**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to provide timely notification for change in condition to the physician for 1 of 3 residents (R1) reviewed for change in condition, when R1 had a weight gain of 13 pounds in her first nine days at the facility, resulting in postpoing her scheduled surgery. Findings include: R1's admission Minimum Data Set (MDS), dated [DATE], indicated R1 had diagnoses of right humerus (arm bone from shoulder to elbow) fracture and coronary artery disease. A progress note, on 1/21/25 at 8:24 p.m., indicated R1 was admitted to the facility from the hospital following a fall on 1/18/25, at home causing a proximal humerus fracture. A progress note, on 1/22/25 at 11:21 a.m., indicated R1's weight was 200 pounds. A progress note, on 1/31/25 at 1:01 p.m., indicated R1 weighed of 213 pounds, and weighed 200 pounds on 1/22/25. A progress note, on 2/2/25 at 3:24 p.m., indicated R1 was short of breath and had a cough. A progress note, on 2/3/25 at 4:26 p.m., indicated R1 was short of breath with oxygen saturation of 90%, on room air. A progress note, on 2/4/25 at 5:52 p.m., indicated R1 was short of breath with activity and conversation and had a cough. R1 had +3 (moderate to severe level of fluid accummulation) edema from her mid-calf to her feet. R1's face and abdomen appeared puffier and her pants were tight. Weight gain since admission. Notified physician. Physician ordered STAT (immediate) dose of Lasix 40mg and labwork to be completed. A progress note, on 2/4/25 at 6:01 p.m., indicated R1's physician felt R1 was not medically stable for scheduled surgery on 2/5/25. A physician visit note, dated 2/5/25, indicated R1 was planned for surgery on 2/5/25 but due to fluid overload, the surgery was postponed. R1 had edema and wheezing in her lungs. R1 had an increase of 13 pounds since admission. Staff contacted the physician on 2/4/25 and started R1 on Lasix (a medication used to treat fluid retention) immediately. On 2/20/25 at 11:58 a.m., the director of nursing (DON) stated she wrote the progress note, on 1/31/25. The DON stated she wasn't paying attention when she entered the note. She did not address the weight gain with the physician or the interdisciplinary team. The DON stated she should have done an assessment, checked for edema, listened to R1's lung sounds, and notified the physician. On 2/20/25 at 2:55 p.m., the physician stated he expected to be notified when the facility noted R1 had gained 13 pounds from 1/22/25 to 1/31/25, but was not made aware until 2/4/25, when R1 was experiencing fluid overload. The physician stated R1 was not medically stable to proceed with surgery for her arm fracture on 2/5/25. The physician stated R1's arm would heal without surgery. A facility document, Change in a Resident's Condition or Status, dated 2/21, directed our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status.

Based on interview and document review, the facility failed to report an allegation of abuse as required for 1 of 2 residents (R82) reviewed for abuse. Findings Include: R82's entry Minimum Data Set (MDS) included an entry date of 10/18/24. R82's Order Summary Report dated 10/30/24, included an order for Hospice. On 10/25/24, a report was filed with the State Agency which reported abuse was witnessed during a hospice aide visit on 10/25/24. The report indicated nursing assistant (NA)-B, a hospice nursing assistant, reported the abuse to registered nurse (RN)-A. During interview on 10/29/24 at 5:29 p.m., RN-A confirmed NA-B reported witnessing rough cares provided to R82. RN-A confirmed she had not completed a body assessment after receiving the report. RN-A stated she had spoken with someone at the facility about the alleged abuse, but did not remember who. RN-A stated she would typically report concerns about abuse to either the director of nursing (DON), administrator, or social worker. RN-A stated she could not remember reporting the concerns to any of the mentioned staff. During interview on 10/29/24 at 5:48 p.m., RN-B confirmed RN-A had not reported abuse to her. RN-B was informed of the concern of abuse during the team meeting the following morning. RN-B stated it was passed on during report that NA-B felt NA-A was rough with R82. RN-B was unsure if any additional follow up was completed. During interview on 10/29/24 at 6:18 p.m., DON stated she received a call from RN-C who reported an aide witnessed rough cares from a facility employee. DON was unable to recall what time she received the call. DON confirmed she did not file a report with the state agency about the alleged abuse. DON confirmed abuse should be reported within two hours of receiving the report. During interview on 10/30/24 at 2:30 p.m., administrator stated a thorough investigation should have been completed with any concerns of abuse. Administrator stated a thorough investigation would take two to three days to complete and the report of abuse should have been file prior to investigation. Facility abuse policy included all alleged violations involving abuse should be reported immediately, but no later than two hours after the allegation was made.

Based on interview and document review, the facility failed to investigate an allegation of abuse as required for 1 of 2 residents (R82) reviewed for abuse. Findings Include: R82's entry Minimum Data Set (MDS) included an entry date of 10/18/24. R82's Order Summary Report dated 10/30/24, included an order for Hospice. On 10/25/24, a report was filed with the State Agency which reported abuse was witnessed during a hospice aide visit on 10/25/24. The report indicated nursing assistant (NA)-B reported abuse to registered nurse (RN)-A. During interview on 10/29/24 at 5:29 p.m., RN-A confirmed NA-B reported witnessing rough cares provided to R82. RN-A confirmed she had not completed a body assessment after receiving the report. RN-A stated she would typically report concerns about abuse to either the director of nursing (DON), administrator, or social worker. RN-A confirmed she had not spoken with the alleged perpetrator after the report of abuse. During interview on 10/29/24 at 5:48 p.m., RN-B confirmed RN-A had not reported abuse to her. RN-B stated she was informed of the concern of abuse during a team meeting the following morning. RN-B stated it was passed on during report that NA-B felt NA-A was rough with R82. RN-B was unsure if any additional follow up was completed. RN-B stated it was standard procedure to take a staff member off the schedule after a report of alleged abuse. During interview on 10/29/24 at 6:18 p.m., director of nursing (DON) stated she received a call from RN-C who reported an aide witnessed rough cares from a facility employee. DON was unable to recall what day or time she received the call. DON stated she had spoken with the alleged perpetrator within the hour of receiving the phone call. DON stated she did not speak with any additional staff members or residents to complete a thorough investigation. DON confirmed she had not attempted to speak with the aide who reported the alleged abuse. DON stated she had completed a skin assessment of R82's but had not documented the assessment. DON stated she should have documented the assessment because if it wasn't documented, it did not happen. DON stated she had handwritten notes regarding the incident, but was not able to produce them at the time of the interview. DON confirmed the alleged perpetrator continued to work after the report of alleged abuse. DON produced an undated, handwritten one page sheet of paper on 10/30/24. During interview on 10/30/24 at 2:30 p.m., administrator stated a thorough investigation should have been completed with any concerns of abuse. Administrator stated a thorough investigation would take two to three days to complete and would include interviews with other residents, mood/behavior monitoring and removing the alleged staff member from the schedule. Facility schedules indicated NA-A worked 10/25/24, 10/26/24, 10/29/24, and 10/30/24. Facility abuse policy included all alleged violations involving abuse should be investigated immediately. The investigation should have included resident's statements, involved staff and witness statements of events, a description of the resident's behavior and environment at the time of the incident, injuries present, and observation of resident and staff behaviors during the investigation. The alleged individual would be immediately removed.

Based on observation, interview and document review, the facility failed to follow standards of practice related to medication administration for 1 of 1 residents (R7) observed to receive an inhalation medication. Findings include: R7's admission Record printed 11/16/23, indicated diagnoses of chronic obstructive pulmonary disease (a condition that blocks airflow and make it difficult to breathe), mild cognitive impairment, heart failure, obesity, and weakness. R31's Order Summary Report printed 11/16/23, included Pulmicort (also known as budesonide) inhalation suspension (medication used to prevent swelling in the lungs) 0.5 mg (milligram)/2ml (milliliter) inhale via nebulizer two times a day, rinse mouth well after nebs. During observation on 11/15/23 at 8:11 a.m., licensed practical nurse (LPN)-C set up R7's nebulizer medication and left the room. During interview on 11/15/23 at 8:11 a.m., LPN-C stated staff cannot go in R7's room when the nebulizer is running due to resident being positive for COVID-19. Staff must stay out of the room for 30 minutes following completion of medication. During interview on 11/16/23 at 10:27 a.m., R7 reported being comfortable with taking nebulizer on her own. She states she does not do anything after completing the nebulizer other than turn off the machine. No one has ever told her to rinse her mouth after and she does not rinse her mouth. During interview on 11/16/23 at 12:19 p.m., consulting pharmacist stated it is standard practice to have the resident rinse their mouth after using this type of nebulizer. It is important to avoid the resident getting thrush (a yeast infection of the mouth). During interview on 11/16/23 at 1:46 p.m., director of nursing (DON) stated it is important for the resident to rinse their mouth after using this type of nebulizer medication to prevent a sore from forming in the resident's mouth. All parameters and guidelines for administering medications should be on the medication administration record (MAR) and the staff should follow them. Facility policy Nebulizer Therapy dated 9/2023 failed to include guidance on rinsing mouth after administration of this kind of nebulizer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure staff were using proper personal protective equipment (PPE) according to the Centers for Disease Control (CDC). Further, the facility failed to prevent Covid positive staff from providing care to 2 of 11 residents (R2 and R15) not on precautions or covid positive and failed to update policies annually for COVID-19 and infection control practices. Findings include: The CDC Interim Infection Prevention and Control Recommendations for Healthcare Personal During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated May 8, 2023, identified when using a NIOSH approved respirator or facemask is indicated for personal protective equipment (PPE) (e.g., NIOSH Approved particulate respirators with N95 filters or higher during the care of a patient with SARS-CoV-2 infection, facemask during a surgical procedure or during care of a patient on droplet precautions), they should be removed and disgarded after the patient care encounter and a new one should be donned. During observations on 11/13/23, 11/14/23, 11/15/23, and 11/16/23, brown paper bags with goggles and N95 masks were sitting on benches on the south, east, and west wings. During an interview on 11/15/23, at 1:22 p.m., infection preventionist (IP) stated staff put the N95 masks in the brown paper bags for five days. There were staff that reused the N95 masks one to two days. During an interview on 11/16/23 at 12:19 p.m., trained medication aide (TMA)-A stated her practice was to switch out the masks every few days. She did not remember being told how often to change out masks during this COVID-19 outbreak. During an interview on 11/16/23 at 12:19 p.m., License practical nurse (LPN)-B stated her practice was to use the same N95 mask twice. During an interview on 11/16/23 at 12:20 p.m., director of nurses (DON) stated staff reused N95 masks for one day, and placed the N95 mask in a brown paper bag between uses. During an interview on 11/16/23 at 11:04 a.m., the administrator stated she was aware of the CDC guidelines that came out in May 2023. She stated staff could reuse N95 masks five times per day and then throw away the masks. Administrator reported the facility had enough masks. During an interview on 11/16/23 at 11:55 a.m., administrator stated she had verified with staff oredering supplies there were a sufficient number of masks available for staff to no reuse. Further, Infection Control Assessment and Response Program (ICAR) had reached out to the facility with an email inquiring on the facility Personal Protective Equipment (PPE) supply. However, she had not yet responded to the email. R2's quarterly Minimal Data Set (MDS) dated [DATE], indicated intact cogitation, history of hypertension, (elevated blood pressure), and cerebral palsy (weakness with using muscles). R2's progress note dated 11/15/23 at 4:44 p.m., indicated negative for COVID-19 from completed outbreak testing. R15's quarterly Minimal Data Set (MDS) dated [DATE], indicated R15 had severely impaired cognition with history of hypertension, (elevated blood pressure), and cardiopulmonary obstructive disease (COPD) (diseases that cause airflow blockage and breathing-related problems). MDS indicated R15 required oxygen therapy. R15's progress note dated 11/15/23 at 11:03 a.m., indicated R15 was negative for COVID-19 from completed outbreak testing. During observation and interview on 11/15/23 at 11:34 p.m., certified nursing assistant (CNA-C) stated she was just going into work with R15 quick and was observed donning and doffing PPE appropriately. CNA-C assisted R15 with personal cares and was in the room for under 10 minutes. During observation and interview on 11/16/23 at 9:11 a.m., CNA-C on west wing donned PPE and was about to enter the room of a COVID-19 positive resident. CNA-C stated that she had recently tested positive for COVID-19 on 11/13/23 and had been assigned to work with only covid-19 positive residents on the east wing. CNA-C stated that she had assisted yesterday with R15 on the east wing and recently with R2 on the west . She was aware that both were negative for COVID-19. CNA-C stated she had been told if she properly donned PPE, she could assist with non-positive COVID-19 residents now, and that previously she could only work with COVID-19 residents on the west wing. CNA-C could not recall who had told her this change. During an interview on 11/16/23 at 10:17 a.m., director of nursing (DON) stated she was not aware of COVID-19 positive staff working with non-positive COVID-19 residents. DON stated positive staff who were asymptomatic were allowed to work as they had qualified for crisis staffing, but they should not be working off the east wing behind the closed doors, where most of the COVID-19 positive residents were located. DON continued, I have just spoken with her, and we have reassigned her off the unit. DON stated scheduling was done by medical records (MR-D). During an interview on 11/16/23 at 10:30 a.m., MR-D stated that when she had covid positive asymptomatic staff who feel well enough to work they were assigned to the east wing and to work with only COVID-19 positive residents. MR-D stated that CNA-C should not have been working with residents not positive for COVID-19. MR-D stated that the rational for using the COVID-19 positive staff was because she had been told the facility was in crisis for staffing. During an interview on 11/16/23 at 11:04 a.m., the facility Administrator stated that they were in Crisis staffing and the reason for not working with a staffing agency was to provide better care and knowledge of residents. The administrator stated that the crisis staff had been reached through review of the CDC crisis staffing criteria, and that they do have contracts for agency or pool staff if needed. The administrator stated that those staff should be working on the east wing only, and that they do have a way of monitoring positive staff through testing and tracking. During an interview on 11/16/23 at 2:30 p.m., facility administrator showed surveyor facility tracking documents for all COVID-19 positive staff, indicated CNA-A was positive on 11/13/23. Upon request of the PPE policy, two polices were provided. One policy titled Donning PPE and Doffing PPE from 2020 which prompted staff to remove facemask/respirator and place in bag with name on it. This policy was on the doors of the isolation rooms. During an interview on 11/16/23 at 11:04 a.m., administrator was shown a copy of the policy from 2020 titled Donning PPE Doffing PPE. Administrator verified that this was the most recent policy that the facility was using. Administrator verified that last time the policy was reviewed was on 8/10/21. Administrator reported her expectations would be to review policies yearly. A second policy from the MED-PASS April 2020, titled Personal Protective Equipment-Contingency and Crisis Use of Facemask (COVID-19 Outbreak), was obtain stating to place masks in a waste container after use. The facility was not abiding to this policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review the facility failed to honor the resident's choice to go to bed at preferred time. This affected 1 of 1 residents (R3) reviewed for self determination. Findings include: R3's Minimum Data Set (MDS) dated [DATE], indicate assistance of one staff with grooming, dressing, transfers. R3 was to be involved with decisions related to ADL tasks. MDS indicated resident's cognitive performance assessment, Brief Interview for Mental Status (BIMS) was a 4/15, indicating severe cognitive impairment. During observation on 12/19/22, at 6:56 p.m. nursing assistant (NA)-A was observed exiting R3's room. NA-A stated R3 was awake in her recliner. On 12/19/22 at 6:57, p.m., R3 was moaning and calling out for help. R3 was seated in reclined chair and dressed in a hospital gown with a blanket covering her body. R3 stated she wanted to go to bed, but NA-A had told her she had to be in the chair. R3 stated she could not sleep like this because of pain in her left shoulder. NA-B entered R3's room and assisted R3 to bed. During interview on 12/19/22, at 6:59 p.m. NA-A stated the rule was residents were not to be assisted to bed before 7:00 p.m. this applied to all residents. NA-A stated she assisted R3 with evening cares and into the recliner. She confirmed R3 had requested to go to bed, however she did not comply. During an interview on 12/19/22, at 6:59 p.m. NA-B stated there was no rule residents were not allowed to go to bed before 7:00 p.m. During an interview on 12/20/22, at 1:36 p.m. NA-C stated there were no rules regarding what time residents got up in the morning or what time they went to bed at night. She stated we do what they request. During an interview on 12/20/22, at 3:00 p.m. licensed practical nurse (LPN)-A stated staff encouraged residents to stay up until about 7:00 p.m. During an interview on 12/20/22, at 3:10 p.m. Director of Nursing (DON) stated residents have the right to choose what time they want to get up in the morning and when they go to bed at night. Further, they encouraged healthy sleep habits. She stated when residents wanted to go to sleep they let them, regardless if it was prior to 7:00 p.m. or not.

Based on interview and document review, the facility failed to ensure the drug regimen reviews were completed by a licensed pharmacist at least once a month for 1 of 1 residents (R15) reviewed for unnecessary medications. Findings include: R15's pharmacy reviews indicated a 43-day gap between drug regimen reviews conducted by a licensed pharmacist. Pharamicists review occurred on 8/31/22 and then again on 10/13/22, resulting in a 43 day gap between pharmacy review of medication. During an interview on 12/21/22, at 12:02 p.m. director of nursing (DON) indicated that drug regimen review was missing for the month of September for R15. During an interview on 12/21/22, at 12:36 p.m. consultant pharmacist (CP) stated September drug regimen review was not completed for R15 due to illness. She stated their contract stated review may be delayed up to ten days, or more frequently than monthly. She stated there should be a back-up pharmacist for instances of absence. She stated pharmacy consults were completed on 8/31/22 and on 10/13/22. She stated the review should have been completed on 9/30/22. Policy titled Drug Regimen Review Policy/Procedure reviewed 12/21/22. Policy indicated consultant pharmacist will review each resident's drug regimen, at least once a month or as deemed appropriate by the pharmacy consultant, either in person or remotely. The consultant pharmacist may need to conduct the medication regimen review more frequently depending on the resident's condition, review short term stay resident's and/or if risk of adverse consequences. Procedure indicated the pharmacy consultant will perform monthly drug regimen review on each resident, unless the resident's condition/risk will indicate a more frequent schedule that is individualized and communicated between the facility clinical staff and the pharmacy consultant.

Based on observation, interview and document review, the facility failed to properly disinfect a glucometer after resident use. This had the opportunity to affect 1 of 1 residents observed for proper disinfection of equipment. Findings include: Record review of medical diagnosis list on 12/20/22 indicated R8 had a diagnosis of diabetes mellitus type 2. During an observation on 12/19/22, at 6:34 p.m. Licensed practical nurse (LPN)-B conducted a blood glucose test for R8 with an Assure Platinum 106 glucometer. She wiped the glucometer with an alcohol wipe after use. However, failed to disinfect the device. During an interview on 12/19/22, at 6:36 p.m. LPN-B stated the glucometer was designated for R8 and each resident had their own. She stated they wiped down meters with alcohol wipes every time they go in and out of the cart. During an interview on 12/21/22, at 9:50 p.m. Registered nurse (RN)-B stated the glucometers were not shared equipment. She stated the glucometers were cleaned with the cleansing wipes and contact was for a designated amount of time, depending on the product. RN-B stated alcohol wipes were not sufficient as a disinfectant. Facility policy titled Glucometer Cleaning and Disinfecting Policy/Procedure, facility issued the Assure platinum glucometer. It was policy to clean and disinfect the blood glucose meters after each use to avoid cross-contamination issues. Blood glucose meters were at a high risk of becoming contaminated with blood borne pathogens such as Hepatits B, Hepatitis C, and HIV per the CDC and by cleaning/disinfecting between resident use it can prevent the transmission of these viruses through indirect contact. To clean the blood glucose meter you may wipe the meter down the soap and water or isopropyl alcohol. To disinfect the blood glucose meter you may use an EPA registered disinfectant detergent or germicide approved for healthcare settings such as super Sani-cloth germ disposable wipe, Sani-cloth HB germ disposable wipes or 1:10 concentration of bleach. Directions continue to wipe all surfaces.