**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to notify the resident representative and the medical provider following discovery of a deep tissue injury (DTI) (pressure injury where damage occurs to the underlying tissue before becoming visible on skin surface) for 1 of 1 resident (R196) reviewed for notification of change. Findings include: R196's Face Sheet printed 7/2/25, included diagnoses of cerebral infarction (stroke), pressure ulcer of sacral region unstageable (a type of pressure injury where the depth of wound cannot be determined because the wound bed is obscured by slough or eschar [black or brown layer of dead tissue]). R196's admission (MDS) assessment dated [DATE], indicated R196 had intact cognition, understands and is understood, and had no behaviors. R196 required partial to moderate assist for bed mobility and transfers and substantial to maximum assist for walking 10 feet. R196 had no known weight loss or gain or chewing/swallowing issues. R196 was not at risk for pressure ulcers (PU) and had no current PU's but did have skin tears present. R196's care plan dated 4/24/25 included impairment to skin integrity on left lower leg, bruising, small openings; appears to be trauma related; skin is also very fragile with bruising upon admission. Interventions included keep skin clean and dry, use lotion on dry skin. Weekly skin observation by licensed nurse. R196's plan of care was updated on 5/9/25, to include the resident has a suspected DTI with open area of coccyx related to immobility and resident prefers to lie on back in bed and spend a large amount of time in wheelchair. Interventions included low air loss air mattress; Roho cushion (used to prevent/treat pressure ulcers PU's); encourage resident to reposition side to side in bed; encourage and assist to turn and reposition at least every 2-2.5 hours when in bed related to current PU and high risk for further skin injury; encourage resident not to be in wheelchair longer than 3 hours if can be avoided. A Skin Assessment by licensed practical nurse (LPN)-A dated 5/7/25, included coccyx and buttocks are reddened and top of coccyx has a dark red area that is still blanchable. A Wound Data Collection by registered nurse (RN)-A dated 5/9/25, included initial data collection on the coccyx. No dressing present with area dark purple surrounding open area; red and excoriated skin distal to open area with bleeding this a.m. A Wound RN Assessment by RN-A 5/9/25, included physician was notified regarding wound status. A provider order signed by nurse practitioner (NP)-B included wound care for coccyx: cleanse area well and pat dry. Apply skin prep to surrounding skin. Warm 2x2 hydrocolloid dressing (2 layer dressing that absorbs drainage to form a hydrated gel over the wound to create a moist environment to promote healing) in hands a few seconds and apply dressing over wound. One time a day every 3 days for coccyx wound. The electronic medical record (EMR) did not include notification of family until 5/21/25, by RN-A. A progress note 5/21/25, by RN-A included wound was open on coccyx, and R196 had decreased progress in therapy over past week, increased weakness, decreased response during conversation and decreased appetite. Explained that condition of wound has quickly deteriorated and may need procedures that facility wound nurse is not able to complete. Explained that wound condition suggests further deep tissue injury under visible wound surface that may lead to bone resulting in infection, sepsis, and death. But also explained that even with a wound clinic treatments/routine visits, the potential of wound healing without adequate nutrition (calories, protein,vitamins/minerals) would still be slim. FM-B verbalized understanding; RN-A explained that all of the above information has also been discussed with R196 but R196 was not able to give an answer on how she would like to move forward. On interview 7/1/25 at 3:18 p.m., family member (FM)-B indicated the family was not notified until 5/18/25, when her family member was at the facility and saw the wound. FM-B stated a phone call was was made to the facility on 5/22/25, and RN-A ensured the facility had the wound under control. FM-B stated she requested to be notified if the wound worsened prior to a wound care clinic appointment on 5/29/25, but was never notified. FM-B stated when R196 arrived at the wound care clinic, the wound had worsened to the point R196 had to be hospitalized because the wound was infected. A Wound and Hyperbaric Healing Center note by NP-D on 5/29/25 at 12:30 p.m., included acute cellulitis (bacterial infection of the skin and underlying tissues) present along with unstageable sacral pressure ulcer requiring hospitalization for stabilization and planning of further care. Discussed with family that this is a very serious ulcer and prognosis. During interview on 7/2/25 at 10:56 a.m., LPN-A indicated she doesn't remember notifying the family or provider on 5/7/25 when the dark red spot was initially identified. LPN-A added if it wasn't documented they likely were not notified. During interview 7/2/25 at 11:37 a.m., RN-A stated there was no documentation family was notified until 5/21/25 regarding the coccyx wound adding the wound progressed very rapidly. RN-A stated she notified the provider on 5/9/25, regarding coccyx ulcer and got orders for treatment. On interview 7/2/25 at 12:16 p.m., FM-A stated a nurse (was unable to identify which nurse) contacted him about the wound initially when it was the size of a quarter and was open, when they were requesting to make an appointment with the wound care clinic. FM-A stated this was about a week before R196 went to the wound clinic (5/29/25) (could not give an exact date). On interview 7/2/25 at 1:14 p.m., medical doctor (MD)-C stated he was not sure when first notified of R196's wound but EMR first noted orders were given on 5/9/25. On interview 7/2/25 at 12:58 p.m., the director of nursing (DON) stated the family and provider should have been notified when initially discovered the dark red spot on the coccyx and then again by the RN when the wound opened. Facility Notification Of Change policy dated 12/21/24, indicated a facility must 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: 1) An accident involving the resident which results in injury and has the potential for requiring physician intervention. 2) A significant change in the resident's physical, mental or psychosocial status. 3) A need to alter treatment significantly - a need to discontinue or change an existing form of treatment or to commence a new form of treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to assess, monitor and implement pressure relieving interventions for 1 of 1 resident (R196) who developed an unstageable pressure ulcer to the coccyx (small, triangular bone located at the bottom of the spine) area. Findings include: Pressure Ulcer stages defined by the Minimum Data Set (MDS) per Center Medicare/Medicaid Services: Deep-Tissue Injury (DTI): Purple or maroon area of discolored intact skin due to damage of underlying soft tissue. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler than adjacent tissue. 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 or eschar.) R196's Face Sheet printed [DATE] included diagnoses of cerebral infarction (stroke), pressure ulcer of sacral region unstageable (a type of pressure injury where the depth of wound cannot be determined because the wound bed is obscured by slough or eschar (black or brown layer of dead tissue), atrial fibrillation with presence of cardiac pacemaker, unsteadiness on feet and back pain. R196's admission (MDS) assessment dated [DATE], indicated R196 had intact cognition, understands and is understood, and had no behaviors. R196 required partial to moderate assist for bed mobility, transfers and personal hygiene and substantial to maximum assist for walking 10 feet, toileting and dressing. R196 had no known weight loss or gain or chewing/swallowing issues. R196 was not at risk for pressure ulcers (PU) and had no current PU's but did have skin tears present. R196's care plan dated [DATE], included impairment to skin integrity on left lower leg, bruising, small openings; appears to be trauma related; skin is also very fragile with bruising upon admission. Interventions included keep skin clean and dry, use lotion on dry skin and weekly skin observation by licensed nurse. R196's plan of care was updated on [DATE], to include the resident has a suspected DTI with open area of coccyx related to immobility and resident prefers to lie on back in bed and spend a large amount of time in wheelchair. Interventions included low air loss air mattress; RoHo cushion (used to prevent/treat pressure ulcers PU's) to wheelchair and recliner; encourage resident to reposition side to side in bed; encourage and assist to turn and reposition at least every 2-2.5 hours when in bed related to current PU and high risk for further skin injury; encourage resident not to be in wheelchair longer than 3 hours if can be avoided. R196's activities of daily living (ADL) plan of care dated [DATE] included assist of 1 with bed mobility, dressing, toileting and transfer and set up assistance with personal hygiene. R196 is able to eat independently. R196's Braden scale assessments (tool used to predict pressure ulcer risk) included: (high risk score of 10-23, Moderate Risk 13-14, Mild risk 15-18). [DATE] - Mild risk score of 18. [DATE] - Mild risk score of 17. [DATE] - Mild risk score of 16. [DATE] - Mild risk score of 16. R196's Care Area Assessment for Pressure Ulcer/Skin dated [DATE], included R196 is at low to moderate risk for pressure injury. R196 ambulates with therapy and is able to reposition herself in bed or with minor assist from staff. No pressure injury present on admission however did admit with healing skin tear on lower left leg. Does have bladder incontinence with staff assist with all tasks related to toileting, transfers, clothing, incontinent pads and peri-care. R196 has intact cognition. Although she has a flat affect, she is alert and oriented and uses call light appropriately. Uses Tramadol 50mg BID due to history of compression fractures and osteoarthritis. Cerebral vascular accident (stroke) with decreased mobility and activities of daily living function and is no concerns for PU at this time; will address impaired skin due to healing skin tear. A progress note dated [DATE] at 12:56 p.m., registered dietician (RD)-E indicated R196 was at risk for malnutrition due to inadequate calorie intake and wounds including coccyx and buttocks reddened. R196 has not had significant weight loss but has inadequate oral intake related to recent acute stroke with variable intake with most meals at 0-50%. Will suggest discussion of possible nutrition interventions due to her history of weight loss and poor current intake at meals. Skin Assessments included: [DATE] (on admit): Sacrum is pink and intact, with right and left arm bruising present. Left lower leg bruising with multiple skin tears. [DATE]: Bruising and skin tears, left lower leg with healing and other bruising on bilateral lower arms, improving, face 1 cm scab present on left check with Band-Aid applied. [DATE]: Left lower leg with long bruise and small skin tear. Area cleansed and new dressing applied. Coccyx and buttocks are reddened and top of coccyx has dark red area that is still blanchable per licensed practical nurse (LPN)-A. [DATE]: Coccyx pink area, but no open areas. Left lower leg with several small scabbed areas 0.8 x 0.5 cm. Completed by RN-B. [DATE]: Coccyx - see Registered Nurse (RN) wound assessment, area with black center. Completed by RN-B [DATE]: Coccyx - see RN wound assessment for measurements. Area black with surrounding tissue red. Completed by RN-B. A Wound Data assessment dated [DATE] by RN-A included initial data collection on the coccyx. No dressing present with area dark purple surrounding open area; red and excoriated (red and inflamed showing signs of trauma or open wounds) skin distal to open area with bleeding this a.m. A Wound Data Collection form by registered nurse (RN)-A dated [DATE] included wound is 1.5 cm x 0.5 cm x 0.2 cm depth on coccyx. Moderate drainage, sanguineous (thin watery liquid that leaks out commonly seen in fresh wounds within 48-72 hours during inflammatory wound healing stages) no odor present. Wound margins with ecchymoses (skin discolorations from damaged blood vessels). Modification to interventions included repositioning/turning and wound treatment. Skin prep (protective barrier) to surrounding skin; hydrocolloid dressing (dressing made from gel-forming agent that helps to rehydrate the wound and absorb excess fluid) over wound. A notification to the provider, by registered nurse (RN)-A [DATE] included physician was notified regarding wound status. A provider order signed by nurse practitioner (NP)-B included wound care for coccyx: cleanse area well and pat dry. Apply skin prep to surrounding skin. Warm 2x2 hydrocolloid dressing (2 layer dressing that absorbs drainage to form a hydrated gel over the wound to create a moist environment to promote healing) in hands a few seconds and apply dressing over wound. One time a day every 3 days for coccyx wound. A physician visit from MD-C on [DATE] included no reported concerns from staff at the nursing facility. Skin was not assessed and no mention of coccyx wound on examination or assessment was present. A progress note on [DATE] at 2:59 p.m., by social worker (SW)-A included Mood/Behavior Note Text: 1 to 1 with res re: mood. Res was watching TV from her recliner, with a container of Boost at hand. Res was asked about her appetite; simply said, I'm not hungry. Res was asked about her long-range plan; she shrugged; indicated she didn't know if she is progressing (with therapy) or not. It seems kind of hopeless, R196 said. R196 was asked if she is purposefully not eating. There was a long silence and then R196 said, My good friend was here and she stopped eating and drinking and died after 22 days. R196 then added, I don't know if it was purposeful or not. R196 was given a little more information (verbally) about the option of stopping all intake; including the physician likely wishing to rule out depression first, and making sure the individual is of sound mind. R196 was encouraged to consider an antidepressant . She commented, My get up and go has got up and went. R196 was offered mental health professionals to talk to via tele-health. R196 looked thoughtful but did not respond. R196 was asked if she would like to discuss with her children . or her PCP .she would not respond. After considerable silence I stated I'd let her think about these options and then she said, ok, if that's what you'd like to do. An RN Wound assessment dated [DATE] at 12:42 p.m., by RN-A included suspected DTI, with full thickness loss. Deterioration of wound evidenced by all of necrotic tissue has opened up revealing larger wound; wound bed/margins remain dark purple in color. Increased drainage over past couple days. Debridement done using mechanical (removal of foreign material or devitalized tissue through physical means) and autolytic (use of moisture retentive dressing to cover the wound and allow devitalized tissue to self digest by enzymes present in the wound fluids). Interventions include repositioning/turning, support surfaces, friction/shear management and wound treatment. Physician was notified regarding wound status and care plan was updated. Physician notified of deterioration of wound (and overall condition) and updated on interventions that already have been and will be put into place. A Wound Data Collection dated [DATE], by RN-A included wound is 3 cm x 2 cm x 0.5 cm visible depth measurement; wound bed deep purple, suspected further deep tissue injury. Dressing present and intact with drainage. No drainage leaking around the dressing. Moist, soft edges. No complications. Resident does voice complaints of pain related to the wound and is tender to touch. Wound bed was not described. Moderate, serosanguinous drainage present with slight odor, with hydrocolloid dressing in place with large amount of drainage. Skin is macerated, deep purple wound margins extending out approx 1 cm to surrounding skin. No undermining or tunneling. Wound treatment included Calcium Alginate Silver rope packing (helps absorb moderate to heavy amounts of wound drainage); border foam cover. R196 continues with poor appetite/intakes with 5 pound weight loss since admission. Is on 4 oz house supplement BID in which she usually drinks. R196 chooses to sit up in wheelchair or recliner a majority of the day. Roho cushion to chair and low air-loss mattress applied. Physician was notified. New orders on [DATE] to include: Wound care for coccyx to include cleanse area well with wound cleanser; pat dry. Apply skin prep to surrounding skin. Pack wound bed with silver calcium alginate rope. Cover with silicone border foam dressing. Change dressing daily and as needed if becomes soiled or loose signed by NP-B. A progress note dated [DATE], by RN-A included wound was open on coccyx, and R196 had decreased progress in therapy over past week, increased weakness, decreased response during conversation and decreased appetite. Explained to FM-B that condition of wound has quickly deteriorated and may need procedures that facility wound nurse is not able to complete. Explained that wound condition suggests further deep tissue injury under visible wound surface that may lead to bone resulting in infection, sepsis, and death. Also explained that even with a wound clinic treatments/routine visits, the potential of wound healing without adequate nutrition (calories, protein,vitamins/minerals) would still be slim. FM-B verbalized understanding; RN-A explained that all of the above information has also been discussed with R196 but R196 was not able to give an answer on how she would like to move forward. A Physician Notification dated [DATE] by RN-B included R196 has wound on coccyx that is black colored. May we have a referral for the wound clinic. An order was received from CNP-F for wound care clinic and CNP also included please schedule exam of area at NH next provider rounds. An RN wound assessment dated [DATE] by RN-A included wound is unstageable with less drainage, odor improved, necrotic tissue slightly loose around edge, maceration improved. Damaged deep tissue now necrotic (dead tissue caused by injury, infection or lack of blood supply). Modifications include support surfaces, nutritional and wound treatment. Physician notified regarding: Requested order to change cover dressing for adequate drainage/moisture management; and will request Juven (drink to support wound healing in patient with inadequate nutrient intake) order if R196 likes Juven. A wound data collection tool dated [DATE] at 10:34 a.m., by RN-A included wound is 3 cm, by 2.6 cm with no depth documented. Dressing was present, and intact with drainage present but not leaking around the dressing. Surrounding tissue is pink and dry and intact. R196 has pain related to wound and is tender to touch. Slough 20%, eschar 80% (dead tissue that develops in severe wounds), moderate serosanguinous (fluids discharge light pink, thin and watery) drainage with odor present with slight foul odor improved over past 2 days. Wound margins are macerated and softened, with wrinkled tissue due to moisture. No undermining or tunneling. Dressing/Treatment: Calcium Alginate Silver rope packing and superabsorbent dressing instead of border foam. Low air loss mattress added. R196 has agreed to try Juven; if res likes supplement will obtain physician's order to give her routinely for wound healing. A provider notification dated [DATE] by RN-A included coccyx wound continues to have some excess of moisture related to drainage; can we DC silicone border dressing and change cover dressing to superabsorbent dressing to better manage drainage/moisture until wound clinic appointment on 5/29? CNP-F responded [DATE] to discontinue silicone border use superabsorbent dressing as cover dressing to coccyx wound daily. A wound data collection dated [DATE] by RN-B included Coccyx wound with dressing present with drainage. There is increased drainage present and complaints of coccyx pain. RN-B answered yes to presence of possible complications, increasing area of ulceration or soft tissue infection increased, redness, swelling around the wound and increased drainage from the wound. A Wound and Hyperbaric Healing Center note dated [DATE] at 12:30 P.M., by NP-D included open PU to the sacrum that family states present for 2-3 weeks. Unstageable PU with cellulitis of surrounding tissue. Wound measured 6 cm length by 3.5 cm width x 1 cm of unstable etiology and located midline coccyx. Large amount of sanguineous (bright red fluid that oozes from wound mainly consisting of blood) drainage noted. Wound margins are distinct with the outline attached to the wound base. There is no granulation within the wound bed. There is a strong malodor associated with the ulcer. There is a large amount of purulent (drainage that is thick from infected wound) brown drainage noted with the cleansing. There is superficial blistering noted along the left lateral border of the ulcer. The ulcer is covered with 100% soft black eschar. Peri wound showing induration (thickening and hardening of tissue) with erythema (redness) and warmth to the tough. Discuss with FM-B that R196 does have acute cellulitis (infection) and unstageable sacral PU and will need at least hospitalization locally for stabilization and planning of further care. Discussed with family that this is a very serious ulcer and prognosis. R196's admission history and physical dated [DATE] by MD-G included admitted to the hospital directly from the wound care clinic for cellulitis and unstageable pressure sore of sacral area with black eschar, not treatable without extensive surgical debridement which the patient and family refuse. A progress note dated [DATE] by RN-A included R196 returned from the hospital PU is present upon readmission, and is unstageable, with improved erythema since hospitalization. Deterioration of wound is present as evidenced by copious amt of drainage with necrotic tissue covering wound bed. Larger dimensions since 5/23 assessment from this nurse. Hospitalization 5/29-[DATE] related to cellulitis requiring intravenous antibiotic therapy and hydration. On interview [DATE] at 2:07 p.m., RN-B stated the DTI for R196 developed at the facility. RN-B stated R196 was sitting a lot and had no interest in doing anything. RN-B stated initially when R196 arrived at the facility she could have repositioned herself but R196 was not eating or drinking much and once the wound appeared she deteriorated rather quickly until a lift was needed to transfer her. On interview [DATE] at 2:19 p.m., RN-A stated R196 was mobile when she was first admitted and could pivot transfer and walk a few steps and was working with physical therapy. RN-A indicated R196 liked to stay sitting in her chair and staff had a difficult time trying to get her to lay down in her bed. RN-A confirmed R196 did not have a wound on coccyx upon admission. RN-A stated interventions were started on [DATE] that included a nutritional supplement, repositioning program every 2-2.5 hours, wound care and treatments, air mattress ordered and Roho cushion to chair and wheelchair. RN-A stated a lot of the problem was lack of nutrition and pressure as R196 was not active. RN-A stated the first wound assessment was done [DATE] by an RN but red area was initially noted on [DATE] and was unsure when the wound was first reported to her or what the delay was for initial assessment. RN-A confirmed the next wound assessment wasn't completed until [DATE], 11 days later due to her absence. The wound was sacral/coccyx and when it opened it progressed up and outwards so became more sacral area. On interview [DATE] at 8:11 a.m., NP-D, wound specialist stated when she first saw R196 at the clinic, she had an infection and was sent to the hospital. NP-D stated unfortunately the wound was extensive and if further intervention had been started earlier, the severity of the wound could have been prevented. NP-D indicated she could not say if the wound was preventable or not but added the severity could have been prevented. On interview [DATE] at 8:54 a.m., RN-A stated I don't believe this was preventable and felt this was related to an end of life ulcer. RN-B stated she hadn't seen the wound from 5/23 until [DATE], so was not sure if signs of infection were present or not but stated the wound on [DATE] prior to going to the wound care clinic was very red. On interview [DATE] at 11:05 a.m., RN-C, also identified as MDS nurse, stated she completed the initial MDS assessment and toileting habits, nutrition, history of skin issues, activity level and diagnosis are taken into consideration when determining if resident is at risk for PU injury. The first Braden scale was completed by RN-D and R196 had a skin tear but her coccyx area was fine without redness. RN-C stated R196 was in therapy and was moving, getting up our of her chair. RN-C stated however R196's appetite wasn't good. RN-C stated initially R196 did not have risk factors for developing a pressure ulcer. On interview [DATE] at 10:56 a.m., LPN-A stated she was unsure if any preventative measures were put into place after discovery of the red area on the coccyx but if nothing was documented no further preventative care was completed at that time. LPN-A stated she does remember R196 was not repositioning herself at the time and was rarely moving. On interview [DATE] at 11:37 a.m., RN-A confirmed there were no interventions to prevent further skin breakdown between [DATE] when red area was discovered until [DATE] when she assessed the area and the wound was open. RN-A stated the facility does not do tissue tolerance tests but rather do a repositioning assessment. RN-A was not able to find a repositioning assessment completed on R196 throughout her stay at the facility. On interview [DATE] at 12:03 p.m., nursing assistant, (NA)-A stated he cared for R196 a lot and she rarely wanted to do anything including therapy. NA-A stated R196 started to give up, and refused to eat. NA-A stated they were repositioning R196 every 2 hours once the wound started. NA-A stated they had to start using the EZ-stand when around the time the wound started and by the time R196 went to the hospital she required use of a lift and 2 staff. On interview [DATE] at 1:14 p.m., MD-C indicated he does not believe he saw R196's pressure ulcer at the facility when he saw R196 at the [DATE] visit. MD-C stated he would expect staff to have preventative cares and treatments in place especially for someone with a recent stroke like R196. MD-C was not able to determine if PU was preventable and stated the first mention of a PU in her medical record at the clinic was [DATE]. On interview [DATE] at 1:23 p.m., MD-G indicated the wound and surrounding area was infected and wound was extensive when he first saw R196 on [DATE] at the Wound Care Clinic. MD-G stated it is difficult to say if wound was preventable, but as soon as evidence of stage I PU (redness) was identified interventions should have been put into place to prevent further damage. On interview [DATE] at 12:58 p.m., the director of nursing (DON) stated if a red area is noted on the skin would expect staff to put preventative measures in place upon discovery. The DON stated she would expect staff to completed measurements on an open wound every 3 days but at least every 7 days until healed. The DON stated she would like an RN to do them more often than weekly especially if the wound is worsening like R196's was. Facility Skin Assessment Pressure Ulcer Prevention and Documentation Requirements, dated [DATE] included: 1. All residents will be identified for their risk of developing pressure ulcers on admission/readmission by a RN using the Braden Scale. Those residents determined to be at risk will have a Braden Scale completed weekly for the first four weeks following admission. 2. The RN will completed a Braden Scale on all residents quarterly or when the resident has a change in condition that could affect his or her risk of developing an ulcer. Residents who are unable to reposition themselves independently, as indicated on the Sit-Stand-Walk Data Collection Tool should be repositioned as often as directed by the care plan approaches. Developing an individualized repositioning scheduled is required for those residents unable to position themselves and is based on nutrition, hydration, incontinence, diagnosis mobility and observation of the resident's skin over a period of time. The Positioning Assessment and Evaluation is a required tool that is used to determine an individualized repositioning plan. 3. Notify the physician/practitioner of the ulcer and resident's condition to obtain orders for treatment. Inquire whether physician/practitioner believes it is clinically necessary to see resident. 4. The pressure ulcer should be assessed/evaluated at least weekly and documented the Wound RN Assessment tool. Daily Wound Data Collection is completed daily for Medicare residents. 5. If the pressure ulcer is not determined to be clinically unavoidable, the ulcer should show signs of improvement within two to four weeks. Signs of improvement might include decrease in size of wound, decrease in amount of exudate and improvement in tissue type. 6. If the resident's ulcer is clinically avoidable, not showing signs of healing and the interdisciplinary team and/or the physician have made modifications to the treatments and interventions, consider a referral to a wound care specialist and discussion with the location's medical director.

**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 (R196) observed to have medications at bedside, had been appropriately assessed and deemed appropriate to self-administer medications. Findings Include: R196's facesheet printed on 6/26/2024, indicated diagnoses of malignant neoplasm of colon (colon cancer), polyneuropathy (nerve pain), and pain. R196's admission Minimum Data Set (MDS) assessment dated [DATE], indicated an admission date of 6/7/24, and no cognitive impairment. R196's care plan on 6/24/24, did not indicate R196's ability to self-administer medications. R196's physicians orders on 6/24/24 did not indicate R196 could self-administer medications. During an observation and interview on 6/24/24 at 1:15 p.m., R196 stated a nurse came to her room and told her that she could not have her diclofenac gel (generic topical pain gel) on her bathroom sink and put it away in her bathroom cupboard. R196 stated that she kept Voltaren (topical pain gel) and Tylenol in her room and used them for years prior to coming to the facility. One tube of diclofenac gel was found in her bathroom cupboard. Medications found in a drawer next to her bed included two bottles of Tylenol 650 milligrams (mg) tablets, one bottle of Systane eye drops, one tube of Voltaren gel, and one tube of Neosporin antibacterial ointment. During an interview on 6/24/24 at 7:13 p.m., registered nurse (RN)-A stated that she knew R196 had Tylenol in her room but did not know if she had an order for self-administration. RN-A stated if R196 had medications in her room there should be a self-administration assessment completed and an order for self-administration of medications. No assessment or order was found by RN-A. During an interview on 6/25/24 at 8:37 a.m., licensed practical nurse (LPN)-A stated that she was aware of the Voltaren gel in R196's room. In addition, LPN-A confirmed that there was Tylenol, Systane eye drops, Voltaren gel, and Neosporin ointment in R196's room. LPN-A verified there should be an order for self-administration of medications if medications are kept in a resident's room. LPN-A stated there was not a current order for self-administration of medications and removed the medications from R196's drawer and cupboard. During an interview on 6/25/24 at 9:43 a.m., the director of nursing (DON) stated that she would expect a self-medication administration assessment would have been completed prior to R196 having medications in her room and that R196 should have had an order for self-medication administration. DON verified that R196 did not have an assessment or order for self-medication administration. The facility Resident Self-Administration of Medication policy revised 10/30/2023, indicated the interdisciplinary team should determine that the resident can safely self-administer medications, and this must be documented. A physician's order must be obtained prior to the resident self-administering medications. The care plan must indicate which medications the resident is self-administering and where they are kept.

Based on observation and interview, the facility failed to ensure professional standards of practice were followed during administration of eyedrops for 2 of 3 residents (R197 and R7) observed for medication administration. Findings include: R197's facesheet printed on 6/26/24, indicated an admission date of 6/11/2024, and a primary diagnosis of pancreatitis (inflammation of the pancreas). R197's admission Minimum Data Set (MDS) assessment was not completed. R197's care plan printed on 6/26/24, did not indicate any care needs related to her eyes. R197's physician's order initiated on 6/14/24, indicated R197 was to receive Alphagen P ophthalmic solution eye drops, one drop in both eyes three times a day to reduce eye pressure. During observation on 6/25/24 at 8:45 a.m., R197 was sitting in a recliner in her room. Licensed practical nurse (LPN)-A informed R157 she had her eye drops. LPN-A placed the tip of the eye drop bottle at the inner corner of each eye to instill drops. LPN-A did not ask R197 to tilt her head back, nor did LPN-A attempt to place the drop in the pocket of the lower lid (conjunctival sac). R7's facesheet printed 6/26/24, indicated an admission date of 5/8/24, and a diagnosis of unspecified macular degeneration (an eye disease that causes vision loss). R7's admission MDS assessment was not completed. R7's care plan printed on 6/26/24, did not indicate any care needs related to his eyes. R7's physician's order initiated on 6/16/24, indicated R7 was to receive brinzolamide ophthalmic solution eye drops, one drop in both eyes two times a day for glaucoma. During observation on 6/26/24 at 8:05 a.m., R7 was seated in his wheelchair in the dining room. LPN-A assisted R7 to the side of the room and informed him she had his eye drops. LPN-a did not ask R7 to tilt his head back. LPN-A instilled the eye drop in the inner corner of each eye and did not attempt to place the drop in the pocket of the lower lid (conjunctival sac). During interview on 6/26/24 at 10:30 a.m., LPN-A verified that she instills eye drops in the inner corner of the eye. LPN-A further stated this is how she was taught and has not had any education from her employer on eye drop instillation. During interview on 6/26/24 at 8:44 a.m., director of nursing (DON) stated that she would expect nurses to gently pull down the lower lid and instill eye drops in the pocket formed in the center of the eye. DON would not train nurses to instill eye drops in the corner of the eye due to risk of infection or the eye drop not getting fully into the eye. DON stated she does not believe they have completed any training on eye drop instillation. The facility provided an untitled and undated document printed from Elsevier online training. This document educated on administration of eye drops and stated ask the patient to look at the ceiling.

**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 (R36) reviewed for immunizations were offered and/or provided the pneumococcal vaccine series as recommended by the Centers for Disease Control (CDC) to help reduce the risk of associated infection(s). Findings include: A CDC Pneumococcal Vaccine Timing for Adults feature dated 3/15/2023, identified various tables when each (or all) of the pneumococcal vaccinations should be obtained. This identified when an adult over [AGE] years old had received the complete series (i.e., PPSV23 and PCV13; see below) then the patient and provider may choose to administer Pneumococcal 20-valent Conjugate Vaccine (PCV20) for patients who had received Pneumococcal 13-valent Conjugate Vaccine (PCV13) at any age and Pneumococcal Polysaccharide Vaccine 23 (PPSV23) at or after [AGE] years old. R36's face sheet dated 6/26/24, indicated she was [AGE] years old. The immunization record, dated 6/26/24, indicated she received a PPSV23 on 10/15/2008 followed by the PCV13 on 10/2/2014. The record lacked evidence of shared clinical decision making with the physician for PCV20 at least 5 years after the last pneumococcal dose. The record lacked evidence that R36 was offered or received PCV20. During interview with infection preventionist (IP), on 6/25/2024 at 11:18 a.m., the IP indicated immunizations are reviewed upon admission to determine if resident is eligible for any immunizations. If resident is eligible for an immunization, it is reviewed with the resident and/or representative upon admission to see if they were interested in receiving immunization. IP verified R36's pneumococcal immunizations as listed above and stated that she was unable to find any documentation stating that resident was offered and declined the PCV20. IP verified there had been no shared clinical decision making with the provider regarding pneumococcal immunizations for R36. IP stated it was important to ensure residents are offered all available vaccinations to prevent the risk of developing symptoms to lead to acute illness. During interview on 6/25/24 at 1:55 p.m., R36 stated that she does not recall any facility staff discussing available immunizations when admitted . R36 stated she would be interested in receiving the PCV20 as she usually receives all recommended vaccines that are available. During interview on 6/26/24 at 8:27 a.m., director of nursing (DON) stated IP reviewed immunizations upon admission and eligible immunizations are offered to resident and then we either administer immunization or have resident sign a declination page. DON confirmed that documentation was lacking on if R36 was offered the PCV20. DON stated it was important for residents to know what immunizations are available to them as it is there right and would help prevent illness. The facility Immunizations/Vaccinations for Residents, Pneumococcal policy dated 9/21/23 indicated the facility to provide residents and clients the opportunity to receive immunizations as they fit into their healthcare goals. The facility would provide guidance for the location's immunization program including recommended vaccinations. a) Upon admission, each client, resident and/or resident representative will receive the Vaccination Information Statements (VIS) for influenza and pneumococcal vaccines and the VIS or Face Sheet for Recipients and Caregivers for the COVID-19 vaccine. b) If the client, resident and/or the resident representative consent to vaccination, obtain written consent if required by state regulation. If written consent is not required, obtain and document verbal consent. c) If the resident and/or resident representative chooses not to be vaccinated after discussion of benefits, document declination.

Based on observation, interview, and policy review, that facility failed to ensure beverageware and metal pans were completely dry before storing to prevent bacterial growth. This had potential to affect all 47 residents who resided in the facility. Findings include: During an observation and interview on 6/24/24 at 11:37 a.m., with cook (C)-A observed multiple metal steam table pans stacked upside down, one on top of the other, on a wire shelving rack. When C-A removed the top pan, it had visible water on the inside surface. C-A acknowledged staff should not have put pans away while still wet as that could promote bacterial growth. During an observation and interview on 6/26/24 at 9:35 a.m., with C-B on a plastic cart with wheels were multiple drinking cups stacked upside down on a solid plastic tray waiting to be taken to the dining room for storage. Condensation was visible in the clear tumblers. C-B lifted three tumblers and showed condensation inside the tumblers and water pooling and creating water rings on the tray. C-B acknowledged staff should have let the tumblers dry completely before stacking them to be stored. C-B was asked to lift a stacked metal steam table pan which was upside down on top of other steam table pans on a shelving unit. C-B verified the pan had moisture in it and should have been completely dry before being stacked for storage to prevent bacterial growth. The facility Warewashing-Mechanical and Manual-Food and Nutrition policy revised 3/25/24, indicated that dishes are to air-dry before storage or use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure infection control measures were implemented in a dignified manner for 1 of 1 resident (R25) who was reviewed for contact isolation precautions related to recent hospitalization for urinary tract infection. Findings include: Centers for Disease Control (CDC) guidance dated 2/2/2022, includes: Empiric use of Transmission-Based Precautions (quarantine) is recommended for residents who are newly admitted to the facility and for residents who have had close contact with someone with Covid-19 infection if they are not up to date with all recommended COVID-19 vaccine doses. In general, quarantine is not needed for asymptomatic residents who are up to date with all COVID-19 vaccine doses or who have recovered from Covid-19 infection in the prior 90 days; potential exceptions are described in the guidance. However, some of these residents should still be tested as described in the testing section of the guidance. R25 undated face sheet indicated initial admission date of 2/28/22, with diagnosis including infectious gastroenteritis (infection of intestines) and colitis (inflammation of of the inner lining of the colon), Clostridium difficile (infection of large intestine caused by antibiotic use) , myasthenia gravis (autoimmune disease affecting communication between nerves and muscles), and urinary tract infection. R25's Immunization Report indicated R25 received COVID-19 vaccine on 2/25/2, 3/25/21 and 11/5/21. R25's Medicare 5 day Minimum Data Set (MDS) assessment dated [DATE], indicated R25 was cognitively intact with no behaviors, required limited assist of one for transfers and toileting and was frequently incontinent of urine. A progress note dated 3/31/22, indicated R25 had blood in her urine, flushed and diaphoretic and was transferred to the emergency department for further evaluation. A progress note dated 4/5/2022, at 2:25 p.m., indicated R25 returned from the hospital and was alert and oriented. During interview and observation on 4/11/22, at 3:09 p.m., R25 was sitting in her wheelchair in her room. An isolation cart was outside of her room with a sign on her door indicating contact isolation. Nursing Assistant (NA)-A gowned and gloved and entered R25's room. R25 using a raised voice stated I don't belong in isolation and I have rights. NA-A indicated she would talk to the nurse. During interview on 4/11/22, at 3:17 p.m., R25 indicated she has been in and out of the hospital over the past month with frequent urinary tract infections (UTI). Every time she is hospitalized she has to stay in her room and they quarantine her for a week, which is a rights violation. R25 indicated she is fully vaccinated and boosted and there is no reason she has to be in her room or have a sign on her door. R25 further added next time she will just refuse to go to the hospital. During interview and observation on 4/11/22, at 5:20 p.m., R25 was in the hallway in her wheelchair with a mask on the back of her wheelchair. R25 stated she was told she is all clear now and can be out and about the facility. R25 was smiling and joking with others around her. Cart remained outside of her door, but clean gowns bin was gone along with dirty laundry hamper. During interview on 4/11/22, at 7:17 p.m., registered nurse (RN)-A indicated R25 was on day seven of quarantine, was tested around 5:00 p.m. and was negative so is no longer in quarantine. RN-A indicated anyone out of the building for 24 hours or more at the hospital are quarantined for 7 days and are tested on admission and day 7 prior to releasing them from quarantine. During observation on 4/12/22, at 12:36 p.m., R25 was in the lobby waiting for the bus to take her to her infectious disease appointment and was smiling and talkative. During interview on 4/13/22, at 8:17 a.m., R25 indicated her appointment went very well yesterday. R25 indicated every time she goes to the hospital she has been quarantined to her room on return and complains to staff every time about it but the facility doesn't do anything about it except tell me the Centers for Disease Control (CDC) makes the rules and they have to follow it. R25 added being vaccinated and having had Covid-19 recently, she should not have to stay in her room. R25 stated it makes her feel like a three year old and other residents in quarantine indicated the same thing. R25 had to eat in her room, wasn't allowed to participate in anything like exercise classes, and was not allowed to go to the chapel. R25 stated she felt like a second class citizen. During interview on 4/13/22, at 10:09 a.m., RN-B indicated any new admission or resident who comes from the hospital are automatically quarantined for 7 days regardless of vaccination status. During interview on 4/13/22, at 11:14 a.m., with RN-C and interim director of nursing (DON) indicated an e-mail was received from the parent company which indicated new admission or residents that are hospitalized for 24 hours or greater are placed in quarantine and tested 7 days later. E-mail indicated it did not matter if the resident was vaccinated or not. The interim DON indicated she confirmed this information on the Centers for Medicare and Medicaid Services (CMS) website. During interview on 4/13/22, at 12:52 p.m., the interim DON indicated upon further review of the e-mail received, it included the CDC recommendations from 2/2/22, which did not include fully vaccinated residents. The interim DON confirmed if residents are up to date on vaccines, they do not need to quarantine upon readmission to the facility and the practice will no longer be used. Requested policy on resident rights and received Combined Federal and state [NAME] of Rights, dated 2/1/17, included: - The resident has a right to a dignified existence, self-determination, and communication and access to persons and services inside and outside of the facility. -A facility must 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 or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure wishes and directives for emergency treatment (i.e., cardio-pulmonary resuscitation (CPR), was obtained upon admission, to ensure appropriate care would be provided if found without pulse or breathing; as well as facility failed to ensure provider orders for life-sustaining treatment (POLST) was signed by physician in the medical record for 2 of 34 residents (R9, R15) reviewed for advanced directives. Findings include: R9 R9's significant change in status Minimum Data Set (MDS) assessment dated [DATE], identified R9 had severely impaired cognition. R9's face sheet, printed on [DATE], identified diagnoses of generalized idiopathic epilepsy (a seizure disorder condition), difficulty in walking, history of falling, convulsions (a condition that caused uncontrollable muscle contractions), tuberculosis (serious infectious bacterial disease) of lung, and late syphilitic meningitis (a bacterial infection affecting the brain and spinal cord). R9's face sheet, identified no code status in advance directive. R9 was admitted to facility on 1/2022, was identified to not have a health care directive or POLST form in place upon medical record review on [DATE]. During an interview, on [DATE] at 2:57 p.m., family member (FM)-G indicated he could not recall whether or not there was a health care directive in place or if signed a POLST form when R9 was admitted to facility. FM-G indicated he thought R9 had a health care directive form completed at one time. During interview, on [DATE] at 8:43 a.m., licensed practical nurse (LPN)-A was unable to locate R9's code status in resident advance directive binder located at nursing station. LPN-A reviewed R9's electronic medical record (EMR); and was unable to locate R9's code status, health care directive, and POLST form. LPN-A indicated being unaware R9's code status. LPN-A indicated the process of code status completion for residents was at time of admission; resident and/or power of attorney (POA) would provide a completed copy of advance directive and/or POLST form, or if unavailable, licensed nursing staff would assist resident and/or POA in completing questions on POLST form; licensed nursing staff, resident and/or POA would sign and date form, obtain provider's signature and date for order; POLST form placed in resident advance directive binder, signed physician order for code status entered into EMR system. LPN-A indicated if a resident's code status was unknown, CPR would be performed. LPN-A indicated nurses complete facility form titled, New admission Checklist, for all residents at time of admission. LPN-A indicated facility's New admission Checklist form has a section titled, Advance Directives; all nurses were to check off when completed. When interviewed, on [DATE] at 8:51 a.m., interim director of nursing (DON) indicated being unaware R9's code status was not in place. Interim DON reviewed resident advance directive book at nursing station and EMR; unable to locate R9's code status. Interim DON indicated for any resident with unknown code status, CPR would be performed. Interim DON verified R9's code status was not completed at time of admission on 1/2022. Interim DON indicated expectation would be for all residents' code status's to be completed at time of admission with licensed nursing staff, reviewed and updated if needed during interdisciplinary team (IDT) meetings, quarterly reviews, and as needed. Interim DON further indicated acceptable documentation included POLST or advance directive forms. Interim DON indicated once advance directives or POLST forms are completed, the expectation would be for licensed nursing staff to update information in advance directive binder at nursing station and EMR. Interim DON indicated all residents' advance directives or POLST forms would be updated by social services (SS)-A going forward. During interview with interim DON, and LPN-A on [DATE] at 9:24 a.m., LPN-A indicated was able to find a code status of CPR for R9, after reviewing a physician visit note in EMR. R15 R15's significant change in condition assessment dated [DATE], identified R15 had intact cognition. R15's face sheet, printed on [DATE], identified diagnoses of malignant neoplasm of stomach (stomach cancer), Type 2 Diabetes Mellitus (a condition that caused high blood sugar), chronic obstructive pulmonary disease (a chronic lung disease, causing difficulty breathing), a malignant neoplasm of pyloric [NAME] (cancer of lower end of stomach), and ascites (swelling and fluid build-up in abdomen). R15's face sheet, identified an advance directive of limited resuscitation (no chest compressions). R15's POLST, dated [DATE], identified Do not attempt resuscitation/DNR (Allow Natural Death), if no pulse and not breathing. The POLST, dated [DATE], was signed by FM-I and nursing on [DATE], but not signed by the physician. R15's order summary report, printed on [DATE], identified code status as limited resuscitation (no chest compressions). During an interview, on [DATE] at 10:42 a.m., R15 indicated having an advance directive in place, thought this was signed by FM-I When interviewed, on [DATE] at 8:38 a.m., LPN-A indicated R15's code status was noted in EMR, POLST form, and advance directive binder at nursing station; code status identified DNR. LPN-A indicated upon review of R15's POLST, signatures were obtained by FM-I and RN-D on [DATE], and was not signed by the physician. LPN-A indicated POLST form should have been signed by physician. LPN-A verified POLST form not a valid order without physician signature. During an interview, on [DATE] at 8:51 a.m., interim DON indicated staff look in EMR and advance directive binder at nursing station for resident's code status. Interim DON indicated being aware of discrepancy with R15's POLST form not signed by physician, as nursing brought discrepancy with POLST to her prior to surveyor interview. Upon review of R15's POLST, interim DON indicated it is her expectation nursing staff ensure all residents have an advance directive and/or POLST appropriately documented in their medical record. Interim DON indicated all residents' advance directives and/or POLST should be signed by all parties; residents or health care agent, nursing staff, and physician to make it a legal document. The facility policy titled Advance Directive including Cardiopulmonary Resuscitation (CPR) and Automated External Defibrillator (AED), reviewed/revised on [DATE], included: CPR will be initiated unless a valid DNR order is in place, At the time of admission or re-admission, social services or designated staff member asks the resident/healthcare decision-maker whether the resident has prepared an advance directive such as a living will, durable power-of-attorney for healthcare decisions, guardianship, portable and enduring order form, etc. The designated staff member will meet with the resident/healthcare decision-maker to answer questions and determine if the resident/healthcare decision-maker wish to develop or amend advance directives. As necessary, physicians will be contacted for orders that reflect the resident's wishes. Completed portable and enduring order forms (POLST) will be treated as physician's orders and placed in the medical record.

Based on observation, interview and document review the facility failed to ensure activities of daily living (ADLs) were provided, including shaving and nail care for 1 of 2 residents (R12) reviewed, who needed staff assistance for supervision to maintain good personal hygiene. Findings include: R12's quarterly Minimum Data Set (MDS) assessment, dated 2/17/22, indicated R12 had moderate cognitive impairment and required supervision from staff for personal hygiene. R12's care plan was revised and printed on 4/13/22; indicated R12 prefers to be clean shaven, except for mustache; staff to assist daily. R12's care plan did not identify nail care needs. During an observation, on 4/11/22 at 4:31 p.m., R12 was observed to have facial hair stubble (short beard growth), mustache, and debris under long jagged fingernails. Family member (FM)-H presented to room at time of observation and was interviewed. FM-H indicated resident liked his mustache, and wanted to be clean shaven every morning to remove facial stubble. FM-H indicated R12 was always noted to have facial stubble when visiting, FM-H started to shave R12 during visits, a couple times per week. FM-H indicated staff were aware of daily shaving preferences, as FM-H mentioned to staff on previous occasions. FM-H indicated staff should be assisting R12 with nail care, as unable to complete independently, as blind in left eye. On 4/13/22 at 7:39 a.m., R12 was again observed to have longer facial stubble compared to observation on 4/11/22. R12's nails continued to have debris under long, jagged fingernails. During an interview, on 4/13/22 at 9:30 a.m., with licensed practical nurse (LPN)-A and interim director of nursing (DON), both indicated expectation for providing shaving and nail care, was completed by resident preference and as care planned. LPN-A indicated aides bathed R12 once per week, and would check and complete nail care on bath days. LPN-A indicated it was her expectation aides notify licensed nursing staff for any nail care that needed to be completed for diabetics, or concerns with shaving or nail cares. LPN-A indicated staff should document if a resident refused any care. Interim DON indicated it is her expectation residents' nails are trimmed by aides on bath days or by licensed nursing staff if diabetic, all staff should be checking resident's nails weekly. Interim DON observed and verified R12 had facial stubble, fingernails were long and jagged with debris; and indicated unacceptable ADL care, and would inform staff to ensure R12 was clean shaven and nail care was completed. When interviewed, on 4/13/22 at 11:54 a.m., LPN-A indicated R12 was diabetic, and needed licensed nursing staff to assist with nail care. LPN-A indicated R12 was able to shave independently after set-up, and would sometimes refuse to complete independently, staff then assisted. LPN-A indicated R12 had informed her on a previous occasion of liking to keep nails longer, liked to use longer nails as a tool. LPN-A indicated she would ensure R12 was shaven and nail care was completed today. R12 was observed on 4/13/22 at 12:05 p.m. to be clean shaven, nails were clean and trimmed. During an interview, on 4/13/22 at 12:07 p.m., nursing assistant (NA)-B indicated being aware of R12's ADL needs; to be shaven daily per R12's preference. NA-B indicated nail care was completed once weekly on resident bath days, R12 was diabetic and nail care was to be completed by licensed nursing staff. NA-B indicated R12 used to be more independent with shaving, became weak 2 months ago due to infection and sores on feet; and required more staff assistance with ADL care, including shaving. When interviewed, on 4/14/22 at 8:29 a.m., registered nurse (RN)-C indicated being aware of R12's ADL needs. RN-C indicated R12 had increased generalized weakness over past two weeks due to foot problems, required more staff assistance; including shaving daily. RN-C indicated NA's were responsible for assisting with daily shaving, NAs to inform licensed nursing staff to provide nail care due to R12's diabetic history. Policy titled Activities of Daily Living, revised on 1/25/22, indicated: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. ADLs are those necessary tasks conducted in the normal course of a resident's daily life. Included in these are the following: General Personal, Daily Hygiene/Grooming: Care of hair, hands, face, shaving, applying makeup, skin, nails, 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 services were coordinated with the hospice agency for 1 of 1 resident (R17) reviewed who received hospice services. Findings include: R17's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated R17 was totally dependent on staff for locomotion on/off the unit, and required extensive staff assistance with all other activities of daily living. The MDS further indicated a diagnosis of dementia with Lewy bodies; had a condition of life expectancy of less than 6 months, and was receiving hospice services. R17's facility care plan, revised 3/18/22, did not include evidence the resident was receiving hospice services or what those services would provide. Further review of R17's medical record did not include a care plan from the hospice agency or progress notes from visits made (services provided) by the hospice staff. R17's (local hospice agency) Home Home Care Service Plan, dated 2/11/22 (start of care) indicated a registered nurse (RN) would provide services 1-2 times times a week (1-2 x/wk) and as needed (prn); the home health aide (HHA) 1-5 x/wk and prn; the social worker 1-2 x/month and prn; and the chaplain 1-2 x/month and prn. The Home Care Service Plan did not include what services would be provided by each of the hospice staff. Review of the facility's hospice binder, located at the nurses station, included a February 2022 calendar indicating when the RN and HHA would be coming to visit R17. The binder did not include a visit schedule for March 2022 or April 2022. On 4/12/22, at 1:33 p.m. R17 was observed seated in recliner in room with feet elevated and blanket over lap. R17's eyes were closed and the resident appeared to be sleeping; call light was within reach and clipped to the arm of the recliner. There was no evidence of a hospice schedule or hospice book observed in R17's room. When interviewed on 4/12/22, at 2:28 p.m. registered nurse (RN)-C confirmed R17 received services from local Hospice. RN-C stated staff really didn't know when the hospice HHA was coming to the facility, She just comes when she'd able. RN-C further stated the hospice RN usually came to the facility twice a week on Mondays and Thursdays and would call the facility and let staff know if the day/time was going to change. RN-C reviewed the local Hospice binder and confirmed there was no evidence of a hospice care plan or a current schedule for R17. RN-C stated the hospice care plan was probably scanned into R17's electronic medical record. When interviewed on 4/14/22, at 9:34 a.m. case manager RN-D stated the hospice nurses let the staff know verbally when they would be coming to the facility. RN-D further indicated the hospice RN came one a week and more often by request and was unsure how often the HHA came to the facility. RN-D reviewed R17's electronic medical record and confirmed it did not include a hospice care plan. When interviewed on 4/14/22, at 12:30 p.m. licensed practical nurse (LPN)-B stated she didn't work at the facility often so usually wasn't present when hospice staff arrived. LPN-B stated there should be a schedule staff could refer too indicating when hospice staff were coming to the facility. When interviewed on 4/14/22, at 12:45 p.m. hospice RN-G stated she usually came to the facility on Tuesdays and Fridays but if she had a Friday off would come on Tuesday and Thursday instead. When asked if hospice usually provided a hospice care plan, RN-G stated it should be in the local hospice binder at the nurses station. Surveyor informed RN-G the facility did not have a hospice care plan for R17. RN-G stated RN-D had requested a hospice schedule be sent to the facility earlier that day; RN-G confirmed she would send the care plan at that time as well. RN-G confirmed a HHA also provided services at the facility two days a week and her schedule would be included on the calendar RN-G was sending to the facility. When interviewed on 4/14/22, at 1:40 p.m. interim director of nursing (DON) confirmed staff should be aware of the hospice staff's schedule and residents receiving hospice services should have a hospice care plan in order to coordinate care. Interim DON reviewed R17's facility care plan and confirmed the care plan did not identify the resident received hospice services and what that entailed. The Hospice and Nursing Facility Service Agreement with . (local hospice) @Home hospice signed 7/3/20, indicated: 1.8 Joint Plan of Care or JPOC means a coordinated joint plan of care for an individual Patient for the palliation or management of the Patient's terminal illness and related conditions that (a) clearly delineates the services to be provided by Hospice and Facility; (b) is consistent with Hospices's philosophy; (c) is based on an assessment of the Patient's current medical, physical, psychological and social needs and unique living situation; (d) reflects the participation of Hospice, Facility, the Patient and the Patient's family, as appropriate; and (e) complies with applicable federal and state laws and regulations. A facility policy on hospice services was requested and not received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to assess, monitor and implement pressure relieving interventions for 1 of 1 resident (R32) reviewed who was at risk for pressure ulcer (PU) development, resulting in R32 acquiring a stage two pressure ulcer to coccyx (area at the base of the spinal column). Findings include: R32's facesheet printed on 4/14/22, indicated an admission date of 7/2021, and included diagnoses of stroke and mild cognitive impairment. R32's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R32 was cognitively intact; had clear speech, was usually understood and could usually understand. R32 required extensive assistance of one staff for bed mobility, transfers, toileting, and moving about the facility in a wheelchair. R32 was frequently incontinent of bladder and always continent of bowel. R32 was not at risk for PU's and had no PU's. Following the identification of a PU, R32's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated R32's brief interview for mental status (BIMS) could not be completed as R32 was rarely or never understood. Furthermore, the MDS indicated R32 had unclear speech, was only sometimes understood and could sometimes understand simple, direct communication. R32 was frequently incontinent of bowel and bladder, required extensive assistance of one or two staff for bed mobility, transfers, toileting, and moving about the facility in a wheelchair. The MDS indicated R32 was at risk for development of PU's and had two, stage 2 PU's, not present upon admission. R32's care area assessment (CAA) dated 3/24/22, indicated an increased risk for PU development evidenced by presence of pressure areas, skin breakdown on coccyx, with need for increased assist with bed mobility, frequent bladder/bowel incontinence, and gradual weight loss. Furthermore, the CAA indicated R32 had two pressure areas; a stage 2 open area to coccyx measuring 0.7 cm (centimeters) x 0.9 cm and a blister to right buttocks measuring 1.5 cm x 1.9 cm. The CAA indicated R32 had a memory foam mattress; pressure reducing cushion in wheelchair and recently a turn/reposition every two hours was added to her care plan. Staff managed incontinence and assisted with repositioning due to altered mental status. Skin was monitored daily with cares and areas of concern reported to nurse for further observations and interventions prn (as needed). R32's plan of care was revised on 3/30/22, to add a focus area of PU. The plan of care indicated PU development related to immobility and incontinence of bowel and bladder; that R32 would have intact skin, free of redness, blisters or discoloration. Reposition every two hours; notify the nurse immediately of any new areas of skin breakdown. A skin check dated 3/19/22, indicated R32 had no observed skin conditions. R32's progress note dated 3/21/22, at 6:39 a.m., indicated an open area to coccyx; a stage 2 open area measuring 0.7 cm X 0.9 cm and a stage 1 blister to right buttock measuring 1.5 cm X 1.0 cm. Areas were cleansed and border dressing (all-in-one dressing used to create an optimal healing environment) was applied. R32 was positioned onto her side to take pressure off buttocks/coccyx and would be repositioned every two hours and/or as needed. Wounds would be monitored every three days till healed. Hand-written provider orders for R32 dated 3/23/22, indicated to apply hydrocolloid dressing (a dressing which protects wounds) to pressure ulcer on coccyx and change every three to five days or when soiled. Provider orders in the electronic medical record (EMR) dated 3/31/22, indicated: Wound Care: Sacrum and Coccyx: wound cleanser, pat dry, cavilon skin prep (protects skin from body fluids) over wound, fan dry, cover with foam border dressing, change every three days or sooner if becomes soiled. A skin check dated 3/26/22, indicated R32 had a stage 2 open wound to coccyx and another on right medial buttocks, both with minimal serous (a thin, clear fluid) drainage, covered with border dressing. A skin check dated 4/10/22, indicated R32 had an open wound, stage 2, measuring 0.7 cm X 0.5 cm to coccyx. During an observation on 4/12/22, at 2:07 p.m., R32 was laying in bed, supine with eyes closed and oxygen on via nasal cannula. Observed cushioned seat in wheelchair. During an observation and interview on 04/13/22 at 7:42 a.m., nursing assistant (NA)-E verified R32 had sores on her bottom, and they where healing. When asked how R32 may have gotten the sores, NA-E stated maybe from sitting, stating she liked to keep R32 in her wheelchair so she could stay awake, then put her in bed after lunch. When asked if R32 was repositioned periodically to relieve pressure on her bottom, NA-E stated the night shift did that. At 8:07 a.m., NA-E moved R32 from the toilet with the EZ stand (battery powered device used to facilitate transfers) to wheelchair, and took her to the dining room for breakfast. During an observation on 4/13/22, at 9:11 a.m., R32 was returned to her room by an unidentified activity aide, who read religious material to R32 while she sat in her wheelchair. During an observation and interview on 4/13/22, at 9:45 a.m., according to family member (FM)-D, she visited R32 every day. FM-D was aware of recently acquired PU's, adding that the director of nursing (DON) had came in and checked to make sure the mattress was okay and that there was a cushion in R32's chair. FM-D stated when she was there visiting, staff did not reposition R32, adding, I told my daughter, I wonder if they're repositioning her .I told her when I come to visit, R32 is always on her back. During an observation and interview on 4/13/22, at 10:22 a.m., R32 was in her wheelchair in her room. FM-D stated R32 had not been repositioned or toileted since she arrived about 9:15 a.m. During an observation and interview on 4/14/22, at 9:34 a.m., with registered nurse (RN)-F, R32's skin was observed while R32 was standing at the toilet with the aid of an EZ stand. RN-F pulled down R32's slacks, underwear and brief. R32's skin was very damp, with beads of perspiration noted on buttocks. RN-F stated, It's always like that, that's how it is. Observed the PU in the upper gluteal cleft (butt crack) which was very small, approximately 0.5 cm in length with dark material over top. RN-F stated NA's were supposed to reposition R32 every couple of hours. When asked if she knew for certain if NA's did reposition R32, RN-F stated they did most of the time, depending upon what was going on. During an interview on 4/14/22, 9:50 a.m., the interim DON stated she was informed of R32's PU on the same day it was noted in R32's record, which was on 3/21/22. The interim DON read out loud the initial nursing progress note describing the discovery of the PU, including the measurements. The interim DON stated she immediately discussed the PU with the nurses, including the plan of care and how to document the wounds. The interim DON stated she did immediate re-education for the nurses, and added pressure ulcers to the QAPI (quality assurance and performance improvement) plan. During the same interview, the interim DON stated she assumed staff had been repositioning or off-loading (remove pressure from an area for at least one minute) R32 every two hours. When asked if R32 had been on a repositioning schedule prior to the identification of the PU, the interim DON stated, It's standard of practice. The interim DON was then asked to review R32's PU CAA dated 3/24/22. The interim DON confirmed that turning and repositioning was added to the CAA on that date, after the identification of R32's PU. The interim DON was asked if R32's care plan prior to the identification of pressure ulcers, included repositioning, the interim DON stated it should have. When informed repositioning was added to R32's care plan on 3/30/22, after the identification of a pressure ulcer, the interim DON stated, If that's what it says -- I have to go with that. The interim DON stated every resident should be repositioned based on BIMS and comorbidity, otherwise would be at risk for developing a pressure ulcer, and acknowledged R32 had been at risk for developing a pressure ulcer. Facility policy titled Pressure Ulcers, dated 2/8/22, indicated the purpose was to provide appropriate assessment and prevention of ulcers. Based upon a resident's comprehensive assessment, the facility would use prevention and assessment interventions to ensure that a resident entering the facility without pressure ulcers did not develop a pressure ulcer unless the individual's clinical condition demonstrated it was unavoidable.

Based on observation, interview and document review the facility failed to ensure doses of controlled substances were stored in a manner to reduce the risk of theft and/or diversion in 1 of 1 refrigerator observed in use for medication storage. This had potential to affect 1 of 1 resident (R8) who received this medication. Findings include: R8's physician orders printed 4/14/22, included: lorazepam (anitaniety) concentrate 2 milligrams(mg)/milliliter(ml). Give 0.5 ml by mouth every four hours as needed for anxiety, agitation or nervousness related to claustrophobia. On 4/14/22, at 1:56 p.m. the medication room the medication room refrigerator was observed with the interim director of nursing (DON) and the newly hired director of nursing (DON)-E. After unlocking the door to the refrigerator, interim DON and DON-E observed a bottle of lorazepam 2 mg/ml liquid (prescribed to R8) that was on the shelf on the inside door of the refrigerator. The lorazepam was not in a separate compartment or affixed to the inside of the refrigerator in order to prevent theft. Interim DON confirmed the lorazepam should be locked separately in the refrigerator in an affixed container. Facility policy titled Medications: Acquisition Receiving Dispensing and Storage dated 2/8/22, indicated: 10. Controlled drugs (Schedule II) and other drugs subject to possible abuse will be stored in a separate, locked, permanently fixed compartments except when a single unit package drug distribution is used. If the medication requires a refrigerator, these need to be locked in a separate container. These drugs will be reconciled at least daily through an appropriate system of records of receipt and disposition established by the licensed

Based on interview and record review, the facility failed to ensure food was served at the proper temperature for palatability for 2 of 2 residents (R11, R19) who complained food (meatballs) were not warm to taste. Furthermore, at the state-facilitated resident council meeting, 3 of 11 residents (R4, R3 and R19) remarked about being served cold food. Findings include: R19's brief assessment for mental status (BIMS), dated 2/12/22, identified resident was cognitively intact. During an interview on 4/11/22, at 2:38 p.m., R19 stated the food wasn't good since they got some new cooks. R19 stated they were recently served Swedish meatballs and some were cold and some were lukewarm, adding They just heated up the sauce and poured it over the meatballs. And my mashed potatoes were lukewarm too. R19 stated he had been telling the higher-ups about this .I'm calling them out on it; I'm not happy about it. R19 stated he had told registered nurse (RN)-D about the cold meatballs. R11's BIMS dated 2/17/22, identified resident was cognitively intact. During an interview on 4/11/22, at 2:57 p.m., R11 stated that lately the food had been terrible. R11 stated they were recently served Swedish meatballs and they were either frozen or not cooked, Everything was ice cold that day. R11 stated there was a new male cook; she didn't know his name, but that he was not good. R11 stated she had expressed her concerns to social worker (SW)-A, who said she would check into it. R11 stated she had also talked to the dietary manager (DM)-A who said she'd check into it - but no one had gotten back to her. R11 stated food was talked about at resident council meetings, but it fell on deaf ears. During review of 2/9/22, resident council meeting minutes, an unidentified resident commented food was often cold. During review of 4/6/22, resident council meeting minutes, multiple food complaints were identified, including minutes that read: What's the possibility of the cooks serving warm food? The other night the meatballs where cold/still frozen with hot gravy poured on top. During an interview on 4/14/22, at 8:53 a.m., RN-D was asked if any residents had reported to her about cold food and she stated yes, then removed a small, handwritten note from her desk. RN-D stated R19 had come to her last week about meatballs that were cold and the gravy was hot, and also mentioned a day when the roast beef was cold. RN-D wrote this down and was going to give the note to DM-A but had not done so yet. During the State-facilitated resident council meeting on 4/13/22, at 10:00 a.m., the 11 residents in attendance were asked about the temperature of food served to them. R4, who was cognitively intact per 1/13/22, BIMS, stated, The food comes cold, not as warm as you'd like. R3 who was cognitively intact per 1/13/22, BIMS, stated you can send it back and they'll warm it up. R19 talked about receiving frozen Swedish meatballs recently. During review of menu's, it was noted that Swedish meatballs were served for the evening meal on 3/29/22, along with mashed potatoes, gravy and mixed vegetables. According to the Food Temperature Record for that meal, the meat was temped at 171 degrees F (Fahrenheit), but no food temperatures were documented for the mashed potatoes, gravy and vegetables. In addition, there were no initials on the record to indicate which cook temped this meal. Additional food temperature records indicated lack of documentation of food temperatures: 3/28/22: No breakfast temperatures were recorded. Menu included Malt O Meal, french toast and sausage links. 3/29/22: No temperatures were recorded for the noon meal. This included chicken and wild rice casserole and broccoli. 3/29/22: For the evening meal, the menu included Swedish meatballs, mashed potatoes, gravy and mixed vegetable. Only the meat temperature was recorded. Residents complained about Swedish meatballs that were served cold or frozen. 4/2/22: No breakfast temperatures were recorded. The menu included cream of wheat, sausage gravy over a biscuit. 4/3/22: No noon meal temperatures were recorded. The menu included mushroom chopped steak, au gratin potatoes and carrots. 4/3/22: No evening meal temperatures were recorded. The menu included BBQ chicken, macaroni salad and beets. 4/5/22: No noon meal temperatures were recorded. The menu included honey mustard chicken, baked potato and asparagus. 4/6/22: No breakfast temperatures were recorded. The menu included Malt O Meal, sausage patty and french toast. 4/7/22: No evening meal temperatures were recorded. The menu included hamburger on a bun, baked beans, carrot raisin salad and fruit cup. 4/9/22: No breakfast temperatures were recorded. The menu included Malt O Meal, fried egg and sausage patty. 4/9/22: No noon meal temperatures were recorded. The menu included roast pork loin, parsley potatoes and braised red cabbage. During an interview on 4/14/22, at 11:20 a.m., with the administrator and DM-A, DM-A was asked if she was aware of resident complaints regarding cold Swedish meatballs. DM-A stated yes, she was made aware of that and had spoken to the cook about it, who told her he should have put the frozen meatballs (pre-cooked) into the oven sooner and had not realized they were cold when served to the residents. When asked if the cook verified the temperature of the meatballs prior to serving them to residents, DM-A stated the cook told her he had. When asked what the risk would be of having food temperatures not measured or not measured accurately, DM-A stated the food would be cold and residents would complain. The administrator stated it would be a palatability concerns for residents. Both DM-A and the administrator acknowledged that food served cold which was supposed to be served hot, could result in foodborne illness to residents. During the same interview, when asked about oversight over cooks and holding them accountable for measuring the temperature of food before serving it to residents, DM-A stated she was responsible for this, but admitted she did not observe cooks when they prepared and served food, which included measuring food temperatures. In addition, DM-A stated she did not review food temperature records after the fact to ensure food temperatures where being documented. DM-A stated she was very behind on everything. DM-A stated she was ultimately responsible to ensure food palatability and food safety for residents. The administrator added it was an accountability issue .holding staff accountable for their specific job duties. When asked who provided training for new cooks, DM-A stated she did, but stated she was not aware of a training checklist to ensure all elements of a cooks role were addressed during training, nor did she monitor their performance after completion of training. During an interview on 4/14/22, at 1:47 p.m., (RN)-C stated there had not been any residents with symptoms of foodborne illness that she could recall. Facility policy titled Food Temperature Monitoring, dated 3/15/22, indicated food was cooked, reheated or cooled to ensure proper holding temperatures before each meal services. Food temperatures were taken and recorded before each meal service. Periodically, temperatures were taken at other times during or at the end of meal service to ensure temperatures were held within acceptable ranges. Food is served at proper serving temperatures. Before meal service, the cook takes the cook-to and the serve temperatures of all TCS (time/temperature control for safety) menu items and records it on the Food Temperature Record. The cook monitors TCS foods throughout meal service. To correctly take temperatures, the food thermometer is inserted into the center or thickest part of the food for at least 15 seconds or per instructions on the thermometer. TCS hot foods should be served at 135 degrees F or higher. A chart of Minimal Internal Cooking Temperatures indicated a variety of foods and the required temperature prior to serving. Facility policy titled Service of Food and Drinks dated 5/3/21, was received. The policy indicated definitions for attractive and palatable food, proper serving temperatures which were food temperatures that were appetizing to the resident, and proper holding temperature which were foods held below 41 degrees F or above 135 degrees F. Food was served at proper serving temperatures. Check temperatures before food is placed for service. Re-check as needed to ensure proper temperatures during holding.

**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 (R13, R14, R134) reviewed for immunization status, had been provided education regarding the risks, benefits and potential side effects of the influenza and pneumococcal vaccines in accordance with facility policy and the Centers for Disease Control and Prevention (CDC) recommendations. Findings include: R13's face sheet printed 4/14/22, indicated an admission date of 2/3/22. R13's immunization record identified R13 consented to Influenza vaccine, but was not administered. Pneumococcal vaccines were not present on immunization records. Review of documentation in electronic medical record (EMR) failed to indicate whether the resident/family had been provided education regarding risks, benefits and side effects about the influenza or pneumococcal vaccinations or if resident had received the vaccinations or refused. R14's face sheet printed 4/14/22, indicated an admission date of 2/8/22. R14's immunization record indicated pneumococcal conjugated (PCV13) was given 2/25/16. No documentation of influenza or pneumococcal polysaccharide (PPSV23) was present regarding provided education on risks, benefits and side effects in the electronic medical record (EMR). No evidence was present the resident had received the vaccinations or refused. R134's face sheet printed 4/14/22, indicated admission date of 3/22/22. R134's immunization record indicated no immunization history was present. No documentation of influenza, pneumococcal vaccination was present regarding provided education on risks, benefits and side effects was present in the EMR. No evidence was present the resident had received vaccinations or refused. R134's Minimum Data Set (MDS) dated [DATE] was not completed. During interview on 4/14/22, at 8:25 a.m., R134 indicated he did not receive education on any vaccinations on admission. During interview on 4/14/22, at 8:36 a.m., registered nurse (RN)-C indicated immunizations are generally completed on admission. If there is no record of immunizations on file and is not completed on the records that are received on admission, they will contact the local provider. RN-C also indicated that the health information management staff will look in their previous medical records and if there are none present will reach out to her or the case managers who then should complete follow-up. RN-C indicated these three residents fell through the cracks and they could improve on the process. During interview on 4/14/22, at 8:46 a.m., the interim director of nursing (DON) indicated there was no documentation found for education on risks, benefits and side effects of influenza, pneumococcal vaccinations for R13, R14, R134 and there should be. Review of Residents Immunization/Vaccinations policy and procedure dated 3/8/22 included: Upon admission each client resident and/or resident representative will receive the vaccination information statements (VIS) for influenza and caregiver for the Covid-19 vaccine. Review current vaccinations, provide and document education on the benefits and potential side effects of the vaccinations for which the client/resident is eligible. If the client, resident and/or the resident representative consent to vaccination obtain written consent if required by state regulation and administer vaccination. If the resident and or resident representative chooses not to be vaccinated after discussion of benefits, document declination.

**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 (R13, R14, R134) reviewed for immunization status, had been provided education regarding the risks, benefits and potential side effects of COVID-19 immunization in accordance with facility policy and the Centers for Disease Control and Prevention (CDC) recommendations. Findings include: An immunization report printed 4/11/22, included a hand written note from interim director of nursing (DON) that R13, R14 and R134 refused the COVID-19 vaccine. R13's face sheet printed 4/14/22, indicated an admission date of 2/3/22. R13's immunization record did not include COVID-19 vaccination. Review of documentation failed to indicate whether the resident/family had been provided education regarding risks, benefits and side effects about the COVID-19 vaccination or if resident had received the vaccinations or refused. R14's face sheet printed 4/14/22, indicated an admission date of 2/8/22. R14's immunization record did not include COVID-19 vaccination. No documentation of COVID-19 vaccine was present regarding provided education on risks, benefits and side effects in the electronic medical record (EMR). No evidence was present identifying if resident had received the vaccinations or refused. R134's face sheet printed 4/14/22, indicated admission date of 3/22/22. R134's immunization record indicated no immunization history was present. No documentation of COVID-19 vaccine was present regarding provided education on risks, benefits and side effects was present in the EMR. No evidence was present the resident had received vaccinations or refused. R134's Minimum Data Set (MDS) dated [DATE] was not completed. During interview on 4/14/22, at 8:25 a.m., R134 indicated he did not receive education on the COVID-19 vaccination on admission but also indicated he refuses to get the vaccine. During interview on 4/14/22, at 8:36 a.m., registered nurse (RN)-C indicated immunizations are generally completed on admission. If there is no record of immunizations on file and is not completed on the records that are received on admission, they will contact the local provider. RN-C also indicated that the health information management staff will look in their previous medical records and if there are none present will reach out to her or the case managers to complete follow-up. RN-C indicated R13, R14, R134 fell through the cracks and they could improve on the process. During interview on 4/14/22, at 8:46 a.m., the interim director of nursing (DON) indicated there was no documentation found for education on risks, benefits and side effects of COVID-19 vaccination and there should be. Review of Residents Immunization/Vaccinations policy and procedure dated 3/8/22, included: -Upon admission each client resident and/or resident representative will receive the vaccination information statements (VIS) for influenza and the COVID-19 vaccine. Review current vaccinations, provide and document education on the benefits and potential side effects of the vaccinations for which the client/resident is eligible. If the client, resident and/or the resident representative consent to vaccination obtain written consent if required by state regulation and administer vaccination. If the resident and or resident representative chooses not to be vaccinated after discussion of benefits, document declination.

Based on observation, interview and document review, the facility failed to follow Centers for Medicare and Medicaid Services (CMS) and Centers for Disease Control (CDC) guidelines by appropriately implementing measures to prevent the spread of infection when the facility failed to ensure personal protective equipment (PPE) was discarded prior to leaving resident rooms, and failed to clean multi-use equipment between uses. The deficient practices had the potential to affect all 34 residents who resided in the facility. Findings include: Sanitizing re-usable equipment During observation and interview on 4/12/22, at 9:23 a.m., nursing assistant (NA)-C and NA-D came out of R31's room after using the mechanical lift to transfer R31 from wheelchair to recliner and went directly into R134's room with lift. NA-C and NA-D then used lift to assist R134 with transfer from wheelchair to the bed. NA-D, when asked if the resident lift was cleaned between uses, indicated Purell (hand sanitizer) was used to the clean the machine. When questioned when that was completed, NA-D then stated we run out of things all the time and there were no wipes on the machine. During interview on 4/13/22, at 11:10 a.m., the interim director of nursing (DON) indicated lift equipment should be cleaned using appropriate designated sanitizer, which is not Purell, between uses. During interview on 4/13/22, at 12:52 p.m., the interim DON indicated training is occurring today on proper disinfection of equipment. Personal Protective Equipment: The Centers for Disease Control guidance CS250672-E, undated, indicated Remove all Personal Protective Equipment (PPE) before exiting the patient room except a respirator. During observation and interview on 4/11/22, 2:55 p.m., R25, R134 and R136 had cart with drawers present next to the door of the rooms with laundry basket full of uncovered yellow gowns on top along with gloves. A covered linen hamper was present on the other side of the cart. Contact Precaution signs were present on R25, R134 and R136's doors. During interview RN-A indicated the laundry basket has clean gowns in it and all three residents are on quarantine currently. RN-A indicated they take gloves off inside the room and then come out of room and remove gown and place in covered linen hamper. During observation on 4/11/22, at 3:08 p.m., NA-A put on gown, then gloves and entered R25's room and assisted her to restroom. NA-A then came out of room with gown on walking past uncovered clean gowns and removed and discarded contaminated gown in linen hamper. During observation on 4/11/22, at 4:02 p.m., registered nurse (RN)-A put on gown from the laundry basket, gloves and entered R133's room. RN-A came out of R133's room without gloves, walked past cart with gowns present on top in uncovered laundry basket and removed gown, discarding into covered dirty linen hamper. During interview on 4/14/22, at 9:01 a.m., RN-C indicated if the policy and procedure says to discard the gown in the work area, that would be inside the room, not in the hallway. During interview on 4/14/22, at 9:23 a.m., RN-E indicated she does the yearly training for staff on donning and doffing PPE. RN-E stated staff were taught to take all PPE off inside the room and dirty linen hamper should be inside the residents room/door even if the resident is only on quarantine. During interview on 4/14/22, at 11:19 a.m., the interim DON confirmed staff should not be coming out of the room to discard the gown. That should be done inside the room. A policy on Putting on/Taking Off Personal Protective Equipment (PPE) dated 2/15/22 included: -For safe donning and removal of PPE refer to the CDC and Prevention poster. -The Poster indicated Remove all PPE before exiting the patient room except a respirator. - Remove gown (perform gown removal per any isolation requirements) and perform hand hygiene before leaving the contaminated area.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure a sanitary environment in the kitchen when daily cleaning duties were not done, and 1 of 1 fans used in the dishwashing room was observed with dust and debris. This had potential to affect all 34 residents who consumed food prepared in the kitchen. Findings include: The initial kitchen observation and interview on 4/11/22, at 1:38 p.m. was provided by kitchen aide (KA)-B, as the dietary manager had been off duty and the cook had been on break. In the dishroom, a dirty fan was observed blowing on clean, plastic coffee cups that had come out of the dishwasher and were drying in a plastic crate. The fan was secured to a wall and dust was visible on the grate cover. KA-B was asked to shut the fan off, and dark, fuzzy material was observed on the outer edges of each fan blade. KA-B stated the fan was used for staff comfort as it got hot when doing dishes. On the left side of the stove, greasy material was observed on the flat surface underneath the cast iron burners. On the right side of the stove was a flat, stainless steel griddle. Between the stainless steel edge of the stove which was about four inches wide, to the lip of the griddle, there was a crevice which appeared to have food debris caked all along in the crevice which was approximately 18 to 24 inches long. A white, square drain under the three-compartment sink was observed with dark debris in it. The well-worn sheet vinyl flooring was dull, stained, with dark smudges. In the dry storage room was a three-door stainless steel refrigerator. The outside stainless steel doors were smudged, and the back side of the handle of one door had spongy, moveable material on it. The roll top, stainless [NAME] doors on the steam table were smudged with either hand prints or food splattering. Daily cleaning logs were observed posted in various parts of the kitchen and dining room for dates 3/28/22, through 4/10/22, and were rarely documented as being completed. Duties varied where identified, including but not limited to, polishing refrigerators and freezers, cleaning salt and pepper shakers, sugar and jelly containers, peanut butter containers. Cleaning the stove top, microwave, grill shelf, can opener, outside of steamer and handle, left oven, right oven, convection oven, sweep and mop. During an interview on 4/14/22, at 11:20 a.m., dietary manager, (DM)-A, stated all kitchen staff were assigned duties, depending upon their role and if they worked during the day or afternoon. DM-A acknowledged that many of the spaces on the forms were blank and she could not verify whether or not the cleaning duties had been carried out, as she did not monitor this. DM-A stated she did a lot of the cleaning herself, but often forgot to sign off that it had been completed. When asked about the food build-up in the crevice on the stove, DM-A stated she recently noticed that and was going to scrape it out. DM-A stated the square, white drain under the three-compartment sink was not hooked up to a drain and the debris in it was from sweeping in and around the drain. DM-A stated staff were responsible for maintaining cleanliness of the kitchen and dining room, and she was responsible to ensure cleaning duties were carried out. DM-A acknowledged that unclean surfaces had the potential for cross contamination causing foodborne illness to residents. Facility policy titled Cleaning Schedule - Food and Nutrition Services, with revised date of 2/15/22, indicated the purpose was to identify cleaning tasks to be completed. The director of food and nutrition was to post the cleaning assignments and employees were responsible for knowing their assigned duties and carrying them out during the designated work shift. Employees would initial the schedule after completing the cleaning duties. The supervisor was responsible for monitoring employees to ensure that cleaning duties were completed in a satisfactory and timely manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to monitor the condition of food storage containers in the walk-in kitchen refrigerator resulting in mold growing on the outside of multiple containers. In addition, the facility failed to date-mark open containers of food stored in the walk-in kitchen refrigerator, and failed to ensure expired food was identified and removed. In addition, the facility failed to prevent cross-contamination when egg shells were stored with whole eggs. In addition, the facility failed to ensure the trained dietary manager oversaw and supervised all aspects of dietary services and ensured dietary cooks received comprehensive training upon hire and on-going. Furthermore, the facility ensure hand hygiene was performed by staff when plating food and delivering meal trays, failed to ensure proper infection control practices were followed when handling resident drinking cups. This had the potential to affect all 34 residents who were served food from the kitchen. Findings include: The initial kitchen observation and interview on 4/11/22, at 1:38 p.m. was provided by kitchen aide (KA)-B, as the dietary manager had been off duty and the cook had been on break. During an observation of the walk-in freezer, noted a large box of hamburger patties; the patties were inside a bag and the bag was open to the air. Observed the built-in freezer fans had ice on the grates and icicles hanging from them. During an observation of the adjacent walk-in refrigerator, noted the following: 1. [NAME] Honey Mustard dressing, 1 gallon. Written on top with black marker open 8/24. Also written on cover was 3/12. Moldy material - white, gray and fuzzy, was growing on the outside of the container trailing down, and on top of the cover. Manufacturer expiration date not seen. 2. Vinegar, 1 gallon, with manufacturer best by date of 2/14/19. Written on side of container was open 3-4. On top of cover, was written 3/11 with year of either 17 or 19. Product label was full of dark fuzzy mold, so much so that the label could not be read. KA-B stated there was vinegar in the container. In addition, the container had fine dots of black mold trailing down the side. 3. [NAME] brand Sweet and Sour Sauce, 1 gallon, had about 3 inches of product left in the container. Fuzzy white and black mold was growing on the outside of the container. The date written on the side with black marker was 2/12, with lines drawn through it. KA-B did not know what the lines through the date meant. Dried sauce and mold were trailing down the side of the container. 4. Real Lemon Juice, 1 gallon, had spotted mold over entire outside surface of the container. Written on outside of container in black marker was 1-15. Manufacturer best by date was 4/19/21. 5. Sysco Reliance brand Sweet Pickle Relish, 1 gallon. One of two manufacturer labels was covered with black mold and the other was partially covered. Date written on top with black marker was 12/28. This container appeared full, possibly unopened. 6. Lea & Perrin's Worcestershire sauce, 1 gallon. Approximately half of manufacturer label had mold on it, as did areas of the container. The manufacturer best by date was 12/29/21. 7. Mrs. Gerry's Dixie Coleslaw, 4 lb (pound) tub was observed in a box on an upper shelf, the plastic cover was ajar and contents were coming out. There was no date mark indicating when it was opened. Manufacturer expiration date was May 2022. 8. Shredded cheddar cheese, 5 lb bag, open to the air. Bag of lettuce open to air. 9. Roast beef in a plastic container with green cover. Tape read rot [roast] beef 4/6. 10. A small plastic bowl covered with plastic wrap with unidentified contents and no date. [NAME] in color. Texture was like pudding. 11. Mrs. Gerry's Deli Fresh Macaroni Salad, 5 lb tub, two dates were written on the cover with black marker: 3/31 OP and 4/3 -- KA-B did not know how long food in opened containers were good for. 12. Plastic container of leftover Veg soup dated 4/8, with about 3 inches of product left in the container. Observed two large plastic containers on wheels which KA-B stated held sugar and flour. Contents of containers not labeled or dated. In a double-door refrigerator by the pass-through window was a cardboard tray of eggs. There were 11 egg shells still in the tray, along side eight whole, pasteurized eggs. A small plastic bag of what appeared to be deli ham was also noted; contents of the bag were not identified nor was the bag dated. During a interview on 4/11/22, at 1:58 p.m., the administrator was asked to come to the kitchen to observe the findings from the walk-in refrigerator, specifically moldy containers, foods past facility and/or manufacturer expiration date, and from another refrigerator: egg shells with whole eggs. KA-B had removed the containers from the walk-in refrigerator to a stainless steel table in the kitchen. When shown the findings, the administrator stated oh, that's not good adding that the facility had been cited in the past for concerns in the kitchen. During an interview on 4/12/22, at 12:59 p.m., dietary manager (DM)-A was asked if she had been informed of finding from the walk-in refrigerator on 4/11/22, and she confirmed she had been, adding that the administrator had shown her photos. When asked how the containers got moldy and went unnoticed by staff, DM-A stated the mold occurred when staff didn't wash off containers before returning them to the refrigerator. DM-A stated she didn't know how the containers were overlooked by staff, and admitted she was the one who received in food orders and put them away, yet didn't notice the moldy containers either. When asked if contents of the refrigerators were inspected for facility and manufacturer expiration dates on a periodic basis, DM-A stated they were not. DM-A stated when a food product came into the facility it was date-marked with the delivery date. When a container was opened, it was date-marked when opened. When informed food containers were marked with a month and day, but not year, DM-A stated that was what she was told to do. When informed not all open food containers had a date-mark, DM-A stated the facility policy indicated food containers were to be dated when opened, including leftovers, and open containers of food were good for three days. DM-A stated cooks and kitchen helpers were responsible for monitoring this. DM-A stated the bulk containers of sugar and flour on wheels should have had a date on them, and the date must have washed off the lids. DM-A stated she did not review temperature logs to ensure staff were compliant. Together in the walk-in refrigerator, DM-A identified food that had been opened greater than three days and removed them from the refrigerator: - Tuna salad, 5 lb container, dated 4/7 - Leftover rot [roast] beef, dated 4/6 - Ham slices, dated 4/6 - Macaroni salad, 5 lb container, dated 4/3 - Turkey slices, dated 4/2 - Potato salad, 13 lb container, dated 3/28 - Cottage cheese, 3 lb container, dated 3/24. DM-A opened this container, it was full and on top had a layer of pale yellow gel-like substance and gray fuzzy mold. - Bologna slices, dated 3/17 During an interview on 4/13/22, at 10:30 a.m., DM-A was asked when food in moldy containers, mostly condiments, were used last. Honey mustard dressing - couldn't recall. Real Lemon Juice - not often. Worcestershire sauce - used for baked beans which were on lunch menus on 4/7/22, and 3/23/22. Sweet and Sour sauce was used for pork stir fry, but had not been able to get ground pork. Vinegar - used daily to clean the stove. DM-A stated I guess I missed it when referring to the moldy containers. DM-A stated she contacted the maintenance supervisor about the gasket around the walk-in refrigerator door, adding it had been a problem before, and also new fans had been installed, but didn't seem to make a difference. DM-A stated this could attribute to the mold. During an interview on 4/14/22, at 8:46 a.m., maintenance supervisor (MS)-A stated he heard there had been mold growing on containers in the walk-in refrigerator. MS-A stated the gasket around the door to the walk-in refrigerator needed to be replaced, and that he planned to replace the door latches to make sure the door always close behind the staff. MS-A stated he noticed the fan inside the walk-in freezer wasn't running so chipped the ice away and had been watching it closely. MS-A stated he called the refrigeration company and they were coming 4/15/22, to check it. During an interview on 4/14/22, at 11:20 a.m., with DM-A and the administrator, negative findings above were reviewed. When asked how the moldy food containers could go unnoticed, DM-A stated, I can't figure it out, none of the other staff noticed either. When asked what happened to the food items removed from the walk-in refrigerator on 4/11/22, the administrator stated she directed staff to throw away because it was moldy, expired, and might be served to residents which could cause foodborne illness. DM-A stated she discarded food containers on 4/12/22, because they exceeded the three-day maximum for open containers, and if served to residents could cause foodborne illness. When asked why routine duties in the kitchen were not being done, such as monitoring the condition of food containers, dates of food containers, manufacturer expiration dates, DM-A stated, training. DM-A stated she trained new kitchen staff, but did not utilize a tool such as a training checklist to ensure all elements of each role were addressed during training, nor did she monitor performance after completion of training. DM-A stated she was very behind on everything. The administrator stated it had been a long six months of advertising for a cook and getting no applicants; that DM-A had been burning the candle at both ends and working long hours. For some of these tasks, the administrator and DM-A agreed didn't required a cook to do them. DM-A stated she was ultimately responsible to ensure food safety for residents, and the administrator added that it was an accountability issue .holding staff accountable for their specific job duties. During the same interview, the administrator and DM-A were reminded about food service deficiencies with past inspections and asked what actions had been taken to ensure sustained improvements. DM-A stated they had done audits, and survey inspection findings had been added QAPI (quality assurance and performance improvement) plans. DM-A stated they shouldn't have stopped auditing and stated she would need to train dietary staff all over again. The administrator stated it seemed like they had done that every year with the same results. Both the administrator and DM-A acknowledged the findings in the kitchen were a significant concern and could result in foodborne illness to residents. During a telephone interview on 4/14/22, at 12:32 p.m., the registered dietician (RD)-F stated she worked in the facility two times per month, that most of the days were working with resident information and nutritional status. When asked if her role included any oversight for the kitchen, RD-F stated company policy said it did, but since returning to onsite visits after the Covid-19 pandemic in the spring of 2021, she had not done any kitchen audits. RD-F stated she checked in with the kitchen staff when she had questions, but had not done any inspections. RD-F stated she had been in the facility on 4/11/22, and had heard about cleanliness issues in the kitchen and stated had she been doing audits, it might have made a difference. When informed of findings, such as mold growing on the outside of condiment containers, RD-F stated that meant food had been left on the outside of the container. When asked about egg shells stored with whole eggs, RD-A stated that was a concern for cross contamination. RD-F stated they had work to do and would meet with the administrator and DM-A and put a plan in place. Training of new kitchen staff hired in 2022, consisted of on-the-job training with DM-A, however no orientation list/tool was used to verify the content of the training. In addition, new staff completed the following online module titled: Basics of Food Safety in LTC (long term care). Detail of the course included: Three types of hazards to food safety: physical, chemical and biological. Use proper hygiene to prevent contamination. Follow proper protocols to prevent cross-contamination. Maintain safe temperature ranges for food. Use cleaning and sanitizing methods to reduce risk of foodborne illness. [NAME] (C)-D was hired on 3/23/22, and completed the online course on 3/20/22. Kitchen aide (KA)-B was hired on 1/18/22, and completed the online course on 1/26/22. DM-A holds a certified dietary manager certification with expiration date of 8/31/22. Job description for DM-A indicated supervising the quality of performance for employees on the team, assist in training new staff and the development of existing staff members, ensure department meets all regulatory requirements, advises on the appearance, taste and sanitation of food, delegates responsibilities, and supervises staff to be accountable to tasks. Hand Hygiene During observation on 4/11/22, at 5:26 p.m., dietary aide (DA)-A took out tray from enclosed cart and entered R14's room, with no observed hand hygiene completed. DA-A set tray down and touched bedside table and moved into position for eating. DA-A then left the room, did not complete hand hygiene and took out tray for R136 and left on table outside of the door and notified nurse the tray was outside of the room, did not complete hand hygiene. DA-A then took out tray for R134 and entered room, touching the bedside table and R134's water glass. DA-A exited room and did not complete hand hygiene. DA-A then took out R25's tray and delivered it to her room, again touching and moving the bedside table. DA-A exited the room and did not complete hand hygiene and returned to the kitchen. During interview on 4/11/22, at 5:36 p.m., DA-A indicated he does not complete hand hygiene between rooms and no one ever taught him to do that. During an observation in the kitchen on 4/11/22, from 5:36 p.m. to 5:42 p.m., cook (C)-B was observed handling multiple items and surfaces while wearing black gloves, and at no time during this observation did C-B remove gloves and perform hand hygiene. C-B was observed plating food while standing at the pass-through window. C-B handled multiple paper meal slips filled out by staff and residents, placed coleslaw on plates using a scoop, placed half sandwiches on the plates, then covered the plates with a plastic thermal cover and set the plate on the counter of the pass-through window. In addition, while wearing the same gloves, C-B placed food in the microwave to reheat, stirred food on the stove, then reached into a plastic container for the half sandwiches to add to plates. This process was repeated until all resident food orders had been filled. During an observation on 4/13/22, at 10:38 a.m., observed kitchen aide (KA)-C fill beverage cups for water, milk and juice, and set them on resident trays. When setting the filled cups on the tray or re-arranging the cups, KA-C held the cups by the rims with her bare hands. During interview on 4/13/22, at 11:10 a.m., the interim director of nursing (DON) confirmed hand hygiene should be completed if touching personal items such as water glass or bedside table in resident's room when delivering trays to residents. Upon request of hand hygiene education for DA-A, the dietary manager (DM) gave a Food and Nutrition Competency Checklist for Hand washing and Glove use competency form dated 7/18. No name was present on competency. A rating of 3 (moderately skilled), completion date of 2/22 was present with no signature of who completed competency present. An Employee Roster indicated DA-A began employment at the facility on 1/6/22. During interview on 4/13/22, at 12:40 p.m., human resources (HR)-A indicated she was trained by previous DON to complete hand hygiene observations on nursing department staff only and was never requested to complete them on dietary staff members. During an interview on 4/14/22, at 11:20 a.m., the dietary manager (DM)-A and administrator were informed of observations of KA-C holding the rim of drinking cups and of C-B wearing the same gloves for multiple tasks, then handling sandwiches. DM-A stated staff should know not to do that. When asked if dietary staff received infection control training related to their specific duties, DM-A stated she thought so, but didn't know who was responsible for providing this training. During an interview on 4/14/22, at 1:47 p.m., registered nurse (RN)-C stated there had been no residents with symptoms of foodborne illnesses. When asked if she had any involvement with infection control oversight in the kitchen, RN-C stated she had done mock surveys in the kitchen in the past, the last time being 9/10/21. RN-C stated the human resource director had also helped with audits and had done one on 1/19/22. These two audit results were reviewed and pertained primarily to equipment and environment. Facility policy titled Date Marking - Food and Nutrition, with revised date 5/3/21, indicated the policy provided guidelines for proper date-marking to ensure that food was handled and stored safely. Best if used by dates were not expiration dates. Refer to USDA (United States Department of Agriculture) guidance on Shelf Stable Food Safety. When TCS (time/temperature control for safety foods) were received in, employees date-mark the item with the delivery date. Use by date is an expiration date. As much as possible, food items should remain in original containers/packaging; if removed from original packaging, individual items were labeled and dated with date of receiving. Ensure that ready-to-eat TCS foods opened at the location were clearly date-marked for date/time the original container was opened. The date or day by which the food shall be consumed on premises, or discarded. TCS food prepared onsite and held in refrigeration for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. Employees were to count the day of preparation as Day 1. At no time can a TCS prepared food be held more than seven days in a non-frozen state. Facility policy titled Food-Supply Storage, with revised date of 6/23/21, indicated food from approved food sources would be stored in sanitary conditions. Food opened or prepared were placed in an enclosed container, dated, labeled and store properly. Once meal service is over, cover, date and label individually-portioned items. Location-prepared time/temperature control for safety foods are discarded after three days in the refrigerator unless safe storage guidelines are available. In the refrigerator, the temperature was kept between 35 and 40 degrees Fahrenheit (F). In the freezer, the temperature was 0 degrees F or lower. Internal temperatures of all refrigerators and freezers are recorded twice daily. Facility policy titled Food Temperature Monitoring, with revised date of 3/15/22, indicated food was cooked, reheated or cooled to ensure proper holding temperatures before each meal services. Food temperatures were taken and recorded before each meal service. Periodically, temperatures were taken at other times during or at the end of meal service to ensure temperatures were held within acceptable ranges. Food was served at proper serving temperatures. Before meal service, the cook takes the cook-to and the serve temperatures of all TCS (time/temperature control for safety) menu items and records it on the Food Temperature Record. The cook monitors TCS foods throughout meal service. To correctly take temperatures, the food thermometer was inserted into the center or thickest part of the food for at least 15 seconds or per instructions on the thermometer. TCS hot foods should be served at 135 degrees F or higher. A chart of Minimal Internal Cooking Temperatures indicated a variety of foods and the required temperature prior to serving.

Based on interview and document review, the facility failed to implement a process for antibiotic review in order to determine appropriate indications, dosage, duration, trends of antibiotic use and resistance. This had the potential to affect any residents who had infections requiring antibiotic use. Findings include: When interviewed on 4/13/22, at 11:10 a.m., the interim director of nursing (DON) indicated staff initiate infection monitoring by documenting in the electronic medical record (EMR) which is then reviewed daily by her. The McGeer criteria is used. The interim DON indicated the EMR information including date of onset, date of end of symptoms, diagnosis and antibiotic used is entered into a software program. The interim DON indicated from the software program, reports are run and shared quarterly at quality assurance and performance improvement (QAPI) meetings, which includes the medical director and consulting pharmacist. The interim DON indicated nursing staff monitor resident's culture reports to make sure resident's prescribed antibiotics are on the correct medication. Upon request of reports shared at QAPI meetings, a monthly infection summary was received for January, February and March 2022. Information included on this report was resident name, start date, date symptoms resolved, type of infection (urinary tract infection, pneumonia), antimicrobial used, infection source (community or facility) and surveillance criteria met. Culture or x-ray results were not included. Antimicrobial included medication name and dosage but did not include length of use. The interim DON indicated she is not able to run a report that included chest x-ray and/or culture results that included antibiotic prescribed including length of use, symptoms and onset, and resolution of symptoms. Infection control meeting minutes were requested however the interim DON indicated she was not able to locate and unsure if meetings were held or just reported at QAPI meeting. The interim DON did indicate she has not attended a QAPI meeting since her interim employment began at facility. During interview on 4/13/22, at 12:52 p.m., the interim DON indicated 48 hours after an order is received for an antibiotic, nursing staff are responsible to contact the provider using a form to determine if antibiotics should be continued. Upon request of this form or example of a completed form, none was received. The interim DON did indicate the providers are inappropriately starting antibiotics on residents even if minimal symptoms are present prior to culture results and she has discussed this with them but was unable to identify who, or when this occurred. Upon request, the QAPI meeting minutes were reviewed for 2/15/22, 11/11/21, 8/19/21 and 5/13/21. Infection Control portion included COVID-19 status, testing and vaccine updates. The QAPI meeting minutes did not include a summary of antibiotic use, infectious organisms or multidrug resistant organisms. The interim DON was unable to provide documentation that included a periodic review of antibiotic use, review of laboratory and medication orders, and a system of feedback reports on antibiotic use, antibiotic resistance patterns based on laboratory data and prescribing practices. A policy titled Antibiotic Stewardship Rehab/Skilled dated 11/29/21 included: - Purpose is to decrease the incidence of multi-drug resistant organisms, promote appropriate use while optimizing the treatment of infections and reducing the possible adverse events associated with antibiotic use and to provide standard definitions to be used as guidelines when initiating antibiotics.