Based on staff interview, record review, and facility policy review, the facility failed to ensure the medical provider was notified of a resident refusing multiple doses of prescribed antibiotics for one (1) of six (6) residents reviewed for medication use. Resident #21 Findings include: Record review of facility policy titled Medication Administration dated 1/24, revealed, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection .18. Report and document any adverse side effects or refusals . During an interview on 9/25/24 at 3:50 PM, Registered Nurse (RN) #2 revealed Resident #21 had recently been in the hospital and diagnosed with pneumonia and was on antibiotics. She revealed the resident would often refuse her medications and that if a resident refused medications, the nurse was to notify the provider and the resident's representative. On 9/25/24 at 4:10 PM, an interview with the Director of Nursing (DON) revealed Resident #21 refused several doses of the antibiotic medication ordered for the treatment of pneumonia and the provider was not notified. She confirmed it was important to notify the provider so that appropriate care could be ordered. She confirmed the facility failed to notify the provider of the antibiotic medications refused by this resident. During a phone interview on 9/25/24 at 4:30 PM, the Nurse Practitioner stated she was in the facility last week and was aware the resident refused to take her medications for a few days but thought she had restarted taking them. She stated she was unaware that the resident refused her antibiotics which included the past two doses that would have completed her 10-day course of antibiotics. She stated it was important for the provider to be notified of refusals of medications so treatment could be reevaluated, and the treatment course could be changed to ensure the resident received appropriate care. She also stated that not receiving ordered antibiotic medications could lead to an infection not being treated effectively. An interview with the Administrator on 9/26/24 at 8:20 AM, confirmed the facility failed to notify the provider that a resident refused multiple doses of an antibiotic ordered for pneumonia. She confirmed that notifying the provider was necessary so an alternate treatment could be ordered if the provider chose that option. During an interview on 9/26/24 at 12:10 PM, RN #2 stated she was not notified that Resident #21's antibiotic medication was not administered due to the resident refusing. She stated that typically the Licensed Practical Nurse (LPN) would notify the RN and the RN would notify the provider and enter any new orders that were given by the provider. She confirmed that since she was unaware of the resident refusing her last two doses of her antibiotics, the provider was not notified. A phone interview with LPN #1 on 9/26/24 at 12:15 PM, revealed she attempted to give Resident #21 her antibiotics on several different days and would attempt several times each day, but the resident refused each time. She stated during the previous week, she had notified RN #1 of the refusals, but on 9/23/24 and 9/24/24, she did not notify RN #2 of the refusals. She admitted she did not see RN #2 immediately after the refusals and she just forgot. She stated she did document the refusals in the Electronic Medication Administration Record (EMAR), but for the dates of 9/23/24 and 9/24/24, she did not notify the RN. She stated she had been in-serviced on medication administration and was aware of the process for notification to the RN if the resident refused medications and the RN would notify the provider. During a phone interview on 9/26/24 at 12:25 PM, RN #1 stated she had notified the provider of the resident's refusals of medications last week. She stated the process for refusals are for the LPN to inform the RN and the RN would notify the provider. During an interview on 9/26/24 at 12:45 PM, the DON confirmed the facility failed to notify the provider of the resident's refusal of her antibiotics. She confirmed a resident not receiving antibiotics as ordered could lead to the infection not being treated properly. She stated LPN #1 had been in-serviced on medication administration and should have notified the RN so the RN could have notified the provider. Record review of Progress Note of Registered Nurse (RN) #2 dated 9/13/24, revealed, Notified by Cart Nurse that resident was having chest pain. Asked resident if she (by pointing and verbally asking) resident was she having chest pain and resident nodded, 'yes'. Notified (proper name removed) Nurse Practitioner (NP), NP gave orders to send out the the ER (Emergency Room). Record review of Order Summary Report revealed an order dated 9/13/24 to send resident to ER for c/o (complaints of) chest pain. Record review of hospital Emergency Department Note dated 9/14/24, revealed a diagnosis of Pneumonia of left lower lobe due to infectious organism. Record review of nursing Progress Note dated 9/14/24, revealed, Elder returned from hospital per ambulance. Alert and oriented with eyes opened. Report received from ER. Elder x-ray showed pneumonia . Prescription given for Elder's condition. Record review of Resident #21's Order Summary Report revealed an order dated 9/14/24 for Cefdinir Oral Suspension 250 mg (milligrams)/5 ml (milliliters) give 12 ml by mouth in the morning for pneumonia for 10 days with start date of 9/15/24 and end date of 9/25/24. Record review of Resident #21's Electronic Medication Administration Record (EMAR) revealed on 9/23/24 and 9/24/24, the resident did not receive the ordered antibiotic with the reason documented as Drug Refused. Record review of Resident #21's admission Record revealed the facility admitted the resident on 5/6/2016 with diagnoses that included Shortness of breath and Dementia. Record review of Resident #21's quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 8/27/24, revealed Should Brief Interview for Mental Status be conducted? Response to this was, No (resident is rarely/never understood).

Based on staff interviews, record review, and facility policy review, the facility failed to implement a care plan for one (1) of 18 sampled residents' care plans. Resident #21 Findings Include: Record review of facility's policy titled, Comprehensive Care Plans dated 10/22, 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 include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Record review of Resident #21's care plan revealed a focus area dated 9/15/24 of Elder has pneumonia. Interventions listed included administer medications as ordered, Cefdinir for ten days for pneumonia, and to keep informed of changes and update MD as needed. An interview with the Director of Nursing (DON) on 9/25/24 at 4:10 PM, revealed Resident #21 refused several doses of the antibiotic medication ordered for the treatment of pneumonia and the provider was not notified. She stated the care plan gives information to care for the resident's needs and she confirmed the care plan for antibiotic medication administration as ordered for treatment for pneumonia and to keep informed of changes and update RP (Resident's Representative) and MD (Medical Doctor) as needed, was developed but was not followed. During an interview on 9/26/24 at 10:30 AM, the Minimum Data Set (MDS) Coordinator revealed she is one of the facility staff members responsible for developing the care plans for the residents. She stated the care plan is to inform staff of the needs of the residents and the care needed for the resident and should be followed to ensure the care is appropriate. She stated the care plan for Resident #21's diagnosis of pneumonia was developed and included the interventions to administer the medications as ordered, antibiotics each morning for 10 days for pneumonia, and to update Medical Doctor as needed and keep informed of changes. She confirmed the care plan was not implemented. Record review of Resident #21's Order Summary Report revealed an order dated 9/14/24 for Cefdinir Oral Suspension 250 mg (milligrams)/5 ml (milliliters) give 12 ml by mouth in the morning for pneumonia for 10 days with start date of 9/15/24 and end date of 9/25/24. Record review of Resident #21's Electronic Medication Administration Record (EMAR) revealed on 9/23/24 and 9/24/24, the resident did not receive the ordered antibiotic with the reason documented as Drug Refused. Record review of Resident #21's admission Record revealed the facility admitted the resident on 5/6/2016 with diagnoses that included Shortness of breath and Dementia. Record review of Resident #21's quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 8/27/24, revealed Should Brief Interview for Mental Status be conducted? Response to this was, No (resident is rarely/never understood).

Based on observation, interview, record review and facility policy review the facility failed to initiate contact isolation precautions for a resident with Methicillin-resistant Staphylococcus Aureus (MRSA) and failed to prevent the possibility of the spread of infection by not utilizing proper hand hygiene for one (1) of four (4) resident care observations. Resident #19. Findings Include: Review of the facility policy Clean Dressing Change dated 10/2022 revealed, It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination. Review of the undated facility policy Transmission-Based Precautions revealed, It is our policy to take appropriate precautions to prevent transmission of infectious agents Contact Precautions - Intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the resident or the resident's environment . On 09/24/24 at 1:00 PM, on entrance into the facility, a brief interview with Administrator (ADM), revealed that there were no residents on Transmission Based Precautions (TBP). On 09/24/24 at 2:30 PM, an interview with Resident #19 revealed that he had two wounds on his bottom, that the nurses were cleaning them and changing the dressings every day. On 09/25/24 at 10:40 AM, an observation revealed Licensed Practical Nurse (LPN) #1, completed wound care to Resident #19's pressure ulcers to his sacrum and left buttock using enhanced barrier precautions (EBP). LPN #1 washed her hands and donned a gown and gloves. She removed the old dressing and then cleaned the sacral wound and cleaned the wound to his left buttock with normal saline without changing her gloves. LPN #1 changed gloves after cleaning both wounds, applied the ordered treatment to both wound beds and covered the wounds with bordered foam dressings. LPN #1 did not perform hand hygiene between glove changes, and she used the same gloves to clean both wounds. LPN #1 removed her gown and gloves, disposed of them in a trash can designated for Personal Protective Equipment (PPE) just inside the resident's door, and she washed her hands. There was no Contact Precaution signage observed on Resident #19's room door and there were no biohazard containers in his room. On 09/25/24 at 10:50 AM, an interview with LPN #1, revealed that Resident #19 had the wounds to his sacrum and left buttocks for several months and they were improving. She revealed that they used enhanced barrier precautions with any resident with wounds to protect the residents as well as themselves. LPN #1 confirmed that she did not change her gloves after removing the soiled dressing before cleaning both of the wound areas and also failed to change gloves between the two different wound care areas. She also confirmed that she had cleaned both wounds using the same gloves and agreed that she should have completed wound care on one wound before going to the next to prevent cross contamination. In an interview on 09/25/24 at 10:55 AM, LPN #1 revealed that she Just remembered that Resident #19 was diagnosed with MRSA (Methicillin-Resistant Staphylococcus Aureus) to one of the wounds a couple weeks ago and she was Pretty sure he still had it. She also confirmed that any resident with MRSA should be on contact isolation precautions to prevent the spread of infection. On 09/25/24 at 11:00 AM, an interview with Infection Control Nurse (ICN) revealed that Resident #19 was on EBP because of his wounds. She revealed that Resident #19 had a wound culture a couple weeks ago and was on antibiotics. ICN pulled up Resident #19's wound culture results on his Electronic Medical Record (EMR) and confirmed the positive MRSA results and stated, I was not aware that he had MRSA, I didn't catch that. She revealed that Resident #19 should be on contact isolation precautions to prevent the spread of infection and that she would take care of that now. ICN revealed that contact precaution signage should be on the door and that there should be PPE outside the resident's door and they should have red barrels placed inside his room for staff to dispose of their used PPE. She revealed that they reviewed all antibiotics in their Quality Assurance (QA) meetings every month and went over antibiotics and infections weekly in their high-risk meetings. ICN revealed that it was important to follow the correct guidelines when doing wound care on a resident with MRSA to prevent the spread of infection. On 09/26/24 at 9:10 AM, an interview with Certified Nursing Assistant (CNA) #1, revealed that she had heard a couple weeks ago that Resident #19 had MRSA to one of his wounds. She revealed that she was already wearing masks, gloves and gowns and was not told to treat him any differently. She revealed that the ICN placed the contact precaution sign on his door and red barrels in the room yesterday. CNA #1 revealed that usually when a resident was placed on contact precautions, they had in-services, and the nurses let them know. She revealed that it must have been a miscommunication problem. On 09/26/24 at 12:22 PM, a phone interview with Registered Nurse (RN) #1, revealed that Resident #19 had wounds and that the wound center had called in positive MRSA culture results to her a couple weeks ago. RN #1 revealed that Resident #19 was currently taking two antibiotics for the MRSA and was ordered to take it for thirty days. She revealed that this resident should be on contact precautions to prevent the spread of infection in the facility. On 09/26/24 at 1:15 PM, an interview with Director of Nursing (DON) and Administrator (ADM), revealed that the person who took the call about the positive culture results, should have initiated the Contact Isolation Precautions for Resident #19. She revealed that it was everyone's responsibility who knew about the infection to get it initiated. She revealed if they had staff members in the room caring for a resident who they knew had MRSA, the staff should look at protecting the resident and ensuring that measures were in place to prevent the spread of infection. Record review of Resident #19's Wound Culture revealed that the culture of his left buttock pressure ulcer was collected on 08/30/24 and final MRSA results were received on 09/02/24. Record review of Resident #19's admission Record revealed an admission date of 09/01/2015 and had diagnoses that included Hemiplegia and Hemiparesis following Unspecified Cerebrovascular Disease, Stage 2 Pressure Ulcer of Sacral Region, and Stage 4 Pressure Ulcer of Left Buttock. Record review of Resident #19's Order Summary Report revealed an order with start date of 09/04/24 for Amoxicillin Oral Capsule 500 MG (milligrams) . Give 1 capsule by mouth three times a day for MRSA for 30 Days and Bactrim DS Oral Tablet 800-160 MG .Give 1 tablet by mouth two times a day for MRSA for 30 Days. Record review of Resident #19's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 09/12/24 under Section C revealed a Brief Interview for Mental Status (BIMS) score of 13 which indicated that he was cognitively intact. Record review of Resident #19's Progress Note dated 09/03/24 revealed new order for antibiotics related to MRSA infection in wound and was signed by RN #1.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interview, record review and facility policy review, the facility failed to prevent verbal abuse to a resident from a staff member for one (1) of three (3) residents reviewed for abuse. Resident #1 Findings Include: Review of the facility policy titled, Abuse, Neglect and Exploitation-2019 with a review date of 2019 revealed, Policy .It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. This review revealed under, IV. Identification of Abuse, Neglect and Exploitation .B. 5. Verbal abuse of a resident overheard. An interview on 6/11/24 at 8:05 AM, with the Administrator revealed she was notified on 5/26/24 by the Director of Nurses (DON) that Certified Nurse Assistant (CNA) #1 had been witnessed by CNA #2 and CNA #3 talking ugly to Resident #1 and was sent home that day pending an investigation. She stated that she investigated the incident and could not determine that it was verbal abuse, because of different stories from the witnesses and the resident. She stated that CNA #1 had issues with being disrespectful to co-workers and attendance issues and they determined that despite not substantiating that this incident was verbal abuse it was disrespectful to the resident, and she was terminated. She confirmed that telling a resident to stay off of their call light or threatening a resident would be considered verbal abuse and that all staff are in-serviced on abuse on hire. An interview on 6/11/24 at 9:27 AM, with the DON confirmed that Registered Nurse (RN) #1 called her on the morning of 5/26/24 to inform her that CNA #1 had been witnessed talking ugly to Resident #1 by CNA #2 and CNA #3. She revealed that she interviewed CNA #2 and CNA #3 over the phone with RN #1 present and they told her that CNA #1 had yelled at Resident #1 to stay off of his call light because she was shorthanded. She revealed that at that time she told RN #1 to immediately send CNA #1 home until the investigation was complete and to not return until they called her on Monday 5/28/24. An interview on 6/11/24 at 10:36 AM, with CNA #1 confirmed that she had been terminated by the facility for some interaction with resident, (Resident #1.) She denied saying anything inappropriate to Resident #1 but admitted to telling the resident that he had just used his call light to have his remote and cell phone given to him, which was right in front of him on his overbed table. She stated that she was not sure if she had attended any in-services at the facility about abuse, but she knew not to abuse a resident. She admitted to working two jobs but stated that it did not affect her work here at the facility. She admitted that her partner had called in that day, so she had to work alone with about 12 residents. An interview on 6/11/24 at 10:45 AM, with CNA #2 confirmed she was sitting out in the hall not far from Resident #1's room and CNA #1 was standing outside of his door yelling at him for pushing his call light again. She stated that she overheard CNA #1 tell the resident I'm not having it today, I'm shorthanded; keep it up and I'm gonna take that cell phone. She revealed that she thinks CNA #1 took the residents call light away from him. She admitted that she had worked with CNA #1 about 6 months, and she had a bit of an attitude, but she had never heard her talk to any residents that way. She stated that CNA #1's partner had called in that morning, and she thought she was frustrated about that, but that her and CNA #3 had offered to help, but she had refused. An interview on 6/11/24 at 11:00 AM, with CNA #3 confirmed that she was in the hall and heard CNA #1 yell at Resident #1 saying, Did I not tell you to not be on that d _ _ n light, I'm the only one here today, which was not true. Her partner had called in, but CNA #2 and I were there and had offered to help her, but she refused. She stated that shortly after this incident RN #1 walked down the hall toward them and asked why Resident #1 was calling her from his cell phone and that is when we told her what had happened. She stated she had heard CNA #1 talk smart to residents before, but not to this extent. An observation on 6/11/24 at 11:08 AM, of the camera footage during the time of the alleged verbal abuse with Resident #1 on 5/26/24 at approximately 9:35 AM revealed CNA #1 went into Resident #1's room around 9:35 AM and CNA #2 was sitting in the hall and CNA #3 walked out of the laundry room and stopped in the hall for a brief moment as CNA #1 came out of Resident #1 room and stood outside his door facing into the room. The video footage showed that the two CNA's were in hearing distance of Resident #1's room when CNA #1 went into the room. An observation on 6/11/24 at 11:10 AM of the area that CNA #2 and CNA #3 were standing in relation to Resident #1's room according to the camera footage was approximately 20 feet. An interview on 6/11/24 at 11:18 AM, with RN #1 confirmed that CNA #2 and CNA #3 reported to her on the morning of 5/26/24 that CNA #1 had told Resident #1 that he did not need to be on his call light because she was busy. She stated that she talked with Resident #1, and he told her that CNA #1 had told him that if he did not stay off of his call light that she was going to put him in his chair. She revealed she notified the DON and was told to send CNA #1 home, so she did after telling her it was concerns about how she was talking to Resident #1. An interview on 6/11/24 at 11:30 AM, with Resident #1 confirmed that CNA #1 had taken his call light and put it behind his bed because she said he was using it too much, so he used his cell phone and called the facility. He stated that (CNA #1's proper name) told him if he did not stay off of his call light, she was going to put him in his chair. He revealed he did not think she was yelling but was talking loudly and it did not upset him because he still had his phone and was able to call the facility to ask for help in his room. He revealed this was not the first time she had talked to him that way but admitted that he had never reported it to anyone. Record review of the facilities in-services on abuse revealed an in-service was held 2/21/24 but was not attended by CNA #1. Record review of CNA #1's new hire information revealed she was hired at the facility on 11/17/23 and signed acknowledgement of the Vulnerable Adults Act on 11/17/23. Record review of CNA #1's timesheet revealed she came in on 5/26/24 at 6:38 AM and left at 10:48 AM. Record review of Resident #1's admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Infarction and Aspergers Syndrome. Record review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/15/24 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and facility policy review the facility failed to develop a person-centered care plan for a resident with a contracture for one (1) of 14 resident care plans reviewed. Resident #16 Findings Include: Review of the facility policy titled, Comprehensive Care Plans with an implementation date of 10/2022 and no revision date revealed, Policy .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 a resident's medical, nursing and mental and psychosocial needs that are identified in the resident's comprehensive assessment. An observation on 07/11/23 at 9:55 AM, of Resident #16 revealed the resident had a right-hand contracture with a carrot roll placed in the right hand. Record review of Resident #16's care plans revealed there was no care plan regarding the right-hand contracture or placement of the carrot roll as to how long, how often or which days to apply the hand roll. An interview on 7/12/23 at 2:45 PM with the Minimum Data Set (MDS) nurse revealed she is responsible for developing care plans and entering them into the computer for nursing issues. She confirmed that Resident #16 had a hand contracture and did not have a care plan regarding her contracted right hand but she should have and stated that the care plan directs the care for the residents. An interview on 7/12/23 at 3:00 PM, with the Director of Nurses (DON) confirmed that Resident #16 did not have a care plan regarding her right-hand contracture. She confirmed that the resident should have a care plan regarding the hand contracture because that is what helps the staff to know how to care for the resident. Record review of the Task List Report revealed tasks with the date initiated of 3/8/23, Apply carrot orthosis in right hand with large end of carrot closest to thumb. Position at level II for up to 6 (six) hours every day and Remove carrot orthosis to right hand every day at 1 pm. May remove earlier if elder complains of intolerance. Record review of Resident #16's admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Parkinson's Disease. Record review of Resident #16's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/22/23 revealed in Section G that the resident had functional limitations in both upper extremities and in Section C a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident is moderately cognitively impaired.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and facility policy review, the facility failed to provide personal hygiene to a resident requiring assistance as evidenced by long nails with a brown substance underneath for one (1) of 14 residents sampled. Resident #5 Findings include: Review of the facility policy titled Nail Care with no revision date revealed, Policy: The purpose of this procedure is to provide guidelines for the provision of care to a resident's nails for good grooming and health. Policy Explanation and Compliance Guidelines: . 3. Routine cleaning and inspection of nails will be provided during Activity of Daily Living (ADL) care on an ongoing basis. 4. Principles of nail care: a. Nails should be kept smooth to avoid skin injury. b. Only licensed nurses shall trim or file fingernails of residents with diabetes . An observation on 7/12/23 at 8:15 AM, revealed a contracture to Resident # 5's right hand with all fingers bent inwardly toward the palm of the hand. A hand roll was observed intact and inside the palm of the hand and the skin was intact. Fingernails noted to be approximately three-eighths (3/8) inch in length with a brown substance underneath. An observation and interview on 7/12/23 at 9:32 AM, with Certified Nurse Aide (CNA) #1 confirmed that Resident # 5's fingernails on the right hand were long and had a brown substance underneath. She stated, Yeah, they are pretty long and need cleaning. She acknowledged that Resident # 5's long nails and hand contracture could result in skin breakdown. Furthermore, she revealed that the CNA's should clean and trim the residents' nails whenever they are needed. An interview with the Director of Nursing (DON) on 7/12/23 at 9:38 AM, confirmed that Resident #5's fingernails on the right hand were long and had a brown substance underneath. She stated, They are dirty and way too long. She confirmed that the aides are responsible for cleaning and trimming the fingernails of the residents that are not diabetic. She stated, They should be looking at the nails every day and during bathing; This is everyday stuff. Record review of the admission Record revealed Resident #5 was admitted to the facility on [DATE] with medical diagnosis that included Alzheimer's disease, Unspecified Osteoarthritis and Cerebrovascular Disease. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/28/23 revealed under section C a Brief Interview for Mental Status (BIMS) score of 09, indicating Resident #5 is moderately cognitively impaired and in Section G that the resident was totally dependent on staff for personal hygiene and bathing.

Based on observations, staff interview and facility policy review, the facility failed to store food items in a manner that maintains the safety of the food as evidenced by uncovered, unlabeled and undated food in the refrigerator and freezer for one (1) of two (2) kitchen tours. Findings include: Record review of the facility policy titled Storage of Food and Supplies with a revision date of 12/7/2020 revealed, Description: all food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Also revealed under, Method/How To/Procedure: . Cover, label and date unused portions and open packages. An observation of the chest freezer with the Dietary Supervisor on 7/11/23 at 9:15 AM, revealed a large round clear container with a dark yellow substance inside and no covering. There was no label observed to identify the substance or the date it was opened. An interview with the Dietary Supervisor revealed the item was frozen mango ice cream that was left over from 2 days ago. She confirmed that the mango ice cream did not have a cover and was unlabeled and undated. She confirmed that all items placed in the freezer should have a lid or cover over it and a label with the date it was opened so that food does not become contaminated. An observation of the refrigerator with Dietary Staff #2 on 7/11/23 at 9:45 AM, revealed three (3) small clear bowls with a tan substance inside and no covering. There were no labels noted to identify the substance or the date it was prepared. An interview with Dietary Staff #2 revealed the substance was applesauce, and she confirmed the bowls were uncovered and undated. She stated, I'm not going to lie to you; I don't know how long that's been in there. She stated, That's not supposed to be in there like that. She revealed it's important to label and date everything in the kitchen so that the food can be thrown out when the use by date has expired. She also stated, It's no way to know how long it's (the applesauce) been in there. An observation of the walk-in freezer with the Dietary Supervisor on 7/11/22 at 9:55 AM, revealed an open package of four (4) ounce whole kernel corn and an open clear bag of fries that were both unlabeled and undated. An interview with the Dietary Supervisor confirmed that the package of corn and fries had been opened and were not labeled or dated. She stated, They should have labeled it when they opened the bag. She confirmed that placing items in the refrigerator and freezer without a cover could cause contamination of the food item. She also confirmed that placing unlabeled, undated items in the refrigerator and freezer could be a concern to the residents health. An interview with the Administrator on 7/11/23 at 3:45 PM, acknowledged that all open items in the refrigerator and freezer should be covered, labeled, and dated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review and facility policy review the facility failed to follow the care plan for Activities of Daily Living related to Shaving residents for two (2) of five (5) residents reviewed and Position and Mobility related to placement of a splint for one (1) of three (3) residents reviewed with splints. Resident #1, Resident #15, and Resident #402. Findings Include: Review of facility policy titled, Comprehensive Care Plans, with a revision date of 11/2017 stated, It is the policy of [NAME] 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 a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. An observation, during initial tour, on 11/01/21 at 11:55 AM, revealed Resident #1, had a resting hand splint on her bedside table. Resident #1 had a contracture of the right wrist. An observation, on 11/2/21 at 01:30 PM, revealed Resident #1 was not wearing the resting hand splint on her right wrist. The resting hand splint was not observed visible on any surface in the room. An observation, on 11/3/21 at 09:16 AM, revealed Resident #1 did not have her resting hand splint on the right wrist. Resident #1 did respond to the request to pull her covers back and allow her right wrist to be observed for resting hand splint placement. The resting hand splint was observed across Resident #1's room in a chair. An observation, on 11/3/21 at 03:06 PM, revealed Resident #1 had the resting hand splint on her right wrist and appeared to be resting comfortably with the resting hand splint on. She did not show any visible signs of discomfort. An initial tour observation, on 11/01/21 at 11:30 AM, revealed Resident #15, had facial hair that appeared to be from several days of growth. Resident #15 appeared to need a shave. When asked if he wanted to shave, Resident #15 answered, Yes. An observation, on 11/2/21 at 09:39 AM, revealed Resident #15 continues to have facial hair and has not been shaved. An observation, on 11/3/21 at 09:12 AM, revealed Resident #15 continues to have facial hair and has not been shaved. An observation, on 11/4/21 at 08:40 AM, revealed Resident #15 continues to have facial hair and has not been shaved. Resident #15's facial hair was observed to be approximately one (1) inch long on today. An initial tour observation, on 11/1/21 at 11:30 AM, revealed Resident #402 was not shaved. Resident had facial hair that appears to be a result from several days growth. An observation, on 11/02/21 at 09:10 AM, revealed Resident #402 continues to have facial hair and has not been shaved. An observation, on 11/3/21 at 09:12 AM, revealed Resident #402 continues to have facial hair and has not been shaved. An observation, on 11/4/21 at 08:40 AM, revealed Resident #402 continues to have facial hair and has not been shaved. Resident's facial hair was observed to be approximately one-half inch long. An interview, on 11/3/21 at 03:11 PM, with Certified Nursing Aide (CNA) #2, revealed she had been assigned to Resident #1 on second shift for the past two (2) weeks. CNA #2 stated she had noticed Resident #1 had not been wearing the resting hand splint much in the past two (2) weeks. CNA #2 stated she saw Resident #1 did not have the resting hand splint on yesterday, 11/2/21. CNA #2 stated that she did not put the resting hand splint on Resident #1 on 11/2/21, because she could not find it in Resident #1's room. CNA #2 stated Resident #1 was supposed to wear the resting hand splint every day, for a certain number of hours, and it needed to be taken off to let Resident #1's hand rest. CNA #2 also stated the splint had to be removed to clean Resident #1's hand. CNA #2 stated she did not know why the resting hand splint was not being used on Resident #1's wrist. An interview, on 11/3/21 at 03:20 PM, with Licensed Practical Nurse, (LPN) #1 revealed she was not aware Resident #1 had a discrepancy with the order and care plan documentation regarding the resting hand splint. LPN #1 stated she did not remember how many times Resident #1 had not worn the resting hand splint for the past 3 days this week. An interview, on 11/3/21 at 04:10 PM, with the Director of Nursing (DON), revealed she had no knowledge the resting hand splint was not being adequately applied on Resident #1 according to the order and care plan. She stated she was not aware the documentation of the order and the documentation on the care plan, for the resting hand splint, did not match, regarding the use of the resting hand splint for Resident #1. The DON stated she was aware some of the facility care plans needed corrections. The DON stated all resident orders should match their care plans to ensure all care is being given to all residents. An interview, on 11/3/21 at 04:10 PM, with the Administrator, revealed she had no knowledge the resting hand splint was not applied on Resident #1 according to the order and care plan. She stated she was not aware the documentation on the order and the documentation on the care plan, for the resting hand splint, did not match, regarding the use of the resting hand splint for Resident #1. Administrator stated all resident orders should match their care plans. She stated she was aware some of the facility care plans needed corrections. An interview, on 11/4/21 at 08:36 AM, with the Minimum Data Set (MDS) Nurse, revealed she was not aware of the care plan, for Resident #1, not matching information on the orders for the resting hand splint. The MDS Nurse stated she and Medical Records shared the responsibility of developing and updating the nursing care plans. The MDS Nurse stated Medical Records may have been the one responsible for Resident #1's care plan entry. An interview, on 11/4/21 at 08:45 AM, with Medical Records, revealed she was not responsible for developing or updating care plans for any of the residents. Medical Records stated she did change Resident #1's Activities of Daily Living (ADL) Care Plan in the Electronic Health Record (EHR), for the resting hand splint, last evening, 11/3/21, per administrator's request. An interview, on 11/4/21 at 08:45 AM, with the Administrator, revealed the MDS Nurse was assigned the task of developing and updating nursing care plans. Administrator stated the incorrect entry on the care plan, related to use of the resting hand splint, for Resident #1 was entered by the MDS nurse. Administrator stated she did request Medical Records to correct Resident #1's Care Plan to match the order for the resting hand splint on last evening, 11/3/21. An interview, on 11/3/21 at 09:45 AM, with CNA #4 revealed the ADL care for Resident #15 was complete for 11/3/21. CNA #4 revealed she observed there was hair on Resident #15's face. CNA #4 stated the shaving ADL task fires in the Kiosk for the second shift CNAs, but did see the ADL task had not been completed by the second shift CNA. CNA #4 stated she saw Resident #15 had facial hair when she was assigned to him on Monday. CNA #4 stated that she should have shaved him and reported the task was not done on 2nd shift. An interview, on 11/4/21 at 09:35 AM, with the DON, revealed Resident #15 and Resident #402 should have been shaved before today and was not aware Resident #15 and Resident #402 needed to be shaved all week. The DON stated Resident #15 and Resident #402 did not receive adequate assistance with all ADLs as Care Planned. The DON stated all ADL tasks for residents should be completed every day, the CNA's are responsible for completing all ADL tasks, for all residents, every day and the Lead CNA has the responsibility to round in each resident's room, daily, to ensure all ADL tasks, for every resident, had been completed. An interview, on 11/4/21 at 09:41 AM, with the Lead CNA #5, revealed all CNAs were aware of the ADL Care Plans and all ADLs are to be completed for every resident, every day. CNA #5 stated she has the responsibility, of making rounds, in every resident's room to assess residents, behind the other CNA's, to ensure all ADL care was completed for all residents. CNA #5 stated she was not aware Resident #15 and Resident #402 had received a shave all week. CNA #5 recognized Resident #15 and needed to be shaved from today's observation. An interview, on 11/1/21 at 12:00, with Resident #402, revealed he wanted to be shaved. He stated that this is very important. An interview, on 11/3/21 at 09:45 AM, with CNA #4 revealed ADL care for Resident #402 was complete for 11/3/21. CNA #4 revealed she observed there was hair on Resident #402's face. CNA #4 stated the shaving ADL task fires in the Kiosk for the second shift CNAs, but did see the ADL task had not been completed by the second shift CNA. CNA #4 stated she saw Resident #402 had facial hair when she was assigned to him on Monday. CNA #4 stated she should have shaved him and reported the task not being done by 2nd shift. Record review revealed Resident #1 had a Care Plan developed with an approach that revealed the Patient is to wear resting hand splint at all times, only to be removed for bathing, hand hygiene, and monitor skin integrity. Record review, of Resident #1's orders, with LPN #1, revealed an order stating, Patient to wear resting hand splint on the right forearm/wrist/hand six (6) hours each day in order to prevent contracture. Record review, of the ADL Care Plan for Resident #15 revealed the problem I require assistance with my ADLs. and an approach that directed staff to Assist elder with ADLs, as needed, to maintain current function and improve independence with ADLs. Record review, of ADL Care Plan for Resident #402, revealed the problem I require assistance with my ADLs. and the approach that directed staff to Assist elder with ADLs, as needed, to maintain current function and improve independence with ADLs. Record review, of an annual MDS, for Resident #1, with an Assessment Reference Date (ARD) of 5/6/21, revealed a Brief Interview for Mental Status, (BIMS), score of 99, indicating severely impaired cognitive skills. Record review of an Annual MDS with an ARD of 5/6/21 for Resident #402 revealed a BIMS, score of eight (8), indicating moderately impaired cognitive skills. Record review of a Quarterly MDS with an ARD date of 8/9/21 for Resident #15 revealed a BIMS score of 5, indicating severely impaired cognitive skills.

Based on observation, interview of residents and staff, and record review the facility failed to shave residents who were dependent for Activities of Daily Living (ADL) for two (2) of five (5) residents observed. Resident #15 and #402. Findings include: Review of facility policy titled, Grooming a Resident's Facial Hair, dated 11/1/2016, revealed, It is the practice of this facility to assist residents with grooming facial hair to meet their preference. Initial tour observation of Resident #402, on 11/01/21 at 12:00 PM, revealed Resident #402 was not shaved. He had facial hair that appeared to be a result from several days growth. Resident #402 stated he would like to be shaved. He stated that this is very important. Initial tour observation revealed Resident #15, had facial hair that appeared to be from several days of growth. Resident #15 appeared to need a shave. When asked if he wanted a shave, Resident #15 answered, Yes. An observation, on 11/2/21 at 09:39 AM, revealed Resident #15 continues to have facial hair and has not been shaved. An observation, on 11/3/21 at 09:12 AM, revealed Resident #15 continues to have facial hair and has not been shaved. An observation, on 11/4/21 at 08:40 AM, revealed Resident #15 continues to have facial hair and has not been shaved. Resident # 15's facial hair was observed to be approximately one (1) inch long on today. An observation, on 11/02/21 at 09:10 AM, revealed Resident #402 continued to have facial hair and had not been shaved. An observation, on 11/3/21 at 09:12 AM, revealed Resident #402 continued to have facial hair and had not been shaved. An observation, on 11/4/21 at 08:40 AM, revealed Resident #402 continued to have facial hair and has not been shaved. Resident's facial hair was observed to be approximately one-half inch long. An observation and interview, on 11/4/21 at 09:35 AM, with the Director of Nursing (DON), revealed she recognized Resident #402 needed to be shaved. The DON asked Resident #402 if he wanted to be shaved today and Resident #402 answered Yes. The DON revealed Resident #402 should have been shaved before today and was not aware Resident #402 needed to be shaved all week. The DON stated she was aware Resident #402 did not normally wear facial hair and liked his face to stay clean shaved. The DON asked Resident #15 if he wanted to be shaved today. Resident #15 answered Yes to wanting to be shaved today. The DON stated Resident #15 should have been shaved before today and was not aware Resident #15 needed to be shaved all week. The DON stated she was aware Resident #15 did not normally wear facial hair and liked his face to stay clean shaven. She stated the CNA's are responsible for completing all ADL tasks, for all residents, every day. The DON stated the Lead CNA has the responsibility to round in each resident's room, daily, to ensure all ADL tasks, for every resident, had been completed. The DON stated Resident #15, and Resident #402 should not have gone all week without being shaved. She stated Resident #15 and #402 did not receive adequate assistance with all ADLs. An interview, on 11/3/21 at 09:45 AM, with CNA #4 revealed the morning ADL care for Resident #402 had been completed. CNA # 4 revealed she observed there was hair on Resident #402's face, the shaving task fires in the Kiosk for the second shift CNAs, and male residents are to be shaved every other day. CNA #4 revealed she was not at work yesterday but saw Resident #402 had facial hair when she was assigned to him on Monday. CNA #4 stated she should have shaved Resident #402 on Monday and reported the task not being done, by the second shift CNA, to her supervisor. An interview, on 11/4/21 at 09:41 AM, with the Lead CNA #5, revealed all CNAs were aware that all male residents were to be shaved every day. CNA #5 stated she has the responsibility of making rounds, in every resident's room, to assess residents, behind the other CNA's, to ensure all ADL care was completed for all residents. CNA #5 stated she was not aware Resident #15 and Resident #402 had not received a shave all week. CNA #5 stated she has been at work all week this week. CNA #5 stated she has been tied up, all week, weighing every resident in the facility, and did not observe Resident#15 and Resident #402 needed a shave when he was weighed. CNA #5 stated Resident #15, and Resident #402 should have received a shave every day this week. CNA #5 stated Resident #15, and Resident #402 liked to stay clean shaved. An interview, on 11/3/21 at 09:45 AM, with CNA #4 revealed she had completed Resident #15's ADL care for 11/3/21. CNA # 4 revealed she observed there was hair on Resident #15's face, the shaving task fires in the Kiosk for the second shift CNAs, and male residents are to be shaved every other day. CNA # 4 revealed she was not at work yesterday but saw Resident #15 had facial hair when she was assigned to Resident #15 on Monday. CNA #4 stated she should have shaved Resident #15 on Monday and reported the task not being done, by the second shift CNA, to her supervisor. Record review of the form, Assigned Tasks List from the Kiosk for CNAs, revealed Resident #15 did not have a task listed for shaving to be completed by the CNAs. Record review of the form, Assigned Tasks List, from the Kiosk for CNAs, revealed documentation for Resident #402 stating, Daily shave on two to ten (2-10) shift. Use an electric razor to shave me. Record review of an Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/6/21 for Resident #402 revealed a Brief Interview for Mental Status, (BIMS), score of eight (8), indicating moderately impaired cognitive skills. Record review of a Quarterly MDS with an ARD date of 8/9/21 for Resident #15 revealed a BIMS, score of 5, indicating severely impaired cognitive skills.

Based on observation, staff interview, record review and facility policy review, the facility failed to prevent decrease in range of motion as evidenced by failure to apply a splint as ordered for one (1) of three (3) residents reviewed for splints. Resident #1. Findings include: Review of facility policy titled, Prevention of Decline in Range of Motion, dated 11/1/2016, revealed Residents who enter the facility without limited range of motion will not experience a reduction in range of motion unless the resident's clinical condition demonstrated that a reduction in range of motion is unavoidable. An observation, during initial tour, on 11/01/21 at 11:55 AM, revealed Resident #1, had a resting hand splint on her bedside table. An observation, on 11/2/21 at 01:30 PM, revealed Resident #1 was not wearing the resting hand splint on her right wrist. The resting hand splint was not observed visible on any surface in the room. An observation, on 11/3/21 at 09:16 AM, revealed Resident #1 did not have her resting hand splint on the right wrist. Resident #1 did respond to the request to pull her covers back and allow her right wrist to be observed for resting hand splint placement. The resting hand splint was observed across Resident #1's room in a chair. An interview with Certified Nurse Aide (CNA) #1, on 11/3/21 at 9:16 AM, revealed the facility CNAs were trained by the therapy department to apply splints on the facility's residents. She stated the CNA's are responsible to remove and reapply the braces for residents to get a bath and to complete hand hygiene. An interview, on 11/3/21 at 03:11 PM, with CNA #2, revealed she had been assigned to Resident #1 on second shift for the past two (2) weeks. CNA #2 stated she had noticed Resident #1 had not been wearing the resting hand splint much in the past 2 weeks and Resident #1 did not have the resting hand splint on yesterday, 11/2/21. CNA #2 stated that she did not put the resting hand splint on Resident #1 on 11/2/21, because she could not find it in Resident #1's room. CNA #2 stated she was one of the staff members responsible for putting the resting hand splint on Resident #1's right wrist and Resident #1 was supposed to wear the resting hand splint every day, for a certain number of hours, and it needed to be taken off to let Resident #1's hand rest. CNA #2 also stated the splint had to be removed to clean Resident #1's hand and she did not know why the resting hand splint was not being used on Resident #1's wrist as ordered. CNA #2 stated she and other CNA's, who are assigned to Resident #1, had been in-serviced last week by the therapy department about putting the resting hand splint on Resident #1's right wrist. An interview, on 11/3/21 at 03:20 PM, with Licensed Practical Nurse, (LPN) #1 revealed she did not remember how many times Resident #1 had not worn the resting hand splint for the past 3 days this week. An interview, on 11/3/21 at 3:37 PM, with the Certified Occupational Therapy Assistant (COTA), revealed no in-service was held with CNA's regarding applying the resting hand splint on Resident #1 last week. An interview, on 11/3/21 at 03:45 PM, with the Physical Therapist (PT), revealed no in-service was done by her, with the nurse aides, regarding the resting hand splint for Resident #1's right wrist. An interview, on 11/3/21 at 03:55 PM, with the Rehabilitation Director, revealed no in-service had been completed in the past week with the CNAs regarding the resting hand splint for Resident #1. The Rehabilitation Director stated an in-service was completed with nursing staff, at the time Resident #1 was on the active therapy case load, when the resting hand splint was ordered. An interview, on 11/3/21 at 04:10 PM, with the Director of Nursing (DON), revealed she had no knowledge the resting hand splint was not applied on Resident #1 as ordered in the medical record. The DON was not aware the documentation of the order and the documentation on the care plan was different regarding the use of the resting hand splint for Resident #1. The DON revealed she was not aware of an in-service with the CNAs, by the therapy department, last week, regarding applying the resting hand splint for Resident #1. During an interview, on 11/3/21 at 04:10 PM, the Administrator stated, If the splint was not being used correctly on resident's contracted wrist, this could cause more contracture. An interview, on 11/4/21 at 08:36 AM, with Minimum Data Sheet (MDS) Nurse, revealed she was not aware the care plan, for Resident #1, did not match the physicians orders for the resting hand splint. The MDS Nurse stated she and Medical Records shared the responsibility of developing and updating the nursing care plans and Medical Records may have been the one responsible for Resident #1's care plan entry. An interview, on 11/4/21 at 08:45 AM, with Medical Records, revealed she was not responsible for developing or updating care plans for any of the residents. Medical Records stated she did change Resident #1's Activities of Daily Living (ADL) Care Plan in the Electronic Health Record (EHR), for the resting hand splint, on 11/3/21. An interview with Rehabilitation Services Director, revealed she requested an (OT) evaluation for Resident #1, to be completed on 11/4/21, for assessment of the contracture, to the right wrist, for decline in range of motion, due to staff possibly not using the resting hand splint as ordered. An interview, on 11/4/21 at 09:02 AM, with CNA #3, revealed the nurses are the only ones responsible for taking splints off residents. CNA #3 stated she always asked the nurse to remove any kind of splint or brace from a resident. CNA #3 stated she had not been in-serviced in the past week by the therapy department regarding application of the resting hand splint for Resident #1. An interview, on 11/4/21 at 09:02 AM, with CNA #4 revealed CNAs are in-serviced by the therapy department to apply and remove splints and braces from facility residents and there is a sign off sheet showing understanding of the training. CNA #4 stated she had not been in-serviced in the past week by the therapy department regarding placement of the resting hand splint for Resident #1. CNA #4 stated CNAs are responsible for charting on splints and braces, if it comes up on the tasks on their Kiosk. CNA #4 stated she had seen the task, on the Kiosk, for Resident #1, for the resting hand splint. During an interview, on 11/4/21 at 09:15 AM with the DON, she revealed that the resident could have worsening contractures with the right-hand splint not being worn. An interview, on 11/4/21 at 11:00 AM, with the OT revealed Resident #1 had noted a decline in her contracted right wrist. An interview, on 11/4/21 at 11:10 AM, with LPN #2, revealed she could not say the resting hand splint was applied to Resident #1's right wrist every day. LPN #2 revealed Resident #1 removed the hand splint at times and she did not reapply the resting hand splint, because Resident #1 would not want it back on. LPN #2 confirmed that she did not document this. Record review of Resident #1's Face Sheet revealed a diagnosis of Heimiplegia following a Cerebral Infarction affecting the right donimant side. Record review revealed Resident #1 had an order, dated 3/15/21 and a reorder dated 4/16/21, which stated, Patient to wear resting hand splint on the right forearm/wrist/hand six (6) hours each day in order to prevent contracture. Record Review of the OT's form titled Functional Maintenance Program, dated 3/15/21 revealed a recommendation for Resident #1 that stated, Right resting hand splint should be worn for four (4) to six (6) hours daily. Record Review of ADL Assigned Tasks List from the facility Kiosk for CNA documentation revealed Patient is to wear resting hand splint on patient's right forearm/wrist/hand for 6 hours each day in order to prevent contractures. Remove resting hand splint on patient's right forearm/wrist/hand and monitor skin integrity. The Assigned Tasks List revealed the tasks were assigned to the CNAs to complete, every day, starting at 08:00 AM and ending at 02:00 PM. Record review with LPN #2 revealed the Electronic Treatment Authorization Record (ETAR) showed Resident #1 with documentation for the resting hand splint to be applied to Resident #1's right forearm/wrist/hand at 08:00 AM and was to be removed at 02:00 PM each day. Record review of nurse's notes revealed no documentation from any discipline that Resident #1 refused to wear the resting hand splint or removed the resting hand splint from her own wrist. Record review, of the ETAR, revealed documentation that stated, Patient is to wear resting hand splint on patient's right forearm/wrist/hand 6 hours each day in order to prevent contractures. Remove resting hand splint on patient's right forearm/wrist/hand and monitor skin integrity. The TAR revealed Resident #1 had documentation for the resting hand splint as follows: 10/23/21 - An entry of N at 08:00 AM that indicated the resting hand splint was not administered, but a green check mark at 02:00 PM that indicated the resting hand splint was removed at 02:00 PM. 10/11/21 - An entry of N documented that stood for the resting hand splint was not administered. 10/9/21 - No entry showed the resting hand splint was applied on this date. 10/3/21 - No entry showed the resting hand splint was applied at 08:00 AM, but was removed at 02:00 PM 10/2/21 - No entry showed the resting hand splint was applied on this date. 09/26/21 - No entry showed the resting hand splint was applied on the date. 09/25/21 - An entry of N at 08:00 AM that stood for the resting hand splint was not administered. Record review, of a Minimum Data Set, (MDS), Annual Assessment, with an Assessment Reference Date of 5/6/21, revealed a Brief Interview for Mental Status, (BIMS), score of 99, indicating severely impaired cognitive skills.