**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure a medication was administered safely for 1 of 1 resident (R10) who had been assessed as unable to safely self-administer medications. Findings include: R10's quarterly Minimum Data Set (MDS) dated [DATE], indicated R10 was cognitively intact, had no hallucinations, delusions, behaviors and did not refused cares. MDS indicated R10 was independent with activities of daily living and mobility. MDS indicated diagnoses of Alzheimer's disease, hypertension, anemia and arthritis. R10's Clinical Orders printer 5/28/25, indicated orders for levothyroxine sodium 75 micrograms (mcg) by mouth once a day in the evening without a diagnosis for this medication. Levothyroxine is prescribed for hypothyroidism. R10 also had and order for NPO (nothing per mouth) except for pleasure foods in liquid form. All other medications were ordered to be administered via tube feeding (TF). R10's care plan printed 5/28/25, indicated she had impaired cognition/thought processes related to Alzheimer's disease and bipolar disorder and directed staff to administer medications as ordered. Also, the care plan indicated R10 had hypothyroidism and directed staff to give thyroid replacement therapy as ordered. R10's Self Administration of Medications Assessment (SAM) dated 3/16/25, indicated resident did not want to self-administer her medications and was not able to identify the expiration date of each medication. During observation and interview on 5/27/25 at 10:36 a.m., R10 was in her room sitting at the edge of the bed. Two round pills were observed on the floor. R10 stated sometimes the nurses leave my thyroid medication in a small cup, and I take it on my own. Sometimes the pill slips out of my hand, falls on the floor, and I often forget to tell the nurses, and they don't ask if I took it. R10 added, I don't take the medication in front of the nurses, they leave the room. I put the pill in my mouth, take a sip of water and let the pill dissolve and I swallow it. During interview on 5/27/25 at 10:46 a.m., licensed practical nurse (LPN)-B stated R10 can swallow a little bit and takes the pill with water. LPN-10 stated she did not know why R10 took this medication by mouth when all other medications were administered through her TF. During interview on 5/28/25 at 1:48 p.m., LPN-A stated she usually worked in the evenings, and R10 took her levothyroxine by mouth. LPN-A stated the nurses tried to give it, but sometimes R10 couldn't take it or wanted to take it later. I leave the medication with her, I go back to her room and if the medication is no longer in the medication cup, it means she [R10] took the medication. I don't see her taking the medication. LPN-A stated R11 had never reported dropping the medication on the floor. LPN-A verified the SAM indicated R10 was not able to self-administer medications and had no order for self-administration of medications. During interview on 5/28/25 at 2:21 p.m., nurse manager/registered nurse (RN)-E verified R10 did not have a physician's order to self-administer medications. RN-E also verified R10's SAM indicated she was not capable of self-administering medications. During interview on 05/29/25 at 1:25 p.m., director of nursing (DON) stated on admission a SAM was completed for all residents. DON stated if a resident requested to self-administer their own medications, the nursing staff will determine if it's appropriate and call the physician to obtain an order for self-administration of medications. DON stated the expectation was for nurses to administer the medications as ordered and never leave the medications at bed side without an order for self-administration. Facility's policy titled Self-Administration of Medications dated 12/13/21, indicated as part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure symptoms of potential psychiatric distress were recorded; and non-pharmacological interventions were attempted then documented prior to the use of as-needed (i.e., PRN) psychotropic medication to improve continuity of care for 1 of 5 residents (R56) reviewed for unnecessary medication use. Findings include: R56 R56's significant change in status Minimum Data Set (MDS), dated [DATE], identified R56 had both long-term and short-term memory impairment, demonstrated hallucinations during the review period, and had episodes of rejection of care behaviors. The MDS recorded R56 as consuming multiple psychotropic medications and being on hospice care while a resident. On 5/28/25 at 7:36 a.m., R56's morning cares were observed with nursing assistant (NA)-A and NA-B involved. R56 was lying in bed which had an air-pressure mattress in place; along with staff helping to wash him up. R56 would converse with staff as they provided care, however, it was not always sensical to the situation including, A bridge of bread, that's perfect for ya. NA-A and NA-B completed R56's morning cares without R56 having any visible, physical behaviors towards them. R56's care plan, dated 9/2024, identified R56 had behaviors including yelling, cursing, accusations and physical aggression. The care plan listed multiple non-pharmacological interventions which could be attempted including redirection, distraction, and providing a calm environment. The care plan continued and identified R56 consumed psychotropic medications due to sleep issues and behavioral needs. The care plan directed to administer the medications as ordered, monitor for their effectiveness, and monitor/record occurrences of R56's target behaviors and interventions. R56's Order Summary Report, signed 5/2/25, identified R56's current provider-ordered medications and treatments. These included lorazepam (anti-anxiety medication) 0.5 milligrams (mg) three times a day scheduled and every 4 hours PRN, haloperidol (anti-psychotic medication) 0.5 mg every 4 hours PRN, and Dilaudid (narcotic medication) 1 mg every hour as needed for pain/shortness of breath. R56's Medication Administration Record (MAR), dated 5/2025, identified R56's medications and treatments along with spacing to record their administration or refusals. The MAR recorded multiple administrations of the PRN medication(s) including: On 5/5/25 at 10:23 a.m., R56 was given a PRN dose of haloperidol which was recorded as, U [unknown]. A corresponding progress note, dated 5/5/25, identified the medication was given with symptoms recorded, agitated yelling help help. However, again, the note lacked what, if any, non-pharmacological interventions were attempted or offered prior to the medication. On 5/19/25 at 4:31 a.m., R56 was given a PRN dose or lorazepam which was recorded as effective. A corresponding progress note, dated 5/19/25, identified the medication was given, however, lacked any symptoms R56 displayed to warrant the medication nor what, if any, non-pharmacological interventions were attempted prior to help calm or settle R56 down. Further, the MAR recorded on 5/19/25 at 4:30 a.m. (same time), R56 was provided Dilaudid for a pain rating of six (6) and was recorded as effective. However, again, the record lacked information or evidence on what symptoms R56 displayed, rationale why both medications were provided at nearly the same time nor what, if any, non-pharmacological interventions were attempted prior to multiple PRN(s) being given. R56's POC (Point of Care) Response History, printed 5/29/25, identified spacing for staff to record behaviors and interventions attempted to reduce them. This identified: On 5/5/25, R56 was recorded as having no behaviors present by the nursing assistant (NA) staff members. The corresponding response of interventions attempted recorded, Response Not Required. On 5/19/25, R56 was recorded as having no behaviors present by the NA staff members. However, the corresponding response of interventions recorded staff attempted providing a calm environment but the behavior was unchanged. This entry of the intervention attempted was recorded at 6:43 p.m. (over 12 hours after the PRN medication was given). When interviewed on 5/29/25 at 9:30 a.m., licensed practical nurse (LPN)-A stated R56 demonstrated behaviors like calling out and would, at times, become immediately aggressive with staff adding, It can be challenging [to care for him]. LPN-A stated R56 was hard of hearing which they felt contributed to his behaviors, and expressed staff often had to leave him alone and then reproach him to get cares done. LPN-A stated giving R56 snacks seemed to help with his behaviors. LPN-A explained if a PRN medication needed to be given, staff should attempt non-pharmacological interventions prior and those should be documented in the progress notes. LPN-A stated PRN medications should only be given one at a time and rarely, if ever, should multiple ones be given at the same time. LPN-A stated it was important document symptoms and the non-pharmacological interventions attempted so as to see if that will help and stuff before you give the medication. LPN-A added, Maybe he just needs someone to talk to, or maybe he's hungry. On 5/29/25 at 12:50 p.m., the assistant director of nursing (ADON) was interviewed, and verified they had reviewed R56's medical record. ADON stated, I saw what you saw, and verified the lack of consistent symptom or non-pharmacological charting with the PRN medication use. ADON stated the charting was a PIP (performance improvement project) they were addressing and verified staff should be attempting and charting symptoms and non-pharmacological interventions with PRN psychotropic medication use. ADON stated this was important to help the IDT see what's working and not working for the resident. ADON added medication may not always be needed if non-pharmacological interventions were attempted prior.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure a comprehensive care plan for hospice care and services was developed and/or readily available to promote continuity of care for 1 of 1 resident (R56) reviewed for hospice services. Findings include: R56's significant change in status Minimum Data Set (MDS), dated [DATE], identified R56 had both long-term and short-term memory impairment and demonstrated hallucinations and rejection of care behaviors. Further, the MDS outlined R56 received hospice services while a resident. On [DATE] at 7:19 a.m., R56 was observed lying in bed while in his room. R56 could be heard from the hallway speaking aloud and had mostly non-sensical speech, however, at times would have statements which could be understood such as, Thank you very much, goodbye, and, What's the subject matter? R56 would also, at times, shout loudly with, Help me! A female staff member did enter R56's room and expressed staff would be down shortly to help get him up and ready for the day. R56's facility care plan, dated [DATE], identified R56 was at the end stage(s) of life and using hospice or palliative care services. The plan listed a goal which read, The resident will be comfortable, along with interventions including calling hospice when new physician orders were received, coordinating with hospice and other end-of-life services, and others which read: Hospice pastoral care visits are scheduled for: See hospice binder at nursing station, Hospice social service visits are scheduled for: See hospice binder at nursing station, The Hospice [sic] staff will provide bathing services on: See hospice binder at nursing station, Medications will be ordered through: See hospice binder at nursing station, and, Supplies will be ordered through: See hospice binder at nursing station. The facility' care plan lacked any further specifics on these services nor how often they'd be provided for R56 while at the care center. A white-colored binder was located at the nursing station which was labeled, Our Lady of Peace Hospice & Home Care, along with a telephone number to contact them. This binder was inspected and R56's name was recorded inside. The binder contained various medical paperwork including a POLST (Provider's Orders for Life Sustaining Treatment), hospice emergency contact information, and multiple 'summary' notes completed by hospice staff when they visited. The binder included a yellow-colored copy of the Service Agreement and Election of Hospice Benefit, dated [DATE], which identified a hospice registered nurse (RN), social worker (SW), and chaplain would visit along with anticipated frequencies (i.e., 1-2 times/month); however, lacked information on what services these disciplines would be doing or performing while onsite with R56. R56's medical record and hospice binder both lacked a complete, comprehensive care plan detailing what services the outside hospice agency would provide. SEE F684 FOR ADDITIONAL INFORMATION. On [DATE] at 9:07 a.m., licensed practical nurse (LPN)-B was interviewed, and explained they were waiting for a call back from hospice as some of R56's as-needed medication supply had expired. LPN-B stated there was no hospice aide coming in to see R56 to their recall and the hospice nurse (HRN) they'd see about once a week, if I'm lucky. LPN-B stated the HRN typically visited with R56 for a bit and then left again adding such was what a majority of them do. LPN-B stated they couldn't recall ever seeing a hospice care plan in R56's binder of information but then added, I can't say I've looked, either. When interviewed on [DATE] at 10:02 a.m., HRN stated they visited the campus once or twice a week, and the hospice SW would visit once or twice a month. HRN stated they typically obtained R56's vital signs and reviewed him for pain control when they visited. HRN stated they'd also, at times or if needed, visit with R56's family members on his condition. HRN stated the hospice care plan was usually housed in their own electronic record which was just for us with no care center staff having access to it. HRN stated a copy should have likely been printed and placed into R56's binder of information. On [DATE] at 1:30 p.m., the assistant director of nursing (ADON) was interviewed, and verified they had looked into R56's hospice binder and medical record. ADON stated the care center had hospice outlined on their own care plan, however, the interventions were somewhat generic and mostly directed to the hospice binder for information. ADON verified the hospice care plan was not provided prior to survey and expressed it was important to have both the care center and hospice plans together and available so staff were on the same page. A provided Care Plans - Comprehensive policy, dated 6/2022, identified an individualized, comprehensive care plan with measurable objectives and timetables would be developed for each resident. This care plan was to be developed within seven (7) days after the completion of the comprehensive MDS.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to coordinate care with an outside hospice agency to ensure ongoing, consistent care delivery and promote comfort for 1 of 1 resident (R56) reviewed for hospice services. In addition, the facility failed to assess and appropriately monitor developing bruising to ensure healing for 1 of 1 resident (R46) reviewed who had visible bruising on their skin. Findings include: R56 R56's significant change in status Minimum Data Set (MDS), dated [DATE], identified R56 had both long-term and short-term memory impairment and demonstrated hallucinations and rejection of care behaviors. Further, the MDS outlined R56 received hospice services while a resident. On 5/28/25 at 7:19 a.m., R56 was observed lying in bed while in his room. R56 could be heard from the hallway speaking aloud and had mostly non-sensical speech, however, at times would have statements which could be understood such as, Thank you very much, goodbye, and, What's the subject matter? R56 would also, at times, shout loudly with, Help me! A female staff member did enter R56's room and expressed staff would be down shortly to help get him up and ready for the day. R56's facility care plan, dated 4/16/25, identified R56 was at the end stage(s) of life and using hospice or palliative care services. The plan listed a goal which read, The resident will be comfortable, along with interventions including calling hospice when new physician orders were received, coordinating with hospice and other end-of-life services, and multiple others including, Hospice pastoral care visits are scheduled for: See hospice binder at nursing station, and, Medications will be ordered through: See hospice binder at nursing station. However, the facility' care plan lacked any further specifics on these services nor how often they'd be provided for R56 while at the care center. A white-colored binder was located at the nursing station which was labeled, Our Lady of Peace Hospice & Home Care, along with a telephone number to contact them. This binder was inspected and R56's name was recorded inside. The binder contained various medical paperwork along with a yellow-colored copy of the Service Agreement and Election of Hospice Benefit, dated 4/3/25, which identified a hospice registered nurse (RN), social worker (SW), and chaplain would visit along with anticipated frequencies (i.e., 1-2 times/month); however, lacked information on what services these disciplines would be doing or performing while onsite. SEE F656 FOR ADDITIONAL INFORMATION. The binder contained a single, white-colored calendar page labeled, 2025 [space] April [space] 2025, along with hospice' staff names handwritten on 4/3, 4/4, 4/9, and 4/14, respectively. This calendar showed a total of three nurse visits and two social worker visits were completed. On the reverse side of the calendar, a handwritten label was made reading, May, along with, Mon May 5 - [staff name] SW. The entire binder lacked any further calendar(s) or direction on when hospice staff would be visiting the campus. On 5/28/25 at 9:07 a.m., licensed practical nurse (LPN)-B was interviewed, and explained they were waiting for a call back from hospice as some of R56's as-needed medications had expired and needed to be renewed. LPN-B stated R56 had been on hospice a couple months now and they were unsure when hospice would visit most of the time prior to them arriving adding they'd see the hospice nurse once a week, if I'm lucky. LPN-B explained R56's as-needed lorazepam (anxiety medication) needed to be renewed before it could be given adding if staff were not Johnny on the spot with watching it then this would happen where the timeframe to give it would lapse. LPN-B reiterated the hospice staff would never tell care center staff prior to coming, rather, just show up which had been the practice since they came onboard. LPN-B stated the calendar used in the binder was for staff to write their names on when they visited, not beforehand, and expressed the hospice staff never seemed to stay very long when they did visit. LPN-B stated they rarely, if ever, even looked in the hospice binder at the calendar or notes adding they only had it with them now to get the number to call about the expired medication. During the interview, at 9:12 a.m., hospice registered nurse (HRN) then entered into the building. LPN-B and HRN then discussed the expired medications before HRN left the desk to see R56. When interviewed on 5/28/25 at 10:02 a.m., HRN stated they visited R56 one to two times per week, and the hospice social worker would visit one or two times per month. HRN stated they couldn't recall another time when R56's medication prescriptions lapsed like had just happened, and expressed they tried to always ask staff when they visit if they needed anything, like prescriptions renewed, at their visits. However, HRN stated it was ultimately care center staff whom were responsible to ensure they don't lapse the medication availability. HRN stated they felt there was collaboration between hospice and the care center adding it was good for what it is here. HRN stated R56 was their only patient at the campus and things were still being worked out adding, It still feels like new, adding there was always opportunity to communicate better. HRN stated they were going to adjust R56's Seroquel order today, and acknowledged the lack of a hospice care plan being readily available for the care center staff. HRN then reviewed the provided calendars in their hospice binder which was left for the care center. HRN acknowledged it lacked a May 2025 calendar (despite being almost June) and it did not outline upcoming visits for care center staff to be aware of adding, I'm not very good at this part. HRN stated having a more routine, set schedule in writing for staff to see would be an area of opportunity, too. On 5/28/25 at 1:30 p.m., the assistant director of nursing (ADON) was interviewed, and verified they had reviewed R56's medical record. ADON explained they didn't typically work with R56's hospice agency and verified the hospice care plan had not been provided to the campus prior to survey. ADON stated one should have been adding it was important to ensure the care plans were available and meshing together so staff were all on the the same page. ADON verified a calendar had also just been placed into the binder to help show when hospice would be visiting more easily adding, prior, it had been a struggle to know exactly what day they're coming. ADON stated the hospice staff should be reviewing R56's medication supplies and prescriptions when onsite to ensure they don't lapse with availability adding, The hospice nurse would catch this [assumed]. ADON verified the importance of coordinating care with a hospice provider adding they should be working together to take care of this resident. A facility provided Hospice Program policy, dated 7/2017, identified the care center would have written agreements with hospice providers and those providers would be held to the same professional standards of service as other contracted agencies or individuals. The policy outlined responsibilities of both the hospice and the care center, however, the spacing to record a person designated to coordinate with the hospice was left blank and not filled out with text reading, 12. Our facility has designated __________ (Name) __________ (title) to coordinate care provided to the resident by our facility staff and the hospice staff. R46 R46's quarterly Minimum Data Set (MDS) dated [DATE], indicated R46 had moderately impaired cognition and no hallucinations, delusions, or rejection of cares. R46 required partial and/or moderate assistance to roll left and right, required substantial/maximal assistance with upper body dressing and transfers, and was dependent with lower body dressing and toileting hygiene. R46's diagnoses included peripheral vascular disease, arthritis, hip fracture, dementia, Parkinson's Disease, and depression. R46's anticoagulant care plan, revised 4/23/25, indicated R46 was on anticoagulant therapy related to atrial fibrillation. Interventions directed staff to complete labs as ordered and report abnormal lab results to the provider and administer anticoagulant medications as ordered by physician and observe for side effects and effectiveness every shift. R46's skin integrity care plan, revised 4/23/25, indicated R46 had an impairment to skin integrity related to new colostomy and surgical wound on abdomen and surgical incision on right hip. R46 had the potential for further skin integrity concerns related to redness on coccyx and groin. Interventions directed staff to use barrier cream after each incontinent episode, keep skin clean and dry, use lotion but not to open areas, use pressure relieving/reducing cushion to protect the skin while in wheelchair and mattress to protect the skin while in bed. R46's care plan lacked resident specific interventions to prevent bruising. R46's Order Summary Report printed 5/28/25, indicated: -11/18/24, apixaban (an anticoagulant medication used to treat and prevent blood clots) oral tablet 2.5 mg by mouth two times a day. -11/18/24, weekly skin check and complete the weekly skin review assessment in the electronic health record every Saturday day shift. -5/28/25, anticoagulant medication- monitor for discolored urine, black tarry stools, sudden severe headache, nausea and vomiting, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status and/or vital signs, shortness of breath, and nose bleeds. Document Y if monitored and none of the above observed. N if monitored and any of the above was observed, select chart code Other/ See Nurses Notes and progress note findings three times a day related to long term (current) use of anticoagulants. R46's progress notes indicated: -1/1/25 at 2:07 p.m., R46 had multiple bruises on bilateral upper extremity. -3/22/25 at 12:35 p.m., R46 had a bruise on back of left hand, and staff would continue to monitor. R46's assessments and other documents viewable in the electronic health record lacked information on bruising assessment and monitoring. During observation on 5/27/25 at 9:28 a.m., R46 was in bed and had bruising on both hands. During observation on 5/29/25 at 8:08 a.m., R46 sat at a dining room table. R46 had general discoloration and a bruise approximately less than one inch by one inch to his left hand and general discoloration and a bruise approximately greater than one inch by one inch to his right hand. R46's right hand had a dark bluish-black scab with reddish drainage between his first and middle finger. During interview on 5/29/25 at 8:23 a.m., nursing assistant (NA)-F stated they notified a nurse when they saw a bruise on a resident. NA-F stated they worked with R46 once in a while and was not aware of bruising to R46. When asked about the new area on R46's right hand, NA-F stated they thought R46 bumped their hand this morning and notified the nurse right away. During interview on 5/29/25 at 1:46 p.m., registered nurse (RN)-E stated staff followed-up on bruises to residents' hands on a case-by-case basis. RN-E stated R46 was on a blood thinner, and staff should evaluate bruises for a potential cause. RN-E stated staff documented new skin concerns in risk management. RN-E stated R46 came out of their room a lot and sat in their wheelchair, and RN-E would have to review R46's progress notes and risk management documents to comment further on R46's skin or bruising. During follow-up interview on 5/29/25 at 2:31 p.m., RN-E stated they looked at RN-E's hands and offered skin protectors or gloves, and R46 declined. RN-E stated R46's hands lined up with the dining table when he sat in his wheelchair and stated R46 was able to move in their wheelchair. RN-E stated they reviewed R46's progress notes and did not see follow-up on R46's bruising. RN-E reviewed R46's risk management documents and stated on 3/5/25, R46 had a scratch from a call light clip, and on 3/28/25, a skin tear was identified on R46's left forearm. RN-E did not see a risk management entry related to bruising. During interview on 5/29/25 at 3:00 p.m., the assistant director of nursing (ADON) expected bruises to be documented in risk management and staff to assess the root cause to prevent future bruises and monitor until healed to ensure the skin does not worsen. R46's skin assessments were requested from the facility. The facility provided Integrated Wound Care progress notes, which lacked documentation of bruising, and did not send any documentation related to the weekly skin assessments. The facility Prevention of Skin Breakdown policy dated 7/2/18, indicated the care plan was to be evaluated and revised based on response, outcomes, and needs of the resident. The facility policy Anticoagulation - Clinical Protocol undated, directed the staff and physician to monitor for possible complications in individuals who are being anticoagulated, and will manage related problems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to comprehensively reassess to help determine what, if any, additional interventions were required to promote healing and reduce the risk of complication after an in-house acquired pressure injury developed for 1 of 2 residents (R56) reviewed for pressure ulcer care. Findings include: R56's significant change in status Minimum Data Set (MDS), dated [DATE], identified R56 had both short-term and long-term memory impairment, demonstrated hallucinations, and had rejection of care behaviors one (1) to three (3) days during the review period. The MDS recorded R56 was enrolled in hospice care and had several medical conditions including high blood pressure, coronary artery disease (CAD), and Alzheimer's Disease. Further, the MDS contained a section labeled, Section M - Skin Conditions, which recorded R56 was at risk of developing pressure ulcers, however, had no current pressure ulcers during the review period. R56's most recent Braden Scale For Predicting Pressure Sore Risk, dated 4/4/25, identified R56 scored a cumulative score of 19.0 which was not considered to be 'at risk' for pressure ulcer development. In addition, R56's Quarterly Resident Review, dated 4/7/25, identified a review of R56's health status (i.e., vital signs, oral status, respiratory status) which included a section labeled, L. Skin[.] This outlined R56 had no current, unhealed pressure injuries adding, Does the resident have any skin integrity issues? answered with, 2. No. However, R56's progress note, dated 4/17/25, identified R56 had irritated skin areas which included, . has got a reddened spot at the sacral area. The note identified R56 was assisted with repositioning and staff continued to monitor the skin integrity. A subsequent Integrated Wound Care (IWC) note, dated 5/5/25, identified R56 was being seen and treated for multiple burns but now outlined, 5/5/25: Burns to bilateral thighs are improving. Staff noticed blistering to sacrum in the last few days. There was no clear cause. The IWC note continued and listed a section labeled, Wound(s):[,] which recorded a pressure ulcer to R56's sacrum including, Stage 2, and, 4.2 X 1.3 X 0 [cm], adding further, 50% Blood blister. A subsequent section of the note labeled, Plan, directed to apply barrier cream with pericares and as-needed; and start an offloading mattress. The note outlined factors which could affect wound healing and directed, Medical management per primary team, and, Optimize nutrition. An additional IWC note, dated 5/26/25, identified a timeline of R56's wound history including the developed pressure ulcer on his sacrum. The note dictation included, 5/12/25 . His sacral ulcer has now evolved into a stage 3 with slough as base, do not suspect any further injury in the past week. Will update orders to a silicone foam border dressing changed M,W, F and [as needed]. Pressure reducing mattress ow [sic] in place. The timeline continued and outlined, 5/16/25 . Burns and pressure ulcer to sacrum have improved in size. Furthermore, the timeline then outlined, 5/26/25 . PU [pressure ulcer] to sacrum has stalled, some stool has seeped under bandage, will change POC [plan] to Triad paste without cover dressing to avoid this. On 5/28/25 at 7:36 a.m., R56's morning cares were observed with nursing assistant (NA)-A and NA-B involved. R56 was lying in bed which had an air-pressure mattress in place; along with staff helping to wash him up. R56 would converse with staff as they provided care, however, it was not always sensical to the situation including, A bridge of bread, that's perfect for ya. R56 was assisted to turn onto his right side which exposed his coccyx and buttocks. R56 had a visible pressure ulcer present on the medial aspect of his coccyx which was approximately 50-cent piece sized, nearly symmetrical in shape, and had a dark-red colored center with lighter pink-colored peri-wound perimeter. The wound bed was not immediately visible and the wound, as a whole, had a visible white-colored, semi-hardened paste-like substance both around and in the wound. NA-A stated they thought the wound looked a little bit better and expressed staff often attempted to get R56 to lay down between meals, however, he was not always cooperative and would refuse at times. NA-A and NA-B stated R56 was repositioned every couple hours which had been the same both before and since the pressure injury developed adding aloud, I think it's the same. NA-B stated the wound had different treatments being applied, too, adding aloud, [It's] sometimes a dressing, sometimes cream. NA-A and NA-B both stated they were unsure what, if any, other interventions being done to help heal the developed ulcer except R56's bed having an air mattress placed on it. NA-A then took a tube of medicated cream labeled, Remedy Protect Zinc Oxide Paste, from R56's bedside table and applied it to R56's coccyx. NA-A then placed a new incontinence product underneath R56 and secured it before helping him to pull up the pants. NA-A and NA-B then finished R56's morning cares. R56's Medication Administration Record (MAR), dated 5/2025, identified R56's current physician-ordered medications and treatments along with staff initials to demonstrate their administration or refusal. This included an order which read, Mighty shakes . two times a day for weight loss, which ended on 5/12/25. These intakes were recorded and ranged from 0 (ml) to 170 ml with multiple spaces just recording, NA [not applicable]. The MAR lacked any further supplement use. On 5/28/25 at 9:22 a.m., licensed practical nurse (LPN)-B was interviewed, and verified they provided care to R56 prior. LPN-B stated R56 developed the sacral pressure ulcer back in May 2025, and was currently getting Triad cream applied to the wound. LPN-B explained when a new pressure ulcer is identified, the staff finding it should report it to the assistant director of nursing (ADON) who would then update the wound nurse adding it would then be looked at and reviewed on their next visit (i.e., Mondays). LPN-B stated staff who find the wound would in the mean time just update the physician and get an order until that happened. LPN-B stated the floor nurse didn't usually review nutrition or do any other comprehensive review of the person or their pressure ulcer risk adding, I don't go over that with anybody. LPN-B stated R56 was not real mobile and used a Broda-type wheelchair for mobility adding R56 would, at times, be combative with staff and resistive to cares. LPN-B reiterated any type of comprehensive evaluation of pressure ulcer risk or determining what interventions were needed for them was not their responsibility adding aloud, It's not my wheel house. When interviewed on 5/28/25 at 10:02 a.m., R56's hospice registered nurse (HRN) stated they were aware of R56's sacral pressure ulcer adding he developed it a few weeks prior. HRN stated they believed the ulcer was improving and looking good as of late. HRN recalled they believed R56 was on a nutritional supplement and expressed interventions for pressure ulcer care was always tough adding they were always walking that line between comfort and restorative. HRN stated they believed the sacral ulcer developed from extended periods of sitting in his wheelchair adding, He's in his chair a lot, and further, There's only so much repositioning you can do. HRN verified they had provided R56 with his current wheelchair and believed it had a cushion present but added, I can follow up on that. Further, HRN stated nobody from the care center had discussed R56's cushion or what, if any, other options were available since R56 developed the ulcer. R56's medical record was reviewed and lacked evidence R56 had been comprehensively reassessed by the care center to determine what, if any, additional or proactive interventions were needed (i.e., protein supplement, different wheelchair cushion) or could be used to help promote healing of the developed pressure ulcer; nor evidence the facility had reviewed R56's nutrition to determine potential nutritional interventions to promote wound healing despite the IWC note directing to optimize nutrition. On 5/28/25 1:30 p.m., the ADON was interviewed. ADON verified R56's sacral ulcer was in-house acquired, and explained when a new ulcer is found the staff notify the provider for immediate orders and place them on the wound team listing to be seen at next visit. ADON stated a comprehensive review, like which would be done with the interdisciplinary team (IDT), would in theory be located in the risk management charting and contain the facility' investigation and reports about it. However, this was not routinely done for pressure ulcer development for some reason. ADON verified there was nothing they could locate in the risk management section of the record regarding R56's sacral pressure ulcer. ADON verified the record lacked a comprehensive evaluation of R56's skin risk since the ulcer developed and expressed their approach had been more just kinda constant reminders to staff about offloading and repositioning him, however, these were also not documented and just more verbal discussions. ADON acknowledged the need to re-assess after a pressure ulcer develops and expressed doing so was important to help prevent further injury adding aloud, If it's not documented, it's not done. A facility-provided Prevention Of Pressure Ulcers policy, dated 3/2025, identified the resident should be assess for pressure ulcer risk upon admission with the assessment repeated weekly and . upon any changes in condition. The policy outlined a comprehensive skin assessment should be done with each risk assessment, as indicated, according to the resident's risk factors and prior to their discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to comprehensively assess for, and implement as appropriate, a nursing functional maintenance program to ensure 1 of 3 residents (R15) maintained and/or improved their highest level of range of motion (ROM). Findings include: R15's quarterly MDS dated [DATE], indicated R15 had severely impaired cognition and required staff assistance with all activities of daily living (ADLs). The MDS indicated R15 had a Functional Limitation in Range of Motion on all extremities. The MDS indicated R15 was not on a restorative nursing program during the look-back period (LBP). R15's care plan, dated 3/20/25, indicated R15 had an ADL performance deficit related to Alzheimer ' s disease and inability to perform self-cares. The care plan outlined R15's daily routine as, she prefers to remain in bed as long as possible, getting up as close to breakfast and lunch as possible, laying back down as soon as possible after meals, and remaining in bed for dinner. The care plan did not include R15's current ROM status or specific interventions or exercises to ensure R15 maintained her ROM and prevented further decline. R15's medical record (including Tasks) was reviewed and did not include an assessment of R15's specific ROM status or interventions/exercises to ensure R15 maintained her ROM if needed. During an interview and observation on 5/27/25 at 2:09 p.m., R15 was observed lying in bed on her back, slightly reclined with no obvious contractures observed. Resident representative (RR)-A stated he commonly assisted R15 with her ADLs and had noticed that R15's legs appeared to have stiffened up. RR-A stated he was concerned as he did not think staff were completing exercises to stop R15's leg stiffening from getting worse. During an interview on 5/28/25 at 11:55 a.m., nursing assistant (NA)-E confirmed she was R15's aide for the day and stated she did not do any passive or active ROM activities with R15. NA-E stated she had not been instructed to complete these with R15 and thought the therapy department did these activities. During an interview on 5/29/25 at 8:54 a.m., registered nurse (RN)-B confirmed he was R15's nurse for the shift, and stated he was not aware of any functional maintenance program for R15 or if she had been assessed for one but recommended asking therapy about it. During an interview on 5/29/25 at 8:59 a.m., the director of rehabilitation (DOR, an occupational therapy assistant) stated her department would make recommendations for a restorative nursing program after discharge from therapy. The DOR stated the therapy department was also happy to assist in screening residents for maintenance programs if consulted by the nursing department, but this did not commonly occur. The DOR stated she did not think that they had created or been consulted to create a maintenance program for R15. During an interview on 5/29/25 at 10:08 a.m., physical therapist (PT)-A stated they do not commonly create restorative or functional maintenance nursing programs but would be willing to if asked. PT-A stated assessing for and following functional maintenance programs would help prevent a rapid decline in functional status as well as help to improve a resident ' s quality of life, especially for residents with degenerative diseases. During an interview on 5/29/25 at 12:26 p.m., the assistant director of nursing (ADON) stated usually the nursing department got their nursing restorative programs for residents after a resident was discharged from therapy. The ADON stated they would then add the program to the care plan and the aides' tasks on the electronic health record (EHR). The ADON stated first she has heard anything regarding a functional maintenance program for R15 and confirmed she did not think R15 had been assessed for her specific ROM status or the need/appropriateness for a maintenance program as needed. The ADON stated usually the nursing department would consult therapy for a functional program if it was something the provider had ordered or if a resident had increased/developed contractures but was not usually completed preventatively unless requested. The facility's Rehabilitative Nursing Care policy dated 5/25/25, indicated nursing personnel were to be trained in rehabilitative nursing care which would be developed and coordinated through the resident's care plan including position changes in bed and routine range of motion exercises.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to complete ongoing pain assessments and timely intervention when signs of pain were observed for 1 of 4 residents (R15) reviewed for pain, with severely impaired cognition. Findings include: R15's quarterly MDS dated [DATE], indicated R15 had severely impaired cognition and required staff assistance with all activities of daily living (ADLs). The MDS indicated R15 was on a scheduled pain medication regimen but had not received any PRN pain medications during the look-back period (LBP). The MDS indicated R15 had non-verbal sounds (crying, whining, gasping, moaning, or groaning) of pain during the LBP, and these indicators occurred three to four days out of the last five days of the LBP. R15's Medical Diagnosis list dated 1/5/24, indicated R15 was diagnosed with Alzheimer's disease, pain in her thoracic spine, and other chronic pain. R15's care plan dated 3/20/25, indicated R15 had chronic pain related to a history of fractures and chronic thoracic back pain. R15's care plan indicated the nursing assistants were to monitor, record, and report to the nurse any signs of non-verbal pain including vocalizations such as grunting, moans and yelling out, irritability, restlessness, tearing, crying, grimacing, etc. but did not include how quickly this should be completed. The care plan indicated R15 had severe cognitive impairment, and impaired thought processes related to late-onset Alzheimer's disease and indicated R15 required assistance with all decision-making and was dependent on staff for meeting all her emotional, sensory, physical, spiritual, and social needs. R15's progress notes from 4/28/25 to 5/28/25, were reviewed and did not include an indication R15's pain had been assessed during the period. R15's Medication Administration Record (MAR) dated 5/1/25 through 5/27/25, indicated R15 received the following pain medications: -one 12 micrograms/hr (mcg/hr) Fentanyl (a narcotic pain medication) patch applied every three days. -five milligrams (mg) of oxycodone (a narcotic pain medication) four times a day. -650 mg of acetaminophen (an over-the-counter pain medication) four times a day. -five mg of oxycodone every four hours as needed, which had not been administered during the period. -650 mg of acetaminophen daily as needed which had not been administered during the period R15's Pain Level record printed on 5/28/25, indicated the last pain score taken was on 3/6/25 and was 1 out of 10. During an interview on 5/27/25 at 1:38 p.m., resident representative (RR)-A stated he felt that the facility staff didn't follow R15's care plan and did not know her well enough due to the number of agency staff used. RR-A stated he had a camera in R15's room and although he didn't watch it all the time, he felt she was not getting pain intervention as often as she should because he would see her yelling out on the camera and not see anyone intervening. RR-A stated that R15 could no longer tell anyone she was in pain, but she used to often tell him her back was killing her and now he could tell she was in pain when she was yelling out. RR-A stated that RR-A had compression fractures to the vertebrae, and he was very concerned that her pain was not being managed when he was not at the facility. During continuous observation and interview on 5/28/25 from 9:15 a.m. to 11:44 a.m., R15 was observed lying in bed on her back with her room door open. At 9:44 a.m., R15 was observed loudly (heard from the hallway) moaning. R15 continued intermittently moaning as heard from the hallway. Nursing assistant (NA)-E and NA-F were observed intermittently passing by R15's room as she loudly moaned. At 10:34 a.m., NA-E and NA-F were observed entering R15's room and closing the door. On interview, NA-F stated they had not assisted R15 but solely were helping her roommate. At 10:46 a.m., as R15 loudly moaned, NA-E was observed entering R15's room and a few seconds later exited. At 10:50 a.m., NA-E was observed to quickly walk a few feet into R15's room as R15 loudly moaned and then walked away. R15 continued to loud moan. Unless noted above, staff were not observed to enter R15's room. During an interview on 5/28/25 at 11:55 a.m., NA-E stated she worked with a staffing agency and was not super familiar with R15 but had worked with her before. NA-E stated she had heard R15 make these moaning sounds previously and thought it was normal for her, so had not completed any nonpharmacological pain interventions for her. NA-E stated she had notified the nurse of the moaning but was not sure of the exact time she had done so. During an interview on 5/28/25 at 12:55 p.m., registered nurse (RN)-D confirmed she was R15's nurse for the shift. RN-D stated that R15 was nonverbal and was unable to tell facility staff when she was in pain. RN-D stated that R15's resident representative was very involved with her care and would sometimes call the facility and ask them to check on her because he would see signs of R15 in pain on the camera he had placed in her room. RN-D stated she could tell R15 was in pain when she was moaning, restless, moving around a lot, or making sounds. RN-D had said that NA-E had notified her of R15 having signs of pain around noon, so she had administered her scheduled pain medication and confirmed she had not completed a formal pain assessment. RN-D stated she would expect the aides to notify her immediately if signs of pain were noticed so she could complete an assessment and intervene as needed. RN-D stated for some residents an assessment prompt was given to complete an assessment with pain medication administration, but she did not see that this was in place for R15, so she had not been completing pain assessments. RN-D stated sometimes they would put pain assessments in the progress notes but confirmed she had reviewed the medical record and was unable to find that regular pain assessments were being completed for R15. During an interview on 5/28/25 at 1:13 p.m., the assistant director of nursing (ADON) stated pain assessments were completed quarterly or as needed when as needed pain medications were given. The ADON stated if an NA had observed signs of possible pain in a resident, she would expect them to immediately notify the nurse so the resident could be assessed. The ADON stated she would expect staff to complete a progress note if they had noted something out of the ordinary but confirmed they did not have a process for ensuring pain assessments were being completed more regularly than quarterly for residents receiving scheduled pain medications who were unable to verbally notify staff of their pain. The facility's Pain Assessment and Management policy dated 10/7/21, indicated acute pain should be assessed every 30 to 60 minutes after the onset and reassessed as indicated until relief is obtained. The policy indicated that staff should assess residents with stable chronic pain at least weekly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to comprehensively assess and attempt alternatives for 1 of 1 resident (R46) reviewed who had grab bars affixed to their bed. Findings include: R46's quarterly Minimum Data Set (MDS) dated [DATE], indicated R46 had moderately impaired cognition and no hallucinations, delusions, or rejection of cares. R46 required partial and/or moderate assistance to roll left and right, required substantial/maximal assistance with upper body dressing and transfers, and was dependent with lower body dressing and toileting hygiene. R46's diagnoses included peripheral vascular disease, arthritis, hip fracture, dementia, Parkinson's Disease, and depression. R46's Order Summary Report printed 5/28/25, indicated okay for bilateral assist bars to serve as an enable to promote independence with order date of 11/18/24. R46's bedrail care plan revised 4/14/25, indicated R46 used bedrails related to need for assistance with bed mobility. Interventions included to anticipate and meet needs, be sure call light within reach and respond promptly to all requests for assistance, educate resident/representative on benefits and risk of bed rail/grab bar use, inspect grab bar per manufacturer direction, and reassess/evaluate use of grab bar quarterly and as needed. R46's quarterly Bed Rail/Assist Bar Evaluation dated 4/5/25, indicated no bed rail or assist bar/grab bar was in use and the need for bed rails was not indicated at the time of the assessment. R46's progress notes lacked indication of risk and benefit conversation of grab bars with resident and/or representative. During observation on 5/28/25 at 8:57 a.m., nursing assistant (NA)-D and NA-H assisted R46 with cares. R46 had two grab bars affixed to bed and used them to roll from side to side while cares were performed. During interview on 5/28/25 at 1:37 p.m., NA-D stated R46 had grab bars since he was in the room and helped him with movement. Further document review of Bed Rail/Assist Bar Evaluations indicated: -11/18/24, R46 admitted on [DATE] and assist bar/grab bar was requested and/or currently in use. New Admit was indicated in the area to describe which alternative was attempted prior to request. Evaluation factors were noted, and summarized findings indicated bed rail or assist bar was indicated and served to promote independence. The resident/family notification areas were left blank. -1/3/25, indicated assist bar/grab bar was requested and/or currently in use, and the areas to describe alternatives and resident/family notification were blank. Evaluation factors were noted, and summarized findings indicated bed rail or assist bar was indicated and served to promote independence. -1/6/25, indicated assist bar/grab bar was requested and/or currently in use, and the areas to describe alternatives and resident/family notification were blank. Evaluation factors were noted, and summarized findings indicated bed rail or assist bar was indicated and served to promote independence. During interview on 5/29/25 at 12:30 p.m., registered nurse (RN)-E stated grab bars were assessed prior to installation and assessments were completed quarterly. RN-E reviewed the Assist Bar Evaluations and acknowledged the lack of documentation of alternatives and family notification. RN-E stated there were ongoing conversations about risks and benefits of grab bars with the resident/family and documentation of conversations would either be in the progress notes or assessments. RN-E stated grab bar assessments were important to ensure resident used the grab bars appropriately and safely. During interview and document review on 5/29/25 at 3:00 p.m., the assistant director of nursing (ADON) stated the facility had an admission consent form and education for grab bars, which included a spot to enter alternatives trialed. The ADON stated there were inconsistencies with who completed grab bar assessments. The ADON provided and reviewed R46's Side Rails/Grab Bar Informed Consent and Release form dated 11/18/24. The document identified a resident/representative signature, and the areas listed for alternatives attempted but failed and alternatives considered but not attempted were blank. The ADON stated the facility usually trialed pillows and encouraged residents to grab the edge of the bed before grab bar installation. The ADON stated grab bars were different than bed rails but still had slight risks to residents.

Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure resident choice with meal preferences was attempted and/or honored to promote quality of life for 1 of 1 resident (R35) reviewed who wanted to have fried eggs (i.e., runny yolk) and was told they could not have them. Findings include: The Centers for Medicare and Medicaid (CMS) State Operations Manual Appendix PP, dated 4/2025, identified the Federal regulatory requirements long-term care facilities must abide by in accordance with Federal law. These regulations included F812 which outlined, . To accommodate residents choice for items such as 'sunny side up [eggs]' the facility must use pasteurized eggs only. On 5/27/25 at 8:13 a.m., an initial tour of the kitchen was completed. A series of boxes were stacked on the floor next to the [NAME] walk-in cooler which had been delivered by the food service vendor. Amongst these were two boxes labeled, Pasteurized Eggs. R35's quarterly Minimum Data Set (MDS), dated [DATE], identified R35 had intact cognition and demonstrated no delusional thinking. On 5/27/25 at 9:13 a.m., R35 was observed lying in bed while in his room. R35 had a meal tray placed on a bedside table which extended across his body and on the plate was a stack of pancakes with fruit, along with one hard-boiled (whole) egg. R35 was interviewed and stated his only complaint about the care center was they wouldn't let him have fried eggs with a runny yolk. R35 added, They won't let me have easy-over eggs. R35 stated it was frustrating to him as others were served them adding aloud, It just doesn't make any sense. R35 stated he had asked for them repeatedly but the management kept telling him no adding, They override me. R35's progress note, dated 4/10/25, was authored by the campus dietary manager (DM) and outlined they had spoken to R35 and informed him they couldn't served over-easy eggs adding, . all eggs will be fully cooked. The note recorded R35 accepted the information and enjoyed the food at the campus. However, the note lacked any rationale on why R35 was unable to have fried eggs despite the campus having pasteurized eggs available for use. R35's nutritional care plan, last revised 4/2025, identified R35 had potential for nutritional risk due to a history of infection, multiple sclerosis, diabetes and a high BMI (Body Mass Index). A goal was listed for R39 to maintain his weight around 200 pounds (lbs) and multiple interventions were listed to help him meet this goal including weights per order, and a protein supplement as directed/ordered. However, the care plan lacked information on why R39 was not allowed to consume fried eggs as outlined in the progress note (dated 4/10/25). The following day, on 5/28/25 at 8:29 a.m., R35 was again observed laying in bed while in his room. R35 had a meal tray placed on the bedside table which R35 expressed staff had just brought in. The tray had a single plate which had French Toast, two hard-boiled eggs, and a small bowl of oatmeal present. A white-colored menu slip was also present on the tray which read several food categories including, Egg: _______, and opposite the slip on the same line, 1 each. The menu slip lacked information on which type of prepared egg(s) R35 wanted. R35 reiterated he wanted fried eggs and expressed aloud, Maybe I will have to call up Denny's [restaurant chain] or something. Immediately following this, at 8:33 a.m., the second floor main dining room was observed. The room had multiple tables present with various residents seated around them including another male resident who was eating eggs on a regular plate which had a visible yellow-colored, runny yolk smeared on the plate. When interviewed on 5/28/25 at 8:36 a.m., nursing assistant (NA)-C stated they were assigned care for R39. NA-C explained R39 typically ate breakfast is his room and thought he (R39) was usually served fried eggs. NA-C stated they were unsure why R39 had been served hard-boiled eggs for the past few days but reiterated they felt R39 was typically served fried eggs. On 5/28/25 at 10:31 a.m., cook (CK)-A was interviewed, and verified they often helped prepare the breakfast meals for residents. CK-A stated they recalled R39 wanting to have fried eggs adding staff had been battling for a couple months with him about it. CK-A stated they believed fried eggs were acceptable to serve as long as pasteurized eggs were used to make them which CK-A verified were available. CK-A stated R39 would eat fried eggs for every meal if allowed, and recalled DM had visited with him about it in the past. CK-A stated, to their knowledge, R39 was not allowed to have fried eggs due to the facility owner not allowing it adding, The owner didn't want to do it. CK-A stated they were unsure of the rationale and advised the DM likely would have more information about it. When interviewed on 5/28/25 at 11:05 a.m., the assistant director of nursing (ADON) stated there had been discussion through an email thread about R39 wanting to consume fried eggs. ADON explained they originally had believed R39 couldn't consume fried eggs due to other regulations (i.e., F812), however, the food service vendor then corrected them saying fried eggs could be made as long as pasteurized eggs were used. ADON stated the interdisciplinary team (IDT) had discussed this just the week prior but still had not come to an ultimate decision on how, when or if R39 would be allowed to consume fried eggs as he wanted. ADON acknowledged resident' choice being important with meal items adding, It's their right to have choice, and staff should do the best we can to accommodate this. On 5/28/25 at 11:29 a.m., the DM was interviewed, and verified they were aware R39 wanted to consume fried eggs with some meals. DM explained if R39 had his way he'd get fried eggs with each meal adding R39 had reported them to her as comfort food. DM verified pasteurized eggs were available and expressed they were still trying to figure out how or if they'd serve them to R39 adding aloud, It's a battle. DM expressed some of the issue was other departments not wanting R39 to have them and it created a situation where they had to decide do we allow resident satisfaction and [or] not. DM acknowledged not being provided foods of choice could be a resident rights violation. A facility' policy on meal choices was requested, however, none was received.

ROOM KNOCK During observation and interview on 5/27/25 at 2:34 p.m., R62 was in their bed in a shared room near the window and furthest from the door. Nursing assistant (NA)-I peeked into the room without knocking, made an unheard comment, and then brought in linens and set them on a chair close to the door before exit. R62 confirmed they did not hear a knock on the door. Surveyor exited the door after interview with R62, and NA-I entered R62's shared room without knocking and went into the bathroom. During interview on 5/27/25 at 2:55 p.m., NA-I acknowledged not knocking on R62's door. During interview on 5/28/25 at 2:13 p.m., R62 stated he was bothered by staff entering the room when not knocking and stated the action made him feel vulnerable. During interview on 5/29/25 at 8:17 a.m., NA-F stated staff should knock on residents' doors before entering, introduce themselves with their name, and explain why they are there. During interview on 5/29/25 at 1:46 p.m., registered nurse (RN)-E expected staff to knock and announce themselves when entering a room. During interview on 5/29/25 at 3:00 p.m., the assistant director of nursing (ADON) stated they would not want anyone barging in their home and could be scary if staff did not have permission to enter. The facility Quality of Life - Dignity policy dated 4/17/24, indicated residents' private space and property shall be respected at all times. The policy directed staff to knock and request permission before entering residents' rooms. Based on observation, interview and document review, the facility failed to provide a dignified dining experience by serving meals on hard plastic trays which had the potential to affect all residents who ate in the dining room. Additionally, the facility failed to ensure all staff knocked on individual resident bedroom doors and introduced themselves prior to entry for 1 of 1 residents (R62) reviewed with concerns with staff entering their room. Findings include: DIGNIFIED DINING: R47's quarterly Minimum Data Set (MDS) assessment, dated 4/11/25, indicated R47 was severely cognitively impaired with no hallucinations or delusions. Further indicated R47 was set up assistance for eating. During an observation on 2nd floor dining room on 5/27/25 at 8:41 a.m., residents were observed to be eating breakfast. On the table in front of each resident was a breakfast meal that sat on a hard plastic tray. During an observation on 3rd floor dining room on 5/27/25 at 8:44 a.m., residents were observed to be in the dining room eating breakfast. In front of all residents, were a hard plastic tray that contained breakfast items. R40 was observed to be seated in his wheelchair with his head down on his plate which sat on a hard plastic tray. Unidentified staff prompted him to sit up and eat. R40's hard plastic tray, which contained breakfast items, was moved from directly in from on him and R40 put his head back on the table. On 5/27/25 at 12:03 p.m., the lunch meal service on the first floor was observed in the main dining room. The room had multiple tables present with residents seated at each and, in the middle of the room, was a large metallic mobile cart which had meal trays inside them. The staff members removed the trays from the mobile cart, brought them to another table and set them down while they prepared drinks, and then took the drinks and place them back onto the hard-plastic meal tray. The entire hard-plastic tray was then delivered to the seated resident at their table. However, the hard-plastic service trays were then left on the table with plates, cutlery and drinks on top of them. During this time, no staff serving trays were observe to ask or offer to remove the items from the tray and place them onto the table. At 12:07 p.m., R13 was observed eating from the hard-plastic meal tray despite sitting at the table. When asked about using a tray despite being at the table, R13 shrugged his shoulders and responded aloud, I don't mind it. R13 added, Given the clientele here, on the plate [removed from tray] would be too messy. At 12:09 p.m., a single table positioned by the hallways was observed which had three residents present along with nursing assistant (NA)-A and NA-B whom were seated at the same table. The three residents each had a hard-plastic meal tray placed in front of them on the table and were being assisted with eating by NA-A and NA-B. NA-A and NA-B were asked about the trays being used and both responded meals were always served on them, adding items weren't removed from the trays and placed on the tables as everything comes together on the tray from the kitchen. Further, NA-A and NA-B expressed nobody from management had ever told them to offer to remove items from the trays for residents when served. During an observation on 3rd floor dining room on 5/27/25 12:08 p.m., residents were observed coming to the dining area for lunch. Lunch carts were brought to 3rd floor and delivered to the 2nd floor dining room by unknown dietary staff. Each lunch cart was an enclosed metal cart on wheels with slots which held hard plastic trays that contained resident meals. Each slot could hold two hard plastic trays which could be slid from the front or back of the approximately 6-foot metal cart. The hard plastic trays each contained a paper slip that identified who the meal was intended for, and a plate of food that was sitting on a plate warmer covered with a hard plastic dome shaped lid. The tray contained a set of silverware along with a napkin. Staff grabbed the trays from the lunch cart, added the drinks that were requested from a different cart, and delivered the entire tray to residents sitting at the table. Staff left the food and drinks on the hard plastic tray that contained the entire meal including the drinks and silverware. At 12:23 p.m., R47 was served lunch on the hard plastic tray, just as all residents were. R47 was non-interviewable. During an observation on 5/27/25 at 12:28 p.m., all residents (approximately 15) seated in the second-floor dining room were observed at dining tables with filled cups and plates placed on top of hard gray plastic trays. During interview on 5/27/25 at 12:41 p.m., registered nurse (RN)-B stated resident food and drinks came on trays so they were served in the same manner. RN-B stated residents usually seemed to eat okay with their food and drinks on the trays and was not aware of any concerns with food or dining. During an interview on 5/27/25 at 12:51 p.m., nursing assistant (NA)-F stated it was the nursing assistant's responsibility to serve the residents the meals during mealtimes, make sure they get what they need, and give them their preferences. NA-F stated all meals were served on hard plastic trays as that is how we are supposed to do it. NA-F stated the meals came up from the kitchen that way and it was expected to serve it that way. NA-F stated it was more dignified to serve meals on hard plastic trays but was not able to explain this. On 5/28/25 at 11:29 a.m., the dietary manager (DM) was interviewed, and they verified each floor's meal service was done on hard-plastic serving trays. DM stated they had, prior, attempted to remove the trays and leave items on the table but then some residents got upset. As a result, they just served all meals on the trays to everyone, however, DM expressed removing the items and placing them on the table was more dining etiquette. DM stated the management had a discussion about this, however, it was not recorded or documented adding they had discussed potentially care-planning which residents wanted or didn't want the trays kept on the table. Further, DM stated they had not ever brought the issue to the resident council for review or input, either, adding aloud, I never thought about that. During an interview on 5/29/25 at 12:58 p.m., the administrator and director of nursing (DON) verified residents had not been individually assessed for preferences on meals served on hard plastic trays. Furthermore, they stated it has not been discussed during resident council meetings. DON stated after the last annual survey they discussed dining with residents but did not recall if the conversations were related to serving meals on the hard plastic trays and how that related to a dignified dining experience, nor did they have documentation of any such conversations. DON stated no resident care plans had been updated to reflect preferences regarding a resident's preference to keep their meals on a hard plastic tray. DON and administrator verified it was important to have a dignified, home-like dining experience for residents as this was their home. A policy regarding dignified dining was requested and not received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to obtain and document an informed consent, including with explanation of risk and benefits, for 4 of 4 residents (R56, R10, R40, R47) reviewed for use of psychotropic medications. Findings include: R56 R56's significant change in status Minimum Data Set (MDS), dated [DATE], identified R56 had both long-term and short-term memory impairment, demonstrated hallucinations during the review period, and had episodes of rejection of care behaviors. The MDS recorded R56 as consuming multiple psychotropic medications and being on hospice care while a resident. R56's Order Summary Report, signed 5/2/25, identified R56's current provider-ordered medications and treatments. These included lorazepam (anti-anxiety medication) 0.5 milligrams (mg) three times a day scheduled and every 4 hours as needed (PRN), haloperidol (anti-psychotic medication) 0.5 mg every 4 hours PRN, and Dilaudid (narcotic medication) 1 mg every hour as needed for pain/shortness of breath. In addition, R56's Medication Administration Record (MAR), dated 5/2025, identified R56's medications and treatments along with spacing to record their administration or refusals. The MAR recorded multiple administrations of the PRN medication(s) including: On 5/5/25 at 10:23 a.m., R56 was given a PRN dose of haloperidol which had a response recorded as, U [unknown]. A corresponding progress note, dated 5/5/25, identified the medication was given with symptoms recorded, agitated yelling help help. On 5/19/25 at 4:31 a.m., R56 was given a PRN dose or lorazepam which was recorded as effective. However, R56's medical record was reviewed and lacked evidence a signed consent for use of the medication was obtained prior to them being provided. Further, the record lacked evidence the risks of expected benefits of the medication regimen had been reviewed or discussed with R56 or his responsible family member prior to initiation of the medications. On 5/29/25 at 8:34 a.m., a telephone call was placed to R56's family member (FM). However, they were unable to be reached. When interviewed on 5/29/25 at 9:30 a.m., licensed practical nurse (LPN)-A explained the medical provider who ordered the medication was responsible to review the medication risks and benefits with the resident adding the direct care nurses rarely, if ever, do it. LPN-A added, Usually we don't [do that]. LPN-A reiterated, Usually the nurse practitioner does. LPN-A stated any conversation on the medications, including consent or risks and benefits, would be charted in the progress notes. R10 R10's quarterly Minimum Data Set (MDS), dated [DATE], indicated R10 was cognitively intact, had no hallucinations, delusions, behaviors and did not refused cares. MDS indicated R10 was independent with activities of daily living and mobility. MDS indicated diagnoses of Alzheimer's disease, hypertension, anemia and arthritis. R10's Clinical Orders, printed 5/28/25, indicated orders for quetiapine fumarate (antipsychotic medication used to treat schizophrenia, bipolar disorder and depression) 125 milligram (mg) tablets via gastric tube for anxiety, paranoia related to bipolar disorder currently in remission. R10's electronic medical record lacked a consent including risk and benefits related to the anti-psychotic medication. During interview on 05/28/25 at 1:48 p.m., LPN-A stated she was not sure if R10 had a consent to take a psychotropic medication. R40 R40's annual MDS assessment, dated 3/21/25, indicated R40 was moderately cognitively impaired with no hallucinations or delusions, no behaviors, wandering or rejection of care. MDS indicated R40 was on an antidepressant. Relevant diagnoses included: depression. R40's Order Summary Report, printed 5/27/25, included the following orders: -duloxetine HCL (antidepressant medication) give 60 milligrams (mg) by mouth one time a day for depression R40's May's Medication Administration Record (MAR), printed 5/28/25, included the following orders: -DULoxetine HCl Oral Capsule Delayed Release Particles (Duloxetine HCl) Give 60 mg by mouth one time a day for depression -Start Date- 10/10/2024. Documentation indicated administered as ordered. A review of R40's progress notes in the electronic medical record (EMR), dated 11/27/24 to 5/28/25, lacked documentation of education being provided regarding duloxetine. Review of R40's entire EMR lacked evidence of a signed consent for antidepressant medication which would include risks, benefits and alternatives. R47 R47's quarterly Minimum Data Set (MDS) assessment, dated 4/11/25, indicated R47 was severely cognitively impaired with no hallucinations or delusions, no behaviors or rejection of care. MDS did note R47 wandered daily. Further, identified R47 was on an antidepressant. R47's relevant diagnoses included: Parkinson's disease without dyskinesia and without fluctuations (a disorder of the central nervous system that affects movement, often including tremors), orthostatic hypotension (condition when blood pressure decreases when rising from sitting or lying down causing dizziness, lightheadedness or fainting), dementia (a group of thinking and social symptoms that interferes with daily functions), depression, psychotic disorder, hypopituitarism (condition where the pituitary gland doesn't produce enough hormones), benign neoplasm of pituitary gland, and tremor. R47's Order Summary Report, printed 5/29/25, included the following orders: -Celexa (antidepressant medication) give 10 mg by mouth one time a day for major depressive disorder with a start day of 5/13/25. R47's May Medication Administration Record (MAR), printed 5/29/25, included the following: - CeleXA Oral Tablet 10 MG (Citalopram Hydrobromide) Give 10 mg by mouth one time a day related to MAJOR DEPRESSIVE DISORDER, RECURRENT, IN FULL REMISSION (F33.42). Start celexa after zoloft is d/c [discontinued]-Start Date- 05/13/2025. Documentation indicated administered as ordered. - Sertraline (antidepressant medication) HCl Tablet 25 MG Give 25 mg by mouth one time a day for Major Depression Disorder related to MAJOR DEPRESSIVE DISORDER, RECURRENT, IN FULL REMISSION (F33.42) for 7 Days -Start Date- 05/06/2025. Documentation indicated it was administered all scheduled days except 5/11/25 and 5/12/25 when it was coded as 6 indicating R47 was hospitalized . -Sertraline HCl Tablet 25 MG Give 50 mg by mouth one time a day for Major Depression Disorder related to MAJOR DEPRESSIVE DISORDER, RECURRENT, IN FULL REMISSION (F33.42) -Start Date- 11/21/2023 0900 -D/C Date- 05/05/2025. Documentation indicated administered as ordered. During an observation on 5/27/25 at 12:30 p.m., R47 was observed sitting at the dining room table for lunch. During an observation on 5/28/25 at 9:04 a.m., R47 was observed sitting in the dining room in his wheelchair with his eyes closed. R47 does not respond to questions when asked. A voicemail was left for resident representative (RR)-B on 5/29/25 at 9:35 a.m. requesting a call back. No return call was received. A review of R47's progress notes in the EMR, dated 4/1/25 to 5/29/25, lacked documentation of notification of starting new antidepressant (Celexa), decreased doses of sertraline, or notification to the RR-B. Furthermore, lacked documentation of risks vs benefits of medications or alternatives. Review of R47's EMR lacked evidence of a signed consent for antidepressant medication which would include risks, benefits and alternatives. During an interview on 5/29/25 at 10:23 a.m., registered nurse (RN)-A stated that floor nurses did not obtain consents for any psychotropic medications. RN-A stated she was unaware of who did that and added I know we (floor nurses) don't do that. On 5/29/25 at 12:50 p.m., the assistant director of nursing (ADON) was interviewed, and verified they had reviewed the medical records for R56, R10, R40, and R47. ADON acknowledged the lack of a clear signed, informed consent for several of the residents' psychotropic medications and explained the standard practice was to notify family when a medication was started and to document that. ADON verified the records lacked evidence of this, and explained they were currently trying to develop a consent form to record this moving forward. ADON stated consent was important as residents and families have the right to choose if they want to take that medication or not. During interview on 05/29/25 at 1:34 p.m., director of nursing (DON) stated their QAPI (Quality Assurance and Performance Improvement) team had been talking about psychotropic medications. DON stated the facility needed to get consents and educate the residents and families about psychotropic medications to ensure residents were aware of the risks and benefits, and it was documented. A facility policy on residents rights regarding medications 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 ensure a low-temperature sanitization commercial dishwasher used in 1 of 1 main production kitchen was adequately monitored (i.e., every shift) to ensure effective chemical concentration and dishware sanitization to reduce the risk of foodborne illness. This had potential to affect all 72 residents, staff and visitors who consumed food from the kitchen. Findings include: On 5/27/25 at 8:13 a.m., an initial kitchen tour was completed of the main production kitchen located in the basement-level of the care center. The kitchen had a single CMA low-temperature commercial dishwasher placed along the wall with various chemicals positioned below in bottles and connected to the machine via clear tubing. These chemicals included rinsing aid(s) and sodium hypochlorite (used as a chemical sanitizer). Later, at 8:22 a.m., dietary aide (DA)-A was present at the machine and rinsing soiled dishware before placing it onto hard-plastic racks and into the machine causing the machine to activate upon the entry door closure. DA-A stated the care center had just gotten this new dishwasher installed a few months prior and verified it was a low-temperature sanitization machine. DA-A pointed to a single gauge positioned below the machine which displayed the water temperature during each cycle. This gauge displayed a washing temperature of 126 degrees Fahrenheit (F) and a rinse temperature of 140 F. DA-A stated they checked the machine for chemical concentration using a Hydrion strip and showed this process to the surveyor. DA-A removed a strip from the packaging and placed one-half of it into pool water in the base of the machine after the dishwasher stopped. The strip turned a purple-color which DA-A compared to the packaging showing a concentration of 50 parts-per-million (PPM). DA-A stated the concentration should be like 50 to 100 [PPM] to ensure sanitization adding the machine was checked every day in the morning before cooking and food service started. DA-A provided a flow sheet labeled, St [NAME] Park Home, which was dated, May 2025, and had columns to record the date, wash temperature, chlorine concentration (i.e., PPM), rinse temperature and staff initials. This identified only a single recording for each date (5/12 to 2/27) and only listed a PPM reading being completed/documented since 5/21 (i.e., six times) with each days' reading being recorded, 50 [ppm]. There were no other recorded ppm checks on the flow sheet. DA-A verified the flow sheet lacked any additional readings and expressed, Maybe they [staff] forgot. DA-A reiterated the machine was only checked once a day to their knowledge for a PPM reading, and they verified the strips were the only testing mechanism used to check the PPM. Later, on 5/27/25 at 2:02 p.m., dietary aide (DA)-B was interviewed. DA-B verified they worked the evening (i.e., second) shift and helped with washing dishes using the CMA commercial dishwasher in the main kitchen from the supper meal. DA-B stated the machine was just installed a few months prior and the morning shift was responsible to check the machine for PPM concentration. DA-B verified they do not complete any checks of the PPM using the Hydrion strips or any other mechanical indicators adding aloud, I don't do that, no. On 5/28/25 at 11:26 a.m., the dietary manager (DM) was interviewed, and they verified the dishwasher was only checked once-a-day for ppm concentration of the sanitizing solution. DM acknowledged the flow sheets used to record this process only started having a documented PPM check on 5/21/25, and expressed it took awhile for staff to get used to running the machine and checking it for function and sanitization. DM stated they would adjust the flow sheet to ensure a twice-a-day check (i.e., every shift) was completed and recorded. DM stated it was important to ensure the machine was checked adequately for sanitization so as to make sure the chemicals are at equal levels to make sure the dishes are getting sanitized. A facility provided Cleaning Dishes/Dish Machine policy, undated, outlined all flatware, dishes and cookware would be cleaned, rinsed, and sanitized after each use adding, The dish machines will be checked prior to meals to assure proper functioning and appropriate temperatures for cleaning and sanitizing. The policy outlined a process to ensure sanitization for both a high-temperature sanitization machine and a low-temperature machine. This directed a 50 PPM hypochlorite reading should be obtained, however, the policy lacked a frequency for how often to test this PPM reading.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** HAND HYGIENE AND GLOVE USE R62's quarterly Minimum Data Set (MDS) dated [DATE], indicated R62 had intact cognition and no hallucinations, delusions, behaviors, or rejection of cares. R62 had impairment to both lower extremities, required partial and/or moderate assistance for upper body dressing and to roll left and right, and was dependent on toileting hygiene and lower body dressing. R62's diagnoses included heart failure, hypertension, malnutrition, anxiety, depression, post traumatic stress disorder, respiratory failure, and chronic obstructive pulmonary disease. During observation on 5/28/25 at 11:10 a.m., nursing assistant (NA)-G wore gloves, unhooked R62's incontinent product, and completed peri-cares. NA-G disposed of R62's incontinent product soiled with urine and used the same gloves to apply a clean brief and clean bed pad. NA-G removed their gloves, did not perform hand hygiene, exited the room, and grabbed a clean gown from the floor's clean linen area. NA-G returned to R62's room with the gown, applied new gloves, and assisted R62 to apply the gown. NA-G bagged soiled linen and garbage, removed gloves, and washed their hands. During interview on 5/28/25 at 11:22 a.m., NA-G stated they changed their gloves after changing R62's incontinent product. NA-G acknowledged they did not complete hand hygiene with glove change or when they exited room to get clean gown. During interview on 5/29/25 at 1:46 p.m., registered nurse (RN)-E expected staff to change gloves and complete hand hygiene after a dirty process and before touching clean products. During interview on 5/29/25 at 3:00 p.m., the assistant director of nursing (ADON), who was the facility's infection preventionist, stated hand washing was the best form of infection prevention. The facility Handwashing/Hand Hygiene policy dated 1/18/22, directed staff to complete hand hygiene after removing gloves, before and after direct contact with resident, before moving from a contaminated body site to a clean body site during resident care, and after contact with blood or bodily fluids. BLOOD GLUCOSE MACHINE The Medline Evencare G2 Blood Glucose Monitoring System dated 2017, included the following cleaning instructions: Wash hands with soap and water, inspect the machine for blood debris, etc., clean the machine with a validated disinfecting wipe, allow it to air dry, and if cracking of the plastic housing is noted, stop using the device. R40's annual Minimum Data Set (MDS) dated [DATE], indicated R40 had moderately impaired cognition and was diagnosed with kidney disease and diabetes. The MDS indicated R40 received insulin (an injection used to lower blood sugar) during the look-back period (LBP). R40's order summary dated 5/29/25, indicated R40 had orders for: -Insulin Lispro (fast-acting insulin) three times a day per sliding scale based on blood glucose level (70 - 149, zero units; 150 - 199, 2 units; 200 - 249, 4 units; 250 -299, 6 units; 300 - 349, 8 units; 350 - 399, 10 units; 400 or greater, 12 units and notify provider) -Humulin 70/30 insulin (combination of insulin isophane and regular, both short and intermediate-acting insulin), 52 units in the morning and 44 units in the evening. During an interview and observation on 5/28/25 at 8:13 a.m., registered nurse (RN)-F stated R40 had insulin due this morning, so he was going to check his blood sugar. RN-F was observed to take a Medline Evencare G2 blood glucose machine which had about an inch-long crack in the plastic housing on the left side of the machine, sporadic white building up on the machine, and was missing a back battery cover which was instead covered with clear medical tape. RN-F was observed to complete hand hygiene, apply gloves, and use the machine to take R40's blood glucose reading. RN-F confirmed this machine was used for the floor and not solely for R40. RN-F stated he was unsure how long the machine had been cracked. During an interview on 5/28/25 at 12:45 p.m., RN-E, the unit nurse manager, stated she was unsure if the blood glucose machine was still a cleanable surface but was going to take the machine out of service and see if they had a different blood glucose machine to use instead. During an interview on 5/29/25 at 12:38 p.m., the director of nursing (DON) stated if a blood glucose machine was cracked, she would expect nursing staff to take it out of service as it was no longer a cleanable surface and could affect the accuracy of the measurements. The facility's Obtaining a Fingerstick Glucose Level policy dated 9/30/21, indicated that blood glucose monitoring equipment was to be cleaned and disinfected according to manufacturer's instructions and current infection control standards of practice. Based on record review and interview, the facility failed to report a suspected Norovirus outbreak to the State Agency (SA) as required. This had the potential to affect all 72 residents residing in the facility. In addition, the facility failed to ensure a blood glucose machine was kept in good repair to ensure the surface could be adequately disinfected and for 1 of 4 residents (R40) reviewed for medication administration. The facility also failed to ensure proper hand hygiene and glove use was utilized for 1 of 2 residents (R62) observed during personal cares. Findings include: NOT REPORTING SUSPECTED NOROVIRUS OUTBREAK TO STATE AGENCY According to 2024-2025 Norovirus Information for long-term care facilities from www.health.state.mn.us, By Minnesota state law ([NAME]. Rules part 4605.7050), any pattern of cases, suspected cases, or increased incidence of any illness beyond the expected number of cases in a given period shall be reported immediately to MDH. This includes suspected outbreaks, increases in GI illnesses, or unusual disease activity at your facility. The Antibiotic Surveillance and Symptom Tracker report, printed 5/28/24, was reviewed. The log included the following information: resident names, date of birth , unit, room numbers, onset date of symptoms, diagnostic order and results, current prescription, infections, isolation, organism, status and signs and symptoms. The report identified between 1/31/25 -2/16/25, 14 residents were suspected of Norovirus. One resident was also identified on 2/26/25 and another on 4/18/25. Recorded signs and symptoms included vomiting, diarrhea, nausea, abnormal bowel movement and GI complaints. Isolation precautions were listed as contact for all residents listed for Norovirus. During an interview on 5/28/25 at 1:57 p.m., assistant director of nursing (ADON) stated she was the facilities infection preventionist (IP) and had been in the IP role for over a year. ADON stated she did all the required reporting for any suspected outbreaks in the facility. ADON stated the facility had a Norovirus outbreak in February, however she did not have any documentation that the outbreak was reported to the state agency as she did not report the outbreak and was unsure if it was required to report a Norovirus outbreak. ADON stated she thought one resident was tested for Norovirus but any residents with symptoms were treated as though they had Norovirus. During an interview on 5/29/25 at 12:52 p.m., director of nursing (DON) stated it was the facilities responsibility to report any suspected outbreak to the state agency. DON stated there was a Norovirus outbreak in February and it should have been reported. A facility policy titled Reporting Communicable Diseases, undated, indicated the infection preventionist is responsible for notifying the local, district, or state health department of confirmed cases of state-specific reportable diseases.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to implement an antibiotic stewardship program which included development of protocols and a system to monitor appropriateness of antibiotic including prophylactic antibiotic use to prevent antibiotic resistance and help prevent the spread of infectious diseases. This had the potential to affect all 72 residents residing in the facility. In addition, the facility failed to ensure an ongoing review of prophylactic antibiotic use for 1 of 1 residents (R51) reviewed for oral antibiotic use. R51 R51's admission Minimum Data Set (MDS) dated [DATE], indicated R51 had intact cognition and had been admitted to the facility on [DATE]. R51's provider note dated 5/20/25, indicated R51 was diagnosed with anemia and wounds of the left and right ankle. The note did not indicate that R51 had a history of urinary tract infections or an indication of review for the continued use of cephalexin. R51's Order Summary Report dated 5/27/25, indicated R51 had an order for cephalexin (an antibiotic) 250 milligrams (mg) daily for urinary tract infection (UTI) prophylaxis. R51's medical record was reviewed and did not indicate that R51' s order for prophylactic cephalexin had been reviewed with indication for its continued use. During an interview on 5/27/25 at 8:46 a.m., R51 stated she had seen a urologist sometime in 2023 after she had fallen and broken her pelvis, and he had started the cephalexin because she had multiple UTIs. R51 stated thought the urologist had told her to keep taking the cephalexin until the body heals but did not recall being told an exact duration of use. During an interview on 5/28/25 at 1:27 p.m., the assistant director of nursing (ADON), also in the role of infection preventionist, confirmed she had reviewed R51' s medical record and was unable to find documentation that the Cephalexin had been reviewed by the provider for the appropriateness of continued use. The ADON stated she would prefer to get rid of prophylactic antibiotics when a resident was admitted to the facility but had been struggling with getting provider participation in reviewing these medications for residents. During an interview on 5/29/25 at 2:27 p.m., nurse practitioner (NP)-A stated R51 had been admitted with the cephalexin, and she had thought R51 had been taking the medication for years and she tend[s] to leave it[those medications] alone. NP-A stated that R51 was currently on a transitional care unit status, so she was not going to review if the continued use of the cephalexin was appropriate for R51, until she transitioned to long-term care as was her practice. NO PROPHYLACTIC ANTIBIOTIC MONITORING The Antibiotic Surveillance and Symptom Tracker report, printed 5/28/25, was reviewed. The log included the following information: resident names, date of birth , unit, room numbers, onset date, diagnostic order and results, current prescription, infection, isolation, organism, signs and symptoms and status. The report lacked prophylactic antibiotic tracking. During an interview on 5/28/25 at 1:57 p.m., assistant director of nursing (ADON) stated she was the facilities infection preventionist (IP). ADON stated she has been in the IP role for over a year. ADON stated she was not tracking any prophylactic antibiotics in the facility and verified they were not included on the antibiotic tracking sheet which was reviewed in QAPI (Quality Assurance and Performance). ADON stated she was currently not reviewing prophylactic antibiotics and was not able to state the number of residents on prophylactic antibiotics. ADON stated she had not determined where or how she was going to track them. ADON stated she relied on the pharmacy to review the prophylactic antibiotics but was unsure how this was completed. ADON stated it was important to monitor prophylactic antibiotics as according to a lot of people they are not effective. During an interview on 5/29/25 at 1:56 p.m., consulting pharmacist (CP)-A stated that during her monthly audits of resident charts, she reviewed antibiotics to ensure they were the appropriate dose for the resident. CP-A stated she did not review for the duration of the antibiotic and stated, I would leave it up to the provider to determine how long the resident should be on a prophylactic antibiotic. During an interview on 5/29/25 at 12:51 p.m., director of nursing (DON) stated it was important to track prophylactic antibiotics to make sure they were appropriate for why they were prescribed. A facility policy titled Antibiotic Stewardship Policy, dated 10/4/21, indicated The Infection Control Nurse will complete monthly chart reviews of all ordered and administered antimicrobials for the residents. The data will be recorded and presented at the Quarterly Quality Assurance Committee Meeting. A review of possible trends will be discussed at this time. The Consulting Pharmacist will complete a monthly review for indications and justification of use to verify that antibiotics are used in accordance with CDC recommended guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN; CMS-10055) upon the termination of Medicare A coverage for 1 of 3 residents (R74) reviewed who remained in the nursing home after Medicare A coverage ended. Findings include: R74's Prospective Payment System (PPS) Part A Discharge (End of Stay) Minimum Data Set (MDS) dated [DATE], indicated he was discharged from Medicare Part A services on 7/23/24 and had intact cognition with diagnoses of Alzheimer's disease (a type of dementia that affects memory, thinking, and behavior) and depression. Under Point Click Care's (PCC) census header, Medicare Part A was identified as R74's primary payer on 6/3/24. Private pay was identified as R74's primary payer on 7/24/24. A Notice of Medicare Non-Coverage (NOMNC) form indicated, a final day of skilled nursing services will be provided on 7/23/24 due to decrease of tube feeding. On 7/26/24, this client's family member(FM)/power of attorney (POA) was informed of this decision. Client unable to sign due to cognitive impairment. Family wants client remain in this facility for LTC at this time, while pursuing Part B or MA coverage for additional therapy services. The form lacked signature or date by resident or his representative. There was a handwritten note below the signature line that read, Multiple attempts made for pt's FM/POA to sign NOMNC (7/23/24, 7/22/24, 7/23/24, and 7/24/24). POA demo's lack of understanding of this document and frequently moves onto other unrelated subjects during conversation. POA has been informed of the right to appeal but has not provided a decision at this time. The form was signed and dated by the occupational therapist (OT) and therapy program manager on 7/24/24. R74's electronic health record (EHR) lacked documentation of discussion with R74 and/or representative about NOMNC or covered services prior to 8/7/24. A progress note dated 8/7/24, indicated social services spoke to R74's family member and the awareness of the cost per day of services. The progress note documented that R74's family member cannot afford that. During interview on 8/7/24 at 1:39 p.m., the OT reviewed verified being responsible for providing NOMNCs and Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage forms (SNF ABNs). The OT reviewed therapy records for R74 and verified R74's Medicare Part A skilled coverage ended on 7/23/24 and the final day skilled services were given was on 7/23/24. The OT recalled having an initial conversation about R74's non-coverage on 7/19/24. The OT stated there were multiple conversations with R74's POA about the NOMNC but the POA declined to sign the form. The OT was unable to locate documentation of such conversations and stated, I don't see any supporting documentation aside from what I have on the NOMNC. Additionally, the OT stated no SNF-ABN was provided to R74 or his representative because the regional director of the consultant therapy company reported NOMNCs were for skilled stays and ABNs were for therapy services and not room and board. The OT stated it was a rare occasion in which they would provide both forms. The OT verbalized they did not believe a SNF ABN form needed to be given to R74 after he discharged from Medicare Part A services. A facility policy titled Medicare Reimbursement Resource Manual Beneficiary Liability Notices dated 2021, indicated it was the policy of the organization to follow Medicare SNF Part A rules and regulations for advance beneficiary non-coverage notices by issuing the correct form in a timely manner. Under the procedure header, the policy guided staff to issue a non-coverage notice in advance of the anticipated last covered day when a resident was nearing discharge, would no longer meet clinical coverage criteria, or had exhausted the MA authorized length of stay. Furthermore, the policy guided staff to provide the SNF ABN (Advance Beneficiary) (CMS 100055) before providing care or services that do not meet Medicare coverage criteria. The policy provided an example of a resident being covered by Medicare Part A but staying in the facility for custodial care. The policy provided a hyperlink for SNF ABN instructions. The policy indicated the NOMNC should be delivered at least two days prior to the last covered day and ensure that the beneficiary or legal representative signs and dates the NOMNC or telephone a beneficiary's legal representative to advise them when services would no longer be covered. The policy indicated if staff telephoned the beneficiary's legal representative, staff should confirm the telephone contact by sending a written notice in the mail on the same date, and if direct contact could not be made, a notice should be sent via registered mail and a dated copy of the notice should be placed in the medical record.

Based on interview and document review, the facility failed to respond to and resolve a report of missing clothing for 1 of 1 residents (R182) reviewed for grievances. Findings include: R182's quarterly minimum assessment data (MDS) indicated, R182 had severe cognitive impairment, no behaviors, hallucinations, or delusions. R182 had limited range of motion in one side of her body, was dependent with grooming, toileting, dressing, and transfers. R182 was unable to ambulate, needed help to set up her meals, and was able to propel her wheelchair. R182's Clinical Diagnosis record printed 8/7/24, indicated diagnosis of hemiplegia and hemiparesis (paralysis and weakness of one side of the body) following cerebral infarction (stroke) affecting left non-dominant side (area of damaged tissue on the brain), lymphedema (swelling due to build-up of lymph fluid in the body), vascular dementia (problems with reasoning, planning, judgement, memory, and other thought processes caused by brain damage from impaired blood flow to the brain), essential hypertension (an abnormally high blood pressure that's not the result of a medical condition) , neuralgia (pain caused by damaged or irritated nerves) , chronic pulmonary embolism (condition caused by a blood clot blocking the pulmonary artery, reduces blood flow and increases pressure in the lungs), chronic pain syndrome, and major depressive disorder. R182's progress note dated 11/21/23 at 2:32 p.m., by a licensed practical nurse (LPN)-C indicated the resident is complaining of her missing dresses. Facility's grievance log for 2023 lacked documentation of a grievance filed on behalf of R182 regarding the missing clothing. During interview on 8/7/24 at 1:46 p.m., social worker (SW) stated when a resident reports a missing item, staff look in the residents' room and call the laundry. SW stated, sometimes they will call me or the administrator. The family will file a grievance form. SW stated we usually find the clothes and if we can't find the items, we call the family and let them know. SW stated, the administrator is in charge and directs the director of nursing (DON) and SW if any further action is necessary. During interview on 8/7/24 at 1:24 p.m., administrator stated, typically missing items are brought up to the nurse's attention. The nurses search the resident's room and call the laundry. This information would be discussed during the daily IDT meeting [Monday-Friday]. Depending on the item it will be assigned to the appropriate department and be followed up. During the weekend, concerns are brought up to the nurse in charge, and depending on the seriousness of the concern they will contact the DON or the administrator. Administrator was not aware a progress note was made indicating R182 reported missing dresses. Administrator stated grievance forms sometimes are part of the process to report missing personal items. Administrator stated grievance forms were available to staff, residents, and families. The facility's policy titled Filling Grievances/Complaints dated 12/14/21, indicated Any resident, family member, or appointed resident representative may file a grievance or complaint concerning care, treatment, behavior of residents, staff members, theft of property, or any other concerns regarding his or her stay at the facility. The facility's policy titled Staff Responsibility Grievances/Complaints dated 10/28/21, indicated staff members are encouraged to guide residents about where and how to file a grievance and/or complaint when the resident believes his/her rights have been violated. Additionally, policy indicated: Any allege abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, must be reported to the administrator immediately, but no later than 2 hours after the allegation is made if the events that cause the allegations involve abuse or result in serious bodily injury, or no later than 24 hours if the events that cause the allegations do not involve abuse and do not result in serious bodily injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure allegations of potential abuse were reported in a timely manner to the state agency (SA) for 1 of 1 residents (R21) whose allegations were reviewed. Findings include: R21's quarterly Minimum Data Set (MDS) dated [DATE], identified R21 had severely impaired cognition with no hallucinations or delusions, and was dependent on staff for all activities of daily living (ADLs) including bed mobility and transfers. R21's care plan, printed 8/7/24, identified R21 transferred with a Hoyer (mechanical lift) and assist of 2 staff. In addition, R21 was unable to adequately verbalize her needs, Speech is nonsensical, disorganized and unintelligible when she speaks. Furthermore, the care plan identified, my safety is at risk and there is potential for abuse due to: Cognitive Impairment, Dementia, or poor decision making. R21's progress note dated 8/1/24, identified the following entry: Residents son flagged writer to come to his mom's room He said there's a bruise here, has anyone reported it, it's probably from the Hoyer but I wanted you to see it. He showed me a very faint discoloration on L chest below her breast. Will monitor. R21's progress notes from 8/1/24 to 8/7/24 reviewed and lacked evidence of any other progress notes monitoring bruise mentioned. A Skin and Wound Evaluation, dated 8/5/24, identified a bruise on left chest. Exact date of bruise was noted as 8/1/24 and area was measured as followed: Area: 35.0 cm (centimeters)2[squared] Length: 9.3 cm Width: 5.9 cm: A section on the bottom of the assessment indicated, son reported faded bruise on left chest. Will continue to monitor. Notifications completed: a radio-button answered: resident/responsible party notified. During an interview on 8/06/24 at 3:07 p.m., family member (FM)-A stated he reported the bruise on R21's chest to the nurse on 8/1/24. FM-A stated they are concerned that staff aren't gentle and if I don't advocate for her, she will be neglected. FM-A stated the bruise on R21's chest was reported to FM-A from the hospice nurse on 7/31/24 and stated that no staff from the facility reported the bruise to FM-A. FM-A stated, I get really worried as staff isn't equipped to handle this population, they aren't trained, they bring in agency staff who don't know anyone and don't care, they just flop them around and not gentle. R21's medical record was reviewed and lacked any evidence the allegation of potential abuse or neglect had been reported to the State Agency (SA). During interview on 8/07/24 at 11:18 a.m., registered nurse (RN)-C indicated that a bruise with unknown origin would be entered into the risk management section of the electronic medical record (EMR). RN-C verified R21's bruise was not entered into the risk management section of the (EMR). RN-C verified the provider should be notified of all injuries of unknown origin and that had not occurred with R21's bruise. RN-C verified R21's bruise was not being monitored in the skin/wound tab section and verified that is the other area that it may be monitored. RN-C verified the EMR lacked evidence of monitoring R21's bruise. During interview on 8/07/2024 at 1:38 p.m., assistant director of nursing (ADON) verified that she along with other leadership are responsible for filing reports to the state. ADON verified that she did not assess R21's bruise and did not know if it was a reportable event. During an interview on 8/07/2024 at 2:11 p.m., director of nursing (DON) verified she was aware of the R21's bruise on 8/5/24 after the wound care nurse took a picture of it. DON verified the bruise was not reported to the SA despite it being of unknown origin the location of the bruise being under the resident's breast. DON verified she has not assessed the bruise and the bruise was not assessed by the wound care nurse until 5 days after the entry of the progress note on 8/1/24. DON verified that a bruise could lighten and shrink in size significantly in that time frame. DON stated, the bruise might have been caused by the Hoyer. DON verified, after review, that R21's bruise should have been reported to SA and investigated to determine the cause. A policy titled Abuse, Neglect, Exploitation or Misappropriation -Reporting and Investigating, dated 3/22/23, was provided. Document indicated, All reports of resident abuse (including injuries of unkonwn origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and throroughly investigated by facility management.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R31 R31's quarterly Minimum Data Set (MDS), dated [DATE], indicated R31 had severely impaired cognition with no hallucinations or delusions. Diagnoses included: dementia (loss of memory, language, problem,-solving and other thinking abilities that are severe enough to interfere with daily life), anxiety, depression, other frontotemporal neurocognitive disorder (progressive disease of the brain involving frontal and temporal lobes of the brain; can also be referred to as frontotemporal dementia), and polyosteoarthritis (type of arthritis that involves five or more joints at the same time). In addition, R31 was dependent on staff for all ADLs including bed mobility and all hygiene needs. In section H: Bladder and Bowel: section H0300 Urinary Continence: R31 was coded as Always incontinent (no episodes of continent voiding), and in section H0400: Bowel Continence: R31 was coded as Always incontinent (no episodes of continent bowel movements). R31's care plan, printed 8/6/24, indicated R31 has functional bladder and blower incontinent r/t [related to] severe cognitive impairment d/t [due to] dx [diagnosis] of Frontotemporal Dementia with the following interventions: - BRIEF USE: The resident uses disposable XL yellow briefs, Change per schedule and prn [as needed]. - INCONTINENT: Check/change 2-3 hours and as required for incontinent. Wash, rinse and dry perineum. Change clothing PRN after incontinent episodes. Care plan further indicated, ADL self-care needs total assist of one secondary to advanced dementia with the following interventions: - PERSONAL HYGIENE/ORAL CARE: The resident is totally dependent on (1) staff for personal hygiene and oral care. - TOILET USE: The resident is not toileted. Dignity protocol every 2-3 hours. R31's progress notes, dated 7/9/24 to 8/7/24, were reviewed. Progress notes lacked evidence of R31 refusing staff assistance or documentation of any behaviors. R31's [NAME], printed 8/7/24, indicated R31 required assistance of 1-2 [staff] for bed mobility and to be repositioned every 2-3 hours. Furthermore, the document identified R31 as Incontinent: Check/change 2-3 hours and as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN after incontinence episodes. During continual observation on 8/06/24: -8:42 a.m., R31 was observed to be seated at the dining room table in her wheelchair, facing the television with two other residents at the table with her breakfast tray in front of her. -8:56 a.m., R31 was assisted with her breakfast -9:34 a.m., R31 continues to sit in the dining room in the same position and a group activity was starting. -10:23 a.m., R31 continues to sit in her wheelchair in the same spot she had breakfast in. R31 has not moved from the location. -11:15 a.m., R31 continues to be seated in her wheelchair in the dining room, in the same position and location. -11:39 a.m., R31 continues to be seated in her wheelchair in the dining room, in the same position and location. -12:15 p.m., R31 continues to be seated in her wheelchair in the same position, in the same location she has been in since observation began. -12:22 p.m., R31's meal is placed in front of her on the table. -12:30 p.m., staff sit next to R31 to assist with her meal. -1:54 p.m., R31 remains seated in the dining room, has not been repositioned or brought back to her room. -2:14 p.m., R31 remains in the dining room. R31 has been in the same location, in the same position (5 hours 32 minutes after observation began). -3:06 p.m., R31 was observed lying in bed. During interview on 8/06/24 at 2:04 p.m., nursing assistant (NA)-C stated the expectation is to check and change a resident that is incontinent is every 2 hours along with repositioning them. NA-C verified they have not repositioned or changed R31 since this morning before breakfast. NA-C verified this was over two hours. NA-C stated, I haven't had a chance because I have a lot of work to do. We are short staffed. NA-C stated they were going to work on it now and verified they are working with R31 today. During interview on 8/06/24 at 2:14 p.m., NA-B stated it is expected to reposition, check and change any resident that is incontinent every 2 hours. NA-B stated they helped transfer R31 this morning prior to breakfast. NA-B stated they have not assisted R31 with any cares, repositioning, or transfers since before breakfast. During interview on 8/06/24 at 3:36 p.m., NA-C stated that after talking with surveyor they brought R31 to their room, transferred her to bed and provided incontinent cares. NA-C verified that R31 had been incontinent of urine and a small amount of bowel movement. During interview on 8/07/2024 at 1:38 p.m., assistant director of nursing (ADON) stated the expectation is residents who are incontinent of bowel and bladder need to be checked and changed every 2-3 hours along with repositioned. ADON stated, it would be based on the residents care plan. During interview on 8/07/2024 at 2:11 p.m., director of nursing (DON) stated the expectation for residents who are incontinent is they are checked and changed every 2-3 hours or what the care plan says. DON stated it is important to do to offload residents to reduce pressure and to ensure they are clean and dry. A policy titled Activities of Daily Living (ADLs), Supporting, dated 12/7/21, indicated, residents who are unable to carry out activities of daily livening independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Based on observation, interview, and record review the facility failed to ensure routine personal care (i.e., incontinent cares, nail care) were provided for 2 of 3 residents (R6, R31) reviewed for dependent activities of daily living (ADL's). Findings include: R6 R6's significant change Minimum Data Set (MDS), dated [DATE], identified R6 had moderate cognitive impairment but demonstrated no delusional thinking. Further, the MDS outlined R6 was dependent on staff for most personal hygiene needs and was not diabetic. On 8/5/24 at 1:47 p.m., R6 was observed seated in a recliner chair while in his room. R6 had long fingernails present on both hands, with the nail edge both having a dark-colored debris present and being several millimeters (mm) long on multiple nails. R6 was questioned on his nail care and who, if anyone, helps him with it. R6 looked at his nails and expressed aloud, My nails need to be clipped. R6 stated he used to clip them himself, however, had lost the clippers awhile back. R6 stated the staff helped him with showers on a weekly basis but nobody from the care center, to his recall, had asked him about clipping his nails in the past few weeks. R6's care plan, dated 7/2024, identified R6 had an ADL self-care deficit due to post-polio syndrome and impaired mentation. The care plan directed, PERSONAL HYGIENE/ORAL CARE: Requires assistance of 1. The care plan lacked any information on nail care (i.e., preferred length, clipping frequency). On 8/6/24 at 9:40 a.m., R6 was observed again seated in his recliner chair. R6's fingernails remained long and soiled as had been observed the day prior. R6's Weekly Skin Review Assessment, dated 8/3/24, identified R6 had no skin issues along with dictation, [R6] had shower. skin check completed with no new skin issue noted. The completed evaluation lacked evidence if nail care had been offered, provided or refused. Further, R6's medical record, including progress notes, lacked evidence nail care had been done, offered or refused within the last week despite R6 having long, potentially soiled nails present. When interviewed on 8/6/24 at 10:02 a.m., nursing assistant (NA)-F stated they had worked with R6 multiple times prior and described him as needing total help with cares and hygiene. NA-F stated R6 rarely, if ever, refused care and the NA's would be responsible to help him complete nail care with his showers. NA-F stated if nail care was refused, then the nurse should be told and they likely charted it but the NA charting didn't have spacing to record such. At 10:06 a.m., NA-F observed R6's nails while licensed practical nurse (LPN)-B was present in the room helping R6's roommate. NA-F verified R6's nails were long adding, They need to be trimmed and cleaned. NA-F stated it looked as it had been awhile since nail care was last done and verified R6 was unable to clip his own adding, He's total [care] and we have to do everything for him. NA-F stated they had never seen or heard of R6 having his own clippers before. On 8/6/24 at 10:20 a.m., LPN-B was interviewed. LPN-B was questioned on R6's fingernails adding aloud, I noticed that [just prior]. LPN-B stated the nails appeared like they'd been cut and expressed, I will cut them. LPN-B stated nail care, including cleaning and clipping, should be done on scheduled bath days adding the care center had recently switched to a new form (i.e., Weekly Skin Review) which not longer asked about nail care so it was maybe being missed by staff. LPN-B verified R6's nail length and condition adding, That is the longest I've seen them. LPN-B stated R6's nails grow fast and the length of them appeared it had been well over a week since they were last clipped. LPN-B stated R6 was not a diabetic and the NA could help him with clipping, too, if needed. Further, LPN-B stated there was no current place to record nail care being done or offered, but they verified nail care should be completed regularly as long nails could break off, create injury, or promote infection. When interviewed on 8/6/24 at 11:32 a.m., registered nurse (RN)-E stated the care center had recently changed with UDAs [assessments] and no longer had nail care recorded on the weekly skin review. However, RN-E stated nail care should be completed with bathing adding, That's always been the expectation. RN-E stated if nail care was refused, then the nurse should record such in the progress notes after re-approaching the resident; however, RN-E verified the medical record lacked evidence of such. RN-E stated nails should be clipped and kept clean so R6 didn't hurt himself or others with them. A provided Fingernails/Toenails, Care Of policy, dated 2022, identified nail care included daily cleaning and regular trimming adding, Proper nail care can aid in the prevention of skin problems around the nail bed. The policy directed nail care should be recorded in the medical record, including if offered and refused.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review the facility failed to ensure assessed and care-planned interventions for preventative skin care were consistently implemented for 1 of 1 residents (R31) reviewed for pressure ulcers. Findings include: R31's quarterly Minimum Data Set (MDS) dated [DATE], indicated R31 had severely impaired cognition with no hallucinations or delusions. Diagnoses included: dementia (loss of memory, language, problem,-solving and other thinking abilities that are severe enough to interfere with daily life), anxiety, depression, other frontotemporal neurocognitive disorder (progressive disease of the brain involving frontal and temporal lobes of the brain; can also be referred to as frontotemporal dementia), and polyosteoarthritis (type of arthritis that involves five or more joints at the same time). In addition, R31 was dependent on staff for all ADLs including bed mobility and all hygiene needs. In section H: Bladder and Bowel: section H0300 Urinary Continence: R31 was coded as Always incontinent (no episodes of continent voiding), and in section H0400: Bowel Continence: R31 was coded as Always incontinent (no episodes of continent bowel movements). In Section M: Skin Condition: M0150 risk of pressure ulcers: R31 was identified at risk for developing pressure ulcers. R31's care plan, printed 8/6/24, indicated R31 has potential impairment to skin integrity r/t [related to] incontinence, immobility, impaired cognition, and history of pressure ulcer right heal, with the following interventions: -reposition q[every] 2-3 hrs [hours] R31's care plan further indicated R21 has functional bladder and blower incontinent r/t [related to] severe cognitive impairment d/t [due to] dx [diagnosis] of Frontotemporal Dementia with the following interventions: - BRIEF USE: The resident uses disposable XL yellow briefs, Change per schedule and prn [as needed]. - INCONTINENT: Check/change 2-3 hours and as required for incontinent. Wash, rinse and dry perineum. Change clothing PRN after incontinent episodes. Care plan further indicated, ADL self-care needs total assist of one secondary to advanced dementia with the following interventions: - PERSONAL HYGIENE/ORAL CARE: The resident is totally dependent on (1) staff for personal hygiene and oral care. -TOILET USE: The resident is not toileted. Dignity protocol every 2-3 hours. R31's progress notes, dated 7/9/24 to 8/7/24, were reviewed. Progress notes lacked evidence of R31 refusing staff assistance or documentation of any behaviors. R31's [NAME], printed 8/7/24, indicated R31 required assistance of 1-2 [staff] for bed mobility and to be repositioned every 2-3 hours. Furthermore, document identified R31 as Incontinent: Check/change 2-3 hours and as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN after incontinence episodes. During continual observation on 8/06/24: -8:42 a.m., R31 was observed to be seated at the dining room table in her wheelchair, facing the television with two other residents at the table with her breakfast tray in front of her. -8:56 a.m., R31 was assisted with her breakfast -9:34 a.m., R31 continues to sit in the dining room in the same position and a group activity was starting. -10:23 a.m., R31 continues to sit in her wheelchair in the same spot she had breakfast in. R31 has not moved from the location. -11:15 a.m., R31 continues to be seated in her wheelchair in the dining room, in the same position and location. -11:39 a.m., R31 continues to be seated in her wheelchair in the dining room, in the same position and location. -12:15 p.m., R31 continues to be seated in her wheelchair in the same position, in the same location she has been in since observation began. -12:22 p.m., R31's meal is placed in front of her on the table. -12:30 p.m., staff sit next to R31 to assist with her meal. -1:54 p.m., R31 remains seated in the dining room, has not been repositioned or brought back to her room. -2:14 p.m., R31 remains in the dining room. R31 has been in the same location, in the same position (5 hours 32 minutes after observation began). -3:06 p.m., R31 was observed lying in bed. During interview on 8/06/24 at 2:04 p.m., nursing assistant (NA)-C stated the expectation is to check and change a resident that is incontinent is every 2 hours along with reposition them. NA-C verified they have not repositioned or changed R31 since this morning before breakfast. NA-C verified this over two hours. NA-C stated, I haven't had a chance because I have a lot of work to do. We are short staffed. NA-C stated they were going to work on it now and verified they are working with R31 today. During interview on 8/06/24 at 2:14 p.m., NA-B stated it is expected to reposition, and check and change any resident that is incontinent every 2 hours. NA-B stated they helped transfer R31 this morning prior to breakfast. NA-B stated they have not assisted R31 with any cares, repositioning, or transfers since before breakfast. During interview on 8/06/24 at 3:36 p.m., NA-C stated that after talking with surveyor they brought R31 to their room, transferred her to bed and provided incontinent cares. NA-C verified that R31 had been incontinent of urine and a small amount of bowel movement. During interview on 8/07/2024 at 1:38 p.m., assistant director of nursing (ADON) stated the expectation is residents who are incontinent of bowel and bladder need to be checked and changed every 2-3 hours along with repositioned. ADON stated, it would be based on the residents care plan. During interview on 8/07/2024 at 2:11 p.m., director of nursing (DON) stated the expectation for residents who need to be repositioned and are incontinent is they are checked and changed every 2-3 hours or what the care plan says. DON stated it is important to do to offload residents to reduce pressure and to ensure they are clean and dry. A policy titled Prevention of Pressure Injuries, dated 9/29/21, indicated reposition all residents with or at risk of pressure injuries on an individualized schedule, as determined by the interdisciplinary care team.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R64 R64's significant change MDS dated [DATE], indicated R64 had severely impaired cognition and had no rejection of care behaviors. The MDS indicated R64 was diagnosed with dementia, kidney disease, and diabetes. The MDS indicated R64 used a walker as a mobility device and was independent with transferring and walking. R64's care plan dated 5/3/24, indicated R64 was a high risk for falls related to impulsivity and a history of falls. The care plan indicated staff were to anticipate and meet R64's needs and R64 needed prompt responses to all requests for assistance. The care plan indicated R64 required the assistance of one staff member with ambulation and used a walker. The care plan did not include R64's need for reminders to use his walker. R64's incident report dated 7/19/24 at 11:57 p.m., indicated R64 had an unwitnessed fall and R64 reported that he was unable to grab his walker because it was too far from him. The report included a predisposing situation factors section with using a walker selected. The report indicated immediate action taken was assessing R64's vital signs and assisting R64 back to bed. The report did not include what fall interventions were newly attempted to prevent further falls based on a root cause analysis of the fall. R64's medical record was reviewed and did not include what if any, new fall interventions were attempted after the fall on 7/19/24 based on a root cause analysis. During an observation on 8/6/24 at 9:13 a.m., R64 was observed walking in his room, barefoot, with no walker. NA-B was observed in the room, facing R64 but assisting his roommate. R64 was observed to bend over and attempt to pick something up off the floor. R64 was observed to walk out of his room with no walker and barefoot while occasionally using the wall for assistance when he stumbled, and NA-B was not observed reminding him to use his walker. R64 was observed to turn around and walk back into the room. R64 was observed to sit down in a chair and put socks on. R64's walker was not within reach from this R64's chair but was on the far side of the room. NA-B was then observed to leave the room and was not observed to move the walker closer to R64 or remind him to use it if he got up. At 9:24 a.m., R64 was observed stumbling towards the walker that was on the far side of the room and caught himself on the double closet doors. R64 was then observed to walk back to his chair without his walker and sit back down. On observation, signs, or visual reminders for R64 to use his walker were not noted. During an interview and observation on 8/6/24 at 9:32 a.m., NA-B stated she worked with R64 multiple days a week. NA-B stated R64 was independent with ambulation but was supposed to use his walker but commonly forgot it. NA-B acknowledged she had noticed R64 walking without his walker but had not attempted to redirect or remind R64 to use his walker before leaving the room. NA-B stated she thought he might have fallen in the past previously but was unsure. NA-B was observed reviewing R64's [NAME] and stated it indicated R64 was supposed to have assistance while walking but no one [facility staff] provided assistance to R64 during ambulation. During an interview on 8/7/24 at 12:36 p.m., the assistant director of nursing (ADON) stated R64 had fallen on 7/19/24 and after reviewing the medical record and the incident report with related notes dated 7/19/24, a fall analysis that had related interventions had not yet been implemented. The ADON stated R64 was impulsive, and they had talked about possible fall interventions this week, and they were going to implement a reminder such as signs in R64's room to remember his walker but had not gotten to it yet. The ADON stated R64 was independent with ambulation but needed frequent reminders to use his walker. The ADON stated R64's care plan and [NAME] had not been updated to demonstrate this and continued to show he needed assistance with ambulation. The ADON stated she would now update the care plan and [NAME] to demonstrate R64's current independence with ambulation with reminders to use a walker. During an interview on 8/7/24 at 1:28 p.m., the director of nursing (DON) stated they reviewed falls every morning and discussed possible root causes and ideally, this would be documented with appropriate care plan interventions but that might not always have been occurring. The facility Falls and Fall Risk Managing policy dated 10/4/21 indicated facility staff would identify fall interventions based on the resident's specific risk factors and potential fall causes to prevent further falls. Based on observation, interview and document review, the facility failed to ensure behaviors of potential wandering were comprehensively assessed and, if needed, interventions placed to ensure safety and prevent elopement for 1 of 1 residents (R330); and failed to ensure fall interventions were implemented to prevent fall and injury for 1 of 3 residents (R64) reviewed for falls and accidents. Findings include: R330 R330's Nurse Admission/readmission 05212021 - V15, dated 7/31/24, identified R330 admitted to the care center from the hospital. R330 was recorded as being alert to person and time, however, not to place or aware of her clinical situation with an option being checked, Short term memory loss. The evaluation concluded with a section labeled, admission Summary, which outlined, . alert and oriented X2 with forgetfulness . assist of one with cares . On 8/5/24 at 2:35 p.m., R330 was observed lying on her bed while in her room which was at the end of a hallway next to a stairwell. R330 smiled at the surveyor upon entrance to the room and expressed aloud, You remember me?! R330 added, I'm your first cousin! R330 stated she had been at the care center just a few days. R330 had flip-flop style shoes in place on her feet, however, did not have any visible wanderguard devices (alerts when attempting to leave an area or building) on her person. Immediately following, at 2:39 p.m., registered nurse (RN)-B was interviewed and stated R6 was very confused. RN-B stated R6 could fool you for awhile but had impaired cognition adding it had been like that since she admitted . R330's initial Elopement Risk Evaluation - V2, dated 8/2/24, identified R330 was non-ambulatory or able to self propel her wheelchair, did not have a history of exit-seeking, and had not eloped or attempted to elope from the facility since the previous observation. The option to select which read, 3. Resident is a new admit, was left unchecked. The evaluation determined R330 was at low-risk for elopement and listed spacing to record what, if any, interventions were implemented including a personal safety alarm, exit alarm, or visual barriers. However, these were all left unchecked. The evaluated concluded, Was the care plan: Initiated [marked]. However, R330's progress note, dated 8/3/24 at 2:03 p.m., identified R330 was seen wandering on another floor looking for the bathroom. The note outlined, During breakfast, Staff was unable to locate resident on her floor and found resident on the first floor, towards the front entrance, sitting on the cough [sic]. It appears as if resident did not remember how to get back to her floor. Resident was redirected. The note lacked what, if any, interventions to reduce the risk of wandering and/or subsequent potential elopement were placed or offered. When interviewed on 8/6/24 at 9:52 a.m., nursing assistant (NA)-G stated they had worked with R330 the evening prior and was again assigned to her care for the current shift. NA-G stated R330 was ambulatory but only walking mostly with therapy and rarely, if ever, found to be self-transferring. NA-G stated they were not really sure if R330 used or wanderguard-type device or if she'd been wandering since admission adding, I worked with her only once. R330's care plan, dated 8/2/24, identified R330 was at low risk for elopement/wandering and listed a goal, The resident's safety will be maintained through the review date, along with a single intervention which read, Assess elopement status quarterly and as needed. The care plan lacked evidence or intervention after being found on another unit near the entrance (progress note, dated 8/3/24). Further, R330's medical record was reviewed and lacked evidence R330 had been comprehensively reassessed for wandering or a potential elopement risk despite being found on a different floor near the exit of the building. When interviewed on 8/6/24 at 10:13 a.m., licensed practical nurse (LPN)-B explained they were currently assigned care for R330 but had also worked with her prior since she admitted a week or so prior. LPN-B verified R330 had cognitive impairment and stated she needed help with transfers and could move with some assistance needed. LPN-B stated they were unaware of any wandering episodes for R330, and explained any re-evaluation of their wandering risk would be according to how alert and oriented they [resident] are. LPN-B stated they felt R330, if found to be wandering at some point, would likely need a wanderguard adding, I would think she would need one. LPN-B stated this was due to R330 not always knowing where she was and being 'forgetful.' Further, LPN-B stated any re-assessment of the need for a wanderguard or similar intervention would be done by the nurse manager or director of nursing (DON) adding, [They] can do their little assessment and say yay or nay. On 8/6/24 at 11:27 a.m., registered nurse manager (RN)-E was interviewed, and verified they had reviewed R330's medical record. RN-E stated the IDT was aware of R330's episode of being found on the first floor and had verbally discussed it, however, felt since it was not actually 'exit-seeking' that a wanderguard wasn't needed. However, RN-E stated the floor staff were going to repeat the elopement screening tool as R330 was now more ambulatory, and they verified the record lacked any re-evaluation despite R330 being found by an entrance on another floor days prior. RN-E stated if staff see behaviors of exit-seeking or wandering, then it should be reported and it was important to do an evaluation so staff is aware and it's communicated and her [R330] safety is maintained. A provided Resident Elopement policy, dated 6/2022, identified staff should report any resident who attempts to leave the premises or is missing. The policy outlined procedures to follow when a resident including upon a resident return (if discovered as missing) which included, Apply a wander guard bracelet with MD order as needed, and, Document relevant information in the resident's medical record. However, the policy lacked information on how wandering, including with potential to elope, would be evaluated or assessed and care-planned (i.e., frequency, person responsible).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review the facility failed to comprehensively assess past trauma and develop a comprehensive person-centered care plan with goals and interventions utilizing a trauma-informed approach including monitoring of PTSD (post-traumatic stress disorder) for 1 of 1 (R76) residents reviewed for trauma-informed care. Findings include: R76's admission Minimum Data Set (MDS), dated [DATE], identified R76 with moderately impaired cognition and diagnoses included: PTSD, bipolar disease (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), anxiety disorder, and fibromyalgia (medical syndrome which caused chronic widespread pain). R76's Trauma Informed Care History Assessment, dated 6/27/24, identified R76 as alert, orientated and cognitively intact. The document identified through a question with a radio-button answered yes that R76 experienced any life traumatic events. The assessment form disclosed a traumatic event that happened to R76 related to her time in military service. Furthermore, assessment indicated are you aware of any particular triggers that may make this worse for you, the box below had a typed response of N/A. R76's care plan, printed 8/6/24, indicated a PASARR [preadmission screening and resident review] screening has determined that a serious mental disorder, intellectual disability or related disorder exists (Bipolar, PTSD) with an intervention of coordinate PASARR Level II recommendations. Psychiatry referral as ordered. The care plan lacked evidence of any other mention of R76 suffering from PTSD, discussing possible triggers, interventions to determine triggers, measurable objectives, interventions, and timeframes for how staff are expected to meet R76's desired goals and outcomes concerning her PTSD. Furthermore, the document identified R76 was dependent on staff etc. for meeting emotional, intellectual, physical, and social needs r/t [related to] cognitive deficits, physical limitation. During an interview on 8/07/24 at 10:05 a.m., R76 was observed lying in bed. R76 stated, No one from here has ever talked to me about any of my past trauma .I have sexual trauma from the military .I would like it if someone would talk to me .I do have triggers that make it worse .Sometimes when the men lean over me to provide cares, it triggers me, I know they have to do that when they provide cares but it does trigger me at times. R76 stated she would like to work with the social worker to identify triggers as no one has ever asked me about what triggers me. On 8/07/24 at 11:09 a.m., nursing assistant (NA)-D verified they are familiar with R76. NA-D stated they are not sure if R76 has PTSD or any triggers. On 8/06/24 at 3:36 p.m., NA-C verified they are familiar with R76 and work with her often. NA-C stated they are not aware if R76 has PTSD or any triggers that make it worse. NA-C stated they received training on trauma informed care. On 8/07/24 at 11:18 a.m., registered nurse (RN)-C verified they are responsible for R76's care and familiar with her care. RN-C stated they are unsure if R76 has PTSD or any known triggers. After review of care plan, RN-C verified there was no documentation on the care plan relating PTSD except for reference to diagnosis with the PASARR. RN-C verified there were no interventions to determine any triggers, known triggers, or for staff to assess for triggers in R76's care plan. On 8/07/24 at 1:21 p.m., social worker (SW) verified that she is familiar with R76. SW stated that she has visited with R76 about her time in the military. SW verified she has not talked with R76 about any triggers. SW verified R76 did not identify any triggers for R76. SW stated a trauma informed assessment was completed upon assessment and verified that N/A stands for not applicable. On 8/07/2024 at 1:38 p.m., assistant director of nursing (ADON) stated that she believes staff get trained on trauma informed care annually and during orientation. ADON stated, I do not know if it [PTSD] is on the care plan when asked about R76 diagnosis and triggers. A facility policy titled Trauma-Informed and Culturally Competent Care, dated 10/18/22, was provided. The document purpose is to address the needs of trauma survivors by minimizing triggers and/or re-traumatization. In the section Resident Care Planning it identified to develop individualized care plans that address past trauma in collaboration with the resident and family, as appropriate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to act upon the consultant pharmacist's recommendation for 1 of 1 resident (R13) reviewed for unnecessary medications. Findings include: R13's quarterly Minimum Data Set (MDS) dated [DATE], indicated R13 was cognitively intact, did not experience hallucinations or delusions and did not refuse cares. MDS indicated R13 needed extensive assistance with transfers, hygiene, bathing, and dressing. R13 needed set up with oral hygiene and eating. R13's Clinical Diagnosis report printed 8/7/24, indicated Parkinson's disease with dyskinesia (disorder of the central nervous system that affects movement, often including tremors), dementia with other behavioral disturbances, neurocognitive disorder with Lewy Bodies (type of dementia characterized by build up of protein deposits in regions of the brain memory, thinking and movement) , essential hypertension(abnormally high blood pressure that's not the result of a medical condition) , and vitamin d deficiency. R13's Clinical orders report printed 8/7/24, included an order dated 9/11/23 for quetiapine (an antipsychotic medication) 25 milligrams (mg) at bedtime for hallucinations. R13's Consultant Pharmacist Recommendation to Physician dated 4/16/24 and 7/20/24 indicated the quetiapine 25 mg dose was active since 3/7/22. Recommendation read Within the first year in which a resident is admitted on a psychotropic medication or after the prescribing practitioner has initiated a psychotropic medication, the facility must attempt a GDR [gradual dose reduction] in two separate quarters (with at least one month between the attempts), unless clinically contraindicated. After the first year, A GDR must be attempted annually, unless clinically contraindicated. The recommendation included a message directed to the provider, as follow: Resident is due for a dose reduction assessment. During your next visit could you please review whether resident continues on the lowest doses of his/her regimen. If a dose is contraindicated, please document clinical rationale below. Both recommendations did not contain documentation showing and answer to the recommendations. During interview on 8/6/24 at 3:26 p.m., assistant director of nursing (ADON) stated the facility switched providers in April. In July, in order to make changes to the residents' psychotropic medications the new nurse practitioner requested a detailed psychosocial review and when the last GDRs were done for each resident. ADON stated the psychosocial reviews were on her to do list. During interview on 8/7/24 at 2:02 p.m., director of nursing (DON) stated the previous nurse practitioner left on April 10th. DON stated when the new nurse practitioner started, she didn't want to make any changes without knowing the residents. DON stated in July she asked for the psychosocial reviews and our ADON will be working on them. DON verified the pharmacist recommendations for the month of April and July were not done. The facility title Medication Monitoring and Management, Antipsychotics dated 5/2022, indicated If a resident is admitted on an antipsychotic medication or the facility initiates antipsychotic therapy, the facility must attempt a GDR in two separate quarters (with at least one month between the attempts) within the first year, unless clinically contraindicated. After the first year, a GDR must be attempted annually, unless clinically contraindicated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure non-pharmacological interventions were attempted and recorded prior to administration of as-needed (PRN) narcotic medication to reduce the risk of potential complications for 1 of 5 residents (R4) reviewed for unnecessary medication use. Findings include: R4's admission Minimum Data Set (MDS), dated [DATE], identified R4 had intact cognition and consumed opioid (i.e., narcotic) medication during the review period. R4's care plan, dated 8/5/24, identified R4 had potential for pain due to recent hip surgery. A goal was listed which read, . will not have an interruption in normal activities due to pain through the review date, along with several interventions to help R4 meet this goal including, The resident's pain is alleviated/relieved by: Ice, rest, pain medications. The intervention start date was recorded as, 08/05/2024. R4's Order Summary Report, signed 7/29/24, identified R4's physician orders while at the care center. This included an order which read, HYDROmorphone HCL [Dilaudid, a narcotic] Oral Tablet 2 MG [milligrams] . by mouth every 6 hours as needed . , with a start date recorded, 07/22/2024. R4's corresponding SKILLED note, dated 7/29/24, identified R4 was seen by the nurse practitioner (NP) for a follow-up visit with notation of R4 having been hospitalized until 7/9/24 for a femur fracture and post-surgical infection. The note outlined R4's pain regimen with dictation, . Reports pain increased overnight last night and some difficulty sleeping but overall well controlled. Seen working with PT [therapy] prior to visit and no observed significant pain. PT reports [R4] is able to perform all exercises with some pain but overall she does not feel it is interfering with [R4] progress. The NP identified R4 was consuming the narcotic 2-3 times per day and listed several orders including, DECREASE dilaudid frequency to BID PRN [twice daily, as needed] - separate doses by at least 4 hours. On 8/7/24 at 8:52 a.m., R4 was observed in the dining room on her unit. R4 finished eating and stood up next to the table with nursing assistant (NA)-I immediately beside her. R4 took several steps using a front-wheeled walker and ambulated down the hallway to her room without any obvious physical signs of pain (i.e., grimace, moaning) present. Following, at 9:01 a.m., R4 was interviewed and stated she felt her pain was being well-managed at the care center. R4 stated she was taking the hydromorphone since I've been here and expressed the NP was trying to take me off it before I go home. R4 stated the staff had not offered or asked about ice packs or heat packs before giving the narcotic before but expressed she was open to trying such interventions, if offered. R4's Medication Administration Record (MAR), dated August 2024, identified R4's consumed medications for the month-period. This included R4's hydromorphone with directions, . 2 mg by mouth every 12 hours as needed ., with a corresponding pain level being written with each recorded administration. A total of six administrations for the month, so far, had been recorded as follows: On 8/1/24 at 3:30 a.m., for pain rated nine out of 10 with the dose being effective. A corresponding progress note, dated 8/1/24, identified the medication was given with dictation, . Resident requested and given for right hip pain. Rated pain as 9/10 on the pain scale. However, the note lacked further information on what, if any, physical symptoms were demonstrated (i.e., grimace, crying) or what, if any, non-pharmacological interventions were offered or refused prior to the narcotic being given. On 8/2/24 at 12:17 a.m., for pain rated 10 out of 10 with the dose being effective. A corresponding progress note, dated 8/2/24, identified the medication was given with dictation, . Resident requested and given for right hip pain. Rated pain as 10/10 on the pain scale at this time. However, the note lacked further information on what, if any, physical symptoms were demonstrated (i.e., grimace, crying) or what, if any, non-pharmacological interventions were offered or refused prior to the narcotic being given. On 8/2/24 at 11:17 p.m., for pain rated nine out of 10 with the dose being effective. A corresponding progress note, dated 8/2/24, identified the medication was given, however, lacked any further dictation or rationale for the medication; nor information on what, if any, physical symptoms were demonstrated (i.e., grimace, crying) or what, if any, non-pharmacological interventions were offered or refused prior to the narcotic being given. On 8/4/24 at 1:28 a.m., for pain rated nine our of 10 with the dose being effective. A corresponding progress note, dated 8/4/24, identified the medication was given, however, lacked any further dictation or rationale for the medication; nor information on what, if any, physical symptoms were demonstrated (i.e., grimace, crying) or what, if any, non-pharmacological interventions were offered or refused prior to the narcotic being given. On 8/4/24 at 7:05 p.m., for pain rated 10 out of 10 with the dose being effective. A corresponding progress note, dated 8/4/24, identified the medication was given with dictation, . Res c/o [complain] pain 10/10 on right hip. However, the note lacked further information on what, if any, physical symptoms were demonstrated (i.e., grimace, crying) or what, if any, non-pharmacological interventions were offered or refused prior to the narcotic being given. On 8/5/24 at 7:41 a.m., for pain rated eight out of 10 with the dose being effective. A corresponding progress note, dated 8/5/24, identified the medication was given, however, lacked any further dictation or rationale for the medication; nor information on what, if any, physical symptoms were demonstrated (i.e., grimace, crying) or what, if any, non-pharmacological interventions were offered or refused prior to the narcotic being given. R4's medical record was reviewed and lacked evidence non-pharmacological interventions had been attempted prior to the administration of the PRN narcotic medication despite newly care-planned, effective non-pharmacological interventions for her pain being listed and the medical provider actively trying to decrease the frequency of the narcotic use. When interviewed on 8/7/24 at 9:48 a.m., NA-F stated they had worked with R4 prior but had not, at least to their recall, ever heard R4 complain about pain adding, I've never heard her. NA-F stated they had not offered or given R4 ice packs or anything; nor had they ever been told to by the nurses adding, Not that I know of. NA-F verified R4 was working with therapy and reiterated R4 had not complained about pain to their recall adding, I never see her do that [pain symptoms]. On 8/7/24 at 9:51 a.m., registered nurse (RN)-A was interviewed. RN-A verified they had worked with R4 prior and explained she (R4) had hydromorphone ordered two times max a day for pain. RN-A stated R4 would most often have pain in the early morning but added the pain, overall, seemed to be going down a little bit. RN-A stated with use of as-needed pain medications, including narcotics, the staff should be trying ice or topicals prior to giving it. RN-A reviewed R4's medical record and stated R4 used to have an order for ice to be applied but added, We might have taken it out. RN-A verified non-pharmacological interventions should be attempted prior to a as-needed narcotic being given and recorded in the progress notes adding, Technically, that's what were supposed to do. RN-A stated it was important to attempt non-pharmacological interventions and chart them to help ensure the least dose of medication is used adding, If it's not charted, it's not done. When interviewed on 8/7/24 at 11:25 a.m., registered nurse manager (RN)-E verified they had reviewed R4's medical record, and they could not find anything non-pharmacological [recorded], adding further, The expectation is they're offered prior. RN-E stated the care center was looking into building non-pharmacological use into the order set and verified they should be offered, attempted and recorded with as-needed narcotic use adding such was important due to medications can have side effects, so if they can be avoided [better]. A facility' policy on as-needed narcotic management was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure an appropriate indication was given for continued antipsychotic medication use for 1 of 5 residents (R68) reviewed for unnecessary medications. Findings include: R68's quarterly Minimum Data Set (MDS) dated [DATE], indicated R68 had severely impaired cognition and was diagnosed with dementia, anxiety, depression, and a stroke. The MDS indicated R68 had no signs of psychosis such as hallucinations or delusions and did not have behavioral symptoms during the look-back period (LBP). The MDS indicated R68 was dependent on staff for all activities of daily living and was receiving hospice services. R68's medical diagnoses report dated 1/16/24, indicated R68 had dementia without behavioral disturbance. R68's Order Summary Report dated 1/16/24, included an order dated 1/16/24, for quetiapine (an antipsychotic medication) 12.5 milligrams (mg) every evening for agitation. R68's care plan dated 1/29/24, indicated R68 had a behavioral problem related to dementia and would call out for family members as well as experience hallucinations and delusions. The care plan indicated facility staff were to document behaviors and the potential causes. The care plan indicated staff could intervene by giving reassurance, using distraction, rest, or providing a less stimulating environment. The care plan dated 1/17/24, indicated R68 used psychotropic medications related to dementia and end of life. The care plan indicated staff were to record occurrences of target behavior symptoms including agitation, restlessness, sadness, and isolation. R68 Medication Administration Record (MAR) dated 5/1/24 through 8/6/24, indicated nursing staff were to document if behaviors were observed related to quetiapine use and no was charted daily during the period. R68's Behavior Monitoring and Interventions report dated 5/21/24 through 8/8/24 indicated, facility staff documented whether R68 had behaviors, what these behaviors were, and what interventions were taken approximately every shift. All entries during this period were documented as no behaviors observed or not applicable. R68's progress note dated 5/21/24 at 12:42 p.m., indicated R68 was sleeping and had no behaviors or hallucinations that morning. R68's provider note dated 5/21/24, indicated R68 was declining and was on hospice. The note indicated R68 was mostly sleeping and mostly nonverbal. The note indicated R68 was confused but had no behaviors. R68's Consultant Pharmacist Recommendation to Physician dated 6/23/24, indicated R164 was receiving quetiapine for a diagnosis of agitation which is not considered an appropriate indication for antipsychotic use. The report indicated if the antipsychotic use was to continue, to clarify the appropriate diagnosis. The provider responded on 7/15/24 by indicating the associated diagnosis was behavioral or psychological symptoms of dementia (BPSD) that present a danger to the resident or others. R68's provider note dated 7/22/24, indicated R68 had severe dementia and was nonverbal. The note indicated R68 appeared comfortable and was sleeping. The note did not indicate what behaviors or psychological symptoms of dementia that R68 had that would present a danger to R68 or others. R68's progress note dated 8/3/24 at 8:33 a.m., indicated R68 had yelled out for family early in the morning but was now sleeping. R68's progress notes dated 5/21/24 through 8/5/24 were reviewed and did not indicate R68 had presented with behaviors that were a danger to the resident or others. During an interview and observation on 8/6/24 at 9:22 a.m., nursing assistant (NA)-A stated she worked with R68 frequently and had noticed that he got confused. NA-A stated if R68 was left in his wheelchair for a while, R68 would become very uncomfortable and then somewhat restless but once they would move him out of his wheelchair into bed, they did not notice any restlessness. NA-A stated she had not noticed R68 having any other behaviors. R68 was observed sitting in his wheelchair in his room with his eyes closed and no signs of agitation. During an interview on 8/6/24 at 1:59 p.m., NA-B stated R68 was always sleeping and she had not noticed any behaviors or agitation. During an interview on 8/6/24 at 2:00 p.m., registered nurse (RN)-F stated she was the nurse in charge of R68's care. RN-F stated R68 was usually just dosing off and she had not noticed any behaviors or signs of agitation. During an interview on 8/7/24 at 11:17 a.m., nurse practitioner (NP)-A stated she had been working with R68 since April of this year. NP-A stated it looked like quetiapine had been started in January for behavioral issues. NP-A stated she had signed the pharmacist review dated 6/23/24. NP-A stated the resident was so new to her so she was unsure if R68 was currently or previously had behavioral symptoms that were a danger to himself or others. NP-A stated she now reviewed the medical record and did not see any behaviors documented since April of this year. NP-A stated she was not sure why behavioral or psychological symptoms of dementia (BPSD) that present a danger to the resident or others was the diagnosis chosen as she did not see documentation that this was correct. NP-A stated if R68 was having behavioral symptoms warranting antipsychotic use, she would have expected nursing staff to document these symptoms. NP-A stated she would defer to the assistant director of nursing (ADON) as she knew the resident and what behaviors he might be presenting with, better than she would. During an interview on 8/7/24 at 12: 42 p.m., the ADON stated she had reviewed the medical record and did not see any evidence of active behaviors or signs of agitation for R68. The ADON stated she knew he had a history of hallucinations but did not see evidence in the medical record that those were still present. The ADON stated she had reviewed R68's pharmacist review dated 6/23/24 and acknowledged that R68 did not have any behaviors that made him a danger to himself or others and was unsure why the provider had selected that as the diagnosis. The facility policy dated Medication Monitoring and Management dated 5/22, was received but did not address indications for antipsychotic use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure the need for routine dental care (i.e., dental appointment) was assessed and, if needed or wanted, offered to promote oral hygiene and reduce the risk of complication for 1 of 1 resident (R4) reviewed who reported losing their dentures just prior to admission. Findings include: R4's admission Minimum Data Set (MDS), dated [DATE], identified R4 admitted to the care center on 7/9/24 from the acute care hospital. The MDS outlined R4 had intact cognition and demonstrated no delusional thinking. Further, The MDS recorded under, Section L - Oral/Dental Status, R4 had no broken or loosely fitting dentures, abnormal mouth tissue, or obvious cavities with a check placed next to the option reading, Z. None of the above were present. R4's Clinical Census listing, printed 8/6/24, identified R4's current payer source was listed as, MSHO Medicaid. On 8/5/24 at 1:15 p.m., R4 was interviewed and stated she admitted to the care center about a month prior. R4 was asked if she had any issues with her teeth or dental care while at the care center, and R4 responded she had no teeth on the top palate and only a few remaining on the bottom palate. R4 stated she had lost my dentures at the hospital prior to admitting to the care center and, so far, nobody from the care center had discussed or asked about getting a dental appointment made to possibly get new ones. R4 reiterated she'd like to pursue getting new dentures, if able, adding not having them was frustrating as it was hard to chew without [them]. R4's Nurse Admission/readmission 05212021 - V15, dated 7/10/24, identified R4 admitted from the hospital and listed a primary rationale for admission, TCU- [transitional care unit]. The evaluation contained a section labeled, Oral Status, which had a checkmark placed next to the option reading, Broken or loose fitting full or partial denture ., and a location of broken, carious or missing teeth listed, Upper gum. The evaluation outlined R4 used an upper denture and a partial lower denture; however, the evaluation lacked any information or evidence of when R4's last dental visit had been or if was was currently wanted/needed. R4's Social Service Care Conference - IDT 03302021 - V3, dated 7/26/24, identified R4's care conference was held with R4 present. The form outlined spaces for respective disciplines to record information including, Section E: Social Services, which contained a subsection asking, Any referrals needed (podiatry, optometry .):, however, this section was left blank. The completed summary lacked evidence what, if any, appointments were asked or offered to R4. R4's care plan, dated 8/5/24, identified a section for oral health which was initiated on 8/5/24 and outlined, The resident has potential oral/dental health problems r/t [related to] denture fit. The care plan listed interventions to help R4 remain free of oral infection or pain which included, Coordinate arrangements for dental care, transportation as needed/as ordered. When interviewed on 8/6/24 at 10:08 a.m., nursing assistant (NA)-F stated they had worked with R4 prior. NA-F explained R4 did not, at least to their knowledge, have their own teeth and used dentures but often didn't wear them adding, I've never seen her put it on [in] before. NA-F stated they were unsure if R4's dentures were even at the care center or not and expressed R4 had never made any comments about them. NA-F stated any dental appointments, if needed or wanted, would be made by the nurses. At 10:11 a.m., NA-F and the surveyor checked R4's room for what, if any, dentures were present. R4 was present laying in her bed and stated aloud, I don't have none. NA-F verified no dentures were present. R4's medical record was reviewed and lacked evidence R4 had been asked, offered or referred to a dental provider despite admitting to the care center nearly a month prior and being assessed upon admission as having potential broken or loose-fitting dentures. When interviewed on 8/6/24 at 10:23 a.m., licensed practical nurse (LPN)-B stated dental care, including the need or desire for an appointment, was done upon admission and recorded in the admission assessment [i.e., Nurse Admission/Readmission]. LPN-B stated if there was concerns or complaints about dentition then, it would be referred to the dental provider and, if not, then re-evaluated in three months during the next routine review (i.e., MDS cycle). At 10:25 a.m., the medical records coordinator (MRC) joined the interview and verified they scheduled appointments for the campus. MRC stated R4 had not yet been scheduled for any dental appointments and nobody had referred any concerns about it to them. MRC stated they would go follow-up with R4 about it. On 8/6/24 at 1:44 p.m., the assistant director of nursing (ADON) was interviewed, and verified they had followed up on R4's dental appointment adding MRC was working on getting R4 scheduled for one now. ADON stated the nurses complete the admission assessments and, from that, information gets pulled to the care plan adding the care conference is also an opportunity to record what, if any, appointments are needed or offered but R4's section was blank. ADON stated residents' on the TCU are usually more therapy focused but verified dental appointments and the need for such should be looked at. ADON verified the medical record lacked evidence R4 had been offered or evaluated for what, if any, dental appointments were needed or wanted; and expressed the care center was looking at their assessments to see if they could add more to them to ensure it was addressed. ADON stated it was important to ensure dental needs were offered or provided to ensure we're getting their needs [met] and continuity of care. A provided Dental Services policy, dated 2/2022, identified routine and emergency dental services were available to meet resident' oral health needs in accordance with the assessment and plan of care. The policy outlined the social services team would assist with appointments, transportation arrangements and reimbursement, if needed. The policy concluded, All dental services provided are recorded in the resident's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure recommended pneumococcal immunizations, as outlined by the Centers for Disease Control (CDC), were offered and/or provided in a timely manner to reduce the risk of severe disease for 1 of 5 residents (R18) reviewed for immunizations. This had the ability to affect all 80 residents residing the in the facility Findings include: A CDC Pneumococcal Vaccine Timing for Adults feature, dated 3/2023, identified several tables with corresponding recommendations when to receive various versions (i.e., PPSV23, PCV13, PCV20) of the pneumococcal vaccine. The graph labeled, Adults 19-[AGE] years old with chronic health conditions ., identified persons who received only a PPSV23 had an option to either get a PCV15 or PCV20 a year after the last PPSV23 dose. The conditions listed including alcoholism and cigarette smoking. Further, The graph labeled, Adults [at or older than] [AGE] years old, outlined persons with a complete series of pneumococcal vaccination (i.e., PCV13 at any age, PPSV23 at or above [AGE] years old) should have shared clinical decision-making between the resident and healthcare provider to determine if PCV20 was appropriate. R18's quarterly Minimum Data Set (MDS) dated [DATE], indicated R18 admitted to the facility in March of 2024, was [AGE] years old and had intact cognition. R18 had diagnoses of Alzheimer's disease (a type of dementia that affects memory, thinking, and behavior), anemia, high blood pressure, kidney failure, anxiety, and depression. R18's Minnesota Immunization Information Connection form dated 3/22/24 indicated R18 received the PPPSV23 most recently on 10/4/07, and received the PCV-13 on 1/26/15, prior to her admission. R18's PointClickCare (electonic medical record) Clinical Immunization form, printed 8/7/24, did not include further record of a pneumococcal vaccine. A review of R18's medical record did not include, based on shared clinical decision making, R18 had been offered and/or provided the PCV-20 per CDC guidelines. A facility form titled Revolving Immunization Consent or Declination, dated, 3/12/24 and signed by R18 indicated R18 consented to receive the influenza vaccination, the pneumococcal vaccination, and the COVID vaccination per CDC guidelines. During interview on 8/6/24 at 2:25 p.m., the assistant director of nursing (ADON) verified responsiblity as the facility's infection preventionist (IP). The ADON explained when a resident admitted to the facility, the admission nurse was responsible for consenting the resident for vaccines and providing the Vaccine information Sheet (VIS). The ADON stated the consent forms were reviewed and entered into the vaccine spreadsheet tracking log to maintain which residents consented to receive or declined the vaccines. The ADON stated a resident's immunization records were reviewed and the CDC's mobile app, PneumoRecs VaxAdvisor, was utilized to determine a resident's pneumococcal vaccination eligibility. The ADON stated it was important to assess a resident's vaccination status and offer eligible vaccinations because residents living in closer quarters, and it placed them at a higher risk for getting things. The ADON reviewed the spreadsheet tracking log for R18 and stated it appeared R18 had refused the pneumococcal vaccinations. The ADON reviewed R18's electronic health record (EHR) and verified her consent to receive the pneumococcal vaccination dated 3/12/24 and verbalized being unsure of what happened, but maybe it fell through the cracks. The ADON stated R18 initially refused the vaccinations but later changed her mind and the spreadsheet was not updated. During interview on 8/7/24 at p.m., the director of nursing (DON), stated there was a formal audit system in place to ensure vaccinations statuses are checked and updated and stated the vaccination would of been found on the next audit. A facility policy titled Pneumococcal Vaccine last reviewed 7/24, indicated all residents would be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. The policy indicated prior to admission, residents would be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. Furthermore, the policy indicated assessments of pneumococcal vaccination status would be conducted within five (5) working days of the resident's admission if not conducted prior to admission, and administration of the pneumococcal vaccines or revaccinations would be made in accordance with current CDC recommendations at the time of the vaccination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure resident's needs were addressed in a respectful and dignified manner when a resident (R34) used a call light for help. Additionally, the facility failed to ensure all staff knock on individual resident bedroom doors and introduce themselves prior to entry for 3 residents (R68, R76, R74). Furthermore, the facility failed to provide a dignified dining experience for 3 residents (R21, R31, R68). Findings include: Call Lights R34's quarterly Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnoses of hemiplegia (one-side paralysis) and hemiparesis (weakness or the inability to move on one side of the body) after a stroke and high blood pressure. R34's care plan dated 8/30/23, indicated he was dependent on staff/volunteers/family for meeting his emotional, intellectual, physical, and social needs related to his tendency to not seek out activities. The care plan also identified R34's activities of daily living (ADL) self-care needs related to his left-sided weakness, including an assist of one staff person to transfer with an EZ stand medium harness. During continuous observation on 8/6/24 between 12:51 p.m. and 1:24 p.m., two call lights were on in the same hallway with an alarm sounding. - At 12:55 p.m., R34's call light was noted to be on as indicated by the light on above his door, however the alarm was not sounding. - At 12:58 p.m., registered nurses (RN)-D and RN-F were standing in front of the medication carts in the dining area when R34 was heard calling, hello from his room. - At 12:59 p.m., nursing assistant (NA)-C exited a room in the same hallway as R34's room with meal trays in hand and walked towards the dining area. RN-F walked towards R34's room but turned and knocked to go into a different room to assist another resident. - At 1:00 p.m., RN-D approached the room where the first call light was observed to be on, knocked and entered the room and turned the call light off. - At 1:01 p.m., RN-D exited the room with a meal tray. R34's call light remained unchanged. - At 1:02 p.m., the assistant director of nursing (ADON) walked out from behind the nurse's station, into the dining area and down the hallway where R34's room was. The ADON turned into the tub/shower room. R34's call light remained unchanged. - At 1:03 p.m., RN-D was standing at the medication cart in the dining room. - At 1:05 p.m., NA-B walked down the hallway and into the room RN-F was in. - At 1:07 p.m., the call light alarm box at the nurse's station displayed the text, W226 NORMAL and was alarming with sound. It did not display a duration the call light had been on for. - At 1:08 p.m., RN-F exited the room and walked away from R34's and into the dining area. - At 1:11 p.m., RN-F walked down the hallway towards R34's room and entered another resident's room without a call light on. - At 1:12 p.m., RN-F exited the room and performed hand hygiene. RN-F walked down the hallway towards R34's room and entered a different resident's room without a call light on. RN-D was standing at the medication cart in the dining area. - At 1:13 p.m., RN-F exited the room with the resident and walked to the dining area. RN-F performed hand hygiene at the medication cart. R34's call light remained unchanged. - At 1:14 p.m., R34 stated in an interview he turned his call light on at 12:51 p.m. because he wanted to transfer into his recliner. He stated he needed staff assistance and the EZ Stand to transfer. R34 stated he experienced long call light wait times most of the time and stated, it's getting old. - At 1:18 p.m., RN-F walked down the hallway with a medication cup in hand towards R34's room. RN-F entered another resident's room that had a call light on. - At 1:19 p.m., RN-F exited the room and walked down the hallway towards the dining area. R34's call light remained unchanged. - At 1:21 p.m., NA-C walked down the hallway with another unidentified resident and entered a different room. - At 1:22 p.m., NA-C stopped into a room with a call light on near R34's room. - At 1:23 p.m., NA-C answered R34's call light request. - At 1:28 p.m., NA-C pushed R34 down the hallway in his wheelchair and into the tub/shower room. During interview on 8/6/24 at 1:37 p.m., RN-D stated the goal is to keep the call light wait time under 20 minutes but understood that a lot of residents required two staff for assistance. RN-D verified waiting 30 minutes was pushing it and stated the floor was pretty full census wise so it could be a strain. During interview on 8/6/24 at 3:04 p.m., the ADON stated, I do expect there would be someone to answer the call light, even if you can't help them, to acknowledge them and see what they need. The ADON confirmed 30 minutes was too extended and expected the call light to be answered sooner. The ADON expected any staff, from activities to housekeeping to all my nursing staff, to address a call light if passing by. The ADON stated the risks of not answering a call light in a timely manner included the risk of incontinence, bowel incontinence, and a potential for unsafe self-transfers, although the ADON didn't believe R34 would attempt to self-transfer. During interview on 8/7/24 at 11:52 a.m., the director of nursing (DON) stated it was disappointing to hear about a call light being on for 30 minutes and stated the expectation was for it to be answered in a reasonable time and suggested 10 minutes as a reasonable time. The DON stated the facility attempts to staff up during the day shift to accommodate resident needs. The DON verified concern for dignity with the extended call light wait time and expected all staff, including nurses, to answer call lights. A facility policy titled Answer the Call Light dated 10/18/22, indicated its purpose was to ensure timely responses to the resident's requests and needs. The policy guided staff to answer the resident call system immediately. A facility policy titled Dignity dated 12/8/21, indicated each resident should be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feels of self-worth and self-esteem. The policy indicated residents were treated with dignity and respect at all times and the facility culture supported dignity and respect for residents by honoring resident goals, choices, preferences, values and beliefs. Dignified Dining R31's significant change Minimum Data Set (MDS) assessment, dated 4/23/24, indicated R31 had severely impaired cognition with no hallucinations, or delusions. Further indicated R31 was dependent on staff for all activities of daily living (ADLs) including eating. R21's quarterly MDS assessment, dated 6/11/24, indicated R21 had severely impaired cognition with no hallucinations, or delusions. Further indicated R21 was dependent on staff for all activities of daily living (ADLs) including eating. R68's quarterly MDS assessment, dated 7/15/24, indicated R68 had severely impaired cognition with no hallucinations or delusions. Further indicated R68 was dependent on staff for all activities of daily living (ADLs) including eating. On 8/06/24 at 8:42 a.m., a table of three residents were seated in wheelchairs at a table. One resident was sitting with her eyes closed with an almost empty plate of food in front of her. The second resident was being assisted by a staff member to eat. R31 was the third resident at the table. Directly in front of R31, on the table, sat a hard plastic tray that contained on it, a warming plate with a cover, bowl with a plastic cover along with covered drinks. R31 was intermittently yelling out which caused other residents to look over at her. R31 continued to sit at the table with a clothes protector on with the covered food tray in front of her. No staff were interacting with R31. At 8:56 a.m., staff sat next to R31, uncovered the food in front of her and started to feed her (14 minutes after observation started). R31's food was left on the hard plastic tray during the meal. R31 stopped yelling out when staff started to assist her with her breakfast. During observation on 8/6/24 at 12:18 p.m., two lunch carts were brought to 2nd floor and delivered to the 2nd floor dining room by unknown dietary staff. Each lunch cart was an enclosed metal cart on wheels with slots, that held hard plastic trays that contained resident meals. Each slot could hold two hard plastic trays which could be slid from the front or back of the approximately 6-foot metal cart. The hard plastic trays each contained a paper slip that identified who the meal was intended for, a plate of food that was sitting on a plate warmer and was covered with a hard plastic dome shaped lid. The tray contained a set of silverware along with a napkin. Staff would grab the trays from the lunch cart, add the drinks that were requested from a different cart and deliver the entire tray to residents sitting at the table. Staff would leave the food and drinks on the hard plastic tray that contained the entire meal including the drinks and silverware. At 12:22 p.m., R31, R21 and R68 were observed to be seated at the same table. R31 and R21's lunch trays were set in front of them (just the way trays sent up from the kitchen). At 12:23 p.m., R68's tray was set in front of him. Staff proceed to get drinks for all the trays and set them in front of R31, R21 and R68 on the hard plastic trays. At 12:30 p.m., staff sat next to R31 to assist her to eat. At 12:35 p.m., a second staff sat next to R68 to assist him to eat (13 minutes after the food had been placed in front of him). At 12:38 p.m. a third staff sat next to R21 to assist her to eat (16 minutes after her food had been sitting in front her). R21, R31 and R68 were non-interviewable as unable to answer questions. During an interview on 8/06/24 at 2:04 p.m., nursing assistant (NA)-C stated meal trays are not handed out in a certain order, and we just make sure residents get the right tray. NA-C verified they do not take food off the hard plastic trays to serve the residents. NA-C verified that some residents must wait to be assisted with their meals. During an interview on 8/06/24 at 2:14 p.m., NA-B stated that each staff passes out their own resident trays. NA-B stated that after all the trays are handed out to residents then they assist residents who need help. NA-B verified that residents may have to wait a little while for assistance with their meals as they have other to help and must pass out other trays. NA-B verified the plates and drinks are not removed from the plastic trays when they are served to residents as it makes serving easier. During an interview on 8/07/24 at 11:09 a.m., NA-D stated that residents in the dining room are served first, then room trays are delivered and then residents who need assistance are assisted. NA-D stated all meals are served on the hard plastic trays to residents and have always done that, adding it makes it easier to clean up. During an interview on 8/07/24 at 11:18 a.m., registered nurse (RN)-C stated that meal trays are not served in any order but we try to serve independent people first, then those who need supervision and then those who we assist last. RN-C stated there is no assigned seating in the dining room but try to have resident who need supervision or assistance sit together. RN-C stated, trays are left underneath the meals. On 8/07/2024 at 1:38 p.m., assistant director of nursing (ADON) stated meal trays are not served in a certain order and there is no assigned seating. ADON verified that meals are served to residents on the hard plastic trays (food items are not removed and placed directly on the table) stating, there is not a reason why we do that It is easier to carry. On 8/07/2024 at 2:11 p.m., director of nursing (DON) verified there is no specific reason that meals are served on hard plastic trays to residents. DON stated residents should be served meals at the same time and staff should be able to assist when meals are served. NOT KNOCKING ON RESIDENTS' DOOR PRIOR TO ENTERING R68's quarterly MDS assessment, dated 7/15/24, indicated R68 had severely impaired cognition with no hallucinations or delusions with an admission date of 1/16/24. R76's admission MDS assessment, dated 6/24/24, indicated R76 has moderately impaired cognition with no hallucinations or delusions with an admission date of 6/18/24. R74's admission MDS assessment, dated 6/7/24, indicated R74 had severely impaired cognition with no hallucinations or delusions with an admission date of 6/3/24. During observation on 8/06/24 between 10:30 a.m. and 10:55 a.m., nursing assistant (NA)-B entering R68's room numerous times without knocking or announcing self. NA-B was also observed entering R76's room, during that time, without knocking, announcing self, or talking with R76 prior to entering room. During interview at 8/6/24 at 11:01 a.m., NA-B verified that they entered R68's numerous times within the last 30 minutes without knocking or announcing self. R68 stated, I am very busy but should've knocked. NA-B couldn't count how many times she had been in and out of R68's room without knocking but stating, a lot. NA-B verified they entered R76 room without knocking as she could see me in the hallway, and I was talking to her. NA-B verified they should always knock before entering a resident's room as it is a privacy and dignity thing to knock on a door prior to entering rooms. On 8/07/24 at 10:10 a.m., housekeeper (HSK)-A was observed opening R74's room door and entering R74's room without knocking or announcing self. On 8/7/24 at 10:12 a.m., HSK-A verified they had delivered soap to R74's room. HSK-A verified they had not knocked or announce themselves prior to opening R74's door and entering room. HSK-A stated, I thought they were sleeping. HSK-A further indicated, you should always knock because you are entering their room. On 8/07/24 at 10:14 a.m., R74 was observed to be lying in bed. R74 answered questions mumbled and non-sensical. On 8/07/24 at 10:16 a.m., R68 did not respond when asked questions. During interview on 8/07/2024 at 1:38 p.m., assistant director of nursing (ADON) stated it is expected to knock prior to entering a resident's room and should be done all the time. ADON stated, we should treat everyone like humans .we a lot of people have dementia, and we don't want to scare them .it's just the right thing to do. During interview on 8/07/2024 at 2:11 p.m., with director of nursing (DON) stated it is expected that staff either knock or announce themselves by saying hello announce. DON stated this is for dignity and alert them so don't startle them. A facility policy titled Dignity, dated 12/8/21, indicated residents are treated with dignity and respect at all times. Further indicated, residents are provided with a dignified dining experience.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to take appropriate steps to ensure the proper sanitization of dishware used for meal preparation and resident service when 1 of 1 high-temperature commercial dishwashers was identified as not reaching adequate final rinse temperature (i.e., 180 F). This had potential to affect all 80 residents within the nursing home, staff, and visitors who consumed food from the main production kitchen. Findings include: On 8/5/24 at 7:06 p.m., a kitchen tour was completed with dietary staff (DS)-A and DS-B present. A single [NAME] Tempstar commercial dishwasher was present along the wall with several hard plastic racks placed in front of the machine on the floor. DS-B loaded several metallic cookware pans onto other hard plastic racks and placed them into the dishwasher. A single, white-colored gauge present on top of the machine which did not move for the entirety of the wash or rinse cycle. A silver-colored plate was mounted to the side of the machine, under the counter area, which identified the make and model of the dishwasher along with, Minimum Rinse Temperature . 180 F [Fahrenheit]. DS-B moved the stacked hard-plastic racks from in front of the machine which exposed two, white-colored analog gauges labeled, R and W, respectively. Both gauges were covered with a hard white film. DS-B stated these gauges were for the dishwasher temperatures. DS-B stated she is not able to read the gauges and requested DS-A assistance. DS-A verified that she cannot read the gauges on the dishwasher. DS-A verified that she does write on the dishwasher temperature log and verified again that she is unable to read the gauges due to the gauges being full of a hard white film. Surveyor was unable to read the temperature on the gauges. On 8/06/24 at 8:13 a.m., an additional follow-up kitchen tour was completed with dietary manager (DM). DM verified the dishwasher is a high temperature dishwasher and needs to 180 F. DM rinsed a few dishes, set them in onto other hard plastic racks and placed them into the dishwasher. The dishwasher was run at least four times with the highest temperature of 172 F. DM stated the dishwasher was serviced last week. DM stated it is important the dishwasher is reaching 180 F so the dishes are getting sanitized or there is risk for food borne illnesses. On 8/6/24 at 8:37 a.m., DS-A verified that when they checked the temperature on the dishwasher this morning it was 121 and 127 degrees, and verified the log sheet was not recorded correctly. DS-A verified, the dishwasher did not reach 184 this morning even though the log sheet says it does. On 8/06/24 at 2:22 p.m., administrator verified that he was notified this morning of the dishwasher not reaching temperature and was going to follow up now to see if the service company had been out today to fix the issue. Administrator stated that if the issue has not been addressed then the facility would be using paper and plastic products until the dishwasher is fixed to ensure resident safety. On 8/06/24 at 2:35 p.m. DM and administrator met with surveyor. DM informed surveyor that the dishwasher was reaching temperature and dishwasher cycle and was observed to have reached 184 F. DM stated, we ran a lot of cycles to get it to hit temp, and verified the cycles ran this morning with temperatures not meeting the required 180 F. Administrator stated the facility will use paper and plastic until the dishwasher can be serviced due to the inconsistency of the temperatures. On 8/07/24 at 11:45 a.m., administrator updated surveyor that the dishwasher was just fixed. Administrator stated they fixed a pressure valve that was malfunctioning causing the dishwasher to not reach temperature consistently. During observation on 8/07/24 at 12:06 p.m., temperature on dishwasher was observed and reached 186 F. A provided Cleaning Dishes/Dish Machine policy, dated 2017, identified all flatware, serving dishes, and cookware will be cleaned, rinsed and sanitized after each use. The policy outlined, Staff should check the dish machine gauges throughout the cycle to assure proper temperatures for sanitiation [sic], along with a corresponding table which outlined the type(s) of dish machines and their corresponding final rinse temperatures. This included, High Temperature Dishwasher . 180 F.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review the facility failed to ensure a provider and resident representative were notified in a timely manner of a change in status for 1 of 1 residents (R66) who had new onset of signs and symptoms of a possible infection and was tested for COVID-19. Findings include: R66's quarterly Minimum Data Set (MDS) dated [DATE], indicated R66 had severe cognitive deficits, required supervision for eating, limited assistance for transfers and was extensive assistance for all other activities of daily living (ADLs). R66's diagnoses included Parkinson's disease, neurocognitive disorder with Lewy Bodies (a brain disorder that can lead to problems with thinking, movement, behavior, and mood.), falls, diabetes, end stage heart failure, liver cancer, and cirrhosis of the liver (impaired liver function caused by the formation of scar tissue). R66's Care Area Assessment (CAA) dated 6/20/23, indicated R66 triggered for delirium, cognitive loss/dementia, communication, ADL function, falls, nutrition, and pressure ulcers. R66's care plan dated 5/30/23, indicated R66 was dependent on staff/family/volunteers to meet emotional, intellectual, physical, and social needs. R66 also had ADL deficits and impaired communication and cognition. Interventions included anticipating R66's needs, to monitor/document physical/nonverbal indicators of discomfort or distress: follow up as needed and communicate with R66's family and caregivers regarding R66's capabilities and needs. The care plan also indicated R66 had potential for altered cardiovascular status. Interventions included observing vital signs and notifying the provider of any significant abnormalities. R66 also had diabetes. Interventions indicated if infection was present, to consult with a provider regarding necessary changes in diabetic medications. R66 also had liver disease and cancer. Intervention included monitoring/documenting/reporting lethargy, fatigue, anorexia, and altered level of consciousness to the provider. R66's orders dated 8/1/23, indicated when any standing orders were initiated, results were to be communicated to the provider the next working day. R66's progress note dated 9/13/23, indicated R66 was noted to be cold, had voice changes and a runny nose. R66 was tested for COVID-19 and was negative. Was then offered warm water, and a supplement shake. R66 ate only 50% of breakfast and lunch, took a nap after breakfast and had confusion during the shift. The progress note indicated the nurse would push fluids, continue to monitor, and notify the provider if R66's condition worsens. During an interview on 9/25/23 at 6:16 p.m., R66's family member (FM)-A stated she was unaware R66 had new onset of signs and symptoms that prompted him to be tested for COVID-19 and stated she would have wanted to be notified. FM-A further stated the family had been unable to determine if R66 should get the current COVID-19 booster vaccine and knowing he was showing possible signs or symptoms may have helped them make a decision. During an interview on 9/26/23 at 1:34 p.m., licensed practical nurse (LPN)-C stated residents were given a rapid COVID-19 test as soon as they had signs or symptoms of a possible infection including a runny nose or cough. LPN-C stated she was unaware if the resident tested negative, the provider should have been notified, and the resident should have been retested after 48 hours. LPN-C further stated if the resident tested negative, they would not need to be isolated. LPN-C stated R66's voice had changed, and he had a runny nose, so she tested him for COVID-19 on 9/13/23; however, since he was negative, she did not notify the family, provider, or management. LPN-C stated she also did not place R66 on isolation or retest him after 48 hours according to the CDC guidelines. During an interview on 9/27/23 at 9:43 a.m., the assistant director of nursing (ADON) who was also the infection preventionist (IP) stated she was not aware R66 had new onset of symptoms of a possible infection including a runny nose and change of voice and would have expected to be, even though R66 tested negative for COVID-19. The ADON also would have expected the family and provider to be notified of the change in R66's condition and a second COVID-19 test should have been administered 48 hours after the first negative to ensure he was still negative. During an interview on 9/28/23 at 10:27 a.m., the director of nursing (DON) stated she was unaware R66 had new signs or symptoms of a possible infection or that he had been tested for COVID-19 on 9/13/23. The DON stated she and/or the ADON, the provider, and R66's family should have been notified even though he tested negative. During an interview on 9/28/23 at 1:44 p.m., nurse practitioner (NP)-A stated she was not notified R66 had been tested for COVID-19 or had developed a runny nose and changes in his voice and would have expected to have been, regardless of the results. The facility Standing Orders dated 3/9/23, indicated to complete COVID-19 antigen testing as indicated for outbreak and/or routine testing per facility policy. The facility Change in Resident's Condition or Status policy dated the facility notified the resident's provider and representative of changes in the resident's medical/mental condition and/or status including a need to alter the resident's medical treatment significantly. A significant change was defined as having an impact on more than one area of the resident's health status, was not self-limiting, and required interdisciplinary review and/or revision to the care plan. The policy further indicated notifications were to be made within 24 hours of the change occurring.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure timeliness of person-centered care conferences for 2 of 2 (R45, R53) and to include review and revision by an interdisciplinary team and the resident in adjusting their care plan and making decisions about his or her care. Findings include: R45's quarterly Minimum Data Set (MDS) dated [DATE], identified R45 with intact cognition, and required extensive assistance with all activities of daily living (ADL's). In addition, R45 had diagnosis of Parkinson's, delusions, spinal cord injury, anxiety, paraplegia (paralysis of all or part of your trunk, legs, and pelvic organs), and depression. R45's previous MDS assessments were 5/18/23, 2/15/23, and 11/17/22. R45's Care conference notes titled, Social Service Care Conference-IDT were dated 8/31/23, 4/25/23, and 8/25/22. R45's electronic medical record (EMR) failed to indicate a care conference was completed within the time frame for MDS assessments for 5/18/23, 2/15/23 and 11/17/22. R53's quarterly MDS dated [DATE], identified R53 with intact cognition, required assistance with transfers, and haD diagnoses of diabetes, stage three chronic kidney disease and chronic pain. R53's previous MDS assessments were 6/16/23, 5/3/23, 2/9/23 and 12/27/22. R53's Care conference notes titled, Social Service Care Conference-IDT were dated 6/8/23, 3/14/23, 9/11/22. R53's EMR failed to indicate a care conference was completed within the time frame for MDS assessments for 5/3/23, 2/9/23, and 12/27/22. During interview with R53 on 9/26/23 at 9:55 a.m., R53 stated indicated she could not recall if she was involved in any of her care conferences regarding care planning. During interview with director of nursing (DON) on 9/26/23 at 12:39 a.m., DON stated all care conference notes and documentation were in the EMR under Social Service Care Conference-IDT notes. Further, the DON stated care conferences, should be done quarterly or with significant change. DON stated last care conference note for R53 was 6/8/23 and there should have been one around the 7/27/23 MDS. DON stated, Looks like they are not being done reliably. During interview with DON and assistant director of nursing (ADON) on 9/27/23 at 11:03 a.m., both reviewed R45's care conference notes from the EMR and DON indicated there were missed care conferences. During interview with social worker (SS)-A on 9/28/23 at 10:30 a.m., SS-A stated all care conferences were her responsibility and she was to schedule them and, should be done quarterly or with significant change status. SS-A stated a Big gap with scheduling the MDS and care conferences. SS-A stated the concern with missing care conferences would be a failure to review resident care plans and goals with caregivers, residents, and families. Facility policy titled Resident Care Conference/Care Plan Review updated 03/30/2021 indicated the purpose of care conferences were to, develop and plan care and to ensure that the resident goals and preferences be discussed and established.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review the facility failed to comprehensively assess significant weight changes for 1 of 1 residents (R51) reviewed for nutritional status. Findings include: R51's quarterly Minimum Data Set (MDS) dated [DATE], indicated R51 had intact cognition, was independent with eating and required extensive assistance for all other activities of daily living (ADLs). R51's diagnoses included atherosclerotic heart disease, depression, diabetes, high cholesterol, osteogenesis imperfecta (genetic disease resulting in brittle bones), and high blood pressure. R51's Care Area Assessment (CAA) dated 4/25/23, indicated R51 triggered for ADL function, psychosocial well-being, mood state, nutrition status, pressure ulcers, and psychotropic drug use. R51's care plan dated 12/10/22, indicated R51 had diabetes. Interventions included monitoring/documenting/reporting signs and/or symptoms of hyperglycemia (high blood sugar) including increased appetite, noncompliance with prescribed diet and malnutrition. Interventions also included weighing R51 according to provider orders. R51 also had the potential for nutritional risk. Interventions included a controlled (consistent) carbohydrate (CCHO) diet, encouraging greater than 75% intake of meals, offering a supplement if R51 refused meals. R51's dietary progress note dated 12/30/22, indicated the registered dietician (RD) recommended weekly weight monitoring due to R51's significant weight changes. R51's dietary progress note dated 2/24/23, indicated R54 had significant weight differences and more frequent weight checks were requested to determine accurate baseline. R51's dietary progress note dated 3/6/23, indicated R51 had significant weight discrepancies and therefore, nursing was notified to complete weekly weight monitoring. R51's dietary progress note dated 4/23/23, indicated R54 continued to show significant weight discrepancies. The note indicated nursing was notified of recommendation to complete weekly weight monitoring due to the discrepancies. R51's orders dated 6/12/23, indicated R51 was on a consistent carbohydrate (CCHO) diet. The orders lacked indication of an order to obtain weights for R51. R51's weights (in pounds-lbs) were as follows: -1/12/23 at 6:57 p.m., 203.3 -2/12/23 at 10.21 a.m., 201 -2/23/23 at 3:03 p.m., 245 (21.89 % gain) -3/2/23 at 12:44 p.m., 243 -3/9/23 at 1:57 p.m., 243 -4/17/23 at 8:50 a.m., 202 (16.87% loss) -4/19/23 at 1:27 p.m., 209 -5/7/23 at 7:42 a.m., 206 -5/23/23 at 8:22 a.m., 207 -6/7/23 at 3:16 p.m., 202.1 -7/9/23 at 2:25 p.m., 209 -8/7/23 at 7:31 a.m., 220 (5.26% gain) -9/3/23 at 2:29 p.m., 213 R51's nutrition assessment dated [DATE], indicated R51 was to continue on a CCHO diet with no added salt. R54's Body Mass Index (BMI) was 34.8 (obese) and weighed 209 lbs. The assessment indicated diet education was provided and would be offered as needed. R51's provider note dated 9/11/23, indicated R51 had worsening over-all control of his A1C levels (a blood test that averages blood glucose levels over a three-month period to determine effectiveness of diabetes management and confirming a diagnosis of diabetes if over 6.5%) as follows: -1/10/23, 6.7% -4/25/23, 8.3% -7/18/23, 8.6% During an interview on 9/25/23 at 1:59 p.m., R51 stated he was concerned about his weight and wanted to know what his weight was. R51 stated he had not been weighed for a couple of weeks and did not know how often he was supposed to be weighed. R51 further stated he wondered if the scale was broken because his weight fluctuated a lot. During an interview on 9/28/23 at 11:03 a.m., the RD stated she met with R51 pretty frequently due to his excessive calorie intake and poor food choices, although he had been improving. The RD stated she received monthly weights for R51; however, after review of R51's dietary progress notes, the RD verified she had requested weekly weights due to significant discrepancies in December, February, March, and April, and they had not been done. The RD further stated R54 should have had weekly weights completed until she was able to determine a baseline weight and then she would discontinue the order. The RD verified she had suspected R54's weight of 220 lbs on 8/7/23, was an error; however, a re-weight had not been completed until 9/7/23, and should have been done immediately to determine accuracy. The RD stated an accurate weight was important to determine if R51 was reaching his goals or was having an acute medical concern such as fluid retention. During an interview on 9/28/23 at 11:49a.m., the director of nursing (DON) verified a resident's weight log was expected to reflect the resident's most accurate weight. The DON verified R51's electronic medical record (EMR) lacked documentation explaining R51's significant weight discrepancies. The DON stated because the RD was in the facility only two days a week and did not attend the morning interdisciplinary team (IDT) meetings, she would have expected the RD to communicate recommendations for a change in resident care to the staff and management directly and for staff to follow her recommendations including weekly weights for R51. The facility Weight Assessment and Intervention policy dated 1/20/22, indicated the multidisciplinary team's (MDT) goal was to prevent, monitor, and intervene for undesirable weight loss. Any weight change of 5% or more since the previous weight assessment was to be retaken the following day. If the weight was verified, the dietician was to be immediately notified in writing and the dietician was to respond within 24 hours. The policy further indicated the dietician was to review resident weights on the 15th of the month to monitor for trends and report negative findings to the treatment team to determine if significant weight change criteria had been met. The MDT was to determine the resident's target weight range, current intake, relationship between the resident's medical condition and weight fluctuation and if weight stabilization or improvement could be anticipated. The policy indicated the dietician would discuss undesired weight gain with the resident and/or family and interventions should consider resident preferences and rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure oxygen tubing was changed according to standards of care to prevent possible respiratory infections for 2 of 2 residents (R18, R54) who used oxygen. Findings include: R18 R18's quarterly Minimum Data Set (MDS) dated [DATE], indicated R18 was unable to complete the Brief Interview for Mental Status (BIMS) and had severe cognitive deficits, was totally dependent on staff for eating and required extensive assistance for all other activities of daily living (ADLs). R18's diagnoses included toxic encephalopathy (a brain disorder caused by exposure to a neurotoxic substance), acute respiratory failure with hypoxia (low oxygen), pneumonia due to COVID-19, cardiac arrhythmias, deep vein thrombosis and stroke. R18's orders dated 7/3/23, indicated R18's oxygen tubing was to be changed and dated every Monday, and received 2 liters per minute (lpm) of oxygen by nasal cannula to maintain an oxygen saturation level of greater than 90%. During an observation on 9/25/23 2:52 p.m., R18 was lying in bed, oxygen tubing was attached to a humidified bubbler with a piece of tape dated 9/12 indicating that was the last time the tubing had been changed. During an interview on 9/26/23 at 1:45 p.m., nursing assistant (NA)-E stated nurses were responsible for changing resident oxygen tubing. During an interview on 9/26/23 at 1:50 p.m., registered nurse (RN)-E stated she had never changed resident oxygen tubing and did not know how often it was supposed to be changed. RN-E verified R18's oxygen tubing indicated it was last changed on 9/12/23. R54 R54's quarterly MDS dated [DATE], indicated R54 had severe cognitive deficits, required limited assistance for toileting, dressing and transfers, and supervision for bed mobility and personal hygiene. R54's diagnoses included Alzheimer's disease, dementia with behavioral disturbance, heart disease, obstructive sleep apnea (OSA), chronic obstructive pulmonary disease (COPD), morbid obesity, anxiety, congestive heart failure (CHF, resulting in fluid in the lungs), and nonspecific abnormal finding of the lung field. R54's orders dated 7/13/23, indicated R54 was to use oxygen while in bed to keep oxygen saturation level above 90%. The orders also indicated R54's oxygen tubing was to be changed every evening shift on Tuesday. During an observation on 9/25/23 at 3:37 p.m., R54 was lying in bed. Nasal cannula oxygen tubing was connected to a concentrator and draped over the foot of his bed. The tubing had a label dated 9/12. R54 stated he used the oxygen when he needed it. During an observation on 9/26/23 at 2:27 p.m., R54 was in bed with oxygen tubing draped over his side table and dated 9/12. During an observation and interview on 9/26/23 at 2:38 p.m. RN-F stated she last changed R54's oxygen tubing on 9/12/23, but was unsure how often oxygen tubing was supposed to be changed and that the licensed nursing staff were responsible to ensure it was completed. During an interview on 9/27/23 at 10:00 a.m., the assistant director of nursing (ADON) who was also the infection preventionist (IP) stated oxygen tubing was to be changed weekly according to provider orders to avoid possible infection control concerns. The facility Departmental (Respiratory Therapy)-Prevention of Infection policy dated 1/10/23, indicated to mark the resident hydration bottle (bubbler) with date and initials upon opening and discard after 24 hours and also to change the oxygen cannula and tubing every seven days or as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review the facility failed to ensure psychotropic medications were reviewed for the appropriateness of a gradual dose reduction (GDR) for 1 of 1 residents (R54) reviewed for unnecessary medications. Findings include: R54's quarterly MDS dated [DATE], indicated R54 had severe cognitive deficits, required limited assistance for toileting, dressing and transfers, and supervision for bed mobility and personal hygiene. R54's diagnoses included dementia with behavioral disturbances, anxiety, and visual hallucinations. R54's care plan dated 8/10/22, indicated R54 received psychotropic medications. Interventions included consulting with the provider and pharmacy to consider dose reductions at least quarterly, and discuss the need for R54's ongoing use with the provider and family. R54's orders dated 9/13/23, indicated R54 had not had a GDR completed since his sertraline (an anti-depressant) was increased on 8/16/22, from 25 milligrams (mg) to 50 mg. The orders also indicated R54 had not had a GRD since his quetiapine (an anti-psychotic) was increased from 50 mg in the morning and 150 mg at bedtime to 100 mg in the morning and 200 mg at bedtime on 8/6/22. During an interview on 9/28/23, at 12:16 p.m., consulting pharmacist (CP)-A stated he had consulted for the facility briefly while they transitioned to a new consulting pharmacy. CP-A stated the previous pharmacist scheduled a GDR for R54's sertraline on 9/4/23 and on 10/5/23 for his quetiapine; however, CP-A stated the GDRs should have been done by August 2023, within a year of them being increased. CP-A further verified there was no indication either medication had had a GDR attempted nor a reason why the GDRs would have been inappropriate. During an interview on 9/27/23 at 1:36 p.m., CP-B stated she began consulting for the facility when they switched pharmaceutical providers on 9/1/23, and therefore was unfamiliar with R54 or the status of his psychotropic medications. CP-B stated, however, that she would have expected the facility to attempt a GDR for his sertraline and/or quetiapine in the previous year according to the regulations or have a reason why it would have been inappropriate and verified she could not find evidence of either recommendation. The facility Gradual Dose Reduction Guideline dated 11/30/21, indicated a GDR should be attempted after a newly initiated psychotropic medication has been in use or the resident had been in the facility for one year. The GDR was to occur in two separate quarters unless the provider had documented a GDR was contraindicated.

During observation and interview the facility failed to ensure safe and secure storage of medications and to limit access to only authorized personnel for 2 of 3 medication storage rooms reviewed. Findings include: During observation on 9/26/23 at 9:47 a.m., the door to the third floor medication storage room was observed with door wedged open with no staff around the area. Six narrow and one small portable oxygen cylinders, a Pyxis (medication dispensing machine) with one means of securing medications instead of two. Also, a small, unlocked refrigerator containing medication and a locked large tackle box (with one means of securing contents instead of two) were visible from the dining room and nursing station. During observation on 9/26/23 at 12:45 p.m., third floor medication storage room observed with door wedged open. Six narrow and one small portable oxygen cylinders, a Pyxis (with one means of securing medications instead of two). Also, a small, unlocked refrigerator containing medication and a locked large tackle box (with one means of securing contents instead of two) were visible from the dining room and nursing station. Lunch was being served in the dining room and several residents and facility staff were present in the dining room. No one was in or near the opened medication storage room. During interview with registered nurse (RN)-A on 9/26/23 at 12:45 p.m., RN-C stated the medication storage room door should be closed and locked. During interview with RN-B on 9/26/23 at 12:46 p.m., RN-B stated the medication storage room door should be closed and locked because the emergency kit and other meds are in there too including the Pyxis with narcotics. During observation on 9/27/23 at 7:47 a.m., the second floor medication storage room door was visibly open with no staff in the room. Twelve tall and 2 small portable oxygen cylinders were present in the medication storage room along with a Pyxis (with one means of securing medications instead of two). Also, a small unlocked refrigerator with medications inside. During interview with RN-C on 9/27/23 at 7:47 a.m., RN-C stated the door is not supposed to be open. The door should be closed and locked. I think someone forgot to close it. During interview with the director of nursing (DON) and assistant director of nursing (ADON) on 9/27/23 at 10:56 a.m., the DON stated, medication storage rooms are supposed to be locked at all times. During observation and interview on 9/27/23 at 1:25 p.m., the third floor medication storage room was unlocked and door open. RN-D stated, it should be closed. During observation and interview on 9/28/23 at 9:21 a.m., RN-A stated the medication storage room doors is supposed to be locked at all times because only nurses are allowed to access the meds. RN-A stated the Pyxis machine contained prescribed narcotics. With the medication storage room door unlocked and open there would be one form of securing the narcotics instead of two. Facility policy titled Storage of Medications reviewed 12/03/2021 state purpose is to store, all drugs and biologicals in a safe, secure, and orderly manner. Further, Only persons authorized to prepare and administer medications have access to locked medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to take appropriate steps to ensure the proper sanitization of dishware used for meal preparation and resident service when 1 of 1 high-temperature commercial dishwashers was identified as not reaching adequate final rinse temperature (i.e., 180 F). This had potential to affect all 67 residents within the nursing home, staff, and visitors who consumed food from the main production kitchen. Findings include: On 9/25/23 at 11:41 a.m., an initial kitchen tour was completed with cook (CK)-A and CK-B present. A single [NAME] Tempstar commercial dishwasher was present along the wall with several hard plastic racks placed in front of the machine on the floor. CK-A loaded several metallic cookware pans onto other hard plastic racks and placed them into the dishwasher. A series of wash chemicals, including rinse aide, were present on or around the machine with visible tubing connected to the dishwasher; along with a single, white-colored gauge present on top of the machine which did not move for the entirety of the wash or rinse cycle. A silver-colored plate was mounted to the side of the machine, under the counter area, which identified the make and model of the dishwasher along with, Minimum Rinse Temperature . 180 F [Fahrenheit]. There were no other visible gauges present on the machine to demonstrate what temperature the final rinse cycle was being completed at while dishes were loaded. Later, on 9/25/23 at 12:30 p.m., a return visit to the kitchen was made and the dishwasher inspected with CK-A present. CK-A stated the machine had been installed since forever and was a high-temperature sanitization machine. CK-A then moved the stacked hard-plastic racks from in front of the machine which exposed two additional, white-colored analog gauges labeled, R and W, respectively. CK-A stated they don't know what each of the written letters meant. CK-A then placed a loaded rack of dishes into the machine to demonstrate the cleaning and sanitization process. The machine activated and completed the wash and rinse cycle, however, the only gauge which moved was the one labeled, W, which attained only 163 F. A second load was then placed and ran through the machine and, again, the same gauge only attained a high temperature of 164 F on the final rinse cycle. These readings were verified by CK-A who then stated the machine had not been working for a few days adding the final rinse should be 180 F if we went by the book [regulations]. CK-A explained the machine stopped reaching 180 F the week prior and, as a result, they contacted an outside company to come out and inspect it which happened over the weekend. The inspection identified a new pressure valve was needed which had been ordered, however, not yet installed so the machine remained in disrepair. CK-A verified themselves and other kitchen staff were still doing dishes, including cookware and resident serviceware, in the machine despite it not hitting the 180 F expected to ensure proper sanitization. CK-A stated they had not been directed or asked to use disposable items (i.e., paper plates) or check surface temperatures of the washed items to ensure they were being sanitized properly. However, CK-A stated they had been trying to run loads of the dishes through the machine twice for safety since it wasn't hitting proper temperature. CK-A then presented a white-colored paper flow sheet which was attached to the walk-in cooler. The provided High-Temperature Dish Machine Temperature Log, dated 9/14/23 to 9/25/23, identified multiple columns to record various information including the date, time, wash temperature, rinse temperature and staff initials. This outlined a hand-written, 180 [degrees] was needed for the rinse temperature along with 17 recorded temperature checks. These included: - 9/23/23 at 5 a.m., with 180 F rinse temperature recorded; - 9/23/23 at 1:00 p.m., with 180 F rinse temperature recorded; - 9/23/23 at 6:00 p.m., with 180 F rinse temperature recorded; - 9/24/23 at 6:00 (blank Latin identifiers for reference, i.e., a.m.), with 180 F rinse temperature recorded; and, - 9/25/23 at 5:00 p.m. (in the future), with 180 F rinse temperature recorded. The final four entries were initialed by CK-A. CK-A reviewed the provided flowsheet and stated the time for the 9/25/23 entry, timed 5:00 p.m., was in error and actually done in the morning (i.e., a.m.). When questioned on if the machine had hit 180 F and, if so, how such temperature was checked (since the gauge only read 164 F), CK-A stated they documented the temperature based on the same gauge and wrote 180 F as it was around the 180 F mark. CK-A stated they were unaware if the machine actually attained the 180 F or not, but they reiterated the administrator and the outside company were both aware of the machine not hitting 180 F and working to address the issue. Following, on 9/25/23 at 12:48 p.m., the administrator was interviewed, and they verified the dishwasher was a high-temperature sanitization machine. They verified knowledge of the dishwasher not reaching temperature (i.e., 180 F) and, as a result, an outside company had been out over the weekend to inspect it which identified a new valve was needed. The administrator stated they had not directed staff to use disposable items for service or cooking while the machine was in disrepair, nor had they directed dietary staff to implement other measures to ensure proper sanitization (i.e., surface temp checking) but expressed they would do so immediately. The following day, on 9/26/23 at 9:33 a.m., a subsequent visit to the kitchen was made. The dishwasher had visible steam coming from it and was in a run cycle, with dietary aide (DA)-A loading various cookware and serviceware into the machine (i.e., plastic water pitchers, divided plates, dish domes). The same white-colored gauges were present and, again, the gauge labeled, R, did not move during the various run cycles. The working gauge labeled, W, only reached 158 F on the final rinse cycle. DA-A removed the items from the machine and verified they were items just used for the breakfast meal service. DA-A stated the dishwasher was no good and, as a result, they had been using disposable items for resident serviceware (i.e., plates, silverware), however, were still washing and cleaning the non-serviceware items in the dishwasher. [NAME] (CK)-C then presented to the dishwasher and verified the staff were still using it to wash, rinse and sanitize various items such as ice cups and plate domes. CK-C stated they had not been advised or directed to implement other washing or sanitizing methods for cookware items, such as manual washing and sanitization, but verified the administrator had discussed the dishwasher being in disrepair with them. Further, CK-C stated they were told the outside company would be onsite that day to repair the dishwasher. The kitchen manager was offsite and unavailable for interview for the entirety of the survey. During follow-up interview, on 9/26/23 at 2:26 p.m., the administrator stated they were helping as the acting dietary manager currently, and they explained the dishwasher was first noticed to be not hitting appropriate sanitization temperature during the previous week. As a result, they contacted the outside company to inspect it which happened over the previous weekend, and it was then determined a new pressure cylinder needed to be installed as the machine was losing part of the rinse pressure and, likely, 10-12 degrees of rinse temperature as a result. However, the outside company did not, to his knowledge, check the actual final rinse temperature of the machine at the time to determine what it was. The administrator stated disposable items should have been implemented when the machine was determined to be malfunctioning, however, it was not. When asked about the continued use of the machine, as was observed a few hours prior, they explained they had not directed staff to do manual washing and chemical sanitization of cookware items (i.e., pans, divided plates) but expressed, at the moment, was not too worried about it. The administrator stated the lack of instruction to staff to use a manual wash, rinse and sanitization method of cookware was possibly just due to my [administrator] lack of full understanding [of what was needed]. Further, the administrator verified no gastrointestinal (GI) symptoms had presented in any residents since the dishwasher malfunctioned several days prior. On 9/27/23 at 7:59 a.m., the registered dietitian (RD)-A was interviewed. RD-A explained they were onsite at the nursing home on a weekly basis and were aware the administrator was helping to oversee the kitchen in the absence of the dietary manager. RD-A stated they were not aware the dishwasher had malfunctioned the previous week, and verified the final rinse temperature on the nursing home' dishwasher should be 180 F to ensure proper sanitization. RD-A stated had they been updated, their direction would have been to use disposable items until the machine could be inspected and fixed. There was no provided evidence during the recertifcation survey, from 9/25/23 to 9/28/23, to demonstrate the outside company had checked or verified the actual final rinse temperature of the dishwasher while onsite the weekend prior (9/23/23 to 9/24/23). A provided Cleaning Dishes/Dish Machine policy, dated 2017, identified all flatware, serving dishes, and cookware will be cleaned, rinsed and sanitized after each use. The policy outlined, Staff should check the dish machine gauges throughout the cycle to assure proper temperatures for sanitiation [sic], along with a corresponding table which outlined the type(s) of dish machines and their corresponding final rinse temperatures. This included, High Temperature Dishwasher . 180 F.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Water Management During interview on 9/27/23 at 10:03 a.m. Maintenance Supervisor (MS) stated that he does not have a current facility water supply flow diagram or a related water supply map to identify potential areas at risk for Legionella bacterial growth. During interview on 9/27/23 at 1:17 p.m., administrator stated that the facility is required to develop and maintain a water management plan/program. Administrator provided a policy which outlined this directive but could not provide documentation of a current water management plan, facility water supply flow diagram, or water flow map that identified potential areas of risk for Legionella bacterial growth. Administrator further stated he could not find requested documents on the facility's/organization's shared computer drive or in the existing hard files still located on-site. The facility's water management program policy, dated 10/18/22, indicted the facility would identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease. The water management program includes the following elements: An interdisciplinary water management team, a detailed description and diagram of the water system in the facility. The identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria. R66's quarterly MDS dated [DATE], indicated R66 had severe cognitive deficits, required supervision for eating, limited assistance for transfers and was extensive assistance for all other activities of daily living (ADLs). R66's diagnoses included Parkinson's disease, neurocognitive disorder with Lewy Bodies, hallucinations, falls, diabetes, end stage heart failure, liver cancer, and cirrhosis of the liver. R66's Care Area Assessment (CAA) dated 6/20/23, indicated R66 triggered for delirium, cognitive loss/dementia, communication, ADL function, falls, nutrition, and pressure ulcers. R66's care plan dated 9/26/23, indicated R66 had potential for altered cardiovascular status. Interventions included observing vital signs and notifying the provider of any significant abnormalities. R66 also had diabetes. Interventions indicated if infection was present, to consult with a provider regarding necessary changes in diabetic medications. R66 also had liver disease/cancer. Intervention included monitoring/documenting/reporting lethargy, fatigue, anorexia, and altered level of consciousness to the provider. R66's progress note dated 9/13/23, indicated R66 was noted to be cold, had voice changes and a runny nose. R66 was tested for COVID-19 and was negative. Offered warm water, and a supplement shake. R66 ate only 50% of breakfast and lunch, took a nap after breakfast and had confusion during the shift. The progress note indicated the nurse would push fluids, continue to monitor, and notify the provider if R66's condition worsens. R66's orders dated 8/1/23, indicated R66 may be placed on isolation precautions per facility infection control policy. During an interview on 9/26/23 at 1:34 p.m., LPN-C stated residents were given a rapid COVID-19 test as soon as they had signs or symptoms of a possible infection including a runny nose or cough. LPN-C stated she was unaware if the resident tested negative, the resident should have been placed on transmission based precautions (TBP) and retested after 48 hours. LPN-C stated on 9/13/23, R66's voice had changed, and he had a runny nose, so she tested him for COVID-19; however, since his result was negative, she did not place R66 on TBP or retest him after 48 hours according to the CDC guidelines. During an interview on 9/27/23 at 9:43 a.m., ADON who was also the IP, stated she was not aware R66 had new onset of symptoms of a possible infection including a runny nose and change of voice and would have expected to be, even though R66 tested negative for COVID-19. The ADON also would have expected a second COVID-19 test to have been administered 48 hours after the first negative test was completed. During an interview on 9/28/23 at 10:27 a.m., the director of nursing (DON) stated she was unaware R66 had new signs or symptoms of a possible infection or that he had been tested for COVID-19 on 9/13/23. The DON stated she and/or the ADON, the provider, and R66's family should have been notified even though he tested negative, and staff should have followed the facility policy regarding any further testing and/or TBP requirements. During an interview on 9/28/23 at 1:44 p.m., nurse practitioner (NP)-A stated she was not notified R66 had been tested for COVID-19 or had developed a runny nose and changes in his voice and would have expected to have been, regardless of the results. NP-A further stated she was unsure of the requirements regarding subsequent testing if a resident had a negative initial test; however, NP-A would have expected staff to follow the CDC guidelines. The facility Standing Orders, dated 3/9/23, indicated to complete COVID-19 antigen testing as indicated for outbreak and/or routine testing per facility policy. A provided COVID-19 Outbreak Testing policy, dated 5/16/23, identified facilities were required to test residents and staff based on parameters and frequency set forth by the CDC guidance and local health department. The policy outlined, Testing of residents who have signs or symptoms of COVID-19, regardless of their vaccination status, must be tested as soon as possible. While test results are pending, residents with signs or symptoms should be placed on [TBP] in accordance with CDC guidance. However, the policy lacked what, if any, specific symptoms which needed to be screened or present (i.e., respiratory versus other) before testing would begin in accordance with the policy. Use of PPE During observation on 9/27/23 at 9:07 a.m., a PPE cart was placed outside the door of R38 room. Signage on R38's door indicated Isolation room, special droplet/contact precautions and instructed all staff who enter the room to don PPE gown, N95 mask and gloves. Nursing assistant (NA)-A entered R38's room without sanitizing hands or putting on N95 or PPE gown and new gloves. NA-A assisted R38 to bathroom. Surveyor then asked registered nurse (RN)-B to R38 room and observed NA-A exiting R38's bathroom with R38. RN-A stated the PPE cart outside R38's room and the signage on R38's door, is for guiding staff to wear PPE before entering the room. RN-A stated NA-A should know to wear PPE before entering R38 room. RN-A stated importance of wearing PPE is, so we don't spread Covid virus. RN-A stated R38 was placed on isolation precautions because his roommate tested positive this weekend and was moved to first floor of facility leaving R38 alone. During observation and interview with NA-A on 9/27/23 at 9:16 a.m., NA-A exited R38's room with breakfast tray. NA-A did not sanitize hands upon exiting R38 room. NA-A stated the PPE cart and signage on R38's door means you have wear PPE before entering the room. NA-A stated he did not wear a PPE gown or N95 mask. NA-A stated importance of wearing PPE is to limit transfer of virus. During interview on 9/27/23 at 9:22 a.m., NA-B indicated a PPE cart and signage on door guides staff as to what precautions to take before entering resident room. NA-B stated PPE use is important to not spread the virus. During interview with R38 on 9/27/23 at 10:10 a.m., R38 stated he was informed about being placed in isolation the morning of 9/27/23 along with a PPE cart and signage was posted on his door. R38 stated no one from facility informed him that he should be on isolation at the same time his roommate was transferred out of their shared room following a positive covid test on 9/24/23. During interview with director of nursing on 9/27/23 at 11:07 a.m., DON stated R38 place on isolation due to precautions for malaise and that covid testing of R38 was negative. Facility policy titled Isolation-Categories of Transmission-Based Precautions revised October 2018 state, When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and, the signage informs the staff of the type of CDC precautions(s), instructions for use of PPE, and/or instructions to see nurse before entering the room. Based on observation, interview, and document review, the facility failed to ensure a water management program was developed and maintained to help reduce the risk of Legionnaires' (Legionella) bacterial growth and subsequent contamination in the facility' water supply and/or storage. In addition, the facility failed to ensure potential signs and symptoms of COVID-19 were acted upon and evaluated (i.e., tested, transmission base precautions implemented) in accordance with current Centers for Disease Control (CDC) guidelines for 2 of 2 resident (R8, R66) reviewed who displayed potential symptoms of COVID-19; and failed to ensure transmission-based precautions (TBP) were implemented as posted for 1 of 2 residents (R38) reviewed in such precautions. These findings had potential to affect all 67 residents, staff, and visitors within the nursing home. Findings include: COVID-19 SYMPTOM TESTING: The CMS QSO-20-38-NH, dated 9/23/22, identified the most recent guidance for COVID-19 testing and management in the nursing home setting. The memo outlined nursing homes' were able to achieve prompt testing using either a rapid, point-of-care test or a laboratory test, and listed residents must be tested as soon as possible if having symptoms regardless of their vaccination status. While the results were pending, the resident should be placed on transmission based precautions (TBP) in accordance with CDC (Centers for Disease Control) guidelines. Further, the memo outlined nursing homes' were expected to document all administered tests to demonstrate compliance with applicable testing requirements. The corresponding CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated May 2023, identified anyone with even mild symptoms of COVID-19 should be tested for the virus as soon as possible. The recommendations included, Asymptomatic patients with close contact with someone with [COVID-19] should have a series of three viral tests . recommended immediately . and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. Further, the recommendations outlined empiric TBP should be implemented and discontinued using clinical judgement and after any completed diagnostic testing. R8's quarterly Minimum Data Set (MDS), dated [DATE], identified R8 had severe cognitive impairment. On 9/25/23, upon entrance to the nursing home for the recertification survey, a single room was identified to have transmission based precaution (TBP) equipment posted outside with signage on the door outlining, Droplet Precautions. During the entrance conference, on 9/25/23 at 11:56 a.m., it was verified R8 resided in the room with the posted information and was COVID-19 positive. When interviewed on 9/25/23 at 5:34 p.m., R8's family member (FM)-A stated R8 had COVID-19 and was in isolation as a result. FM-A stated the staff confirmed the infection on Sunday, 9/24/23, and moved R8 to a private room from his shared room. FM-A stated they felt R8 had a change and the COVID-19 symptoms prior to 9/24/23, however, with a runny nose and eye drainage starting about a week ago. FM-A stated they were unaware if staff had tested R8 for COVID-19 upon the start of those symptoms. R8's progress note(s), dated 9/21/23 to 9/28/23, were reviewed and identified the following: On 9/21/23, R8 was recorded as having . an increase in temp 99.2 [F] . cool cloth [applied] on forehead . dropped down to [98.5 F] . There was no COVID-19 testing recorded as completed. On 9/21/23, R8 was recorded as . was tired and difficult to arouse, with stable vital signs. The nurse practitioner was updated and a urinalysis (UA) was ordered. There was no COVID-19 testing recorded as completed. On 9/22/23, R8 denied pain and had a recorded temperature of 98.9 F. On 9/23/23, R8 was recorded as having redness noted in both eyes along with ocular discharge adding, [R8] states its itchy. A note was left for the nurse practitioner. However, again, there was no COVID-19 testing recorded as completed. On 9/24/23, R8 was recorded as now having a hoarse voice but denied a sore throat. R8's temperature was 97.9 F and a rapid COVID-19 test was completed with dictation, . was positive. R8's family was updated along with the nurse practitioner, and medication was ordered. When interviewed on 9/26/23 at 1:07 p.m., nursing assistant (NA)-C stated they had worked with R8 prior to him getting infected with COVID-19. NA-C stated R8 needed total care but was able to feed himself, nor did R8 have any history of having eye drainage prior to getting sick. NA-C stated R8 had not been placed in TBP, to their knowledge, prior to changing rooms (i.e., double room to private for isolation). R8's medical record, including the progress notes and Treatment Administration Record (TAR), were reviewed and lacked any evidence R8 had been promptly tested for COVID-19 prior to 9/24/23, despite having objective symptoms of the illness (i.e., eye drainage, fatigue, elevated temperature). Further, there was no evidence TBP were implemented timely after these symptoms started until infection could be definitively verified or ruled out. On 9/26/23 at 1:14 p.m., licensed practical nurse (LPN)-B was interviewed. LPN-B stated they had never cared for R8 prior to his isolation for COVID-19, however, expressed anyone having ocular drainage or a temperature should be tested for COVID-19 adding, I think you might want to do COVID testing. LPN-B verified the nursing home had onsite, rapid COVID-19 tests available along with ongoing, standing orders to complete them if symptoms were observed or infection suspected. LPN-B stated any completed testing or implemented TBP should be recorded in the progress notes or TAR, and the director of nursing (DON) or assistant director of nursing (ADON) should be notified. On 9/27/23 at 9:42 a.m., the the assistant director of nursing (ADON) was interviewed and verified they were the infection preventionist (IP) for the nursing home. ADON verified they had reviewed R8's medical record and explained R8's temperature of 99 point something would not necessarily trigger enough concern on it's own to warrant COVID-19 testing given R8 displayed no respiratory symptoms with the elevated temperature. ADON stated they had heard the most recent variant of COVID-19 did display more allergy signs and symptoms than previous ones, however, even the combination of R8's symptoms, including fever and fatigue and eye drainage, still likely wouldn't warrant testing for COVID-19 given the lack of respiratory symptoms in their opinion. However, ADON explained the UA being ordered, on 9/21/23, should have triggered an infection control case to be opened to ensure appropriate UA-related monitoring, however, they had not been notified so it had not been done. ADON acknowledged appropriate infection monitoring should begin the moment someone has a symptom but reiterated the lack of respiratory symptoms on the initial progress notes did not warrant COVID-19 testing in their opinion, until R8 developed the hoarse voice and was subsequently tested and placed in TBP. ADON verified any completed COVID-19 testing, and subsequent placement in TBP, should be documented in the medical record which R8's lacked. ADON acknowledged the CDC guidelines which outlined to test as soon as possible with symptom development and they stated COVID-19 could present itself in so many ways, however, again voiced they were comfortable with how R8's symptoms and subsequent testing were handled. Further, ADON expressed testing residents or staff for single, potentially one-off symptoms could overwhelm the nursing home so they also relied on nursing judgement to help make these decisions.