**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure personal privacy was maintained to promote dignity for 1 of 1 resident (R21) observed with bare skin and undergarments visible from the hallway to other residents, visitors, and staff. Findings include: R21's admission Minimum Data Set (MDS) dated [DATE], identified R21 had severe cognitive impairment, displayed disorganized thinking, had physical behaviors directed towards others (sexual), that interfered with care, or social interactions, did not reject care, and required maximal assistance for activities of daily living (ADLs). Further, the MDS identified R21 was incontinent of both bowel and bladder, had diagnoses of dementia, Parkinson's disease, coronary artery disease (CAD), peripheral vascular disease (PVD), heart failure, and had a history of falls. R21's Care Plan dated 1/28/25, lacked information regarding preserving privacy and dignity. The care plan indicated brief use for incontinence, check upon rising, before and after meals, at bedtime, on NOC rounds and as needed. R21 was incontinent of bowel and bladder and dependent on staff for hygiene. Furthermore, R21's care plan identified inappropriate sexual advances towards residents and staff with the intervention of providing care with two staff members but failed to identify how to preserve dignity while keeping R21 safe in between cares. R21's [NAME] dated 1/30/25, indicated staff ensured safety for R21 by offering to help resident lay down in bed after meals when tired and to provide a safe environment, R21 moved closer to the nursing station to increase observation on 12/31/24, and the door was to be left ajar to avoid isolation. During an interview on 1/27/25 at 5:25 p.m., family member (FM)-A, stated, the last time she visited, R21 was lying in a wet brief in his room, and further stated her and her family were embarrassed seeing R21 in just a brief, and was also embarrassed for R21 because he would be embarrassed if he realized he was lying in a brief with the door open. During an observation on 1/28/25 at 1:15 p.m., R21 was lying in bed in his private room with the door wide open, and fully visible to the hallway. R21 had the overhead lights off, was wearing a t-shirt, cream colored brief, bare legs, pants pushed down to his socks, and a sheet and blanket pulled to the side. R21's room had a visible track installed on the ceiling which had metallic hooking devices, however, the room lacked privacy curtains. During an observation on 1/28/25 at 1:21 p.m., social services designee (SS)-A walked past R21's room that had the door wide open, SS-A looked in R21's room, and kept walking. During an observation on 1/28/25 at 1:23 p.m., SS-A walked back down the hall and looked in R21's room, but did not talk to staff regarding R21 laying in the bed in a t-shirt and brief and the blankets pushed aside. During an observation on 1/28/25 1:29 p.m., nursing assistant (NA)-C walked past R21's room and did not look in R21's room. NA-C came back approximately 1:30 p.m., to answer R21's ringing telephone. NA-C handed R21 the phone and R21 answered the phone but stated no one is there. NA-C covered R21 with a blanket and he grabbed at her. At this time, the director of nursing, (DON), walked past and entered registered nurse (RN)-A's office. NA-C then covered R21 up with a blue blanket and R21 made inappropriate comments to NA-C and attempted to reach out and grab her. NA-C redirected his behavior and left the room leaving the door open. During an observation on 1/28/25 between 1:44 p.m. and 1:48 p.m., R21 was lying in bed and remained covered with a blanket and the door was open. During an observation on 1/28/25 at 1:51 p.m., trained medication aide, (TMA)-A walked by R21's room, R21 had removed his blanket and unfastened his brief on the left side. TMA-A closed the door without talking to resident or going inside. During interview on 1/28/25 at 1:56 p.m., TMA-A stated R21 was at risk for falling, and the door should remain open for safety. TMA-A walked back to R21's door and confirmed with surveyor the door had been shut and remained shut during our interview outside R21's door. TMA-A opened the door during our interview. The brief was loosely on with no private areas visible for the staff and visitors in the hallway to see. TMA-A verified there was no curtain hanging to provide privacy. During observation on 1/28/25 at 2:12 p.m., TMA-A exited R21's room carrying a trash bag containing a tan brief and left the door open. R21 was covered with a blue blanket. During observation on 1/28/25 at 2:35 p.m., R21's door was open, and R21 was lying in bed, scratching left side of his hip. R21's pants were pushed to end of bed and the blanket was pushed aside. Health Unit Coordinator (HUC)-A came out of the office directly across from R21's room, looked into R21's room and introduced self to state surveyors then went back in the office. There were two staff and two visitors walking down the hall. During observation on 1/28/25 at 2:42 p.m., NA-C walked down the hallway and shut R21's door. At 2:45 p.m., NA-C returned to R21's room, went inside and closed the door behind her. NA-C opened the door and as she was leaving R21 was making inappropriate sexual comments and reached out asking for a rub down. R21 was covered with a blanket and NA-C closed the door. NA-C walked over to the nursing station and discussed the inappropriate comments and gestures to other NA's and began discussing dinner plans. At 2:59 p.m., R21 was moaning and could be heard from the hallway. During an interview on 1/29/25 8:42 a.m., the DON, verified R21's door should be open due to being at risk for falls. Further R21's door could be partially shut to provide as much privacy as possible, but safety was first. [NAME] Policy Resident Dignity-Rehab/Skilled, dated 12/11/24 and [NAME] Policy Falls Resource Packet-Rehab/Skilled 5/7/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review the facility failed to ensure 1 of 1 resident (R25) received assistance with shaving and nail care reviewed for activities of daily living (ADL). Findings include: R25's quarterly Minimum Data Set (MDS) dated [DATE], indicated moderately impaired cognition and a diagnosis of blindness. It further indicated R25 required supervision with personal hygiene. R25's physician's orders dated 1/24/25, indicated weekly skin assessment, please check skin and document findings in the skin observation V-3, chart vital signs, trim nails and obtain weight, offer to shave resident if he wishes, every day shift on Friday. R25's weekly skin observation dated 1/24/25, lacked documentation R25's nails were trimmed, he had been shaved, or that staff offered or he had refused. R25's care plan indicated R25 had an ADL self care performance deficit related to a history of cerebral vascular accident (CVA), blindness evidenced by a shuffling, slow gait, and required more help with ADLs. It further indicated an intervention for staff to provide assistance with bed mobility, transfers, eating, dressing, toilet use and personal hygiene. During observation and interview on 1/27/25 at 1:31 p.m., R25 was sitting in his recliner in his room. The fingernails on both hands were approximately a 1/2 an inch long and he had a few weeks worth of facial hair. R25 stated he wanted his fingernails to be trimmed and to be clean shaven. He wanted to keep his moustache. During observation and interview on 1/28/25 at 2:00 p.m., R25 was sitting in his recliner and his fingernails on both hands were approximately a 1/2 inch long and he stated he would like them cut. He also stated he wasn't clean shaven and would like to be. During interview on 1/29/25 at 6:40 a.m., nursing assistant (NA)-A stated NA's were responsible for trimming residents nails (who are not diabetic) and shaving resident's once a week on their bath day. There was no place to document it specifically, its just part of what they were supposed to do. If the resident refused, they should re-approach and let the nurse know. During interview on 1/29/25 at 6:46 a.m. NA-B stated NA's were responsible for shaving and trimming (non-diabetic) residents nails and shaving them once a week on bath day. There was no specific place to document and if the resident refused they should re-approach 3 times then let the nurse know. During interview on 1/29/25 at 9:05 a.m., licensensed practical nurse (LPN)-A verified R25's nails and facial hair were long (more 1-2 weeks growth). LPN-A also stated nursing assistants were responsible for trimming residents nails (non-diabetic) and shaving residents once a week on bath day. The nurses were responsible for documenting it had been completed and the NA's should let nurses know if a resident refuses. During interview on 1/30/25 2:35 p.m., the director of nursing (DON) stated NA's were responsible for trimming resident's nails and shaving them once a week on bath day. They should also be documenting if the task was completed and if the resident refused, they should also re-approach, let the nurse know, and document the refusal. A facility policy on ADL's dated 11/29/22, indicated the purpose of the policy was to provide residents with appropriate treatment and services to maintain or improve abilities in ADL for the well being of mind, body and soul

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R17's significant change Minimum Data Set (MDS) dated [DATE], indicated R17's cognition was unable to be assessed and diagnoses of congestive heart failure (CHF) and localized edema. It further indicated R17 required supervision with dressing. R17's physician's orders dated 3/23/23, indicated Tubi-grips (compression bandages) to bilateral lower legs, on in the morning, off at hour of sleep (HS), every day shift for edema. R17's care plan dated 11/9/22, lacked any indication of R17 wearing Tubi grips on bilateral lower extremities, potential for excess fluid, or edema related to CHF. R17's medication administration and treatment administration records (MAR/TAR) for the month of January 2025 lacked documentation R25's Tubi grips were being applied in the morning or removed in the evening. During observation on 1/27/25 at 6:02 p.m., R17 was sitting in the dining room waiting for dinner. He was wearing slippers and the legs of his sweat pants were bunched up approximately 2-3 inches in which his bare ankles/lower legs were visible and he was not wearing Tubi grips. During observation on 1/29/25 at 6:30 a.m., R17 was asleep in his recliner in his room. His legs were elevated on the foot rest and he was wearing bilateral Tubi grips. During observation and interview on 1/29/25 at 6:46 a.m. NA-B verified R17's Tubi grips were on and stated they should have been removed last night before he went to bed. NA- further stated NA's were responsible for applying R17's Tubi grips each morning and removing them in the evening. During interview on 1/29/25 at 9:05 a.m., licensed practical nurse (LPN)-A stated NA's were responsible for applying R17's Tubi grips in the morning and removing them at night when he goes to bed. They should also re-approach, let the nurse know, and document any refusals. During interview on 1/30/25 2:35 p.m., the director of nursing (DON) stated nursing staff were responsible for ensuring R17's Tubi grips were applied during the day and removed at night and to document the task was completed. They were also expected to document refusals and let the nurse know. A facility policy regarding monitoring for edema was received but didn't address the use of assistive devices such as compression socks, Tubi grips, etc. Based on observation, interview and record review the facility failed to ensure bruising was monitored for 1 of 1 residents (R14) reviewed for bruises. The facility further failed to ensure interventions for edema care were implemented for 1 of 1 residents (R17) reviewed for edema. Findings include: R14's quarterly Minimum Data Set (MDS) dated [DATE], indicated R14 had moderate cognitive impairment and diagnoses of dementia and heart disease. Furthermore, R14 received an anticoagulation (AC, medication to thin the blood) daily. R14's provider order summary indicated R14 required the following: - on10/4/23, Eliquis (AC medication) 5 milligrams (mg) daily to prevent blood clots. - on 5/28/24, weekly skin assessment every evening shift on Sundays. -on 5/21/24, required monitoring due to AC use. Instructed staff to report to the provider blood in the urine or stools, severe headache, unusual bruising. R14's care plan revised 5/21/24, indicated R14 was on AC therapy and directed staff to monitor resident based on clinical standards related to AC use and easily bruising. R14's weekly skin assessment dated [DATE], indicated R14 was assessed for skin alterations including bruising, however lacked indication bruising was identified. R14's weekly skin assessment dated [DATE], indicated R14 was assessed for skin alterations including bruising, however lacked indication bruising was identified. R14's weekly skin assessment dated [DATE], indicated R14's skin alterations had resolved. R14's medical record lacked indication of when R14's bruising was identified and/or monitored. An observation on 1/27/25 at 2:58 p.m., R14 was sitting in their wheelchair. R14's left forearm had a purple quarter sized bruise. Below was a second purple bruise with yellowing in the middle. R14's right hand around the second knuckle had a dime size dark purple bruise. When interviewed on 1/28/25 at 1:10 p.m., nursing assistant (NA)-A verified R14's bruises and stated R14 had them for a while. R14 was on blood thinners and always had bruises on their hands and arms. NA-A wasn't sure how she always gets the bumps and bruises, but believed they were from hanging on to the grab bars tightly and bumping her arms with repositioning. When interviewed on 1/29/25 at 12:09 p.m., licensed practical nurse (LPN)-A stated if bruising was noticed on a resident, staff attempted to determine when it happened and how it happened. LPN-A stated monitoring if the bruising was significant or suspicious, more investigation and monitoring would occur. LPN-A further stated it was common for residents on blood thinners to have bruising on their hands and arms so there may not be any specific monitoring orders in place however the bruising would be documented on the weekly skin assessments. LPN-A verified R14 had bruising and stated it was not unusual for R14 to have multiple bruises from bumping their hands or arms during repositioning and transfers. LPN-A verified there was no specific monitoring, just the weekly observations and stated one bruise goes away and another one comes. When interviewed on 1/29/25 at 12:37 p.m., registered nurse (RN)- A stated all residents who are on AC medication have monitoring in place for bruising. RN-A further stated any bruising would also be noted on the weekly skin assessments. If bruising was noted during cares or in between the weekly assessments, a separate skin assessment would be completed. If the bruising was suspicious or very large the provider would be notified, and additional monitoring orders would be placed. RN-A stated R14 was prone to bruising on the hands or forearms as she was on an AC medication and often bumped the grab bars or the bedside table. RN-A wasn't aware if R14 had any bruising currently as the bruising comes and goes. RN-A further stated if they were not listed on the weekly skin assessment, R14 may have just gotten them and would expect an assessment done to document when they were identified. When interviewed on 1/30/25 at 1:51 p.m., the Director of Nursing (DON) expected staff to identify any bruising on the weekly skin assessments for routine monitoring. If the bruise was large or abnormal, additional investigation or monitoring would also be in place. A facility policy titled Skin Assessment Pressure Ulcer Prevention and Documentation revised 4/26/24, directed staff to monitor bruising weekly and any changes and or progress toward healing should be documented on the skin observation assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to fully assess and implement fall prevention interventions for 2 of 2 residents (R21, R187) reviewed for falls. Findings include: R21: R21's Optional State Assessment (OSA) dated 1/5/25, indicated moderate cognitive impairment, did not have delusions or hallucinations, did not reject care, had other behavioral symptoms not directed toward others 1 to 3 days, required extensive assist with bed mobility, eating, and toileting and was dependent on staff for transfers. R21's admission Minimum Data Set (MDS) dated [DATE], indicated R21 was frequently incontinent of urine and always incontinent of bowels, had fallen in the month prior to admission, had fallen once since admission with no injuries. R21's Medical Diagnosis form undated, indicated the following diagnoses: acute on chronic systolic heart failure, muscle weakness, unspecified dementia, and Parkinson's disease. R21's care area assessment (CAA) dated 1/5/25, indicated R21 had an actual falls risk and would be addressed on the care plan. The assessment further indicated falls put R21 at risk for injuries like fractures or head injuries that could result in rehospitalization, further functional and cognitive decline, disability and even death and a referral to other disciplines was warranted including the provider, therapy, and nursing to help design and implement patient specific interventions and strategies like improving balance and strength to reduce the risk of falls. R21's care plan dated 12/31/24, indicated R21 had an actual fall on 12/31/24, and had the following interventions: staff to offer to help resident lay down in bed after meals when tired (1/25/24), educate resident and family about safety reminders and what to do if a fall occurs, educate resident and family and IDT as to the causes of falls, remind resident not to bend over to pick up dropped items, encourage use of grabber or to ask for assistance, modify environment to maximize safety, call light in reach, tap call light placed for easier access for resident due to dementia, night light used to maximize resident safety, ensure and provide a safe environment moved closer to the nursing station on 12/31/24 to increase observation, leave the door ajar to avoid isolation, 1/20/24 cues and reminders to resident to wait for assistance and not self-transfer. 1/21NP review of falls with labs ordered, signage placed on bathroom door to remind resident to have staff assist to the bathroom, review bowel and bladder continence status and establish and or review toileting plan based on resident's needs. 1/20/25 toileting, check and change upon arising, before and after meals, bedtime and as needed. 1/30/25 wheelchair in locked position beside bed. R21's [NAME] dated 1/28/25, indicated encourage and monitor independent interests, assist with resources as needed, turn on the TV, R21 liked to watch channels 37, 47, or cop shows, and action movies. Invite and remind resident of scheduled activities, assisting to and from locations as needed, and responds well to redirection. Attempts to self-transfer back to bed after meals, staff to offer to help resident lay down in bed after meals when tired 1/25/24. Provide a safe environment, move closer to the nursing station to increase observation, leave the door ajar to avoid isolation. 1/20/24 cues and reminders to resident to wait for assistance and not self-transfer, signage placed on bathroom door to remind resident to have staff assist to the bathroom. Place the call light in reach, use a night light, remind resident not to bend over to pick up dropped items. Encourage use of grabber or to ask for assistance. R21's Falls Tool form dated 12/31/24 at 8:39 a.m., indicated R21 had one or more falls between 3 to 12 months ago, took two risk factor medications, had moderately impaired cognition, and risk factors included cognitive status, restlessness, confusion, poor memory, impulsive, and under the heading, Action Plan indicated, Refer to therapy. R21's Falls Tool form dated 1/20/25 at 6:26 a.m., indicated R21 took two risk factor medications, appeared severely affected psychologically, had risk factors including, mobility and transfers related to impaired balance, and cognitive status problems of reduced insight. Under the heading, Action Plan was undocumented. R21's Falls Tool dated 1/21/25 at 12:32 a.m., indicated R21 was at high risk for falling, had one or more falls in the last three months, took two risk factor medications, appeared severely affected psychologically, had severe cognitive impairment, had restlessness, reduced insight, delirium, confusion, poor memory, was impulsive, withdrawn, disorientated, had difficulty following instructions and had sleep problems, used equipment unsafely, forgot to use equipment, had medical problems, and continence problems, multiple falls during a shift and under the heading, Action Plan was undocumented and under the heading, Multiple Falls indicated the care plan was updated to include the wheelchair had anti roll-back brakes applied. R21's Group and Self-Directed Activities 30 day look back form from 1/29/25, indicated no data was found for activities, community, creative, educational/cognitive, physical, sensory stimulation, social, and spiritual activities. R21's one to one Activities 30 day look back form from 1/29/25, indicated R21 had eye contact, and a social activity on 12/31/24. Further, the forms lacked documentation R21 had any spiritual, sensory, physical, educational/cognitive, creative, or community activities. No additional activities were documented. R21's Risk Management Report dated 1/20/25 at 6:17 a.m., indicated R21 was on the floor in the bathroom. R21 stated he was getting up and fell. R21 was assessed for injury and moved back to bed by Hoyer lift. He was not transferred to the hospital. Under the heading, Predisposing Situation Factors not applicable was documented, no medications identified as factors. IDT reviewed the incident on 1/20/25. R21's Risk Management Report dated 1/20/25 at 11:44 p.m., indicated R21 fell in the bathroom and was found between the sink and the toilet lying on his back. His right pointer finger had a 1 cm x 2 cm cut that was bleeding when staff found him. A bruise formed on the back of his head. The fall could not be described by R21. Paramedics were called and assessed R21 and was not transferred to the hospital. Under the heading, Injury Type no injuries observed at time of incident was documented. Under the heading, Predisposing Situation Factors other, unable to determine if resident was using a device at time of fall, and no medications were documented as factors to the fall. The risk management document does not identify resident had a fall within the past 24 hours, R21's had fallen at 6:17 a.m. and IDT reviewed the incident on 1/21/25. R21's Risk Management Report dated 1/25/25 at 10:01 a.m., indicated R21 was found on the floor next to his bed with his head against the nightstand. Under the heading, Injuries Observed at Time of Incident Other and back of head were documented. The note documented on 1/25/25 stated R21 was trying to self-transfer to bed from wheelchair. IDT reviewed the incident on 1/28/25. R21's progress notes dated 12/31/24 at 11:15 a.m., indicated R21 arrived back to the facility from the emergency room. R21's progress notes dated 12/31/24 at 11:34 a.m., indicated the after-visit summary was due to a fall and the CT and x-rays showed no broken bones. Progress notes from 12/31/24, lacked information regarding R21's fall. R21's progress notes dated 1/3/25 at 2:56 p.m., indicated an MDS review and was at high risk for falling with one fall with no injury since admission, poor safety awareness, impulsive, attempts to self-transfer out of bed and was moved closer to the nursing station and a night light was placed in R21's room. R21's progress notes dated 1/20/25 at 6:24 a.m., indicated staff saw R21 on the floor and had apparently tried to get up by himself and fell. R21's progress notes dated 1/20/25 at 8:45 p.m., indicated R21 was found on the floor in the bathroom between the sink and toilet and 911 was called. R21's progress notes dated 1/21/25 at 4:16 p.m., indicated the nurse practitioner was updated earlier regarding R21's two falls. There was no other documentation on 1/21/25, regarding the falls in the progress notes. R21's progress notes dated 1/25/25 at 9:59 a.m., indicated R21 was found sitting on the floor next to the bed with the head against the nightstand and was attempting to get back to bed from the wheelchair when R21 fell. R21's progress notes dated 1/25/25 at 10:01 a.m., indicated the care plan was updated with new falls intervention to offer to help to lie down after meals when tired. During interview on 1/27/25 at 5:25 p.m., family member (FM)-A stated R21 had three falls and went to the hospital for one of the falls. During observation on 1/27/25 at 6:33 p.m., care plan indicated to assist to bed after meals and R21 was up in the chair. During observation on 1/28/25 at 8:48 a.m., R21 was up in his wheelchair and appeared to be asleep at the nursing station. During interview and observation on 1/28/25 at 1:29 p.m., nursing assistant (NA)- C stated they looked to the [NAME] on the computer to know what cares a resident required. She added R21 fell all the time and now they locked the wheelchair next to the bed and lower the bed, tied the call light to the bed and stated sometimes closed the door to resident's room., She stated, R21 was at risk for falling and they were trying to find a low bed because R21's bed did not go all the way to the floor. NA-C verified R21 did not have a grabber and stated she thought the facility took it away because R21 was falling. NA-C verified no [NAME] was hanging in the room. During observation on 1/28/25 at 1:51 p.m., trained medication aid (TMA)-A shut R21's door and did not go inside the room. At 1:56 p.m., R21's door remained closed. During interview and observation on 1/28/25 at 1:56 p.m., TMA-A stated they checked the care plan and residents at risk for falling had an arm band, needed the call light close and the bed needed to be down. TMA-A confirmed the door was closed and that she walked by and closed the door. During observation on 1/28/25 at 2:12 p.m., staff set a new grabber on R21's bed side table. During observation on 1/29/25 at 7:15 a.m., R21's call light was on the night table across but out of reach no grabber. During interview on 1/29/25 at 8:42 a.m., director of nursing stated nursing assistants and nurses are expected to use the [NAME] and for residents at risk for falls the [NAME] should be posted in the resident's room. R21's door should be opened, the call light within reach, checked, and changed every couple hour, wheelchair locked and near bed. She confirmed that NA-C was told on 1/28/2025 to place a new grabber in R21's room and does not believe the grabbers work as this is an intervention implemented by therapy, not nursing. She is looking into a low bed for R21 and identified interventions that could be implemented in the care plan like increased time at activities, and stated R21 is just bored and restless. R187: R187's admission MDS in progress dated 1/26/25, indicated moderate cognitive impairment. R187's Medical Diagnosis form indicated the following diagnoses: traumatic ischemia of muscle, cystitis, and chronic kidney disease stage 3. R187's Nursing Admit Data Collection form, dated 1/22/2025 at 3:15 p.m., indicated the resident was admitted from the hospital for fall, traumatic, rhabdomyolysis. Physical and occupational therapy is recommended. R187's Orders form indicated the following orders: 1/22/25, trazodone (an antidepressant) 50 mg tablet, give 0.5 tablet by mouth at bedtime for trouble sleeping. 1/22/25, buspirone (an anxiolytic) 10 mg tablet, give 1 tablet by mouth two times a day for major depressive disorder. 1/22/25, mirtazapine (an antidepressant) 30 mg tablet give 1 tablet by mouth at bedtime for major depressive disorder. 1/22/25, tramadol (an opioid) 25 mg tablet, give 0.5 tablet by mouth every 4 hours as needed for pain. Pain: 4-6. Must chart effectiveness and give 1 tablet by mouth every 4 hours as needed for pain. Pain: 7-10. Must chart effectiveness. 1/23/25, escitalopram oxalate (an antidepressant) oral tablet 5 mg give 1 tablet by mouth one time a day for major depressive disorder. 1/22/25, diphenhydramine hcl (an antihistamine) 50 mg capsule, give 1 capsule by mouth as needed for skin reaction if consuming shrimp. D/C Date 1/24/25 R187's Pharmacy New Admit Review was electronically sent to the DON, physician, and nurse practitioner on 1/23/25 at 7:08 p.m., indicated recommendations to update directions for diphenhydramine and lidocaine. The pharmacist recommended once R187 was settled consider decreasing the doses or discontinuing some of the five psychoactive medications prescribed. Noting she doesn't have any mental diagnoses under the tab. R187's care plan dated 1/22/25, indicated R187 was on medications with an FDA black boxed warning or warnings of adverse consequences related to atrial fibrillation, migraine, depression, hypertension, pain, and trouble sleeping. Interventions included to refer to the boxed warnings in the orders or eMAR, or medication reference of choice for mirtazapine, escitalopram, tramadol, and trazodone. R187's care plan dated 1/23/25, indicated R187 had an activity of daily living (ADL) deficit due to cystitis, fall, rhabdomyolysis and required limited assist of one staff with a walker and gait belt for ambulating short distances in the room. Further, R187 required limited assist to use the toilet and transferred with limited assist of one using a walker and gait belt. R187's care plan revised 1/28/25, indicated R187 had actual falls due to rhabdomyolysis, history of traumatic brain injury, deconditioning, gait and balance problems, and a history of falls and had the following interventions: educate resident and family about safety reminders and what to do if a fall occurs, educate the resident, family, and IDT of the cause of the fall, educate and instruct the resident and family on the safe use of assistive devices, 1/28/25 keep the walker within reach, remind to cue resident to call for assistance, remind resident not to bend over to pick up dropped items, encourage use of grabber or to ask for assistance, modify the environment to maximize safety, call light should be in reach, 1/28/25 offer toileting assistance upon arising, before and after meals, bedtime and as needed. R187's Falls Tool form dated 1/22/25 at 6:28 p.m., indicated R187 had recent falls, took two or more risk factor meds such as sedatives, anti-depressants, anti-Parkinson's, diuretics, anti-hypertensives, hypnotics. Under the heading, Risk Factor-Psychological (Anxiety, Depression, Decreased Cooperation, Decreased Insight or Decreased Judgement especially related to mobility) indicated, Does not appear to have any of these. Further, the risk factor check list and intervention plan had check boxes that were checked for mobility and transfers, changes in mobility related to muscle weakness or strength, impaired balance or coordination, cognitive status, poor memory, medical problems included check boxes for changes in medication, high risk medications, changes in condition, and under the heading, Action Plan included check boxes to refer to therapy, restorative nursing, provider or practitioner, obtain a pharmacy consult, refer to the registered dietician, and update the care plan. The only box checked was to update the care plan. R187's Fall Scene Huddle Worksheet dated 1/28/25, at 6:45 p.m., indicated anticoagulant, antidepressant, cardiovascular were given in the past eight hours. R187 was found on the floor, had attempted to ambulate and self-transferred, used walker and lost balance. Last toileted at 5:30 p.m. and complained of back pain with movement. R187's Falls Tool form dated 1/28/25 at 8:56 p.m., and saved on 1/29/25 at 12:05 p.m., indicated there were no fall risk factors indicated, no risks factor checklists or interventions; no action plans were identified. R187's dispatch health imaging final report dated 1/30/25 at 12:59 p.m., indicated thoracic spine two views, there are no prior examinations for comparison. There is diffuse bony demineralization and kyphosis. There is a compression deformity of a midthoracic vertebral body of uncertain age. This is probably T7. There is a diffuse degenerative disc disease throughout the thoracic spine. Compression, midthoracic vertebral body compression fracture of uncertain age. Fax was received at 1/30/25 at 12:16 p.m. and certified nurse practitioner notified 1/30/25 at 12:30 p.m. R187's progress notes dated 1/22/25 at 5:38 p.m., indicated R187 had traumatic rhabdomyolysis of the right shoulder and arm and had not fallen prior to this one. R187's progress notes dated 1/24/25 at 9:18 a.m., indicated R187 had a recent fall at home and R187's PHQ-9 score was a 1 out of 27, indicating minimal depression. R187's progress notes dated 1/27/25 at 8:43 p.m., indicated R187 forgot to take her medications at times and the assisted living facility set up R187's medications and R187 scored low on cognitive assessments. R187's progress notes dated 1/29/25 at 9:18 a.m., indicated R187 had a fall and would get an x-ray. The notes lacked information when R187 fell, how R187 fell, what R187 was doing at the time of the fall, or any type of fall assessment. R187's progress notes dated 1/29/25 at 12:54 p.m., indicated the nurse practitioner was updated R187's son requested x-rays because R187 fell and had pain. R187's progress notes dated 1/30/25 at 12:41 p.m., indicated the nurse practitioner was at the facility and reviewed the x ray results. No other information was documented. R187's Potential Clinically Significant Medication Issues form dated 1/24/25 at 9:14 a.m., indicated a drug regimen review did not find issues of a potentially clinically significant medication issue. Additionally, check boxes indicating the date and time the prescriber was contacted was undocumented. R187's Interim Medication Regimen Review dated 1/28/25 and signed by admitting physician indicated physician orders reviewed with high-risk monitoring recommendations for anticoagulant and tramadol. R187's Risk Management Report from 1/28/25 at 9:20 p.m., stated the resident was found on the floor after trying to open the door. Assessed by registered nurse (RN)-A and recommended two certified nursing assistants to use the Hoyer lift to get R187 off the floor. Under the heading, Predisposing Situation Factors, not applicable was documented and no documentation of psychopharmacological medications. IDT reviewed incident on 1/29/2025. R187's Mar/Tar indicated on 1/29/25 amlodipine was given for hypertension, escitalopram oxalate was given for major depressive disorder, lisinopril for hypertension, melatonin for insomnia, mirtazapine for major depressive disorder, trazadone HCL for sleep, buspirone twice for major depressive disorder, carvedilol twice for atrial fibrillation, divalproex sodium twice for migraine, apixaban twice for atrial fibrillation, acetaminophen once for pain, tramadol three times for pain. R187's was referred to therapy due to a fall on 1/18/25 at home. R187's occupational therapy (OT) report dated 1/23/25 through 2/21/25 indicated, a baseline assessment was completed on 1/23/25. R187 demonstrated good rehab potential as evidenced by ability to follow one-step directions, able to make needs known, active participation in skilled treatment, motivated to a participate, motivated to return to prior level of living, strong family support and supportive caregivers/staff. R187 was assessed for activities of daily living (ADL's) and needed substantial to maximal assistance for toileting hygiene, shower/bathe, putting on/taking off footwear. Set up assistance for eating and oral hygiene. Supervision for upper body dressing and partial assistance for lower body assistance. R187 transferred with supervision or touching assistance, ambulated 10 feet with touching assistance, toilet transferred with supervision or touching assistance, partial assistance with bed mobility. R187 was able to sit up unsupported for 30 seconds with feet flat on floor and no back support. Ability to communicate wants and needs. Followed one step directions. Modified decision making. Therapy noted, patient presents with impairments in balance, mobility, strength, follow through, planning and problem solving resulting in limitations and/or participations restrictions in the areas of general tasks and demands, mobility and selfcare which requires skilled OT services to maximize independence with ADLs to facilitate ability to live in environment with least amount of supervision and assistance. Due to the documented physical impairments and associated functional deficits, without skilled therapeutic interventions, the patient is at risk for falls and further decline in function. R187 attended OT on 1/23/25, 1/24/25, and 1/27/25. OT notes for 1/28/25 and 1/30/25 indicated resident was not able to participate in therapy due to fall on 1/28/25. R187's physical therapy (PT) report dated 1/23/25 through 2/21/25 indicated resident demonstrates good rehab potential as evidenced by high prior level of functions, motivated to participate, motivated to return not prior level of living and stable medical condition. R187 attended PT on 1/23/25, 1/24/25 and 1/28/25. PT notes for 1/29/25 and 1/30/25 indicated resident was not able to participate in therapy due to fall on 1/28/25. During observation on 1/27/25, at 2:28 p.m., no grabber or call light in reach. During observation on 1/27/25 at 6:10 p.m., call light pressed for R187 to check response time. At 6:12 p.m. staff did not respond to call light but did deliver meal tray. At 6:14 p.m. through 6:17 p.m. the call light remained on in the resident's room, but the marquee in the hallway closest to the resident's room was not displaying room ten and had a black screen. However, the marque near the nursing station on the opposite end did have Room ten scrolling on the marquee. During observation on 1/28/25 at 8:26 a.m., R187 was in her recliner, had vomited and attempted to use remote for lift chair to sit up. Call light was out of reach, assisted R187 with call light and she stated she was ready to go back to bed. Notified nursing assistant (NA)-D that resident vomited. The marquee near room ten was on. During observation on 1/29/25 at 11:57 a.m., verified with nursing assistant (NA)-C there was no grabber in R187's room. During an interview on 1/30/25 at 9:11 a.m., with registered nurse, (RN)-C, stated that she was not working at the time R187 fell, but neurological assessments are checked for three days following a fall. During observation on 1/30/25 at 9:30 a.m., dispatch health imaging arrived for imaging. The nurse practitioner was notified at 1/30/25 at 12:30 p.m. of the results. During an interview on 1/30/25 at 9:32 a.m., with registered nurse, (RN)-A, stated the floor nurse was on break when R187 fell. I assessed R187 and she was doing fine so the aids got her up using the lift. The fall assessment would be completed once the floor nurse returned from break. Verified with RN-A no progress note was entered regarding the initial fall assessment when R187 was on the floor. Licensed practical nurse (LPN)-B must have called R187's son because he is aware of the fall and inquired if this would change discharge planning. During a phone interview on 1/30/25 at 11:00 a.m. with LPN-B, stated she works for Focus One agency and has been trained for falls at this facility. LPN-B was on break during the fall. RN-A assessed R187, and LPN-B contacted the family. LPN-B completed the fall scene huddle worksheet and falls management checklist. LPN-B confirmed that RN-A assessed R187. Vital signs were entered in the medical chart at 1/29/25 at 4:15 p.m. and again 1/30/25 7:12 a.m. During interview on 1/30/25 at 12:31 p.m., pharmacist stated admission medications are reviewed within three days. If issues are identified the review will be completed immediately. The pharmacist looked for medication duplicates, same class of medications and any information that doesn't look right. The pharmacist stated, the current process is to email the DON, nurse practitioner and physician with recommendations. Red is used to identify a nursing task and black is used to identify a physician task. The nurse practitioner looked at medication orders and the DON looked for accuracy in the eMAR. This system has been used since he started reviewing at this facility. The pharmacist did review R187's medications and emailed the DON, nurse practitioner, and physician with recommendations on 1/23/25 at 7:08 p.m. The pharmacist stated in his email, she takes 5 psychoactive meds. I'm not sure if she was in the hospital for a fall because she has [NAME] appointments. Once she is settled, consider decreasing the doses or discontinuing some of them. She doesn't have any mental diagnoses under that tab. The pharmacist stated that taking all five of these psychoactive medications could have potential incompatibilities, fall risk, clarity issues and since she did not have a mental diagnosis the facility should review the medications and that was his recommendation. During interview on 1/30/25 at 1:03 p.m., with the minimum data set (MDS) coordinator, registered nurse (RN)-D, stated she is aware of the process the pharmacist uses when reviewing new admission medications, but could not find an email forwarded by the DON, Nurse Practitioner, or Physician to her regarding the recommendations and was not on the original email sent by the pharmacist regarding R187's medication review. RN-D stated she usually receives gradual dose reductions (GDR's) from the pharmacist or DON. RN-A and the HUC will also work on transcribing orders, but confirmed an RN would always double check the HUC's work. RN-D verified that the MDS for R187 is not completed, but she did confirm she marked NO for assessments needed for medications and crossed off the NO during this interview. RN-D stated, the MDS system will flag the new file if there is a black box warning for medications or duplicate medications but isn't aware if the system will identify five drugs in the same class. RN-D agreed that in this case the pharmacist recommendations have not been completed. During interview on 1/30/25 at 1:28 p.m., the DON stated the nurse practitioner did not respond back to the pharmacist email regarding the recommendations for R187's psychoactive medications. The expectation is that if it is a nursing error or fix, she will take care of it. RN-D could also make this change. The DON confirmed there is no system in place for duplicate or multi-class medications dispensed to residents and that nursing would have to use critical thinking skills for dispensed medications. The DON confirmed in this situation the floor nurses should have recognized that R187 was receiving five psychoactive medications in addition to identified as a fall risk. The DON stated what should have happened was the nurse practitioner reviews the discharge summaries from the hospital and if R187 was on medications prior to the hospitalization then these are considered home meds, and the provider will not change the order. The DON thinks R187 came to the facility on these medications, the review was sent to the pharmacist, and she is not sure what happened here. When asked what did happen, the DON said survey stress, documentation from the nurse that day should have been better and then the completed fall tool would have been reviewed earlier. The DON verified the nurse practitioner did sign off on the review from the pharmacist but did not make the recommended changes. At the next pharmacy review meeting the DON will suggest another layer of review to be added to this system. During interview on 1/30/25 at 1:36 p.m., RN-A stated there is no treatment needed for R187's fall that occurred on 1/29/25. R187's injured back will need to heal itself and to talk to the DON for more information. At 1:38 p.m., the DON stated R187 sustained an L4 and mid thoracic compression fracture of uncertain aging. Reviewed [NAME] Policy Falls Resource Packet Rehab/Skilled dated 5/7/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure facial hair was removed for 1 of 1 residents (R6) reviewed for dignity. R6's quarterly Minimum Data Set (MDS) dated [DATE], indicated R6 had cognitive impairment and diagnoses of multiple sclerosis and dementia. R6 had no refusals of care and required supervision for personal hygiene (combing hair, shaving, washing/drying face). R6's [NAME] as of 4/16/24, indicated R6 required assist of one for bathing and personal hygiene of washing face and upper body. R6's [NAME] lacked indication of any cares or preferences for chin hairs. R6's care plan revised on 6/21/23, indicated R6 had impaired assistance of daily living (ADL) performance related to multiple sclerosis and impaired mobility. R6 required assistance with personal hygiene and to encourage to wash face and upper body. R6's care plan lacked indication of preference of chin hairs or assistance for removal or shaving. An observation on 4/15/24 at 2:25 p.m., R6 was sitting in a wheelchair in their room. R6 had several white and gray hairs on her chin. R6 rubbed at them and stated yes they bother me- how do I get rid of them? An observation on 4/16/24 at 9:00 a.m., R6 was observed in the dining room finishing up breakfast. R6's chin hairs were present. When interviewed on 4/16/24 at 2:26 p.m., nursing assistant (NA)-C stated when residents had shower day, the shower, hair wash, nails and bed linens were changed. NA-C further stated a shave was completed if the resident wanted one, but an electric razor was needed and not all residents had an electric razor. If residents refused cares the nurse had to be notified and any refusals. NA-C verified R6 had chin hairs and was not aware of any requests to shave and did not know if the hair bothered R6. NA-C a shower on 4/15/24 and did not know if R6 had an electric razor for use. When interviewed on 4/16/24 at 3:36 p.m. licenced pratical nurse (LPN)-C stated nursing assistants will let them know of any refusals of showers or shaves. If cares are refused, would need to check the care plan or [NAME] on what cares were wanted and talk to the resident. If anything was refused or missed, it was passed on to the next shift. LPN-C did not recall if R6 had requested to be shaved or asked if the hair was bothersome. LPN-C further stated if wanted them removed, family would need to bring in an electric razor as there are not razors available for use. When interviewed on 4/22/24 at 2:08 p.m., the Director of Nursing (DON) expected staff to be asking about chin hairs or offering to shave them on bath days or anytime to ensure the resident was comfortable. DON further stated some residents have razors, but the facility has some available if needed. A facility policy titled Resident Dignity revised 11/16/23, directed staff to promote, support and maintain dignity for all residents. The policy directed staff to maintain dignity by grooming (hair, beards shaved, and nail) how the resident wished.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R189 R189's admission MDS dated [DATE], indicated R189 was admitted to the facility on [DATE], at risk for falls and had a fall with injury prior to admission. Further indicated, diagnosis of open reduction internal fixation (ORIF) of the left femur. R189's fall CAA dated 9/2/23, indicated R189 was at risk for falls related to being unable to ambulate without staff assistance due to unsteadiness, fall history within the last month prior to admission, and a fall after admission. R189's activity of daily living (ADL) functional/Rehabilitation potential CAA dated 9/2/23, indicated R189 required assistance with ADL's due to unsteadiness, weakness, and a fall prior to admission. R189's care plan dated 8/30/23, lacked any evidence of a fall care plan, fall history or any interventions to decrease the risk for falls. Further, indicated R189 had an ADL self care performance deficit related to [specify]. The care plan lacked any evidence of what R189's ADL self care performance deficit was related to and had no interventions. R189's [NAME] dated 8/30/23, lacked any evidence of R189's fall risk status or interventions to prevent falls. Further, lacked evidence on how to assist R189 during transfers or ambulation. During interview on 4/22/24 at 1:58 p.m., the director of nursing (DON) stated when their is a new admission the facility had 48 hours to complete a baseline careplan and the MDS or receiving nurse were responsible for initiating it. It can also be triggered from the [NAME]. The DON further stated the MDS nurse was responsible for adding interventions to make it more comprehensive but anyone can add them. She would expect the care plans to be individualized and it's important so staff can provide the right care for the residents and know how to take care of them. The facility's policy on baseline careplans dated 11/1/23, indicated each resident will have an individualized, person-centered, comprehensive plan of care that will include mesureable goals and timetables directed toward achieving and maintaining the resident's optimal medical, nursing, physical, functional, spiritual, emotional, psychosocial, and educational needs. Based on interview and document review, the facility failed to ensure a baseline careplan had been completed for 2 of 2 residents (R89, R189) reviewed for baseline care plans. Findings include: R89's medical record indicated she was admitted to the facility on [DATE] and had diagnoses of fracture of lower end of right humerus, pain in right arm, and congestive heart failure (CHF). R89's medical record lacked a baseline care plan. During interview on 4/18/24 at 11:32 a.m., licensed practical nurse (LPN)-C stated when there was a new admission the receiving nurse was responsible for completing the nursing admission/readmission assessment ([NAME]) and that assessment would trigger the baseline care plan. LPN-A further stated I don't know what happens after that regarding the comprehensive care plan, adding interventions, and who was responsible for completing it. During interview on 4/18/24 at 11:49 a.m. LPN-B stated when there was a new admission the receiving nurse was responsible for completing the [NAME] and that assessment would trigger the baseline care plan. Then any nurse can add interventions to make it more comprehensive. During interview on 4/18/24 at 1:45 p.m, the nurse manager registered nurse (RN)-B stated the Minimum Data Set (MDS) nurse or the director of nursing (DON) were responsible for initiating the baseline careplan. The nurse receiving the new admit can also complete the [NAME] and that will trigger the baseline careplan. After, the nurses were responsible for letting the MDS nurse or herself know if something should be added to the care plan to make it more comprehensive but everyone is qualified. RN-B also stated baseline care plans should include things like how a resident transfers, mobility, activities of daily living (ADL), special treatments, if they have a catheter, etc. and verified R89 did not have one. RN-B stated careplans were important for the safety of the residents and so staff know how to care for them. During interview on 4/19/24 at 8:38 a.m. the MDS nurse stated when there was a new admission, she was responsible for creating the baseline careplan and this was done by talking to the resident, talking to therapy, and completing an assessment. The receiving nurse usually completes the [NAME] but anybody can put in an intervention. The MDS nurse verified R89 did not have a baseline care plan and wasn't sure why it was missed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R3's quarterly MDS dated [DATE], indicated R3 was cognitively impaired and had diagnoses of chronic lung disease, kidney disease and weakness. R3's medical record lacked evidence an assessment had been completed to ensure safe use of the Kureg coffee maker. R3's care plan lacked evidence of use or assistance needed to ensure safe use of Kureg coffee maker. R3's assessment for use of Kureg coffee maker was requested however was not received. An observation on 4/16/24 at 1:49 p.m., R3 was sitting in the recliner watching television. R3 had a Kureg sitting on a side table next to their recliner. There was a small basket of coffee pods sitting in a basket next to it and a pink cup sitting under the spout. R3 stated family brings in the coffee pods and staff help fill the water revisor. R3 stated she made her own coffee when she wanted. When interviewed on 4/18/24 at 7:44 a.m., NA- A verified R3 had a Kureg coffee maker in their room. NA-A stated staff make sure it was filled with water and have it set up next to the recliner where she likes to watch television. NA-A wasn't sure if there were any safety concerns with R3 having it in place. When interviewed on 4/18/24 at 11:00 a.m., LPN-B stated they were not sure why R3 had a Kureg coffee maker and that was not normally something residents had in the facility. LPN-B further stated it could cause a safety concern with it being hot liquids, and some sort of assessment would be needed to make sure it was safe to use. When interviewed on 4/22/24 at 2:08 p.m., DON stated she wasn't sure how long R3 had been using the coffee maker as normally residents do not have appliances in their room. DON stated they expected some sort of assessment to be completed and it to be included in R3's care plan. DON further stated this was important to ensure safe use. An accidents policy related to appliance use was requested however was not available. Based on interview and document review the facility failed to comprehensively assess 1 of 1 resident (R13) reviewed for demetia care and 1 of 1 resident (R3) reviewed for accidents. Findings include: R13's quarterly Minimum Data Set (MDS) dated [DATE], indicated severely impaired cognition, and diagnosis of dementia. It further indicated R13 was dependent on staff for activities of daily living (ADL) and mobility. R13's care plan dated 3/28/24, lacked any indication R13 had dementia. During interview on 4/18/24 at 11:32 a.m., licensed practical nurse (LPN)- C stated when there was a new admission the receiving nurse was responsible for completing the nursing admission/readmission assessment ([NAME]) and that assessment would trigger the baseline care plan. LPN-A further stated I don't know what happens after that regarding the comprehenisive careplan, adding interventions, and who was responsible for completing it. During interview on 4/18/24 at 11:49 a.m. LPN-B stated when there was a new admission the receiving nurse was responsible for completing the [NAME] and that assessment would trigger the baseline care plan. Then any nurse can add interventions to make it more comprehensive. During interview on 4/18/24 at 1:45 p.m, the nurse manager registered nurse (RN)-B stated the MDS nurse or the director of nursing (DON) were responsible for initiating the baseline careplan. The nurse receiving the new admit can also complete the [NAME] and that would trigger the baseline careplan. After that the nurses will let the MDS nurse or herself know if something should be added to the care plan to make it more comprehensive but everyone is qualified. RN-B further indicated if a resident had a diagnoses of dementia it should be included in their comprehensive careplan and careplans were important for the safety of the resident and so staff know how to care for them. During interview on 4/19/24 at 8:38 a.m., the MDS nurse stated when there was a new admission, she was responsible for creating the baseline careplan and this was done by talking to the resident, talking to therapy, and completing an assessment. The receiving nurse usually completes the [NAME] but anybody can put in an intervention. The MDS nurse stated if a resident had a diagnosis of dementia it should be addressed in their careplan and verified R13's comprehensive care plan didn't address it. During interview on 4/22/24 at 1:58 p.m., the director of nursing (DON) stated when their is a new admission the facility had 48 hours to complete a baseline careplan and the MDS or receiving nurse were responsible for initiating it. It can also be triggered from the [NAME]. The DON further stated the MDS nurse was responsible for adding interventions to make it more comprehensive but anyone can add them. She would expect the care plans to be individualized and it's important so staff can provide the right care for the residents and know how to take care of them. The facility's policy regarding comprehensive care plans dated 12/4/23, indicated the care plan was driven by identified resident issues/conditions and their unique characteristics, strengths, and needs. When implemented in accordance with standards of good clinical practice, the care plan becomes a powerful practice tool representing the best approach to quality of care and quality of life.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review the facility failed to ensure nail care was completed for 1 of 1 resident (R19) dependent on staff for nail care. Findings include: R19's annual Minimum Data Set (MDS) dated [DATE], indicated R19 had moderately impaired cognition, diagnosis of traumatic brain injury (TBI), rejection of cares 1-3 times per week, and was dependent on staff for personal hygiene. R19's care plan dated 3/31/24, indicated R19 had an activities of daily living (ADL) self care performance deficit related to bradycardia evidenced by activity intolerance and required extensive assist of 1 with personal hygiene. R19's medical record lacked any documentation that nail care had been completed (nails had been cut). During observation and interview on 4/15/24 at 1:57 p.m., R19's nails were observed to be approximately 1/2 inch long with brown matter and chipped and jagged on his right hand. R19 stated he would like his fingernails to be cut short and he didn't like how long they were. During observation and interview on 4/16/24 at 1:18 p.m., R19 was sitting in his room in his wheelchair and stated his fingernails haden't been cut. R19's nails were observed to be approximately 1/2 inch long with brown matter and chipped and jagged on his right hand. During observation and interview on 4/17/24 at 12:38 p.m., R19 was sitting on his bed eating lunch at his bedside table and his nails were observed to be approximately 1/2 inch long with brown matter and chipped and jagged on his right hand. R19 stated his nails were still long, hadn't been cut and would like them to be. During interview on 4/18/24 at 9:00 a.m., nursing assistant (NA)-B stated nurses were responsible for cutting the residents nails even if they are not diabetic. During interview on 4/18/24 at 9:12 a.m., licensed practical nurse (LPN)-C stated NA's were responsible for cutting the residents nails, but wasn't sure who was responsible for cutting them if the resident was diabetic. LPN-C verified R19's nails were long and should've been cut. During interview on 4/18/24 at 1:45 p.m., the nurse manager registered nurse (RN)-B stated the NA's were responsible for trimming the residents nails, unless they are diabetic then it's the nurses responsibility. RN-B further indicated staff should let her or the MDS nurse know if a resident refused nail care and if the resident refused a lot then it would be added to the care plan. RN-B verified R19's nails were very long and she had cleaned and trimmed his nails after hearing the surveyor had asked about them. During interview on 4/22/24 at 1:58 p.m., the director of nursing (DON) stated nurses and NA's were responsible for cutting residents nails. If the resident was diabetic it was preferable for a nurse to cut them but a NA could do it. She further stated the residents should have their nails cut once a week on bath day and if the resident refused it should be documented in their medical record. The facility's policy regarding ADL's dated 11/29/22, indicated the facility will provide residents with appropriate treatmemt and services to maintain or improve abilities in activities of daily living for the well being of mind, body, and soul.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility to ensure weekly skin assessment was completed for 1 of 1 resident (R24) who had fall and sustained bruising and lacerations. Findings include: R24's quarterly Minimum Data Set (MDS) dated [DATE], indicated R24 was cognitively intact and had diagnoses of congestive heart failure, atrial fibrillation, vascular disease, and weakness. Furthermore R24's MDS indicated R24 had a vascular wound and a skin tear. R24's care plan revised on 4/9/24, indicated R24 had actual impairment to skin integrity related to venous stasis ulcers to lower legs and required monitoring location, size, and treatment. Furthermore, R24 required weekly skin observations by licensed nurse. R24 had an actual fall with serious injury and required monitor/document/report as needed for 72 hours to health care provider any signs or symptoms of pain or bruising. R24's care plan lacked indication of any continued monitoring of R24's bruising and facial lacerations after 72 hours. R24's [NAME] directed nursing assistant (NA) staff to notify nurse immediately of any new areas of skin breakdown noted during baths or daily cares. R24's nursing assistant task documentation dated 3/15/24-4/15/24, lacked indication R24 had skin monitoring completed on bath days. R24's medical record lacked indication a weekly skin assessment was completed by a licensed nurse since 1/2024. R24's nursing and provider orders reviewed on 4/16/24, indicated R24 required warfarin (anticoagulant medication to thin the blood and prevent clotting) 3 milligrams (mg) on Mondays and 4mg daily Tuesday- Sunday. R24's nursing and provider orders lacked indication of monitoring of left knee or left forehead injury sustained from R24's fall on 3/27/24. A review of R24's nursing progress notes showed the following: -on 3/27/24 at 7:20 p.m., R24 had a grape sized bump on left side of forehead, bleeding on face between lip and swelling/bruising on left knee, and a large skin tear to right deltoid. -on 3/27/24 at 10:44 p.m., R24 was noted to have bruise on forehead, bruise/skin tear on right arm. Continue to monitor. -on 3/28/24 at 2:34 p.m. R24 had increased bruising on left face related to fall and dressings were changed to right arm skin tear. -on 4/2/24 at 7:53 a.m., R24 complained of increased pain to left knee and leg. R24 was noted to have large bruise from above knee to mid-calf. Leg appeared more swollen. Message left for NP. R24's medical record lacked indication of further assessment or monitoring of R24's facial and left leg bruising. An observation on 4/18/24 at 2:00 p.m., R24 was laying in bed. R24 had a dark scabbed area on the left forehead and a dark purple colored bruise on the left knee. R24 stated she had rolled out of bed a few weeks back and still had bruising. R24 further stated it was taking a long time for the bruising to go away because of the warfarin, but thought it was better. When interviewed on 4/18/24 at 8:28 a.m. licensed practical nurse (LPN)-B stated nurses complete the skin checks on bath days. If there was anything abnormal, then the provider would be notified for cares and monitoring. Usually, a weekly skin assessment would trigger for nurses in the electronic medical record during bath days but wasn't sure the process at this facility. LPN-B further stated if there were skin issues noted, the provider would be notified for treatment or monitoring orders. With any skin alteration an assessment would be needed and then continued weekly until improved. When interviewed on 4/18/24 at 2:18 p.m., nursing assistant (NA)-A was aware of R24's fall. NA-A further stated R24 was sent to the hospital and the following day had stitches under her nose, and a lot of bruising. NA-A stated nursing assistants monitored skin during the baths. NA-A further stated if anything was seen, the nurse would be notified. NA-A stated the bruising was known by the nurses. Some nurses will look at the skin themselves, but not all of them. NA-A further stated they do not document anything with the skin monitoring, just know it was done on bath day and the nurse completes documentation. When interviewed on 4/18/24 at 2:31 p.m. LPN-C stated when R24 rolled out of bed, she had open cuts to her face and was bleeding a lot due to taking an anticoagulant. When interviewed on 4/22/24 at 2:08 p.m., the Director of Nursing (DON) stated resident skin was monitored by all staff daily with cares. On bath days, NA's competed skin monitoring task and were expected to document in the tasks. If NAs found any skin concerns, redness, bruising, open areas, etc, they would report to the nurse. The nurse then would assess the area, document, and notify the provider. DON expected R24 to have weekly monitoring for her bruising and skin lacerations that occurred after their fall. This could be in a progress note or a weekly assessment. Monitoring skin with cares were important to catch any changes or complications. A facility policy titled Skin Assessment Pressure Ulcer Prevention and Documentation revised 4/26/23, directed staff to monitor any bruise, contusion, or skin tear weekly and any changes and/or progress toward healing should be documented on the skin observation assessment and on the resident care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure weekly skin assessments were completed for 1 of 1 residents (R8) reviewed for pressure injury. Findings include: R8's quarterly MDS assessment dated [DATE], indicated R8 was cognitively intact and had diagnoses of chronic lung disease, heart disease and pain. R8's MDS further indicated R8 required oxygen, had no current pressure injury but was at risk of developing skin injury. R8's skin Care Area Assessment (CAA) dated 12/3/23, indicated R8 was at risk of pressure injuries due to recent weight loss, terminal illness and devise use that may cause pressure (oxygen). R8's [NAME] as of 4/18/24, indicated R8 had oxygen therapy and directed staff to notify nurse of any new skin breakdown, redness, blisters or bruising during bath and daily cares. R8's care plan revised 3/6/24, indicated R8 had potential for pressure ulcer development due to decreased mobility. Interventions included to education resident/family on causes of skin breakdown, importance of good nutrition and positioning. Interventions further included notification for any new areas of skin breakdown redness or blisters noted during bath days or in daily care. R8's care plan lacked indication weekly assessment of R8's skin was required on a weekly basis. A review of R8's active nursing and provider orders on 4/16/24, lacked indication R8 required routine skin assessments from nursing. R8's NA task for skin check on bath day dated 3/19/24-4/15/24, indicated the skin check was completed on 3/20/24. R8's medical record lacked a skin check was completed on a weekly or routine basis. An observation on 4/15/24 at 1:00 p.m., R8 was in bed. R8 was receiving oxygen via a nasal cannula. R8 stated there was some pain and irritation right below their nose the oxygen tubing. There was a small, reddened area just below R8's nose. R8 stated staff were aware but was not sure if anything was being done about it to prevent it. When interviewed on 4/17/24, at 1:18 p.m., R8 was sitting in their room. R8 stated there was no longer any pain or irritation from the oxygen. R8 no longer had a red area. When interviewed on 4/18/24 at 7:30 a.m., nursing assistant (NA)-A was not aware of any skin issues with R8's oxygen. NA-A stated nursing assistants monitored skin during the baths. NA-A further stated if anything was seen, the nurse would be notified. Some nurses will look at the skin themselves, but not all of them. NA-A further stated they do not document anything with the skin monitoring, just know it was done on bath day and the nurse completes documentation. When interviewed on 4/18/24 at 8:28 a.m. licensed practical nurse (LPN)-B stated nurses complete the skin checks on bath days. If there was anything abnormal, then the provider would be notified for cares and monitoring. Usually, a weekly skin assessment would trigger for nurses in the electronic medical record. LPN-B stated R8 was at risk for skin injury and verified there were not weekly skin assessments that triggered for R8. LPN-B further verified there was wound monitoring on bath day listed as a task but had never documented there before. When interviewed on 4/22/24 at 2:08 p.m., the Director of Nursing (DON) stated resident skin was monitored by all staff daily with cares. On bath days, NA's competed skin monitoring task and were expected to document in the tasks. If NAs found any skin concerns, redness, bruising, open areas, etc, they would report to the nurse. The nurse then would assess the area, document, and notify the provider. Monitoring skin with cares were important to catch any skin concern early and start treatment. A facility policy titled Skin Assessment Pressure Ulcer Prevention and Documentation revised 4/26/23, directed staff to accurately document observations and assessments of resident skin. Furthermore, a systematic skin inspection will be made daily by the nursing assistant assigned to those at risk for skin breakdown. The nursing assistant will report any abnormal findings to the licensed nurse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the consulting pharmacists recommendations were acted upon for 1 of 3 residents (R24) reviewed for taking anticoagulation medication. Findings include: R24's quarterly Minimum Data Set (MDS) dated [DATE], indicated R24 was cognitively intact and had diagnoses of congestive heart failure and atrial fibrillation (rapid heartbeat). Furthermore R24's MDS indicated R24 was on an anticoagulation medication (medication used to thin the blood and prevent blood clots). R24's nursing and provider orders reviewed on 4/16/24, indicated R24 required warfarin (anticoagulant medication) 3 milligrams (mg) on Mondays and 4mg daily Tuesday- Sunday. R24's nursing and provider orders lacked indication R24 required monitoring for bleeding, bruising or other side effects of an anticoagulation medication. R24's care plan revised on 4/9/24, lacked indication R24 had monitoring for bleeding, bruising or other side effects of an anticoagulation medication. R24's monthly medication regimen review dated 12/8/24, indicated R24 was on a warfarin and the recommended staff to monitor for signs and symptoms of bleeding and bruising; monitor for thromboembolism (blood clots). R24's pharmacy progress notes from 1/2024- 3/2024, indicated R24 had no medication irregularities. When interviewed on 4/18/24 at 1:45 p.m., registered nurse (RN)-B stated pharmacy sends the recommendations to the nurse practitioner. The nurse practitioner then determines what they want to do from there. RN-B further stated if the nurse practitioner wanted monitoring, it would be ordered. When interviewed on 4/22/24 at 1:15 p.m., the Director of Nursing (DON) stated pharmacy recomendations were recieved monthly. The DON works on them or delegates them out. They go into a folder for the provider right away. Usually the provider is given a month to review and act on the recomendation. If not complted, the pharmacist will let us know and would follow up with the physician again. When interviewed on 4/22/24, at 2:48 p.m. the consultant pharmacist stated monthly reviews were completed for all residents. During the reviews, high risk medications, such as anticoagulant medications were reviewed to ensure appropriate dosing, indications, and any monitoring was in place. The consulting pharmacist further stated recommendations were needed for anticoagulant monitoring such as bleeding, excessive bruising, etc and should be included in the resident care plan. If the care plan did not have the monitoring during the monthly review, they would put a recommendation in. If the recommendation was placed and not completed, it would be marked as pending, and then reviewed or followed up with the provider. However, the monitoring of side effects was not dependent on a provider order and would go to the nurse to implement and wouldn't be marked as pending. I would expect that to be implemented when received. The consulting pharmacist stated R24 was on coumadin therapy since 12/2023 and acknowledged there had not been any further direction or follow up on the initial recommendation for anticoagulation monitoring since one was sent in December. A facility policy titled Pharmacy Services revised 8/29/23, directed the pharmacist to report any irregularities to the attending physician or the director of nursing or both. The reports must be acted upon, and follow-up documentation maintained.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #8 R8's quarterly MDS dated [DATE], indicated R8 was cognitively intact and had diagnoses of heart disease, kidney disease and high blood pressure. When interviewed on 4/15/24 at 1:35 p.m., R8 stated the food was not always great and there were not many choices. R8 further stated there were a lot of soup that we could have, but not a lot of other items. R8 further stated she preferred to eat in their room. Staff let them know what the two meal options were but didn't always get the request and often felt like they get whatever's left. An observation on 4/16/24 at 8:55 a.m., the menu posted in the common area on long term care unit indicated the menu for the week was week 4. When interviewed on 4/17/24 at 7:11 a.m., dietary supervisor (DS) stated they had been coming to the facility for about a month to help as there was no dietary manager (DM). DS stated it was difficult to follow what the previous DM was doing as they had been following their own menu. DS further stated the food that was available was not what the menu called for and DS was still working on the process to get on an ordering schedule that matched up with what the menu was supposed to be. DS verified the facility was supposed to be on week one menu and wasn't sure what was posted in the main areas. DS verified the menu was not being followed and the situation was a big mess that was taking time to figure out and did not realize how bad it was until he arrived. DS was not aware of how residents were asked what they wanted or when that was determined. DS cooked to what the census was, for example for 37 residents, they would cook 30 main dish and then 7 or so of the alternative. DS verified sometimes it doesn't work out as more want the alternative than the main and sometimes there wasn't enough. DS verified on 4/16/24, the alternative meal was Salisbury steak. DS stated more residents wanted that than the main dish and didn't have enough to deliver to some of the rooms. DS wasn't sure what was told to the residents or what options for those residents were provided. When interviewed on 4/17/24 at 7:26 a.m., dietary aide (DA)-A stated either the nursing assistants (NA) or DA's go around from room to room to ask what option residents would like. The residents who came to the dining room were asked when they come in. DA-A further stated there wasn't a copy of the menu given to residents ahead of time. There were items that were always easy to make like soup, sandwiches, salads. DA-A stated there wasn't a list however residents knew about it. When interviewed on 4/18/24 at 7:30 a.m., nursing assistant (NA)-A stated before meals, they check with the kitchen to see what is on the menu. Then they ask the residents. They let us know what they want and if they don't like the choices, they can ask for something else and we can check with the cook. NA-A further stated sometimes residents just want cold cereal for lunch. When interviewed on 4/22/24 at 1:39 p.m., the administrator expected kitchen staff to be following the menu as scheduled. Furthermore, the residents' preferences for food should be known and taken into consideration when preparing meals. A facility policy titled Menu Requirements- Food and Nutrition Services dated 12/6/23, directed staff to prepare menus at least one week in advance of when the meal was served, and temporary menu changes were kept to a minimum. A facility policy titled Resident Choice in Dining- Food and Nutrition dated 1/22/24, directed staff to ensure pre-planned menu items were available for each resident. Furthermore, the policy directed staff to ensure dining services take into consideration each resident preferences, ensure there were available food and drink options that align with the resident's needs and preferences when the primary and secondary options were not to the resident's liking, there was a process to communicate all food and drink options to the residents including having an ala-carte menu list available to residents. Based on observation, interview and document review, the facility failed to serve menu items as listed and planned for 2 of 2 residents (R25, R8) reviewed for nutrition services. Findings include: R25's admission Minimum Data Set (MDS) dated [DATE], indicated intact cognition, diagnoses of chronic obstructive pulmonary disease (COPD), dysphagia, and required set up/clean up assistance with eating. R25's care plan dated 3/1/24, indicated R25 had a nutritional problem related to end stage COPD and to encourage pleasure eating (foods of patient choice) for comfort. During interview on 4/16/24 at 2:31 p.m. R25 stated on Monday (4/15/24) he was supposed to get a Salisbury steak and potatoes for dinner but instead he received a bowl of soup and half a grilled cheese sandwich. During a follow up interview on 4/17/24 at 12:47 p.m., R25 stated a nursing assistant comes to his room before each meal and gives him two choices off the menu to pick from but he often doesn't get the option he picked.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure adequate monitoring was in place for 3 of 3 residents (R24, R91, R31)reviewed for unnecessary medications. Furthermore, the facility failed to ensure duplicative medications were prescribed for 1 of 5 residents (R91) reviewed for unnecessary medications. Findings include: R24 R24's quarterly Minimum Data Set (MDS) dated [DATE], indicated R24 was cognitively intact and had diagnoses of congestive heart failure and atrial fibrillation (rapid heartbeat). Furthermore R24's MDS indicated R24 was on an anticoagulation medication (medication used to thin the blood and prevent blood clots). R24's medication regimen review dated 12/8/24, indicated R24 was on a warfarin and the recommended staff to monitor for signs and symptoms of bleeding and bruising; monitor for thromboembolism (blood clots). R24's nursing and provider orders reviewed on 4/16/24, indicated R24 required warfarin (anticoagulant medication) 3 milligrams (mg) on Mondays and 4mg daily Tuesday- Sunday. R24's nursing and provider orders lacked indication R24 required monitoring for bleeding, bruising or other side effects of an anticoagulation medication. R24's care plan revised on 4/9/24, lacked indication R24 had monitoring for bleeding, bruising or other side effects of an anticoagulation medication. R91 R91's admission MDS dated [DATE], indicated R91 was cognitively intact and had diagnoses of skin infection of lower extremity, arterial fibrillation, and diabetes. Furthermore R91's MDS indicated R91 required anticoagulation medication. R91's Potentially and Significant Medicaion Issues assessment dated [DATE], indicated no medicaton issues identified. R91's nursing and provider orders reviewed on 4/16/24, indicated R91 required the following: -Eliquis (anticoagulant medication) 5mg twice daily for blood thinning -clotrimazole topical cream1% (ointment to treat fungal infection) apply to affected area topically two times a day for candida yeast skin infection -Nystatin cream 100000units/gram (ointment to treat fungal infection) apply under breast/abdominal folds topically every day and evening shift for rash R91's nursing and provider orders lacked indication R91 had monitoring for bleeding, bruising or other side effects of an anticoagulation medication. R91's medication regimen review dated 4/7/24, requested clarification on the nystatin cream and clotrimazole cream and recommended monitoring for signs/symptoms of bleeding or bruising and monitor for thromboembolism (blood clot). R91's care plan initiated 4/10/24, lacked indication R91 had monitoring for bleeding, bruising or other side effects of an anticoagulation medication. When interviewed on 4/18/24 at 11:00 a.m., licensed practical nurse (LPN)-B stated any resident who takes an anticoagulation should have monitoring in place for bleeding or bruising. LPN-B further stated the monitoring may be in an order but otherwise was included in the care plan. LPN-B further stated upon admission, the admitting nurse reviews and enters the medication orders and a second person signs off on them. Nurses look to ensure high risk medications have monitoring in place, if any of them need stop dates, or if there are any duplicative medications. LPN-B verified whoever was doing the checks or notices something was missing or duplicative medications, clarification from the provider is needed. LPN-B verified no anticoagulation monitoring was in place for R24 and R91. LPN-B further verified R91 had both nystatin cream and clotrimazole cream and said they should have been clarified. When interviewed on 4/18/24 at 1:45 p.m., registered nurse (RN)-B stated nursing monitors for bruising, but there was no documentation of it. pharmacy sends the recommendations to the nurse practitioner. The nurse practitioner determined what they want to do with the recommendation. RN-B further stated if the nurse practitioner wanted monitoring, it would be ordered. RN-B further stated R91 was not at the facility long enough for a pharmacy review. R91 came with orders from the hospital and the nurse practitioner signed off on them. If there were one's the NP didn't want, they wouldn't have been signed off on. Findings include: R31's admission Minimum Data Set (MDS) dated [DATE], indicated R31 had intact cognition and diagnoses of bladder cancer, difficulty walking, and stroke. It further indicated R31 required staff assistance with activities of daily living (ADL) and mobility and was taking an anticoagulant (AC). R31's physician's orders dated 4/1/24, indicated Apixaban oral tablet 2.5 milligrams (mg). Give 1 tablet by mouth every morning and at bedtime for persistent atrial fibrillation. R31's Potentially Clinically Significant Medication Issues report dated 4/1/24, indicated a review of R31's medications had been done and there were no concerns. R31's care plan dated 4/1/24, lacked any indication of AC side effect monitoring. R31's medical record lacked any indication of AC side effect monitoring. During interview on 4/18/24 at 8:23 a.m., registered nurse (RN)-A verified R31 did not have any documentation of monitoring for AC side effects. RN-A further stated I know off hand to look for it (side effects) and we can always document it in the progress notes. When interviewed on 4/22/24, at 2:48 p.m. the consultant pharmacist stated during monthly reviews high risk medications, such as anticoagulant medications were reviewed to ensure appropriate dosing, indications, and any monitoring was in place. The consulting pharmacist further stated recommendations were needed for anticoagulant monitoring such as bleeding, excessive bruising, etc. and should be included in the resident care plan. If the care plan did not have the monitoring during the monthly review, a recommendation was placed. If the recommendation not completed, it would be marked as pending, and then reviewed or followed up with the provider. However, the monitoring of side effects was not dependent on a provider order and would go to the nurse to implement the recommendation. I would expect that to be implemented when received. The consulting pharmacist further stated when a resident was newly admitted , they would review the medications after the first day or two. Any recommendations would be sent to the Director of Nursing (DON) and the nurse practitioner. The pharmacist stated notification was sent on 4/7/24, for R91's duplicative medications. The consulting pharmacist stated there was some over prescribing of the same kind of medications. The pharmacist further stated usually there was a quick response from the nurse practitioner but had not received a response yet. When interviewed on 4/22/24,at 1:58 p.m., the DON stated anticoagulation monitoring was not documented but should be included in the resident plan of care. Any skin monitoring was compelted during cares and on bath days. Upon admission, the pharmacist and the provider both review medications to ensure there are not concerns. Staff are always able to reach out to providers for clarification as well. DON expected staff to clarify R91 Nystatin and clotrimazole ointment orders. A policy for high risk medication side effect monitoring was requested and received but did not address side effect monitoring for AC's.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to have a method or system to ensure the facility offered or provided updated vaccine per Centers for Disease Control (CDC) vaccination recommendations for 5 of 5 residents (R7, 18, R24, R30, R32) to ensure residents were appropriately vaccinated against pneumonia upon admission. This had the ability to affect all 37 residents. Findings include: Review of the current CDC pneumococcal vaccine guidelines located at https://www.cdc.gov/vaccines/vpd/pneumo/hcp/pneumo-vaccine-timing.html, identified for: 1) Adults 19-[AGE] years old with specified immunocompromising conditions, staff were to offer and/or provide: a) the PCV-20 at least 1 year after prior PCV-13, b) the PPSV-23 (dose 1) at least 8 weeks after prior PCV-13 and PPSV-23 (dose 2) at least 5 years after first dose of PPSV-23. Staff were to review the pneumococcal vaccine recommendations again when the resident turns [AGE] years old. 2) Adults [AGE] years of age or older, staff were to offer and/or provide based off previous vaccination status as shown below: a) If NO history of vaccination, offer and/or provide: aa) the PCV-20 OR bb) PCV-15 followed by PPSV-23 at least 1 year later. b) For PPSV-23 vaccine ONLY (at any age): aa) PCV-20 at least 1 year after prior PPSV-23 OR bb) PCV-15 at least 1 year after prior PPSV-23 c) For PCV-13 vaccine ONLY (at any age): aa) PCV-20 at least 1 year after prior PCV13 OR bb) PPSV-23 at least 1 year after prior PCV13 d) For PCV-13 vaccine (at any age) AND PPSV-23 BEFORE 65 years: aa) PCV-20 at least 5 years after last pneumococcal vaccine dose OR bb) PPSV-23 at least 5 years after last pneumococcal vaccine dose e) Received PCV-13 at Any Age AND PPSV-23 AFTER age [AGE] Years: aa) Use shared clinical decision-making to decide whether to administer PCV20. If so, the dose of PCV-20 should be administered at least 5 years after the last pneumococcal vaccine. Review of 5 sampled residents for vaccinations identified: 1) R7 was [AGE] years old and admitted to the facility in November of 2023. R7 received the PPSV-23 on 3/1/10, and the PCV-13 on 10/17/16. Based on shared clinical decision-making, R7 should have been offered and/or received the PCV-20 at least 5 years after the last pneumococcal vaccine dose. R7's quarterly Minimum Data Set (MDS) dated [DATE], indicated she was up to date on her pneumococcal vaccinations. R7's electronic health record (EHR) lacked documentation of shared clinical decision-making regarding PCV-20 dose. 2) R18 was [AGE] years old and admitted to the facility in February of 2024. R18 received the PPSV-23 on 1/1/13 and 2/10/15, and the PCV-13 on 2/10/15. Based on shared clinical decision-making, R7 should have been offered and/or received the PCV-20 at least 5 years after the last pneumococcal vaccine dose. R18's significant change MDS dated [DATE], indicated he was up to date on his pneumococcal vaccinations. R18's electronic health record (EHR) lacked documentation of shared clinical decision-making regarding PCV-20 dose. 3) R24 was [AGE] years old and admitted to the facility in December of 2023. R24 received the PPSV-23 on 9/21/07, and the PCV-13 on 1/27/16. Based on shared clinical decision-making, R24 should have been offered and/or received the PCV-20 at least 5 years after the last pneumococcal vaccine dose. R24's quarterly MDS dated [DATE], indicated she was up to date on her pneumococcal vaccinations. R24's electronic health record (EHR) lacked documentation of shared clinical decision-making regarding PCV-20 dose. 4) R30 was [AGE] years old and admitted to the facility in March of 2024. R30 received the PPSV-23 on 11/15/18, and the PCV-13 on 11/15/18. Based on shared clinical decision-making, R30 should have been offered and/or received the PCV-20 at least 5 years after the last pneumococcal vaccine dose. R30's admission MDS dated [DATE], indicated she was up to date on her pneumococcal vaccinations. R30's electronic health record (EHR) lacked documentation of shared clinical decision-making regarding PCV-20 dose. 5) R32 was [AGE] years old and admitted to the facility in March of 2024. R24 received the PPSV-23 on 10/13/11, and the PCV-13 on 9/30/15. Based on shared clinical decision-making, R32 should have been offered and/or received the PCV-20 at least 5 years after the last pneumococcal vaccine dose. R32's admission MDS dated [DATE], indicated she was up to date on her pneumococcal vaccinations. R32's electronic health record (EHR) lacked documentation of shared clinical decision-making regarding PCV-20 dose. During interview on 4/18/24 at 10:47 a.m., the infection preventionist (IP) stated the facility utilized the CDC's guidelines and Pneumorex Advisor application to determine if residents were eligible for pneumococcal vaccinations. The IP stated consent and risk versus benefits were discussed with new admissions and any eligible residents and a vaccine information sheet (VIS) was provided. The IP stated the facility utilized a standing order for vaccinations and documented administration in Point Click Care (PCC) once completed. When asked about R7, R18, R24, R30, and R32, the IP stated they were agreeable to receiving the additional vaccine dose, but the pharmacy was out. A review of R18's progress notes revealed a note dated 4/18/24 at 12:12 p.m., that indicated per primary provider recommendation, okay to give Pnemovac 20 if indicated per CDC guidelines. A review of R30's progress notes revealed a note dated 4/18/24 at 12:14 p.m., that indicated per primary provider recommendation, okay to give Pneumovac 20 if indicated per CDC guidelines. A review of R32's progress notes revealed a note dated 4/18/24 at 12:14 p.m., that indicated per primary provider recommendation, okay to give Pnemovac 20 if indicated per CDC guidelines. A facility policy titled Immunizations/Vaccinations for Residents, Pneumococcal, Influenza, COVID-19, Other, AL, R/S, LTC, HBS- Enterprise dated 9/21/23, indicated the purpose was to provide residents and clients the opportunity to receive immunizations as they fit into their healthcare goals. The policy's procedure indicated upon admission, each resident and/or resident representative would receive the Vaccination Information Sheets (VIS) for influenza and pneumococcal vaccines and if the resident and/or resident representative consented to vaccination, the facility would ensure physician's order was obtained for the vaccine(s) to be administered, obtain written consent if required by state regulation, complete a vaccination screening prior to vaccine administration, and administer the vaccination or refer to provider or pharmacy for vaccine administration. If the resident and or resident represented chose not to be vaccinated after discussion of benefits, the facility would document declination. Furthermore, the policy indicated residents would be reviewed for vaccine eligibility on an ongoing basis as immunization recommendations changed and the admission steps would be followed for each vaccine each time eligibility was determined. Additionally, the policy indicated it is recommended that all residents receive pneumococcal vaccination(s) per CDC guidelines for eligibility and timing.

Based on interview and record review, the facility failed to employ either a full-time registered dietitian (RD) or a qualified dietary manager (DM) to carry out the functions of the food and nutrition service. This had the potential to affect all 39 residents who resided in the facility. Findings include: The facility's undated list of hires did not include a DM. The interim dietary supervisor (DS)'s qualifications for a dietary manager was requested however was not received. When interviewed on 4/15/24 at 1:08 p.m., the DS stated there was not a DM currently employed at the facility. DS was a DS at a sister facility and was currently working both facilities. DS further stated there had been a lot of turnover in the kitchen staff and the facility was working on hiring. A follow up interview on 4/18/24 at 10:46 a.m., DS stated he had been at the facility for about a month trying to help. DS further stated he had food safety manager certificate, however, was not able to find it. When interviewed on 4/18/24, the RD stated they did not work full time at the facility and were on site twice weekly on Tuesdays and Thursdays. When interviewed on 4/22/24 at 1:39 p.m., the administrator verified there had not been a dietary director for a month or so and that was why DS was helping in the kitchen. The administrator further stated there was a new DM hired but was unsure of a start date as they were waiting on a background check.

Based on observation, interview, and record review the facility failed to ensure sufficient support staff with the appropriate competencies to carry out the functions of the food and nutrition services. This had the potential to affect all 39 residents who reside in the facility. Findings include: The facility's undated list of hires did not include a dietary manager (DM). An undated facility document titled Annual and New Hire Education Dietary indicated all dietary staff had required training titled Basics of Food Safety in Long Term Care Facilities and IDDSI training for safe swallowing. Dietary aide (DA)-A's new hire education dated 4/18/24, lacked indication DA-A had completed the required training for dietary staff titled Basics of Food Safety in Long Term Care Facilities and IDDSI training for safe swallowing. An observation on 4/16/24 at 8:06 a.m., residents were being served breakfast in the dining room. There was no daily menu posted in the dining room. DA-A was serving up cold cereal, yogurt, and toast. DA-A stated there was no cook this morning due to an ill call. DA-A stated she was on her own until 9:00 a.m., and she isn't a cook so breakfast was toast and cereal. DA-A stated she wasn't sure what breakfast was supposed to be. When interviewed on 4/15/24 at 12:50 p.m., cook-A stated they were working late to help with dishwashing as there wasn't enough staff. When interviewed on 4/15/24 at 1:08 p.m., dietary supervisor (DS) stated they had been coming to work at the facility for about a month to help as there was not a dietary manager (DM). DS was also working as a supervisor at a sister facility. When starting here, DS stated there was not a good process for labeling and dating foods or for ordering what was needed. DS stated he wanted to get some processes in place for ordering what was needed for menu items, labeling, and dating foods, and a kitchen cleaning schedule. DS stated he was working in the facility almost every day and stated there just was not enough staff or time to work on the needed processes. DS stated everyone was just trying to do their best with what they have. A follow up interview on 4/19/24 at 8:34 p.m., DA-A stated she had not had any education related to food service when hired and had initially started as a housekeeper. DA-A started working as a DA due to being short staffed in the kitchen. DA-A further stated she did not train with anyone and just jumped in as the help was needed. A follow up interview on 4/19/24 at 9:06 a.m., DS stated he was aware of no cook on 4/16/24 but was scheduled at the other facility. DS stated if he came here, then no cook would be over there, so there was not a good solution. DS was not aware of the training DA-A received as DS was not here when DA-A was hired. DA-A was hired prior to DS starting at the facility and was initially a housekeeper and switched to kitchen a week or so ago. Furthermore, DS stated he tried to train as best they can and wasn't aware of any checklist or sign off, just what staff were assigned to in the online training. When interviewed on 4/22/24 at 1:39 p.m., the administrator expected any general education for dietary staff would come from the supervisor. The administrator further stated any further education would depend on the employee and their experience. A policy on kitchen training and requirements was requested however was not received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure frozen and refrigerated food items were properly stored, labeled, and dated and disposed of after expiration date. Furthermore, the facility failed to ensure the ice machine and air vents were clean and sanitary. This deficient practice had the potential to affect all 39 residents who receive food from the kitchen. Findings include: Food Storage During the initial kitchen observation on 4/15/24, at 12:46 p.m., the walk-in freezer contained the following: -a Ziplock bag labeled corn beef hash dated 2/11/24. The contents of the bag were brown meat with crystals of ice that had formed on the meat and the inside of the bag. -a Ziplock bag labeled turkey dated 4/12/24. The contents of the bag were white meat with crystals of ice that had formed on the meat and the inside of the bag. -Two plastic tub containers labeled potato salad with a date of 3/20/24 and 3/12 -a plastic tub that stated seafood salad dated 3/22. -four foil containers with foil tops had no label to identify contents, but had a date of 3/20. The walk-in refrigerator contained the following: - a container of [NAME] strawberries. The strawberries contained a greenish black fuzzy substaines -a container of Sysco ham soup base had a label that stated opened on 1/21 and lacked a use by date. -a container of Sysco chicken-based soup had an open date of 1/6 and lacked a use by date. -a white container of cucumber salad had no open date or use by date. -a tray of brownies on a plate was sitting on a cart with no label or date on when they were made. When interviewed on 4/15/24 at 1:08 p.m., the dietary supervisor stated food storage was on a first in first out basis. So, items that are the oldest should be used first but wasn't sure of the system in the facility as they were helping from a sister facility. DS verified the frozen meat appeared to not be good any longer and wasn't sure if the date was when it was put in the freezer. The potato salads and seafood salad were regular menu items and DS stated those were homemade items and were not normally items to be frozen and they should be thrown out. DS had no idea what was in the foil pans and stated they needed to be thrown out. The DS verified the mold on the strawberries, containers of soup base, and cucumber salad. DS was not sure when the salad was made or the trays of deserts, but most likely should be thrown. DS stated currently there was no dietary manager (DM) and since coming to help at the facility DS was trying to figure out the ordering process and menus. DS stated the previous DM saved everything, which was not always a good thing as items get old. DS acknowledged there was not a good process for dating, labeling, and storing food. This was something DS needed to get in place. Clean vents A kitchen cleaning schedule was requested however was not provided. An observation on 4/17/24 at 7:11 a.m., DS was prepping for breakfast. Over the kitchen prep area were two air vents on the ceiling. The vents had large grey clumps of dust in the grates. Across from the vents were clean pitchers, plates, and trays. DS verified the grey clumps of dust and verified the air was blowing out of the vents. When interviewed on 4/17/24 at 7:30 a.m., DS stated there was no cleaning schedule for the kitchen. DS stated since coming to help, they had been trying to get the kitchen cleaned better but it was challenging with working both places and not having a lot of help. DS stated there was work to be done to ensure there was a more streamlined process as almost all the staff was new. Ice Machiene A facility document titled Work History Report dated 1/2024-3/2024, indicated ice machine inspection and cleaning was completed on 1/31/24 and 2/29/24. An observation on 4/17/24 at 8:13 a.m., the ice/water machine for resident use was in the dining room. On the spouts where ice and water were obtained, there were large amounts of crusty white substance on the tray and around both the water and ice spigots. The sides of the tray also had crusty white substance on it that ran down onto the cooler located under the machine. When interviewed on 4/18/24 at 11:50 a.m., the maintenance personal stated there were 2 ice machines, but only one for resident use. The ice/water machines were cleaned quarterly. The log indicated a cleaning was done in January for the ice/water machine in the dining room and were required to be cleaned quarterly. The resident ice/water machine was due to be cleaned this month. Maintenance personal stated the white substance was hard water and calcium build up and it happened quickly. They attempted to try to clean it more often if there was time, but it just builds up quickly and doesn't get cleaned until the next quarter. When interviewed on 4/22/24 at 1:39 p.m., the administrator, stated he expected food to be dated and stored properly and there shouldn't be moldy items. Furthermore, staff were expected to follow the cleaning schedule for the kitchen and ice/water machines. If items needed to be cleaned more often, it should be completed. This was all important for sanitary and safe food for the residents. A facility policy titled Food Supply Storage revised 5/11/23, directed staff to ensure foods that have been opened or prepared were placed in an enclosed container, dated, labeled, and stored properly. Furthermore, leftovers or food items prepared for service that were not served were stored for use within 7 days. A facility policy titled Cleaning Schedule- Food and Nutrition Services revised 11/27/2023, directed staff post written daily, weekly and monthly cleaning assignments in the kitchen areas. Furthermore, the policy directed daily inspections of ceilings daily for dust and cobwebs, and for walls and vents to schedule a cleaning every 6 months. A facility policy titled Ice Machine Use and Maintenance dated 12/11/23, directed staff to clean, descale, and change filters according to the water/ice machine's manufacture recommendations. Furthermore, the policy indicated to adjust the frequency based upon use and conditions related to the machine (location, quality of water, etc.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to follow standard precautions, contact precautions, droplet precautions, and perform evidence-based hand hygiene for GI symptomatic residents for 4 of 4 (R4, R24, R13, and R91) reviewed for infection control practices. Findings include: R4's annual Minimum Data Set (MDS) dated [DATE], indicated she had intact cognition and had diagnoses of overactive bladder, kidney disease, diabetes, and muscle weakness. R4's Care Area Assessment (CAA) for functional abilities (self-care and mobility) dated 3/21/24, indicated R4 required assistance with activities of daily living (ADLs) and one or two staff assistance. R4's CAA for urinary incontinence and indwelling catheter dated 3/21/24, indicated R4 required assistance with toileting, had incontinence, and was at risk for developing UTIs. R4's care plan dated 4/28/21, indicated she had an ADL self-care deficit related to a history of UTIs and required extensive assistance of one with toilet use. Furthermore, the care plan identified R4's history of UTIs with a goal to remain free of UTI. R4's care plan listed interventions of monitoring, documenting, and reporting signs and symptoms of infection to the nurse and provider and encouraging fluid intake. During observation and interview on 4/17/24 between 7:20 a.m. and 7:44 a.m., nursing assistant (NA)-A entered R4's without performing hand hygiene. NA-A assisted R4 out of bed and into the bathroom. NA-A donned gloves and assisted R4 to stand up and pivot onto the toilet. NA-A assisted R4 with dressing her upper body, putting on deodorant, and cleaning her eyeglasses while NA-A continued to wear the same gloves. NA-A instructed R4 to use the grab bars to help herself stand up, and once R4 was standing upright, NA-A reached from behind and wiped R4's perineal (peri) area from back to front with disposable wipes. Then, reaching from the backside of R4's perineal area, NA-A wiped front to back. NA-A removed the gloves and disposed of the wipes and gloves in the garbage can, pulled up R4's pants, and did not perform hand hygiene. NA-A wheeled R4 in front of the sink to complete morning ADLs independently. When interviewed, NA-A verified no hand hygiene was performed prior to entering R4's room. NA-A stated it was important to clean from front to back and ensure any soap used was rinsed and ensure there was no feces for the prevention of UTIs. Additionally, NA-A stated, in reality, I should wash my hands coming into the room, before peri-cares, then do peri-cares with gloves, then remove gloves after peri-cares and wash my hands, and then wash my hands before leaving the room. NA-A stated it was difficult to perform peri-cares because R4 was standing awkwardly, but R4 had a bath later in the day. During interview on 4/17/24 at 7:50 a.m., R4 stated she recently had a UTI and was feeling fine. She denied symptoms of infection and acknowledged staff allowed her the opportunity to perform hand hygiene after bathroom use. During interview on 4/18/24 at 10:47 a.m., the infection preventionist (IP) stated staff were expected to perform hand hygiene before entering and exiting a resident room and before and after glove use to protect residents from infection. The IP stated staff should clean front to back for female residents during peri cares to prevent fungal skin infections and UTIs. During interview on 4/18/24 at 1:45 p.m., registered nurse (RN)-B stated when performing perineal cares on a female resident, staff were expected to wipe from front to back and use a clean side of a washcloth or wipe for each swipe. RN-B stated staff were expected to perform hand hygiene before cares, don gloves during cares, change gloves after perineal cares and perform hand hygiene before donning new gloves. During interview on 4/18/24 at 3:30 p.m., the director of nursing (DON) stated staff were expected to use standard precautions when providing cares for residents. Additionally, the DON stated the expectation was to perform hand hygiene upon entering and before leaving a resident's room and, for female residents during perineal cares, for staff to wipe from front to back. The DON stated the goal was to prevent infection and it would not be an acceptable practice to enter a resident's room without performing hand hygiene, nor would performing perineal cares by wiping back to front. R24's quarterly Minimum Data Set (MDS) dated [DATE], indicated R24 was cognitively intact and had diagnoses of congestive heart failure, atrial fibrillation, vascular disease, and weakness. R24 required assistance of a walker and wheelchair for mobility and for rolling left to right in bed. Furthermore, R24 was continent of bowel and bladder and was assist of one to the bathroom. R24's nursing and provider order summary indicated: -on 4/15/24, R24 required a COVID-19, influenza, urine analysis, and stool sample for enteric pathogen -on 4/15/24, gastrointestinal (GI)/contact/respiratory/droplet isolation until labs return An observation on 4/15/24 at 2:32 p.m., R24's door was closed. Outside the door was an isolation cart and two white garbage cans. On top of the isolation cart was a bottle of hand sanitizer. On the wall above the isolation cart were two signs. One stated enhanced barrier droplet precautions and instructed staff to wear gown gloves, eyewear, and surgical mask upon entering and if completing an aerosol generating procedure a N95 mask was required. Below that sign was a sign that read contact precautions and directed staff to use GI precautions if loose stools or C-diff. When interviewed on 4/15/24 at 2:44 p.m., LPN-C stated R24 started having diarrhea, nausea, and fevers today. The provider was notified and labs for COVID-19, influenza were ordered, and a urine and stool sample needed to be collected and sent for testing. LPN-C stated TBP were started as R24 was having a COVID-19 test and stool testing for enteric pathogens. An observation on 4/15/24 at 6:26 p.m., nursing assistant (NA)-E exited R24's room with gown, gloves, eyewear, and surgical mask in place. NA-E removed their gown and with gloved hands lifted the garbage can lid and placed the gown inside. NA-E then removed gloves and lifted the garbage can lid and place them in there. NA-E then removed eyewear and placed on isolation cart before using the hand sanitizer on top of the cart to perform hand hygiene. NA-E had not worn an N-95 mask. Without using soap and water to wash hands, NA-E then knocked and entered room [ROOM NUMBER] to provide resident assistance. When interviewed on 4/15/24 at 6:40 p.m., NA-E stated R24 had an unknown droplet infection as well as weakness and diarrhea. NA-E stated R24's tests were pending. NA-E verified the isolation signs outside of R24's room. The top one stated enhanced droplet precautions and verified just a surgical mask was ok. NA-E further stated if R24's COVID test returned positive then a N95 mask was needed, but test had not come back yet. NA-E verified the contact isolation sign outside R24's room directed to use GI precautions with loose stools. NA-E stated that indicated to use gown and gloves when entering the room. NA-E further stated washing hands with soap and water was always the best to do, but hand sanitizer was ok to use as well, even with GI precautions. An observation on 4/16/24 at 8:10a.m., laboratory technician (LT)-A was observed exiting R24's room with gown, gloves, eyewear, and N-95 mask in place. LT-A removed gloves and placed in the garbage can outside of the room. LT-A then removed N-95 mask and eyewear and placed into garbage. LT-A used hand sanitizer located on the isolation cart outside of R24's room and walked down the hallway and entered room [ROOM NUMBER]. When interviewed on 4/16/24 at 8:27 a.m., LT-A stated R24 had a blood draw and that was why she was in R24's room. R24 had a COVID-19 test pending and was aware R24 was having loose stools. LT-A further stated that was why R24 was on TBP. LT-A stated there was nothing different with isolation or hand hygiene for GI symptoms and acknowledged washing with soap and water was best, but you just use what you have so sometimes it was just hand sanitizer. An observation on 4/16/24 at 2:13 p.m., the enhanced barrier for droplet sign that was outside R24's room was removed. The orange contact isolation sign remained. When interviewed on 4/17/24 at 1:34 p.m., LPN-F stated they were not sure what was going on with R24 and was confused about why they are on TBP. In morning report, LPN-A was told R24's tests were negative and so TBP were removed. LPN-F had not been using any TBP all morning until an order was placed for enteric precautions an hour or so ago. LPN-F verified the signs, cart, and garbage bins outside of R24's room and stated I just didn't pay attention to them as I was told tests came back negative. LPN-F further verified GI precautions included gown, gloves and handwashing with soap and water. When interviewed on 4/17/24 at 1:44 p.m., the Director of Nursing (DON) stated residents with GI symptoms were placed on enteric precautions. Enteric precautions were contact precautions where hand washing with soap and water was expected. DON was aware of R91's norovirus and further stated they were admitted with it. DON was not aware of any other residents with GI symptoms except R24 and there were no trends in GI illness. DON stated staff were expected to complete handwashing when residents were in GI/contact TBP. If testing for infectious process was in place, the residents were treated as if they have the infection until a test was resulted. DON would also expect residents with pending COVID-19 tests to be in full droplet precautions and not in enhanced barrier precautions as staff were required to use precautions as if the resident had the infection until the test proved otherwise. R7significant change Minimum Data Set (MDS) dated [DATE], indicated R7 had mild cognitive impairment. An observation on 4/18/24 at 8:44 p.m., housekeeper (H)-A was cleaning R13's room. H-A swept the floors with a sweeper to the doorway and then took a broom and dustpan to sweep up and placed the dirt in the garbage on the housekeeping cart. Without hand hygiene, H-A then went to the clean linen room and took a towel and went back into R13's room and placed the towel in the bathroom. Without hand hygiene, H-A exited room and again went to the clean linen room and obtained sheets and brought back into R13's room. H-A proceeded to make R13's bed. At 8:59 a.m., H-A exited R13's room with no gloves and no hand hygiene was carrying R13's dirty bedspread that contained brown/tan substance on it that appeared to be bowl movement. The bedspread was not bagged but freely hanging in the open. The bedspread was brought to the soiled utility room and placed in a bin. Without hand hygiene, H-A left the soiled utility room and went to the clean linen room to obtain a clean bed spread and returned to R13's room to finish making the bed. After completing the bed, without hand hygiene, exited R13's room carrying a folded sheet and brought it back to the clean linen room. H-A then went to the cart and without hand hygiene placed a glove on the right hand only, obtained a wet washcloth from the cart and proceeded to clean high touch areas of R13's room. H-A then went back to the cart and placed washcloth in dirty linen bag attached to housekeeping cart and with same gloved hand took the toilet brush and went to clean the toilet. After completion, brought the brush back to place in the cart removed one glove and performed hand hygiene and entered room [ROOM NUMBER]'s room to clean. When interviewed on 4/18/24 at 9:35 a.m., H-A verified they only had one glove on and did not perform hand hygiene with each exit of R13's room or when exiting the soiled utility room. H-A stated they try to clean up the resident rooms and bring extra linens that were not used back to the clean linen. H-A had not been told that is not ok to do. H-A further acknowledged R13's bedspread had bowel movement on it and should have had gloves on and placed it in a bag before bringing to the soiled utility room. When interviewed on 4/18/24 at 11:50 a.m., housekeeping supervisor stated generally any linens were not touched by housekeepers unless turning over a room for discharge. HS expected staff to be wearing gloves when entering and exiting the room as well as when handling any soiled linens or towels. HS stated extra linens should not be brought out of resident rooms and placed back in storage as they were already placed on resident surfaces. All these things helped to prevent any spread of germs/bacteria. During interview on 4/18/24 at 10:47 a.m., the infection preventionist (IP) stated if a resident tested positive for something, staff were notified immediately to place the resident on isolation precautions and the resident's provider would be updated for further guidance regarding any type of outbreak testing. The IP stated enhanced barrier precautions (EBP) were initiated for residents with chronic wounds, pressure ulcers, surgical wounds and incisions, and catheterization. When asked when transmission based precautions (TBP) would be intitated for a resident, the IP stated, when they have a diagnosis. The IP was unsure what type of standing precautions could be implemented for the facility if a resident had gastrointestinal (GI) symptoms, such as diarrhea, and stated, I'm not aware of any standing orders for this facility for precautions, but for the other facility and during our regional infection preventionist call, the expectation is the resident be placed on contact or droplet or ehanced barrier precautions until we can rule that out. If a resident was GI precautions, the IP stated staff were expected to wear gloves, gown, and a mask for all direct cares with the resident. The IP stated handwashing should be done whenever going in and out of the resident's room to prevent cross contamination, and handwashing should be done if staff are providing cares with the resident. The IP stated hand sanitizer would be appropriate if staff are, going in and out of the room to just verbally speak to the resident. A facility policy titled Activities of Daily Living - Rehabilitation/Skilled Care and Long Term Care (R/S, LTC), dated 11/29/22, indicated any resident who is unable to carry out activities of daily living will receive necessary services to maintain good nutrition, grooming and personal and oral hygiene. Furthermore, the policy indicated ADLs are those necessary tasks conducted in the normal course of a resident's daily life and included toileting, transferring on and off the toilet, use of bedpan, urinal or commode, cleansing after elimination, changing any protective pads, and adjusting clothing after toileting. A facility policy titled Standard and Transmission Based Precautions revised 4/2/24, indicated: -standard precautions were used to protect residents from all recognized and unrecognized sources of infection, blood, and bodily fluids. Standard precautions include hand hygiene and personal protective equipment (PPE) such as glove use. The policy directed all staff to use standard precautions with all residents when cleaning equipment or handling of potentially soiled items and entering/exiting rooms. -enhanced barrier precautions were used for residents with wounds or indwelling medical devices. Enhanced barrier was used only during high contact cares that involve close physical contact with the resident. -contact precautions will be used in addition to residents with a known or suspected infection or evidence of syndromes that represent an increased risk for contact transmission. Contact GI precautions should be used when GI illness was suspected. -droplet precautions will be used in addition to residents with a known or suspected infection with organisms transmitted by droplets generated by sneezing, coughing, or talking. Findings include: R91's admission Minimum Data Set (MDS) dated [DATE], indicated R91 had intact cognition and diagnoses of sepsis, chronic kidney disease (CKD), chronic respiratory failure with hypoxia, and urinary tract infection (UTI). It further indicated R91 required maximal assistance with toileting hygiene and was frequently incontinent of bowel. R91's care plan dated 4/4/24, indicated R91 had bowel incontinence related to Crohn's disease and Norovirus and an activities of daily living (ADL) self-care performance deficit related to incontinence cares with an intervention of R91 required extensive assistance of one staff dependent for hygiene with incontinent bowel movement. During observation on 4/17/24 at 9:00 a.m., nursing assistant (NA)-D used hand sanitizer, donned a gown, gloves, mask, and entered R91's room. NA-D then assisted R91 to use the bathroom and exited the room still wearing the same gloves, gown, and mask and went into the hallway outside R91's room. NA-D then removed her gown and gloves and threw them away in the bins in the hallway, used hand sanitizer, and walked down the hallway towards the nursing station. During an interview on 4/17/24 at 9:19 a.m., nursing assistant (NA)-D stated she was aware R91 was on gastrointestinal (GI) and contact precautions but wasn't sure why. NA-D further stated she had assisted R91 to use the bathroom and R91 had diarrhea so had also assisted her to clean up. NA-D verified she used hand sanitizer after removing her gloves and did not wash her hands with soap and water stating You should just use soap and water when you get the chance because we don't have time in between residents so hand sanitizer works the best. NA-D verifed there was a sign on R91's door indicating she was on GI and contact precautions and staff should wash their hands with soap and water when leaving the room. NA-D works with all the residents in the facility, not just on one unit. During interview on 4/17/24 at 1:44 p.m., LPN-A stated if a resident was on GI/contact precautions staff should wear a gown and gloves before entering the room. It was okay to use hand sanitizer when entering and exiting the room but you should alternate with washing your hands with soap and water if you can. During interview on 4/17/24 at 1:52 p.m., nurse manager registered nurse (RN)-B stated R91 was admitted with Norovirus and continued to have diarrhea so they put her on GI/contact precautions. RN-B stated these precautions required staff to wear a gown and gloves stating whatever the sign says. and that staff should be washing their hands with soap and water (not hand sanitizer) when leaving the room.

Based on observation, interview, and record review the facility failed to ensure the facility's walk-in freezer was maintained to ensure water drippings and ice build up would not impact frozen food storage. This had the potential to impact all 39 residents who reside in the facility. Findings include: During the initial kitchen observation on 4/15/24 at 12:46 p.m., the walk-in freezer was observed. Inside the freezer, near the top, at the far end were two fans. The right one was in motion while the left one was not moving due to a large ice dam inside the fan. In the fan blades and grate the large ice dam extended from the fan down all three shelves to the floor of the freezer. The ice dam appeared to be frozen water that had dripped down and frozen as it went down, as it gotten smaller as it went down. As it extended down the shelves, the ice had frozen on to several unopened boxes located on the back three shelves. When interviewed on 4/15/24 at 1:08 p.m., the dietary supervisor (DS) verified the ice dam and stated it had been there since he started at the facility a few weeks ago. DS stated it was something to do with the fan and wasn't sure how long it had been that way. DS further stated maintenance had been aware, but nothing had gotten fixed yet. DS verified the boxed items on the back shelves and was not sure if it impacted the items inside. When interviewed on 4/18/24 at 11:50 p.m., the maintenance personal stated he was made aware of the ice dam in the freezer a week or so ago and wasn't sure how long it had been there. Maintenance personal further stated he had been working on trying to chip it away, but it just kept building up. Maintenance personal further stated they had some help from another facility yesterday and were able to get the ice dam cleaned out and determine what the problem was. A temporary fix was now in place until the needed part arrived. When interviewed on 4/22/24 at 1:39 p.m., the administrator had not been aware of the ice dam in the freezer and expected all equipment in the kitchen to be in good working condition. If something wasn't working, it should be followed up on in a timely manner. A policy for maintaining equipment was requested however was not received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to maintain wheelchairs in clean and sanitary manner for 1 of 1 resident (R12) reviewed who utilized wheelchairs. Findings include: R12's annual Minimum Data Set (MDS) dated [DATE], indicated R12 was cognitively intact and was diagnosed with dementia, depression, delusion disorder, weakness and required extensive assistance for activities of daily living (ADLs). During an interview on 6/20/23, at 2:07 p.m., family member (FM)-A stated R12's wheelchair was always dirty and smelled of urine. FM-A stated she cleaned R12's wheelchair in October but did not think it should be her responsibility to keep the wheelchair clean. During an observation on 6/21/23 at 7:21 a.m., R12's wheelchair smelled of urine, had food crumbs on the top of and under the wheelchair cushion, a dried white substance was scattered on both wheelchair pedals, and a sticky brown substance was on the left side of the wheelchair. During an interview on 6/22/23 at 8:08 a.m., housekeeper-A stated the housekeeping department cleaned wheelchairs after a resident discharged . Housekeeper-A stated housekeeping was told wheelchairs should be cleaned more often but stated they did not have time to. Housekeeper-A confirmed R12's wheelchair was dirty and should be cleaned. During an interview on 6/22/23 at 9:44 a.m., director of ancillary services stated housekeeping cleaned and disinfected wheelchairs after a resident discharged and the night shift nurses would clean wheelchairs when needed. During an interview on 6/22/23 at 10:08 a.m., administrator stated the facility did not have a cleaning schedule for wheelchairs but housekeeping would clean wheelchairs after a resident discharged and the night shift nurses would clean wheelchairs when needed. Administrator confirmed R12's wheelchair was dirty and should be cleaned. A facility policy for wheelchair cleaning was requested but administrator stated the facility did not have a policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure residents were free from physical restraints for 1 of 1 resident (R26). Findings include: R26's significant change Minimum Data Set (MDS) dated [DATE], indicated severe cognitive impairment and was diagnosed with dementia, osteoarthritis, weakness, hypertension (high blood pressure), pain, chronic kidney disease and was dependent on staff for most activities of daily living (ADLs). The MDS further identified physical restraints were not used. R26's care plan dated 6/5/23, indicated R26 was at risk for falls related to weakness, deconditioning, gait and balance and history of falls and had the following interventions in place: encourage resident to participate in activities that promoted exercise, physical activity for strengthening and improved mobility, ensure resident was wearing appropriate footwear, avoid clothing that fit too loose, slippery or too long, frequent checks at night, provide assistance when needed, review and modify environmental hazards that could cause or contribute to fall, ensure and provide a safe environment (alternative call light, bed at appropriate height, avoid isolation). R26's physical device and/or restraint evaluation and review assessment dated [DATE], indicated R26 utilized grab bars but had no restraints in use. During an observation on 6/21/23 at 7:23 a.m., R26 was in bed. Bed was in low position, pushed up against the wall, one pillow tucked under fitted sheet on the right side of her body. During an observation on 6/21/23 at 9:32 a.m., R26 observed in bed with one pillow tucked under fitted sheet, on right side of body. During an observation and interview on 6/21/23 at 10:08 a.m., licensed practical nurse (LPN)-A administered medications to R26 while in bed. LPN-A stated the pillow under the fitted sheet prevented R26 from rolling or getting out of bed as R26 was at risk for falls. LPN-A stated R26 had weakness and would not be able to remove the pillow from under the sheet on her own. During an observation and interview on 6/21/23 at 10:49 a.m., nursing assistant (NA)-A removed pillow that was under the fitted sheet and repositioned R26 onto her left side and placed the pillow back under the fitted sheet on the right side of R26's body. NA-A stated the pillow under the fitted sheet kept R26 from falling out of bed and to assist with repositioning. NA-A stated R26 would not be able to remove the pillow from under the sheet on her own. During an interview on 6/21/23 at 12:32 p.m., registered nurse (RN)-A stated the facility did not use restraints. RN-A stated pillows tucked under a fitted sheet would be considered a restraint. -at 12:36 p.m., RN-A confirmed R26 had one pillow tucked under the fitted sheet on the right side of R26's body and stated R26 would not be able to remove the pillow on her own. -at 12:55 p.m., RN-A removed pillow from under fitted sheet. During an interview on 6/21/23 at 1:48 p.m., director of nursing (DON) stated the facility did not use restraints. DON stated pillows should not be placed under a fitted sheet as it would be considered a restraint. DON stated she did not think R26 would be able to remove the pillow under the fitted sheet. DON expected all pillows used for repositioning would be placed over the sheet and not tucked under. A facility policy physical restraints/psychotropic medications alternatives dated 3/29/23, indicated the purpose of the policy was to provide non-pharmacological alternative to the use of a physical restraint or psychotropic medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure effective pain management for 1 of 1 resident (R189) reviewed for pain. Finding include: R189's admission Minimum Data Set (MDS) dated [DATE], included diagnoses of displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing, and orthopedic aftercare. It further included R189 required physical assistance of one staff with all activities of daily living (ADL), had frequent pain (rated at a 7 out of 10) that affected his sleep and daily activities. R189's physician's orders dated 6/11/23, included dilaudid oral tablet 2 milligrams (mg). Give 1 mg orally every 4 hours as needed for pain, give 1/2 tab which equals 1 mg every 4 hours as needed (PRN). It further included an order to encourage ice to left hip every shift for pain dated 6/16/23, and acetaminophen oral tablet 500 mg, give 1,000 mg by mouth three times a day for acute pain dated 6/12/23. P189's admission MDS dated [DATE], triggered a care area assessment (CAA) for pain which included resident has c/o [complains of] frequent pain that affects his sleep and his activities rated at a 7 when interviewed. It further included staff will enourage non-pharmacological intervetnions for pain and provide scheduled/PRN [as needed] pain medications per medical doctor order and montior effectiveness or any side effects of pain medications. P189's care plan dated 6/12/23, included R189 had actue pain/discomfort related to hip fracture as evidenced by pain medication use, voices complaints of pain with interventions to notify health care provider if interventions are unsuccessful or if current complaint was a significant change from residents past experience of pain and attempt non-pharmacological interventions. During observation and interview on 6/21/23 at 1:55 p.m., R189 was sitting in his wheelchair in his room, he had facial grimacing, rocking back and forth, and rubbing his left thigh. He stated, I need something to kick this pain. I have to ask for the medication and then I have to wait for it. R189 further stated the pain was in his left hip and right shoulder and rated the pain in his hip at an 8 (out of 10). He also stated he had received his medications a half an hour ago but they're not working, and sometimes re-positioning helps. R189 asked if I (surveyor) could lay him down in bed because he was in so much pain. The surveyor notified the nurse and staff assisted him into bed. During an observation and interview on 6/21/23 at 10:09 a.m., R189 was laying in bed. The head of his bed was elevated to almost a 90 degree angle and his right foot was pushed up against the footboard. His left foot was off the edge of the bed. He stated he wasn't doing so good, and had facial grimacing and was putting his hand up to his head and holding it. R189 pointed to his left groin area when asked where he was having pain and he rated it at a 10 and even higher. He also stated he had a headache that's way more then it should be! -At 10:18 a.m., the surveyor reported licensed practical nurse (LPN)-A, R189 was in pain and rated it at a 10. LPN-A stated she had already given him his pain medication at 7:27 a.m and he can't get another one until 11:27 a.m. LPN-A did not go into R189's room to assess him, offer any non-pharmacological pain interventions, or call the provider. -At 10:40 a.m., nursing assistant (NA)-A was observed reporting to LPN-A R189 stated he was in pain and hadn't received his pain medication this morning. LPN-A stated he received his pain medication at 7:27 this morning and he can't get another one until 11:27 a.m. LPN-A did not go in and assess him, offer any non-pharmacological pain interventions, or call the provider. During an interview on 6/21/23 at 10:50 a.m., NA-A stated R189 had been complaining of pain all morning and she had reported it to LPN-A on three separate occasions. NA-A stated LPN-A's response was the same each time stating he had already received his pain medication and he can't get it again until 11:27 a.m. NA-A stated she had worked with R189 before and he had never complained of pain, which was why she kept reporting it to the nurse so she made sure she was staying on top of it. During an interview on 6/21/23 at 11:09 a.m., LPN-B stated he would try to use non pharmacological pain interventions such as ice, bio freeze [if there was a physician's order], and repositioning, if a resident was in pain and all pain medication had been given. LPN-B further stated if that didn't work I would notify the supervisor or call the physician. During an interview on 6/21/23 at 11:12 a.m., registered nurse manager (RN)-A manager stated we try non medication interventions, re-positioning, ice pack, etc. and if that doesn't work, then we would go to the nurse practioner or doctor. If they [resident] are screaming in pain, I would call the on-call or send them to the emergency room (ER), when asked what nurses should do if a resident is in pain and all pain medications had been given. During an interview on 6/22/23 at 1:55 p.m., the director of nursing (DON) stated the nurses should be offering ice, heat, moving [repositioning], and if the pain is still not relieved, they can call the provider to see if there's anything they can do, when asked what nurses should do if a resident is still in pain but has received all their pain medications. The DON also stated the nurses should be assessing for non verbal signs of pain such as grimacing, guarding, crying, etc. The facility's policy on pain management dated 12/19/22, included the nurses working directly with residents must continually monitor and observe the resident for success of the pain management plan and report to the nurse manager and prescriber as necessary to keep the resident comfortable.

Based on observation, interview, and document review, the facility failed to ensure foods were labeled, stored off the floor, and scoops were stored outside their bulk dry goods containers which had the potential to affect all 35 residents who consumed foods from the kitchen. Additionally, the facility failed to ensure the refrigerator in the main dining room was maintained. Findings include: During the initial kitchen tour with the supervisor of nutrition and food services (SNFS) on 6/20/23 at 12:59 p.m., observed the following: Kitchen Freezer: 1 box of strawberry ice cream was stored directly on the floor 1 box of potato fries was stored on the floor 1 box of crinkle cut fries was stored on the floor, SNFS stated, foods should not be stored on the floor. 1 package of four chicken breasts were located in a bag was undated 1 opened bag of onions and peppers with no date and the bag was lying opened on the shelf Dry Storage: The sugar bin contained a plastic cup inside the bin located in the sugar The flour bin contained two plastic scoops located in the flour, SNFS stated, the plastic cup and scoops should not be located in the sugar and flour bins, because it was touched by staff and should not be stored in the bins. Refrigerator Cooler: Brown colored fluid was located inside the bottom of the cooler A container was located in the cooler the SNFS stated, It's my lunch. A plastic container SNFS stated, looked like mashed potatoes but had no date or label so it would be discarded. During interview and observation on 6/22/23 at 8:13 a.m., in the main dining room, the main dining room refrigerator had a thick layer of ice located on the top of the inside of the refrigerator. The refrigerator contained thickened cranberry juices and prune juices. There was no thermometer located inside the refrigerator. Dietary Aide (DA)-A stated the kitchen staff took turns cleaning the refrigerator in the main dining room. During interview on 6/22/23 at 8:21 a.m., nursing assistant (NA)-C verified the refrigerator did not have a thermometer and the thick build up of ice and stated the refrigerator could benefit from a cleaning or a defrosting. During interview on 6/22/23 at 8:29 a.m. to 8:39 a.m., SNFS verified the refrigerator did not have a thermometer and had a thick build up of ice. During interview on 6/22/23 at 12:12 p.m., SNFS stated food should not be stored on the floor because people could trip over the boxes and it could provide easy access for rodents. The buildup of ice in the refrigerator could cause temperatures to rise because it blocked the fan and the cooling element and there was no thermometer in the refrigerator. A policy, Food-Supply Storage-Food and Nutrition Services dated 5/11/23, indicated personal food was not considered approved food and was not stored in the food preparation kitchen or location refrigerators and storage areas. All food supply items are stored off the floor. Foods that have been opened or prepared are placed in an enclosed container, dated, labeled and stored properly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure an allegation of potential physical abuse for 1 of 1 resident (R2) who complained of rough care by staff, and an allegation of mental abuse for 1 of 1 resident (R3), who complained of being spoken to in an intimidating and frightening manner by staff were reported immediately but no later than 2 hours to the State Agency (SA). Findings include: R2's annual Minimum Data Set (MDS) dated [DATE], indicated R2 was severely cognitively impaired and required assistance of one staff for transfers and bed mobility. R2's progress notes lacked mention of the incident. Review of the facility Suggestion or Concern form dated 9/25/22, indicated R2 told a nursing assistant (NA) early in the morning, (no time was indicated), NA-A was rough when NA-A helped R2 out of bed. The Minnesota Incident Report filed 9/26/22 at 12:56 p.m., by the facility social worker (SW)-A documented the incident occurred 9/25/22, at approximately 7:00 a.m., and was reported to the SA on 9/26/22, at 12:56 p.m., which was greater than 24 hours after the alleged incident. R3's discharge MDS dated [DATE], indicated R3 was cognitively intact. R3's progress notes lacked mention of the incident. Review of the facility Suggestion or Concern form dated 9/24/22, at 5:45 p.m., indicated NA-A was verbally aggressive towards R3, at the dinner table when R3 did not know NA-A's name and called NA-A, That guy, and NA-A pulled his mask down and said to R3, Don't ever call me 'Whatever his name is' again. Learn my name, I'm not a dog. The form further indicated NA-A was, Angry-looking and became, Very hostile and dismissive. The Minnesota Incident Report filed on 9/26/22, at 12:36 p.m., by SW-A for that incident identified the incident occurred 9/24/22, at 5:45 p.m. When interviewed on 3/30/23, at 12:10 p.m. registered nurse (RN)-A stated she was required to report alleged abuse as soon as the incident occurred to the facility leadership staff. RN-A stated she knew how to report abuse but didn't report the incident with R3 immediately because she was unsure if the incident qualified as abuse. RN-A stated she waited until she talked to the SW, who then reported the allegations. When interviewed on 3/30/23, at 2:33 p.m., the director of nursing (DON) stated SW-A who filed both Minnesota Incident Reports no longer worked at the facility. The DON further stated she was unsure why the reports were filed late, but acknowledged both reports should have been filed within two hours after the incidents. The [NAME] Abuse and Neglect-Rehab/Skilled, Therapy and Rehab policy dated 10/13/22 indicated if there is an allegation of abuse, and/or there is serious bodily injury, then it will be reported immediately, but not later than two hours after the allegation is made. The [NAME] Abuse Definitions-Rehab/Skilled and Therapy/ Rehab policy dated 12/27/22, indicated abuse included intimidation and verbal abuse. The [NAME] Indicators of Abuse and Neglect-Rehab/Skilled and Therapy/Rehab policy dated 10/13/22, indicated behavior indicators of abuse included fear of person.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to thoroughly investigate physical abuse for 1 of 1 resident (R1 who alleged rough cares. In addition, the facility failed to thoroughly investigate an allegation of verbal and emotional abuse for 1 of 1 resident (R3) who alleged feeling afraid of and intimidated by a staff member. Findings include: R2's annual Minimum Data Set (MDS) dated [DATE], indicated R2 was severely cognitively impaired and required assistance of one staff for transfers and bed mobility. R2's progress notes lacked mention of the incident. Review of the facility Suggestion or Concern form dated 9/25/22, indicated R2 told a nursing assistant (NA) early in the morning, (no time was indicated), NA-A was rough when NA-A helped R2 out of bed. The Minnesota Incident Report filed 9/26/22 at 12:56 p.m., by the facility social worker (SW)-A indicated R2 reported the NA, Is rough getting him out of bed. R2's medical record lacked information about the incident. Upon review of the facility investigation file, the investigation lacked evidence of interviews with R2, the alleged perpetrator, the alleged witness, and other staff. R3's discharge MDS dated [DATE], indicated R3 was cognitively intact. R3's progress notes lacked mention of the incident. Review of the facility Suggestion or Concern form dated 9/24/22 at 5:45 p.m., indicated NA-A was verbally aggressive towards R3, at the dinner table when R3 did not know NA-A's name and called NA-A, That guy, and NA-A pulled his mask down and said to R3, Don't ever call me 'Whatever his name is' again. Learn my name, I'm not a dog. The Suggestion or Concern form further indicated NA-A was, Angry-looking and became, Very hostile and dismissive. The Minnesota Incident Report filed 9/26/22 at 12:36 p.m., by the facility social worker (SW)-A indicated R3 reported NA-A was verbally aggressive, was very angry-looking, and became hostile and dismissive. The report further indicated registered nurse (RN)-A witnessed the incident. Upon review of the facility investigation file, the investigation lacked evidence of interviews with the alleged perpetrator, the alleged witness, and other staff. When interviewed on 3/30/23 at 12:10 p.m., RN-A stated she witnessed the incident with R3, and stated R2, Would not make a report unless he actually felt like staff was rough, and acknowledged she had not been interviewed during the facility investigation for either incident. When interviewed on 3/30/23 at 11:15 a.m., the director of nursing (DON) stated she had no additional information about either facility investigation, but expected to see interviews with the witness, the employees involved, the residents involved, and anyone else identified as having potential for the same type of allegation. The [NAME] Abuse and Neglect-Rehab/Skilled, Therapy and Rehab policy dated 10/13/22, indicated the facility would have evidence that all alleged or suspected violations are thoroughly investigated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure medications were secured at all times to minimize loss or diversion in 3 of 4 medication carts used. Findings include: During observation and interview on 11/21/22, at 11:26 a.m. observed both the north and south medication carts to be unlocked. At 11:27 a.m. RN-B stated the medication carts are supposed to be locked and stated she had to go in the nursing station and came back. During observation and interview on 11/21/22, at 1:05 p.m. observed the north medication cart to be unlocked and RN-B came and locked the cart and acknowledged she had not locked the cart again. R4's annual minimum data set (MDS) dated [DATE], indicated R4 was moderately cognitively impaired, used a wheelchair with one-person physical assist. R4's diagnoses included dementia, anxiety and major depressive disorder. R4's care plan revised 4/18/22, indicated R4 used a wheelchair for locomotion and could self-propel in wheelchair around the facility. R5's quarterly MDS dated [DATE], indicated R5 was moderately cognitively impaired, used a wheelchair with one-person physical assist. R5's diagnoses included rheumatoid arthritis, pain, and cognitive decline. R5's care plan revised 7/7/22, indicated, [R5] mobilizes in the facility in manual wheelchair on her own. During observation and interview on 11/21/22, at 2:00 p.m. one of the two medication carts on long term care (LTC) was unlocked and situated in the large dining area. There were no staff in sight and there were three residents sitting in wheelchairs in the room. At 2:04 p.m. LPN-C walked into the dining area. LPN-C stated the medication carts should locked when staff were not using them. LPN-C further stated R4 and R5 were independent in mobility and could have approached the cart and accessed it while it was unlocked. During interview on 11/21/22, at 2:56 p.m. DON stated the med carts should be secured if the nurse was not in sight of the cart. DON further stated residents could potentially open an unlocked cart and access the medications inside. During interview on 11/21/22, 3:29 p.m. Administrator stated the expectation was that medication carts were locked if out of sight of the nurse to prevent unwanted access. Review of facility policy Medications: Acquisition Receiving Dispensing and Storage-Rehab/Skilled dated 2/8/22, indicated, Medications will be stored in a locked medication cart, drawer or cupboard.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure 2 of 3 residents (R1, R2) reviewed for drug diversion were free from misappropriation of resident property when a staff member took R1 and R2's narcotic pain medications for personal use. This failure had the potential to effect all residents who were prescribed a narcotic medication. Findings include: R1's clinical diagnosis included: unspecified osteoarthritis, osteoarthritis of the left shoulder, migraine, wedge compression fracture of unspecified thoracic vertebra, infection and inflammatory reaction due to internal right hip prosthesis. R1's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated moderately impaired cognition and received both scheduled and as needed pain medication. R1's physician orders indicated R1 had an order 8/17/22, for tramadol 50 milligram (mg) tablet, one tablet three times a day for pain. Additionally, R1 had an order 10/19/21 for tramadol 50mg tablet by mouth every six hours as needed for pain. R1 also had an order 8/27/21, for morphine sulfate 100mg/5 milliliter (ml), give 0.25 ml by mouth every one hour as needed for pain or dyspnea and call hospice if pain was not relieved after three doses. R1's medication administration record (MAR) for November 2022, indicated R1 utilized eight doses of the as needed tramadol, six of the eight doses were administered by licensed practical nurse (LPN)-A. R1 also utilized as needed morphine twice, one of the doses was administered by LPN-A. R1's care plan revised on 9/13/21, indicated R1 had chronic pain related to chronic infection/inflammation of the artificial right hip joint which included interventions to monitor pain characteristics throughout each shift and as needed and R1 could rate her pain on a numerical 0-10 pain scale. R2's clinical diagnosis included: unspecified fracture of the right femur, pain in the right leg, and lumbago with sciatica on the right side. R2's MDS dated [DATE], indicated intact cognition and R2 frequently had pain and had both scheduled and as needed medications for pain. R2's physician orders 11/8/22, indicated R2 had oxycodone 5mg tablet give 5 mg every six hours as needed for pain rated three to six, and give 7.5 mg every six hours as needed for pain rated seven to ten. R2's MAR for November 2022, indicated R2 utilized oxycodone 54 times. R2's care plan revised 11/18/22 indicated R2 had acute and chronic pain related to a right femur fracture with interventions to record pain characteristics throughout each shift and R2 rated her pain using a numerical 0-10 pain scale. The investigative report submitted 11/11/22, indicated an explanation of the policy or procedure not followed included missing initials on form GSS#247A-Controlled Drugs-Count Record. The report indicated that registered nurse (RN)-B contacted the pharmacy and confirmed that 90 tablets of tramadol was delivered on 11/3/22. A drug screen was conducted and licensed practical nurse (LPN)-A was positive for opiates. According to the report, LPN-A stated she took as needed medications and no resident went without medications. Officer-C was contacted by the facility and LPN-A admitted to officer-C she took 30 tablets of oxycodone, nine tablets of Percocet, and 30 tablets of tramadol. Additionally, a white tablet was removed from one of LPN-A's pockets and four other pills were discovered after a search of LPN-A's vehicle. LPN-A was immediately terminated, removed from the facility, and her staffing agency was notified of the incident. The incident was reported to both the Minnesota and Wisconsin Boards of Nursing. The facility reviewed all narcotic books, nursing schedules from 11/3/22, through 11/10/22, form GSS#247A Controlled Drug Count Record, and policy Medication-Controlled policy and procedure. Form GSS #247A Controlled Drugs-Count Record dated 11/22, for unit 3 north indicated there were 25 missing initials. At the top of the form, it was written that by signing below, staff acknowledged they counted the controlled drugs on hand and found the quantity of each medication counted was in agreement with the quantity indicated on the controlled drug count. Form GSS #247A Controlled Drugs-Count Record dated 11/22, for unit 3 south indicated there were 36 missing initials. Additionally, the north cart for 11/22, indicated eight missing initials from 11/11/22 through 11/21/22, and the south cart for 11/22, indicated 11 missing initials from 11/11/22 through 11/21/22. During interview on 11/21/22, at 10:34 a.m. the director of nursing (DON)-B stated R1 and R2's controlled medications were identified as being missing. Per the investigative report, RN-B reported a missing card of R1's tramadol on 11/10/22. DON-B stated R2's oxycodone and percocet had also been taken. DON-B stated about three months ago, LPN-A had lost her dad and had a miscarriage. DON-B stated it happened around 4:00 p.m. where the nurses were drug tested and LPN-A's test came back positive and admitted to taking the medications. DON-B stated the residents were not interviewed and stated R2 had discharged . LPN-A was working at the time and they did not know it was her until the positive drug screen around 8:30 p.m. During interview and observation on 11/21/22, at 11:30 a.m. R1 was in her bed and stated she was not aware of missing medications and stated the facility had not discussed missing medications with her. R1 stated her pain level was pretty good when she is in bed, but when she sits up, R1 stated her pain is sometimes pretty bad, but tolerable. R1 stated she does ask for additional pain medication, but very seldom took morphine which she stated she took for sleep, but could not recall taking this month. R1 stated that missing her medications made her feel very nervous and unhappy. During interview on 11/21/22, at 11:52 a.m. resident representative (RR)-D stated she visits mid-afternoon and noticed R1 had increased pain the past three months and stated R1 did not usually get up until after 1:00 p.m. RR-D stated she saw staff administer morphine in the last month, but not in the past week or two. RR-D stated the facility had not contacted her with concerns of missing medications. RR-D stated there had been situations where R1 had more pain that was not relieved with what she received. During interview on 11/21/22, at 1:05 p.m. RN-B stated when asked about the missing controlled medications that she noticed a drug label for another resident was placed over a drug she had logged the day prior and the RN-C informed her after review of R1's medications, she thought there were medications missing. RN-B stated she looked on the north cart on the narcotic log and found that a page was missing. She stated they count the controlled medications every shift with the oncoming nurse and both nurses sign or initial together. RN-B added that LPN-A would come in early or leave early and did not always count the medications. RN-B also stated that residents had not reported they did not receive medications, but added she had not interviewed residents because she stated they would not remember. RN-B stated that residents received more as needed pain medications from LPN-A. During interview on 11/21/22, at 2:13 p.m. DON-B stated she was checking the narcotic books and stated she educated staff when they were interviewed and had a quiz for the nursing staff, but had not yet administered the quiz. The education included speaking up and how to monitor the logs, which included both nurses initialing off to verify the count. DON-B stated they reconcile at the start of the shift, one nurse would take the book, and one nurse takes the medication card and both of the nursing staff would initial. During interview on 11/21/22, at 2:22 p.m. DON-B stated the check marks on the GSS #247A form indicated the medication count was verified and accurate and if there was no check mark, the count was not completed. During interview on 11/21/22, at 2:44 p.m. RN-C stated she visited R1 on 11/10/22, and asked facility staff to check medication quantities to assure R1 had enough tramadol and viewed the cards and stated they did not look right. RN-C stated there were 90 tablets or three cards and thirty tablets were missing. RN-C stated she had not noticed an increase in R1's pain and stated when R1 was in bed she was fine, however when she was up she had chronic back pain. During interview and observation on 11/21/22, at 3:21 p.m. LPN-B stated she worked through an agency staffing company. LPN-B and RN-B began reviewing the narcotic logs for the north and south medication carts for the end of the first shift at 3:21 p.m. LPN-B initialed in the area for the nurse coming off of the first shift and as the nurse coming off of the second shift and RN-B instructed LPN-B to only sign off for the nursing coming on to the second shift. During interview and observation on 11/21/22, at 4:28 p.m. LPN-B stated she had been working at the facility about two weeks and stated she completed Relias training on abuse prior to working at the facility, but had not received any formal training from the facility on their medication narcotic logs. LPN-B added they counted narcotics when she first started coming to the facility, but stated there was not a sheet to sign. Call attempted to LPN-A on 11/21/2022, at 1:33 p.m., with no return call. A policy, Medications: Controlled-Rehab/Skilled dated 12/7/21, indicated each time keys that secure controlled medications change from one nurse/medication aide to another, the oncoming and off-going nurse/medication aide will work together to reconcile all controlled medications, including all discontinued controlled medications and document the same. The nurse going off shift unlocks the controlled medication storage unit(s) and will then go to the narcotic count book and read each GSS #247 or Controlled Substance Bound Book page to the on-coming nurse. The on-coming nurse will verify that the physical medication count matches the remaining amount listed in the GSS #247 or Controlled Substance Bound Book for each medication. If the GSS #247 or Controlled Substance bound book and the physical controlled medication count are in agreement, both nurses will sign the Controlled Drugs-Count Record (GSS #247A for the appropriate date and shift. A policy, Abuse and Neglect Rehab/Skilled, Therapy and Rehab reviewed 12/28/21, indicated the purpose of the policy was to ensure there was an effective system in place that prevented mistreatment, neglect, exploitation, and abuse of residents and misappropriation of their property. The policy indicated the resident had the right to be free from abuse, neglect, misappropriation of resident property and exploitation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to have a system in place to properly reconcile controlled medications which had the potential to affect all residents receiving controlled medications and affected R1 and R2 who had their controlled medications diverted. The investigative report submitted [DATE], indicated an explanation of the policy or procedure not followed included missing initials on form GSS#247A-Controlled Drugs-Count Record. The report indicated registered nurse (RN)-B contacted the pharmacy and confirmed that 90 tablets of tramadol was delivered on [DATE]. A drug screen was conducted and licensed practical nurse (LPN)-A was positive for opiates. According to the report, LPN-A stated she took as needed medications and no resident went without medications. Officer-C was contacted by the facility and LPN-A admitted to officer-C she took 30 tablets of oxycodone, nine tablets of Percocet, and 30 tablets of tramadol. Additionally, a white tablet was removed from one of LPN-A's pockets and four other pills were discovered after a search of LPN-A's vehicle. LPN-A was immediately terminated, removed from the facility, and her staffing agency was notified of the incident. The incident was reported to both the Minnesota and Wisconsin Boards of Nursing. The facility reviewed all narcotic books, nursing schedules from [DATE], through [DATE], form GSS#247A Controlled Drug Count Record, and policy Medication-Controlled policy and procedure. Form GSS #247A Controlled Drugs-Count Record dated 11/22, for unit 3 north indicated there were 25 missing initials. At the top of the form, it was written that by signing below, staff acknowledged they counted the controlled drugs on hand and found the quantity of each medication counted was in agreement with the quantity indicated on the controlled drug count. Form GSS #247A Controlled Drugs-Count Record dated 11/22, for unit 3 south indicated there were 36 missing initials. Additionally, the north cart for 11/22, indicated eight missing initials from [DATE] through [DATE], and the south cart for 11/22, indicated 11 missing initials from [DATE] through [DATE]. During interview on [DATE], at 10:34 a.m. the director of nursing (DON)-B stated R1 and R2's controlled medications were identified as being missing. During interview on [DATE], at 1:05 p.m. RN-B stated when asked about the missing controlled medications that she noticed a drug label for another resident was placed over a drug she had logged the day prior and the hospice nurse informed her after review of medications she thought there were medications missing. RN-B stated she looked on the north cart on the narcotic log and found that a page was missing. She stated they count the controlled medications every shift with the oncoming nurse and both nurses sign or initial together. Contrary to facility policy, Medications: Controlled-Rehab/Skilled dated [DATE], RN-B added that LPN-A would come in early or leave early and did not always count the medications. During interview on [DATE], at 2:13 p.m. DON-B stated she was checking the narcotic books and stated she educated staff when they were interviewed and had a quiz for the nursing staff, but had not yet administered the quiz. The education included speaking up and how to monitor the logs, which included both nurses initialing off to verify the count. DON-B stated they reconcile at the start of the shift, one nurse would take the book, and one nurse takes the medication card and both of the nursing staff would initial. During interview on [DATE], at 2:22 p.m. DON-B stated the check marks on the GSS #247A form indicated the medication count was verified and accurate and if there was no check mark, the count was not completed. During interview and observation on [DATE], at 3:21 p.m. LPN-B stated she worked through an agency staffing company. LPN-B and RN-B began reviewing the narcotic logs for the north and south medication carts for the end of the first shift at 3:21 p.m. LPN-B initialed in the area for the nurse coming off of the first shift and as the nurse coming off of the second shift and RN-B instructed LPN-B to only sign off for the nursing coming on to the second shift. During interview and observation on [DATE], at 3:27 p.m. LPN-B and RN-B counted R6's controlled medications. R6 expired on [DATE], and had 29.75 milliliters (ml) of lorazepam 2 milligrams (mg) per 1 ml concentration logged on the narcotic log book with about 30 ml left in the bottle, and morphine 20mg/5ml concentration with an amount recorded in the log book of 24.25 ml, and had a little over 24 ml in the bottle. RN-B stated the controlled medications for residents who are expired stay in the medication cart until they have time for two nurses to destroy the medication. During interview and observation on [DATE], at 4:28 p.m. LPN-B stated she had been working at the facility about two weeks and stated she completed Relias training on abuse prior to working at the facility, but had not received any formal training from the facility on their medication narcotic logs. LPN-B added they counted narcotics when she first started coming to the facility, but stated there was not a sheet to sign. A policy, Medications: Controlled-Rehab/Skilled dated [DATE], indicated each time keys that secure controlled medications change from one nurse/medication aide to another, the oncoming and off-going nurse/medication aide will work together to reconcile all controlled medications, including all discontinued controlled medications and document the same. The nurse going off shift unlocks the controlled medication storage unit(s) and will then go to the narcotic count book and read each GSS #247 or Controlled Substance Bound Book page to the on-coming nurse. The on-coming nurse will verify that the physical medication count matches the remaining amount listed in the GSS #247 or Controlled Substance Bound Book for each medication. If the GSS #247 or Controlled Substance bound book and the physical controlled medication count are in agreement, both nurses will sign the Controlled Drugs-Count Record (GSS #247A for the appropriate date and shift. Controlled medications that have been discontinued should be placed in a locked box in the medication room as soon as they have been discontinued, or as indicated by state regulation. Controlled medications should continue to be counted by two nurses until disposal is completed. During observation and interview on [DATE], at 2:04 p.m. LPN-C stated that at the beginning and end of every shift, the off-going and on-going nurses would count the narcotics and then both nurses would initial the facility-controlled drugs count sheet indicating the counts were correct. LPN-C stated being told recently by the director of nursing (DON) to make sure the counts were completed, and the count sheets were signed every shift. LPN-C confirmed the sheets had many missing initials and it would be difficult to know whether the counts had been completed on those shifts. During interview on [DATE], at 2:56 p.m. DON confirmed the count sheets for the long-term care (LTC) medication carts were not complete and acknowledged stated that the expectation was that the counts should be completed, and the count sheets initialed by two nurses every shift. DON stated, I feel confident that they are counting they are just not consistently signing the sheet, but the sheet should be signed off. DON further stated there was no accountability if it was not signed off. DON stated that all the nurses were educated on this process on [DATE] and a knowledge quiz had been developed, but not provided to the nurses yet. During interview on [DATE], at 3:29 PM administrator stated the expectation was that medication carts should be locked if out of sight of the nurse. Review of LTC medication cart's Controlled Drugs-Count Records (GSS-#247A) dated November, 2022, indicated 43 missing nurse initials on one one cart and 58 missing nurse initials on another cart. Review of policy dated [DATE] Medications: Controlled-Rehab/Skilled to ensure safe storage for all controlled medications and to provide verification and reconciliation of all controlled medications. The policy further indicated the facility would establish a system that would provide an accurate reconciliation to determine that all controlled drugs were maintained and periodically reconciled. The policy instructed, each time the keys that secure controlled medications changed from one nurse or medication aide to another, the two would work together to reconcile all controlled medication. For all schedule II-controlled meds-the nurse going off shift unlocks the controlled medication storage unit(s) and will then go to the narcotic count book and read each GSS #247 or controlled substance bound book page to If the counts were correct, both staff would sign the controlled drugs-count sheet for the appropriate date and shift.