**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to comprehensively assess wounds including measurements weekly for 1 of 3 residents (R24) reviewed for pressure ulcers. Findings include: R24's facesheet printed 12/5/24, included diagnoses of severe dementia, difficulty in walking, and dysphagia (difficulty swallowing). R24's quarterly minimum data set (MDS), dated [DATE], identified R24 had severely impaired cognitive decision making skills, disorganized thinking and inattention constantly present. R24 required substantial to maximum assist with bed mobility and dependent on staff for wheelchair mobility. R24 did not have a pressure ulcer but was identified at risk of pressure ulcer development and had a pressure reducing device in wheelchair. R24's physician orders dated 10/15/24, included left heel wound: Cut to fit Aquacel Ag (sterile dressing to cover wounds that excrete fluids and includes antimicrobial) to the wound bed, cover with 4x4 Allevyn gentle border foam (water/bacteria-proof silicone adhesive dressing) and change every other day and as needed. R24's plan of care dated 9/12/24, included R24 has a potential for skin integrity impairment with goal indicating the skin will remain intact. Interventions included weekly skin assessment. Treat skin concerns per protocol as able. Update provider with issues or concerns. Monitor every 2 hours, turn and reposition schedule. The care plan did not include pressure reducing device for heels. During interview and observation on 12/2/24 at 3:25 p.m., R24 was sitting in her broda chair (provides comfort, support and mobility) with slippers on both feet. Prevalon boot (heel protector) was on the floor next to the television. The foot rest on left side of Broda chair was off and R24 had her left heel suspended with her foot resting on on her right foot. Family member (FM)-A stated she has had a heel ulcer for the last few months. FM-A stated he removes the prevalon boot because R24 likes to kick her feet around and he doesn't think it does any good even though staff tell me it does. FM-A added the wound is doing good now and healing but is still open. During observation and interview on 12/3/24 at 8:42 a.m., R24 was sitting in her chair in her room with FM-A present. Left foot rest on Broda chair remained off and R24 had her left foot resting on top of her right foot. R24 had slippers on both feet. Registered nurse (RN)-B entered room to complete wound care and observed FM-A remove old dressing. Scant serosanginous drainage was present on old dressing. FM-A stated the wound has always been dime size and it is even smaller now. RN-B measured wound at 7 x 9 millitimeters (mm) across and stated it is healing, no tunneling present or redness or signs of infection. RN-B when questioned about the wound type, and wound bed description stated I'm unsure what to call this wound at this time. RN-B indicated wound assessments and measurements are documented in the progress notes when done. RN-B was unsure how frequently this facility requires a comprehensive wound assessment to be done. R24's completed skin assessments included: 10/3/24: Generalized self-inflicted scratches. Otherwise skin intact 10/10/24: Light redness inner buttocks, skin tear right hand and fourth finger. No mention of heel issues A Wound Management Detail Report dated 10/14/24, by RN-A for R24 included unspecified left heel ulcer. Moderate amount of serosanguineous (clear thin liquid that oozes from wounds) drainage present with no tunneling. Tissue type is slough (dead tissue within the wound). Comments included newly discovered stage 3 (full thickness skin loss with damage to subcutaneous tissue) pressure ulcer to left heel with wound nurse assessment and recommendations for treatment. Podiatry appointment is scheduled for 10/24/24. A Podiatry Note dated 10/22/24, included R24 is being seen for pressure ulcer on the posterior, plantar lateral aspect of her left heel. History of this ulcer is not known. FM-A who is with R24 today stated she had some type of callused lesion over that area for quite some time however, there is no record of any open ulceration until 10/15/24. A padded heel boot was recommended to help offload pressure at the ulcer site. Silver alginate with an Allevyn dressing was applied and this has been changed frequently since then. The day after the wound care nurse visit, the patient's primary care provider thought there was some concern of infection at the wound and prescribed doxycycline (antibiotic) 100 mg twice a day for ten days. Assessment of wound included stage 2 (one that has progressed to affect both the top and bottom layers of the skin but not fatty tissue beneath) pressure ulcer measuring 0.5 x 0.4 cm which is an improvement from 1.0 x 0.8 cm when she was seen by wound care 1 week ago. The base of the ulcer is red and granular with about 2 mm of depth at the center tapering out to 1 mm and lesser on the edges. No active drainage or sign of infection at this time. There is no necrotic (dead) or devitalized tissue surrounding or over the wound. R24's wound evaluations from 10/25/24 to 12/4/24, included: 10/25/24: Scant serous drainage on bandage. Open area posterior 0.3 cm x 0.4 cm. Wound description not completed. 10/31/24: Pressure sore to left heel open to air. Pea sized open area, not red, calloused edges have softened. Depth 0.3 mm. Scant drainage, no edema. 11/7/24: Pressure ulcer related to left heel not changed this shift, not measured, or assessed. Has been charted as improving. 11/8/24: 0.5 cm x 0.5 cm light serous drainage, 50% epithelial tissue and 50% non granulation tissue. Wound is improving. 11/18/24: No drainage from left inner heel scabbed area, is size of a pea. 11/23/2024: Left inner heel has a pea sized red shiny area, scab appears to have sloughed off. Treatment was completed with no indicators of pain. No signs of infection. Receives Aquacell AG and mepilex border with gauze wrapping. 11/27/24: Heel is open now, red and clean, appears 0.3 cm deep 1cm circular - no drainage or odor. 12/1/24: Stage 2 pressure ulcer to left heel. Minimal serosanguinous drainage. Wound is 1 cm x 0.8 cm. Comments: Stage 2 pressure injury to left heel appears to be healing well with current treatment. No surrounding pink discoloration, redness or warmth. Scant amount of drainage present. The wound assessments lacked consistent weekly measurements and comprehensive wound assessments including but not limited to wound bed description, drainage, and wound edges. During interview on 12/4/24 at 7:43 a.m., RN-D indicated wound care including assessments of the wound are required to be completed weekly. RN-D stated we do a brief note with all dressing changes. During interview 12/4/24 at 10:12 a.m., RN-A, also identified as covering nurse manager, upon review of wound documentation, confirmed wound measurements and comprehensive wound assessments were not completed weekly but should have been. During interview 12/5/24 at 1:19 p.m., the administrator indicated weekly wound measurements and wound assessment including secretions, wound base, tissue at wound bed should be documented per policy and procedure. Facility Skin Care policy dated 7/2023, included: When a skin ulcer or other wound is identified, an assessment of that specific wound will be completed and documented in the electronic medical record (EMR) by the nurse . The assessment will include: measurements of the pressure ulcer, other wound or bruising, condition of wound bed, condition of surrounding tissue and any other signs and symptoms of infection. Weekly skin assessment of the area will be added to the medication administration record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and document review, the facility failed to complete a comprehensive, person-centered care plan, to promote fecal continence to the extent possible that is dignified, and per resident choice for 1 of 2 residents (R34) who were reviewed for bowel incontinence. Findings include: R34's minimum data set set (MDS) dated [DATE], indicated R34 had a Brief Interview for Mental Status (BIMS) score of 9, indicated moderate cognitive impairment. R34 required extensive assistance for mobility, transfers, and toileting. R34 had a diagnosis of diarrhea. R34 did not have an active bowel program to manage bowel continence. R34's care plan dated 10/9/2024 did not include bowel care interventions or a bowel management regimen. R34 required a two-wheeled walker, gait belt, and assist of one for transfers. R34's physician orders did not address bowel diagnosis and incontinence care and prevention. During observation on 12/2/24 1:57 p.m., R34 stated he has a full depends (disposable product used for incontinence), but nursing assistant (NA)-B is coming back to help him. R34 already had his light on. R34 stated he is uncomfortable, and stated he has crap in his depends. R34 yelled at surveyor go away cause if you can't change me then you are no help. Enhanced precaution at door (resident has catheter). No obvious smells in room. During observation on 12/02/24 2:03 p.m., R34 was yelling from his room sitting here with . [explicit language] in my pants, what are you going to do, everyone just walks out and leaves me . [female name] where are you? I need your help. Can you get me my walker? I need help. I want my walker to walk out. You aren't doing a . [explicit language] thing for me. Aren't you going to help me get clean? I have to have help. Gotta have help. Can you help me? R34 became angry, yelling can I have someone help me? During interview on 12/02/24 at 2:22 p.m., R34 stated he does not like sitting in own poop. He stated he would rather use the toilet, so he doesn't get stool all over himself. R34 stated he needs assistance getting to the toilet but once there, he could have a bowel movement without soiling himself. During interview on 12/03/24 at 10:25 a.m., NA-B stated she usually checks on R34 every 2 hours to see if his catheter needed emptying or if his brief was dirty. NA-B stated she does not offer the restroom periodically to prevent stool incontinence. NA-B stated R34 has a history of clostridium difficile (bacterial infection that can cause diarrhea and other intestinal conditions) and does have more episodes of stool incontinence than most other residents. NA-B stated R34 can be predictable; with his bowel movements mostly a short while after he eats. During interview on 12/3/24 at 01:24 p.m., registered nurse (RN)-C stated R34 should be checked for safety every hour and his catheter should be checked every two hours. RN-C stated the NA's will also check his brief for signs of a bowel movement. RN-C stated R34 was not offered periodic restroom visits to prevent stool incontinence. RN-C stated approximately 30 to 45 minutes after R34 eats, he will likely experience a fecal blow-out or large fecal incontinence episode. RN-C stated a resident with this predictable bowel pattern should have a bowel care plan or bowel management program. RN-C stated R34 did not have a current or previous bowel care plan or bowel management program. RN-C stated R34 she had not written or entered a care plan for R34 because the staff know R34's bowel pattern after eating so they assist him with cleaning after his incontinent bowel movements. RN-C acknowledged R34 should have a bowel care plan so staff know to assist R34 to the bathroom after lunch before he has a blowout. During interview on 12/5/24 at 9:43 a.m., administrator stated the current practice is to use the facility standing orders and check and change every two hours until resident orders or care plans are developed after admission. If a resident experiences a change in bowel habit, new orders and a care plan are completed. Administrator stated a resident with a predictable bowel pattern such as R34, should have a bowel care plan or bowel management plan to optimize fecal continence. Administrator verified R34 does not have an active or previous bowel care plan or bowel management program. Administrator verified the facility had a policy to assess and manage fecal incontinence. Facility Toileting and Incontinence Care Standard Work policy dated 11/18/19 stated if the resident is continent, assist with the use of the toilet per frequency indicated in their care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure side rails were comprehensively assessed to determine if they were appropriate and safe, discuss risks and benefits, and obtain informed consent prior to use of bed rails for 3 of 3 residents (R1, R27, R38), who were observed to have assist bars raised on their beds. This had the potential to affect all 48 residents who utilized an assist bar(s) for mobility. Findings include: R1's facesheet printed on 12/5/24, included diagnoses of spastic cerebral palsy and osteoarthritis. R1's annual Minimum Data Set (MDS) assessment dated [DATE], indicated moderately impaired cognition, clear speech, could understand and be understood. R1 was dependent upon staff for activities of daily living, including rolling from side to side in bed, transferring and toileting. R1 was not able to move from lying in bed to sitting on the edge of the bed. R1's care plan dated 4/12/23, indicated R1 required assistance of two staff and a Hoyer lift (mechanical lift device) for transfers. R1 used a manual wheelchair for mobility and did not walk. R1's care plan did not identify use of assist bars. R1's fall risk assessment dated [DATE], indicated R1 was a moderate fall risk. R1's electronic medical record lacked side rail assessment, documentation of informed consent and discussion of risks and benefits for use of bed rails. During an observation on 12/2/24 at 1:56 p.m., observed two cane shaped assist bars on R1's bed in the elevated position toward the top of R1's bed, near the location of her head/pillow as R1 laid in bed. R1 stated they had always been on her bed, and she had not had a problem with them. R27's facesheet printed on 12/5/24, included diagnoses of repeated falls and Parkinson's disease. R27's quarterly MDS dated [DATE], indicated moderately impaired cognition, could usually understand, and was understood. R27 was dependent on staff for most ADLs. R27 required substantial assistance to roll side to side in bed, and to move from lying in bed to sitting on the edge of the bed. R27's care plan dated 10/25/24, indicated R27 had falls related to cognitive impairment. Interventions included if tired, recommend doing pivot transfers to bed in the later evening. Care plan dated 11/15/24, indicated assist of two pivot transfer or EZ stand (mechanical assist device). Have R27 stand for a second to get bearings before taking a step. Remind him to push up using grab bars. A fall risk assessment dated [DATE], indicated R27 was a high fall risk. R27's electronic medical record lacked side rail assessment, documentation of informed consent and discussion of risks and benefits for use of bed rails. During an observation on 12/3/24 at 5:02 p.m., one assist bar on R27's bed was observed in the upright position on the side of the bed away from the wall. The assist bar was positioned toward the head of the bed and the C shape of the assist bar was facing the head of the bed. R38's facesheet printed on 12/5/24, included diagnoses of dementia, carpel tunnel syndrome (numbness and tingling in fingers), and back pain. R38's quarterly MDS dated [DATE], indicated severe cognitive impairment. R38 could be understood and could usually understand. R38 was independent with mobility and used a wheelchair. R38's care plan dated 10/11/24, indicated she was a fall risk related to dementia diagnosis. R38's care plan did not identify use of assist bars. A fall risk assessment dated [DATE], indicated R38 was a high fall risk. R38's electronic medical record lacked side rail assessment, documentation of informed consent and discussion of risks and benefits for use of bed rails. During an observation on 12/3/24 at 5:02 p.m., both assist bars on R38's bed were observed in the upright position on either side of the bed. The bars were positioned toward the head of the bed and the C shape of the assist bars were facing the head of the bed. During a telephone interview on 12/3/24 at 12:54 p.m., manufacturer technician support (TS)-F, was asked for a service manual for the Hill-Rom assist bars. TS-F stated there used to be instructions online, but they were no longer available. TS-F had a physical copy in his files and took screen shots of the installation directions for the assist bar and provided them via phone text. TS-F stated their products were designed and tested in the orientation documented to ensure proper patient and user safety. The illustration provided via text was titled: Installation Instructions - Side rail, Assist Bar and Headrail Upgrade Kits dated 10/20/09. The instructions on page 175 indicated: point the cane (A) on the assist bar assembly (B) toward the foot end of the bed (see figure 1 on page 176). The figure on page 176 illustrated the assist bar positioned at the lower half of the bed frame, and the C of the assist bar facing the foot of the bed. The assist devices at the facility were installed on the beds in the opposite location and direction -- toward the head of the bed and the C facing the head of the bed. During an observation on 12/3/24 at 5:02 p.m., 48 of 57 residents had either one or two assist bars in the elevated position on their beds. The assist bars were installed closer to the head of the bed, at the level of the resident's pillow/head, and the C shape of the assist bars were facing the head of the beds rather than the foot of the bed. A Hill-Rom brochure received via email from manufacturer representative (MR)-D on 12/4/2024 at 1:06 p.m., for the Resident® LTC Bed, dated 2015, indicated the bed was designed specifically for long-term care. Options were available including an optional assist bar. A picture on page two of the brochure showed side rails on either side of the bed toward the top end, and assist bars on either side of the bed toward the lower end. The assist bars were C shaped resembling a walking cane. The C was facing the foot of the bed in the picture. During a telephone interview on 12/4/24 at 11:27 a.m., MF-D was asked questions about installation of the assist bars, including the proper location and direction, and who installed them when purchased in 2017. MR-D stated he would check and call back. In addition, a photo of the assist bars on R118's bed was emailed to MR-D to illustrate current position and direction of assist bars at the facility. In an email dated 12/4/24 at 1:06 p.m., MR-D wrote: as you can see, the brochure (page 2) shows the assist bar pointing toward the foot of the bed. Also, on the cover page, you can see how they also fold down out of the way toward the foot section of the bed. I am able to confirm that an order was placed for 106 assist bars back in early June of 2017. That said, I cannot confirm if someone at the site or someone on the Hill-Rom team installed them. During an interview on 12/5/24 at 9:48 a.m., registered nurse (RN)-C, who was also a nurse manager, stated the facility did not conduct siderail assessments on residents who used a grab bar (assist bar), as they were not considered a siderail. RN-C stated residents were asked upon admission if they wanted to utilize a grab bar, but their preference was not documented. RN-C stated the facility did not do a safety risk assessment, address risk/benefits, obtain a consent, or add grab bars to the care plan because grab bars were not considered a side rail. In an email dated 12/5/24 at 11:56 a.m., MR-D wrote: in speaking internally, we do not recommend removing the upper side rails of the bed, and per our documentation, we only recommend the assist bars be used at the foot section of the bed as seen in the image in the brochure. (To clarify, the purchase proposal to the facility from Hill-Rom dated 5/19/17, included beds, assist bars and pendant controls - no side rails). During a telephone interview on 12/5/24 at 12:08 p.m., MR-D was asked if the assist bars were installed correctly based upon a photo emailed to him earlier (specifically the assist bars being positioned closer to the head of bed and C facing the head of the bed). MR-D stated it was not how we (Hill-Rom) built it or tested the bed but could not comment if the current configuration posed a safety risk to residents. MR-D stated it was the facility's bed and they could do what they wanted. MR-D stated the bed and assist bar purchase and installation was so long ago, he was not able to determine how the beds would have arrived at the facility -- with the assist bars attached, and/or if Hill-Rom personnel would have installed the assist bars on new and/or existing beds. On 12/5/24 at 1:14 p.m., the administrator was sent via email, the assist bar installation sketches received from TS-F on 12/3/24 at 1:10 p.m. which indicated the installation instruction illustrations came from a Hill-Rom document titled Installation Instructions - Siderail, Assist Bar and Headrail Upgrade Kits dated 10/20/09. The instructions on page 175 indicated: point the cane (A) on the assist bar assembly (B) toward the foot end of the bed (see figure 1 on page 176). The figure on page 176 illustrates the assist bar positioned at the lower half of the bed frame, and the C of the assist bar toward the foot of the bed. During an interview on 12/5/24 at 11:08 a.m., the administrator stated if a resident requested a grab bar, it would be added to the bed. The administrator stated she realized that a grab bar was considered a siderail and therefore the resident should be assessed for safety, risks and benefits, according to their policy. Facility policy Side Rail Use dated 1/2023, indicated typically, side rails were not used, however, if needed residents would be assessed for use on admission, prior to, or with any significant change. Before initiating use of any side rail, an assessment would be completed including consent form and discussion of risks and benefits. Risks and benefits were discussed, and the consent form given to the resident or the decision maker of the cognitively impaired resident, that has been individually assessed by a licensed nurse whose assessment determines side rails as beneficial for the resident's use and are not classified as a restraint. admission side rail assessment documentation was to include the side rail length; number of rails; which side of the bed the railing is to be up on; reason for being up; and any other comments that pertain to side rail use. The admission assessments were documented in electronic record (EMR) under the appropriate category pertaining to the intended use of the side rail. Ongoing documentation for side rail use was done in the EMR and should include the same information as the initial admission assessment. The care plan should reflect the use of side rails and their purpose to the resident.

During interview and observation on 12/03/2024 at 11:30 a.m., food service worker (FSW)-D did not follow proper procedure when sanitizing the dietary thermometer in between temping foods for the residents in the main dining room on the first floor of the facility. FSW-D was observed not to use a alcohol wipe on the thermometer when cleaning it in between checking food temps. FSW-D was observed using a sanitizer bucket full of QUAT (quaternary ammonium - a chemical sanitizer). This sanitizer is food safe, however the thermometer was not wiped with alcohol after the use of the quat sanitizer. During observation on 12/04/2024 at 12:26 p.m., on the second floor dining room FSW-B was checking temps of food that would later be returned to the kitchen and possibly used for other meals. FSW-B was observed taking the thermometer out of a sanitizer bucket and then took the thermometer and rubbed the thermometer on the bottom of pants to help dry off the thermometer and then temped the gravy behind the steamer. During interview on 12/4/2024 at 12:32 p.m., FSW-B was asked about the process for temping foods and the steps for cleaning the thermometer to temp the food prior to returning it back to the kitchen for later use. FSW-B stated when they are done with the lunch meal they verify which foods will be returning to the kitchen or maybe kept for further use. FSW-B explained the process for temping the foods and the use of the thermometer in the following steps 1) clean the sanitizer in either a red bucket that is next to the food on the counter or 2) use the sterilizer container each time. When specifically asked about the cleaning of the thermometer, FSW-B stated that the red bucket that was used was the same as the small container of QUAT and can be used to sanitize all surfaces and items that need to be properly cleaned to prevent food born illness. This container looked like a small salt and pepper shaker and was used on both of the dining rooms observations. The tip of the thermometer was submerged in the sanitizer container prior to temping the foods During the interview, FSW-B was aware that the thermometer was wiped on his pants and explained it was an accident. When asked, FSW-B explained that the rationale, stated because the food was not going to all be used so perhaps it was out of instinct. FSW-B verified that the normal process was to either use the red bucket full of sanitizer or the small container of QUAT. FSW-B stated they temp the food prior to sending what is left back to the kitchen for further use. During an interview on 12/4/2024 at 1:22 p.m., Director of Environment & Risk Management Services (DERM)-B verified that they have a specific process for cleaning the thermometer after each time for temping the foods. While at Kitchenette #2 on the second floor verification of the difference between the red bucket of sanitizer and the small container of sanitizer. DERM-B stated that there is the same sanitizer in the red bucket as the small container of QUAT. When asked about the process for cleaning the thermometer DERM-B explained the process for temping foods was to place it in the small QUAT container and then wipe it down with an alcohol wipe prior to temping foods and in between. The DERM-B explained that the sanitizer in the bucket was the same as the small red container however this was to be used when cleaning down the area behind the steamer and not the thermometer during temping foods. During an interview on 12/4/24 at 2:48 p.m., DERM-B reiterated the following: -- Hair nets: hair must be secure/covered for anyone behind steam table. When staff report to work, everyone goes to kitchen first to wash hands and put on hairnet. DERM-B stated there was not a mirror in this area for staff to visibly determine if their hair was fully covered. --Hand hygiene and glove use: DERM-B stated it was the expectation that dietary staff wore gloves when working the steam table and dishing up food, adding they had been doing that for 20 years and believed it to be best practice. DERM-B stated it was the expectation staff stayed behind steam table and if they went outside of it, to remove gloves and wash hands. --DERM-B stated it was FSW-B fifth day on the job. Day one of orientation included organization-wide training, day two included handbook, expectations, and safe food handling videos, then partnering with staff for four to six shifts and with a manager observing during meal service. Due to survey observations, DERM-B stated FSW-B had been removed from the schedule for additional training. --Regarding FSW-A holding chicken tenders with contaminated gloves, DERM-B stated that was unacceptable. --Regarding disinfecting the food thermometer probe, DERM-B stated staff were supposed to wipe the probe with an alcohol wipe to remove debris between temping foods. When not in use, DERM-B stated the thermometer probe could rest in the QUAT solution. DERM-B was unaware staff were not wiping the probe with an alcohol wipe. --Regarding pureed shrimp temping at only 114 degrees and FSW-B not taking action on his own, DERM-B stated that was something FSW-B should have known and that there were appropriate temperature references in the food temperature log. DERM-B provided a documented titled Hazard Analysis Critical Control Point Food Safety System, dated 2019. In an email dated 12/5/24, DERM-B indicated the document was not used for training or orientation, however the topics covered in the plan were in the Safe Food Handler training videos that new employees watched on the second day of employment and before they did any food service in the department. The document included the following: --Hair restraints (hairnets, hats, or caps) must cover the hair sufficiently to prevent hair from falling onto food or food equipment and to minimize hand contact with hair. --Disposable gloves must be used when handling ready-to-eat foods (foods that require no further processing and cooking/heating). Gloves must be changed before starting another job and when they are torn, dirty or contaminated. Hands must be washed before putting on gloves. --Thermometer stems must be washed, rinsed, and sanitized. Three sanitizing methods were approved: Sanitizing solution with immersion time of one minute. Hot water method (185 F or above) immersion time of three seconds, or alcohol swabs (antibacterial probe wipes containing 70% isopropyl alcohol). FSW-A's training checklist titled Food and Nutrition Services New Hire Checklist indicated FSW-A completed Food Handler Training Videos, parts 1-5 on 6/13/23, and FSW-B the same on 11/26/24. During an interview on 12/5/24 at 1:22 p.m., the administrator who had been informed of dietary findings by DERM-B, stated she expected staff to be fully trained and follow food service policies. Based on interview, observation, and document review the facility failed to ensure proper food safety practices when food service workers (FSW-A and FSW-B) were observed not having hair secured, not properly disinfecting food thermometer, not recognizing need to reheat food when needed, and touching food with contaminated gloves. This practice had the potential to affect all 65 residents who received meals from 2 of 2 dining rooms observed. Findings include: During an observation and interview on 12/2/24 at 5:04 p.m., in the second-floor dining room, observed FSW-A standing behind the steam table preparing to plate food for the evening meal. FSW-A's hair which was long and curly, had not been fully secured in his hairnet -- all hair below the level of his ears was outside of the hairnet. FSW-A was asked not to proceed and to secure his hair. FSW-A stated he would try and left the dining room. FSW-A returned a few minutes later and his hair was still not fully secure. He tucked the rest of his hair into the hairnet, washed his hands and donned gloves. During an observation on 12/2/24 5:10 p.m., FSW-A touched his face with gloved hand, and opened the door to the thermal plate base warmer to remove more thermal bases. At 5:15 p.m., FSW-A handled French fries and chicken tenders with his contaminated gloved hands as he plated food for residents. FSW-A then handled multiple resident meal slips, opened, and closed equipment doors, and pushed up his eye glasses. At no time did FSW-A remove his gloves, wash his hands and re-glove. FSW-A stated he had been doing this job for over a year. At 5:20 p.m., FSW-A was observed cutting chicken tenders with a knife while holding the chicken with his contaminated gloved hand. FSW-A continued to handle meal slips, a pen, and rested both hands on the counter of steam table. At 5:28 p.m., FSW-A was again cutting chicken tenders while holding the chicken with his contaminated gloved hand. During this observation, he also latched a thermal cart, wrote on paper with a pen, and handled the food thermometer. At no time did FSW-A remove his gloves, wash his hands and re-glove. FSW-A was observed setting a food thermometer with the probe open and with visible food debris, on top of the steam table ledge. At 5:33 p.m., FSW-A wiped the thermometer probe with a paper towel and handed it to FSW-C who temped fruit with it. During an interview on 12/2/24 at 5:36 p.m., director of environment & risk management (DERM)-B with oversight over food and nutrition services, was in the dining room and was informed of observations. DERM-B stated food service workers were expected to have their hair fully covered in a hairnet when serving food. Further, DERM-B stated FSW were trained to wear gloves during meal services and were expected to remove gloves, wash hands and re-glove as they moved between tasks and before handling food. In addition, DERM-B stated staff were to place the probe of the food thermometer in a solution of food-safe QUAT (quaternary ammonium - a chemical sanitizer) to disinfect it between temping food. . During an observation on 12/3/24 at 11:46 a.m., in the second-floor dining room, FSW-B stated he had been in his role for a week. FSW-B was standing behind the steam table waiting to plate food for residents and was observed wearing gloves. While waiting, FSW-B was observed talking on the phone, opening and closing the refrigerator, cupboard and cart doors, handling resident meal slips, putting on and taking off his eye glasses that were strapped around his neck, bending over and putting his gloved hands on his knees while looking at meal slips on the lower shelf of a cart. At 11:51 a.m., FSW-B temped pureed shrimp on the steam table and verbalized the temperature was 114 degrees F (Fahrenheit). When FSW-B did not take action, he was asked if that temperature was warm enough and he replied, yes. An unidentified dietary worker standing nearby said, no and she re-temped it, obtaining 116 degrees. The pureed shrimp was taken back to the kitchen. FSW-B stated the shrimp should have been 140 degrees or greater. At 11:55 a.m., a coworker whispered to FSW-B to put on new gloves, which he did, but did not wash his hands first. Again, FSW-B put on and took off his eye glasses multiple times, plated food, handled utensils, and filled cups with water from a dispenser. At 11:58 a.m., FSW-B removed and put on new gloves without washing his hands. At 12:03 p.m., FSW-B continued to plate food and continued to put on and take off his eye glasses, bend over and place hands on knees, and open and close the warmer. During an interview on 12/3/24 at 12:17 p.m., food & nutrition manager (FNM)-C who was in the dining room, stated new food service workers were trained for six shifts before they were on their own. It was the expectation workers wore gloves during meal services and to change gloves and wash hands before handling food directly. FNM-C also observed FSW-B touch face and eye glasses, then touch edges of a grilled cheese sandwich several times. FNM-C did not intervene.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure enhanced barrier precautions (EBP) were implemented for 3 of 3 residents (R27,R24,R58) reviewed for wounds, and proper donning and doffing of personal protective equipment (PPE) was completed per standard guidelines for 2 of 3 residents (R20,R27). Findings include: R20's facesheet printed on 12/5/24, included diagnosis of chronic foot ulcer. R20's quarterly MDS assessment dated [DATE], indicated R20 was cognitively intact; was usually understood and could understand. R20 was dependent on staff for most activities of daily living (ADL), and had a stage 2 pressure ulcer on her foot. R20's care plan dated 10/4/24, indicated impaired skin integrity related to left foot pressure ulcer and enhanced barrier precautions were in place. During an observation on 12/2/24 at 2:38 p.m., in hallways on the north and south units on second floor, PPE carts and doffing receptacles (metal stands with blue garbage bags) were observed lining the hallways outside multiple resident rooms. On the doorframe of these rooms were laminated signs indicating the residents were in EBP. The signs did not provide guidance as to where staff should doff - inside or outside of the resident's room. During an observation on 12/3/24 at 9:44 a.m., outside R20's room was a three shelf PPE cart, doffing receptacle and a CDC (Center for Disease Control) sign on the door frame indicating R20 was in EBP. Observed nursing assistant (NA)-A don PPE consisting of gloves and a yellow reusable gown and entered R20's room. During an observation on 12/3/24 at 10:04 am, NA-A exited R20's room, removed PPE and placed it in the doffing receptacle. NA-A stated sometimes the doffing receptacle was located inside the resident's room, and sometimes it was outside the resident's room. NA-A thought staff were supposed to doff inside the resident's room, but since the receptacle was on the outside of the room, that's where she doffed. During an observation on 12/4/24 at 7:26 a.m., doffing receptacles were still outside resident rooms on the north and south units on second floor. An undated documented titled Enhanced Barrier Precautions in Nursing Homes Algorithm located on a bulletin board on second floor identified for staff training, indicated: position trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room, or before providing care for another resident in the same room. R27's facesheet, printed 12/5/24, included diagnoses of Parkinson's disease (movement disorder), chronic myeloid leukemia (blood cancer that starts in the blood forming cells of the bone marrow), and gastrostomy status (external opening into the stomach). R27's quarterly minimum data set (MDS) assessment dated [DATE], identified R27 had moderately impaired cognition and received tube feedings for more than 50% of nutritional needs. On observation 12/3/24 11:35 a.m., R27 had a sign outside of his room indicating enhanced barrier precautions (EBP) and to gown and glove to provide cares. Upon entry into the room, registered nurse (RN)-B was present in R27's room and was flushing R27's gastric tube (GT). RN-B did not have a gown on but was wearing gloves. RN-B upon exit of the room indicated she is not aware of the exact procedure at facility but was aware of the sign on the door for enhanced barrier protection for R27. RN-B stated I wore gloves and that is what I did. A linen hamper for nondisposable gowns was located outside of R27's room. On observation and interview 2/3/24 11:38 a.m., nursing assistant (NA)-C and NA-D gowned and gloved and assisted R27 from his recliner to his wheelchair. NA-C and NA-D took R27 in his wheelchair to the doorway and removed gloves and disposed in trash in the room. NA-C and NA-D exited the room and took off non-disposable gowns and discarded in the laundry hamper outside of R27's room. NA-C stated she is not sure why the laundry hamper was outside of the door, but since it was, they wore the gowns into the hallway to discard them. R24's facesheet printed 12/5/24, included diagnoses of severe dementia, difficulty in walking, and dysphagia (difficulty swallowing). R24's quarterly MDS assessment dated [DATE], identified R24 had severely impaired cognitive decision making skills, disorganized thinking and inattention constantly present. R24 required substantial to maximum assist with bed mobility and is dependent on staff for wheelchair mobility. R24 did not have a pressure ulcer but was identified at risk of pressure ulcer development. On observation and interview 12/3/24 at 8:42 a.m., no sign was present on R24's door indicating EBP. R24's family member (FM)-A indicated R24 has had a pressure ulcer on the heel of her foot for the past few months. A Wound management Detail Report dated 10/14/24, by RN-A included unspecified left heel ulcer. Comments included newly discovered Stage 3 pressure ulcer (pressure causes a wound into the skin's fatty layer) to left heel with wound nurse assessment and recommendations for treatment. On observation and interview 12/3/24 8:42 a.m., RN-B did not gown, but gloved and completed wound care on R24's left heel. Wound measurements included 7 millimeter (mm) x 9 mm open area. RN-B indicated she is not sure what to call the wound at this time but it is still open but healing. R24's room did not have an EBP sign at the door or PPE present. R58's facesheet printed 12/4/24, included diagnoses of heart failure, dementia, and lupus erythematosus (audtoimmune system attacks the body's tissues and cells). R58's readmission MDS assessment dated [DATE], included moderately impaired cognition with delirium symptoms of inattention and disorganized thinking that fluctuates. R58 has 2 unstageable pressure ulcers (wound bed covered with slough/eschar {dead tissue}and can't be properly staged) present at the time of reentry. On observation 12/2/24 at 5:49 p.m., R58 was asleep in his bed. There was no sign present for EBP outside of the room or PPE equipment present. On observation and interview 12/4/24 at 1:22 p.m., R58 was asleep in his bed. No EBP sign was present outside of R58's room and no PPE present. RN-E completed wound care on both R58's heels wearing gloves but no gown. RN-E identified both wounds as pressure ulcers and open wounds but was unsure what stage they were presently. On interview 12/4/24 at 11:46 a.m., RN-A, also identified as infection preventionist, indicated doffing (removal of PPE) should occur in the residents room prior to exiting. RN-A indicated she was not aware the disposal hampers were outside of the rooms and stated they should be inside of the room by the door. RN-A stated she is unsure how contracted staff are trained on the facilities infection prevention policies, but would assume they are trained on EBP and hand hygiene prior to working at the facility. RN-A indicated R58 is on EBP precautions due to pressure ulcers, but upon arrival at R58's room indicated there was no sign or indication he was on EBP. RN-A indicated she is not sure what happened and why the EBP sign and equipment was removed from his room. RN-A confirmed R58 and R24 should both be on EBP due to open wound pressure ulcers. RN-A indicated EBP should be used for any wound stage 2 (one that has progressed to affect both the top and bottom layers of the skin) or higher. During interview on 12/5/24 at 1:19 p.m., the administrator, confirmed staff should doff PPE prior to exiting the room, before reaching the hallway. The administrator also confirmed anyone with an open wound should be in EBP precautions. Facility training slide deck titled Infection Control dated 8/7/24, and which according to RN-A was used for staff training, indicated PPE would be doffed before exiting the resident's room. Facility Infection Control policy dated 4/2024, indicated: A. A sign that indicates the type of precautions required will be placed outside each infectious room. B. Clean PPE needs to be applied when entering. C. Dirty PPE needs to be removed and discarded prior to exiting the room. D. PPE DON/DOFF instructions will be placed outside and inside each isolation room. E. Random audits of PPE use and placement will be conducted by the Infection Control Nurse or designee. A summary of these audits will be included in the monthly Infection Control review. Facility Infection Control policy dated 4/2024, included Multi-drug resistant organisms (MDRO) may require enhanced barrier precautions to align with nationally accepted standards. EBP's (generally gown and gloves) are recommended for certain residents during specific high-contact/high -risk activities conditions associated with MDRO transmission: Residents with indwelling medical devices regardless of colonization or infection (urinary catheter's, intravenous lines, feeding tube); Residents with open wound (does not include short lasting wounds such as small skin tears requiring a simple dressing such as a band-aid) ; High risk activities include device care or use, and wound care with any skin opening requiring a dressing. A. A sign that indicates the type of precautions required will be placed outside each infectious room. B. Clean PPE needs to be applied when entering. C. Dirty PPE needs to be removed and discarded prior to exiting the room. D. PPE DON/DOFF instructions will be placed outside and inside each isolation room. E. Random audits of PPE use and placement will be conducted by the Infection Control Nurse or designee. A summary of these audits will be included in the monthly Infection Control review.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure proper hand hygiene and glove use practices were maintained for 1 of 1 resident (R1) observed during peri care and full body lift transfer. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1's diagnoses included non-traumatic brain dysfunction including dementia. MDS identified R1 was usually understood and usually able to understand others. However, the cognitive patterns indicated R1 was rarely or never understood and had severe cognitive impairment with fluctuating behaviors present. In addition, R1's MDS identified R1 was dependent on staff for all activities of daily living (ADL)'s. R1's care plan revised on 1/31/24, indicated R1 needed assist of 2 staff with toileting using a full body lift due to safety concerns with the use of the standing lift. Staff to provide peri hygiene and apply barrier cream with cares. During an observation on 3/7/24 at 12:59 p.m., nursing assistant (NA)-A and NA-B entered R1's room. Both NA-A and NA-B did not wash or sanitize hands upon entering the room, grabbed gloves, and put them on after pulling the full body lift into the room. NA-A and NA-B put transfer sling around R1 and transferred R1 from the Broda wheelchair to the commode. NA-A removed the soiled brief from between R1's legs while she was on the commode and pulled the commode into the middle of the room. NA-B began using wipes and removing bowel movement from R1's bottom when R1 began to void on the floor. NA-B then removed her soiled gloves and put on new gloves without sanitizing or washing hands and pushed the commode with R1 back over the toilet in the bathroom. NA-A then grabbed some towels and cleaned the floor and continued to use the same gloves throughout cares, including putting a new brief on R1, transferring her back to her wheelchair from the commode, removing the transfer sling and brushing R1's hair. NA-A then removed her gloves and disposed of them in the trash before NA-B took the trash out of the bin, put in a new bag, removed her gloves and put them in the old bag and spun and knotted the old bag setting it aside by the door. During interview on 3/07/24, at 1:15 p.m., NA-A stated she should have washed or sanitized her hands when entering and or leaving a resident's room. NA-A stated she should have sanitized or washed her hands during cares or whenever she encountered any bodily fluids. NA-A verified she had not appropriately sanitized or washed hands during R1's cares but was unable to articulate why she hadn't. During an interview on 3/07/2024, at 1:16 p.m., NA-B stated she should have washed or sanitized her hands when she entered and exited R1's room and after changing her gloves. NA-B identified she had not washed or sanitized her hands when she had changed her gloves in the room and stated she just hadn't thought about it. During an interview on 3/12/24 at 1:59 p.m., the director of nursing (DON) stated it was an expectation staff should wash or sanitize hands when entering and exiting residents' rooms and each time they moved from a dirty area to a clean area. DON further stated staff were expected to perform hand hygiene with each glove change. The DON expressed all staff are expected to follow facility policy when it came to hand hygiene and infection control. The policy Hand Hygiene updated 9/2023, indicated good hand hygiene technique should be used to prevent the spread of infection. Several types of cleaning agents are available including surgical scrub preparations, antiseptic lotion soaps and alcohol-based sanitizers. Adequate hand hygiene facilities are available throughout the facility. Hand hygiene should occur: -Before and after a work shift. -Before and after eating, drinking, or handling food. -After using the toilet; after hand contact with mouth and nasal secretions (cough, sneezes, ect.). -Before and after significant contact with any resident. -Before and after preforming invasive procedures. Although gloves are worn for certain procedures, hand hygiene before donning gloves and after removal is necessary because of the possibility of tears or holes in the gloves. -Between care activities on the same resident involving different body sites (i.e. care of foley/IV/wound/trach). -After contact with wounds or mucous membranes, or items such as dressings, bed pans, collecting devices with may be contaminated with secretions, excretions, or blood. -When there is doubt about the possibility of hand contamination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to keep remote to chair within reach for 1 of 1 residents (R31) reviewed for possible restraint. Findings include: R31's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R31 had severely impaired cognition and required moderate staff assistance to transfer and walk, extensive assistance to stand, and was dependent on staff for personal hygiene. The MDS indicated a bed alarm was used for R31's care. R31's Face Sheet dated 10/24/22, indicated R31 was diagnosed with Alzheimer's disease, arthritis, and osteoporosis (a condition causing weak, brittle bones that are much more likely to break). R31's care plan dated 4/12/23, indicated R31 had a risk for falls, and to intervene, staff should ensure R31's recliner remote was not tucked into the recliner seat but left on the side of the chair. During an observation on 10/24/23 at 12:46 p.m., R31 sat in the recliner on the right side of her room with the leg rest in the extended (elevated) position. The cord for the recliner remote was observed in the pocket on the side of the recliner. During an observation on 10/24/23 at 3:29 p.m., R31 was observed lying in her recliner with the leg rest in the extended position, yelling out, Help, help, pretty please, help! No staff were observed to answer R31's calls. R31's recliner remote was observed inside the right pocket of the recliner. During observation and interview on 10/25/23 at 10:51 a.m., R31 sat in the recliner with the leg rest in the extended position. A trash can was observed immediately to the right of the recliner with the remote control panel hanging over the far side of the trash can. Registered nurse (RN)-E entered R31's room and asked R31 if she was able to reach the recliner remote. R31 leaned over the right arm rest but could not reach the remote. RN-E stated R31 was unable to reach the remote, but she was unsure if R31 was allowed to have it within reach. During observation on 10/25/23 at 10:55 a.m., trained medical assistant (TMA)-B was observed entering R31's room. R31 remained in recliner, leg rest in extended position with recliner remote placed on far side of trash can. TMA-B observed talking with R31 and then leaving the room while the recliner remote remained on the far side of the trash can. During an interview on 10/25/23 at 10:57 a.m., RN-E stated she would move the recliner remote within reach of the patient because she was concerned the recliner would act as a restraint or increase R31's fall risk. During observation and interview on 10/25/23 at 12:40 p.m., R31 sat in the recliner with the leg rest in the extended position. A pillow was observed over both the recliner's right arm rest and extending some of the trash can. The recliner remote was observed halfway down the inside of the trash can. TMA-A entered R31's room, observed the recliner remote in the trash can, and stated R31's recliner remote was out of R31's reach because she was not allowed to have it. TMA-A stated that staff do not give the recliner remote to R31 because she has fallen after putting the leg rest down in the past. During an interview on 10/26/23 at 10:28 a.m., the director of nursing (DON) stated R31 was able to use the recliner remote, and she would expect it to be within her reach. The DON stated she would be concerned that R31's movement would be restricted if the recliner remote was out of her reach. The DON stated they did not have a specific assessment for recliner use and only did an assessment if an issue was noted. The facility Restraints policy dated 11/22, indicated that when staff assisted a resident into a chair they could not get out of, it was considered a restraint. The policy indicated a restraint, such as a chair, should not be used to limit a resident's movement for the convenience of staff. If a physical restraint is used for a resident with behaviors that are threatening their own well being, it must be used with a treatment procedure designed to modify that behavioral problem. The policy indicated that if a physical restraint was used, documentation must be completed demonstrating behaviors occurring and interventions that failed prior to restraints being implemented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and document review, the facility failed to complete a significant change in status assessment (SCSA) Minimum Data Set (MDS) within fourteen (14) days after the facility determined, or should have determined, that there had been a significant change in the resident's physical or mental condition for 2 of 2 residents (R15 and R20). Findings include: The Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.18.11 dated October 2023, Chapter 2, page 2-25, indicated a significant change in status assessment (SCSA) is required to be performed when a resident is receiving hospice services and then decides to discontinue those services (known as revoking of hospice care. The current RAI manual indicates on page 2-26: The MDS completion date must be no later than 14 days from the assessment reference date (ARD) (ARD + 14 calendar days) and no later than 14 days after the determination that the criteria for an SCSA were met. This date may be earlier than or the same as the CAA(s) completion date, but not later than. The CAA(s) completion date must be no later than 14 days after the ARD (ARD + 14 calendar days) and no later than 14 days after the determination that the criteria for an SCSA were met. This date may be the same as the MDS completion date, but not earlier than MDS completion. The care plan completion date must be no later than 7 calendar days after the CAA(s) completion date (CAA(s) completion date + 7 calendar days). R15's quarterly MDS dated [DATE], indicated R15 had diagnoses of non-traumatic brain dysfunction, hypertension (high blood pressure), dementia, anxiety disorder, depression, visual hallucinations (seeing items that are not visible to others), chronic pain, and edema (swelling). A MDS significant change of status assessment (SCSA) had been started for R15 with an ARD date of 10/19/2023. A progress note dated 10/4/23 at 11:37 a.m., stated that resident was discharging from hospice services on 10/6/23 as patient no longer considered terminal. On 10/2/23, an event report note generated from provider visit indicated discussion of discharging R15 from hospice services as R15 remains stable. During interview with RN-B, on 10/24/23, at 3:26 p.m., verified they assist with completion of MDS for the campus indicated that a significant change in status assessment (SCSA) would be completed if a resident is not responding to treatment or coming on and off hospice. They verified R15 had discharged from hospice services on 10/6/23. They indicated the ARD [assessment reference date] is set within 14 days after identifying the significant change. They have 14 days to complete the MDS/care plan from the ARD. They indicated that the ARD was chosen for R15 as 10/19/23 as discharge from hospice was 10/6/23. They indicated this would be within the 14-day window and must have a 7 day look back period. They indicated that you have 14 days to complete the MDS from the ARD date. MDS completion date would be 14 days from 10/19/23 [ARD date]. Reviewed the RAI OBRA - required Assessment Summary which they acknowledged and indicated this is how we have always done it. During interview with RN-B on 10/24/23, at 4:06 p.m., indicated after review of RAI assessment tool that if you look at it that way, it makes sense. During interview with RN-C on 10/25/23, at 8:20 a.m., verified they complete MDS' for the campus indicated that they interpreted the rules differently regarding the ARD date. They indicated the concerns with not having MDS done according to timeframe given it would affect payment, the residents care plans would not be up to date which could affect care. RN-C acknowledged that the significant change in status assessment for R15 had not been completed in the timeframe required. During interview with administrator on 10/26/23, at 2:01 p.m., indicated that R15 should have had a SCSA completed. She indicated a SCSA should have been completed for R15 in the timeframe allotted as this can have an impact on the resident and payment. R20 R20's quarterly MDS dated [DATE], indicated R20 required setup or cleanup assistance for eating and oral hygiene, and was dependent for all other activities of daily living (ADLs). R20's diagnoses included multiple sclerosis (MS), heart disease, high blood pressure, anxiety, insomnia, and congestive heart failure (CHF, causing fluid in the lungs and body, and shortness of breath). R20's quarterly MDS dated [DATE], indicated R20 had intact cognition and was dependent for all ADLs. R20's care plan dated 9/20/23, indicated R20 had an indwelling urinary catheter. Interventions included encouraging fluids. R20 was also on a functional maintenance program to maintain joint mobility. Interventions included assisting R20 with stretches. R20 was also at risk for nutritional status with a goal to consume adequate fluids. Interventions included serving food in bowls and fluids in covered mugs. The care plan also indicated R20 had a self-care deficit related to impaired mobility. Goals included to maintain her current level of participation related to washing her face. Interventions included the use of an adaptive touch call light due to increased difficulty with a standard call light. The care plan further indicated R20 required only setup for grooming/oral hygiene and eating. R20's progress notes indicated the following: -8/8/23, indicated R20 had continued worsening of hand dexterity and difficulty feeding herself. Although a referral was made to occupational therapy (OT), R20 refused to be seen by OT, but was agreeable to meeting with dietary services regarding the use of adaptive devices. -8/9/23, indicated after meeting with registered dietician (RD)-B, R20 will have food served in bowls, sausage and gravy in a bigger bowl, covered mugs with straws for hot liquids and mugs for soup. -10/13/23, provider note indicated We have noticed some worsening of R20's physical mobility, more specifically her hand dexterity. Her fluid intake has decreased due to her hand dexterity and she is requiring more assistance from nursing with feeding. -10/13/23, R20 noted to be hollering and reported she was unable to press her call light. A touch pad call light was provided and R20 was able to activate. Staff were to continue to monitor R20 due to poor hand dexterity. During an interview on 10/24/23 at 10:01 a.m., R20 stated she noticed a decrease in her hand mobility approximately six weeks prior and believed it was due to the progression of her MS. R20 stated she was also a big water drinker but was now unable to drink by herself and had to call staff to assist her. During an interview on 10/25/23 at 11:42 a.m., RD-B stated R20 was having difficulty moving her arms and was becoming more limited with what she was able to do so registered nurse (RN)-A, the nurse manager, asked RD-B to assess her. During an interview on 10/26/23 at 8:06 a.m., RN-A stated R20's hand mobility had been decreasing over the previous few months and had been requesting more help with eating, so RN-A referred R20 to RD-B. RN-A also stated she recently switched R20's call light to a touch pad because she was having trouble activating the button. During an interview on 10/26/23 at 10:51 a.m., MDS RN-C stated she was aware R20's hand mobility had declined, causing her to require assistance with eating and other related tasks, however; she thought R20 was receiving occupational therapy to address the concern and therefore did not complete a significant change assessment for her. RN-C stated had she known R20 had refused occupational therapy she probably should have done one. RN-C also stated she was unsure of the cause of R20's decline in mobility but assumed is was related to her diagnosis of MS. The facility provided the Resident Assessment Instrument Omnibus Budget Reconciliation Act (RAI OBRA) Required Assessment Summary dated October 2023, as guidance for completion of MDS assessments. The RAI indicated a significant change assessment was to be completed 14 calendar days after a significant change had occurred in a resident's health status. No further policy was provided related to MDS assessments or significant changes in resident health status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and document review, the facility failed to implement the care to provide restorative range of motion (ROM) for 1 of 1 resident (R5) reviewed for range of motion. Findings include: R5 was admitted to the facility on [DATE] with diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (one sided muscle weakness) following cerebral infarction (stroke) affecting right dominant side and contracture of muscle, unspecified upper arm. R5's quarterly Minimum Data Set (MDS) assessment, dated 09/14/23, indicated Impairment on one side for both upper and lower extremity. R5's care plan, dated 8/11/23, identified R5 has a functional maintenance program with a goal to maintain joint mobility. R5 was at risk for decline in ROM related to diagnosis of hemiplegia. Care plan indicates for upper and lower extremities: 5 reps and hold count for 5 seconds to provide short stretch to bilateral wrists, elbows, shoulders, knees, ankles, feet, and toes. M-W-F. To be performed by aide. During an interview on 10/25/23 at 1:09 p.m., RN-A stated R5 is a long-term resident of facility, suffered a stroke, and his care plan and orders includes maintain joint mobility. RN-A stated the stretches/exercises are to be attempted and completed at morning and evening cares. RN-A stated R5 can be resistant to exercises and stretches for joint mobility and this resistance had increased. During an interview on 10/26/23 at 9:45 a.m., NA-A stated R5 has orders to complete ROM during morning and evening cares. NA-A stated she completed the stretches/exercises at morning and evening cares, depending on her shift, and if the resident did not refuse, but there is currently no place in the facility's EMR [electronic medical record]to chart completion or resident refusal. During an interview on 10/26/23 at 12:33 p.m., RN-A stated currently there are no posted graphics/depictions of the types of stretches to be performed in R5's room. RN-A stated she demonstrates the stretches/exercises to the aides so they know which ones to be attempted and performed. RN-A stated aides are to complete these stretches/exercises twice daily, at morning and evening cares. RN-A acknowledged there had not been a proper area in the facility's EMR to chart completion or resident refusal to stretches/exercises for R5. RN-A stated in the past this was put in progress notes. Upon review of R5's progress notes, no charting of stretches/exercises noted since 12/08/22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure that reported symptoms of a urinary tract infection (UTI) were assessed and acted upon to reduce the risk of severe infection or complication for 1 of 1 residents (R9) who reported burning and increased frequency with urination. Findings include: R9's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R9 had intact cognition with diagnoses including heart failure, hypertension, and debility. R9 was independent with toileting hygiene and transfers and required moderate assistance with bathing. R9 was occasionally incontinent of the bladder and did not have a UTI during the review period (past 30 days). R9's care plan dated 5/26/23 (with no update), indicated R9 had a current UTI infection so staff were to observe and report signs or symptoms of worsening infection or medication reactions to the physician/nurse practitioner (NP). R9's care plan dated 7/25/23, indicated R9 was independent with toileting and used a bedside commode at night related to increased urination. The care plan indicated R9 was occasionally incontinent of urine and required assistance to remain dry and clean. During an interview on 10/23/23 at 2:49 p.m., R9 stated she had started having to urinate all the time as well as experiencing burning and pain with urination a few weeks ago. R9 stated she had informed the registered nurse (RN)-A of burning, pain, and increased frequency of urination when it started and she was aware it was still going on. R9 stated she did not think her urine had been tested. After a review of R9's medical record, no urine cultures were noted to have been completed from 9/23 through 10/23. During an interview on 10/24/23 at 2:11 p.m., RN-A stated R9 had complained of urinary frequency and burning a couple of weeks ago. RN-A stated R9 needed three symptoms of a urinary tract infection before urine would be tested for an infection, she only had two, burning and frequency, so her urine was not tested. During an interview on 10/26/23 at 10:41 a.m., medical doctor (MD)-A stated she would have expected the facility to notify her or the nurse practitioner if R9 started to develop, pain, burning, increased frequency, or increased urgency with urination. MD-A stated she would have expected notification if a resident became symptomatic with just one symptom of a urinary tract infection. MD-A stated the nurse practitioner or herself should have been made aware of the symptoms, so they could have been treated. MD-A stated if a urinary tract infection went untreated, the infection could have become systemic leading to sepsis(a life-threatening infection of the blood) and then possibly death. During an interview on 10/26/23 at 10:48 a.m., the director of nursing (DON) stated if a resident demonstrated one symptom of a urinary tract infection such as burning, she would have expected staff to follow the standing orders and collect a urine sample for testing. The DON stated she would have been worried that if the urine was not tested for an infection, the infection could continue to worsen and spread. The facility's Standing Orders dated 3/23, indicated a urine test could have been ordered for a urinary tract infection by licensed staff if the resident had symptoms such as pain with urination, fever, or blood in the urine. The order did not indicate a minimum number of symptoms. A policy regarding urinary tract infections was not received from the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and document review, the facility failed to comprehensively analyze the root cause of falls and promptly incorporate new fall interventions to help prevent future falls and possible injury for 2 of 2 resident (R31, R10) reviewed for accidents. Findings include: R31 R31's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R31 had severely impaired cognition and required moderate staff assistance to transfer and walk, extensive assistance to stand, and was dependent on staff for personal hygiene. R31's Face Sheet dated 10/24/22, indicated R31 was diagnosed with Alzheimer's disease, arthritis, and osteoporosis (a condition causing weak, brittle bones with a high likelihood of breaking). During an observation on 10/24/23 at 12:46 p.m., R31 sat in the recliner with the leg rest in the extended (elevated) position. The cord for the recliner remote was observed in the pocket on the side of the recliner. During an observation on 10/24/23 at 3:29 p.m., R31 was observed lying in her recliner with the leg rest in the extended position, yelling out, Help, help, pretty please, help! No staff were observed to answer R31's calls. R31's recliner remote was observed inside the right pocket of the recliner. During observation and interview on 10/25/23 at 10:51 a.m., R31 sat in the recliner with the leg rest in the extended position. A trash can was observed immediately to the right of the recliner with the remote control panel hanging over the far side of the trash can. Registered nurse (RN)-E entered R31's room and asked R31 if she was able to reach the recliner remote. R31 leaned over the right arm rest but could not reach the remote. RN-E stated R31 was unable to reach the remote, but she was unsure if R31 was allowed to have it within reach. During observation on 10/25/23 at 10:55 a.m., trained medical assistant (TMA)-B was observed entering R31's room. R31 remained in recliner, leg rest in extended position with recliner remote placed on far side of trash can. TMA-B observed talking with R31 and then leaving the room while the recliner remote remained on the far side of the trash can. During an interview on 10/25/23 at 10:57 a.m., RN-E stated she would move the recliner remote within reach of the patient because she was concerned the recliner would act as a restraint or increase R31's fall risk. During observation and interview on 10/25/23 at 12:40 p.m., R31 sat in the recliner with the leg rest in the extended position. A pillow was observed over both the recliner's right arm rest and extending some of the trash can. The recliner remote was observed halfway down the inside of the trash can. TMA-A entered R31's room, observed the recliner remote in the trash can, and stated R31's recliner remote was out of R31's reach because she was not allowed to have it. TMA-A stated that staff do not give the recliner remote to R31 because she has fallen after putting the leg rest down in the past. R31's care plan dated 9/26/23, indicated R31 was at risk for falls with the following interventions outlined in the care plan: - The intervention created on 9/11/23, indicated gripper socks should have been worn in bed, sheets should have been kept untucked, and the number of blankets on the resident should have been minimized. - The intervention created on 9/15/23, indicated staff should have offered toileting, repositioning, or sitting near the nurse's station when R31 was noted to be restless. - The interventions created on 9/18/23, indicated a floor mat should have been placed at R31's bedside and R31 should have been encouraged to participate in activities during the day to prevent restlessness at night. - The intervention last updated on 9/26/23, indicated R31's personal alarm string should have been shortened at used at all times. R31's John Hopkins Fall Risk assessment dated [DATE], indicated R31 had a total score of 18, indicating a high risk for falls. R31's progress note dated 8/28/23 at 7:58 a.m., indicated family member (FM)-A was informed of R31's fall. R31's progress note dated 8/29/23 at 8:34 a.m., indicated the nurse practitioner (NP)-I was informed of R31's fall out of bed on 8/26/23. No fall report or progress note was found relating to the fall on 8/26/23. R31's Safety Events- Fall report dated 9/10/23 at 11:06 p.m., indicated staff found R31 on the floor with her back against the bed after her bed alarm went off. The new interventions, as outlined in the care plan, were gripper socks worn in bed, sheets kept untucked, and the number of blankets on the resident was to be minimized. The report did not indicate an assessment of possible reasons R31 was attempting to get out of bed unassisted or a reassessment of the effectiveness of past fall interventions. R31's Post Fall Investigation report, completed on 9/13/23 at 2:55 p.m., for the falls on 8/26/23 and 9/10/23, indicated staff had to anticipate R31's needs related to her cognition and impulsiveness. The report indicated R31 had two falls over the last month attempting to get out of bed and she required assistance for transfers. The report acknowledged existing fall interventions as listed in the care plan above but failed to reevaluate them for effectiveness and update them as necessary. The report indicated staff should offer toileting, repositioning, or sitting near the nurse's station when R31 was noted to be restless. These new interventions were added to the care plan 20 days after the first fall. No new interventions were noted between the fall on 8/26/23 and the fall on 9/10/23. R31's Safety Events- Fall report dated 9/17/23 at 9:50 p.m., indicated staff found R31 on the floor lying next to her bed after hearing her alarm sounding. The report indicated R31 was attempting to get out of bed when she fell and staff thought she fell related to her losing her balance. The interventions put in place immediately following the fall included a bed alarm and rest, although an alarm had been in place when R31 fell. New interventions included encouraging R31 to participate in activities during the day to prevent restlessness at night. R31's Safety Events- Fall report dated 9/18/23 at 8:30 p.m., indicated staff found R31 lying on the floor with her head under the bed with a small skin tear to her left forearm after hearing her alarm sounding. The report indicated that R31 fell after attempting to get out of bed for an unknown reason. The new intervention listed indicated a floor mat would be placed at R31's bedside to prevent injuries with falls but did not address any interventions to prevent the fall itself. A root cause analysis of R31's desire to get out of bed was not noted. R31's Safety Events- Falls report dated 9/19/23 at 7:20 p.m., indicated staff found R31 on the floor mat next to her bed after hearing her alarm sound. The report indicated that R31 had a behavioral and mental status change over the last two weeks. The report did not indicate interventions or investigations had been completed related to this change. The report did not indicate staff had assessed possible needs R31 had that led her to self-transfer out of bed repeatedly in the evening. The facility initiated a personal alarm that was care planned on 9/26/23. R31's Post Fall Investigation report completed on 9/24/23 at 10:09 p.m., for the fall on 9/17/23, included no fall pattern, no root cause analysis, and indicated the care plan was updated but did not describe the changes or evaluation of previous interventions. R31's Safety Events- Fall report dated 9/25/23 at 10:20 p.m., indicated staff found R31 on the floor next to her bed after hearing her call out. The report indicated the personal alarm had not sounded when she fell so staff shortened the personal alarm string as the intervention. The report indicated no analysis of possible factors contributing to R31 attempting to self-transfer out of bed. R31's Post Fall Intervention report dated 9/26/23 at 1:24 p.m., addressed the falls on 9/17/23, 9/18/23, 9/19/23, and 9/25/23. The report indicated that R31 became increasingly agitated in the evening hours and attempted to self-transfer leading to falls. The report indicated, there have been multiple changes to her care plan made to prevent similar occurrences. The report referenced the care plan interventions placed on 9/18/23 and 9/26/23 but the report did not indicate an analysis of the effectiveness of prior interventions as R31 continued to fall after they were placed. During an interview on 10/25/23 at 11:08 a.m., nurse manager (RN)-A stated R31 normally slept during the day but they had attempted to take her to activities a few times. RN-A stated staff reports R31 did not seem to enjoy the activities so they no longer attempted to bring her. RN-A stated that R31 was more awake during the evenings and occasionally more restless, leading to more of her falls. RN-A stated she would expect the care plan to be followed and updated with the Post Fall Interventions and quarterly assessments when an intervention was not effective. R10 R10's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R10 had moderately impaired cognition and diagnoses of heart failure, hypertension, and Parkinson's disease. The MDS indicated that R10 required moderate assistance with standing, transferring, and walking. R10's care plan dated 10/20/23, indicated R10 was at risk for falls related to Parkinson's disease, medications, weakness, and a fluctuation in gait. The care plan included the following fall interventions: - Last updated on 4/12/23, the care plan indicated staff should offer to assist R10 to the bathroom and out of his wheelchair immediately following meals. - Last updated on 7/12/23, the care plan indicated R10 should not have been left alone in his room or bathroom when in his wheelchair or using the toilet. - Last updated on 7/20/23, the care plan indicated staff should have assisted with all cares and transfers, completed comfort level checks every two hours, ensured the bed was in the lowest locked position and R10's call light was within reach. The care plan indicated hourly safety checks should have been completed and documented on the safety check form and then scanned into the medical record. - Last updated on 7/27/23, the care plan indicated staff should have ensured a non-slip pad was placed under the cushion and on top of the sheet in R10's recliner and his personal items were within reach. - Created on 10/20/23, the care plan indicated staff should have provided and ensured placement of proper footwear such as rubber-soled shoes or gripper socks for R10, a non-slip pad should have been placed on the seat of his electric scooter at all times, staff should have instructed R10 not to use side table for support during transferring, and a black non-skid mat should have been placed in front of R10's recliner. R10's Safety Event- Fall report dated 9/29/23 at 10 p.m., indicated staff heard R10 yelling and found him on the floor between his recliner and the bathroom. R10 reported he had attempted to sit on the recliner, missed, and landed on the floor. The report indicated possible contributing factors to R10's falls were a diagnosis of a neurological disorder, a recent decline in physical ability, and antihypertensive's and anticoagulants use. The report indicated before the fall, R10 was on every two-hour safety checks with the call light and personal items within R10's reach. The report indicated new interventions included: two-hour safety checks, call light and personal items within reach, room decluttered, and reminded to call for help when needed. The report did not show an analysis of the possible contributing factors listed or an evaluation of the possible root cause of the fall. The resident was noted to have new bruises on both knees, the area below the left eye, and the sacrum. R10's Safety Events- Fall report dated 10/2/23 at 11:00 a.m. (closed on 10/20/23), indicated staff found R10 was found lying on his back on the floor. The report indicated R10 was attempting to move his side table and lost his balance and fell. The report indicated R10 was encouraged to not use the side table as support during transfer and ask for assistance. The report did not indicate any additional interventions. R10's Safety Events- Fall report dated 10/11/23 at 1:47 p.m. (closed on 10/20/23), indicated R10 was found kneeling in front of his recliner after he had reportedly attempted to self-transfer. R10 had a surgical shoe on at the time of the fall that was indicated to have been the cause. The report indicated the surgical shoe was removed per Podiatry approval and no further interventions were noted. R10's record was reviewed and an hourly Safety Checks form was not found for 10/11/23. R10's Safety Events- Fall report dated 10/14/23 at 9:24 p.m. (closed on 10/20/23), indicated R10 was found on the floor of his bathroom during hourly checks after he had attempted to pick something up off the floor. The report indicated that R10 had a skin tear on the top of his right hand and an abrasion on his left elbow following the fall. The report indicated new interventions as, continue current plan of care. No root cause analysis was noted or immediate changes to prevent similar occurrences. R10's Post Fall Investigation report, completed on 10/20/23 at 1:38 p.m., for the fall on 9/29/23, indicated R10 had the following fall risks: assistance needed for transferring and ambulating, impulsivity, muscle weakness, urinary tract infection, unsteadiness on feet, and Parkinson's disease. The report indicated that R10 fell after slipping when he attempted to self-transfer to the recliner. The report indicated a non-skid mat would now be used in front of the recliner (added to the care plan on 10/20/23, 21 days after the fall). R10's Post Fall Investigation report, completed on 10/20/23 at 2:41 p.m., for the fall on 10/11/23, indicated R10 had a surgical shoe on at the time of the fall that was claimed to have caused the fall. The report indicated the surgical shoe had been replaced and a change was made to the care plan for rubber-soled shoes. The report indicated R10 required assistance with ambulation at all times but did not address how this was to be assured. R10's Post Fall Investigation report, completed on 10/20/23 at 2:47 p.m., for the fall on 10/2/23, indicated R10 was encouraged to avoid using the side table for support during transfer and to ask for assistance (added to the care plan on 10/20/23, 18 days after the fall). The report listed previous fall prevention methods used when R10 fell but did not evaluate their effectiveness. R10's Post Fall Investigation report, completed on 10/20/23 at 2:52 p.m. for the fall on 10/14/23, indicated R10 had fallen after attempting to pick something up off the floor and a non-slip pad would be added to the resident's electric scooter (added to the care plan on 10/20/23, six days after fall). The report listed previous fall prevention methods used but did not evaluate the effectiveness of them. During an interview on 10/23/23 at 3:21 p.m., R10 indicated he has fallen a few times by slipping out of his recliner or losing his balance while walking. During an interview on 10/26/23 at 8:21 a.m., RN-A stated R10 had fallen multiple times and was not safe to self-transfer. RN-A stated staff had tried all of the alarms but none were effective. RN-A stated hourly checks were expected to be done daily for R10 to help prevent falls. RN-A stated they had to anticipate his needs because he was impulsive and would expect that to have been included in the care plan. RN-A stated that R10 teared up and appeared upset when he discussed his falls with staff. RN-A stated the Post Fall Investigation and the following update of the care plan was expected to be completed within 24 hours after the fall. RN-A stated concern that if these steps were not completed promptly, the resident may fall again. During an interview on 10/26/23 at 10:06 a.m., the director of nursing (DON) stated she expected staff to complete a fall report immediately and a Post Fall Investigation within 24 hours of the fall to prevent further falls and possible injury. The DON stated the Post Fall Investigation should be used to analyze fall patterns and determine the appropriateness of current and future fall interventions. The DON stated it was important for an immediate change to be implemented to the plan of care to prevent further falls. The Cumulative Fall Record policy dated 7/22, indicated the Post Fall Investigation should have been completed by a registered nurse within 24 hours of the fall and should have included a comprehensive assessment of similar falls, risk factors, medication changes, and changes in the resident's overall health. This assessment should then have been used to assess the appropriateness of interventions in place and determine if additional changes to the care plan were needed. The policy indicated the care plan should have been reviewed after each fall and changes to interventions and new interventions should have been discussed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure respiratory equipment was changed weekly according to professional standards to prevent infection for 2 of 2 residents (R17, R52) reviewed for respiratory care. Findings include: R17's quarterly Minimum Data Set (MDS) dated [DATE], indicated R17 had severe cognitive impairments and had diagnoses that included stroke with right-sided paralysis, aspiration pneumonia, diabetes, chronic obstructive pulmonary disease (COPD-resulting in difficulty breathing and low oxygen levels), obstructive sleep apnea (OSA-breathing periodically ceases during sleep), and morbid obesity. R17's care plan dated 6/14/23, indicated R17 had potential for ineffective breathing patterns related to COPD, OSA, cough and aspiration pneumonia. R17 also became short of breath when lying down. Interventions lacked indication R17 was on supplemental oxygen. R17's orders dated 5/11/23, indicated to maintain R17's oxygen levels between 90-94%. The orders lacked indication for changing R17's oxygen tubing. During an observation on 10/23/23 at 6:22 p.m. R17 was sleeping in bed with one liter per minute (lpm) of oxygen being delivered by nasal canula. The oxygen tubing lacked a label to indicate when it was last changed. A portable oxygen tank was also hanging off the back of R17's wheelchair with unlabeled oxygen and nasal canula tubing. During an observation on 10/24/23 at 1:33 p.m. R17 was sitting in a recliner in her room with nasal canula oxygen tubing. The tubing lacked a date to indicate when it was last changed. During an interview on 10/24/23 at 2:39 p.m. registered nurse (RN)-A verified R17's electronic medical record (EMR) lacked an order to change R17's oxygen tubing weekly and therefore, could not verify when it had last been changed. During an observation and interview on 10/24/23 at 2:10 p.m. the infection preventionist (IP) verified R17's oxygen and nasal canula tubing lacked a label to indicated when they were last changed. The IP also verified there was no documentation to indicate when the tubing was last changed. The IP stated the tubing was to be changed weekly for infection prevention. R52 R52's quarterly MDS dated [DATE], indicated R52 had intact cognition and diagnoses that included acute and chronic respiratory failure with low oxygen levels, diabetes, heart failure, COPD, pneumonia, and bronchiectasis (a widening and weakening of the lung tissue increasing the risk for infection and inflammation in the lungs). R52's care plan dated 10/9/23, indicated R52 had ineffective breathing patterns related to heart failure and COPD. The care plan lacked interventions related to the bubbler or humidified oxygen. R52's orders dated 12/01/22, indicated R52 was on 2-4 lpm of oxygen by nasal cannula but lacked orders related to R52's humidified bubbler or how often it was to be changed. During an observation on 10/24/23 at 1:36 p.m. R52 was sleeping in a recliner with a nasal canula on. The nasal canula was connected to a bubbler that was dry and the canister lacked a date to indicate when it was last changed. During an observation and interview on 10/24/23 at 2:14 p.m. the IP verified R52's bubbler canister had no water and lacked a date to indicate when it was last changed. The IP stated the canister should be filled with distilled water to ensure humidified oxygen was being delivered and the bubbler should have been dated to ensure it was changed weekly to avoid infection concerns. During an interview on 10/26/23 at 11:33 a.m. the director of nursing (DON) stated she thought oxygen tubing and bubblers were to be changed every 30 days or according to the facility policy. The DON further stated they were not expected to be labeled because the residents' EMRs should have had orders to indicate when they were to be changed. The DON further stated R52's bubbler should have been filled with distilled water if the resident required humidified oxygen. The facility Oxygen policy dated 12/2018, indicated nasal cannula oxygen could be set from 1-6 lpm and a humidified bottle may be added for flows over 4 lpm. The policy lacked directions for changing and/or dating the oxygen tubing or humidified bottles.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure appropriate and manufacturer-directed steps to prevent post-administration complication (i.e., thrush) of a dry powedered inhaler (DPI) were completed for 1 of 1 residents (R48) observed to receive a DPI during the recertification survey. Findings include: An Advair Diskus Highlights of Prescribing Information manual, dated 6/2023, identified the medication was used to treat asthma and COPD, along with various dosage, storage instructions, and administration information for the medication. The manual outlined some patients had experienced localized candida albicans (i.e., oral fungal infections) with use of the medication and directed, Advise patients to rinse the mouth with water without swallowing after inhalation to help reduce the risk of thrush. In addition, a section labeled, How should I use ADVAIR DISKUS?[,] directed a bulleted point which read, Rinse your mouth with water without swallowing [bolded] after each dose . This will help lessen the chance of getting a yeast infection [thrush] in your mouth and throat. R48's significant change Minimum Data Set (MDS), dated [DATE], identified R48 had intact cognition and had several medical diagnoses including chronic obstructive pulmonary disease (COPD). On 10/23/23 at 6:49 p.m., licensed practical nurse (LPN)-A prepared R48's medications, including an Advair Diskus inhaler, for administration on a mobile cart next to the nursing station. LPN-A brought the prepared medications and inhaler to R48's room. LPN-A removed the Advair inhaler from the package and primed the device before handing it to R48 to inhaler per self. R48 inhaled the medication and provided the inhaler back to LPN-A who then asked, Anything else? R48 declined and LPN-A left the room. There was no mention or direction from LPN-A to R48 to swish her mouth out, without swallowing, using water after R48 inhaled the medication. Immediately following, R48 was interviewed. R48 explained she had been on Advair for many years due to COPD. R48 stated she recalled someone informing her, years ago, of the need to swish-and-spit after using the Advair, however, she often forgot to do such. R48 stated the nurses at the nursing home did remind her, at times, to take a drink after she inhaled the medication, however, described it as very infrequent with the administration(s) adding when such was done, the nurses typically told her to take a drink of water and drink it down and not spit it back out. R48's signed Physician Order Report, dated 9/26/23, identified R48's current physician-ordered medication regimen and subsequent administration instructions. This included an order for Advair Diskus 250-50 micrograms (mcg/per dose) one inhalation orally twice daily for COPD. The order lacked any other specific administration directions (i.e., swish mouth and spit). When interviewed on 10/23/23 at 7:04 p.m., LPN-A verified they had not offered or directed R48 to swish and spit water after the inhaler. LPN-A stated the physician orders would typically say if such was needed or not, but then added they were not entirely sure, either. LPN-A reviewed R48's medication administration record (MAR) and verified the order for the inhaler lacked direction to offer a swish-and-spit using water post-administration. LPN-A stated they had just started working at the nursing home recently from the agency pool and reiterated they were unsure if a swish-and-spit after the inhaler was needed since it wasn't on the specific administration instructions. LPN-A added, I don't know how they do it here [to communicate if needed or not]. On 10/25/23 at 2:30 p.m., registered nurse unit manager (RN)-A stated most inhalers, including Advair Diskus, should have a water swish-and-spit provided after inhalation. RN-A stated doing such was standard practice and they expected the floor nurses to know such from schooling and the facility' orientation. RN-A stated it was important to provide a swish-and-spit to help prevent oral issues. When interviewed on 10/25/23 at 2:54 p.m., the acting director of nursing (DON) stated the use of a swish-and-spit after a DPI was likely not outlined on each individual physician order, however, should be completed if directed by the manufacturer. DON stated the pool agency nurses' did have a general medication administration orientation, however, was potentially not as in depth as the employed nurses' orientation. DON reiterated they expected a swish-and-spit to be offered, if needed, and added, That is something we have to correct. A provided Dry Powder and Metered Dose Inhalers policy, dated 12/2018, identified steps to complete the administration of such and outlined, It is advisable to have the patient rinse their mouth out with water or mouthwash after using a DPI as it may cause thrust [sic] or other mouth sores.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review the facility failed to ensure a prophylactic antibiotic without an end date was monitored and evaluated for the appropriateness of its continued use for 1 of 2 residents (R20) reviewed for antibiotic administration. Findings include: R20's quarterly Minimum Data Set (MDS) dated [DATE], indicated R20 had intact cognition and was dependent for all ADLs. R20's diagnoses included multiple sclerosis (MS), urinary tract infection, heart disease, high blood pressure, and congestive heart failure (CHF, causing fluid in the lungs and body, and shortness of breath), obesity, neuromuscular dysfunction of the bladder, constipation, and diarrhea. R20's Care Area Assessment (CAA) dated 12/22/22, indicated R20 triggered for indwelling catheter. R20's care plan dated 4/12/23, indicated R20 had an indwelling urinary catheter related to a neurogenic bladder. The care plan lacked indication of, or interventions for R20's long-term, prophylactic antibiotic use related to recurrent UTI's and possible organism colonization. R20's Report of Consultation dated 6/10/22, indicated to start R20 on 250 milligrams (mg) of amoxicillin (an antibiotic) daily. No end date was indicated for the antibiotic. R20's electronic medical record (EMR) indicated the following events: -12/29/22, indicated R20 was diagnosed with a UTI. Order for cephalexin 500 mg twice a day for five days. No documentation addressing the ongoing order for amoxicillin 250 mg. -3/9/23, indicated R20 was diagnosed with a UTI. Order for ciprofloxacin (cipro-an antibiotic) 500 mg twice a day from 3/8/23 to 3/15/23. No documentation addressing the ongoing order for amoxicillin 250 mg. -9/19/23, indicated R20 was diagnosed with a UTI. Order for cipro 500 mg twice a day from 9/19/23 to 9/25/23. No documentation addressing the ongoing order for amoxicillin 250 mg. R20's progress notes were as follows: -8/15/23 at 2:20 a.m., indicated R20 had a dry, red, rashy area extending around R [right] hip region into R groin area. Lotion applied to area's of dryness per request. NP [nurse practitioner] to address skin concern today. -8/15/23 at 2:50 p.m., NP updated on poor skin condition to R20's buttocks. New orders received for fluconazole (an antifungal) 150 mg [milligrams] 1 x per week x 2 weeks. -8/16/23, no improvement to R20's lower back, buttocks, groin, and upper posterior thighs. -8/19/23, redness noted under both breasts, groin, upper posterior thighs, lateral left thigh, right lateral thigh, and buttocks being treated with fluconazole. 8/20/23, New, raised, pink speckled rash present over upper thighs and within groin, which appear to be heat/moisture related. Found today resident is reddened under both arms without yeast odor. No improvement noted. -8/21/23, skin condition has worsened since yesterday. -8/22/23, resident seen by NP for worsening skin condition and yeast concerns. -8/24/23, R20 continued to have several areas of skin irritation. -8/27/23, a preliminary report of a recent urine analysis indicated >100,000 cfu/ml gram negative rods (indicating a possible urinary tract infection). -8/28/23, Skin on buttocks and upper thighs/groin continue to be reddened, moist, irritated. Minimal improvement noted. -8/29/23, due to likelihood of colonization, R20 will not be treated for a UTI. R20 continues to have a fungal outbreak on her skin and thus treatment for UTI will also cause worsening to skin condition. -9/19/23, due to increased sediment in urine and recent catheter changes, will not obtain urine specimen and treat for UTI with previously know[n] bacteria. New orders for cipro (an antibiotic). During an interview on 10/24/23 at 2:27 p.m., licensed practical nurse (LPN)-B stated because R20 was prone to UTI's, staff were monitoring her for signs and symptoms of an infection; however, LPN-B stated she did not monitoring R20 for any signs or symptoms related to her ongoing use of amoxicillin. During an interview on 10/26/23 at 7:52 a.m., registered nurse (RN)-A, stated she last reached out to MD-B on 2/23/23, regarding R20's continued urinary catheter occlusions and was advised R20 was receiving the maximum therapy. No further treatment was suggested. During an interview on 10/26/23 at 10:22 a.m., RN-A stated she was unaware if R20's prophylactic antibiotic was held or discontinued while she was being treated with another antibiotic for her UTI's although it should have been. RN-A further verified there was no documentation to indicate a discussion related to the dual antibiotic use was discussed with the providers at the time of her subsequent UTI's. During an interview on 10/25/23 at 2:57 p.m., the infection preventionist (IP) stated she did not recall why R20 was on a prophylactic antibiotic and could not recall when R20 first began taking the antibiotic. The IP further verified R20 was not being tracked on the facility antibiotic surveillance log for her long-term use of an antibiotic. During an interview on 10/25/23 at 9:03 a.m., registered nurse (RN) from R20's urology clinic stated R20 had not been seen by the urologist since her initial appointment in June 2022, when the order for the prophylactic amoxicillin was written. A message was left for the urologist with no return call received. During an interview on 10/25/23 at 9:40 a.m., the consulting pharmacist (CP) stated she believed R20 was being followed by urology related to her urinary catheter and repeated UTI's. The CP stated she had not reviewed R20's long-term use of amoxicillin since it was first ordered on 6/10/22, but would have expected the antibiotic to be reassessed at least annually for its appropriateness. The CP further confirmed that R20 had been treated with additional antibiotics multiple times since she began taking the prophylactic amoxicillin. The CP was unaware if R20's prophylactic antibiotic had been discontinued during the administration of the new antibiotics but would have expect it to be to avoid complications including clostridium difficile (C-Diff, a potentially deadly bacteria that can grow as a result of long-term antibiotic use). The CP further stated the prophylactic antibiotic was started at the same time R20 began receiving acidic acid flushes in her bladder and would have expected a trial discontinuation of the antibiotic to rule out which treatment was effective. The CP also stated the prophylactic antibiotic should have been re-evaluated for its appropriateness when R20 acquired a fungal skin infection as it could have lowered her resistance and delayed her healing capacity. During an interview on 10/26/23 at 11:37 a.m., the director of nursing (DON) stated R20's prophylactic antibiotic should have been monitored and reassessed for its efficacy and appropriateness. The DON further stated R20's culture and sensitivity test results also should have been reviewed for the appropriateness of the prophylactic amoxicillin. The DON stated the prophylactic antibiotic also should have been stopped if R20 was started on a new antibiotic. During an interview on 10/25/23 at 12:36 p.m., the nurse practitioner (NP) stated she was unfamiliar with any conversations related to R20's UTI's; however, the NP stated the facility's primary care physician had anticipated R20 was colonized with bacteria in her urinary tract and was therefore, only treating R20 for a UTI if she was having signs and/or symptoms of a UTI. A message was left for the primary provider but no return call was received. The facility Antimicrobial Stewardship Program policy dated January 2018, indicated the purpose of the program was to promote the appropriate use of antimicrobials in order to improve resident outcomes while minimizing toxicity and the emergence of Antimicrobial resistance by selecting the appropriate dose, route and duration of treatment. The program committee was responsible for: demonstrating improvements, including sustained improvements in proper antibiotics use, such as through reductions in C-Diff, adherence to nationally recognized guidelines and best practices, providing ongoing healthcare practitioner education regarding Antimicrobial initiatives, and collecting, tracking, and analyzing Antimicrobial use and resistance patterns. The policy also indicated, in accordance with the CDC Core Elements of Hospital Antibiotic Stewardship Program recommendations, all prescriber's were required to document the duration of Antimicrobial therapy and to review its appropriateness after 48-72 hours from the initial order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review the facility failed to ensure psychotropic medications were reviewed for the appropriateness of a gradual dose reduction (GDR) for 1 of 1 residents (R17) reviewed for unnecessary medications. Findings include: R17's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R17 had severe cognitive impairments and diagnoses that included bipolar disorder. R17's care plan dated 6/13/23, indicated R17's mood was to be monitored due to bipolar disorder, depression, and cognitive changes due to a stroke. Interventions included assessing medication effectiveness. R17 also had a potential for alteration in thought process due to late effect cognitive deficits, difficulty making decisions, and an inability to express self. Interventions included observing for medication effectiveness and side effects. R17's orders dated 12/5/22, indicated R17 received 50 milligrams (mg) of sertraline (an antidepressant) for bipolar disorder. The orders indicated R17's order was discontinued in the facility from 5/8/23-5/11/23, because R17 was admitted to the hospital. R17's pharmacist Note to Attending Physician/Prescriber dated 3/14/23, indicated sertraline was to be assessed annually or have a clinical contraindication documented. The note further indicated R17 's last GDR request was February 2022, however, R17's Power of Attorney (POA) declined the GDR. The note indicated to consider reducing the sertraline or document a clinical rationale. The provider response dated 3/24/23, indicated POA declines GDR indefinitely. No clinical contraindications or rationale were documented. During an interview on 10/26/23 at 2:28 p.m. the director of nursing (DON) stated there should have been a documented medical reason why a GDR would not have been appropriate for R17's psychotropic medication and a resident's representative was not authorized to refuse a GDR attempt. R17's provider was not available for interview. No facility policy related to GDR's was received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to implement the current standards of vaccinations regarding pneumonia for 2 of 5 residents (R25, R39) over [AGE] years old whose vaccinations histories were reviewed. Findings include: The Center for Disease Control and Prevention identified on the Pneumococcal Vaccine Timing for Adults Chart, dated 3/15/23, Adult [AGE] years of age or older who had received the PPSV23 (pneumococcal polysaccharide vaccine 23) only at any age should receive one dose of either pneumococcal 20-valent Conjugate Vaccine (PCV20) or pneumococcal 15-valent Conjugate Vaccine (PCV15). The dose of PCV20 or PCV15 should be administered at least one year after the most recent PPSV23 dose. R15's facility immunization record indicates she was [AGE] years old. The record indicated she received the PPSV23 vaccine on 3/6/2017 followed by the PCV13 on 3/19/2018. There was no evidence that R15 was offered or received PCV20 or PCV15 following the PCV13. R39's facility immunization record indicates he was [AGE] years old. The record indicated he received the PPSV23 on 6/29/2015 followed by the PCV13 on 10/6/2021. There was no evidence that R39 was offered or received PCV20 or PCV15 following the PCV13. During an interview with registered nurse (RN)-D, at 12:03 p.m., indicated that it is infection control's responsibility to ensure the policy related to immunizations is up to date. Indicated admission coordinator verifies immunizations upon admission through MIIC (Minnesota Immunization Information Connection). This information is added to the provider rounding forms and nurse managers are responsible for ensuring residents are up to date on vaccinations. Indicated the vaccination chart is in the policy and it might not be up to date. Pneumococcal Vaccine Timing for Adults chart, dated 4/1/2022, was provided and verified as what is being used to determine needs. RN-D indicated she is unsure if there is an updated pneumococcal vaccine timing from the CDC. Verified dates and pneumococcal vaccines for R15 and R39. Verified they do not follow the current CDC recommendations. RN-D indicated when R15 and R39 received their vaccines, there were probably different guidelines which were followed. During an interview with registered nurse (RN)-B, at 12:21 p.m., indicated that is a collaboration to ensure residents are up to date on vaccinations. Indicated it is primarily infection control's responsibility, but it is reviewed on assessments. Indicated vaccinations are listed on provider rounding forms. Vaccination records are obtained from MIIC, and the pneumococcal vaccine timing is determined by the chart in the office. RN-B indicated that the pharmacist would be consulted for any questions. During an interview with administrator, on 10/26/23, at 2:01 p.m., she verified that infection control had previously been ensuring all resident were up to date with immunizations. She indicated there have been some movement in the roles and will follow up. A facility policy titled Immunizations with a review date of 8/2021 was provided. Policy indicated that pneumococcal vaccination is offered year-round in accordance with CDC guidelines; see attachment A. Attachment A was an image from CDC website dated 10/11/2016.

Based on observation, interview and document review the facility failed to ensure residents were provided a private meeting place without staff present for resident council meetings. In addition the facility failed to ensure concerns brought forward at the resident council meetings were addressed in a timely manner. This deficiency had the potential to affect all 13 residents who attended the monthly resident council meetings. Findings include: During an interview with resident council members, R3, R12, R55, R48, and R46 on 10/25/23 at 1:00 p.m., residents indicated resident council meetings were held in the open dining room and provided no privacy. The residents stated staff being present was intimidating and There are times you hate to bring up concerns in front of staff. Residents also stated follow up regarding their concerns was not there and things didn't often change. During an observation on 10/25/23 at 1:54 p.m., 13 residents, two family members and five staff members were gathered in the resident main dining room for the resident council meeting. The main dining room is located in front of a nurse's station where nurses, nursing assistants, health unit coordinators (HUCs) and other staff were working and passing through. An unknown staff member used a microphone to speak to the residents. A few residents appeared to be sleeping and one was reading a magazine. The staff member then asked if there were any concerns regarding each individual department and pointed out staff present from each department including maintenance who was walking through the dining room at the time. Two residents spoke up and consistently praised each department. Review of the Resident Council Meeting Minutes dated 9/29/23, indicated the following: -No findings to report related to the findings in the August 2023 meeting. -New business indicated new cases of COVID in the facility and testing procedures were discussed. -Concerns included an unidentified resident complained of their baked potato being hard and the kitchen would be notified, an unidentified resident complained her slippers were returned damp from laundry, and it was the chaplain's last service as they found other employment. The minutes lacked indication of who attended the meeting. Review of the Resident Council Meeting Minutes dated 8/30/23, indicated the following: -No findings to report related to the findings in the July 2023 meeting. -New business indicated the call light system had been replaced, the dentist would be coming to the facility on 9/14/23, and residents who wanted to see him should let the staff know, and the menus were going to a three-week rotation instead of a six-week rotation. -Concerns included an unidentified resident expressing concern about a therapeutic recreation position being eliminated. Residents were reassured outings would continue and the following month's outings were discussed and residents were informed the bus lift needed to be repaired and could impact the weekend. The minutes lacked indication of who attended the meeting. Review of the Resident Council Meeting Minutes dated 7/26/23, indicated the following: -Findings from the June 2022 meeting indicated residents were notified that necklace/bracelet type call lights were not an option with the new call light system, and that there was a short time that the laundry labeler was not working and therefore, marker was being used to label clothing-this is not fixed. -New business indicated the new call light system was being installed. -Concerns indicated residents were advised now that they had to share the activities bus with the assisted living facility, attendance would be limited, and a staff was introduced in their new role. The minutes lacked indication of who attended the meeting. During an interview on 10/26/23 at 9:40 a.m., the social worker (SW) stated the resident council meeting was always held in the dining room and often resident family members would attend also. The SW stated she believed the purpose of the resident council meeting was to allow the residents an opportunity to discuss their concerns and support each other, however; she admitted meeting in the open dining room could provide a barrier for residents feeling safe to discuss concerns about staff if those staff are present. The SW stated concerns brought up during the resident council meetings may be addressed on a one-to-one basis or with an individual department depending on what the concern was. The SW stated the expectation was for concerns to be handled immediately and either documented in the resident council meeting minutes or in a resident's progress notes in their electronic medical record (EMR), however; that was not always done, and it was possible the concern would not be documented. The SW further stated a grievance form would not be filled out for the concerns brought up during the resident council meetings. The facility Resident Council Monthly Council Meeting process dated 12/4/22, indicated a calendar invite would be sent to invite/inform staff including the administrator, director of nursing (DON), nurse managers, therapeutic recreation staff, social services, chaplain services, director of hospitality, food and nutrition manager, of monthly resident council meeting, agenda, and outcome actions. The day before the meeting all above listed staff were to receive an agenda and be asked for any other announcements. Staff were to use a microphone and designate another staff as a note taker for the meeting. The following topics were to be discussed: -introduce any new residents -read and approve previous meeting minutes -old business (review actions taken since previous meeting -new business (announcements from staff or facility news) -review 1-2 resident rights -review of departments and/or announcements related to each -other resident concerns Also included was the following: Statement Regarding Complaints: We appreciate any and all feedback, and hope that you continue to bring your concerns forward to any of our staff. Please know that if there are issues you do not wish to bring up today, you may reach out to any of our staff at any time. We also provide formal grievance forms for you located outside the SW offices and at the elevator entrance on the Transitional Care Unit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review the facility failed to ensure continued monitoring and surveillance for efficacy and appropriateness was completed for 2 of 2 residents (R7, R20) who were on long-term, prophylactic antibiotics. In addition, the facility failed to ensure an appropriate antibiotic was administered for 1 of 1 (R9) residents who had an infected wound and were prescribed an ineffective antibiotic. Findings include: R7's quarterly Minimum Data Set (MDS) dated [DATE], indicated R7 had severe cognitive deficits and had diagnoses that included diabetes, epilepsy, morbid obesity, and urinary tract infections (UTI's). R7's Care Area Assessment (CAA) dated 3/28/23, indicated R7 triggered for indwelling catheter, cognitive loss/dementia, and pressure ulcers. R7's care plan dated 8/17/23, indicated R7 had a self-care deficit related to alteration in urinary/bowel function. Interventions included monitoring void patterns, assess for a UTI, administering medications as ordered and observing for side effects. R7's care plan lacked indication of or interventions for R7's long-term antibiotic use. R7's order dated 10/31/22, indicated R7 received sulfamethoxazole-trimethoprim (an antibiotic) 400-80mg orally for UTI's with no end date listed. R20 R20's quarterly MDS dated [DATE], indicated R20 had intact cognition and was dependent for all ADLs. R20's diagnoses included multiple sclerosis (MS), UTI, heart disease, high blood pressure, and congestive heart failure (CHF, causing fluid in the lungs and body, and shortness of breath), obesity, neuromuscular dysfunction of the bladder, constipation, and diarrhea. R20's CAA dated 12/22/22, indicated R20 triggered for indwelling catheter and pressure ulcers. R20's care plan dated 4/12/23, indicated R20 had an indwelling urinary catheter related to a neurogenic bladder. The care plan lacked indication of, or interventions for R20's long-term, prophylactic antibiotic use related to recurrent UTI's and possible organism colonization. R20's Report of Consultation dated 6/10/22, indicated to start R20 on 250 milligrams (mg) of amoxicillin (an antibiotic) daily. No end date was indicated for the antibiotic. During an interview on 10/24/23 at 10:05 a.m., R20 stated she had not had a UTI for a few months but recently began having loose stools and did not know why. During an interview on 10/25/23 at 2:57 p.m., the infection preventionist (IP) stated she did not recall why R20 was on the prophylactic antibiotic and could not recall when R20 first began taking the antibiotic. The IP further verified neither R7 nor R20 were being tracked on the facility antibiotic surveillance log for their long-term use of an antibiotic. During an interview on 10/26/23 at 7:52 a.m., registered nurse (RN)-A who was also the nurse manager, stated she had been notified R20 had been having loose stools for the past few days. RN-A stated staff would need to obtain an order from the provider to test R20 for clostridium difficile (C-Diff-a potentially deadly bacteria that can grow as a result of long-term antibiotic use) as there were no standing orders related to testing a resident for C-Diff. RN-A also stated there was no specific guidelines indicating when a resident should have been tested for C-Diff. RN-A further stated there should have been better monitoring for the antibiotic use for both R7 and R20 to ensure they were not experiencing any complications or side effects. During an interview on 10/26/23 at 11:37 a.m., the director of nursing (DON) stated long-term, prophylactic antibiotics should have been monitored and reassessed for their efficacy and appropriateness. The DON further stated residents on long-term antibiotics should be monitored for signs and/or symptoms of complications including bowel function related to possible C-Diff, although the DON was unsure if there were standing orders related to testing residents for C-Diff. During an interview on 10/25/23 at 9:40 a.m., the consulting pharmacist (CP) stated she would have expected antibiotics prescribed for prophylactic use to be reviewed at least annually for their appropriateness and efficacy. The CP also expected staff to monitor residents who were on antibiotics, especially long-term for complications including C-Diff. R9 R9's quarterly Minimum Data Set (MDS) dated [DATE], indicated R9 had intact cognition with diagnoses including heart failure, hypertension, and debility. R9 had a venous ulcer (wound caused by poor blood circulation to the lower extremities), required moderate assistance with bathing and dressing, and was independent with transferring and bed mobility. R9's care plan dated 5/26/23, indicated R9 had intact skin but was at risk for skin integrity loss. Staff were to prevent pressure, moisture, shearing, and injury to the skin. The care plan did not address the wound on R9's right lower extremity. R9's Order History report dated 10/6/23, indicated a new order for Cephalexin 500 milligrams (mg) four times a day for seven days for cellulitis. The report indicated a lab culture of the venous ulcer was ordered one time during the period of 9/1/23 and 10/26/23, dated 10/20/23. The report indicated an order active until 10/24/23 for once-a-day wound care on the venous ulcer and did not indicate the use of special safety precautions related to antibiotic resistance organisms present in her wound. The order dated 10/24/23, indicated R9 was prescribed Levofloxacin (antibiotic) 750 mg given every other day for ten days. The order dated 10/24/23, indicated R9 received once-a-day wound care on the venous ulcer and indicated the use of special safety precautions related to antibiotic resistance organisms present in her wound. R9's progress note dated 10/6/23 at 1:23 p.m., indicated R9 had increased complaints of pain to venous ulcer. The area around the wound was reddened and the drainage was a green-yellow color. The note indicated a new order for cephalexin but did not indicate the wound had been cultured. R9's progress note dated 10/12/23 at 3:17 p.m., indicated R9 had continued pain to the venous ulcer despite antibiotic treatment. R9's progress note dated 10/17/23 at 11:15 a.m., indicated R9 had a moderate amount of drainage from her venous ulcer on her right lower extremity (RLE) as well as redness around the wound. R9's Nursing Home Note dated 10/19/23 at 3:36 p.m., indicated R9 had an opened wound on her RLE that was slow to heal. The note indicated that R9 had taken cephalexin for presumed cellulitis. Nurse practitioner (NP)-I indicated the wound was actually worse than it was prior to the antibiotic. R9's progress note dated 10/19/23 at 4:51 p.m., indicated R9 had a wound on her RLE that was worsening. During an interview on 10/23/23 at 2:52 p.m., R9 stated she had a wound that she acquired while in the facility on her right lower leg, that hurts really bad. During an interview on 10/26/23 at 10:33 a.m., medical doctor (MD)-A stated R9's wound had reopened while at the facility, so they had reached out to the nurse practitioner, who had prescribed cephalexin (a broad-spectrum antibiotic). MD-A stated after R9's seven-day course, the wound had not resolved. MD-A stated the wound was then cultured for the infectious agent on 10/20/23 and she was started on Levofloxacin, an antibiotic that would work more effectively against the bacteria in the wound. MD-A stated that R9's wound may not have progressed to the degree it had if the correct antibiotic had been utilized. The facility Antimicrobial Stewardship Program policy dated January 2018, indicated the purpose of the program was to promote the appropriate use of antimicrobials in order to improve resident outcomes while minimizing toxicity and the emergence of Antimicrobial resistance by selecting the appropriate dose, route and duration of treatment. The program committee was responsible for: demonstrating improvements, including sustained improvements in proper antibiotics use, such as through reductions in C-Diff, adherence to nationally recognized guidelines and best practices, providing ongoing healthcare practitioner education regarding Antimicrobial initiatives, and collecting, tracking, and analyzing Antimicrobial use and resistance patterns. The policy also indicated, in accordance with the CDC Core Elements of Hospital Antibiotic Stewardship Program recommendations, all prescriber's were required to document the duration of Antimicrobial therapy and to review its appropriateness after 48-72 hours from the initial order.

Based on observation and interview the facility failed to ensure a home-like environment was provided during dining services in 1 of 2 dining rooms reviewed. Findings include: During observation 4/13/22, at 7:30 a.m. six (6) residents were sitting in the second-floor dining room waiting for breakfast roughly 20 feet away from meal serving area. At 7:35 a.m. dietary aide (DA)-A, in a loud voice shouted to DA-B, regarding other co-workers, this is frustrating, no one seems to do what they are supposed to I am tired of this, they need to get this together. DA-B, stated He did not know, he needed to do that. On 4/13/22, at 8:14 a.m. during observation, maintenance staff proceeded to clean the hallway floors on an industrial auto ride-on floor scrubber in front of the dining room. The floor scrubber put out an excessive amount of loud noise which caused the nursing and dietary staff to raise their voice as they tried to communicate to the residents sitting in the dining room. During this observation, a resident got up from his table and covered his ears as he walked out of the dining room said, too much noise. On 4/13/22, at 9:30 a.m. when interviewed registered nurse (RN)-B, stated she had provided DA-A verbal coaching previously regarding her behavior and communication in front of the residents during mealtime. RN-B further stated it does not bring a calm environment when you hear staff complaining about other staff. On 4/13/22, at 10:08 a.m. when interviewed certified dietary manager (CDM)-A stated she had spoken to DA-A before regarding concerns of her behavior, especially in front of residents. CDM-A further stated, I know we are short staffed, but this is not an excuse for venting to other staff in front of residents. She stated if staff feel they need to vent frustrations, they should remove themselves away from residents and return when done. CDM-A further stated her expectation would be for all staff to promote and provide a homelike environment and keep all negative conservation out of the dining room. On 4/14/22, at 1:10 p.m. when interviewed director of nursing (DON) stated her expectation would be for staff not to complain in common areas where residents are located. DON further stated it is hard to figure out when would be a good time to clean the floor with the floor scrubber because it does put out a lot of noise. A policy for homelike environment was requested, but not provided by the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to comprehensively assess and implement interventions to ensure proper wheelchair positioning and prevent potential complications for 1 of 1 resident (R32) reviewed with positioning concerns. Findings include: R32's quarterly Minimum Data Set (MDS) dated [DATE], indicated R32 had severe cognitive impairment and diagnoses which included, arthritis and dementia. R32 did not walk, was not steady, required extensive assistance with transfers, totally dependent on staff for locomotion on unit, and had impairment on both sides of upper body and lower body. R32's annual Care Area Assessment (CAA) dated 9/2/21, indicated R32 did not trigger for activities of daily living (ADL), or functional ADL was addressed on the care plan. R32's care plan dated 3/7/22, identified R32 required assistance with mobility and all ADL's. R32 care plan directed staff to use a wheelchair with standard footrest and provide assist of one (1) to two (2) to assist with ADL's. R32's care plan further directed staff to use a horn cushion (a cushion to help prevent patients from sliding forward or out) in wheelchair to help with proper positioning. On 4/11/22, at 7:35 p.m. R32 was sleeping while sitting in a standard wheelchair with footrest wearing bilateral Prevlon boots (a boot cushioned bottom that floats the heel off the surface of the mattress, helping to reduce pressure) near the nurse's station. R32 had a lateral leaning of her upper body over the right side of her arm rest. R32's head and neck were positioned extremely forward and to the right shoulder which extended pass the wheelchair back support and right arm rest. No staff was observed to reposition R32 while in the wheelchair or offer to lay R32 down in bed. On 4/12/22, at 1:15 p.m. R32 was observed sleeping while sitting in a standard wheelchair with footrest wearing bilateral Prevlon boots in her room. R32 had a lateral leaning of her upper body over the right side of her arm rest. R32's head and neck were positioned extremely forward and to the right shoulder which extended pass the wheelchair back support and right arm rest. On 4/13/22, at 7:46 a.m. R32 was sitting in her wheelchair in dining room waiting for breakfast. R32's upper body leaned to the right side of her wheelchair over the right arm rest. R32's head and neck were again extremely forward and to the right shoulder which extended pass the wheelchair back support and right arm rest. Review of R32 nurse progress notes lacked indication R32 had issues with positioning or leaning over the armrest of her wheelchair. R32 physician order dated 4/13/22, indicated a consult for (occupational therapist) OT for wheelchair positioning due to leaning and positioning in wheelchair. On 4/13/22, 9:30 a.m. during interview registered nurse (RN)-B stated she had noticed R32 was leaning more in her chair and had difficulty sitting up straight in her wheelchair. RN-B further stated R32 could benefit from an OT evaluation to assess better positioning. On 4/14/22, at 9:17 a.m. during interview with OT-A stated, she not seen R32 previously and would be seeing her today regarding leaning in the wheelchair. OT-A stated R32 needs to be assessed for possible need for interventions and R32 could benefit from a wedge to realign her hips, a thicker pillow for propping up R32 body, possible exercises to strengthen her back, or a different back on wheelchair for support. On 4/14/22, at 1:10 p.m. director of nursing (DON) stated her expectation for staff would be, if staff notice concerns regarding positioning of a resident, they will notify the physician and family, and obtain an order for therapy to assess and evaluate for positioning if appropriate. The facility Standard Work for Chair Position dated 11/30/18, indicated residents should be repositioned every two hours and ideally the resident should be repositioned to the bed or recliner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure the second floor kitchenette and dining room cleaning chemicals were secured away in a locked cabinet or cart, which had the potential to affect 21 of 37 residents who resided on the second floor and could access the kitchenette and dining room. Findings include: On 4/11/22, at 7:00 p.m. during observation on second floor dining room and kitchenette, a three-quarter full bottle labeled Ecolab Lemon-[NAME] Cleaner, a half full container of Comet with Bleach Cleaner, and a three-quarter full bottle of Dawn dishwashing liquid were in the second-floor kitchenette unsecured in a cabinet under the sink. A three-quarter full bottle of dishwashing liquid was observed sitting on the counter next to the faucet. Two residents were observed walking in and around the kitchenette area where the chemicals were in a unsecured cabinet. On 4/12/22, at 3:13 p.m. during observation on second floor of the dining room and kitchenette, a three-quarter full bottle labeled Ecolab Lemon-[NAME] Cleaner, a half full container of Comet with Bleach Cleaner, and a three-quarter full bottle of Dawn dishwashing liquid were found under sink in the second-floor kitchenette unsecured. Multiple residents were walking in and around the kitchenette area where the chemicals were in a unsecured cabinet. On 4/13/22, at 9:23 a.m. during observation with dietary aide (DA)-A, DT-A verified a three-quarter full bottle labeled Ecolab Lemon-[NAME] Cleaner, a half full container of Comet with Bleach Cleaner, and a three-quarter full bottle of Dawn dishwashing liquid were in the second-floor kitchenette unsecured. She further verified the door was unlocked and unsecured with resident coming in and out of the kitchenette. DT-A stated residents wander all the time in this area. On 4/13/22, at 9:24 a.m. administrator verified the chemicals were in the unlocked cabinet and stated her expectation for staff was to never leave chemicals unsecured where residents may have access. On 4/13/22, at 9:53 a.m. registered nurse (RN)-B, stated the cleaners should not have been left in the unsecured anywhere on second floor. She further stated second floor had quite a few residents with cognitive impairment and who are independently ambulatory and could have accidentally ingested the chemicals. On 4/13/22, at 11:17 a.m. the housekeeper (HSKP)-A stated it was a shared responsibility between the dietary department and housekeeping department to clean the kitchenette in the second-floor dining room. HSKP-A further stated chemicals should never be left in the kitchenette unlocked or unsupervised because of the residents who have memory issues on this floor, who could accidentally ingest the chemicals. On 4/13/22, at 2:10 p.m. the director of nursing (DON) stated her expectation would be all chemicals be stored properly per the storage guidelines. DON further stated chemicals should not be stored in the kitchenette if the cabinet could not be locked because the risk for a resident accidentally ingesting or spilling chemicals on themselves. DON further stated the responsibility of housekeeping and dietary to kitchenette and dining room, and properly store chemicals after they are done using them. The Procter and Gamble material safety data sheet (MSDS) for Comet Cleanser with Bleach dated 4/7/15, indicated the cleanser was hazardous to a person's health. The MSDS indicated to avoid contact with skin, eyes, or ingestion. The MSDS further to seek immediate medical attention if ingestion or eye or skin contact occurred. The P&G MSDS for Dawn Dishwashing liquid dated 10/5/15, indicated the cleanser was hazardous to a person's health. The MSDS indicated to avoid contact with eyes, or ingestion. The MSDS further to seek immediate medical attention if ingestion or eye contact occurred. The Ecolab Lemon-[NAME] cleanser MSDS dated 8/24/14, indicated Lemon-[NAME] Cleanser was hazardous to a person's health. The MSDS indicated to avoid contact with skin, eyes, or ingestion. The facility policy Management of Environment of care Hazardous chemicals review date 7/19, indicated the storage of hazardous chemicals shall be segregated from other storage areas.

Based on observation, interview, and document review, the facility failed to ensure floors, walls, equipment, and appliances were kept clean, and foods were stored and/or labeled. Additionally, the facility failed to ensure food was properly stored in resident refrigerators. These deficient practices had the potential to affect 68 of 69 residents who receive meals prepared in the facility's only kitchen. Findings include: During the kitchen tours with the assistant certified dietary manager (ACDM) on 4/11/22, at 12:17 p.m. and 4/12/22 at 1:58 p.m. with the certified dietary manager (CDM) on 4/13/22, at 9:30 AM the following observations were made and confirmed: Kitchen proper (place where food preparation occurs): On 4/12/22, the reach-in freezer located in the preparation area was observed with three opened bags of potato products (French Fries, tater tots, and potato patties) that were without a date or label. On 4/13/22, an opened bag of French Fries was observed without a date or label. On 4/12/22 and 4/13/22, the reach-in freezer located in the back kitchen area was observed with an opened blue bag of mixed vegetables that was without a date or label. The ACDM stated on 4/12/22 the kitchen policy was to keep protein foods for three days and other foods up to seven days. On 4/11/22, 4/12/22, and 4/13/22, the cooking station was observed. The two convection ovens were observed to be heavily soiled inside the doors and the interior with baked-on debris and spillage. The floor, wall, and pipes in and around the fryer, range ovens, and convection ovens were heavily soiled with grease residue, spillage, and food debris. On 4/11/22, 4/12/22, and 4/13/22, adjacent the cooking station, the floor, base boards and wall between equipment and appliances was observed with dried splatters and food debris. On 4/12/22, at 2:20 p.m. the ACDM stated the cooks cleaned their station and after hours the vent-a-hood company came to do the deep cleaning on a regular basis. At 2:44 p.m., the ACDM stated the cleaning company hadn't been coming due to COVID to clean the floors and ovens, so she put these items on the cleaning schedule. The ACDM was asked when the last time the cleaning service came, and she stated whenever they cleaned the vent-a-hood. An invoice for, clean kitchen hoods and complete grease exhaust vent systems was provided with a date of 12/7/21. On 4/13/22, at 9:25 a.m., the CDM stated the facility had a service that cleaned the interior of the ovens. However, they stopped their service of cleaning the ovens, and another company that deep cleaned the kitchen floors also stopped. Now, the staff were responsible for cleaning the ovens and floors. She went on to say the expectation for food storage was to seal the opened bag with a tie or transfer it into another container and a date and/or label placed on it. Kitchenettes: On 4/12/22 at 2:30 p.m. the second-floor kitchenette was observed with dried spillage in the refrigerator. The ACDM stated at this time the dietary staff managed the refrigerator during mealtime and the nursing staff managed it between mealtimes. Review of the kitchen's policy for food storage, dated 12/11/19, revealed perishable foods Refrigerate promptly upon receiving using the first in, first out (FIFO) method, frozen foods freeze promptly upon receiving the 1st in, 1st out method. Review of the kitchen's policy for kitchen sanitation, revised 04/2020, revealed Purpose: To maintain a clean, safe, and effective environment of care, and to prevent the transmission of disease-carrying organisms. Procedure: Positions have daily cleaning outlined on their sanitation sheets, including weekly deep cleaning projects. Review of the kitchen's master cleaning schedule revealed ovens were to be cleaned as needed/weekly walls as needed/weekly, and floors sweep as needed and mop daily. Observation of the resident area on the first floor on 4/11/22 at 5:35 p.m. revealed an unsecured refrigerator with multiple foods with and without labeling of dates opened and content. Contents included plates of resident foods, an opened container of cream cheese, multiple packages of opened sandwich meats and cheeses, multiple bottles of condiments including pickles, olives, and salad dressings. An open box of cereal was on top of the refrigerator. An open box of waffles was in the freezer along with multiple individual servings of ice creams. The refrigerator had signage that the refrigerator was for residents only and had a temperature tracking log that was current to 4/11/22. No staff was observed in the area. Observation of the resident area on the first floor on 4/12/22 at 8:30 a.m. revealed that staff and residents were in the dining room that was on the other side of the common area. The common area was a large L-shaped area with a satellite kitchen service area separating the dining area from another sitting area. The resident only refrigerator was in the separate area of the common area away from the dining area and not in sight of the nursing station or dining area. The refrigerator was noted to be unsecured and contained unlabeled foods including a paper bag from Arby's containing French fries with a resident name but no date and other foods in the refrigerator, most labeled with resident names, some labeled with dates opened including open pickle jars and potato salad with name, but no date opened (store bought). Observation of the resident only refrigerator on 4/12/22 at 9:54 a.m. revealed open and unlabeled items including buttermilk waffles in the freezer with the inner package open (resident name, no date opened), an opened bottle of jam (resident initials, no date opened), an open plastic carton of whipped cream spread (resident name, no date opened), chunk salmon in a bagel bag (resident name, no date), deli turkey slices in a baggie (resident name, no date), unlabeled wrapped white cheese slices, pickle loaf from a deli (no name, dated 04/1/22), an Arby's paper bag with French fries in bag (resident name, no date, not observed previous evening), an open package of sandwich ham (resident name, no date opened), a Ziploc package of sliced American cheese with obvious mold on part of the cheese (resident name, no date opened), multiple bottles of open olives (no resident names or dates opened), open bottles of olives (no name, dates opened 05/2/21 and 12/23/21), an open jar of banana peppers (no name or date opened), an open bottle of bread and butter pickles (no name or date opened), a bottle of open salad dressing (no name or date opened), and an open box of Cheerios cereal on top of refrigerator with the inner package also open to the air (resident name, no date opened). Observation on 4/13/22 at 12:15 p.m. revealed a resident opening the resident only refrigerator and removing something. No staff were with the resident. During an interview on 4/12/22, at 10:03 a.m. with health unit coordinator (HUC)-A she stated that usually only staff get in the resident only refrigerator but agreed that the refrigerator was accessible to residents. HUC-A said that she did not know why the refrigerator was not secured and does not know who is in charge. During an interview on 4/12/22, at 10:05 a.m. licensed practical nurse (LPN)-C stated the dietary department goes through the refrigerator daily. During an interview on 4/12/22, at 10:08 a.m. with Certified Dietary Manager (CDM) C, she said that Food and Nutrition Services (FNS) department monitors the refrigerator. She agreed that some of the items were not labeled properly and threw away the Cheerios and the Arby's bag. Said that the refrigerator used to be in another room and agreed that this refrigerator was accessible to residents. CDM-C She agreed that it should be more secure but stated that this was the FNS department responsibility and took the surveyor to that department. During an interview on 4/12/22, at 10:16 a.m. with the Operations Manager she stated that she was the new Operations Manager and did not know the resident refrigerator rules if the food has been opened. She stated that she would ask the Director of FNS to provide the policy for food brought in by residents/families. She also stated that in the hospital the foods are secured. During an interview on 4/12/22, at 1:35 p.m. with registered nurse (RN)-A she stated all food should be labeled with the resident name and date opened and discarded if not. RN-A said that FNS monitored the refrigerator. She agreed that having foods readily available to residents could be a problem and it was her expectation that the refrigerator be monitored by staff. RN-A requested advice on whether to lock the refrigerator. During an interview on 4/12/22, at 3:00 p.m. with certified dietary manager (CDM)-A she stated that she was the Director of FNS. CDM-A she stated that they want a homelike atmosphere in the facility, and that the common refrigerator was better than refrigerators in the resident rooms. She said that FNS only monitors refrigerator temperatures, and nursing and families should follow food labeling guidelines. She said there is no ownership of the issue and no policy addressing foods in resident refrigerators. During an interview on 4/13/22, at 2:40 p.m. with the director of nursing (DON) the DON stated that it was her expectation that all food storage and labeling policies be followed. Review of the facility policy Food Handling and Storage revised 1/10/20 reflected Labeling Foods .all items not in original containers must be labeled .Food labels must contain common name of food item or other identifying name and Dating Foods .each food item must have an opened on date clearly marked. Review of the facility policy Food Storage revised 12/11/19 reflected POLICY The Food & Nutrition Services Department (is) (sic) to develop a mechanism to ensure the safe and accurate storage of food and nonfood products. Food storage methods are strictly defined. Review of the facility policy Outside Food - (facility, sic) revised 1/10/20 reflected Residents and patients have the right to bring food from outside sources if they desire .Any food not purchased through or produced at (facility, sic) will be placed in designated refrigerators and/or freezers (labeled For Resident Use Only or 'For Patient Use Only') .All food items must be labeled with the date the food was brought into the facility and the resident/patient name and/or room number .Per MN Food Code guidelines, food items will be discarded after 7 days unless otherwise stated. (See above). FNS staff reserves the right to discard sooner if applicable. Review of the posting on the refrigerator Please keep our refrigerator safe, clean, and organized by following these regulatory guidelines dated 03/10/21 by FNS reflected: The state of Minnesota's Food Code requires us to dispose of Potentially Hazardous Food with-in (sic) seven (7) (sic) calendar days of preparation. See below; 4626.0400 3-50 1. 1 7 READY-TO-EAT, POTENTIALLY HAZARDOUS FOOD; DATE MARKING. Refrigerated, ready-to-eat potentially hazardous food prepared and held refrigerated for more than 24 hours in a food establishment shall be marked with the date of preparation to indicate the date by which the food shall be consumed, which is seven calendar days or less from the day of preparation, including the day of preparation .Any food items in refrigerator without a name or date on it will be thrown out immediately.