**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and facility policy review, the facility failed to accurately complete a Minimum Data Set (MDS) Discharge assessment for one (1) of nineteen (19) assessments reviewed. Resident #93. Findings Include: A review of the facility's policy titled Conducting an Accurate Resident Assessment, revised in February 2023 and October 2023, revealed: Policy: The purpose of this policy is to assure that all residents receive an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas. A record review of the admission Record revealed that the facility admitted Resident #93 on 09/19/24 with diagnoses including Chronic Kidney Disease. A record review of the Order Summary Report revealed Resident #93 had a Physician's Order dated 10/4/24 to discharge to home on [DATE]. A record review of the Discharge (MDS with an Assessment Reference Date (ARD) of 10/06/24 indicated Resident #93 was discharged to a Short-Term General Hospital. During an interview on 10/22/24 at 11:00 AM, the Director of Nursing (DON) explained that Resident #93 was only at the facility for therapy, and although the discharge was planned, it was sudden due to the resident's insurance status and personal choice. She confirmed that Resident #93 was discharged to his home with his wife. At 1:15 PM on 10/23/24, during an interview with Licensed Practical Nurse (LPN) #1, she confirmed that she completes Section A of the MDS. She initially believed that she coded Resident #93's discharge correctly as discharged home but, after reviewing the Discharge MDS, she confirmed it was coded as though the resident discharged to short-term general hospital, which was not accurate. During an interview on 10/24/24 at 09:50 AM, the DON acknowledged awareness of the inaccurate discharge status for Resident #93 and recognized it as a coding error. She stated that she signs off on assessments for accuracy and completion, explaining that she expects all MDS staff, as well as herself, to complete assessments accurately and correctly. The DON confirmed that the discharge status for Resident #93 was completed in error and emphasized her expectation of accuracy in all assessments conducted by the facility staff.

Based on observation, interviews, record review, and facility policy review, the facility failed to implement care plan interventions for one (1) of nineteen (19) sampled residents. Resident #6. Findings Include: A review of the facility policy titled Comprehensive Care Plans, revised 8/24/22 revealed, .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs as identified in the resident's comprehensive assessment . A record review of the comprehensive care plan for Resident #6 revealed a Problem of The resident is dependent on staff for meeting emotional, intellectual, physical, and social needs with Interventions including Provide the resident with materials for individual activities as desired. The resident likes the following independent activities: Spanish word search puzzles .add content of interest i.e. Spanish speaking programs . A record review of the admission Record revealed the facility admitted Resident #6 on 03/04/21 with diagnoses including Parkinson's Disease. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/20/24 revealed Resident #6's preferred language was Spanish, and she had a Brief Interview for Mental Status (BIMS) score of four (4), which indicated her cognition was severely impaired. On 10/21/24 at 11:01 AM, during an observation, Resident #6 was lying in bed, awake, with the television on an English-language channel. Upon asking Resident #6 if she would prefer the television to be on a Spanish-speaking channel, she nodded affirmatively. On 10/21/24 at 1:16 PM, in an interview, the Activities Assistant explained that the primary in-room activity she engaged in with Resident #6 involved brief visits to chat about family topics, including children and grandchildren. The Activities Assistant noted that the resident preferred staying in her room and did not participate in group activities. She added that Resident #6 enjoyed music, Spanish puzzles, coloring sheets, and watching television; however, she admitted that the television was set to English channels and that no attempts had been made to explore Spanish-language options. She acknowledged that no in-room activities were currently available that catered to Resident #6's cultural preferences. On 10/22/24 at 11:25 AM, during an observation and interview, the Activities Director confirmed that the facility had no culturally specific activities for Resident #6, who is Spanish speaking. While in Resident #6's room, she confirmed the presence of a CD player but observed no CDs or materials for the resident to play. The Activities Director stated she knew it was important for the resident to have activities that she specifically enjoyed because this was her home, and it was a part of making her feel loved and considered. On 10/23/24 at 8:13 AM, in an interview, the Administrator stated that she was not aware the activities department was not following the care plan regarding activities for Resident #6. She emphasized the importance of quality and continuity of care for all residents, noting that this is the resident's home, and the facility should cater to Resident #6's preferred activities and cultural preferences to ensure her satisfaction. During an interview on 10/23/24 at 8:45 AM, the Minimum Data Set (MDS) Coordinator explained that the purpose of each care plan is to guide facility staff in providing individualized care to each resident. She stated that not following the care plan for Resident #6's preferred activities was an issue, reinforcing the need for all staff to adhere to the resident's care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, and facility policy review, the facility failed to implement individualized and culturally relevant activities to meet the interests and preferences of one (1) of two (2) Spanish-speaking residents reviewed for activities. Resident #6. Findings Include: A review of the facility's policy, Activities, dated 10/1/22, revealed, Policy: It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on the comprehensive assessment, care plan, and preferences. Facility-sponsored group, individual, and independent activities will be designed to meet the interests of each resident .Policy Interpretation and Implementation .2. Activities will be designed with the intent to .g. Reflect cultural and religious interests of the residents .4. Activities may be conducted in different ways .b. Person Appropriate - activities relevant to the specific needs, interests, culture, background, etc. for the resident they are developed for . During an observation on 10/21/24 at 11:01 AM, Resident #6 was observed lying in bed, awake, with the television on an English-language channel. Upon asking Resident #6 if she would prefer the television to be on a Spanish-speaking channel, she nodded affirmatively. During an interview on 10/21/24 at 1:16 PM, the Activities Assistant explained that the primary in-room activity she engaged in with Resident #6 involved brief visits to chat about family topics, including children and grandchildren. The Activities Assistant noted that the resident preferred staying in her room and did not participate in group activities. She added that Resident #6 enjoyed music, Spanish puzzles, coloring sheets, and watching television; however, she admitted that the television was set to English channels and that no attempts had been made to explore Spanish-language options. She acknowledged that no in-room activities were currently available that catered to Resident #6's cultural preferences. During an observation and interview on 10/22/24 at 11:25 AM, the Activities Director confirmed that the facility had no culturally specific activities for Resident #6, who is Spanish speaking. While in Resident #6's room, she confirmed the presence of a compact disc (CD) player but observed no CDs or materials for the resident to play. The Activities Director stated she knew it was important for the resident to have activities that she specifically enjoyed because this was her home, and it was a part of making her feel loved and considered. During an interview on 10/23/24 at 8:13 AM, the Administrator stated that she was unaware that the activities department was not providing culturally relevant activities. She emphasized the importance of providing quality and consistent care for all residents, acknowledging that Resident #6's cultural preferences should be respected as part of honoring her home environment. During an interview on 10/24/24 at 9:55 AM, Resident #6's granddaughter, acting as her Resident Representative (RR), shared that in her four years of visiting the facility, she had not observed any activities provided that aligned with her grandmother's cultural background. She expressed that her grandmother would benefit from having television programs or audio content in Spanish, as she believed this would enhance her enjoyment and connection to her heritage. A record review of the Visual/Bedside [NAME] Report as of 10/22/24 revealed .Resident Care .Activities .Proved the resident with materials for individual activities as desired. The resident likes the following independent activities: Spanish word search puzzles . A record review of the admission Record revealed the facility admitted Resident #6 on 03/04/21 with diagnoses including Parkinson's Disease. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/20/24 revealed Resident #6's preferred language was Spanish and she had a Brief Interview for Mental Status score of 4 which indicated her cognition was severely impaired.

Based on staff interview, record review, and facility policy review, the facility failed to accurately document a resident's weight in the medical record for one (1) of 19 sampled residents. Resident #49 Findings include: A review of the facility's policy, Weighing and Measuring the Resident, dated 8/2/22, revealed, .The purpose of this procedure are to determine the resident's weight .to provide .an ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident .Documentation .The following information should be recorded in the resident's medical record .2. The .weight of the resident .Reporting 1. Report significant weight loss/weight gain to the nurse supervisor . A record review of the admission Record revealed the facility admitted Resident #49 on 5/29/2023 with diagnoses including End Stage Renal Disease. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/30/2024 revealed Resident #49 had a weight loss of 5% or more in the last month or loss of 10% or more in last six (6) months. A record review of the Weights and Vitals Summary revealed Resident #49 had a Warning on 5/17/24 of a significant weight increase in which his weight was recorded as 211.4 pounds. On 5/20/24, there was a Warning that Resident #49 had a significant weight loss in which his weight was recorded as 186.5 pounds. On 10/22/2024 at 3:29 PM, in an interview with the Director of Nursing (DON), she explained she was unaware that Resident #49 had triggered a warning for weight loss as it had not been on the weekly weight reports. The DON expressed she believed the weight entered for Resident #49 on 5/17/24 was entered in error and that the resident's weights have been between 175-192 pounds since his admission by the facility. In an interview on 10/23/24 at 2:20 PM, with the Dietary Manger, she explained she was responsible for entering the information to complete Section K of the Minimum Data Set (MDS). She stated that she entered the residents' weights that are given to her from the weight team. She said that she if she saw a weight that looked inaccurate, she would question the weight team. The Dietary Manager expressed that having accurate resident weight information was important because the one inaccuracy can have a negative effect on other parts of the MDS. On 10/23/24 at 3:10 PM, in an interview with Registered Nurse (RN) #1, she explained there were several factors that could contribute to a change in a resident's weight. She further explained that any major weight gains or losses would be triggered by the computer system and the resident would be re-weighed to ensure accuracy. RN #1 reviewed the weights entered into the medical record for Resident #49 and expressed that the weights were not accurate, and she was unsure as to why the resident was not re-weighed.

Based on observation, interview, and facility policy review, the facility failed to store reusable medical equipment in a manner to prevent the possible spread of infection as evidenced by mechanical lift batteries stored in the biohazard room on the rehabilitation hall for one (1) of two (2) biohazard storage rooms reviewed. Findings include: A review of the facility's policy, Infection Prevention and Control Program, revised 6/15/23, revealed, Policy: This facility has established and maintained an infection prevention and control program to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines .Policy Explanation and Compliance Guidelines .10. Equipment Protocol .a. All reusable items and equipment requiring special cleaning, disinfection, or sterilization shall be cleaned in accordance with current procedures . During an observation on 10/24/24 at 10:11 AM, of the biohazard room located on the Rehabilitation Hall, there was two (2) mechanical lift batteries on charging stations and two (2) batteries stored in the room. On 10/24/24 at 11:00 AM, in an interview and observation with Certified Nurse Aide (CNA) #1, the mechanical lift battery charging station and batteries were in the biohazard room on the Rehabilitation Hall. CNA #1 explained that the biohazard room was considered a dirty area and where she would place batteries that needed to be charged and would get the charged batteries as needed. There were no cleaning supplies available in area for sanitizing the batteries before using them on the mechanical lifts. On 10/24/24 at 11:08 AM, in an interview and observation with the Director of Nursing (DON), Registered Nurse (RN) #2, and RN #3 (Infection Control Team) they confirmed the mechanical lift charging stations and batteries were stored in the biohazard room on the Rehabilitation Hall and that any items retrieved from the contaminated room should be cleaned before re-using. The infection control team also confirmed there were no cleaning supplies in the area for the staff to clean the batteries before using. On 10/24/24 at 11:14 AM, in an interview with the Administrator, she stated she expected the facility staff to not store clean items in an area that is considered contaminated.

Based on interviews, observations, and facility policy review the facility failed to prevent the possible spread of infection during medication preparation for one (1) of three (3) medication administration observations. A record review of the facility's policy, Administering Medications, revised 8/2/22, revealed, .Medications shall be administered in a safe .manner .Policy Interpretation and Implementation .19. Staff shall follow established facility infection control procedures . On 2/15/23 at 8:12 AM, during an observation of medication pass with License Practical Nurse #1 (LPN), she prepared medications to be administered by placing medications in a clear medication administration cup. She dispensed Duloxetine HCI capsule 30 mg (milligrams) from a medication card into her bare hand, and then placed the capsule into a clear medication administration cup, along with medications she had previously placed in the cup for the resident. LPN #1 entered the Resident #342's room and administered the medications to the resident. Record review of the Order Summary Report for Resident #342, included an order dated 2/3/23, for Duloxetine HCI capsule delayed release particles 30 mg. Give 1 capsule by mouth one time a day for (Depression). On 2/15/23 at 8:45 AM, in an interview with LPN #1, she stated that she should not have put the medication into her bare hand and that she was not paying attention to what she was doing. She confirmed that she should have dispensed the medication directly into the cup and that she had contaminated the other medications she had previously placed in the cup. On 2/15/23 at 9:49 AM, in an interview with the Director of Nursing (DON), she stated that when LPN #1 touched the medication with her hands, it was an infection control issue, and she should have discarded the medication. On 2/15/23 at 10:09 AM, in an interview with Registered Nurse #1 (RN)/Infection Prevention Nurse/Staff Development Nurse, she stated that LPN #1 should have discarded the medication when she touched it with her bare hand and that these actions increased the resident's chance of getting an infection because, Whatever was on the nurses' hands was on the medications when she gave them to the resident. A record review of the .Nurse Skills Checkoff List revealed LPN #1 completed a skills checkoff that included Medication Administration and was signed by LPN #1 and an Evaluator on 8/5/22. A record review of the facility document Infection Control for Medication Cart, dated 8/5/22, revealed the facility provided training to LPN #1 which included, Do not touch pills without gloves on hands .

Based on observation, record review, facility policy review, and staff interview, the facility failed to prevent the possible spread of infection, during medication preparation for two (2) of five (5) nurses observed administering medications. Findings include: Review of the facility's Administering Medications, policy, dated 12/2017, revealed staff should follow established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) when these apply to the administration of medications. Review of the facility's Infection Control Guidelines for All Nursing Procedures, dated August 2015, revealed the purpose of this document is to provide guidelines for general infection control while caring for residents. The document indicated standard and transmission-based precautions are used to prevent the spread of infection. The document noted that employees must wash their hands. The document noted in most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. The document noted the alcohol based hand rub is to be used before preparing or handling medications. During an observation on 9/24/2019 at 9:15 AM, Licensed Practical Nurse (LPN) #1 prepared to administer oral medications to a resident. LPN #1 placed her ungloved right (R) index finger into a bottle of Aspirin to retrieve a tablet. LPN #1 placed the tablet with her bare hand from the bottle into the medication cup. LPN #1 placed seven (7) additional pills into the same medication cup. LPN #1 administered all of the medications from the medication cup to a resident. During an interview on 9/24/2019 at 9:29 AM, LPN #1 confirmed that she had retrieved the Aspirin tablet with her bare hand and put it in the medication cup for a resident. LPN #1 stated, That was stupid, I knew I shouldn't have done that. LPN #1 stated that you should never touch a medication with your bare hands to give to a resident. LPN #1 stated that touching medications with your bare hands could cause the spread of infection. During an observation on 9/25/2019 at 9:07 AM, LPN #2 prepared oral medications for a resident. LPN #2 placed each oral medication, from it's respective bubble pack, into the palm of her bare hand, and then into the medication cup. LPN #2 prepared a total of nine (9) oral medications in this manner. LPN #2 administered all nine (9) oral medications to the resident. During an interview on 9/25/2019 at 9:20 AM, LPN #2 confirmed she had placed each pill, for a total of nine (9) oral medications, into her bare hand, placed the medication into the cup, and administered the medication to the resident. LPN #2 stated there could have been bacteria on her hands, and it could have spread to the resident. LPN #2 stated she had been trained on the correct way to dispense medications. During an interview on 9/24/2019 at 11:50 AM with the Director of Nursing (DON), the DON stated that nurses should never touch the oral medications with their bare hands. The DON stated that touching medications with bare hands would be an infection control concern. During an interview on 9/26/2019 at 11:46 AM, the Director of Nursing (DON) confirmed that touching or placing medications into your bare hands is not how she would expect the nurse to prepare and give oral medications. Review of the facility's in-service documentation records revealed LPN #1 and LPN #2 had both been trained on the steps and process to follow proper infection control techniques during medication administration. LPN #1 on 10/17/18, and LPN #2 on 9/6/19.

Based on resident interviews, observations, and facility statement, the facility failed to ensure residents were aware of the location and availability of the most recent survey results, for four (4) of five (5) residents who attended the group meeting. Findings include: Review of the facility statement, signed by the Administrator, dated 9/26/19, revealed: One (1) of the Resident's rights is to have survey results, with plans of correction, for the past three (3) years, posted in a place accessible to residents. Per the Resident Rights, these results are in the facility at each nurse's station. During the group meeting on 9/24/2019 at 1:30 PM, four (4) of five (5) residents did not know where the survey results were located in the facility. During an interview, on 09/25/19 at 2:45 PM, Social Worker #1 did not know where last year's survey results were posted. Social Worker #1 stated she did not know how the residents were being educated as to where the survey results were posted. During an interview on 09/25/19 at 2:50 PM, Activity Director #1 stated that Social Services conducts Resident Council meetings. Activity Director #1 stated she had not educated the residents on where last year's survey results were posted. Observation on 09/25/19 at 9:30 AM, revealed survey results were posted on the table in the front lobby. There was a sign on the wall in the South Nursing Station, that survey results are posted in the front lobby. A sign was not posted on the North Hall or on the Rehabilitation unit, indicating where survey results were posted.