**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to obtain informed consent and provide education to the resident or resident representative on the risks and benefits regarding the use of opioid medication for 1 of 5 residents (R22) reviewed for unnecessary medications. Findings include: Review of R22's quarterly Minimum Data Set (MDS) dated [DATE], identified R22 had intact cognition and had diagnosis which included anemia (A condition in which the body does not have enough red blood cells), hemiparesis (a medical condition characterized by weakness on one side of the body, often affecting the arm, leg, and potentially the face), and multiple sclerosis (MS) (A chronic autoimmune disease that affects the central nervous system brain and spinal cord). Identified R22 had pain and was on a pain regimen. R22's significant change Care Area Assessment (CAA) dated 3/26/25, identified R22 reported pain as always present. Identified R22's pain made it difficult for R22 to sleep and that pain medication was available. R22's care plan revised 4/5/25, identified R22 had pain related to MS and received pain medication. Care plan directed staff to administer medications as ordered and monitor and document side effects. R22's Order Summary Report dated 5/19/25, identified orders for the opioid medication Oxycodone 5 milligrams (mg) every four hours as needed for pain with a start date of 5/16/25. R22's medication administration record (MAR) identified R22 received Oxycodone 5 mg two times on 5/16/25, and two times on 5/17/25. R22's medical record lacked evidence of education to R22 or R22's representative regarding the risks and benefits of the opioid medication. During an interview on 6/9/25 at 1:30 p.m., R22 stated she has used oxycodone a few times in the past month. R22 stated she did not recall anyone talking with her regarding the risks and the benefits of oxycodone use. During an interview on 6/10/25 at 10:33 a.m., registered nurse (RN)-A verified R22 had a new order for oxycodone since 5/16/25, and R22 had received four dosed of the opioid medication in the past month. RN-A confirmed education regarding risk and benefits regarding the opioid medication had not been done with R22 or her representative. RN-A stated the current process is to only provide education regarding risk versus benefits with psychotropic medication use. During an interview on 6/10/25 at 10:43 a.m., acting director of nursing (DON) stated she did not think anyone had completed education with R22 regarding the benefits and risk of the opioid medication. DON stated her expectation was that education regarding the risks and benefits of the opioid medication should have been completed with R22 prior to starting the opioid medication. During an interview on 6/10/25 at 11:39 a.m., pharmacist consultant (PC) stated it was important to educate residents regarding the risks and benefits of using an opioid medication. CP stated her expectation was the facility would have provided R22 with education regarding the risks and benefits of the opioid prior to starting the opioid medication. Review of a facility policy titled High Risk Medication revised 2/19/25, identified the facility recognized some medications were associated with greater risk of adverse consequences than other medications. Identified high risk medications could include: antidiabetic's, psychotropics, cardiac medications, opioids, diuretics and antibiotics. Identified residents and/ or representatives would have been educated on the use and risks/benefits of high risk medications including, adverse effects.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to comprehensively assess the use of a restrictive device as a potential restraint for 1 of 1 resident (R22) reviewed for restraints. Findings include: Review of R22's quarterly Minimum Data Set (MDS) dated [DATE], identified R22 had intact cognition and had diagnosis which included anemia (A condition in which the body does not have enough red blood cells), hemiparesis (a medical condition characterized by weakness on one side of the body, often affecting the arm, leg, and potentially the face), and multiple sclerosis (MS) (A chronic autoimmune disease that affects the central nervous system (brain and spinal cord). Indicated R22 required extensive assistance for activities of daily living (ADL's) which included bed mobility, transfers, and toileting. Identified R22 had not had any falls since the last assessment and required a wheelchair for mobility. Indicated R22 did not use any restraints. Review of R22's significant change Care Area Assessment (CAA) dated 11/15/24, identified R22 had intact cognition, was a high risk for falls related to medication use. CAA identified R22 did not use any restraints. Review of R22's quarterly fall assessment dated [DATE], identified R22 was at high risk for falls related to history of falls and current diagnosis. Review of R22's current physician orders signed 5/19/25, did not identify an order for a restraint. R22's medical record lacked any evidence a restraint assessment had been completed. Review of R22's care plan revised 6/1/25, identified R22 had a self care deficit related to hemiparesis of the left side. Identified R22 required staff assistance and a non mechanical lift for transfers. Identified R22 required a wheelchair for mobility. Care plan lacked any evidence of a seat belt being used in R22's wheelchair. During an observation on 6/9/25 at 11:35 a.m., R22 was seated in a motorized wheelchair in her room with a seatbelt fastened around her waist. During an interview on 6/9/25 at 11:40 a.m., R22 stated she was not able to remove the seatbelt from her waist. R22 stated she was only able to use her right hand to operate her motorized wheelchair but was not strong enough to remove the seatbelt. R22 stated the seatbelt did make it difficult to move while in the wheelchair. R22 further stated staff told her the seatbelt was for her safety so she did not fall out of the wheelchair. During an observation on 6/9/25 at 5:30 p.m., R22 was seated in a motorized wheelchair in the dining room with a seatbelt fastened around her waist. During an observation on 6/10/25 at 8:05 a.m., R22 was seated in a motorized wheelchair in her room with a seatbelt fastened around her waist. During an interview on 6/10/25 at 8:10 a.m., nursing assistant (NA)-B stated R22 had the seatbelt in her motorized wheelchair fastened around her waist for a while. NA-B stated staff removed the seatbelt from R22's waist for her since R22 was not able to remove it herself. NA-B further stated she was told R22 needed the seatbelt around her waist to keep R22 from sliding out of the motorized wheelchair. During an interview on 6/10/25 at 8:15 a.m., licensed practical nurse (LPN)-B verified R22 was seated in her room in a motorized wheelchair with a seatbelt fastened around her waist. LPN-B stated the seatbelt was to prevent R22 from falling out of the wheelchair. LPN-B confirmed R22 was unable to remove the seatbelt. During an observation on 6/10/25 at 8:20 a.m., licensed practical nurse (LPN)-B asked R22 to remove the seatbelt from her waist. R22 used her right hand and attempted to remove the seatbelt and stated she was not able to remove the seatbelt. During an interview on 6/10/25 at 10:49 a.m., registered nurse (RN)-A stated she was aware that R22 used a seatbelt around her waist while in her motorized wheelchair to prevent R22 from sliding out of the wheelchair. RN-A stated she was aware R22 was not able to remove the seatbelt but did not consider the seatbelt a potential restraint since R22 was able to ask staff to remove the seatbelt. During an interview on 6/10/25 at 10:57 a.m., acting director of nursing (DON) stated she just noticed the seatbelt fastened around R22 waist in her wheelchair yesterday and prior to that she was not aware that R22 used a seatbelt around her waist while in the motorized wheelchair. DON stated the seatbelt would be considered a potential restraint since R22 was not able to remove the seatbelt and it restricted her movement. DON stated her expectation was that staff would have assessed the seatbelt to determine if it was being used as a restraint. Review of a facility policy titled Restraint Free Environment revised 2/19/25, identified a physical restraint referred to any manual method, physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body. Physical restraints may include, but were not limited to: using devices in conjunction with a chair, such as trays, tables, cushions, or belts that the resident could not remove and prevented the resident from rising.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to accurately code the Minimum Data Set (MDS) correctly for 1 of 1 residents (R12) reviewed for resident assessment. Findings include: The Centers for Medicare and Medicaid (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual dated 10/2023, identified Section J 1800: Any Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent (cont.) Code 1, yes: if the resident has fallen since the last assessment. Continue to Number of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS) item (J1900), whichever is more recent. J1900: Number of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent code the number of falls since last assessment and if there were any injuries. R12's quarterly Minimum Data Set (MDS) dated [DATE], Section J1800 identified R12 had a fall since last assessment. Section J1900 identified R12 had one fall without an injury since last assessment. Review of R12's falls progress notes from 12/30/24 to 2/18/25, revealed the following: -on 12/30/24 at 4:20 p.m., R12 had an unwitnessed fall with no injuries. -on 2/18/25 at 8:30 p.m., R12 had an unwitnessed fall with no injuries. During an interview on 6/10/25 at 9:45 a.m., acting director of nursing (DON) verified R12 had two falls between 12/30/24 and 2/18/25. DON stated her expectation was that the MDS should have been coded accurately. Review of a facility policy titled MDS 3.0 Completion revised 2/19/25, identified residents were assessed, used a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan. Indicated persons completing part of the assessment must attest to the accuracy of the section they completed by signature.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R3 R3's significant change of status MDS dated [DATE], identified R3 was cognitively intact and had diagnoses which included: heart failure, arthritis and chronic obstructive pulmonary disease (lung condition that restricts breathing). Identified R3 used a walker for mobility and required supervision or touching assistance for dressing, transfers and walking. R3's activity of daily living (ADL) Function/Rehabilitation Potential CAA dated 5/22/25, identified R3 required assistance in ADLs, had impaired balance and transition during transfers and functional impairment in activity. R3's contributing factors included generalized weakness and decreased safety awareness. R3's Skilled Nursing Facility (SNF) Morse Fall Scale assessment dated [DATE], identified R3 had a history of falling, and had a score of 65, which indicated R3 was at high risk for falls. R3's comprehensive care plan revised 5/15/25, identified R3 had an ADL self-care performance deficit related to muscle weakness, and required maximum assistance with bathing, and supervision touching assistance with tub/shower transfer. R3's care plan also identified R3 was at risk for falls related to past history of falls. During an observation on 6/10/25 at 2:17 p.m., NA-A and R3 left the tub room. R3 was seated on her four wheeled walker dressed in a gown and housecoat. NA-A pushed R3 down the hall backward while R3 sat on the four wheeled walker seat, then they entered R3's room. During an interview on 6/10/25 at 2:33 p.m., NA-A stated she had given R3 a shower then transported R3 to her room. NA-A indicated R3 sometimes got overheated after her shower and needed help getting back to her room. NA-A stated she had R3 sit on the walker seat, then pushed her backwards down the hall to her room. NA-A stated this was her usual practice, and had done this for years. At 2:37 p.m. NA-A and surveyor knocked then entered R3's room and looked at R3's walker. On the rear left leg of the walker was a warning sticker that indicated this is a walking aide only. Do not use as transportation device. NA-A indicated she was unaware that walkers were not to be used to transport residents. During an interview on 6/10/25 at 10:00am., acting (DON) stated R12 had falls in the facility and was at high risk for further falls. DON stated one of R12's fall interventions was to have the wheelchair within reach of R12. DON stated her expectation was staff would have followed care planned interventions to prevent falls. During a follow-up interview on 6/10/25 at 2:53 p.m., DON stated the four wheeled walkers were not to be used to transport residents because of a tipping hazard. DON indicated she would expect staff to obtain a wheelchair to transport a resident if they were unable to walk with their walker. DON also indicated in the past R3 had transported herself while sitting on the seat of the walker, and had been educated on proper use of the walker. Review of a facility policy titled Fall Prevention Program revised 2/19/25 identified, each resident would be assessed for fall risk and receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Identified the nurse would initiate interventions on the resident's care plan in accordance to the resident's level of risk. The facility policy titled Safe Resident Handling/Transfers revised 2/19/25, identified the facility ensured that residents were handled and transferred safety to prevent or minimize risks for injury and provide and promote a safe and secure and comfortable experience. The policy identified the interdisciplinary team or designee would evaluate and assess each resident's individual needs, on admission and reviewed quarterly, after a significant change in condition or based on direct care staff observations or recommendations. Based on observation, interview and document review, the facility failed to implement interventions for 1 of 1 residents (R12) who had several falls in the facility and remained at high risk for falls. Further, the facility failed to ensure safe transportation of a resident (R3) who was at risk for falls. Findings include: R12's significant change Minimum Data Set (MDS) dated [DATE], identified R12 had severe cognitive impairment and diagnosis which included cancer, hypertension (elevated blood pressure) and dementia. Identified R12 required extensive assistance with activities of daily living (ADLs), which included: bed mobility, transfers, and toileting. R12's significant change Care Area Assessment (CAA) dated 3/26/25, identified R12 was at risk for falls related to previous falls, cognitive and visual impairment. R12's care plan revised 12/30/24, identified R12 was high risk for falls related to confusion, gait/balance problems and lack of safety awareness. Identified R1 required maximum assistance of 1 to 2 staff to move between surfaces. Identified various interventions for falls which included: ensure wearing non skid socks at night, call light within reach and walker within reach at all times. Review of R12's fall assessment dated [DATE], identified R12 had an impaired gait, weakness, and required a walker. Identified R12 was at high risk for falls. Review of R12's falls progress notes from 12/30/24 to 5/31/25, revealed the following: -on 12/30/24 at 4:20 p.m., R12 had an unwitnessed fall and was found in his room lying on the floor in front of the recliner. No injuries noted, R12 was unable to say what happened. Root cause: R12 was attempting to self transfer. Intervention added to the care plan: ensure walker was within reach. -on 2/18/25 at 8:30 p.m., R12 had an unwitnessed fall and was found lying on the floor in his room with regular socks on his feet with soft touch call light on. No injuries noted, R12 was unable to say what happened. Root cause -self transferring. Intervention: wear non skid socks at night. -on 4/23/25 at 5:00 p.m., staff heard R12's wife yell for help and found R12 on the floor in his room next to the bed, no injuries noted. Root cause wife was attempting to transfer R12 out of his recliner when R12 lost his balance. Intervention: wife to not transfer R12. -on 5/31/25 at 5:13 p.m., staff was walking with R12 when wife started walking with R12 and R12 fell landing on his wife, no injuries to R12 or wife. Root cause: R12 lost balance as wife began walking with R12. Intervention: Remind wife to not walk with R12. During an observation on 6/9/25 at 1:48 p.m., R12 was seated in his recliner in his room, walker was turned around and pushed up against the wall approximately five feet from R12. During an observation on 6/9/25 at 2:58 pm., R12 was seated in his recliner in his room, walker continued to be turned around and pushed up against the wall approximately five feet from R12. During an observation on 6/10/25 at 9:34 a.m., R12 was seated in his recliner in his room, walker was turned around and pushed up against the bed approximately six feet from R12. Nursing assistant (NA)-B and registered nurse (RN) acting director of nursing (DON) verified R12's wheelchair was pushed up against the bed approximately six feet from R12. During an interview on 6/10/25 at 9:38 NA-B stated R12 required staff assistance for transfers. NA-B stated R12 had previous falls and was at risk for further falls. NA-B stated R12's walker should have been within reach of R12.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to comprehensively assess and attempt alternatives prior to use of bed rails for 2 of 2 residents (R5, R26 ) reviewed who were observed to have bed rails. Findings include: R5's quarterly Minimum Data Set (MDS) dated [DATE], identified R5 was cognitively intact and had diagnoses which included: heart failure, arthritis, and dementia. R5's MDS identified R5 was independent with dressing, hygiene, rolling left to right, transfers and walking, and required substantial/maximal assistance with putting on/taking off footwear. R5's care plan revised 6/5/25, identified R5 had an activities of daily living (ADL) self-care performance deficit related to pain and forgetfulness. R5 had the ability to roll from lying on back to left and right side and return to lying on back on the bed independently. R5 was independent lying to sitting on side of bed and transfers. R5's care plan lacked identification of a grab bar on R5's bed. R5's Bed Rail Consent form dated 3/7/25, identified R5 had a grab bar on bed to aid in positioning. The form included potential benefits and risks of bed rail use. R5's medical record lacked a comprehensive assessment of R5's bed rail including: appropriate use of bed rail, measurements to assure safety and attempted alternatives prior to the use of the bed rail. During an observation on 6/9/25 at 12:43 p.m., R5 had a double sized standard bed with a black grab bar on the right side of bed, measuring approximately 1.5 feet tall and 1 foot wide. The grab bar sat approximately two inches from the mattress, then went under the mattress. R5 indicated her daughter had brought the rail in to be used, and was not aware if any staff member had assessed it. During an observation on 6/10/25 at 10:35 a.m., R5 was dressed in street clothes sitting at her computer in her room. R5's bed continued to have a grab bar attached to bed. During an interview on 6/11/25 at 9:26 a.m., nursing assistant (NA)-A indicated R5 was independent with most cares however, required assistance with her compression stockings. NA-A stated R5 had her own personal bed, and had witnessed R5 use the grab bar a few times, to help her swing her body up and out of bed. During an interview on 6/11/25 at 10:40 a.m., licensed practical nurse (LPN)-A stated R5 was mostly independent, however, staff assisted her to put her socks on. LPN-A confirmed R5 had a grab bar on her bed, and had witnessed R5 use it to get in and out of bed. LPN-A stated their usual practice was to obtain a consent form when bed rails were used, then review them annually. LPN-A indicated R5's family had brought the grab bar to the facility. LPN-A was not aware if R5 had tried anything prior to having the grab bar installed. During an interview on 6/11/25 at 10:44 a.m., R5 indicated she used the grab bar when getting out of bed. R5 stated she would be able to get out of the bed without it however, it was handy. R5 stated her family member attached it to her bed. R26's quarterly MDS dated [DATE], identified R26 was cognitively intact and had diagnoses which included: asthma, anxiety disorder and Guillain barre syndrome ( a rare neurological disorder where the immune system attacks the peripheral nervous system, causing muscle weakness and sometimes paralysis). Identified R26 was independent with dressing, hygiene, transfers and walking, and required substantial/maximal assistance with rolling side to side. R26's care plan revised 2/20/25, identified R26 had an activities of daily living (ADL) self-care performance deficit related to Guillain barre syndrome. R26 required partial/moderate assistance of one staff in bed to turn and reposition as necessary. At times of increased pain or weakness the resident need extensive assistance of one. R26's care plan lacked identification of a grab bar on R26's bed. R26's Bed Rail Consent form dated 2/5/25, identified R 26 had a grab bar on bed to aid in positioning. The form included potential benefits and risks of bed rail use. R26's medical record lacked a comprehensive assessment of R26's bed rail including: appropriate use of bed rail, measurements to assure safety and attempted alternatives prior to the use of the bed rail. During an observation on 6/9/25 at 1:40 p.m., R26 had a double sized standard bed with a black grab bar on the right side of bed, measuring approximately 1.5 feet tall and 1 foot wide. The grab bar sat approximately two inches from the mattress, then went under the mattress. R26 indicated her bed had the grab bar on it when she came to the facility and was not aware if any staff member had assessed it. R26 stated she used the grab bar to turn herself in bed and to transfer out of the bed. During an observation on 6/11/25 at 7:29 a.m., R26 was lying in bed and used the grab bar to stand up and transfer independently into her wheelchair. R26 stated she liked having the grab bar to use when getting out of bed. During an interview on 6/10/25 at 7:45 a.m., NA-B stated R26 was pretty independent with her mobility during the day. NA-B stated she had observed R26 use the grab bar on her bed to roll herself in bed and to transfer out of bed. During an interview on 6/11/25 at 08:10 a.m., LPN-B stated R26 was mostly independent, but staff assisted her during the night. LPN-B confirmed R26 had a grab bar on her bed, and had witnessed R26 use it to get in and out of bed. LPN-B stated their usual practice was to obtain a consent form when bed rails were used, then review them annually. LPN-B was not aware if R26 had tried anything prior to having the grab bar installed. During an interview on 6/11/25 at 10:57 a.m., acting director of nursing (DON) stated the facility's usual process was to obtain consents prior to using grab bars (bed rails) on resident's beds. DON stated some of the residents had their own beds, and had grab bars on them. DON confirmed the facility had not completed assessments of grab bars. DON confirmed they did not have the manufacturer's instructions for R5 and R26's grab bars. DON indicated it was important to do an assessment of grab bars because they could be a restraint, and to ensure resident safety. Review of the facility policy titled Proper Use Of Bed Rails, revised 2/9/25, identified the facility utilized a person-centered approach when determining the use of bed rails. Appropriate alternative approaches were attempted prior to installing or using bed rails. If bed rails were used, the facility ensured correct installation, use, and maintenance of the rails. The policy identified examples of bed rails included, but was not limited to side rails, bed side rails, safety rails, grab bars and assist bars. As part of the resident's comprehensive assessment, staff were to determine whether or not the use of bed rails met those needs. The evaluation must include an evaluation of the alternatives that were attempted prior the installation or use of bed rails and how those alternatives failed to meet the resident's assessed needs. The resident assessment should assess the resident's risk of entrapment between the mattress and the bed rail or in the bed rail itself. Informed consent from the resident or resident representative must be obtained after appropriate alternatives had been attempted prior to the installation and use of bed rails. The facility would assure correct installation and maintenance of bed rails prior to use, which included: checking with the manufacture to make sure the bed rails, mattress and bed frame were compatible, and assure a proper fit. Ongoing monitoring and supervision would be completed, including documentation in the residents records, including care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to provide a dignified dining experience for 1 of 1 residents (R16) who received assistance with eating in the dining room. Findings Include: R16's quarterly Minimum Data Set (MDS) dated [DATE], identified R16 had severe cognitive impairment and had diagnoses which included: anxiety, depression, cerebral vascular accident (CVA/stroke) hemiplegia (paralysis on one side of body), and hemiparesis (weakness on one side of body) R16's care plan revised 3/4/24, identified R16 had self-care performance deficit related to hemiplegia and hemiparesis affecting left non-dominant side. R16's interventions included assistance with hygiene, bathing and dressing. R16's care plan identified R16 had potential for altered nutritional status related to CVA and required set up and assistance at times with eating. R16's care plan identified R16 received hospice care. During an observation on 3/5/24 at 8:56 a.m., R16 sat in a high back wheelchair in the dining room at a table. Nursing assistant (NA)-B stood near R16's right side, and provided 2 spoonful of eggs while he remained standing on R16's right side. NA-B went to the other side of the table, sat on a stool next to another resident and assisted the other resident. At 9:00 a.m., NA-B stood up, walked over to R16 and stood at R16's right side and provided R16 a spoonful of eggs. NA-B placed the fork into R16's bacon, asked R16 if he wanted the bacon and placed the bacon back onto the plate. NA-B provided R16 a drink of soda in a can with a straw. NA-B remained standing with left hand resting on the back of R16's wheelchair while providing R16 with spoons full of eggs and drinks. At 9:05 a.m. NA-B asked R16 if done, removed R16's dishes from the table, removed R16's clothing protector and transported R16 out of the dining room. During an interview on 3/5/24 at 10:16 a.m., NA-B stated the usual process was to be seated while assisting residents with eating. NA-B indicated it was important not to stand while assisting residents with eating and indicated NA-B should have sat while assisting R16 in order to pay attention to R16 and be at eye level. During an interview on 3/6/24 at 12:05 p.m., registered nurse (RN)-A stated staff were expected to be seated while assisting residents with eating and have conversations with them. RN-A indicated it was important to give the residents their full attention and be at eye level. RN-A verified it was not a dignified practice to stand while assisting residents with eating. During an interview on 3/6/24 at 12:14 p.m., director of nursing (DON) indicated staff were expected to be seated by residents while assisting with eating as it was important to maintain dignity and promote safety. The facility policy titled Serving A Meal dated 8/1/23, identified when residents required assistance with consuming their meal, employees would remain at the table seated, giving their attention to the resident during the duration of the meal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R9 R9's quarterly Minimum Data Set (MDS) dated [DATE], indicated R9 had mild cognitive impairment and had diagnoses which included hemiplegia (a condition caused by brain damage or spinal cord injury that leads to paralysis on one side of the body), aphasia (loss of ability to understand or express speech, caused by brain damage), and cerebral vascular accident (CVA) (Stroke). Indicated R9 required extensive assistance with bed mobility, transfers, toileting and personal hygiene. Review of R9's electronic health record (EHR) revealed a SAM assessment had not been completed and R9 did not have an order for self administration of medications. R9's Physician Telephone Orders dated 2/12/24, and signed 2/20/24, directed staff to administer Ipratropium-albuterol inhalation solution DuoNeb (medication used to relax the muscles in the airways and increase air flow to the lungs) four times daily (QID) and every four hours as needed for congestion. R9's Medication Administration Record dated 2/12/24 to 3/6/24, indicated R9 had been taking (DuoNeb) 0.5-2.5 3 milligrams (mg) per three milliliters (ml) four times per day. R9's care plan dated 2/24, indicated R9 had limited mobility and required staff assistance and supervision with activities of daily living (ADL's). During a continuous observation on 3/6/24 at 7:20 a.m., R9 was seated in his recliner in his room with a mask on his face and a nebulizer running. No staff were observed in R9's room. At 7:26 a.m., trained medication aide (TMA)-A entered R9's room and shut off the nebulizer machine and removed the mask from R9's face. During an interview on 3/6/24 at 7:27 a.m., R9 stated he had been receiving the DuoNeb treatments for a few weeks now a few times a day. R9 indicated he had not been taught how to use the nebulizer machine. R9 verified nursing staff did not remain in the room while the treatment was being administered. R9 stated nursing staff turned on the nebulizer machine and placed the mask on his face and exited the room. During an interview on 3/6/24 at 7:30 a.m., TMA-A verified she had placed the nebulizer treatment on R9 and exited the room. TMA-A stated she was unsure if a SAM assessment had been completed for R9. TMA-A stated she did not have time to sit with R9 while he received his nebulizer so she would place the nebulizer on R9, turned on the machine, left the room and returned when the nebulizer was done. In addition, TMA indicated sometimes R9 would remove the mask himself and sometimes she would have to remove the mask for R9 when the nebulizer was completed. During an interview on 3/6/24 at 7:39 a.m., registered nurse (RN)-A confirmed R9 and R26 did not have a SAM assessment for their nebulizer treatments. RN-A stated none of the current residents had a SAM assessment for nebulizer's as they were not safe to self administer the nebulizers. RN-A indication her expectation was nursing staff would have stayed in the room with R9 and R26 while they received the nebulizer treatments to ensure R9 and R26 received the nebulizer treatments appropriately. During an interview on 3/6/24 at 7:42 a.m., director of nursing (DON) verified R9 and R26 did not have SAM assessments. DON indicated if the resident did not have a SAM assessment or physician's orders, staff were expected to remain with the resident during the entire nebulizer administration. Review of a facility policy titled Resident Self-Administration of Medication dated 8/1/23,identified a resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. Further indicated resident's preference would be documented on the appropriate form and placed in the medical record. Based on observation, interview and document review, the facility failed to ensure nebulizer medications were administered safely for 2 of 2 resident (R26, R9) who were observed to self administer a nebulizer and had not been assessed as safe to self administer medications. Findings include: R26 R26's admission Minimum Data Set (MDS) dated [DATE], identified R26 was cognitively intact and had diagnoses which included: multiple sclerosis (chronic disease that affects central nervous system) hemiplegia (paralysis on one side of body), hemiparesis (weakness on one side of body) and chronic obstructive pulmonary disease (COPD/chronic lung disease that cause airflow and breathing problems). R26's MDS identified R26 was dependent for self care and mobility. R26's care plan revised 12/20/23, identified R26 had an activity of daily living (ADL) self-care performance deficit related to disease processes. R26's care plan interventions included dependence on staff for bathing, dressing, and personal hygiene. Identified R26 had a cerebral infarction (CVA/stroke) which affected R26's left, non-dominant side. R26's Order Summary Report signed 3/1/24, included orders for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) milligram (MG)/3 milliliter (ML) 1 vial inhale orally four times a day for while awake. R26's Order Summary Report lacked an order to self administer medication. R26's medical record lacked documentation of a self-administration of medication (SAM) assessment completed. During an observation on 3/6/24 at 7:13 a.m., licensed practical nurse (LPN)-A administered R26's oral medications and topical medication. At 7:21 a.m. LPN-A opened R26's vial of Ipratropium-Albuterol inhalation solution and poured it into the nebulizer cup. LPN-A applied R26's nebulizer mask, turned on the nebulizer machine, set a timer on her watch and informed R26 she would return. LPN-A exited R26's room and went down to the end of the hall to the medication cart. LPN-A set up another resident's insulin medication, went down a different hallway and administered the insulin. At 7:38 a.m. LPN-A was observed exiting R26's room and stated she had rinsed the nebulizer out. LPN-A stated she was unaware if R26 had an order or SAM assessment for the nebulizer medication. During an interview on 3/6/24 at 7:39 a.m., registered nurse (RN)-A and LPN-A confirmed R26 did not have an order for self administration of medication, including the nebulizer. RN-A verified no residents at the facility currently had a SAM assessment completed and RN-A indicated she expected staff would remain in the room while any resident received a nebulizer medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to accurately code the Minimum Data Set (MDS) correctly for 1 of 1 residents (R79) reviewed for resident assessment. Findings include: The Centers for Medicare and Medicaid (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual dated 10/2023, identified Section 00110C1: Oxygen Therapy Code continuous or intermittent oxygen administered via mask, cannula, etc., delivered to a resident to relieve hypoxia in this item. Code oxygen used in Bi-level Positive Airway Pressure/Continuous Positive Airway Pressure (BiPAP/CPAP) here. R79's admission Minimum Data Set (MDS) dated [DATE], Section O:Special Treatments, Procedures, and Programs. Question 001000 C identified R79 had not received oxygen in the last 14 days. Review of R79's care plan updated 3/5/24, indicated R79 required oxygen with the use of his continuous positive airway pressure (CPAP) (a machine that used mild air pressure to keep breathing airways open while sleeping). Review of R79's signed physician orders dated 2/20/24, identified R79 was to use two liters of oxygen at night with a CPAP machine. During an interview on 3/5/24 at 9:05 a.m., R79 pointed to an oxygen concentrator in his room and stated he used oxygen every night with that machine and pointed to a CPAP machine. Review of R79's admission progress note dated 2/21/24, identified R79 slept with a CPAP with oxygen attached. During an interview on 3/5/24 at 11:06 a.m., MDS coordinator verified R79 utilized oxygen at two liters at night with a CPAP machine. MDS coordinator verified Section O of R79's MDS dated [DATE], had not been coded correctly. MDS stated her expectation would have been the MDS would have been coded correctly. During an interview on 3/5/24 at 3:41 p.m., director of nursing (DON) verified R79 had received oxygen with a CPAP machine at night. DON confirmed R79's MDS dated [DATE], had not been coded accurately. DON stated her expectation would have been for staff to complete the MDS correctly. Review of a facility policy titled MDS 3.0 Completion dated 8/1/23, identified residents were assessed, used a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan. Indicated persons completing part of the assessment must attest to the accuracy of the section they completed by signature.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to provide range of motion services to prevent potential decrease in range of motion (ROM) for 1 of 1 residents (R9) reviewed who required range of motion for restorative nursing exercises. Findings include: R9's quarterly Minimum Data Set (MDS) dated [DATE], indicated R9 had mild cognitive impairment and had diagnosis which included hemiplegia (a condition caused by brain damage or spinal cord injury that leads to paralysis on one side of the body), aphasia (loss of ability to understand or express speech, caused by brain damage), and cerebral vascular accident (CVA) (Stroke). Indicated R9 required extensive assistance with bed mobility, transfers, and toileting. R9's Significant Change Care Area Assessment (CAA) dated 3/17/23, identified R9 required extensive assistance with activities of daily living (ADL's) which included dressing, bed mobility, transfers and toileting. R9's current care plan dated 3/23, indicated passive range of motions (PROM) and active range of motion (AROM) would be provided. Review of Occupational Therapy (OT) Discharge summary dated [DATE], identified discharge recommendations: patient to remain at same skilled nursing facility (SNF) with 24 hour supervision and cares with restorative nursing program (RNP) including PROM 10 reps to right arm daily to maintain range of motion (ROM ) and endurance. In addition, left upper extremity exercises with theraband were to be completed daily. Review of R9's progress notes lacked any indication of a RNP. During an observation on 3/4/24 at 12:35 p.m., R9 was seated in his recliner in his room and used his left arm to pick up his right arm to place it on the armrest of the recliner. During an interview on 3/4/24 at 12:39 p.m., R9 indicated he had limited ROM in his right arm and right leg. R9 stated staff had not been assisting R9 with any ROM exercises. During an interview on 3/6/24 at 8:15 a.m., nursing assistant (NA)-B indicated R9 had very limited ROM on his right side and required staff assistance with ADL's. NA-B stated he had performed RNP for residents in the past however was unaware of any ROM programs currently in place for R9. During an interview on 3/6/24 at 8:20 p.m., NA-A indicated R9 had limited ROM on his right side. NA-A stated she was not aware of any RNP programs currently in place for R9. During an interview on 3/6/24 at 8:25 a.m., registered nurse (RN)-A indicated R9 had right sided hemiplegia and required staff assistance for ADL's. RN-A confirmed R9 had an OT recommendation for an RNP program to maintain ROM. RN-A verified the recommendation had not been communicated to the staff and therefore, had not been completed. RN-A stated her expectation would have been the RNP would have been communicated to staff and started upon R9's discharge from OT to prevent further loss of ROM to his right side. During an interview on 3/6/24 at 8:59 a.m., therapy director (TD) verified R9 had been discharged from OT on 2/20/24, and was to have a RNP to his right arm to prevent further loss of ROM. TD stated it would have been important to implement the RNP for R9 to prevent a decline related to further loss of ROM. During an interview on 3/6/24 at 10:05 a.m., director of nursing DON stated she was unaware R9 had not been receiving restorative services per therapy recommendations. DON indicated her expectation was staff would have followed therapy recommendations. Review of a facility policy titled Restorative Nursing Programs dated 8/1/23, identified restorative nursing programs referred to nursing interventions that promoted the resident's ability to live as independently and safely as possible and actively focused on achieving and maintaining optimal physical, mental, and psychosocial functioning. Identified the discharging therapist would communicate to the appropriate restorative aide the provisions of the residents restorative nursing plan, and provide any necessary training to carry out the plan. . .

Based on observation, interview, and document review, the facility failed to ensure personal laundry was transported in a manner that prevented risk of contamination for 2 of 3 hallways observed for linen transportation. In addition, the facility failed to complete hand hygiene during linen delivery and ensure safe delivery of beverages during dining observation. Findings include: Review of Centers for Disease Control (CDC ) guidance, Appendix D - Linen and Laundry Management updated 5/4/23, identified linens must be sorted, packaged, transported, and stored in a manner that prevented risk of contamination by dust, debris, soiled linens or soiled items. In addition, CDC Handwashing in Communities: Clean Hands Save Lives updated 7/18/22, identified handwashing was the most important thing to prevent food poisoning. During an observation on 3/4/24 at 2:58 p.m., in the 100 hallway nursing assistant (NA)-C pushed an uncovered cart that contained clean linen down the hallway. NA-C sanitized hands and removed a washcloth and a towel from the uncovered cart and delivered the items to R18's room. NA-C returned to the hallway, sanitized hands and removed a washcloth and towel from the uncovered cart as a resident wheeled by the cart. NA-C delivered the items to R24's room. NA-C returned to the hallway, sanitized hands and removed a washcloth and towel from the uncovered cart and delivered the items to R14's room. NA-C returned to the hallway, sanitized hands and removed a washcloth and towel from the uncovered cart and delivered the items to R1's room. NA-C returned to the hallway, sanitized hands and removed a washcloth and towel from the uncovered cart as a staff member walked by the cart. NA-C delivered items to R25's room. NA-C returned to the hallway, sanitized hands and removed a washcloth and towel from the uncovered cart and delivered the items to R4's room. NA-C returned to the hallway, sanitized hands and removed a washcloth and towel from the uncovered cart and delivered the items to R12's room. NA-C returned to the hallway, sanitized hands and removed a washcloth and towel from the uncovered cart and delivered the items to R15's room. During an observation on 3/5/24 at 12:08 p.m., in the resident dining room Minimum Data Set (MDS) coordinator poured two glasses of milk for R20. MDS coordinator placed her right hand around one of the glasses and placed her left hand over the top part of one glass (the area you drink from) and proceeded to carry the two glasses of milk across the dining room. MDS coordinator placed the two glasses on the table in front of R20 who proceeded to drink from the glass the MDS coordinator held in her left hand. During an interview on 3/5/24 at 1:46 p.m., MDS coordinator stated her normal practice was to place her hands around the center of the glass when carrying a glass. MDS coordinator stated it was important not to touch the area of the glass a resident drank from to prevent infections. During an observation on 3/5/24 at 2:46 p.m., NA-D placed several washcloths and towels on an uncovered cart and placed the cart in the hallway near the nurses' station as two staff members walked by the uncovered cart. At 3:11 p.m., NA-D returned to the uncovered cart and pushed the cart down the 200 hallway. In addition,NA-C brought an empty cart down the hallway. NA-C proceeded to remove a washcloth and towel from the uncovered linen cart and delivered the items to R11's room. NA-C returned to the hallway with a dirty water pitcher and placed it on the empty cart and moved the uncovered linen cart down the hallway. NA-C proceeded to remove a washcloth and towel from the uncovered linen cart and delivered the items to R2's room. NA-C returned to the hallway with a dirty water pitcher and placed it on the cart with the other water pitcher. NA-C proceeded to remove a washcloth and towel from the uncovered linen cart and delivered them to R16's room as a visitor walked by the cart. NA-C returned to the hallway with a dirty water pitcher and placed it on the cart with the other water pitchers. At no time did NA-C perform hand hygiene during the above observation. During an interview on 3/5/24 at 3:12 p.m., NA-D stated her normal practice was to pass clean linen on a clean uncovered cart. NA-D stated it was important to cover the linen cart to prevent contamination of the linens. During an interview on 3/5/24 at 3:16 p.m., NA-C stated her normal process was to sanitize her hands before passing linen from a clean uncovered cart. NA-C stated she should have sanitized her hands while passing linen and the cart should have been covered to prevent possible cross contamination. During an interview on 3/5/24 at 3:38 p.m., director of nursing (DON) stated her expectation was staff would perform hand hygiene, cover linens during transport, and staff should not be touching any areas of the glass the resident drinks from. A facility policy titled Infection Prevention and Control Manual Environmental Services/Housekeeping/Laundry dated 2020, indicated the facility was to provide clean, fresh linen to each resident and prevent contamination. Identified clean linen was transported in a clean, covered cart with a solid bottom to prevent contamination while being moved through the facility. A facility policy titled General Food Preparation and Handling dated 8/1/23, indicated food items were to be prepared to be free of injurious organisms and substances. Indicated staff were to handle utensils, cups, glasses, and dishes in such as way as to avoid touching surfaces that food or drink will come in contact with.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to accurately code the Minimum Data Set (MDS) correctly for 1 of 1 residents (R24) reviewed for resident assessment. The Centers for Medicare and Medicaid (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual dated 10/2019, identified Section O0100: Special Treatments, Procedures, and Programs: O0100K, Hospice care: Code residents identified as being in a hospice program for terminally ill persons .is provided . R24's admission Minimum Data Set (MDS) dated [DATE], Section O: Special Treatments, Procedures, and Programs. question O0100K identified R24 had been in hospice care. R24's care plan dated 5/26/23, lacked documentation R24 had received Hospice services. A progress note dated 6/20/23, indicated R24 had been evaluated by Hospice and had not met criteria for their services. During an interview on 6/27/23 at 9:51 a.m., MDS coordinator (MDSC) verified R24 had not received hospice services. MDSC confirmed R24's MDS dated [DATE], had not been coded correctly. During an interview on 6/27/23 at 3:08 p.m., director of nursing (DON) verified R24 had not received hospice services. DON confirmed R24's MDS dated [DATE], had not been coded accurately. DON stated her expectation would have been for staff to complete the MDS correctly. An MDS completion policy was requested however was not provided. DON stated the facility referred to The Centers for Medicare and Medicaid (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual for coding of the MDS.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure physician ordered laboratory monitoring was completed for 1 of 5 residents (R2) reviewed for unnecessary medication use. Findings Include: R2's quarterly Minimum Data Set (MDS) dated [DATE], identified R2 was cognitively intact and had diagnoses which included: schizophrenia, hypertension, chronic kidney disease, and bilateral primary osteoarthritis of knee. Indicated R2 required limited assistance with personal hygiene and supervision with transfers and locomotion. R2's care plan last reviewed 4/18/23, identified R2 required extensive assistance with personal hygiene, set up for dressing and was independent with transfers and toilet use. Identified R2 had limited physical mobility related to osteoarthritis, history of total knee replacement and right knee not properly aligned. Review of R2's Order Summary Report signed and dated 5/17/23, identified the following: -Vitamin D tablet, give 5000 unit by mouth one time a day for supplement. Recheck Vitamin D level in 4 weeks on 8/23/22. -Oysco 500+D tablet 500-200 milligram-unit (calcium carbonate-Vitamin D) give one tablet by mouth one time a day for supplement Review of R2's physician fax communication dated 7/26/22, identified an order for dosage change and lab to be drawn. The Results Notes identified nurse practitioner (NP)-A reviewed R2's vitamin D level, which was within normal range after Vitamin D3 10,000 units orally daily was received over the past four weeks. The plan was to decrease supplement to 5,000 units and see if R2 remained stable at that dose, to recheck in four weeks. Review of R2's medical record (MR) lacked any documentation R2's labs had been drawn as ordered on 8/23/22, or since that time. During an interview on 6/27/23 at 4:14 p.m., director of nursing (DON) stated a fax communication had been received on 7/26/22, with orders to decrease R2's Vitamin D supplement and the facility was ordered to complete a Vitamin D level in four weeks. DON confirmed Vitamin D level had not been completed as ordered. DON indicated she expected lab orders to be completed as ordered. During a telephone interview on 6/27/23 at 5:13 p.m. NP-A, verified she had ordered a vitamin D level to be checked on R2 to determine if the level was stable since they had decreased the dosage. NP-A indicated it was important to recheck her level after the new dosage was decreased. NP-A indicated she expected the lab would have been completed as ordered. During a telephone interview on 6/28/23 at 8:39 a.m., pharmacy consultant (PC)-A verified she was not aware R2's vitamin D level had not been checked. PC-A indicated she would expect R2's vitamin D level to be completed as ordered and confirmed she had not identified the error. PC-A stated Vitamin D supplement was provided for various reasons including calcium absorption and to stabilize mood. During an interview on 6/28/23 at 11:31 a.m., registered nurse (RN)-A confirmed R2 did not have a Vitamin D level completed. RN-A stated the facility's usual process for ensuring labs were completed as ordered was a nurse would complete the orders and another nurse would double check the orders for accuracy. RN-A indicated lab orders were entered on a calendar at the nursing desk for staff to refer to. The facility policy titled Lab And Diagnostic Test Results-Clinical Protocol revised November 2018, identified the physician would identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. The policy indicated the staff would process test requisitions and arrange for tests.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure 1 of 5 residents (R21) was offered or received a pneumococcal vaccination. In addition, the facility failed to document and provide the risks and the benefits of refusing the influenza vaccination for 2 of 5 residents (R21 and R22) in accordance with the Center for Disease Control (CDC) recommendations. Findings include: Review of the Recommended Adult Immunization Schedule for ages 19 years or older, Pneumococcal Vaccination, 2023, scheduled presented from The Center for Disease Control and Prevention (CDC) identified Adults [AGE] years of age or older who have not previously received Pneumococcal 13-valent Conjugate Vaccine (PCV13) and who have previously received one or more doses of Pneumococcal Polysaccharide Vaccine 23 (PPSV23) should receive a dose of Pneumococcal 15-valent Conjugate Vaccine (PCV15) or 1 dose of Pneumococcal 20-valent Conjugate Vaccine (PVC20). The dose of PCV15 or PCV20 should be administered at least one year after the most recent PPSV23 dose. Review of R21's Minnesota Immunization Information Connection (MIIC) form identified R21 had received the Pneumo-poly (PPSV23) vaccination on 10/22/1999. R21's medical record lacked documentation R21 had received or been offered the PCV15 or PCV20 vaccines. Review of R21's Immunization Report identified R21 had refused the influenza vaccination undated. The influenza vaccination refusal lacked documentation of when it was offered and if R21 had received education regarding the risk and the benefits of receiving the vaccine. Review of R22's Immunization Report identified R22 had refused the influenza vaccination undated. The influenza vaccination refusal lacked documentation of when it was offered and if R21 had received education regarding the risk and the benefits of receiving the vaccine. During an interview on 6/28/23 at 11:37 a.m., the director of nursing (DON) confirmed the above findings and indicated she would expect nursing staff to offer the the vaccinations to the residents, document refusals, provide education and answer any questions the residents may have. The DON stated if the resident had refused the vaccine she would expect nursing staff to update the provider as well. Review of facility policy titled, Pneumococcal Vaccine dated 2/1/18, identified all residents would be offered pneumococcal vaccines to aid in prevention of pneumococcal infections. Prior to or upon admission, residents would be assessed for eligibility to receive the pneumococcal vaccine series within 30 days of admission or if medically contraindicated or if the resident had already been vaccinated. Administration of pneumococcal vaccines or revaccination would be made in accordance to CDC recommendations at time of the vaccination.

Based on interview and document review, the facility failed to ensure the infection control program included ongoing surveillance, trending and analysis of resident infections. This deficient practice had the potential to affect all 25 residents currently residing in the facility. Findings include: Review of the facility's untitled infection control logs included the following information: resident name, room number, location of resident, infection date, type of infection, diagnosis, symptoms, medication/antibiotic, provider, outcome, date infection or signs and symptoms resolved, and bacteria type. Review of the untitled infection control logs from 6/28/2022 to 6/28/2023, revealed the following: June 2022, no infections were noted on the logs. July 2022, no infections were noted on the logs. August 2022, no infections were noted on the logs. September 2022, no infections were noted on the logs. October 2022, no infections were noted on the logs. November 2022, no infections were noted on the logs. December 2022, one resident was treated with antibiotics for a urinary tract infection (UTI) who utilized a catheter. January 2023, no infections were noted on the logs. February 2023, two residents had tested positive for COVID-19 and were being monitored. Both residents were placed on transmission based precautions. March 2023, one resident was treated with antibiotics for a UTI who utilized a catheter. April 2023, three residents were treated with antibiotics, one was treated for a UTI and two residents were treated for cellulitis. May 2023, no infections were noted on the logs. June 2023, three residents were treated with antibiotics, two were treated for UTIs and one was treated for pneumonia. The logs lacked ongoing surveillance and trending of all infections which included food-borne illness, and other illnesses caused by other viruses or infections. During an interview on 6/28/23 at 11:37 a.m., the infection control program was reviewed with the director of nursing (DON). The DON confirmed she was responsible for the facilities current infection control program and used a system called Peerlytics for antibiotic monitoring and tracking. The DON confirmed she had not been tracking and trending all infections in the facility and was only tracking and trending infections treated with antibiotics. The DON also indicated the only infections that were being tracked were listed on the infection control logs: such as UTI's, upper respiratory infection (URI), cellulitis, and did not include other infection caused by viruses or food borne illness. The DON confirmed ongoing surveillance had not been completed and the infection control program had room for improvement. Review of the facility policy titled, Infectious Disease Threat Surveillance and Detection revised on 04/2019, indicated a system was in place that identified, reported, investigated, controlled and prevented infections and communicable diseases for all residents and staff. The policy monitored public health surveillance and advisory for ongoing infectious diseases within the community. The policy identified the process for assessments and recognition, cause identification, diagnostic testing and monitoring of signs and symptoms, and worked with the provider to determine the treatment plan for residents and staff.