobility and toileting. R23 was at risk for and had one facility acquired stage III pressure ulcer on her left heel. R23's physician's order dated 9/11/23 indicated to use blue heel protector boots when in bed every evening and night shift for wound prevention. R23's care plan dated 2/21/24, lacked any mention of blue foam boots/heel protectors. During observation on 2/27/24 at 8:29 a.m., R23 was laying in bed on her back with the head of bed (HOB) elevated. She wasn't wearing blue heel protectors and her heels were laying on the mattress. During observation on 2/27/24 at 2:46 p.m., R23 was laying in bed on her back with the HOB slightly elevated. She was not wearing blue heel protectors and her heels were laying on the mattress. During observation and interview on 2/28/24 at 7:45 a.m., nursing assistant (NA)-F went into R23's room to change her brief. R23 was laying in bed on her back. She was not wearing blue heel protectors and her heels were laying on the mattress. During an interview on 2/28/24 at 8:58 a.m. R23 stated No one (staff) puts them on anymore (heel protectors), they put them on once and they didn't work. During an interview on 2/28/24 at 9:03 a.m. nursing assistant (NA)-F stated I don't know if she (R23) has blue foam boots anymore, I think she refuses them, talk to RN-C, she will know. NA-F also verified R23 wasn't wearing her heal protectors when she went into her room this morning at 7:30 a.m. During interview on 2/28/24 at 9:11 a.m., NA-D stated he wasn't sure if R23 has heel protectors anymore. She use to have them when she was on the other unit but he hadn't seen them since. During observation and interview on 2/28/24 at 9:12 a.m., registered nurse (RN)-C stated R23 was supposed to have heel protectors on when she was in bed. RN-C further stated the NA's were responsible for putting them on and documenting if she refused. RN-C was unable to locate the heel protecters in R23's room. During an interview on 2/28/24 at 9:16 a.m., the nurse manager licensed practical nurse (LPN)-F stated R23 was supposed to wear the heel protectors when she was in bed and the NA's were responsible for putting them on and the nurses were supposed to verify. The nurses were also responsible for documenting refusals and to reapproach later when she refused. The surveyor told LPN-F that RN-C was unable to locate the heel protectors in R23's room and asked if the heel protectors were unable to be located would you agree the staff were not putting them on. LPN-F stated she agreed. During interview on 2/28/24 at 10:28 a.m., the director of nursing (DON) stated R23 should be wearing the heel protectors when she was in bed and all staff were responsible for putting them on. If R23 refused, it should be documented and if she continued to refuse the nurse or someone should be notified she was refusing and they should be having a meeting about it. The facilty's policy on pressure injuries dated 7/20/22, indicated this center will complete a comprehensive assessment to identify risk factors for the development of pressure injuries and put in place measures intended to achieve the goal of prevention of pressure injuries in our residents. For those residents admitted with or who subsequently developed a pressure injury or impaired skin integrity, they will receive care, treatment, and services that seek to promote healing, prevent infection, and prevent further development of pressure injuries/impaired skin integrity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure appropriate management of an indwelling catheter was provided for 1 of 2 residents (R35) reviewed for indwelling catheter. Findings include: R35's significant change Minimum Data Set (MDS) dated [DATE], indicated R12 had an indwelling catheter, did not have a trial of a toileting program, and always incontinent of bowel. The MDS indicated R35 was cognitively intact and diagnosis of cirrhosis (condition in which liver is scarred and permanently damaged), manic depression, and post-traumatic stress disorder. R35's Care Area Assessment (CAA) dated 1/29/24, indicated R35 was dependent on staff for toileting hygiene and at risk for urinary tract infections and other complications related to catheter use. R35's indwelling urinary catheter care plan dated 11/13/23, directed staff to change urinary collection bag as needed, provide catheter care, educate resident /representative on catheter care, evaluate as needed for possible removal of catheter and bladder retraining or toileting plan, report any changes in amount and color or odor of urine, and report to provider signs of urinary tract infection such as blood, cloudy urine, fever, increased restlessness, lethargy, c/o pain/burning. R35's Order Summary Report dated 3/1/24, indicated to change foley catheter system every 28 days using a 16 French with 10 cc balloon and as needed with order date of 1/18/24. Orders indicated retention as the diagnosis for the indwelling urinary catheter with order date of 1/18/24. The treatment administration record (TAR) recorded R35's Foley catheter system was changed 2/19/24. During document review, a provider progress note dated 11/8/23 indicated R35 had urinary retention and should follow up with urology because of R35's indwelling Foley catheter. Provider and nurse practitioner progress notes from 12/6/23, 12/13/23, 12/20/23, 12/27/23, and 1/8/24 indicated the same. A provider note from 1/31/24 included the following note: Retention of urine, unspecified: Urology referral supposedly has been set up. The provider note from 2/28/24 again indicated R35 had urinary retention and should follow up with urology because R35's indwelling Foley catheter. On 2/26/24 at 1:35 p.m., R35 stated she was not sure why she had the catheter and if it would be removed. R35 stated interest in having the catheter removed. The catheter and catheter bag were not visible. On 2/29/24 at 9:33 a.m., nursing assistant (NA)-C stated they emptied R35's catheter bag and noted output and had not noticed any concerns with R35's catheter. On 2/29/24 at 10:05 a.m., NA-A and NA-C completed some of R35's morning cares. During cares, the clear part of the catheter bag tubing had speckles and larger oval-shaped crust and sediment with mixed colors of tan and white. The crust and sediment were not moving and urine looked yellowish and did not contain sediment. The yellow part of the catheter tubing closer to the R35's peri area had a brown crusted spot and some other speckles even after cares were complete, and NA-A and NA-C left R35's room. On 2/29/24 at 10:14 a.m., NA-C stated they alert the nurse when there were concerns like urine color or odor, leakage of urine from catheter, or no urine output in catheter bag. NA-C stated it was important to make sure the catheter is clean to prevent infection. NA-C went back to R35's room and wiped the yellow part of R35's catheter tubing with an alcohol prep pad. Some of the crust came off and one area of crust did not come off after wiping. NA-C verified the sediment seen on the clear part of the tubing was on the inside. NA-C notified licensed practical nurse (LPN)-E to observe R35's catheter. LPN-E stated R35's urine looked concentrated, and the tubing did not look normal and should be changed. LPN-E assessed R35, and R35 recalled having a different feeling when she started to urinate. On 2/29/24 at 3:28 p.m., LPN-A stated the director of nursing (DON) and nurse managers reviewed provider notes. LPN-A reviewed provider progress notes and stated they were not aware of the provider's requests for R35 to see urology. LPN-A stated with recommendations for a referral or appointment, providers would write an order, and nursing would let medical records know to make an appointment. LPN-A stated there was a portal the facility used to communicate with the providers, and the DON had sent out a message regarding if R35 should see urology or have catheter discontinued. LPN-A stated R35 had an order to change their catheter every 28 days and as needed. LPN-A stated R35's catheter bag should be changed weekly and upon review there was no order for the catheter bag to be changed weekly. LPN-A stated R35 was prone to urinary tract infections. On 3/1/24 at 12 p.m., DON stated they had not been given direction if R35's catheter is long term or if a voiding trial should be completed and was told the provider was going to follow up with the facility after 2/28/24 rounds. The DON had reviewed the provider note from 2/28/24 and needed to send out another message. DON stated orders to change catheters and catheter bags were individualized and always could change catheters and catheter bags as needed. On 3/1/24 at 4:58 p.m., nurse practitioner (NP) stated R35 had a catheter due to inability to void on her own, and the hospital noted failed voiding trials. NP reviewed an order was sent to the facility on [DATE] about urology because of R35's indwelling Foley catheter for urinary retention. NP stated there were issues with faxed communication and orders disappearing but had recently been better. NP reviewed a note from the facility on 2/20/24 regarding R35's catheter and a note to the facility that the provider would follow up with the facility after rounds. NP reviewed there was nothing to address R35's catheter or urology after rounds which occurred on 2/28/24 and would send another urology order to the facility and add R35 to rounds on Monday. NP stated the goal was to have R35 follow up with urology, and R35 not seeing urology or having a voiding trial yet was a concern. The facility did not have a policy regarding appointments or referrals or orders for such. The facility's policy Indwelling Catheter Use and Removal dated 7/26/22, Indicated catheters and drainage bags should be changed based on clinical indications such as infection, obstruction, or when the closed system is compromised.

Based on observation, interview, and document review, the facility failed to ensure medications were labeled with current, accurate physician orders to reduce the risk of administration error for 1 of 5 residents (R33) observed to receive medication during the survey. Findings include: R33's Order Summary Report dated 3/1/24, identified an order which read Famotidine Oral Tablet 20 MG (Famotidine) Give 20 mg by mouth two times a day related to GASTRO-ESOPHAGEAL REFLUX DISEASE WITH ESOPHAGITIS, WITHOUT BLEEDING with start date of 6/8/23. Another order read tizanidine HCI Oral Tablet 4 MG (Tizanidine HCI) Give 4 mg by mouth two times a day for Spastic left hemiparesis with start date of 2/22/24. On 2/28/24 at 7:40 a.m., licensed practical nurse (LPN-C) prepared medications for R33 in the hallway from a mobile cart. LPN-C presented the Famotidine 20 milligram (mg) medication card, and the directions on the label of the medication card directed, GIVE 1 TABLET VIA TUBE TWICE DAILY. The start date on the label was 2/9/24. There were no other directions or guidance displayed on the label to indicate the order changed since the label was placed. LPN-C prepared another medication for R33. LPN-C presented the tizanidine medication card, and the label read tizanidine HCL 2 MG CAPSULE with directions to GIVE 1 CAPSULE BY MOUTH THREE TIMES DAILY. The issue date on the medication label was 1/26/24. There were no other directions or guidance displayed on the label to indicate the order changed since the label was placed. LPN-C stated they needed to give two capsules since the order in the electronic medication administration record (eMAR) said 4 mg. During further interview on 2/28/24 at 7:45 a.m., LPN-C stated R33 used to have a gastrostomy tube (tube inserted through the abdomen to bring nutrition directly to the stomach) and was discontinued. LPN-C verified the Famotidine 20 mg medication card directed staff to give the medication VIA TUBE. LPN-C stated the pharmacy was supposed to change their label to match the eMAR and somehow the pharmacy did not send an updated label. LPN-C verified the tizanidine medication card label did not match the eMAR. If the label and eMAR did not match, staff followed the eMAR. LPN-C found a medication card in the mobile cart which read tizanidine HCL 4 MG TABLET with directions to give 1 TABELT BY MOUTH TWICE DAILY. LPN-C stated medication cards should be discarded once the pharmacy sent medication cards with updated labels, and the first tizanidine medication card presented should be discarded. During interview on 2/28/24 at 3:22 p.m., LPN-D stated medication cards should be removed from the mobile cart when an order changed, or staff should write on the label to indicate a change. LPN-D stated they had stickers to indicate a changed order but did not have them a lot. LPN-D stated incorrect labels on medication cards may cause a medication error. During interview on 3/1/24 at 12:10 p.m., director of nursing (DON) DON stated there was a risk of medication error when labels and physician's orders did not match. DON expected staff to verify the order and either place a sticker on the label to indicate the order changed or take the medication card out of the mobile cart and send back to the pharmacy. The facility's policy Medication Ordering and Receiving From Pharmacy Provider: Medications and Medication Labels dated 2007, identified improperly or inaccurately labeled medications are refused and returned to the dispensing pharmacy and if directions for use change, the provider pharmacy is informed prior to the next refill of the prescription so the new container will show an accurate label. Further, the policy identified the nurse may place a direction change or similar label on the container to indicate there is a change in directions for use, taking care not to cover important label information, and should check the resident's medication administration record or the prescriber's order for current information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure current standards of practice for glove us and handwashing were being followed for 1 of 3 residents (R35) when staff provided personal care. Findings include: R35's significant change Minimum Data Set (MDS) dated [DATE], indicated R35 was cognitively intact, had an indwelling catheter, and always incontinent of bowel. The MDS indicated R35 was dependent on staff for toileting hygiene and required partial/moderate assistance to roll left to right. During observation on 2/29/24 at 10:05 a.m., nursing assistant (NA)-A and NA-C assisted R35 with catheter and peri-cares. NA-C wiped bowel movement from R35's bottom and removed soiled brief. NA-C removed gloves, did not perform hand hygiene, and placed new gloves on. NA-C assisted R35 with clean incontinent product and placed barrier cream on R35's bottom. NA-C removed gloves, did not perform hand hygiene, and placed on new gloves. NA-C assisted R35 to reposition in bed and gave R35 the bed remote. During interview on 2/29/24 at 10:14 a.m., NA-C stated hand hygiene should be performed between glove changes. NA-C verified they did not perform hand hygiene between glove changes and stated they were looking for hand sanitizer during cares. During interview on 2/29/24 at 3:51 p.m., licensed practical nurse (LPN)-A stated hand hygiene should be performed between glove changes. During interview on 3/1/24 at 12:26 p.m., director of nursing (DON) expected staff to perform hand hygiene after removing gloves and before applying new gloves. Not performing hand hygiene between glove changes contaminated the clean gloves. The facility policy Hand Hygiene dated 11/2/22, indicated the use of gloves did not replace hand hygiene. If tasks required gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately assess residents' eligibility to receive the pneumococcal vaccination according to The Centers of Disease and Control and Prevention (CDC) for 2 of 5 (R 35, R28) residents reviewed for vaccinations. Furthermore, the facility failed to ensure the influenza vaccination was offered 1 of 5 residents (R35) reviewed for vaccinations. Findings include: The Center for Disease Control and Prevention identified on the Pneumococcal Vaccine Timing for Adults Chart, dated 3/15/23, Adult [AGE] years of age or older who had received the PPSV23 (pneumococcal polysaccharide vaccine 23) only at any age should receive one dose of either pneumococcal 20-valent Conjugate Vaccine (PCV20) or pneumococcal 15-valent Conjugate Vaccine (PCV15). The dose of PCV20 or PCV15 should be administered at least one year after the most recent PPSV23 dose. R35's admission Minimum Data Set (MDS) dated [DATE], indicated R35 was cognitively intact and had diagnoses of alcohol dependence and alcoholic cirrhosis of the liver. Furthermore, R25's MDS indicated R35 was up to date on the pneumococcal vaccine and refused the influenza vaccine. R35 was [AGE] years old. R35's Minnesota immunization information connection (MIIC) report dated 11/1/23, indicated R25 received the PPSV23 on 10/24/2019 and had not received a influenza vaccination for the 2023-2024 season. Review of the current CDC pneumococcal vaccine recommendations 03/15/23, indicated due to R35's alcohol dependence, R35 required one dose PCV 15 or 20, at least 1 year after PPSV23. Then the pneumococcal vaccination was complete. R35's consent/declination for the pneumococcal PCV 15 or 20 was requested however was not received. R35's declination for the influenza vaccine was requested however was not received. R28's significant change MDS dated [DATE], indicated R28 had severe cognitive impairment and diagnoses of urinary tract infection and skin infection of right lower leg. Furthermore, R28's MDS indicated R28 was up to date on the pneumococcal vaccine. R28 was [AGE] years old. R28's immunization record indicated R28 received the PPSV23 on 8/25/24 and the PCV13 on 7/18/18. Review of the current CDC pneumococcal vaccine recommendations 03/15/23, indicated shared clinical decision making was needed to determine if a dose of the PCV20 should be given. R28's medical record lacked indication R28 or R28's family had been contacted or had discussion to determine if PCV20 should be given. When interviewed on 2/28/24 at 10:16 p.m., licensed practical nurse (LPN)-A stated when residents were admitted , hospital records or interviews helped determine their vaccination status. The information was then documented in the immunization record. LPN-A then stated the infection preventionist helped determine if vaccinations were needed and obtained consent. When interviewed on 2/29/24 at 9:53 a.m. the infection preventionist (IP) verified there was no documentation of consent/refusal for R35 and R28. The IP recognized work was needed to ensure residents were offered immunizations and the information was documented. Furthermore, the IP stated resident vaccinations were part of their process improvement last year and was going to continue as one for the current year. A facility policy titled Pneumococcal Vaccination revised 1/11/24, directed staff to assess for pneumococcal immunization upon admission and offer each resident the pneumococcal immunization in accordance to CDC guidelines unless medically contraindicated, already immunized, or refused. A facility policy titled Influenza Vaccination revised 8/31/23, directed staff to offer influenza vaccinations annually unless medically contraindicated, the resident was already vaccinated during the time period or refused the vaccination. Furthermore, the resident's record will include documentation to the education consent or declination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to perform monthly preventative maintenance inspections of resident transfer equipment prior to R4's fall during mechanical lift use. This had the potential to impact 14 residents requiring the use of a mechanical lift. Findings include: R4's quarterly Minimum Data Set (MDS) dated [DATE], indicated severe cognitive impairment and R4 was totally dependent on staff assistance for transfers. MDS also indicated diagnoses of right-sided weakness and immobility due to a stroke, dementia (loss of memory, language, problem-solving and other thinking abilities), depression, and anxiety. R4's Care Area Assessment (CAA) for falls dated 6/19/23, indicated R4 was at risk due to his immobility. The CAA indicated R4 required the use of a Hoyer mechanical lift for transfers. R4's CAA for activities of daily living (ADL) functional and rehabilitation potential dated 6/19/23, also indicated R4's dependence on staff assistance and use of a hoyer for transfers with a goal identified to keep R4 safe. R4's care plan dated 6/28/23, indicated he required two staff for transfer assistance. The care plan was updated on 12/5/23 to indicate the requirement of two staff with a mechanical life and large sling. A progress note dated 12/4/23, indicated R4 was being transferred using the hoyer lift when the lift malfunctioned and tipped to the left, lowering R4 to the floor. R4 was assessed by a registered nurse (RN) and no injuries were reported. An incident report dated 12/4/23, indicated there were no predisposing environmental factors that contributed to R4's fall from the mechanical lift. A critical event analysis and action plan worksheet, dated 12/4/23, indicated an action plan that included the following: - ongoing resident assessment for 72 hours. - lift assessments and inspection of mechanical lifts in addition to assessment of residents using Hoyer mechanical lifts, marked completed on 12/4/23. - working staff educated on mechanical lift with return demonstration, marked completed on 12/4/23. - non-working staff had message and education sent to them, marked completed on 12/4/23. - plan to provide relevant information at stand-up meeting, marked completed on 12/5/23. An email dated 12/5/23, indicated the facility's vice president of success requested immediate mechanical lift inspection to ensure proper functioning and repair. A notation at the bottom of the printed correspondence indicated the lifts were inspected 12/8/23. A work history report for resident lifts dated 2/27/23 through 2/9/24, provided a review of monthly resident lift inspection tasks. For the months of 2/2023 through 10/2023, the tasks were marked completed on-time (within seven days of the due date). For the task due on 11/30/2023, the task was marked skipped and dated 1/3/24, with the description of, no maintenance director. For the task due on 12/31/23, the task was marked completed on-time and dated 12/8/23. For the task due on 1/31/24, the task was marked completed on-time and dated 2/9/24. A Wisconsin Biomedical Services work order dated 12/11/23, indicated a preventative maintenance (PM) inspection was performed for model number Jasmine, serial number 15DDS2550008. The work order indicated the lift actuator only functioned going in one direction. Furthermore, the work order indicated one leg opened while the other did not close. The work order indicated this unit failed the inspection. A Wisconsin Biomedical Services work order dated 12/11/23, indicated a PM inspection was performed for model number RPL450-2, serial number 15FS2060066. The work order indicated the frame at the base was bent and the unit did not sit flush on the ground. The work order indicated this unit failed the inspection. A training log and sign-in sheet dated 12/4/23, indicated education was provided to staff with the objectives listed as, Hoyer/sit to stand condition, sling condition, two staff, what to do if there is something wrong. Staff working at the time of the mechanical lift-related incident signed their names in attestation to receiving this education in addition to providing a return demonstration on a mechanical lift transfer. At the bottom of the training log and sign in sheet were staff names handwritten in red ink with the notation, education by phone attached. During interview on 2/28/24 at 12:18 p.m., maintenance (M)-A stated the facility used a maintenance software program called TELS that provided monthly alerts for the PM inspection tasks for mechanical lifts. M-A verified responsibility for ensuring these tasks were completed, but stated in case of absence, the administrator and maintenance director from the other campus would have access to this facility's TELS system to ensure the tasks were completed. During interview on 2/29/24 at 9:09 a.m., the director of nursing (DON) reported being in the building at the time of incident and was notified immediately after R4's fall. The DON stated all mechanical lifts were inspected after the incident, and two were removed from resident use, including the mechanical lift involved in the fall. The DON stated education on mechanical lift and sling condition was provided for all staff in the building at the time of the incident. The DON stated staff were also educated on what to do if a lift or sling was deemed unsafe for resident use and how to ensure oncoming staff were aware. Furthermore, the DON reported the incident was discussed during huddles and interdisciplinary (IDT) meetings. The DON also provided verbal education to staff who were not on the schedule, and the names of those individuals were noted in red ink on the education attendance log. The DON reported witnessing mechanical lift transfers for all nursing staff except one night nurse. During interview on 2/29/24 at 10:50 a.m., M-B verified performing an inspection on the mechanical lifts using the facility's maintenance software program, TELS. M-B stated the functionality of each mechanical lift was verified by ensuring the actuator went up and down to the proper height, ensuring all bolts were on tightly, and inspecting the mechanical parts of the lift. M-B stated the batteries were inspected and some were replaced, the wheels were removed to be cleaned so the wheel bearings worked smoothly. M-B stated there were two mechanical lifts that were out of commission and not being used by staff. M-B added these two lifts were located downstairs, away from resident care areas. During interview 2/29/24 at 11:15 a.m., a senior technician for the manufacturer of the facility's mechanical lifts stated based on the operator's manual, lifts should be inspected once per month by the facility. The senior technician verified if PM inspections were not done between 12/8/23 and 2/9/24, it would be past due as it would exceed the once per month recommendation. During interview on 2/29/24 at 2:34 p.m., the administrator verified receiving a TELS report with uncompleted tasks. The administrator stated it was important to ensure maintenance tasks were being done and the expectation was, that they get done. A facility policy titled NSG - Safe Resident Handling and Transfers dated 8/25/22, indicated all residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them. The policy of the facility is to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident. Additionally, the policy indicated staff will inspect the equipment prior to use to ensure functionality and will alert maintenance or other designee if the equipment is not functioning properly. The policy indicated damaged, broken, or improperly functioning lift equipment will not be used and tagged out according to facility policy. A facility policy title Fall Prevention and Management Guidelines dated 11/8/22, indicated when any resident experiences a fall, the facility will complete a post-fall assessment and review comprised of the following: - physical assessment with vital signs, - neuro checks for any unwitnessed fall or witness fall where resident hits their head, - check for orthostatic blood pressure changes if postural hypotension suspected (a condition in which the blood pressure decreases with a change in position from laying, sitting, to standing), - resident and/or witness statements regarding fall, - environmental review for possible factors - contributing factors to the fall, - medication changes (new or discontinued), - mental status changes, and - any new diagnoses. Furthermore, the policy indicated all assessments and actions should be documented. The policy also indicated facility protocol should include falls review and analysis by the QAPI committee. An undated policy titled North Shore Healthcare Hopkins Health Services Policy and Procedure for Monthly Lift Inspections indicated lift safety inspections should be completed monthly.

Based on observation, interview, and document review, the facility failed to ensure proper sanitization of dishware used for meal preparation and resident service when 1 of 1 high-temperature commercial dishwashers was identified as not reaching adequate wash and rinse temperatures. This had potential to affect all 43 residents within the facility, staff, and visitors who consumed food from the main production kitchen. Findings include: During interview and observation on 2/28/24 at 9:51 a.m., kitchen manager (KM) stated the facility dishwasher used chemical sanitization and required a water temperature of 150 degrees Fahrenheit (°F) during the wash cycle and 180°F during the final rinse, and temperature readings were recorded after the last load of dishes after each meal. KM stated one staff person usually loaded the trays with dishes, placed them on the conveyor of the auto-feed dish machine and KM usually removed them when they were done. KM requested another staff person to demonstrate the machine by starting to wash the dirty breakfast dishes. During the first load at 9:55 a.m., the wash temperature reached 138°F and the rinse temperature reached 148°F. KM stated since the machine was just started it would take a few runs to get up to temperature, but the dishes were still considered sanitized even if the dish machine did not get up to temperature. A second tray was sent through which reached 138°F during the wash cycle and 176°F during the rinse cycle. KM stated it looked like the wash temperature gauge had not moved at all. Eight additional loads were continuously sent through the dish machine with wash temperatures ranging from 138°F to 140°F and rinse temperatures from 142°F to 160°F. KM stated they observed the dishes after they came through the washer and would send them through a second time if there was visible matter present, however all 10 of the observed loads containing two trays of cups, one tray of coffee cups, one tray of water cups, one tray of silverware, one tray of large cooking utensils, various cooking pans, pitchers, and assorted plate holders and lids were considered clean and could be used as they did not appear dirty and they felt clean. Staff continued to wash dishes and stack them on carts to dry until all were completed. The final observed load reached 140°F during the wash cycle and 142°F during the rinse cycle. During interview on 2/28/24 at 10:10 a.m., maintenance director (M)-A stated the dish machine used heat sanitization and not chemical sanitization and a technician had recently been in to fix the unit. They observed a wash temperature of 138°F and rinse temperature of 146°F during one of the loads, and confirmed the machine was not running per manufacturer temperature recommendations. M-A identified the dish machine as an Ecolab EC44 model. During a second interview on 2/28/24 at 10:16 a.m., KM stated he could run all the dishes through the machine one more time and double check to see if they look good. They stated they knew it was not fully getting to temperature, but they knew it would get the job done. KM stated dishes needed to be sanitized to make sure they were fully clean and did not have bacteria on them, but stated he could tell by feeling them if bacteria were present. During observation on 2/28/24 10:24 at a.m., staff began to put dishes away on storage carts for later use. During interview on 2/28/24 at 10:26 a.m., administrator stated they expected the dish machine to reach appropriate temperatures to sanitize the dishes, and indicated they planned to instruct the dietary staff to use paper products until the unit could be fixed. Administrator then called the dietary department district manager (DDM) for further clarification of sanitization expectations. During interview on 2/28/24 at 10:30 a.m. DDM stated staff should check the temperature gauges throughout the dish washing process after each meal to ensure they are sanitized to prevent food borne pathogens from making residents sick. They stated if the machine was not getting up to temperature staff needed to contact maintenance and/or the vendor to look at it and begin using the three-compartment sink or change to paper products until it was fixed. During observation and interview on 2/28/24 at 11:16 a.m. KM identified the machine had been fixed by re-setting the water temperature booster. KM ran the machine twice. The first load reached a wash temperature of 134°F and a final rinse temperature of 184°F. The second load reached 134°F during the wash cycle and 191°F during the rinse cycle. KM indicated the wash gauge appeared to be 'stuck'. The label affixed to the dish machine indicated it was an Ecolab EC44 model and required a minimum wash temperature of 160°F and minimum rinse temperature of 180°F for dish sanitization. The Ecolab EC-44 Dishmachine brochure indicated the machine required operating temperatures of 160°F during the wash cycle and 180°F during the final rinse cycle. The Cleaning Dishes Dish Machine policy dated 7/13/22, instructed staff to verify proper temperatures and dish machine function prior to use, and to check the dish machine gauges throughout the cycle to assure proper temperatures for sanitation.

Based on interview and document review the facility failed to ensure the Quality Assessment and Assurance (QAA)/ and Quality Assurance process improvement (QAPI) committee was effective in implementing approrpiate action plans to correct a quality deficiency identified during a previous survey related to Influenza and Pneumococcal vaccinations which resulted in a deficiency identified during this survey. This deficient practice had the potential to affect all 43 residents curretnly residing in the facility. Findings include: Review of the CASPER report dated 2/15/24, indicated the facility was cited F883 for Influenza and Pneumococcal vaccinations on the surveys which exited on 12/21/22 and will be cited on this survey exited on 3/1/24. See F883: Based on interview and record review, the facility failed to accurately assess residents' eligibility to receive the pneumococcal vaccination according to The Centers of Disease and Control and Prevention (CDC) for 2 of 5 (R 35, R28) residents reviewed for vaccinations. Furthermore, the facility failed to ensure the influenza vaccination was offered 1 of 5 residents (R35) reviewed for vaccinations. QAPI minutes for the past 3 meetings were requested but not provided. During an interview on 3/1/24 at 11:16 a.m., the director of nursing (DON) stated they meet monthly for QAPI and they discuss concerns found on survey. She further stated they had initiated a performance improvement plan (PIP) for immunizations and were working on a process for ensuring the vaccinations were being offered and completed. The job was then handed over to another staff member and there was a lot of staff turnover and no follow up to make sure it was getting done. We have just not succeeded, we looked back at the plan and we gave ourselves 21 days to get it done, we need to document better. The facility's policy on QAPI dated 7/11/22 indicated the facility will monitor multiple data sources and performance indidcators to determine areas of concerns and opportunities for imporvement. All data will be reviewed adn compared with state, national and industry specific benchmarks or theresholds as appropriate and will be reported to the support team on a quartely basis. Potential sources of data may include survey outcomes. The facility will review the designated sources of data and will identify areas where gaps in performance may negatively affect resident or staff outcomes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to assess 2 of 3 residents (R1, R2) reviewed for self-administration of medications. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE] indicated R1 had moderately impaired cognition. R1's admission assessment dated [DATE] indicated R1 did not wish to self-administer medications. R1's Provider Orders dated 6/6/23 included metoprolol tartrate (medication to treat high blood pressure and pulse) 12.5 milligrams (mg) two times a day and apixaban (medication to prevent blockage of blood vessels) 5 mg 2 times a day. Both medications to be administered at 8 a.m. and 8 p.m. R1's electronic medical record (EMR) lacked an assessment and provider order for self-administration of medications. R2's quarterly MDS dated [DATE] indicated intact cognition. R2's admission assessment dated [DATE] indicated R2 did not wish to self-administer medications. R2's Provider Orders dated 3/9/23 included metoprolol tartrate 25 mg 2 times a day to be administered at 8 a.m. and 8 p.m. R2's EMR lacked an assessment and provider order for self-administration of medications. On 9/12/23 at 12:47 p.m., R2 was interviewed and stated some of the nurses would leave her medications on the over-the-bed table, and would leave the room before she swallowed the medications. R2 stated sometimes she would fall asleep before taking the medications, but would wake up in the middle of the night to take them. On 9/12/23 at 2:32 p.m., R1 stated licensed practical nurse (LPN)-A and some other staff left medications on her table, and left the room before she swallowed the medications. R1 stated At the end of last month, LPN-A left a medication cup with pills in it on her table. She woke up and the medications were on the table and one pill was in her bed. R1 stated she does not want staff leaving the medications on the table because she would fall asleep and not take the medications until the middle of the night. R1 stated she was concerned about missing doses of medications and the effects of taking the medications too close together. On 9/12/23 at 12:20 p.m., LPN-A stated that staff will leave medications on R1's table and would check back in with R1 to see if the medications have been swallowed. LPN-A stated he might have left medications in R1's room. LPN-A stated staff were to watch residents swallow the medications. If a resident did not want to take the medications at the time the staff approached, the staff were to take the medications back to the medication cart. LPN-A again stated medications were not to be left in the resident's room. LPN-A stated if a resident requested to self-administer medications, an assessment would be completed, and a provider order would be obtained if the resident was appropriate for self-administration. LPN-A confirmed that R1 had not been assessed and did not have a provider order to self-administer medications. On 9/13/23 at 11:03 a.m., the consultant pharmacist (CP)-A stated apixaban is a medication used to prevent blood clots. A missed dose could increase risk of blood clots. CP-A stated apixaban doses should be taken no less than eight hours apart to decrease the chance of having too much medication in the body. CP-A stated metoprolol lowers heart rate and blood pressure. A missed dose could lead to a higher blood pressure and faster pulse which could put stress on the body. If doses were taken too close together, a resident might have lower heart rate and blood pressure and decreased energy. CP-A stated with both medications, a resident should be monitored for side effects when doses are taken too close together. On 9/13/23 at 12:08 p.m., the director of nursing (DON) stated staff were taught to not leave medications at the bedside. If a resident refused medications or wanted to take the medications later, staff were to bring the medications back to medication cart, then bring the medications back when the resident requests. The DON stated apixaban and metoprolol were medications which need some nursing observation. A staff member must watch the resident swallow those medications. If a resident requested to self-administer medications, staff would assess the resident and the medications to discern if self-administration was appropriate. If self-administration was appropriate, a provider order would be obtained. The DON stated R1 and R2 would not be appropriate for medication self-administration. The facility Medication Self-Administration policy dated 6/01/17 directed residents are not permitted to administer or retain any medication in their room unless their attending physician writes an order for self-administration of the medication, and resident is assessed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure personal hygiene was maintained in a dignified manner for 1 of 1 resident (R100) reviewed for dignity. Findings include: R100's admission record dated 12/21/22, indicated R100 was admitted to the facility on [DATE], with diagnosis of displaced intertrochanteric (between two trochanters, which are two bony protrusions on the femur (thighbone) where the muscles of the thigh and hip attach) fracture of right femur, dementia, and weakness. R100's admission Minimum Data Set (MDS), had not been started at the time of survey. R100's care plan dated 12/16/22, indicated R100 had an activities of daily living (ADL) self-care deficit with an intervention of requiring one staff assistance for personal hygiene. The nursing assistant [NAME] dated 12/21/22, indicated R100 required one staff assistance for personal hygiene however, lacked identification of resident preference of shaving. R100's progress notes dated 12/15/22 through 12/20/22, lacked evidence of refusal of shaving. During observation on 12/18/22, at 1:10 p.m. R100 was lying in bed with a large amount of black and gray facial hair growth on both sides of his face, upper lip, and under his chin. When interviewed on 12/18/22, at 4:15 p.m. R100's resident representative (RR)-A stated R100 not being shaved would, mortify R100 because he always remained clean shaven. During observation on 12/20/22, at 9:36 a.m. R100's long black and gray facial hair growth remained. During interview and observation on 12/20/22, at 12:42 p.m. nursing assistant (NA)-A stated the staff should shave any resident who needs or wants to be shaved during morning cares. NA-A went into R100's room and observed large amount of black and gray facial hair growth on R100's face, upper lip, and under the chin. NA-A verified R100 should have been shaved. R100 stated he definitely wanted to be shaved and didn't like long facial hair. When interviewed on 12/20/22, at 12:49 p.m. licensed practical nurse unit manager (LPN)-B stated the staff were to shave residents during morning cares. Further, LPN-B stated on admission the resident's preference on being shaved was placed on the [NAME] to make staff aware. LPN-B verified the [NAME] lacked evidence of R100's preference to be clean shaven. When interviewed on 12/20/22, at 12:57 p.m. the director of nursing (DON) stated R100 should have been shaved if needed or if wanted. Further, the DON stated if a resident doesn't want to be shaved it should be care planned so the staff are aware of the resident preference. The Resident Rights policy dated 9/26/17, indicated the facility will treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his/her quality of life and recognizes each resident's individuality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to comprehensively assess and implement timely interventions to promote healing and reduce the risk of complications for a newly developed unstageable pressure ulcer for 1 of 2 residents (R42) reviewed for pressure ulcers. Findings include: Unstageable pressure ulcer: Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough (patches of dead cells adhered to the wound bed which is typically white or yellow in color) or eschar (dead/necrotic tissue which appears black, tan, or brown in color). R42's admission Minimum Data Set (MDS) dated [DATE], indicated R42 was moderately cognitively impaired and required extensive assistance of two staff for bed mobility and transfers. The MDS indicated R42 was at risk for pressure ulcers, however, did not indicate R42 had a pressure ulcer at time of admission. R42's care plan dated 12/7/22, indicated R42 had the potential to develop a pressure ulcer due to immobility and incontinence. R42 had a goal of maintaining intact skin, being free from redness, blisters, and discoloration. The care plan identified several interventions to help R42 meet the goal which included following the facility policies/protocols for the prevention/treatment of new skin breakdown. The care plan lacked indication of any active skin conditions. R42's progress notes dated 12/15/22, at 10:56 p.m. indicated, R42's family member (FM)-A visited and reported there was discoloration to both heels Despite documentation of what FM-A reported, R42's record lacked indication of a comprehensive assessment of both heels, notification to the provider, and treatment orders had been sought R42's physician progress note dated 12/15/22, did not identify the physician was notified of the change in R42's skin condition. The nurse practitioner (NP)-B documented, no rash or lesions to the skin. During observation and interview on 12/19/22, at 10:25 a.m. R42's personal care was observed with licensed practical nurse (LPN)-C. R42's left heel had a dime size blanchable reddened area and to the left of the reddened area R42 had a brown and black hard tissue area. There was no dressing on the wound, no heel protectors, and the heels were not floated on pillows. LPN-C was unaware R42 had a wound and stated the wound was an unstageable pressure ulcer. LPN-C measured the ulcer and reported measurements of 1.0 centimeter (cm) x 0.5 cm. R42's written order dated 12/19/22, at 6:13 p.m. NP-B provided the facility with a treatment order to keep the area protected with a foam bordered mepilex (an absorbent foam dressing), keep heels elevated off the bed at all times, continue protective boots to bilateral lower extremities (BLE) while in bed, and to have the wound nurse eval and treat. The treatment order was written four days after the unstageable left heel pressure ulcer was identified by FM-A and presented pictures of the area to the staff on 12/15/22. When interviewed on 12/19/22, at 2:29 p.m. unit manager LPN-B stated the nurse should have assessed the wound, notified the provider, requested treatment orders, completed a risk management form, and documented in the progress notes. LPN-B verified the tasks were not completed by the nurse on 12/15/22. When interviewed on 12/19/22, at 2:36 p.m. LPN-C verified the provider was not notified of the unstageable to the left heel after completing the assessment of the wound. LPN-C stated a facsimile message was sent to the provider regarding another issue but will now update the provider on the unstageable left heel pressure ulcer as well. LPN-C further stated a risk management form should have been completed, the provider notified, requested treatment orders, and documented in the progress notes. Further, LPN-C verified the facility procedure for a new pressure ulcer was not followed. During observation on 12/20/22, at 7:44 a.m. R42 was lying in bed on her back with both heels on the bed and the boots were laying in the chair across the room. When interviewed on 12/20/22, at 7:45 a.m. the nursing assistant (NA)-C stated wasn't aware R42 required her heels to be floated while in bed nor was aware R42 required boots to be worn on both heels while in bed. When interviewed on 12/20/22, at 1:01 p.m. the director of nursing (DON) stated on 12/15/22 when the unstageable pressure ulcer was discovered the nurse should have assessed the wound, completed a risk management form, notified the provider, requested treatment orders, documented in the progress notes, and updated the care plan with interventions to promote healing and to prevent the pressure ulcer from worsening. The pressure and non-pressure injuries policy dated 8/2/21, indicated those residents who develop a pressure injury will receive care, treatment, and services that seek to promote healing, prevent infection, and to prevent further development of pressure injuries. Further, indicated if a residents' skin was compromised complete the following: - If a pressure injury, initiate the pressure injury weekly tracker user defined assessment (UDA). - Ensure the primary care physician is aware of the wound, the location of the wound, and current treatment orders. - Ensure there is proper treatment orders for each wound. - Ensure resident/representative is aware of the wound and the current treatment plan. - Evaluate for pain related to the wound and develop a management plan for the pain if present. - Complete a braden scale.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to properly supervise 1 of 1 residents (R46) reviewed who was at risk of aspiration while drinking fluids. Findings include: R46's admission record dated 12/21/22, indicated R46 admitted to the facility on [DATE] with diagnoses of dysphagia (difficulty swallowing) and pneumonitis (inflammation of lung tissue due to non-infectious causes) due to inhalation of food and vomit. R46's admission Minimum Data Set (MDS) dated [DATE], indicated R46 was moderately cognitively impaired and required total dependence of one staff for assistance with eating. The MDS further indicated R46 had coughing or choking while eating or swallowing medications. R46's care plan dated 12/13/22, indicated R46 required assistance with eating with interventions to provide encouragement and remain with resident during meals, provide total feeding, and feed resident slowly. Secondly, indicated R46 had activity of daily living (ADL) deficit with an intervention for staff to set up tray for meals, have resident sit upright in bed or chair, staff to remain with resident during meals, and to remove all food and fluids when leaving room. R46's [NAME] dated 12/21/22, indicated staff were to set up trays for meals, have resident sit upright in bed or chair, staff to remain with resident during meals, and to remove all food and fluids when leaving room. R46's physician order dated 11/23/22, indicated R46 was to have pureed foods with mildly thick/nectar liquids with one-to-one assistance by staff. During observation on 12/18/22, at 1:06 p.m. R46 was lying in bed with the head of the bed (HOB) at 30 degrees with two cups of thickened liquids and a container of opened yogurt on the bedside table within R46's reach. During observation and interview on 12/18/22, at 7:11 p.m. R46 was lying in bed with the HOB at 30 degrees and had one cup of thickened liquids on the bedside table within reach. R46 stated the staff leave his fluids in the room if he hasn't finished the fluids during meal time. During observation on 12/18/22, at 7:13 p.m. R46 was lying in bed, raised the HOB up to 60 degrees, picked up the cup and drank some of the thickened liquids. R46, right after swallowing the liquids lowered the HOB to 30 degrees. Upon interview on 12/18/22, at 7:14 p.m. nursing assistant (NA)-B stated R46 was not allowed to eat or drink without a staff member in the room to observe him. NA-B went into R46's room and verified R46 had a cup of thickened water in the room and removed the cup. Upon interview on 12/18/22, at 7:19 p.m. licensed practical nurse (LPN)-C verified R46 was to have staff one-to-one while eating and drinking. LPN-C stated staff should remove all liquids and food when they leave the room after R46 completed his meal. Upon interview on 12/18/22, at 7:21 p.m. unit manager LPN-B verified R46 should not have liquids in his room without supervision of the staff and stated R46 could aspirate on the fluids. Upon interview on 12/18/22, at 7:24 p.m. the director of nursing (DON) stated staff should remove all food and liquids when leaving the room. The DON verified the staff did not follow the care plan. Upon interview on 12/19/22, at 1:46 p.m. the speech therapist (ST)-B stated R46 should have one-to-one staff supervision while eating or drinking due to R46 being impulsive during observations of mealtimes. Further, ST-B stated R46 would lower the HOB down immediately after drinking and eating. ST-B advised R46 not to lower the HOB down immediately due to the possibility of aspiration. The Nursing Accidents and Supervision policy reviewed/revised 7/14/22, indicated every resident will receive adequate supervision by identifying risks and implementing interventions to reduce the risks. Further, will use specific interventions to reduce the resident risks process included: - Communicating interventions to all relevant staff - Assigning responsibility - Documenting interventions - Ensuring the interventions are put into action

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on document review and interview, the facility failed to identify triggers to avoid potential re-traumatization and faileded to develop the care plan to include individualized trauma-informed approaches for 1 of 1 resident (R11) who had a history of trauma. Findings include: R11's Medicare 5-day Minimum Data Set assessment (MDS) dated [DATE], identified minimal depressive symptoms. R11 had diagnoses of adjustment disorder with mixed anxiety and depression and confirmed adult physical abuse. PTSD (post traumatic stress disorder) was not identified as a diagnosis. R11 took an antianxiety and antidepressant seven out of seven days in the look back period. R11 required supervision with bed mobility and transfers, was independent with walking, eating, and toileting, and required limited assistance with dressing and extensive assistance with hygiene. R11's admission Psychosocial assessment dated [DATE], identified R11 had a history of being mistreated by an alleged perpetrator (AP) and the hospital had reported it to vulnerable adults. The trauma screen section lacked identification of prior trauma or PTSD. The section for care planning lacked initiation for a psychosocial or trauma informed care plan. R11's physician visit note dated 1/5/22, identified R11 had a confirmed domestic abuse history where an AP pushed R11 to the ground, yelled, controlled phone usage and controlled when R11 could leave the house. R11's vulnerability care plan dated 4/18/22, lacked individualized trauma-informed approaches or interventions and lacked identification of triggers to avoid potential re-traumatization. R11's facility quarterly Psychosocial assessment dated [DATE], trauma screen section lacked identification of PTSD or prior trauma. The section for care planning lacked initiation for a psychosocial or trauma informed care plan. Discharge planning was selected and initiated. R11's physician visit note dated 11/2/22, identified R11 had PTSD related to history of domestic abuse. During an interview on 12/19/22, at 10:11 a.m. R11 stated a counselor from Associated Clinic of Psychology (ACP) used to come to the facility, but those visits stopped a couple of months ago and R11 was not aware why. R11 acknowledged a past history of abuse and stated she had not been asked about potential triggers. R11 stated the facility was currently exploring discharge options and it was triggering to think about moving out of the facility and being on her own, not having help around and feeling unsafe. R11 also stated it would feel triggering to hear people yell. R11 stated it made her feel better to talk to someone. During an interview on 12/20/22, at 9:41 a.m. nursing assistant (NA)-D stated R11 was mostly independent and was ok with male and female caregivers. NA-D stated R11 mostly stayed in the bedroom or went out with a family member. NA-D stated she was not aware of any trauma informed care to be provided to R11 and would use a typical approach such as knock before entering, explain cares and ask about needs. During an interview on 12/21/22, at 8:21 a.m. NA-E stated she would also use a typical approach with R11. NA-E stated R11 had no behaviors or trauma related concerns she was aware of. During an interview on 12/20/22, at 10:24 a.m. the director of social services (DSS) stated a psychosocial assessment was completed upon admission, quarterly and annually which included a trauma screening. The DSS reviewed R11's psychosocial assessments from admission and the next one six months later and verified they lacked a trauma screening and associated care plan initiation. The DSS stated R11's history of abuse would be considered a trauma and should have been identified as such. The DSS stated when R11 was admitted male caregivers were not allowed, staff were notified not to allow phone calls from the AP and R11's phone was removed. R11 also had a counselor came into the facility from an outside agency. The DSS verified these interventions had not been formally care planned. The DSS stated R11's counselor had not passed on any interventions to the facility staff. The DSS stated trauma informed care was important to ensure the facility understood what happened and approached as a team to avoid any potential triggers for re-traumatization. During an interview on 12/20/22, at 12:36 p.m. the ACP social worker (SW) stated she had met with R11 in September and October of 2022 and had not resumed services since then as she had directed R11 to reach out as needed. The SW stated R11 had a history of trauma and she would have expected the facility to assess and implement care planned trauma interventions in accordance with the regulations and R11's needs. The facility policy titled Trauma Informed Care, dated 10/18/22, identified trauma as past or present physical, sexual, mental and/or emotional abuse. Additionally, the facility would collaborate with the resident, and as appropriate the family, friends, primary physician and other health care providers such as psychologist and mental health professionals to develop and implement individualized care plan interventions. Lastly, the facility would identify triggers that could re-traumatize residents with a history of trauma and add them to the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure an intravenous (IV) pole was kept in sanitary condition to ensure proper functioning and prevent infection for 1 of 1 resident (R46) who used the IV pole for tube feedings. Findings Include: R46's admission record dated 12/21/22, indicated R46 admitted to the facility on [DATE] with a diagnosis of dysphagia (difficulty swallowing) and pneumonitis due to inhalation of food and vomit. R46's admission Minimum Data Set (MDS) dated [DATE], indicated R46 was moderately cognitively impaired and required total dependence of one staff assistance for eating. Secondly, the MDS indicated R46 had coughing or choking while eating or swallowing medications. Further, the MDS indicated R46 required tube feeding for 51% of his total calories. R46's care plan dated 12/13/22, indicated R46 at risk for nutritional status changes related to enteral nutrition needs with interventions for enteral nutrition per medical doctor (MD) orders and to administer tube feeding formula, hydration, and flushes per orders. R46's order summary report dated 9/30/22, indicated staff were to elevate head of bed (HOB) to 30 to 45 degrees during feedings and for at least 30 to 40 minutes after the feeding is stopped. R46's order summary report dated 12/9/22, indicated staff to administer Isosource 1.5 at 85 milliliters (ml) per hour (hr) for 16 hours overnight via pump. During observation on 12/18/22, at 1:05 p.m. R46 laid in bed and wasn't hooked up to the tube feeding. A bag of Isosource tube feeding hung on the IV pole which was noted to be caked with dried tan colored tube feeding from the pump located halfway down to the bottom of the IV pole. The IV pole base was caked with dried tan colored tube feeding as well. During observation on 12/19/22, at 9:00 a.m. R46 laid in bed and wasn't hooked up to the tube feeding. A bag of Isosource tube feeding hung on the IV pole which was noted to be caked with dried tan colored tube feeding from the pump located halfway down to the bottom of the IV pole. The IV pole base was caked with dried tan colored tube feeding as well. During observation on 12/20/22, at 7:41 a.m. R46 laid in bed and was hooked up to the tube feeding. A bag of Isosource tube feeding hung on the IV pole which was noted to be caked with dried tan colored tube feeding from the pump located halfway down to the bottom of the IV pole. The IV pole base was caked with dried tan colored tube feeding as well. Upon interview on 12/20/22, at 12:51 p.m. unit manager licensed practical nurse (LPN)-B verified the IV pole was dirty from tube feeding and nursing was responsible for cleaning the IV poles. Upon interview on 12/20/22, at 12:55 p.m. LPN-D verified the IV pole was dirty from tube feeding and nursing was responsible for cleaning the IV poles. Upon interview on 12/20/22, at 12:59 p.m. the director of nursing stated nursing staff should clean the IV poles daily or right after a spill happens because it is important for the resident's dignity, environment, and infection control. An equipment cleaning policy 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 allow active resident and resident representative participation in the development and review of care plans 4 of 4 residents, (R36, R45, R17, and R31) reviewed for care planning and coordination of services while residing at the facility. Findings include: R36's quarterly Minimum Data Set, (MDS) dated [DATE], identified R36 had intact cognition, communicated his needs, and understood direction and conversation. In addition, MDS indicated R36 exhibited no adverse behaviors. R36's medical record indicated the most recent care conference was held on 7/18/22. R36's medical record showed no additional care conferences since 7/18/22. R36 had an additional MDS completed on 10/2/22. There was no indication in the medical record of any care conference had been held at the time of this assessment. R45's admission MDS dated [DATE], identified R45 had intact cognition, communicated her needs, and understood direction and conversation. In addition, MDS indicated R45 exhibited no adverse behaviors. R45's medical record showed no care conferences since admission to the facility. R45 had a significant change in status MDS completed on 11/29/22. There was no indication in the medical record a care conference had been held at the time of this assessment. R17's quarterly MDS dated [DATE], identified R17 had intact cognition, communicated her needs, and understood direction and conversation. In addition, MDS indicated R17 exhibited no adverse behaviors. R17's medical record indicated the most recent care conference was held on 9/26/22. R17 had a significant change MDS completed on 10/25/22. There was no indication in the medical record of a care conference held at the time of this assessment. R31's annual MDS dated [DATE], identified R31 had intact cognition, communicated her needs, and understood direction and conversation. In addition, MDS indicated R31 exhibited no adverse behaviors. R31's medical record indicated the most recent care conference was held on 9/12/22. R31 had an annual MDS completed on 12/3/22. There was no indication in the medical record of any care conference had been held at the time of this assessment. During an interview with Director of Social Services, (SS)-A, she reviewed the medical records for R36, R45, R17, and R31 and confirmed all 4 residents did not have care conferences held per the MDS schedule. During a follow up interview on 12/20/22, at 11:20 a.m., SS-A, stated care conferences should be held on admission, quarterly, annually, significant change or as requested. SS-A stated care conferences are a chance for residents or families to ask questions, address goals, and ensure residents have input in their plan of care. During an interview on 12/20/22, at 11:35 a.m. the director of nursing, (DON), stated care conferences are held according to the MDS schedule. DON stated conferences are an important tool to ensure communication between the interdisciplinary team, the resident, and the resident representative. It is a chance to review and update the resident's plan of care. During a follow up interview, on 12/20/2, at 11:58 a.m. DON stated, I realized care conferences were not being done. DON also stated, [SS-A], was not scheduling care conferences. The facility policy, Care Planning- Resident Participation, (undated), indicated This facility supports the residents right to be informed of, and participate in, his or her care planning and treatment (implementation of care).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 12/20/22, at 9:26 am. R17 was observed to be self-administering a nebulizer (inhaled medication) treatment. R17's quarterly MDS dated [DATE], identified R17 had intact cognition, communicated her needs, and understood direction and conversation. R17 was enrolled in hospice services and had a medical diagnosis of respiratory failure. R17's physician orders printed 12/21/22, included Ipratropium-Albuterol Solution 0.5-2.5 (3) milligrams (mg)/3 milliliters (ml) 3 ml inhale orally via nebulizer for shortness of breath/wheezing 4 times daily scheduled and twice daily as needed. R17's medical record lacked indication that a self-medication administration assessment was done within the last year. Additionally, R17's medical record lacked a physician order to self-administrator the nebulizer treatment. During an interview on 12/20/22, at 9:26 a.m. registered nurse (RN)-A stated medications cannot be in resident rooms. RN-A stated he set up R17's nebulizer treatment and she administered it herself. RN-A did not observe the resident while she was taking the treatment, other than to monitor that she turned the nebulizer machine off within 15 minutes. R19's significant change MDS dated [DATE], identified R19 had intact cognition, communicated her needs, and understood direction and conversation. R19 had a medical diagnosis of chronic obstructive pulmonary disease (COPD). R19 was observed to have an inhaler at bedside. The pharmacy label on the inhaler was unreadable. R19 stated it was her rescue inhaler. R19's medical record lacked an assessment for self-administration of medication for inhaler use. Additionally, R19's medical record lacked a physician order for self-administration of an inhaler. During an interview on 12/20/22, at 8:21 a.m., licensed practical nurse (LPN)-D, stated residents are not allowed to keep medications in their room this includes R19, due to safety concerns. During an interview on 12/20/22 at 08:26 a.m., LPN-B stated residents may keep medications in their room, but first need to be assessed for self-administration of medication and have a doctor's order. LPN-B stated, R19 had not be assessed for self-administration of an inhaler, so there should not be inhalers in the resident room. During an interview on 12/20/22, at 8:35 a.m., R19 stated staff are aware she had the inhaler in her room. She stated she has had it in her room since July when she admitted to the facility. During an interview on 12/20/22 at 9:05 a.m., director of nursing, (DON) stated residents may have medications in room if there is an order and an have been assessed to safely self-administer the medication. If a medication is found, staff should request to have it removed until an assessment is done. The facility policy, Self-Administration of Medications stated, In order to maintain the residents' high level of independence, residents who desire to self-administer medications are permitted to do so if the interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility and there is a prescriber order to self-administer. The policy additionally included, For those residents who self-administer, the interdisciplinary team verifies the residents' ability to self- administer by means of a skill assessment conducted on a quarterly basis or when there is a significant change of condition. Based on observation, interview, and document review, the facility failed to assess self-administration safety for 4 of 4 residents, (R17, R36, R101, and R19) who were observed to have medications at bedside. Findings include: R36's quarterly Minimum Data Set (MDS) dated [DATE], indicated he was cognitively intact and had diagnoses of chronic obstructive pulmonary disease (COPD, a lung disease), heart failure, diabetes, and seizure disorder. R36 was independent with bed mobility, transfers, and toileting, and used a walker for ambulation. R36's Order Summary Report dated 12/19/22, included an order for Fluticasone-Salmeterol Aerosol Powder Breath Activated 100-50 micrograms (mcg) per dose. Inhale one puff orally every 12 hours for COPD starting 2/4/22. The report lacked an order for R36 to self-administer medications. R36's medical record lacked a self-administration of medication assessment. On 12/20/22, at 9:12 a.m. R36 was seated in his room in his wheelchair in front of his bedside table with the door closed. An inhaler labeled Fluticasone-Salmeterol Aerosol Powder Breath Activated 100-50 micrograms (mcg) per dose was on the table within resident reach. R36 stated staff left it there a long time ago. The inhaler had a date of 11/2/22, written in marker on the side. During interview on 12/20/22, at 10:27 a.m. RN-A stated resident inhalers were stored in the medication cart and should not be left in resident rooms. RN-A entered R36's room and verified R36's Fluticasone-Salmeterol inhaler was present in his table within his reach and contained additional doses. RN-A confirmed R36 did not have an order or assessment for self-administration of medications. R101's admission record printed 12/21/22, indicated R101 admitted to the facility on [DATE] with a diagnosis of dementia. R101's admission Minimum Data Set (MDS), had not been started at the time of survey. R101's care plan dated 12/13/22, lacked evidence of R101's capability to self-administer medications. R101's medical record lacked evidence of a self-administration of medications assessment. During observation and interview on 12/18/22, at 1:26 p.m. R101 was observed lying in bed in her room alone with a plastic medicine cup with 30 cubic centimeters (cc) of a red liquid. R101 stated the red liquid was medicine, however, did not know what the medicine was or why she was to take it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure 4 of 5 residents (R7, R29, R45, R46) were offered or received the pneumococcal pneumonia vaccine and failed to ensure 2 of 5 residents (R29, R46) were offered or received the influenza vaccine in accordance with the Center for Disease Control (CDC) recommendations. Findings include: R7's quarterly Minimum Data Set (MDS) dated [DATE], indicated R7 had been admitted to the facility on [DATE], and indicated the pneumococcal vaccine was given or up to date. Review of 7's medical record on 12/21/22, lacked evidence of pneumococcal immunization, education, contraindication, and/or documentation of refusal by the resident or resident representative. R29's quarterly MDS dated [DATE], indicated R29 had been admitted to the facility on [DATE], and indicated the pneumococcal vaccine was not up to date due to the vaccine being offer and declined as well as the influenza vaccine was not received. Review of R29's medical record on 12/21/22, lacked evidence of immunization, education, contraindication, and/or documentation of refusal of the pneumococcal and influenza vaccines by the resident or resident representative R45's significant change MDS dated [DATE], indicated R45 had been admitted to the facility on [DATE], and indicated the pneumococcal vaccine was not given or up to date and was not offered. Review of R45's medical record on 11/29/22, lacked evidence of pneumococcal immunization, education, contraindication, and/or documentation of refusal by the resident or resident representative. R46's admission MDS dated [DATE], indicated R46 had been admitted to the facility on [DATE], and indicated the pneumococcal and influenza vaccines was not given or up to date and was not offered. Review of R46's medical record on 12/21/22, lacked evidence of pneumococcal and influenza immunization, education, contraindication, and/or documentation of refusal by the resident or resident representative. When interviewed on 12/21/22, at 11:30 a.m. the infection preventionist (IP) stated she was unable to locate pneumococcal vaccines or declination documentation for R7, R29, R45, and R46 and influenza vaccines or declination documentation for R29 and R46. The IP verified all four residents should have been offered and/or administered the pneumococcal vaccine and both R29 and R46 should have been offered and/or administered the influenza vaccine. The IP confirmed their medical records lacked evidence of the pneumococcal and/or the influenza immunization, education, contraindication, and/or documentation of refusal by the resident or resident representative. The North Shore Healthcare Influenza and Pneumococcal Immunizations - Residents policy dated 6/17, indicated the following procedure for the pneumococcal and influenza vaccine: 1. Because long term care residents are prone to developing serious complications when they contract the flu, all residents are encouraged to receive an influenza vaccination during the fall of each year, unless otherwise ordered by the resident's attending physician or the resident refuses. 2. The resident's attending physician must provide a written order for the vaccination and the order must be recorded in the resident's medical record. 3. Upon admission to the facility, permission must be obtained from the resident or representative to administer pneumococcal vaccine (one time) and influenza vaccine annually (in the fall) unless contraindicated. 4. All new residents will be assessed for pneumococcal vaccine status upon admission. 5. Residents without proof of previous pneumococcal vaccination should receive one (1) dose only of pneumovax unless contraindicated. 6. Influenza immunization must be offered annually from October 1st to March 31st. Through this time of facility-wide immunization, all new admissions should be assessed for previous immunization that season and immunized, if appropriate. In the event that an outbreak is occurring after March 31st, immunization should be offered until the outbreak is under control.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure 3 of 5 residents (R7, R29, R45) 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: Residents: R7's quarterly Minimum Data Set (MDS) dated [DATE], indicated R7 had been admitted to the facility on [DATE]. R29's quarterly MDS dated [DATE], indicated R29 had been admitted to the facility on [DATE]. R45's significant change MDS dated [DATE], indicated R45 had been admitted to the facility on [DATE]. The facility Resident COVID-19 Vaccine Tracker indicated R7, R29, and R45 had not received any COVID-19 vaccinations and/or refused the COVID-19 vaccinations with no documentation of refusal by the resident or resident representative. The medical records of R7, R29, and R45 lacked documentation they (and/or their representative) were offered the COVID-19 vaccine upon or after admission, or that they were provided education related to the risk and/or benefits of the vaccine. In addition, the medical records lacked documentation that COVID-19 vaccines were administered or contraindicated. During interview on 12/21/22, at 11:30 a.m. infection preventionist (IP) stated each new admission was pre-screened for vaccinations and previous admissions were reviewed through the Minnesota Immunization Information Connection (MIIC). She stated the information was documented on the tracking log, and once admitted she reviewed the resident to determine whether additional doses were recommended, and the additional doses would be offered. She stated if a resident refused would obtain documentation of refusal. She was unsure why there was no follow through with these residents. The facility policy Coronavirus Prevention and Response reviewed/revised on 10/11/22, indicated the facility should offer the COVID-19 vaccine as well as resources/education to residents on the importance of receiving the COVID-19 vaccine.

Based on observation, interview, and document review, the facility failed to store and label food to prevent potentially degraded food from being served to residents. This had the potential to affect all 48 residents who received food from the kitchen. Findings included: On 12/18/22, at 12:50 p.m. surveyor conducted a kitchen tour with the director of dietary services (DDS) and cook-(C)-A and observed the following: Coolers: -Creamy Caesar salad dressing, opened, ½ full - undated - Miracle Whip - 1/2 full, dated as opened on 9/21/22 - Pan of cucumber and onion salad - not dated or labeled - Lunchmeat turkey in plastic container with lid - dated 12/9/22 and 12/13/22 - Bag of 3 whole lemons - undated and 1 lemon with a blue and white mold. - 2 packages of sliced cheese opened and undated - 1 partial bag of celery - undated - Opened bag of 2 green peppers - undated - Barbecue sauce - 1 gallon, 1/2 full - undated - ½ full large jug of Worcestershire sauce - expiration date 7/7/22 Freezers: - 4 bags, 1 partially opened frozen bread - Undated -Open tator tot bag - not secured and undated - Open bag of pancakes - not sealed and undated - Fish sticks opened - undated - Container of chicken cordon blue opened - undated - Open french fries - undated - Open large bag of corn- undated - Ham sliced covered with plastic wrap - undated - Folded cheese omelets opened - not secured and undated Dry storage: - partial bag of rice crispies open date 11/22/22 - partial bag of raisen bran opened 11/01/22 and one unopened expiration dated on 7/29/22 - 3 cans of sweetened condensed milk - expiration date 10/22/21 -Partial opened bag of brownie mix - undated - Partial bag of instant chocolate pudding mix, expiration dated 4/13/22 - Turkey gravy mix opened - undated - [NAME] cake mix opened - undated - 5 cans of diced green pepper - expiration dated- 3/22/22 - Box of baking soda - open date 10/2020, expiration date - 8/7/22 When interviewed during the tour, DDS stated when a food item has been opened or prepared, staff should clearly label with the date. All food items should be used or disposed of within 7 days of that date. DDS stated all open undated food or food prepared more than 7 days ago will need to be discarded. The food storage chart provided by the facility, undated, included, Expiration dates printed by the manufacturer apply until the product is opened. Once opened, use these time limits unless the manufacturer's date is earlier. The day of opening/preparation counts as a day. The facility policy, Food storage: Dry Foods, revised 9/2017, stated, All dry goods will be appropriately stored in accordance with the FDA Food Code. The facility policy, Food storage: Dry Foods, revised 4/2018, stated, All Time/Temperature Control for Safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA Food Code.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to place 1 of 1 resident (R299) reviewed, who had a multi-drug resistant organism (MDRO), on transmission based precautions. In addition, the facility failed to ensure housekeeping staff (H-B) changed gloves and washed hands between cleaning each resident's room and public areas. This practice had the potential to affect all 48 residents who resided in the facility. Findings include: R299's admission Minimum Data Set (MDS) dated [DATE], indicated resident had moderate cognitive impairment. R299 needed assistance of two staff for toileting and dressing and was incontinent of bowel and bladder. The MDS also indicated R299 also had a multidrug-resistant organism (MDRO) diagnosis. R299's medical record indicated R299 had a recent urinary tract infection (UTI) and is positive for methicillin-resistant Staphylococcus aureus (MRSA) in his urine. R299's hospital referral form dated 11/26/22 indicated contact isolation related to MSRA and recurrent UTI. R299's hospital discharge orders dated 12/2/22 indicated R299 was prescribed Linezolid (antibiotic) for MRSA infection. Specific discharge recommendations to be followed up at site: Recurrent UTI, MRSA. Urine culture grew MRSA. Infectious Disease (ID) was consulted and recommended outpatient treatment of 7 days of Linezolid. R299's physician orders identified, Linezolid 600 milligrams (mg) by mouth two times a day for MRSA infection at the facility. The Linezolid was started on 12/3/22 and ended 12/9/22 and again started 12/14/22 and ended 12/21/22. R299 was not listed on the facility's infection control MDRO Surveillance Log. During an observation on 12/21/22, at 9:45 a.m. no infection prevention precaution signage was seen on R299's door and there was no personal protective equipment available outside of R299's room. During an interview on 12/21/22, at 9:47 a.m. licensed practical nurse (LPN)- D stated there would be a sign on the door and a precautions kit outside of the door for a resident that was on infection prevention precautions. Additionally, LPN-A stated during report the staff is made aware of patients on precautions as it is important to avoid infectious disease being spread to other residents. LPN-D was not aware if R299 was on any type of precautions or not. During an interview on 12/21/22, at 9:49 a.m. LPN-B stated there would be a precaution sign on the door when the resident is admitted if there are infection prevention precautions. LPN-B stated it is important to know precautions to reduce transmission to other residents, community, or staff. LPN-B was not aware R299 had any infectious disease. During a follow up interview on 12/21/22 12:28 p.m. LPN-B stated if the resident had a history of MSRA, and the resident is no longer on antibiotics, they do not need to be on increased precautions. LPN- B stated R299 is not on increased precautions. After reviewing R299's medical record, LPN-B, stated this patient was currently on Linezolid, for MRSA, but not put on precautions. LPN-B added, he should have been on contact precautions. During an interview on 12/21/22, at 12:51 p.m., infection prevention registered nurse (IP), stated when a resident is admitted with an infectious disease, she logs it in the monthly infection control log for tracking. If the resident needed enhanced precautions, she would discuss it in daily clinical huddle. There would also be a sign on the resident door outlining the need for contact precautions. IP stated R299 was not on precautions since admission to the facility. After the IP reviewed the hospital referral, IP indicated R299 had been on contact precautions for MRSA at the hospital and was currently on Linezolid at the facility for MRSA. After reviewing the medical record, IP stated R299 should have been on contact precautions. IP stated implementing enhanced precautions are important to reduce risk of cross contamination. The facility policy, Multidrug-Resistant Organisms, revised August 2019, indicated, Appropriate precautions are taken when caring for individuals known or suspected to have infection with a multidrug-organism. The facility policy, Isolation- Categories of Transmission Based Precautions, revised October 2018, indicated Transmission-Based Precautions are initiated when the resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting it to other residents. Hand Hygiene On 12/21/22, at 10:36 a.m. housekeeper (H)-B was observed wearing surgical gloves while cleaning R299's room which included wiping the sink area with a rag and sweeping and moping the floor in the room and bathroom. While cleaning the resident's room H-B was observed touching the handles of R299's walker multiple times, the doorknobs to R299's room and bathroom multiple times and removing a soiled mop pad with her gloved hand. H-B did not change her gloves throughout the cleaning process. Wearing the same gloves and without washing hands, H-B moved on to cleaning the nurses' station, which included sweeping and taking out the garbage. While cleaning the nurses station area H-B was observed touching the staff chairs and the high touch counter area of the nurses' station multiple times with gloved hands. H-B continued to wear the same gloves used to clean R299's room. H-B than moved on to cleaning the neighborhood spa room which included wiping down the sink area, scrubbing the inside and outside of the toilet, sweeping and moping the floor. While cleaning the spa room H-B was observed touching the toilet, the doorknob to the spa room multiple times, and the soiled mop pad with gloved hands. H-B was observed to still be wearing the same pair of surgical gloves they had used to clean R299's room and the nurses station area. H-B then moved on to cleaning a recently vacated resident room which included taking out the trash, cleaning the inside and outside of the toilet, refilling the paper towel and toilet paper dispensers, sweeping the floor, and wiping down high touch surfaces in the room. While cleaning the room H-B was observed walking to the storeroom to gather additional supplies and walking to the laundry room to retrieve additional clean rags to restock the housekeeping cart. All tasks were performed while wearing the same pair of surgical gloves throughout the process. While cleaning the room H-B was observed touching high touch surfaces multiple times such as doorknobs to the room and bathroom, the top of the dresser, the top of the bed-side table, the top of the over-bed table, the footboard of the bed and the window blinds. Additionally, H-B was observed touching a soiled mop pad with her gloved hand. H-B was observed to still be wearing the same pair of surgical gloves they had worn for cleaning R299's room, the nurses station and the spa. H-B then entered the neighborhood dining room, still wearing the same pair of surgical gloves. H-B was observed cleaning the dining room which included taking out the garbage, sweeping the floor, and wiping the tops of all tables in the room along with the counter of the kitchenette. H-B was observed to still be wearing the same pair of surgical glove they had worn to clean R299's room, the nurses station, the spa, and a newly empty resident bedroom. During an interview on 12/21/22, at 11:19 a.m. H-B was unable to answer questions as she indicated she could not speak English but directed writer to H-C who stated housekeepers should perform hand hygiene before entering each resident's room and putting on a clean pair of surgical gloves and again when they are finished cleaning each resident's room after removing their soiled gloves. During an interview on 12/21/22, at 12:28 p.m. the director of housekeeping services, H-A, stated housekeepers are expected to put on a clean pair of surgical gloves before entering each resident's room. Housekeepers are educated to not wear gloves in the hallway as they should be discarded when leaving the resident's room. H-A stated he has not pushed the need to perform hand hygiene before putting on or after removing surgical gloves. H-A added it is important for housekeepers to change gloves between each resident's room to prevent cross contamination and prevent the spread of bacteria and viruses. During an interview on 12/21/22, at 12:36 p.m. the infection preventionist (IP) stated housekeeping staff is expected to change gloves between cleaning each resident's room. The IP stated housekeepers are expected to wash their hands before putting on gloves and after removing gloves. The IP added proper hand hygiene is important to prevent contaminating resident rooms with another resident's germs. The facility policy, Hand Hygiene, dated 11/22/22 indicated, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. Additionally, the policy indicated, The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves.