Based on observation, interview and record review, the facility failed to ensure residents were assessed to self-administer medications and to ensure staff adequately supervised residents during medication administration (Residents #28, #7 and #17). The sample was 16. The census was 62. Review of the facility's Medication Administration-General Guidelines policy, dated July 2021, showed: -Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so; -Administration: -Residents can self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications (see Self-Administration of Medications); -The resident is always observed after administration to ensure that the dose was completely ingested. Review of the facility's Self-Administration of Medications policy, dated July 2021, showed: -Policy: In order to maintain the residents' high level of independence, residents who desire to self-administer medications are permitted to do so If the facility's interdisciplinary team (IDT) has determined that the practice would be safe for the resident and other residents of the facility and there is a prescriber's order to self-administer; -Procedures: -If the resident desires to self-administer medications, and assessment is conducted by the IDT of the resident's cognitive, physical, and visual ability to carry out this responsibility during the care planning process; -The results of the IDT's assessment of the resident skills and of the determination regarding bedside storage are recorded in the resident's medical record, on the care plan. 1. Review of Resident #28's medical record, showed: -Diagnoses included dementia, multiple sclerosis (MS, disease of the central nervous system) and unspecified symptoms and signs involving cognitive functions and awareness; -No assessment identifying the resident as able to self-administer his/her medications. Review of the resident's Physician Order Summary (POS) and Medication Administration Record (MAR), dated September 2024, showed: -An order, dated 10/23/21, for glucosamine (supplement) capsule 500 milligrams (mg), give 500 mg by mouth (PO) one time a day. AM dose for 9/24/24 initialed as administered by Certified Medication Technician (CMT) D; -An order, dated 10/23/21, for losartan potassium (used to treat high blood pressure and heart failure) tablet 50 mg, give one tablet PO one time a day. AM dose for 9/24/24 initialed as administered by CMT D; -An order, dated 10/23/21, for potassium chloride (electrolyte supplement) tablet extended release (ER) 10 milliequivalents (mEq), give one tablet PO one time a day. AM dose for 9/24/24 initialed as administered by CMT D; -An order, dated 10/23/21, for raloxifene (used to treat osteoporosis) hydrochloric acid (HCl) tablet 60 mg, give 60 mg PO one time a day. AM dose for 9/24/24 initialed as administered by CMT D; -An order, dated 10/23/21, for lutein (supplement) and zeaxanthin (supplement) tablet delayed release (DR), one tablet PO one time a day. AM dose for 9/24/24 initialed as administered by CMT D; -An order, dated 10/23/21, for multivitamin tablet, one tablet PO one time a day. AM dose for 9/24/24 initialed as administered by CMT D; -An order, dated 12/2/22, for calcium/vitamin D tablet 600-400 mg-unit, give one tablet PO one time a day. AM dose for 9/24/24 initialed as administered by CMT D; -An order, dated 1/19/23, for lasix (blood thinner) oral tablet 20 mg, give one tablet PO in the morning. AM dose for 9/24/24 initialed as administered by CMT D; -No physician order for the resident able to self-administer his/her medications. Review of the resident's care plan, in use at the time of survey, showed no documentation the resident able to self-administer his/her medications or take his/her medications without supervision. Observation on 9/24/24 at 8:37 A.M., showed the resident seated at a table in the dining room. CMT D placed a cup of medication on the table in front of the resident, and walked back to his/her medication cart in the dining room. CMT stood at the medication cart with his/her back turned toward the resident, and worked on the computer. At 8:39 A.M., the resident took a sip of water and dumped the cup of pills in his/her hand. He/She placed a pill or two in his/her mouth, took a sip of water, and repeated the process three times until his/her medications were gone. Observation on 9/26/24 at 8:14 A.M., showed the resident seated at a table in the dining room with a cup of medications next to his/her plate. CMT D stood at the medication cart in the dining room with his/her back turned towards the resident. During an interview, the resident said he/she can take his/her medications on his/her own. CMT D continued to work at the computer on his/her medication cart and administered medications to other residents while the resident remained seated at the table with the cup of medications next to his/her plate. At 8:39 A.M., the resident began taking pills out of the mediation cup and swallowing them with sips of water, one pill at a time, while CMT D stood at the medication cart with his/her back turned towards the resident. 2. Review of Resident #7's medical record, showed: -Diagnoses included dementia, anxiety, depression and bipolar disorder (mood disorder); -No assessment identifying the resident as able to self-administer his/her medications. Review of the resident's POS and MAR, dated September 2024, showed: -An order, dated 4/13/22, for metoprolol tartrate (used to treat high blood pressure and chest pain) tablet 100 mg, give one tablet by mouth two times a day. AM dose for 9/24/24 initialed as administered by CMT D; -An order, dated 4/13/22, for carbidopa-levodopa (combination medication to treat symptoms of Parkinson's disease (movement disorder)) tablet 25-100 mg, give one tablet PO three times a day. AM dose for 9/24/24 initialed as administered by CMT D; -An order, dated 4/14/22, for duloxetine (anti-depressant) HCl capsule DR sprinkle 50 mg, give one capsule PO one time a day. AM dose for 9/24/24 initialed as administered by CMT D; -An order, dated 4/14/22, for lamotrigine (anti-seizure) tablet 100 mg, give one tablet PO one time a day. AM dose for 9/24/24 initialed as administered by CMT D; -An order, dated 4/14/22, for mirabegron (used to treat overactive bladder) ER tablet ER 24 hour 50 mg, give one tablet PO one time a day. AM dose for 9/24/24 initialed as administered by CMT D; -An order, dated 6/17/22 for risperidone (antipsychotic) 1 mg disintegrating tablet, give one tablet PO in the morning. AM dose for 9/24/24 initialed as administered by CMT D; -An order, dated 7/26/23, for Xanax (sedative) oral tablet 0.25 mg, give 0.25 mg PO three times a day. AM dose for 9/24/24 initialed as administered by CMT D; -An order, dated 8/25/22, for rivaroxaban (blood thinner) tablet 20 mg, give one tablet PO in the morning. AM dose for 9/24/24 initialed as administered by CMT D; -An order, dated 9/23/22, for losartan potassium tablet 100 mg, give one tablet PO one time a day. AM dose for 9/24/24 initialed as administered by CMT D; -An order, dated 10/21/22, for Claritin (antihistamine) tablet 10 mg, one tablet PO one time a day. AM dose for 9/24/24 initialed as administered by CMT D; -An order, dated 10/26/23, for docusate sodium (stool softener) capsule 100 mg, one capsule PO one time a day. AM dose for 9/24/24 initialed as administered by CMT D; -An order, dated 10/26/23, for meloxicam (anti-inflammatory) oral tablet 15 mg, give 15 mg PO one time a day. AM dose for 9/24/24 initialed as administered by CMT D; -No physician order for the resident able to self-administer his/her medications. Review of the resident's care plan, in use at the time of survey, showed no documentation the resident able to self-administer his/her medications or take his/her medications without supervision. Observation on 9/24/24 at 8:14 A.M., showed the resident seated at a table in the dining room. CMT D placed a cup of medication on the table in front of the resident and walked away. CMT D got his/her medication cart and pushed it out of the dining room, leaving the resident unsupervised. The resident put a pill in his/her mouth, took a sip of water, and repeated the process until 8:16 A.M., when he/she finished taking all the medications in his/her cup. During an interview on 9/26/24 at 8:11 A.M., the resident said he/she already got his/her medications this morning. The employee gave him/her the medications and left the room. Some staff watch the resident and some do not; it depends on who is working. He/She thinks staff are supposed to watch people take their medications, but isn't sure. 3. Review of Resident #17's medical record, showed: -Diagnoses included anxiety; -No assessment identifying the resident as able to self-administer his/her medications. Review of the resident's POS and MAR, dated September 2024, showed: -An order, dated 5/13/23, for metoprolol succinate (used to treat high blood pressure and chest pain) ER tablet 25 mg, give 25 mg PO one time a day. AM dose for 9/24/24 initialed as administered by CMT D; -An order, dated 5/13/23, for oyster shell calcium/vitamin D 500-200 mg-unit, give one tablet PO two times a day. AM dose for 9/24/24 initialed as administered by CMT D; -An order, dated 5/13/23 for Pepcid (antacid) oral tablet 20 mg, give 20 mg by mouth two times a day. AM dose for 9/24/24 initialed as administered by CMT D; -An order, dated 5/26/23, for sennosides (stool softener) tablet 8.6 mg, give one tablet PO two times a day. AM dose for 9/24/24 initialed as administered by CMT D; -An order, dated 7/12/23, for bupropion (antidepressant) HCl oral tablet 100 mg, give one tablet PO one time a day. AM dose for 9/24/24 initialed as administered by CMT D; -An order, dated 8/23/23, for aspirin 81 mg chewable, give one tablet PO one time a day. AM dose for 9/24/24 initialed as administered by CMT D; -An order, dated 2/8/24, for duloxetine HCl oral capsule DR particles 40 mg, give 40 mg PO one time a day. AM dose for 9/24/24 initialed as administered by CMT D; -An order, dated 8/27/24, for oxybutynin chloride (used to treat overactive bladder) ER tablet 10 mg, give one tablet PO one time a day. AM dose for 9/24/24 initialed as administered by CMT D; -No physician order for the resident able to self-administer his/her medications. Review of the resident's care plan, in use at the time of survey, showed no documentation the resident able to self-administer his/her medications or take his/her medications without supervision. Observation on 9/24/24 at 7:45 A.M., showed the resident seated at a table in the dining room, eating breakfast. A cup of medications, containing approximately eight pills, next to his/her plate. CMT D stood at the medication cart in the dining room with his/her back turned towards the resident. At 8:27 A.M., the cup of medications remained on the table next to the resident's plate. At 8:31 A.M., CMT delivered a health shake to the resident and walked away. While CMT D stood at the medication cart with his/her back towards the resident, the resident took the medications from the cup. During an interview on 9/26/24 at 8:16 A.M., the resident said he/she already had his/her medication this morning. Some staff watch him/her take his/her medications and others do not. The employee who gave him/her his medications this morning did not watch the resident take them. 4. During an interview on 9/26/24 at 9:02 A.M., CMT D said during medication administration, he/she verifies he/she has the correct resident and medications, dispenses the medications into a cup, and gives the cup to the resident. Some residents require their medications to be crushed or to have their medications spoon fed, and in this case, the resident must be supervised while they take their medications. Otherwise, CMT D can give the resident their medication and walk away. Residents #28, #7, and #17 are all cognitively intact enough to take their medications without supervision. They might have dementia, but they are all cognitively able to take their own medications. 5. During an interview on 9/26/24 at 10:53 A.M., Nurse Supervisor A said during medication administration, staff should verify they have their right resident and right medication, dispense the medications, then supervise the resident while they take the medication. Staff must observe the resident take the medication because the resident might drop them or another confused resident might take the resident's medication. Staff must supervise medication administration for safety and accuracy. If a resident is adamant about taking their medication without supervision, staff should explain it is a regulatory requirement to watch them. Staff could also walk away but remain within eye sight to make sure the resident is taking their medication properly. 6. During an interview on 9/26/24 at 2:17 P.M., the Director of Nurse (DON) and Administrator said when staff are administering medications, they must verify they have the right resident and right dose of medication, and check the MAR. After dispensing the medications, they give them to the resident and watch the resident take the medications. Staff must watch the resident take their medications because the resident might choke or not take the medication. If a resident refuses to be supervised by staff, staff should take the medications back and tell the resident they will come back when the resident is ready. Residents #28, #7, and #17 should be supervised during medication administration and should not self-administer. All residents should be supervised during medication administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a significant change in status assessment was completed within 14 days after a determination was made a significant change occurred for one of two residents sampled for hospice (Resident #27). The facility identified six residents who received hospice services. The census was 62. Review of Resident #27's medical record, showed: -admission date 5/1/23; -Diagnoses included neurocognitive disorder with lewy bodies (degenerative brain disorder characterized by dementia, psychosis and features of parkinsonism (movement symptoms)) and dementia; -A hospice admission form, showed the resident admitted to hospice on 7/19/24 with a diagnosis of failure to thrive. Review of the resident's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, records, showed: -An annual MDS dated [DATE]; -A quarterly MDS dated [DATE]; -No significant change MDS assessment completed within 14 days after the resident's admission to hospice. During an interview on 9/26/24 at 9:51 A.M., the MDS Coordinator said a resident's admission to hospice is considered a significant change. Upon a significant change, a significant change MDS must be completed within 14 days. She is notified of a resident's admission to hospice via email, and the facility's daily clinical meetings and weekly risk meetings. When the resident was admitted to hospice, a physician order was not put in the resident's electronic medical record (EMR), so she did not know the resident was admitted to hospice at that time. During an interview on 9/26/24 at 2:17 P.M. with the Director of Nurses (DON) and Administrator, they said all MDS assessments are completed by the MDS Coordinator. A resident's admission to hospice is considered a significant change. It is expected that a significant MDS assessment be completed within 14 days of a resident's admission to hospice.

Based on observation, interview and record review, the facility failed to ensure Activities of Daily Living (ADL) care needs were met for two dependent residents (Resident #13 and Resident #35). The sample was 16. The census was 62. Review of the facility's activities of daily living policy, dated February 2019, showed: -Policy Statement: the facility will provide care to each resident to ensure that a resident's abilities in activities of daily living do not diminish unless decrease in a resident's function may be expected and unavoidable due to the predictable, cyclical patterns of the resident's clinical condition or the resident or his/her representative's refusal of care and treatment to restore or maintain functional abilities. -Activities of daily living include the resident's ability to bathe, dress, groom, transfer, and toilet, eat, and use speech, language or other functions communication systems; -Appropriate treatment and services are provided for all residents to help them maintain and improve their abilities to perform activities of daily living. If a resident is unable to carry out activities of daily living, he/she shall receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. For these residents, care plan goals may not be stated in terms of what the resident is able to achieve, but in terms of the outcome of care and services provided. The resident's plan of care will be reviewed and revised at least quarterly and more often if a decline in function is apparent. 1. Review of Resident #13's electronic medical record (EMR), showed: -Cognitively intact; -Diagnoses included hemiplegia (paralysis or loss of strength on one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) affecting right dominant side, major depressive disorder, anxiety and morbid obesity. Review of the resident's care plan, dated 8/21/24, showed: -Need: resident has an ADL self-care performance deficit requiring assistance; -Goal: resident will maintain current level in ADL performance; -Interventions: the resident requires extensive assistance on staff for personal hygiene and oral care. During an interview on 9/23/24 at 4:51 P.M., the resident said staff never assist him/her with brushing his/her teeth. The resident's teeth had a white thick matter on them. The resident's chin had a patch of hair growth. Observation on 9/24/24 at 11:23 A.M., showed the resident in bed. The resident's chin had a patch of hair. His/Her teeth had a white/yellow matter on them. During an interview on 9/26/24 at 8:17 A.M., the resident said he/she would like the chin hair shaved off his/her face. Nursing staff have not assisted him/her with brushing his/her teeth. He/She does not even know if he/she owns a toothbrush. He/She said his/her teeth feel icky. During an interview on 9/26/24 at 9:41 A.M., Certified Nursing Assistant (CNA) G said CNAs are responsible for asking residents if they would like their facial hair shaved and to assist residents with shaving. He/She said any nursing staff can assist a resident with brushing their teeth. During an interview on 9/26/24 at 11:26 A.M., the Director of Nursing (DON) said she expected nursing staff to assist the resident with his/her ADL care needs. She expected staff to brush a resident's teeth and assist with oral hygiene. She also expected CNAs to ask residents if they would like their facial hair shaved in a way that is sensitive to the resident's feelings. 2. Review of Resident #35's EMR, showed: -Moderately impaired cognition; -Diagnoses included Alzheimer's disease and muscle weakness. Review of the resident's care plan, dated 7/1/24, showed: -Need: resident has an ADL self-care performance deficit due to Alzheimer's disease; -Goal: resident will maintain current level in ADL performance through next review; -Interventions: the resident is independent for personal hygiene and oral care after set up of grooming items. Observation on 9/23/24 at 11:39 A.M., showed the resident had a strong odor emitting from his/her mouth. The resident's chin had a patch of hair. Observation on 9/25/24 at 7:38 A.M., showed the resident had a strong odor emitting from his/her mouth. The resident's chin had a patch of hair. During an interview on 9/26/24 at 9:41 A.M., CNA G said when he/she assists the resident with oral care, he/she uses mouth swabs to clean the resident's mouth. CNA G expected staff to be consistently assisting the resident with his/her oral hygiene care. He/She has never thought to ask the resident if he/she wants facial hair on his/her chin. CNAs are responsible for assisting the resident with shaving facial hair. During an interview on 9/26/24 at 11:26 A.M., the DON said she expected nursing staff to assist the resident with his/her oral care and personal hygiene.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one resident (Resident #32) with limited mobility received appropriate equipment and assistance to maintain mobility when staff failed to ensure the resident had a palm protector as recommended by therapy to address a left hand contracture (fixed tightening of muscle, tendons, ligaments, or skin, preventing normal movement). The sample was 16. The census was 62. Review of Resident #32's medical record, showed diagnoses included stroke, contracture to left elbow, generalized muscle weakness, dementia and cognitive communication deficit. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/26/24, showed: -Severe cognitive impairment; -Upper extremity impairment on one side; -Dependent for upper body dressing. Review of the resident's care plan, in use at the time of survey, showed: -Need: Resident has limited physical mobility; -Goal: Resident will maintain current level of mobility through review date; -Interventions/tasks included monitor/document/report as needed any signs/symptoms of contractures forming or worsening, and provide supportive care, assistance with mobility as needed; -No documentation regarding the application of a palm protector. Review of the resident's Occupational Therapy (OT) Discharge summary, dated [DATE], showed: -Short-term goal: The patient will wear a palm protector in left hand according to wear schedule with 100% accuracy as applied by trained caregivers. Discharge level of functioning: Patient has palm protector but does not wear it consistently; -Summary since last progress report: Patient and caregiver educated on use of palm protector for increasing range of motion in left hand; -Patient discharging from OT to facility where he/she will receive restorative nursing care. Review of the resident's physician order summary, reviewed 9/23/24, showed no order for a palm protector. Observation on 9/23/24 at 11:24 A.M., showed the resident seated in the dining room. His/Her left hand was contracted with his/her fingers curled into the palm of his/her hand. The resident did not wear a splint. During an interview, the resident used one-word answers and nodded/shook his/her head to respond to simple questions regarding his/her current status. He/She was unable to provide in-depth information regarding his/her status and care needs. Observations on 9/23/24 at 12:39 P.M. and 2:57 P.M., showed the resident with no palm protector on his/her contracted left hand. Observation on 9/24/24 at 8:21 A.M., showed Certified Nurse Aide (CNA) AA propelled the resident down the hall from his/her room to the dining room. The resident's left hand was contracted with fingers curled into his/her palm, and no palm protector on the resident's hand. Observation on 9/24/24 at 1:06 P.M., showed the resident on his/her right side in bed. No palm protector was on the resident's left hand. Observation on 9/25/24 at 7:39 A.M., showed CNA C and CNA B transferred the resident out of bed and into a Broda chair (reclining chair). CNA B brought the resident out to the dining room. The resident's left hand was contracted with no palm protector on the resident's hand. Observation on 9/25/24 at 9:27 A.M., showed Restorative Aide (RA) L provided restorative therapy to the resident in the dining room. The resident's left hand was contracted with no palm protector. RA L moved the resident's left arm and the resident grimaced, closed his/her eyes and winced. RA L apologized to the resident for the discomfort and said he/she did not know why the resident was not wearing his/her brace. RA L said the resident's left hand looked swollen. During an interview on 9/25/24 at 9:31 A.M., RA L said the resident is supposed to wear a brace on his/her left hand every day. The CNA assigned to the resident is responsible for putting the brace on the resident's arm. During the interview, Licensed Practical Nurse (LPN) P approached the resident and assisted RA L in observing the resident's left hand. LPN P said the resident's left hand is slightly swollen and contracted, with indentions in the resident's palm from his/her fingers. The resident should be wearing a brace. During an interview on 9/25/24 at 9:42 A.M., CNA C said the resident cannot use his/her left hand. CNA C had no idea the resident was supposed to wear a brace, no one had told him/her that until today. Nurses make CNAs aware of residents who need splints or braces. During an interview on 9/25/24 at 2:32 P.M., CNA B said he/she did not know the resident is supposed to have a brace or splint. Therapy tells the nurses when a resident is supposed to have a brace, and the nurse tells the CNA. During an interview on 9/25/24 at 9:55 A.M., LPN P said physician orders need to be obtained for the use of a splint or brace. During the interview, LPN P checked the resident's electronic medical record (EMR) and verified the resident did not have orders or documentation to show the resident should have a brace. During an interview on 9/25/24 at 10:34 A.M., Nurse Supervisor A said the resident's left hand is contracted. Therapy has him/her wear a brace on and off. Sometimes therapy will try something like a brace to see if it works and if it does, they will tell nursing if it needs to be ordered by the physician. Nurse Supervisor A was not aware if therapy made someone in nursing aware of a recommendation for the resident to have a brace. During an interview on 9/26/24 at 9:40 A.M., the Therapy Director said the resident was discharged from OT with recommendations for a palm protector. The OT educated nursing staff and documented the recommendation for the palm protector in the resident's discharge summary, but forgot to obtain a physician order for the palm protector. During an interview on 9/26/24 at 2:17 P.M., the Director of Nurses (DON) and Administrator said when a resident is discharged from OT and OT has recommendations for a palm protector, therapy should obtain a physician order for the palm protector and enter in the EMR. Therapy should educate all nursing staff on the floor about application of the palm protector. The RA and CNAs are responsible for applying the resident's palm protector. The DON and Administrator expected residents to have palm protectors as ordered and recommended by therapy to help improve or maintain the resident's range of motion.

Based on observation, interview and record review, the facility failed to ensure one resident (Resident #1) received proper urinary catheter (tube that drains the urine from the bladder) care after an incontinence episode, staff failed to remove the resident's catheter bag off of the floor after providing care and failed to follow the facility's policy of changing the resident's urinary catheter tubing and bag every 30 days. The sample was 16. The census was 62. Review of the facility's Catheter Care policy, review dated February, 2019, showed: -Policy: To keep indwelling catheter free of vaginal discharge and/or crusting, which can cause infections; -Observation and reporting include: -Color and amount of urine; -Check tubing and drainage for sediment; -Attach Foley (a tube that drains the urine from the bladder) to bed frame only; -Change drain bag and tubing every 30 days and as needed; -Change indwelling Foley catheter as indicated based on assessment or per physician order; -Secure urinary drainage bag below the level of the bladder and keep off the floor at all times; -Coil extra tubing and secure. Review of the facility's Perineal Care (cleansing of the genitals) policy, dated July, 2016, showed: -Purpose: To establish routine practices for provide perineal care which will cleanse, reduce the risk of skin breakdown, infection, and odor; -Policy: Residents who are incontinent, have an indwelling Foley (a tube that drains urine from the bladder), or who are identified as requiring perineal care will receive in the morning, every evening, and as needed after bowel movement or urinary incontinence. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/16/24, showed the following: -Diagnoses of multiple sclerosis (MS, disease of the central nervous system), hemiplegia (paralysis or loss of strength on one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) affecting left non-dominant side, and neuromuscular dysfunction of the bladder (when the nerves that control the bladder are damaged resulting in bladder dysfunction); -Moderately impaired cognition. Review of the resident's Physicians Order Summary (POS), in use at the time of survey, showed: -Order, dated 5/24/24, catheter care and document output every shift for Foley catheter care; -Order, dated 5/15/24, Foley catheter 18 French (FR, the catheter size) to promote wound healing. Review of the resident's care plan, dated 7/1/24, showed: -Need: The resident has a urinary catheter; -Goal: The resident will be/remain free from catheter-related trauma through review date; -Interventions: position catheter bag and tubing below the level of the bladder and away from entrance room door; Check tubing for kinks each shift; Monitor and document for pain/discomfort due to catheter. Monitor, record, report to Medical Director (MD) for pain, burning, blood-tinged urine, cloudiness, no output of urine, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, and change in eating patterns; -The care plan failed to address the frequency of indwelling catheter changes, catheter tubing changes or catheter bag changes. Review on 9/25/24 at 11:16 A.M., of the resident's progress notes, showed: -Progress note, dated 5/26/24, said 18 FR Foley catheter was inserted with some difficulty and small amount of blood seen in the urine; -This progress note was the last documented Foley catheter tubing change. Review on 9/26/24 at 10:15 A.M., of the resident's medical record, showed no recent lab work or urinalysis , (UA, a test of urine to check for urinary tract infections, kidney problems, or diabetes). Observation on 9/24/24 at 7:51 A.M., showed the resident's Foley catheter tube appeared cloudy with green residue on the inside of the tubing. The catheter bag had green residue in it with a vertical line of green residue staining the urinary bag. Observation on 9/25/24 at 7:48 A.M., showed the resident's Foley catheter tube looked cloudy with green residue on the inside of the tubing. The catheter bag had green a residue with a vertical line of green residue staining the urinary bag. During an interview on 9/25/24 at 7:46 A.M., the resident said his/her catheter has not been changed in a long time. Observation on 9/25/24 at 8:02 A.M. showed Certified Medication Technician (CMT) D and Certified Nurse Aide (CNA) J entered the room and explained to the resident they were going to turn the resident for a skin assessment. The resident lay in bed on his/her back. The resident's heel protectors were removed by CMT D. The resident was turned to his/her right side. CNA J removed the resident's brief. The resident had stool in his/her brief. CNA J cleaned the resident's left buttock and rectal area. The resident was then turned to his/her left side. CMT D removed the soiled brief and cleaned the resident's right buttock. The resident had a Foley catheter that became unhooked from the resident's bedframe and fell onto the floor while the resident was turned side to side. The resident's Foley catheter remained on the floor. A clean brief was applied. The resident was repositioned to his/her back by CMT D and CNA J and a clean brief was fastened around the resident. CMT D and CNA J removed their gloves, performed hand hygiene and left the resident's room. Catheter care was not provided. The resident's Foley catheter remained on the floor. Observations on 9/25/24 at 8:26 A.M., 9/25/24 at 8:39 A.M., 9/25/24 at 8:42 A.M., 9/25/24 at 9:01 A.M., 9/25/24 at 9:29 A.M., and 9/25/24 at 10:00 A.M., showed the resident's Foley catheter bag lay on the floor next to the resident's bed. Observation on 9/25/24 at 10:23 A.M., showed CNA G removed the resident's Foley catheter bag off of the floor and placed it back on the resident's bed frame. During an interview on 9/25/24 at 1:15 P.M., Nurse Supervisor A observed the resident's catheter bag and said the bag and tube appeared to have a green residue. He/She said he/she was not sure what the green residue was but that it could be discoloration due to a possible manufacturer malfunction. He/She said the resident's catheter tubing should be changed every 30 days. He/She expected there to be an order for when catheter bags are supposed to be changed. During an interview on 9/26/24 at 9:50 A.M., CNA G said he/she is responsible for making observations of the resident's Foley catheter during care to make sure there are no changes to the resident's urine output, cleanliness and coloring of the catheter tubing and bag. He/She was not aware the resident's catheter bag and tubing had a green residue. He/She said when staff is providing perineal care to a resident who has had a bowel movement, the catheter site should be cleaned. He/She said if a resident's catheter bag is found on the floor, staff is to pick the catheter bag up and place it back on the resident's bed. During an interview on 9/26/24 at 3:19 P.M., the Director of Nursing (DON) said the resident's Foley catheter does not need to be changed at a set date and does not require a physician's order. She said a resident's catheter tubing should only be changed if there is a dysfunction or is causing discomfort. She did not know when the last time the resident's catheter tubing had been changed. She was not aware the resident's catheter tubing and bag were cloudy and had green residue. She said the green coloring could potentially be a medication issue. She said if a staff member walked into a resident's room and found their catheter bag on the ground, she expected the staff member to clean the bag and place it back on the resident's bed. She expected staff to perform catheter care after the resident has a bowel movement. Review of the information provided by the DON via e-mail on 9/30/24, showed: -The DON observed the resident's Foley catheter. The catheter was draining clear amber urine with no signs of infection or malfunction. The outside of the tubing was slightly discolored, but the urine inside remained clear and free flowing. Per the Medical Director, Foley catheters are to be changed only for dysfunction or by physician order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure respiratory services were provided, consistent with professional standards of practice, for three residents. The facility failed to obtain physician orders for the use of a continuous positive airway pressure (CPAP, a breathing device that delivers air to a mask worn over the nose and mouth) machine for two residents (Residents #3 and #155). The facility also failed to discontinue an order for continuous oxygen use for one resident no longer requiring oxygen therapy (Resident #3) and failed to have physician orders for oxygen for one resident (Resident # 38) who received continuous oxygen. The sample size was 16. The census was 62. Review of the facility's CPAP policy, revision April, 2019, showed it failed to address the requirement of physician orders. Review of the facility's Oxygen Administration policy, reviewed February, 2019, showed: -Purpose: To provide higher concentration of oxygen than is available in room air; -Procedure: Adjust flow to ordered rate. 1. Review of Resident #3's medical record, showed diagnoses included chronic obstructive pulmonary disease (COPD, lung disease), asthma, and obstructive sleep apnea (recurrent episodes of upper airway collapse during sleep). Review of the resident's electronic Physician Order Sheet (ePOS), showed: -An order, dated 6/13/24, for oxygen at 2 liters (L) per minute, per nasal cannula (NC), every shift, at 2L at all times; -No order for CPAP machine. Review of the resident's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/1/24, showed: -Cognitively intact; -Oxygen therapy not indicated. Review of the resident's care plan, in use at the time of survey, showed: -Need: Resident has COPD and asthma; -No documentation regarding the resident's use of a CPAP machine. Observation on 9/23/24 at 2:29 P.M., showed a CPAP machine on the table next to the resident's bed. During an interview, the resident said he/she has COPD and was recently in the hospital for pneumonia. He/She does not use oxygen, but does use a CPAP machine at night. He/She is responsible for cleaning it, but doesn't. During an interview on 9/25/24 at 9:55 A.M., Certified Nurse Aide (CNA) C said the resident does not use oxygen. He/She uses a CPAP machine every night. During an interview on 9/25/24 at 10:34 A.M., Nurse Supervisor A said the resident used to wear oxygen after a previous surgical procedure, but has not needed it since. The resident's physician order should have been discontinued since it is no longer needed. The resident does have a CPAP machine. The resident should have a physician order for use of the CPAP machine and the evening nurse should provide care to the CPAP machine. Physician orders are required for all CPAP machines. 2. Review of Resident #155's, face sheet, undated, showed -An admission date of 9/20/24; -Diagnoses included COPD, obstructive sleep apnea (when breathing slows or stops when sleeping), stroke and weakness. Review of the resident's care plan, in use at the time of survey, showed it did not address the resident's CPAP machine. Review of the resident's POS dated September, 2024, showed no order for a CPAP machine. Observation and interview on 9/24/24 at 8:02 A.M., showed a CPAP machine on the resident's nightstand. The resident said he/she has sleep apnea and wears the CPAP every night. The resident cleans it and applies it by him/herself. During an interview on 9/26/24 at 8:45 A.M., Licensed Practical Nurse (LPN) T said the resident should have CPAP orders that include maintenance and the settings of the machine. 3. Review of Resident #38's quarterly MDS, dated [DATE], showed: -Diagnoses included heart failure and COPD; -The resident receives oxygen and hospice services. Review of the resident's care plan, in use at the time of survey, showed: -Need: The resident has heart failure and COPD; -Interventions: Oxygen settings as ordered. Observation on 9/23/24 at 12:35 P.M., 9/24/24 at 7:00 A.M. and 9/25/24 at 1:05 P.M., showed the resident lay in bed with an oxygen concentrator set on 3L and the oxygen tubing connected to resident's nares (nostrils). During an interview on 9/26/24 at 8:45 A.M., LPN T said the resident should have oxygen orders when receiving oxygen therapy. 4. During an interview on 9/26/24 at 2:17 P.M., the Administrator and Director of Nurses (DON) said if a resident has orders for continuous oxygen and does not use it or no longer needs it, the order should be discontinued. Oxygen use up to 2L does not require a physician order. Oxygen use at 3L would require a physician order. Residents should have physician orders for the use of CPAP machines. The order should include the settings required for the CPAP machine, but would not include anything specific to cleaning the CPAP machine. Nurses clean CPAP machine masks daily.

Based on observation, interview and record review, the facility failed to ensure the room for one resident was adequately equipped with a call light at the resident's bedside (Resident #32). The sample was 16. The census was 62. Review of Resident #32's medical record, showed diagnoses included stroke, contracture (fixed tightening of muscle, tendons, ligaments, or skin, preventing normal movement) to left elbow, dementia, and cognitive communication deficit. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/26/24, showed: -Severe cognitive impairment; -Usually understood-difficulty communicating some words or finishing thoughts but is able to if prompted or given time; -Upper extremity impairment on one side. Review of the resident's care plan, in use at the time of survey, showed: -Need: Resident has a communication problem; -Interventions/tasks included ensure/provide a safe environment, call light in reach. Observation on 9/23/24 at 11:09 A.M., showed no call light connected to the port in the wall next to the resident's bed. During an interview on 9/23/24 at 11:24 A.M., the resident used one-word answers and nodded/shook his/her head to respond to simple questions regarding his/her current status. He/She was unable to provide in-depth information regarding his/her status and care needs. Observations on 9/24/24 at 7:22 A.M. and 7:53 A.M., showed the resident on his/her left side in bed. No call light was connected to the port in the wall next to the resident's bed. Observation on 9/24/24 at 1:06 P.M., showed the resident on his/her right side in bed. No call light was connected to the port in the wall next to the resident's bed. Observation on 9/25/24 at 7:30 A.M., showed the resident on his/her back in bed. No call light was connected to the port in the wall next to the resident's bed. Certified Nurse Aide (CNA) C was in the resident's room, about to get the resident up for the day. During an interview on 9/25/24 at 9:42 A.M., CNA C said the resident understands commands, instructions, and can respond verbally with yes/no to questions every now and then. He/She cannot use his/her left hand, but can use his/her right hand and is very good with it. The resident is the only resident on the unit without a call light and CNA C was not sure why. During an interview on 9/25/24 at 2:32 P.M., CNA B said the resident cannot use one of his/her hands, but can use the other one. He/She does not have a call light in his/her room. He/She cannot holler out if he/she needs something and should have a call light. All residents should have call lights next to their beds. During an interview on 9/25/24 at 10:34 A.M., Nurse Supervisor A said the resident has dementia and can talk at times. His/Her left hand is contracted, but he/she has use of his/her right hand and could use a call light. All residents should have a call light next to their bed. Nurse Supervisor A was not aware the resident did not have a call light. During an interview on 9/26/24 at 2:17 P.M., the Director of Nurses (DON) and Administrator said the resident is not verbal but would understand how to use a call light. His/Her left hand is contracted, but he/she does have use of his/her right hand. The DON and Administrator expected all residents to have call lights within reach next to their beds. All staff are responsible for ensuring there are call lights within reach of resident beds. If staff observe a call light is missing from a resident's room, they should notify the nurse and maintenance should be notified. Some staff are not good with entering repair requests into the reporting system used by maintenance, so they can call the front desk and notify the receptionist of the issue, and the receptionist can enter the request into the reporting system for staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure weekly skin assessments were completed by a nurse for three residents at risk for skin breakdown or with impaired skin integrity (Residents #7, #27, and #32), failed to complete an admission skin assessment and admission note, obtain a admission weight, and obtain skin tear treatment orders (Resident #155), failed to implement the physician order for thromboembolic deterrent (TEDs. a type of compression stocking applied to legs to prevent blood clots) hose when the resident has a history of edema and blood clots, failed to perform skin assessments, failed to obtain monthly weights and address the resident's weight gain (Resident #6), and failed to ensure wound care was being completed (Resident #1). The sample was 16. The census was 62. Review of the facility's Weight Measurement and Recording, reviewed, February, 2019, showed: -Purpose: To identify changes in the resident's weight and nutritional status and provide availability of weights to appropriated staff by documentation in the medical record. To provide appropriate nutritional interventions to promote health and maintain weight within appropriate parameters; -Policy: Residents will be weighed routinely on admission and re-admission, weekly time for 4 weeks, and then monthly; Residents with weight variations will be weighed more frequently; -Procedure: The community will develop a system for measuring weights on admission, weekly, monthly, and as needed; Monthly weights will be done over a 3-4 day period each month. Weekly weights will be done on a specific day of each week to establish consistence in time between weights; Weights will be reviewed by a qualified individual and re-weights will be obtained; Weights will be entered into the medical record for each resident in a timely manner. Review of the facility's Physician Order policy, revised, February, 2022, showed: -Policy: Resident care will be provided in accordance with physician orders; -Procedure: Orders for a licensed physician can be handwritten, faxed or transmitted electronically; Verbal orders car be given to a qualified nursing staff member; Orders will be entered into the electronic medical record (EMR) and followed accordingly; Nurses are required to follow physician orders unless they are clearly erroneous, dangerous to the resident, or not within the scope of practice; The ordering physician will be contacted with any questions. Review of the facility's wound care policy, dated April 2021, showed: -Policy statement: all residents needing wound care will have wound care provided by nursing staff, in accordance with doctor's orders or wound consultant company; - Procedure: upon notification of a wound, nursing staff will assess the wound and notify physician. Nursing staff will follow doctor's orders to care for the wound, and consult wound consultant company, if directed. If resident removes dressing prior to scheduled dressing change, staff will replace dressing and continue to monitor. 1. Review of Resident #7's medical record, showed: -Room on the A2 unit; -Diagnoses included dementia and lymphedema (swelling in the body's tissues); -No Braden scale assessments (a tool used to assess a patient's risk of developing pressure ulcers or pressure sores) completed in the past 12 months. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/21/24, showed resident at risk of developing pressure ulcers. Review of the resident's care plan, in use at the time of survey, showed: -Need: Resident has potential impairment to skin integrity; -Need: Resident has an activity of daily living (ADL) self-care performance deficit; -Interventions/tasks included skin inspections, the resident requires skin inspections weekly. Review of the resident's skin observation evaluations, completed by licensed nurses, reviewed 9/24/24, showed no skin observations completed after 9/2/24. 2. Review of Resident #27's medical record, showed: -Room on A2 unit; -Diagnoses included dementia and generalized muscle weakness. Review of the resident's scale assessment, dated 7/16/24, showed the resident at risk of developing pressure ulcers. Review of the resident's quarterly MDS, dated [DATE], showed the resident at risk of developing pressure ulcers. Review of the resident's care plan, in use at the time of survey, showed: -Need: Resident has potential for impairment to skin integrity related to occasional incontinence of bladder; -Need: Resident has an ADL self-care performance deficit; -Interventions/tasks included skin inspections, the resident requires skin inspections weekly. Review of the resident's skin observation evaluations, completed by licensed nurses, reviewed 9/23/24, showed no skin observations completed after 8/16/24. 3. Review of Resident #32's medical record, showed: -admission date 8/20/24; -Room on A2 unit; -Diagnoses included stroke, generalized muscle weakness, and contracture (fixed tightening of muscle, tendons, ligaments, or skin, preventing normal movement) to left elbow. Review of the resident's Braden scale assessment, dated 8/20/24, showed the resident at risk of developing pressure ulcers. Review of the resident's admission MDS, dated [DATE], showed: -Upper extremity impairment on one side; -Lower extremity impairment on both sides; -Resident at risk of developing pressure ulcers; Review of the resident's care plan, in use at the time of survey, showed: -Need: Resident has potential for impairment to skin integrity; -Need: Resident has limited physical mobility; -Interventions/tasks included monitor/document/report as needed, any signs/symptoms of skin breakdown. Review of the resident's skin observation evaluations, completed by licensed nurses, reviewed 9/23/24, showed no skin observations completed after 8/20/24. 4. During an interview on 9/25/24 at 10:34 A.M., Nurse Supervisor A said nurses are expected to complete skin assessments weekly, usually on a resident's shower day. Nurses document their assessments as a skin observation in the electronic medical record (EMR). During day shift, a nurse is scheduled on the facility's A3 and E3 units, but nurses are not scheduled on A1 or A2. Nurse Supervisor A is responsible for completing all skin assessments for A1 and A2; however, it is not possible due to his/her other duties. 5. During an interview on 9/26/24 at 2:17 P.M., the Director of Nurses (DON) and Administrator said nurses are expected to complete Braden scale assessments quarterly. Nurses are expected to complete skin assessments weekly. Skin observation tools are completed by nurses in the EMR. The usual floor nurse for the A2 unit was moved into a Nurse Supervisor position in August 2024, which may be why skin assessments for residents on that unit have not been completed since then. Currently, there is one nurse scheduled on A3 and E3, and no nurse scheduled on A1 or A2, while the Nurse Supervisor floats between all floors. Skin assessments performed by the nurse are particularly important for residents at risk of skin breakdown and/or with impaired skin integrity. 6. Review of Resident #155's face sheet, undated, showed -An admission date 9/20/24; -Diagnoses included COPD, stroke, weakness, severe protein malnutrition and overweight. Review of the resident's skin assessments, showed: -No admission skin assessment was available for review; -On 9/24/24 at 9:15 P.M., a left calf small skin tear cleaned with wound cleaner and dry dressing. Review of the resident's progress notes, showed: -No admission note; -On 9/24/24 at 9:17 P.M., this nurse went to the resident's room, a skin tear was noted to his/her left calf; The resident said he/she looked down and he/she was bleeding; Bleeding stopped immediately and was area was cleaned with wound cleaner and a dry dressing was applied; The MD was notified and supervisor aware. Review of the resident's POS, dated September, 2024, showed no treatment orders for the skin tear. Review of the resident's weights, showed no admission weight was obtained. During observation and interview on 9/23/24 at 12:35 A.M., the resident said he/she was admitted on [DATE]. The staff did not weigh him/her or complete any kind of skin assessment when he/she arrived to the facility. The resident had an undated white gauze dressing to his/her left upper arm. The resident said the dressing was placed by hospital staff after they removed his/her peripherally inserted central catheter (PICC, a thin tube inserted in the vein and passed into larger veins). During observation and interview on 9/25/24 at approximately 10:30 A.M., the resident said he/she started to bleed from his/her left calf the night before. The resident raised his/her pant leg and exposed the dressing to his/her left calf. A Kerlix (a specialized wrap dressing) dressing was wrapped around the upper part of his/her calf with a date of 9/24/24. The resident had an undated white gauze dressing to his/her left arm. The resident said it was the same dressing from the hospital. Observation on 9/26/24 at 10:00 A.M., showed the resident was in his/her room in his/her recliner and had a Kerlix dressing to his/her left calf dated 9/24/24. During an interview on 9/26/24 at 8:45 A.M., LPN T said when a residents develops a skin tear, it should be measured and treatment orders obtained when the nurse calls the physician. A head to toe skin assessment, weight and an admission note should be completed on the resident as soon as they arrive to the facility. During an interview on 9/26/24 at 9:15 A.M., CMT X said admission weights are to be completed when the resident arrives to the facility. During an interview on 9/25/24 at 10:30 A.M., the DON said there was no admission checklist and once the resident is placed in the computer system, all the required assessments auto populate. During an interview on 9/26/24 at 2:28 P.M., the Administrator and the DON said new resident admission weights are expected to be obtained within 72 hours of admission. The skin assessments and an admission note are expected to be completed as soon as possible. The nurse should have obtained treatment orders for the skin tear when he/she notified the physician of the skin tear. 7. Review of the Resident #6's quarterly MDS, dated [DATE], showed: -Cognitively intact; -No behaviors or rejection of care; -Requires supervision or touching the resident for putting on or taking off socks and shoes; -Diagnosis include: dementia, hip fracture, arthritis and depression; Review of the resident's EMR, showed diagnoses included left chronic embolism (a blood clot that travels in the blood vessel cause a blockage) and thrombosis (a formation of a blood clot inside the blood vessel) of deep veins of lower extremities. Review of the resident's care plan, in use at the time of survey, showed: -Need: The resident had a left hip fracture: -Interventions: Monitor limb for swelling and skin changes; -The care plan did not address resident refusing care. Review of the resident's skin assessment, dated 7/8/24, showed: -Skin intact; -No further skin assessments were available for review. Review of the resident's progress notes on 4/9/24 at 10:24 P.M., showed the Medical Doctor (MD) saw the resident today with new orders for TED hose on in A.M. off in .PM. Health shake and Eucerin cream (a specialized cream to treat dry skin) discontinued due to resident refusing. The orders have been carried out and passed in report. Review of the resident's Physician Order Sheets (POS), dated April, May, June, July, August and September, 2024 did not show orders for TED hose. Review of the resident's progress notes, showed: -On 8/31/24 at 4:23 P.M., the resident's physician visited the resident, no new orders; Review of the resident's physician progress notes, showed: -On 8/31/24 at 4:24 P.M., the resident was seen sitting in his/her chair; Extremities: chronic stasis changes lower extremities; Review of the resident's weights showed: -On 4/9/24: 156.9 pounds (lbs); -On 5/15/24: 165.8 lbs; -On 6/12/24: 165.4 lbs; -No weight recorded dated July, 2024; -On 8/1/24: 169 lbs: -No weight for September, 2024. Review of the resident's progress notes did not show that the resident's weight gain was addressed. During observation and interview on 9/23/24 at 11:00 A.M. and 9/24/24 at 10:30 A.M. the resident sat in his/her chair in his/her room. The resident's bilateral lower extremities had moderate edema. The resident's left leg appeared more edematous than the right. The resident had on white socks that made an indentation into the resident's mid-calf. The resident said he/she had broken his/her hip and was recovering. The left sock appeared to have a yellowish drainage. The resident also had small scabs to his/her left lower leg above the sock line. The resident said he/she had not noticed any drainage from his/her leg and always has swollen legs. The resident did not have TED hose on. During observation and interview on 9/25/24 at 11:01 A.M., the resident sat in his/her chair in his/her room. The resident had his/her feet elevated on a chair. The resident's legs appeared moderately edematous. The resident's left leg was more edematous than the right leg. A yellow stain on the resident's left white sock was present. Certified Nursing Assistant (CNA) Y removed the resident's socks and the resident had indentations where the socks were. Both feet had long toenails approximately one half an inch curling toward the bottom of the resident's toes and both feet were dry. CNA Y said the resident's nails were long and the resident always has edematous legs but refused any type of treatment for them. CNA Y didn't know where the yellow drainage came from that was on the resident's left sock. The resident did not have TED hose on. During an interview on 9/25/24 at approximately 11:15 A.M., Licensed Practical Nurse (LPN) Z said the resident refused treatments to his/her feet and legs. The resident will not even elevate his/her legs. The resident always has lower extremity swelling because he/she has a history of blood clots. LPN Z reviewed the resident's documentation in the resident's EMR progress notes and said there was an order for TED hose on 4/9/24. LPN Z could not locate the order in the POS or the date it was implemented. LPN Z could not locate the TED stocking order under the discontinued orders. LPN Z said he/she doesn't know what happened regarding the TED hose order. During an interview on 9/26/24 at 9:15 A.M., Certified Medication Technician (CMT) X said everyone pitches in to do the weights. The monthly weights are to be completed the within the first 5 days of the month. The Charge Nurse is responsible to review the weights. During an interview on 9/26/24 at 10:00 A.M., LPN Z said skin assessments are weekly, corresponding with the resident's shower. LPN Z pulled out a laminated schedule of showers and skin assessments out of a cabinet at the nursing station on the [NAME] 3 hall. LPN Z said the resident is to have skin assessment every Friday. Weights are completed monthly on residents by the nursing staff and any changes in the resident's weight needs to be reported to the physician. LPN Z was not aware of any weight gain with the resident. During an interview on 9/26/24 at 2:28 P.M., the Administrator and the DON said the resident weights are to be completed monthly. The Charge Nurse is expected to notify the physician of weight changes. The DON was not aware of the physician order for TEDs on the resident. Documentation of the resident refusing treatment should be added to the resident's medical record in a progress note and on the care plan. 8. Review of Resident #1's quarterly MDS, dated [DATE], showed the following: -Diagnoses of multiple sclerosis (MS, disease of the central nervous system), hemiplegia (paralysis or loss of strength on one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) affecting left non-dominant side, and neuromuscular dysfunction of the bladder (when the nerves that control the bladder are damaged resulting in bladder dysfunction); -Moderately impaired cognition. Review of the resident's POS, in use at the time of the survey, showed: -Order, dated 9/23/24, for triple antibiotic ointment (TAO, neomycin-bacitracin-polymyxin), apply to right foot 3rd digit topically, every day shift for abrasion. Cleanse area with wound cleanser (WC), apply TAO, and a dry dressing. Change daily until healed; -Order, dated 9/23/24, for TAO, apply to right foot 4th digit topically, every day shift for abrasion. Cleanse area with WC, apply TAO and a dry dressing. Change daily until healed; -Order, dated 9/23/24, for TAO apply to right great toe topically, every day shift for abrasion. Cleanse with WC, apply TAO and dry dressing, change daily until healed; -Order, dated 9/23/24 for triple paste external ointment 2% (miconazole nitrate topical) apply to left foot 4th toe topically every day shift for abrasion. Cleanse area with WC, apply TAO, cover with dry dressing. Change daily until healed. Review of the resident's most recent skin observation tool, dated 9/22/24, showed no documentation of the resident's toe wounds. Observation on 9/25/24 at 7:59 A.M., of the resident's feet, showed: -The right big toe had a scab-like dark red wound on the top; -The right 2nd toe had one dark red pinpoint area; -The right 3rd toe had dark red scab-like area covering the too of the toe; -The underneath of the right 4th toe had a dark, red, flaky wound; -The left 4th toe had a dark, red, flaky area. -No dry dressings were observed on the resident's toes. Observation on 9/26/24 at 8:32 A.M., showed no dry dressings on the resident's toe wounds. During an interview on 9/26/24 at 9:29 A.M., the Clinical Supervisor said the resident has abrasions on his/her toes. She is not sure when the abrasions first appeared on the resident's toes. She was made aware of the abrasions on 9/20/24. She expected the resident's dry dressings to be placed on the resident's toes as ordered by the physician. She said nurses are responsible for wound care. During an interview on 9/26/24 at 3:00 P.M., the DON said she expected the resident's dry dressings to be placed as ordered by the physician and dated. She expected all wounds to be on the skin assessments completed by nursing staff. She is not sure when the abrasions first appeared on the resident's toes.

Based on observation, interview and record review, the facility failed to ensure a medication error rate less than 5%. Out of 28 opportunities observed, ten errors occurred, resulting in a 35.71% error rate. (Resident #161, Resident #163 and Resident #162). The census was 62. Review of the facility's Medication Administration policy, dated July, 2021, showed: -Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so; -Medication are administered in accordance with written orders of the prescriber; -The resident is always observed after administration to ensure that the dose was completely ingested. Review of the facilities Electronic First dose Kit policy, dated, July, 2021, showed: -The facility may use electronic first dose kits for first dose and emergency medications, where permitted by regulation or law; -The resident is always observed after administration to ensure that the dose was completely ingested. -Upon receipt of a new medication order, facility staff should remove doses for the electronic first dose kit at each administration time until the order is available from the pharmacy. 1. Review of Resident #161's electronic medical record (EMR), showed: -An admission date, 9/23/24; -Diagnoses included urinary tract infection, atrial fibrillation (a fib, irregular heartbeat), heart failure, kidney disease, major depressive disorder, and heart disease; -An order, with a start date, 9/24/24, metoprolol succinate extended release (ER) (medication to treat high blood pressure) 12.5 milligrams (mg), give one time daily; -An order, with a start date, 9/24/24, amiodarone (medication used to treat irregular heartbeat) 200 mg, give one time daily; -An order, with a start date, 9/24/24, Symbicort inhalation (medication used to treat lung disease) 160-4.5 micrograms (mcg), 2 puffs twice a day; -An order, with a start date, 9/24/24, bupropion extended release (ER) (used to treat depression) 300 mg, give one tablet daily; -An order, with a start date, 9/24/24, furosemide (medication to treat heart failure) 20 mg, give one tablet daily; -An order, with a start date, 9/24/24, gabapentin (used to treat nerve pain), 300 mg, give by mouth three times a day; -An order, with a start date, 9/24/24, nitrofurantoin microcrystals (used to treat UTI) 100 mg, give one capsule twice a day. During observation and interview on 9/24/24 at 9:10 A.M., Certified Medication Technician (CMT) V said some of the resident's medications are not available. CMT V searched the medication cart and could not locate the resident's metoprolol, amiodarone, Symbicort, bupropion, furosemide, gabapentin and nitrofurantoin in the medication cart. CMT V informed the resident that he/she would have to wait until the evening shift to get his/her medications when pharmacy delivered the medications. 2. Review of Resident #163's EMR, showed: -An admission date, 9/18/24; -No diagnosis available to review; -An order, with a start date, 9/19/24, docusate sodium (stool softener) 100 mg, give once a day; -An order with a start date, 9/19/24, Systane complete ophthalmic solution (eye drops) 0.6%, instill one drop into both eyes three times a day. During observation and interview on 9/24/24 at approximately 9:40 A.M., CMT W assisted the resident with his/her medications by providing yogurt to help the resident swallow his/her medications. The resident's docusate sodium remained in the resident's medicine cup on his/her bedside table. CMT W left the resident's docusate sodium at the bedside and then left the resident's room. CMT W searched the medication cart for his/her eye drops and said he/she could not find the resident's Systane eye drops. Observation on 9/24/24 at 10:32 A.M., showed the resident sleeping in his/her recliner in his/her room. The resident's docusate sodium remained in a clear medicine cup on the resident's bedside table. 3. Review of Resident #162's EMR, showed; -An admission date, 9/5/24; -Diagnoses included high blood pressure, heart disease, fracture of left foot and muscle weakness; -An order, with a start date, 9/6/24, Omega 3 fatty acids (a supplement), give one capsule daily. During an interview on 9/24/24 at approximately 10:00 A.M., CMT W said the resident's Omega 3 fatty acids was not available to be administered. CMT W said the facility will probably have to go to Walgreens and purchase the supplement. 4. During an interview on 9/24/24 at approximately 10:00 A.M., CMT W said every CMT and nurse has access to the emergency kit and if they don't have access, they need to find a staff member who does have access or notify the Charge Nurse. New admission medications should be pulled from the emergency kit. 5. During an interview on 9/26/24 at 9:57 A.M., CMT X said new admission medications can be pulled from the emergency kit if available. If the resident's medication is not available, staff is expected to call the pharmacy to determine when the medication is expected to arrive. It is unacceptable to tell the resident they have to wait. If there is a problem getting the medication or it has been missing for several days, staff should notify the nurse or the Director of Nursing (DON). CMTs must watch the resident swallow their pills every time in case they may choke or they might drop the medication. That is the first thing you learn in CMT school is to watch the resident take their medication. 6. During an interview on 9/26/24 at 2:28 P.M., the Administrator and the DON said they expected staff to follow physician orders accurately and correctly. Staff are expected to utilize the emergency kit for newly admitted residents if the medications are not available. The resident should be informed why the medication is not available and should not be told they will have to wait. They expected staff to watch the resident take their medications. If medications are not available, the staff are expected to call the pharmacy and find a solution.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents were provided food that was at a safe and appetizing temperature for three residents (Residents #3, #11 and #13). The sample was 16. The census was 62. Review of the facility's checking food temperatures from the main kitchen policy, dated 3/24/24, showed: -Policy statement: the neighborhood team members will check the temperature of hot and cold foods prepared in and delivered from the main kitchen; -Policy interpretation and implementation: upon arrival of the food from the main kitchen, the neighborhood team member will test the temperature of all foods. Hot foods must maintain a temperature of 140 degrees F (Fahrenheit) or greater. Cold foods must maintain a temperature of less than 40 degrees F. The temperatures will be recorded on the food temperature sheet transported with the cart. Any hot food found to be below 140 degrees F will be sent back to the main kitchen. Any cold food found with a temperature more than 40 degrees will be sent back to the main kitchen. Any questions or concerns related to food temperature will be directed to Food Service Director. 1. Review of Resident #3's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/1/24, showed: -Cognitively intact; -Diagnoses include depression and anxiety. During an interview on 9/23/24 at 2:50 P.M., the resident said the food is not always hot when it is supposed to be hot. Staff bring the food to the hall from the main kitchen and by the time the food is served, it can get pretty cold. 2. Review of Resident #11's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses of type 2 diabetes mellitus and major depressive disorder. During an interview on 9/23/24 at 12:33 P.M., the resident said sometimes when his/her food is served to him/her it is cold when it should be hot. 3. Review of Resident #13's admission MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses of major depressive disorder, anxiety and morbid obesity. During an interview on 9/23/24 at 4:50 P.M., the resident said the food is sometimes cold by the time it is delivered to his/her room. 4. During the resident council meeting on 9/24/24 at 2:05 P.M., six residents whom the facility identified as alert and oriented, said that food is often cold when it is served on the first floor [NAME] hallway. 5. Observation on 9/24/24 at 12:22 P.M., of lunch trays served on the first floor [NAME] hallway, showed the following: -Buttered potatoes measured at 114.2 degrees F; -Cornbread casserole measured at 112 degrees F. 6. Observation on 9/25/24 at 11:57 A.M., of lunch trays served on the first floor [NAME] hallway, showed the following: -Baked ham measured at 118 degrees F; -[NAME] sprouts measured at 136 degrees F. 7. During an interview on 9/26/24 at 10:37 A.M., Dining Service Associate H said that food should be served to residents at a safe and palatable temperature to prevent bacteria and health issues. 8. During an interview on 9/26/24 at 10:40 A.M., the Dining Service Manager said he expected staff to serve residents food that is at a safe and palatable temperature to prevent poor quality of food. 9. During an interview on 9/26/24 at 10:45 A.M., the Director of Dining Services said she expected food to be served at a safe and palatable temperature. 10. During an interview on 9/26/24 at 3:17 P.M., the Administrator and Director of Nursing (DON) said they expected food to be served at a safe and palatable temperature.

Based on observation, interview and record review, the facility failed to implement Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce the transmission of multidrug-resistant organisms (MDROs) that employs targeted gown and glove use during high contact resident care activities) as recommended by the Centers for Disease Control and Prevention (CDC) and as required by the Centers for Medicare and Medicaid Services (CMS) for residents with central lines to include catheters and wounds requiring treatments (Residents #1, #28, #157 and #155). The facility failed to exhibit appropriate infection control practices when staff left the catheter bag for one resident (Resident #1) on the floor with no protective barrier, and when staff dropped gloves on the floor and placed them back in the box, where they were later removed and used on one resident during personal care (Resident #1). In addition, the facility failed to ensure hand sanitizer dispensers were functional and filled on one unit of the facility. The sample was 16. The census was 82. Review of the facility's Transmission-Based Precautions policy, dated 2023, showed: Transmission-based precautions (also known as Isolation Precautions) refer to actions (precautions) implemented in addition to standard precautions that are based upon the means of transmission in order to prevent or control infections; -Additional Precautions: -Enhanced Barrier Precautions: expand the use of personal protective equipment (PPE) and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization; -It is essential both to communicate transmission-based precautions to all health care personnel and for personnel to comply with requirements. Pertinent signage (i.e., isolation precautions in place, PPE instructions) and verbal reporting between staff can enhance compliance with transmission-based precautions to help minimize the transmission of infections within the facility. Signage must comply with the resident's right to privacy and confidentiality. PPE must be available near the entrance to the resident room in order for PPE to be donned prior to entry. 1. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/16/24, showed the following: -Diagnoses of multiple sclerosis (MS, disease of the central nervous system), hemiplegia (paralysis or loss of strength on one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) affecting left non-dominant side, and neuromuscular dysfunction of the bladder (when the nerves that control the bladder are damaged resulting in bladder dysfunction); -Moderately impaired cognition. Review of the resident's Physician Order Summary (POS), in use at the time of the survey, showed: -Order, dated 9/23/24, for triple antibiotic ointment (TAO, neomycin-bacitracin-polymyxin), apply to right foot 3rd digit topically, every day shift for abrasion. Cleanse area with wound cleanser (WC), apply TAO, and a dry dressing. Change daily until healed; -Order, dated 9/23/24, for TAO, apply to right foot 4th digit topically, every day shift for abrasion. Cleanse area with WC, apply TAO and a dry dressing. Change daily until healed; -Order, dated 9/23/24, for TAO apply to right great toe topically, every day shift for abrasion. Cleanse with WC, apply TAO and dry dressing, change daily until healed; -Order, dated 9/23/24, for triple paste external ointment 2% (miconazole nitrate topical) apply to left foot 4th toe topically every day shift for abrasion. Cleanse area with WC, apply TAO, cover with dry dressing. Change daily until healed. Review of the facility's EBP list, showed the resident is on EBP precautions due to wound care and Foley catheter (a thin, flexible tube that drains urine from the bladder into a collection bag) care. Observation on 9/25/24 at 7:58 A.M., showed an EBP sign posted outside of the resident's room. Certified Medicine Technician (CMT) D put on a pair of gloves and walked into the resident's room. He/She lifted the resident's blanket to expose the resident's feet and removed the resident's heel protector cushions. He/She lifted each of the resident's feet and then put the resident's heel protector cushions back on. He/She was not wearing an isolation gown. Observation on 9/25/24 at 8:02 A.M. showed CMT D and Certified Nurse Aide (CNA) J entered the room and explained to the resident they were going to turn the resident for a skin assessment. The resident lay in bed on his/her back. The resident's heel protectors were removed by CMT D and wounds were noted to both feet on the resident's toes with no dressing present. The resident was turned to his/her right side. CNA J removed the resident's brief. The resident had stool in his/her brief. CNA J cleaned the resident's left buttock and rectal area. The resident was then turned to his/her left side and CMT D removed the soiled brief and cleaned the resident's right buttock. A dressing to the resident's right buttocks was noted. A clean brief was applied. The resident was repositioned to his/her back by CMT D and CNA J and the clean brief was fastened around the resident. CMT D and CNA J removed their gloves, performed hand hygiene and left the resident's room. CMT D and CNA J did not wear isolation gowns while providing care. Observation on 9/25/24 at 10:23 A.M., showed CNA G removed a pair of gloves from the glove box located outside the resident's room, put the gloves on, and entered the resident's room. He/She touched the resident's Foley catheter bag to pick it up off the ground and placed it back on the resident's bed frame. He/She was not wearing an isolation gown. Observation on 9/26/24 at 8:32 A.M., showed CNA K performed hand hygiene and put on gloves. He/She entered the resident's room and removed the resident's blanket and lifted up the resident's heel protector cushions. He/She was not wearing an isolation gown. 2. Review of Resident #28's medical record, showed: -Diagnoses included MS, hereditary and idiopathic (disease of unknown cause) neuropathy (nerve damage), and dementia; -An order, dated 7/11/24, to cleanse right malleolus (prominent bone on the outer side of the ankle) with wound cleanser and apply dry dressing, change every other day and as needed, every day shift for open area; -No documentation of the resident on EBP. Review of the resident's skin and wound evaluation, dated 9/19/24, showed a venous wound (lower leg wound that develops when the leg veins fail to return blood back toward the heart normally) to the resident's right lateral (side) malleolus. Review of the resident's care plan, in use at the time of survey, showed: -Need: resident has potential for impairment to skin integrity due to impaired mobility and occasional incontinence of bladder. Area with treatment to right malleolus; -Interventions/tasks included treatment as ordered to right malleolus; -No documentation of the resident requiring EBP. Review of the facility's list of residents on EBP, undated, showed the resident on EBP due to wounds. Review of the sign on the resident's door on 9/23/24 at 11:11 A.M., showed: -Contact Precautions: -Providers and staff must also: -Put on gloves before room entry. Discard gloves before room exit; -Put on gown before room entry. Discard gown before room exit. Observation on 9/23/24 at 11:11 A.M., showed the resident seated in a wheelchair in his/her room. CNA B was in the resident's room with gloves on, but no gown. CNA B used both hands to adjust the resident's feet and smooth the resident's bedspread. During an interview, CNA B said no one in the resident's room is on any type of precautions. He/She did not know why there was a Contact Precautions sign on the resident's door. A gown is not necessary to wear in the resident's room. Observation on 9/24/24 at 7:43 A.M., showed the resident seated in the dining room. Nurse Supervisor A approached the resident and put his/her ungloved hands on the resident's shoulders when asking what was wrong. The resident said he/she could not breathe and did not feel well. Nurse Supervisor A unlocked the resident's wheelchair and propelled the resident in his/her wheelchair down the hall to the resident's room. With ungloved hands and no gown on, Nurse Supervisor A placed in his/her hands on the resident and used a stethoscope on the resident to listen to his/her breathing. During an interview on 9/25/24 at 9:55 A.M., LPN P said the Contact Precautions sign on the resident's door is probably old. There are no residents on the hall who are on disease precautions of any kind. During an interview on 9/26/24 at 9:02 A.M., Certified Medication Technician (CMT) D said the Contact Precautions signs are old and he/she does now know why they are still there. He/She does not know what EBP means. He/She does not know anything about wearing extra PPE for certain residents. During an interview on 9/26/24 at 10:53 A.M., Nurse Supervisor A said the resident has a venous wound and EBP should be used when providing care requiring contact with the resident. 3. Review of the Resident #157's electronic medical record (EMR), showed: -admission date: 9/17/24; -No active diagnoses available for review. Review of the resident's care plan, in use at the time of survey, showed: -Need: The resident has a urinary catheter; -Interventions: EBP per facility protocol. Review of the facility's EBP list, undated, showed the resident on EBP due to urinary catheter. Review of the resident's order summary, dated 9/23/24, showed an order, dated 9/17/23, EBP refers to an infection control intervention to reduce transmission of MDRO that require gown and glove usage during high contact care activities. Observation on 9/23/24 at 10:58 A.M., showed outside the resident's room an EBP sign was not posted. Occupational Therapy Assistant (OTA) R assisted the resident with gloved hands from the recliner to his/her wheelchair with a gait belt. The resident's urinary catheter was attached on his/her walker. OTA R removed the resident's urinary catheter from the walker and then positioned the resident's urinary catheter under the wheelchair. OTA R then propelled the resident out into the hallway. OTA R did not have a PPE gown on during resident care. During an interview on 9/26/24 at 8:45 A.M., LPN T said the resident requires EBP because he/she has a urinary catheter. EBP is wearing gloves and an isolation gown anytime when a staff member touches the resident. 4. Review of Resident #155's face sheet, showed; -An admission date of 9/20/24; -Diagnoses included cellulitis (an infection of the skin and tissue below the skin) of the abdominal wall, fistula (an abnormal passageway that connect an organ to the skin), chronic obstructive pulmonary disease, (COPD, a lung disease that constricts the lungs airway), stroke and weakness. Review of the resident's care plan, in use at the time of survey, showed: -Need: The resident has abdominal incision with a wound vac (a device that manages wounds) in place; -Interventions: EBP per facility protocol. Review of the facility's EBP list, undated, showed the resident on EBP due to wounds. Review of the resident's POS, dated 9/23/24, showed an order, dated 9/20/24, EBP refers to an infection control intervention to reduce transmission of MDRO that require gown and glove usage during high contact care activities. Observation and interview on 9/23/24 at 12:35 P.M., showed the resident in his/her room, sitting in his/her recliner with a wound vac attached to his/her abdomen. The resident's family member said the wound vac was applied this morning and that over the weekend a wet to dry dressing was applied to the resident's abdomen until the wound vac could be applied by the wound care nurse. The resident and the resident's family member did not see any staff with an isolation gown on during care. An EBP precaution sign was not posted outside the resident's room. Observation and interview on 9/24/24 at 9:02 A.M., showed an EBP sign posted outside of the resident's room, however no PPE supplies were outside the resident's room. The resident was in his/her room with OTA S. The resident complained of pain to his/her abdomen and that his/her colostomy (a surgically created opening that is through the abdomen that allows stool to be evacuated) pouch needed to be emptied. OTA S propelled the resident to the bathroom and explained to the resident that he/she was going to show the resident how to empty the stool contents of the resident's colostomy. OTA S wore gloved hands and exposed the resident's abdomen. A wound vac was in place near the resident's colostomy stoma (opening). OTA S emptied the resident's colostomy pouch while he/she instructed the resident on the care of the colostomy. OTA S was not wearing an isolation gown during resident care. Observation on 9/26/24 at 9:02 A.M., showed an EBP sign posted outside the resident's room, however no PPE supplies were outside the resident's room. OTA S entered the resident's room and explained to the resident it was time to go to therapy. OTA S applied a gait belt to the resident with ungloved hands and assisted the resident from the resident's recliner to the resident's wheelchair and then propelled the resident out of his/her room. OTA S did not have an isolation gown on during resident care. During an interview on 9/26/24 at 8:45 A.M., LPN T said the resident requires EBP because he/she has a wound vac. 5. During an interview on 9/26/24 at 8:51 A.M., CNA C said he/she does not know what EBP means. He/She is not aware of any additional precautions that need to be taken or extra PPE required for some residents. During an interview on 9/26/24 at 9:00 A.M., CNA U said EBP are to be used by staff for residents who have wounds and catheters. Staff should wear gloves and an isolation gown. During an interview on 9/26/24 at 9:17 A.M., CNA G said he/she does not know what EBP means. If someone is on precautions, the nurse should let him/her know. During an interview on 9/26/24 at 9:23 A.M., CNA Q said EBP means to wear gowns and gloves while providing care for some residents. He/She has seen EBP implementation at other facilities, but not at this facility. During an interview on 9/26/24 at 10:53 A.M., Nurse Supervisor A said EBP is used for residents with catheters and wounds. This requires staff to put on gowns and gloves before entering the resident's room to provide direct care. He/She has not seen EBP happening in the facility. Residents on EBP should have signs outside of their doors to show they are on EBP, and PPE should be outside of the door as well. The Infection Preventionist (IP) is responsible for making sure signs and PPE are placed outside of resident rooms. 6. During an interview on 9/26/24 at 11:52 A.M., the IP said he began his role with the facility in July 2024. EBP are used to protect from open systems only, to protect the resident from infection. If a resident has a wound with an open channel, there is risk to get further infection and the resident is placed on EBP. This would include a resident who requires dressing changes. If a resident has a wound vacuum, it would be considered a closed system and EBP would not be used, and standard precautions of gloves only would be used. Residents are placed on EBP upon admission or when they develop a new wound or qualifying condition that gets reported to him during the facility's daily meetings. Residents on EBP should have the appropriate signs outside of their rooms, as well as caddies containing PPE. The Contact Precautions signs outside of rooms who do not require this, but who are actually on EBP, are old and should be removed. If a sign is posted showing any type of precautions, he expected staff to follow the guidelines posted and wear the appropriate PPE as indicated. He expected the facility to implement EBP practices in line with the facility's policies and expectations of the CDC and CMS. During an interview on 9/27/24 at 11:50 A.M., the IP said all staff members, including therapy, are to follow EBP when providing high contact care activities. 7. During an interview on 9/26/24 at 2:17 P.M. with the Director of Nurses (DON) and Administrator, they said a change in staffing resulted in a lack of education regarding EBP. EBP should be implemented for residents with catheters or wounds requiring dressings. For residents on EBP, staff should wear gloves and gowns when changing the resident's sheets and during any care requiring direct contact. EBP should be followed by all departments, including therapy. The IP is responsible for ensuring the correct signage is posted outside of the resident's room, and ensuring PPE is available within staff's range of use. The correct signage will communicate to staff what type of PPE is required for the resident. 8. Observation on 9/25/24 at 8:02 A.M., showed LPN D and CNA J assisted Resident #1 with a skin assessment. The resident had a Foley catheter that became unhooked from the resident's bedframe and fell onto the floor while the resident was turned side to side. LPN D and CNA J repositioned the resident and left the room. The resident's Foley catheter remained on the floor. Observation on 9/25/24 at 8:08 A.M., showed CNA J entered the resident's room to perform care. At 8:18 A.M., CNA J exited the resident's room. The resident's Foley catheter bag lay on the ground next to the resident's bed. Observations on 9/25/24 at 8:26 A.M., 9/25/24 at 8:39 A.M., 9/25/24 at 8:42 A.M., 9/25/24 at 9:01 A.M., 9/25/24 at 9:29 A.M., and 9/25/24 at 10:00 A.M., showed the resident's Foley catheter bag on the ground next to the resident's bed. During an interview on 9/26/24 at 9:50 A.M., CNA G said if a resident's catheter bag is found on the ground, to pick the catheter bag up and place it back on the resident's bed. During an interview on 9/26/24 at 11:19 A.M., the DON said if a staff member walked into a resident's room and found their catheter bag on the ground, she expected the staff member to clean the bag and place it back on the resident's bed. 9. Observations on 9/25/24, showed: -At 8:08 A.M., CNA J reached into a glove box located outside of the room of Resident #1, and dropped a pair of gloves on the ground. He/She picked the gloves back up and placed the gloves back into the glove box. He/She when back into the resident's room to perform care to the resident; -Continuous observation from 8:08 A.M. to 10:23 A.M., showed the contaminated gloves remained in the glove box; -At 10:23 A.M., CNA G removed the pair of contaminated gloves from the glove box located outside the resident's room, put the gloves on, and entered the resident's room. He/She touched the resident's Foley catheter bag to pick it off the ground and placed it on the resident's bed frame. During an interview on 9/26/24 at 9:17 A.M., CNA G said if staff drop PPE on the floor, they should discard it. It would not be appropriate to drop PPE, such as gloves, on the floor, and then use it while providing care due to contamination issues. During an interview on 9/26/24 at 9:23 A.M., CNA Q said if staff drop gloves on the floor, they should pick them up and throw them away. It would not be appropriate to use the dropped gloves because they have been exposed to germs. During an interview on 9/26/24 at 12:03 P.M., the IP said he expected staff to dispose of gloves if staff members drop them on the ground. During an interview on 9/26/24 at 2:17 P.M., the DON and Administrator said if PPE, such as gloves, becomes contaminated, it is expected that staff dispose of the PPE, not use it on a resident. 10. Observations of the A2 unit, on 9/23/24 at 11:11 A.M., 9/24/24 at 12:51 P.M., 9/25/24 at 10:24 A.M., and 9/26/24 at 11:25 A.M., showed: -A total of six hand sanitizer dispensers on the three sections of rooms on the unit; -Two sanitizer dispensers were empty on the top section for rooms 215 through 223; -Two sanitizer dispensers were empty on the middle section for rooms 217 through 218; -Two functioning dispensers on the back section for rooms 219 through 222. During an interview on 9/26/24 at 8:51 A.M., CNA C said the hand sanitizer dispensers on A2 have been empty for months. He/She is not sure who fills them. Some residents have signs on their doors instructing staff to sanitize their hands before entering, but the dispensers are empty. During an interview on 9/26/24 at 9:12 A.M., CNA B said the hand sanitizer dispensers on A2 have been out for months. He/She needs to sanitize his/her hands in between each resident's room. During an interview on 9/26/24 at 9:02 A.M., CMT D said the hand sanitizer dispensers have been empty for months. He/She needs to sanitizer his/her hands in between residents during medication administration. He/She uses the sinks to wash his/her hands instead, but it would be helpful to have the sanitizer available. Housekeeping fills the dispensers. During an interview on 9/26/24 at 8:52 A.M., Housekeeping Associate O said he/she did not know who filled the hand sanitizer dispensers. During an interview on 9/26/24 at 10:53 A.M., Nurse Supervisor A said the hand sanitizer dispensers on A2 have been empty for months. Nursing staff need the sanitizer for use in between residents. During an interview on 9/26/24 at 2:17 P.M., the DON and Administrator said the hand sanitizer dispensers on the A2 unit should be functioning and filled for staff use. Maintenance is responsible for ensuring the dispensers are functional.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the main kitchen floors, appliances and food storage areas were clean and free from debris, and that the ceiling was free from dust accumulation. The facility also failed to ensure the [NAME] 2nd floor (A2) dishwashers were in working order, affecting two residents (Resident #24 and Resident #3). The sample was 16. The census was 62. Review of the facility's cleaning rotation policy, undated, showed: -Guideline: Equipment and utensils will be cleaned and sanitized according to the following guidelines, or manufacturer's instructions; - Items cleaned daily: Stove top, grill, kitchen and dining room floors, and exterior of large appliances; - Items cleaned weekly: Storerooms, shelves, and ovens; -Items cleaned monthly: Refrigerators, freezers, and ingredient bins; -Items cleaned annually: Ceilings. 1. Observation on 9/23/24, of the main kitchen, showed: -At 10:18 A.M., the walk in refrigerator had food debris and food substance build up on the main part of the floor and under the storage racks. A dirty white towel lay on the floor next to the back storage rack; -At 10:19 A.M., the walk in freezer had food debris and trash debris on the main floor and on the floor under the storage racks; -At 10:21 A.M., the bulk bins had food debris and white powder substance on all three lids and bins; -At 10:22 A.M., the deep fryer had grease and food debris on the inside. The outside of the deep fryer had sticky grease streaks and build up; -At 10:23 A.M., the freezer next to the deep fryer, had a sticky grease substance on the left side. The right side of the freezer had substance debris and liquid streaks; -At 10:24 A.M., above the main food prep station, two light fixtures and eight ceiling tiles surrounding the light fixtures had dust accumulation and build up; -At 10:25 A.M., the main floor of the kitchen had food debris and trash wrappers in various areas; -At 10:26 A.M., the floor under the prep station had a dirty towel; -At 10:27 A.M., above the spice rack prep station, two lights and three ceiling tiles had dust accumulation and build up; -At 10:29 A.M., the oven doors were caked with substance and food debris; -At 10:31 A.M., the dry storage room floors had food, trash, and food debris on the ground under all of the storage racks. The floor was sticky. Observation on 9/24/24, of the main kitchen, showed: -At 8:08 A.M., the oven doors were caked with substance and food debris; -At 8:09 A.M., the deep fryer had grease and food debris on the inside. The outside of the deep fryer had sticky grease streaks and build up; -At 8:10 A.M., two light fixtures and eight ceiling tiles surrounding the light fixtures had dust accumulation and build up. The light fixtures and ceiling tiles were above the main food prep station where open containers of eggs, bacon, and gravy were located; -At 8:11 A.M., the freezer next to the deep fryer had a sticky grease substance on the left side. The right side of the freezer had substance debris and liquid streaks; -At 8:13 A.M., the dry storage room floors had food, trash, and food debris on the ground under all of the storage racks. The floor was sticky; -At 8:14 A.M., the walk in refrigerator had food debris and food substance build up on the main part of the floor and under the storage racks. A dirty white towel was on the floor next to the back storage rack; -At 8:17 A.M., the walk in freezer had food debris and trash debris on the main floor and on the floor under the storage racks; -At 8:18 A.M., the bulk bins had food debris and white powder substance on all three lids and bins; -At 8:19 A.M., above the spice rack prep station, two lights and three ceiling tiles had dust accumulation and build up; -At 8:36 A.M., the refrigerator by the walk in freezer had food debris and liquid spills on the bottom shelf. Observation on 9/25/24, of the main kitchen, showed: -At 7:23 A.M., the bulk bins had food debris and white powder substance on all three lids and bins; -At 7:24 A.M., above the spice rack prep station, two lights and three ceiling tiles, had dust accumulation and build up; -At 7:28 A.M., the refrigerator next to the ice cream storage had food and liquid spills on the bottom shelf; -At 7:29 A.M., the deep fryer had grease and food debris on the inside. The outside of the deep fryer had sticky grease streaks and build up; -At 7:30 A.M., two light fixtures and eight ceiling tiles surrounding the light fixtures had dust accumulation and build up. The light fixtures and ceiling tiles were above the main food prep station where open containers of breakfast food were located; -At 7:31 A.M., the freezer next to the deep fryer had a sticky grease substance on the left side. The right side of the freezer had substance debris and liquid streaks; -At 7:33 A.M., the walk in refrigerator had food debris and food substance build up on the main floor and under the storage racks. A dirty white towel was on the ground next to the back storage rack; -At 7:35 A.M., the walk in freezer had food debris and trash debris on the main floor and on the floor under the storage racks; -At 7:36 A.M., the oven doors were caked with substance and food debris; -At 7:37 A.M., the dry storage room floors had food, trash, and food debris on the ground under all of the storage racks. The floor was sticky. During an interview on 9/26/24 at 10:37 A.M., Dining Service Associate H said the dish washing staff clean the refrigerators and freezers. The cooks were responsible for cleaning the kitchen appliances. All kitchen staff were responsible for cleaning the floors. During an interview on 9/26/24 at 10:40 A.M., the Dining Service Manager said cooks were responsible for cleaning kitchen appliances daily. The dish washing staff were responsible for cleaning the floors. Maintenance staff were responsible for cleaning the ceiling annually or as needed. He/She would expect the entire kitchen top to bottom to be clean. During an interview on 9/26/24 at 10:45 A.M., the Director of Dining Services said she would expect for the kitchen to be clean at all times. The refrigerators and freezers should be cleaned every Monday and Thursday. The dish washing staff were responsible for cleaning the floors and appliances. Maintenance staff were responsible for cleaning the ceiling annually. 2. Review of Resident #24's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, showed: -Room on the A2 unit; -Severe cognitive impairment; -Diagnoses included anxiety and depression. During an interview on 9/23/24 at 10:52 A.M., the resident said the dishwasher has been on the fritz for a month now, so sometimes the utensils served with meals were dirty. 3. Review of Resident #3's significant change MDS, dated [DATE], showed: -Room on the A2 unit; -Cognitively intact; -Diagnoses included anxiety and depression. During an interview on 9/23/24 at 2:29 P.M., the resident said the dishwasher is broken so all dishes were hand washed and they are not as clean. He/She gets served meals with dirty forks that still had food on the tongs. The dishes were not sanitized because the water does not get hot enough when washing by hand. 4. Observation of the A2 unit on 9/24/24 at 8:16 A.M., showed two dishwashers in a kitchenette with handwritten notes on the front of both dishwashers, showing Not working. Dining Service Associate M placed dishes into the top rack of the dishwasher on the left side, and pressed the start button. He/She rinsed a divided plate in soapy water in the sink, rinsed it with running water, and placed the divided plate on a drying rack on the counter. He/She rinsed a cup under running water, opened the dishwasher on the left side, placed the cup in the top rack of the dishwasher, closed the dishwasher, and pressed the start button. He/She rinsed two more divided plates in soapy water at the sink, rinsed them with running water, and placed them on the drying rack. Observation of the A2 unit on 9/24/24 at 1:12 P.M., showed Dietary Service Associate M with a cart of dirty dishes from lunch, and a bucket of soapy water. He/She dunked several cups into the bucket of soapy water, placed them in the top rack of the dishwasher to the far left of the sink, then turned the dishwasher on. He/She used a rag to wipe regular and divided plates in the bucket of soapy water, rinsed them in the sink, then placed them on the drying rack next to the sink. He/She removed a handful of utensils from the bucket of soapy water and placed them in the top rack of the dishwasher on the left side, then turned the dishwasher back on. The needles on the temperature gauges on the front of the dishwasher did not move during the cycle. Observation on 9/26/24 at 8:27 A.M., showed Dining Service Associate N turned on the dishwasher to the far left of the sink. After running for five minutes, Dining Service Associate N placed a thermometer into the water at the bottom of the dishwasher, and the temperature reached 102.7 degrees Fahrenheit (F). 5. During an interview on 9/24/24 at 1:29 A.M., Dietary Service Associate M said the dishwashers in the A2 kitchen were broken. He/She washes the dishes by hand, then runs them through the dishwasher to sanitize them, and then they dry before being put away or used at the next service. 6. During an interview on 9/26/24 at 8:27 A.M., Dining Service Associate N said the dishwashers in the A2 kitchen were broken. Dishes for the unit have to be washed by hand, but that was not sanitary enough. Dishes can also be taken to the main kitchen to be washed. 7. During an interview on 9/26/24 at 9:32 A.M., the Dining Service Manager said the dishwashers were broken in the A2 kitchen. New dishwashers have been ordered and in the meantime, staff should rinse the dishes in the A2 kitchen, then bring them to the main kitchen to be run through the main kitchen dishwashers. Dishes need to be run through the dishwasher to address germs. Handwashing will not sufficiently clean the dishes. 8. During an interview on 9/26/24 at 2:17 P.M., the Administrator said the dishwashers on A2 were broken, and on 9/12/24, an order was placed for new dishwashers. The new dishwashers should arrive in a few weeks and until then, staff should wash the dishes in the A2 kitchen, then take them to the main kitchen to be washed in the main kitchen dishwasher to ensure proper sanitation.

Based on observation, interview and record review, the facility failed to ensure one resident with pressure ulcers (injury to the skin and underlying tissues as a result of pressure or friction) received services, consistent with professional standards of practice, when staff failed to enter physician orders for wound care into the medical record for one of four residents sampled, which could have resulted in wound care not being provided. (Resident #1). The census was 60. Review of the facility's Pressure Sore Care Policy, undated, showed: Procedures for Stage 2 (a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough, may also present as an intact or open/ruptured blister) or greater pressure sore: Notify physician of pressure sore for treatment orders. Review of Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 3/16/24, showed: -Moderately impaired cognition; -Functional limited range of motion: upper extremity: impairment on one side, lower extremity: impairment on both sides; -Personal hygiene: partial/moderate assistance helper does less than half of the effort; -Roll left to right: substantial/maximal assistance; -Diagnoses included: progressive neurological condition, aphasia (loss of ability to understand or express speech) hemiplegia (paralysis of the arm, leg, and trunk on the same side of the body) or hemiparesis (slight weakness in a leg, arm or face), multiple sclerosis (MS, a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord, which may cause numbness impairment of speech and muscular coordination, blurred vision and severe fatigue); -At risk for developing pressure ulcers. Review of the care plan, in use at the time of the survey, showed: -Focus: The resident was at risk of pressure ulcer due to history of, prefers to stay in bed, refuses to get up out of bed. 4/15/2024 Pressure injury (localized damage to the skin as well as underlying soft tissue), noted to coccyx (tailbone) and left buttock requiring treatment and observation; -Goal: Treatment as ordered to coccyx and left buttock. During an observation and interview on 4/17/24 at 11:40 A.M., the resident lay in bed positioned towards the window watching TV. The resident said he/she had a sore on his/her butt. Review of the Wound Evaluation, dated 4/15/24, showed: -Body location: left ischial tuberosity (IT, V-shaped bone at the bottom of the pelvis that contacts a surface when a person is sitting down); -New: seven days old; -In house acquired; -Length: 3 centimeters (cm) X Width: 1.83 cm; Depth: no depth was documented; -Type of wound: pressure; -Stage: 2. Observation of the wound evaluation photo, dated 4/15/24, showed the wound had defined edges, inside the wound bed was a dark brownish colored area with a small amount of yellowish slough (dead tissue separating from living tissue) noted around the dark brownish area and a small yellowish string of slough. Review of the physician's order summary report, dated 4/17/24, showed, there no treatment order for the wound on the left IT. Review of the Treatment Administration Record (TAR), dated 4/1/24 through 4/17/24, showed, there no treatment order for the wound on the left IT. Review of the progress notes, dated 4/1/24 through 4/10/24, showed: -On 4/10/24 at 3:42 P.M., physician progress note, new sacral (tailbone) decubitus (pressure injury). Plan: turn side to side every two hours. Discussed local treatment of wound with nursing: -On 4/10/24 at 3:56 P.M., seen by the doctor, no new orders noted. Observation on 4/18/24 at 3:00 P.M., showed the resident lay in bed. The wound nurse removed the dressing off the left IT. The wound was open, no depth, irregular shaped with a small brownish colored spot noted inside the wound bed. Review of the Wound Evaluation, dated 4/18/24, showed: -Body location: left IT; -Improving: 10 days old; Review of the Skin and Wound Evaluation, dated 4/18/24, showed: -Description: pressure; -Stage: Stage 2: Partial-thickness skin loss with exposed dermis (skin); -Location: Left IT; -In-House Acquired; -How long has the wound been present? 1 week. During an interview on 4/18/24 at 11:53 A.M., the Wound Nurse said the resident was being treated for wounds on his/her buttocks/coccyx and the left IT. The wound on the left IT was from 4/15/24. She staged the wound as a stage 2 wound, but had been thinking about changing the wound to unstageable (a type of bed sore that occurs due to prolonged pressure on a specific area of the skin, resulting in the lack of blood flow and oxygen to the tissue) because of the dark spot inside the wound bed. She did not know what was under the dark spot. The order for the santyl (used to remove damaged tissue from chronic skin ulcers) was obtained two days ago. She hoped the nurse on the floor would enter the order into the computer. The Wound Nurse verified the yellowish around the dark spot noted in the photo on 4/15/24 was slough. Review of the progress notes, dated 4/11/24 through 4/18/24, showed no documentation of the wound on the left IT or a treatment order was received. During an interview on 4/17/24 at 9:25 A.M., Certified Medication Technician (CMT) B said if a resident had an open area, he/she would tell the nurse. During an interview on 4/17/24 at 9:35 A.M., Care Partner C said if a resident had a redden area, he/she would tell the nurse and document it in the medical record. If the resident had an open area, he/she would tell the nurse and have them look at it. During an interview on 4/18/24 at 9:15 A.M., Registered Nurse (RN) D said if a resident had an open area, he/she would assess and measure the wound, call the doctor, and obtain treatment orders. Wounds are documented in the progress notes and on the 24-hour report sheet and the Wound Nurse would be notified. The Wound Nurse measured and staged the wound. The nurse who found the wound was responsible for notifying the doctor and obtaining the orders. All wounds should have a treatment order. During an interview on 4/18/24 at 3:55 P.M., the Assistant Director of Nursing (ADON) said if a resident had an open area, she would expect for staff to notify the doctor and obtain treatment orders. Wounds were documented in the progress notes and/or on the skin sheet and passed along in report. The nurse should document a description of what the wound looked like and the location of the wound along with the measurements. The person who obtained the treatment order was responsible for entering them into the computer. The ADON would expect staff to follow the facility's policies and procedures. During an interview on 4/18/24 at 4:18 P.M. the Administrator and Director of Nursing said if a wound was found, they expected staff to communicate to the doctor the location and a description of the wound. Wounds should be documented in the progress notes and under the skin integrity section of the medical record. The Wound Nurse was notified, and she measured and staged the wounds for consistency. The nurse who obtained physician orders was responsible for entering the orders into the computer. The administrator would expect for treatment orders to be put in the medical record within 24 to 72 hours. Staff should follow the facility's policies and procedures. MO00234253

Based on interview and record review, the facility failed to ensure that in accordance with acceptable professional standards and practices, medical records maintained were complete and accurately documented for one resident (Resident #1). The sample was five. The census was 60. Review of the facility's job description for Certified Medication Technician (CMT) dated: effective date 7/1/22, showed: -Duties and responsibilities: -Administer prescribed medications to residents; -Pass oral, topical, ophthalmic (having to do with the eyes) and inhalation medications; -Document all medications administered to residents. Review of Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 3/16/24, showed: -Moderately impaired cognition; -Diagnoses included: progressive neurological condition, aphasia (loss of ability to understand or express speech) hemiplegia (paralysis of the arm, leg, and trunk on the same side of the body) or hemiparesis (slight weakness in a leg, arm or face), multiple sclerosis (MS, a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord, which may cause numbness impairment of speech and muscular coordination, blurred vision and severe fatigue). Review of the care plan, in use at the time of the survey, showed: -Focus: The resident was at risk of pressure ulcer (localized skin and soft tissue injuries that form as a result of prolonged pressure and shear, usually exerted over bony prominences) due to history of, prefers to stay in bed, refuses to get up out of bed. 4/15/2024 Pressure injury (localized damage to the skin as well as underlying soft tissue), noted to coccyx (tailbone) and left buttock requiring treatment and observation; -Goal: Treatment as ordered to coccyx and left buttock. Review of the Medication Administration Record (MAR), dated 4/1/24 through 4/17/24, showed: -A physician's order for: Wound Gel (promotes wound healing), first clean the coccyx with wound cleaner or soap & water, apply wound gel, cover with dry dressing or foam padding, change daily. Discontinued on 4/3/24; -Documentation showed: On 4/2 and 4/3/24 CMT E's initials and a 9 (9 meant: other/see progress notes) documented; -A physician's order for: Collagenase Ointment (Santyl, a prescription medication, sterile enzymatic debriding ointment) 250 unit/gram (GM): cleanse coccyx with wound cleanser, apply Santyl, cover with dry dressing change daily and as needed until healed, start date 4/4/24; -Documentation showed: on 4/4, 4/6, 4/8, 4/9, 4/10, and 4/12/24 all showed CMT E's initials and a 9 was documented; -Documentation showed: on 4/5, 4/11, 4/16 and 4/17/24 showed CMT E's initials. Review of the progress notes, dated 4/1/24 through 4/17/24, showed on 4/2, 4/3, 4/4, 4/5, 4/6, 4/8, 4/9, 4/10, 4/11, 4/12, 4/16 and 4/17/24 all medications given were documented. During an interview on 4/18/24 at 9:00 A.M., CMT E said most of the time the nurse supervisor would do the pressure ulcer treatments. CMT's could do pressure ulcer treatments such as applying prescription medications and applying dressings. If the CMT felt comfortable doing a treatment and if they had supplies, they could do it. If a dressing came off CMT E would either reinforce the dressing or apply a new dressing. CMT E said he/she felt comfortable doing the treatments. During an interview on 4/18/24 at 11:53 A.M., the Wound Nurse said she provided wound care for residents one to two times a week. Once a week she completed the wound assessment. The other days she completed wound care on the unit where the CMT was in charge of the unit. The wound nurse said she did not know if CMT's were allowed to complete treatments or not. During an interview on 4/18/24 at 3:55 P.M., the Assistant Director of Nursing (ADON) said the nurse on the floor was responsible for providing the wound the care. CMT's could provide some wound care, such as barrier creams. The person who provided the treatment should be the person who documented the treatment was completed. The staff member whose initials are documented on the MAR was CMT E. She did not know if the documentation which said all medications given included treatments. During an interview on 4/18/24 at 4:08 A.M., the Director of Nursing (DON) said sometimes when the staff documented a medications or treatment in the computer, the computer would not accept it. When that happened, staff sometimes would choose to document a 9. When staff documented all medication given, that would include treatments. The nurses provided wound care. If there was a CMT on the floor, the wound care was provided by the Wound Nurse. If the Wound Nurse was off, the nursing supervisor would provide the treatment. The person who administered the medication/treatment should be the person who documented it. Sometimes the nurses would go to the computer and click on the treatment to document it was completed without the CMT signing out and the nurse signing in. That was why CMT E's initials would appear in the box in place of the nurse's. During an interview on 4/23/24 at 10:30 A.M., the Administrator said, she would expect for the person who completed the task to document it. She expected for the medical record to be complete and accurate, and she would expect for staff to follow the facility's policies and procedures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure they developed an accurate comprehensive person-centered care plan for each resident, for two of 13 sampled residents (Resident's #1 and #21). The census was 51. 1. Review of the list of residents who received hospice services, provided by the facility, showed Resident #1 not listed. Review of Resident #1's medical record, showed: -Diagnoses included neuromuscular disorder of the bladder (difficulty controlling the bladder) and multiple sclerosis (an autoimmune disease where the body attacks its own nervous system); -No order for an indwelling urinary catheter (a tube inserted through the urinary opening and into the bladder); -No order for hospice services. Review of the resident's care plan, in use at the time of the survey, showed: -Need initiated 4/11/20: The resident has potential for pain and discomfort due to multiple sclerosis and age related arthritis and impaired mobility: -Interventions included: Consult hospice team to offer palliative interventions to help relieve symptoms of pain or distress; -Need initiated on 5/30/20: The resident is totally dependent on the staff due to the catheter cares: -Interventions included: Catheter cares every shift. Observe for infection or discomfort at insertion site. Observation on 5/9/23 at 8:59 A.M. and 5/10/23 at 10:42 A.M., showed the resident lay in bed and no catheter visible. Observation on 5/10/23 at 1:23 P.M., showed Nursing Supervisor A and Licensed Practical Nurse E provided incontinence care for the resident. The resident was incontinent of bowel and bladder. No urinary catheter in place. During an interview on 5/9/23 at 10:00 A.M., Certified Nursing Assistant (CNA) B said staff know how to care for residents based on the care plan in the computer. During an interview on 5/11/23 at 9:36 A.M., the Director of Nursing (DON) said the resident was not currently on hospice, but was at one time. The resident does not have a catheter. She would expect the care plan to be accurate. 2. Review of Resident #21's medical record, showed: -Diagnoses included history of falls and left leg fracture; -An order dated 3/28/22, for one person stand pivot transfer with sit to stand (mechanical lift to assist with transfers where the resident can bear weight) as needed; -An occupational therapy Discharge summary, dated [DATE], showed patient has not made a significant progress with recent fall. Remains a Hoyer lift (full body mechanical lift). Observation on 5/9/23 at 11:35 A.M., showed CNA B and CNA D transferred the resident from bed to a medical reclining chair with the use of a Hoyer lift. Review of the resident's care plan, in use at the time of the investigation, showed: -Need: Activities of daily living self-care performance deficit requiring minimum to moderate assistance; -Intervention initiated on 10/12/21 and revised on 1/4/23, showed transfer: The resident requires extensive assistance by one staff to move between surfaces. May use sit to stand lift as needed times two staff. During an interview on 5/11/23 at 7:58 A.M., CNA F said staff know how a resident transfers based on the report and what the nurse says. The resident transfers with the use of a Hoyer lift and two staff. During an interview on 5/11/23 at 9:36 A.M., the DON said the medical record should accurately reflect the resident's transfer needs. Staff know the resident's transfer status by looking at the [NAME] which carries over from the care plan. If therapy recommends the resident to change from a sit to stand mechanical lift to a Hoyer lift, therapy puts in the order and nursing staff activate it. This should be done at the time of the recommendation. She is aware that the resident was changed to a Hoyer lift and she would expect both the physician orders and care plan reflect this change.

Based on observation, interview and record review, the facility failed to ensure each resident receives adequate assistance to prevent accidents, for one resident transferred with stand by assistance (Resident's #11). The census was 51. Review of the facility's Gait Belts policy, dated 10/2011, showed: -Purpose: To provide safety of residents and nursing staff members when transferring or ambulating a resident; -Gait belts will be used when transferring or ambulating residents that require the assistance of staff to transfer; -Procedure: Apply gait belt snugly to the resident's waste area. Place hands on belt at back and sides of resident with palms up and fingers on the inside of the belt. Review of Resident #11's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/10/23, showed: -Severe cognitive impairment; -Extensive assistance of one person required for transfers; -Surface to surface transfer (transfer between bed and chair or wheelchair): Not stead, only able to stabilize with human assistance; -Used a walker and a wheelchair; -Primary medical condition category: Non-traumatic brain dysfunction; -Diagnoses include dementia and malnutrition; -Has the resident had any falls since admission or prior assessment: Yes: -Two or more falls with no injury; -One fall with an injury (except major injury). Review of the resident's care plan, in use at the time of the investigation, showed: -Needs: The resident has an activity of daily living (ADL) self-care performance deficit. Requires limited to extensive assistance with ADLs; -Interventions included: Transfer: Requires extensive assistance by one staff to move between surfaces. Monitor/document/report as needed any changes, any potential for improvement, reason or self-care deficit, expected course, declines in function. Observation on 5/9/23 at 10:34 A.M., showed the resident sat in a recliner in the sitting area with legs elevated and his/her left leg hung off the side of the chair. The resident appeared to be asleep. A wheelchair was positioned at his/her left side. At 10:37 A.M., the resident attempted to get out of the wheelchair on the left side. The legs of the recliner remained up and the resident leaned very far over. There were no staff around. Nurse C, after being informed of the resident's attempt to get up with no staff present, came to the resident's side and assisted the resident back into the chair, lowered the recliner legs, and placed a gait belt around the resident's waste. He/She then attempted to assist the resident to stand. The resident was unable to bear weight and Nurse C sat the resident back down into the recliner. Nurse C moved the wheelchair closer to the left side of the recliner and again attempted to assist the resident to stand. The resident got onto his/her feet, but could not stand strait and his/her left ankle turned inwards and not flat on the ground. Nurse C attempted to talk the resident through pivoting his/her feet, but the resident did not respond. The resident would only say he/she had to go to the bathroom. After several attempts, the resident was able to move his/her left foot to a flat position. Nurse C directed the resident to reach for the arm rest of the wheelchair. The resident grabbed the right arm rest with his/her left hand and the wheelchair started to propel backwards. Nurse C tugged up on the gait belt to assist the resident back to a standing position. The resident had a fearful expression and started to shake his/her head no. Nurse C verified that the wheelchair was locked and used one hand to attempt to physically turn the resident's hips in a left twist motion as he/she used one hand to hold the gait belt. As the nurse did this, the resident's left foot turned, but his/her right ankle remained flat in the original position. This caused a twisting of the ankle. After a few minutes of the nurse pushing on the resident's hips, the resident twisted and sat into the wheelchair at 10:48 A.M. At this time, there was a CNA in the hall. Nurse C told the CNA that he/she got the resident to the wheelchair to go to the bathroom, but could not get him/her to stand. The CNA propelled the resident into the dining room and did not assist the resident to use the bathroom. At no time did Nurse C attempt to locate assistance to transfer the resident or locate a mechanical lift when the resident demonstrated an inability to safely transfer with a gait belt. During an interview on 5/9/23 at 10:37 A.M., the Director of Nursing (DON) said if a resident is being transferred with a gait belt and is not transferring safely or not bearing weight, the method of transfer needs to be reevaluated. This resident does go back and forth on his/her ability to transfer. Staff can use their judgement to go up in level of care to offer more assistance during a transfer if needed. She would expect staff to ask for assistance if the resident was having difficulty transferring.

Based on observation, interview and record review, the facility failed to ensure a resident who is incontinent of bladder received appropriate treatment and services after an incontinent episode, when staff failed to cleanse all areas of the skin potentially contaminated by urine (Resident #4). For one of two residents observed to receive incontinence care. The census was 51. Review of the facility's Perineal Care (cleansing of the surface area between the thighs, extending from the pubic bone to the tail bone) policy, dated 7/2016, showed: -Purpose: To establish routine practices for providing perineal care which will cleanse, reduce the risk of skin breakdown, infection, and odor; -Residents who are incontinent or who are identified as requiring perineal care will receive care in the morning, every evening, and as needed after urinary incontinence; -Procedure: Gather and assemble supplies, wash hands, fill basin half full with warm water and place at bedside. Pace wash cloths in basin, or assemble disposable towels. -Drape resident and assist resident in assuming side lying position. Apply disposable gloves. Cleanse buttocks, washing from front to back. Cleanse, rinse and dry area thoroughly. Remove and discard soiled under pad. Remove soiled gloves. Empty, rinse, and refill basin with warm water and replace at bedside. Place on disposable gloves. Provide perineal care; -Assist resident to dorsal recumbent position (on their back) and help to flex knees and spread legs. Wash genital area front to back. Repeat to other areas of the genital area, using separate wash cloth or towel, or using separate section of the washcloth or towel. Rinse and dry thoroughly; -Remove gloves and apply protective skin lotion or cream. Wash hands. Assist resident with dressing. Assist resident to comfortable position. Dispose of all equipment and supplies from procedure. Review of Resident #4's medical record, showed: -Diagnoses included depression and osteoarthritis; -A care plan, in use at the time of the investigation, showed the resident has an activity of daily living self-care performance deficit. Interventions included: Toilet use: The resident requires extensive assistance by two staff for toileting. Observation on 5/9/23 at 10:52 A.M., showed Certified Nursing Assistant (CNA) B entered the resident's room with a sit to stand lift (a mechanical lift used for resident who are able to bear their own weight). CNA B obtained a clean brief. The resident lay in bed. CNA B placed socks on the resident and assisted him/her to sit on the edge of the bed. CNA B assisted the resident to remove his/her gown and place a sweater on. CNA B placed several rags into the skink basin under running water and placed soap on the rags. He/She then assisted the resident to stand with the use of the sit to stand lift. CNA B moved the lift with the resident to the center of the room, in front of the resident's wheelchair. CNA B removed the resident's brief and dropped it on the floor. The brief was saturated with urine and hit the floor with a loud thud and splat sound. Droplets of urine were observed to be splattered on the floor around where the brief lay. CNA B obtained a handful of rags from the skink basin and used one to wipe the resident in a front to back motion up the buttocks crease, and used a towel to dry the same area. The buttocks, hips, genitals, or any other area that was in contact with the saturated brief were not cleaned. CNA B placed a clean brief on the resident and then assisted the resident to sit in the wheelchair before covering the resident's legs with a blanket. During an interview on 5/11/23 at 9:36 A.M., the Director of Nursing (DON) said her preference would be for staff to provide incontinence care while the resident was still in bed. When providing care, all areas potentially soiled should be cleaned. Soiled linen should not be thrown on the floor.

Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 25 opportunities observed, two errors occurred, resulting in an 8% error rate (Residents #1 and #3). The census was 51. 1. Review of Resident #1's medical record, showed: -Diagnoses included hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body) following a stroke; -An order start date of 4/1/20, for Senna Lax (stool softener), give two tablets by mouth two times a day for constipation. Observation on 5/10/23 at 8:50 A.M., showed Licensed Practical Nurse E administered the resident's medications. He/She administered Senna 8.6 milligram (mg) one tablet. 2. Review of Resident #3's medical record, showed: -Diagnoses included dependence on supplemental oxygen; -An order start date of 1/13/23, for fluticasone propionate suspension (nasal spray used to treat dry nose) 50 micrograms (mcg), one spray in each nostril one time a day for dry nose. Observation on 5/10/23 at 6:52 A.M., showed Registered Nurse (RN) G handed the resident his/her fluticasone propionate suspension nasal spray. The resident administered one spray to the right nostril and handed the spray back to the nurse. RN G took the spray and exited the room without directing the resident to administer a dose in the left nostril. 3. During an interview on 5/11/23 at 9:36 A.M., the Director of Nursing said medications should be administered as ordered. If a resident has an order for a nasal spray to both nostrils and they only administer it to one, she would expect staff to prompt the resident to spray in the other side.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide services by sufficient numbers of nursing personnel on a 24-hour basis to provide nursing care to all residents, when the nurse assigned to [NAME] 1 (A1) was also responsible for oversight of residents in the sister facility 1 (SF1) located in the same building on the first floor and the nurse assigned to [NAME] 2 (A2) was responsible for oversight of residents in the sister facility 2 (SF2) located in the same building on the second floor. The sample was 13. The census was 51. Review of the nursing schedules, dated 5/6/23 through 5/9/23, showed: -5/6/23, shift 10:30 P.M. - 7:00 A.M., nurse scheduled on A1/SF1, nurse scheduled on A2/SF2; -5/7/23, shift 10:30 P.M. - 7:00 A.M., nurse scheduled on A1/SF1, nurse scheduled on A2/SF2; -5/8/23, shift 10:30 P.M. - 7:00 A.M., nurse scheduled on A1/SF1, nurse scheduled on A2/SF2; -5/9/23, shift 10:30 P.M. - 7:00 A.M., nurse scheduled on A1/SF1, nurse scheduled on A2/SF2. During an interview on 5/9/23 at 2:16 P.M., a visitor at the facility said he/she feels the facility is shorthanded at times. The facility does not have nurses on the floor at all times. The visitor said there is not a nurse a lot of time on each floor. A nurse will come down from other floors, and then leave. Review of the nursing schedule, dated 5/10/23 through 5/11/23, showed; -5/10/23, shift 10:30 P.M. - 7:00 A.M., nurse scheduled on A1/SF1, nurse scheduled on A2/SF2; -5/11/23, shift 10:30 P.M. - 7:00 A.M., nurse scheduled on A1/SF1, nurse scheduled on A2/SF2. During an interview on 5/11/23 at 8:03 A.M., Registered Nurse (RN) G said when he/she is scheduled at A1 or A2, he/she has responsibilities at the SF. The assigned supervising nurse is responsible for any needs of the SF the Certified Medication Technician (CMT) cannot provide such as treatments, the gastrostomy tube (g-tube, a tube placed through the abdomen into the stomach to provide nutrition, hydration and medication) feeding that is scheduled four times a day, respond if a resident has a fall and complete the assessment and documentation for that resident, and to assess any residents if they have a change of condition and complete the documentation for that resident. RN G said during the week, the day shift supervisors who are not assigned to A1, A2, or [NAME] 3 (A3) will oversee the SF needs unless they are not available. If the supervisors are not available, then the SF calls the nurse working on A1, A2, or A3 to assist. RN G said during the week, the evening shift supervisor will oversee the SF needs but the evening shift supervisor is assigned to work on A1, A2, or A3 75% of the time. RN G said if the evening shift supervisor is off, a nurse that is working on A1, A2, or A3 will be assigned to be the supervisor and the SF will call that nurse with any needs. RN G said the night shift nurse is responsible daily for the corresponding floor at the SF. When scheduled on A1, that nurse is responsible for the SF1, when scheduled on A2 that nurse is responsible for the SF2. The night shift nurse on A1 is responsible for passing medications on A1 and the SF1, responding if a resident has a fall, completing the assessment and documentation for that resident, and to assess any residents who have a change of condition and complete the documentation for that resident. The night shift nurse on A2 is responsible for passing medications on A2 and the SF2, responding if a resident has a fall, completing the assessment and documentation for that resident, and to assess any resident if they have a change of condition and completing documentation for that resident. During an interview on 5/11/23 at 9:40 A.M., RN C said if he/she is assigned to be the supervisor on the weekend or a holiday, he/she is responsible for all 3 floors at the SF and the floor that was assigned on A1, A2, or A3. The assigned supervising nurse has to go to the SF and provide the tube feedings and treatments for the SF residents. The assigned nurse supervisor on the weekends and holidays are also responsible if the SF has a resident that has a fall, completing the assessment the documentation for that resident, and to assess any resident if they have a change of condition and completing documentation for that resident. RN C said the night shift nurses are always responsible for the corresponding floor at the SF. When scheduled on A1, that nurse is responsible for the SF1, when scheduled on A2, that nurse is responsible for the SF2. The night shift nurse on A1 is responsible for passing medications on A1 and the SF1, and responding if a resident has a fall, completing the assessment and documentation for that resident, and to assess any residents that have a change of condition and complete the documentation for that resident. The night shift nurse on A2 is responsible for passing medications on A2 and the SF2, and responding if a resident has a fall, completing the assessment and documentation for that resident, and to assess any resident if they have a change of condition and completing documentation for that resident. RN C said during the weekends and holidays a nurse that is scheduled on the floor for A1, A2, or A3 is assigned to be the supervisor and will receive calls from the SF for assistance and will be responsible for the needs at the SF that the CMT cannot provide. During an interview on 5/11/23 at 9:54 A.M., RN J said if he/she works night shift, he/she has responsibilities at the SF. It is on the schedule that the night shift nurses are responsible for the corresponding floor at the SF. When scheduled on A1, that nurse is responsible for the SF1, when scheduled on A2 that nurse is responsible for the SF2. The night shift nurse on A1 is responsible for passing medications on A1 and the SF1, and responding if a resident has a fall, completing the assessment and documentation for that resident, and to assess any residents that have a change of condition and complete the documentation for that resident. The night shift nurse on A2 is responsible for passing medications on A2 and the SF2, and responding if a resident has a fall, completing the assessment and documentation for that resident, and to assess any resident if they have a change of condition and completing documentation for that resident. The night shift nurse is also responsible for completing rounds on the assigned SF floor every two hours and on the floor they are assigned on A1, or A2. On the weekends and holidays, if the SF needs something and there is no supervisor, the nurses on A1 or A2 are responsible for the corresponding floor at the SF. The third floor at the SF was closed this month but prior to the third floor closing at the SR [NAME] 3 (A3) was be responsible for the SF third floor (SF3) on weekends and holidays if there was no supervisor. During an interview on 5/11/23 at 11:22 A.M., the Staffing Coordinator said there are charge CMTs scheduled at the SF on day shift and evening shift. CMTs are not scheduled on night shift unless they are short a nurse. If a fall happens, the CMT will call the supervisor or a nurse on the A1, A2, or A3 side. Night shift nurses are scheduled every night to take care of the SF on the same floor. When scheduled on A1, that nurse is responsible for the SF1, when scheduled on A2 that nurse is responsible for the SF2, when scheduled on A3 that nurse is responsible for the SF3. The nurses are responsible for any incidents, medication administration, and any treatments. The supervisor for day and evening shift cover the SF needs during the week. On weekends and holidays, the department heads rotate on call and come in if we are short staffed. On weekends and holidays for day and evening shift, one of the nurses who are scheduled on A1, A2 or A3 are assigned to be the supervisor. The assigned supervisor is responsible for any incidents and treatments that would need to be done at the SF. During an interview on 5/11/23 at 12:26 P.M., the Administrator said nurses scheduled on A1, A2, or A3 have oversite of the SF. The SF has charge CMTs scheduled and they have the ability to escalate things to the nurse or assigned nurse supervisor on A1, A2, or A3. The nurse or assigned nurse supervisor would go to the SF and take over if an incident occurred. Sometimes the nursing supervisor is assigned and working the floor on A1, A2, or A3 and sometimes they are not. Mainly during the week the nurse supervisors are not scheduled to work the floor. On the weekends or holidays would be when the nurse supervisor is assigned to work the floor. The Administrator was not aware that the facility could not share nurses that are scheduled and working on A1, A2, or A3 with the SF. During an interview on 5/11/23 at 12:30 P.M., the Director of Nursing (DON) said the day shift nurses and evening shift nurses on A1, A2, and A3 do not have any responsibilities at the SF. Night shift nurses on A1, A2 and A3 are responsible if anything happens at the SF if the night shift supervisor is not there. The night shift supervisor is assigned to work on A1, A2, or A3. The night shift nurses that are scheduled on A1, A2, and A3 are responsible for the corresponding floors at the SF. The responsibilities include medication administration for the hall assigned on A1, A2, or A3 and the hall assigned at the SF. On the weekends and holidays the nurses on A1, A2, and A3 are not responsible for the SF unless the on call nurse manager is at lunch. There is a member of nursing management at the facility every weekend, nursing management rotates being on call and at the facility on the weekends. There is one resident at the SF who requires a nurse because that resident receives a g-tube feeding. The nursing supervisors take care of that resident and any treatments that need to be completed at the SF. The DON was not aware that the facility could not share nurses who are scheduled and working on A1, A2, or A3 with the SF.

Based on observation and interview, the facility failed to post the direct care staffing information on a daily basis to include the accurate total number and the actual hours worked for licensed staff, per shift and total facility census. In addition, the staffing sheets maintained by the facility did not include the correct facility name, it included the sister facility's name that is located in the same building. The facility also combined the sister facility's staffing numbers with the facility's staffing numbers. The census was 51. Observation on 5/10/23 at 9:00 A.M., on the first floor, showed the direct care staff daily report, dated 5/9/23, with the sister facility's name listed and no resident census listed. Observation on 5/10/23 at 4:25 P.M., on the first floor, showed the direct care staff daily report, dated 5/10/23, with the sister facility's name listed and no resident census listed. During an interview on 5/10/23 at 5:10 P.M., the Administrator said the Staffing Coordinator is responsible for posting the direct care staff daily report. The Administrator said the direct care staff daily report is normally separate for each facility. The Administrator looked at the posting on the first floor and verified the name listed was for the sister facility. The Administrator walked to the sister facility's first floor and it had a posting with the correct name for the sister facility. The Administrator said the Staffing Coordinator must have mixed up the papers and will have the Staffing Coordinator bring the correct sheets. During an interview on 5/10/23 at 5:27 P.M., the Staffing Coordinator said when posting the direct care staff daily report, the numbers are posted with both facilities' direct care staff numbers combined and the sister facility's name listed. The Staffing Coordinator brought in updated direct care staff daily reports for 5/9/23 and 5/10/23 with the sister facility's name listed and no resident census listed. The Staffing Coordinator said these sheets now had only the facility's staffing numbers listed and not the combined staffing numbers listed. Observation on 5/11/23 at 9:38 A.M., on the first floor, showed a direct care staff daily report, dated 5/11/23 with the correct facility name listed and no resident census listed. During an interview on 5/11/23 at 12:26 P.M., the Administrator said she was not aware the Staffing Coordinator was posting both facilities' staffing numbers combined until yesterday.

Based on observation and interview, the facility failed to ensure there was an air gap between the drain pipe of the ice machine and the floor drain in the main kitchen. The census was 51. Observations on 5/9/23 through 5/11/23 between 8:00 A.M. and 4:00 P.M., of the ice machine located in the main kitchen, showed a plastic tube extended from the back of the ice machine, down to the floor. There was a drain in the floor, in front of the ice machine and the tubing went directly down into the drain. During an interview on 5/11/23 at 9:52 A.M., the Maintenance Director said the tubing was installed wrong. There should be a PVC pipe from the back of the ice machine down to the drain. He has been at the facility for five months and is playing catch up.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow accepted infection prevention and control practices per facility policy when the facility failed to implement their water management program to prevent the spread of waterborne pathogens, such as Legionella. This failure had the potential to affect all residents in the facility. In addition, the facility failed to follow proper infection control practices for two of two residents observed to receive perineal care (cleansing of the surface area between the thighs, extending from the pubic bone to the tail bone) when staff failed to remove gloves or sanitize their hands after they became soiled and before they touched clean resident surfaces (Resident's #4 and #1) and staff failed to sanitize shared medical equipment after each resident use for two of two residents observed to be transferred with a mechanical lift (#4 and #21). The census was 51. 1. Review of the facility's Water Management & Legionella Risk Reduction policy, dated November 12, 2017, showed: -Purpose: To reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems; -The bacterium Legionella can cause a serious type of pneumonia in person at risk. Those at risk include those who are at least [AGE] years old, smokers, or those with underlying medical conditions, such as chronic lung disease or immunosuppression. Outbreaks have been linked to poorly maintained water systems in buildings with large or complex water systems including hospitals and long-term care facilities. Transmission can occur via aerosols from devices such as shower heads, cooling towers, hot tubs, decorative fountains, and medical devices; -The facility will form a water management program team that will regularly assess the community's risk areas, and to review the water program to monitor the reduction of risk of growth and spread of Legionella and other opportunistic pathogens in building water systems; -At least annually, the facility will conduct a water program review by the water management program team to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility water system; -All activity of the water management program team should be documented and maintained in a water program log binder. During an interview on 5/9/23 at 9:27 A.M., the water management policies were requested from the Administrator. The Administrator said she was not sure who was part of the water management team, or who was over the water management program. On 5/10/23 at approximately 10:00 A.M., the Administrator provided the water management policy. At this time, the most recent water program review, as identified in the water management policy, was requested. During an interview on 5/11/23 at 8:11 A.M., the Administrator said she has had corporate staff looking and they have not been able to find any documentation regarding the Legionella program implementation. She will verify, but she believes that the policy may not have been implemented. At 8:43 A.M., the Administrator verified the Legionella program review had not been completed. At 9:28 A.M., the Administrator said she does not believe any part of the Legionella program had been implemented. 2. Review of the facility's Infection Prevention and Control Manual, dated 2020, showed: -Standard Precautions: -Staff mush perform hand hygiene even if gloves are utilized; -Wear gloves when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucus membranes, non-intact skin, or potentially contaminated intact skin (e.g., of a patient incontinent of stool or urine) could occur; -Remove gloves after contact with a patient, body fluids/excretions, and the surrounding environment (including medical devices) using proper technique to prevent hand contamination; -Change gloves during patient care if the hands will move from a contaminated body site (e.g., perineal area) to a clean body site (e.g., face, clothing, etc.); -Cleaning, Disinfection, and Sterilization overview: -Device classification: Non-critical (touches intact skin but not mucous membranes): Examples included resident lifts. Process classification: Low-level disinfection. Product classification: Hospital disinfectant, detergent or germicide approved for healthcare settings; -All items, other than disposables, are cleaned, disinfected, or sterilized, following federal, state and local guidelines and manufacturers recommendations; -All personnel who perform these tasks are trained about proper procedure, protective equipment required (if any), and safety precautions; -Low-Level Disinfection: Low-level disinfecting is used for non-critical items and surfaces that come into contact with intact skin, but not mucous membranes, such as blood pressure cuffs, stethoscopes, wheelchairs, side rails, bedside tables, etc.); -All items, other than disposables, are cleaned and disinfected following federal, state and local guidelines and manufacturers' recommendations. 3. Review of the facility's Perineal Care policy, dated 7/2016, showed: -Purpose: To establish routine practices for providing perineal care which will cleanse, reduce the risk of skin breakdown, infection, and odor; -Residents who are incontinent or who are identified as requiring perineal care will receive care in the morning, every evening, and as needed after urinary incontinence; -Procedure: Gather and assemble supplies, wash hands, fill basing half full with warm water and place at bedside. Place wash cloths in basin, or assemble disposable towels; -Drape resident and assist resident in assuming side lying position. Apply disposable gloves. Cleanse buttocks, washing from front to back. Cleanse, rinse and dry area thoroughly. Remove and discard soiled under pad. Remove soiled gloves. Empty, rinse, and refill basin with warm water and replace at bedside. Place on disposable gloves. Provide perineal care; -Assist resident to dorsal recumbent position (on their back) and help to flex knees and spread legs. Wash genital area front to back. Repeat to other areas of the genital area, using separate wash cloth or towel, or using separate section of the washcloth or towel. Rinse and dry thoroughly; -Remove gloves and apply protective skin lotion or cream. Wash hands. Assist resident with dressing. Assist resident to comfortable position. Dispose of all equipment and supplies from procedure. 4. Review of Resident #4's medical record, showed: -Diagnoses included depression and osteoarthritis; -A care plan, in use at the time of the investigation, showed the resident has an activity of daily living self-care performance deficit. Interventions included: Toilet use: The resident requires extensive assistance by two staff for toileting. Observation on 5/9/23 at 10:52 A.M., showed Certified Nursing Assistant (CNA) B entered the resident's room with a sit to stand lift (a mechanical lift used for residents who are able to bear their own weight). CNA B obtain a clean brief. The resident lay in bed. CNA B placed socks on the resident and assisted him/her to sit on the edge of the bed. CNA B assisted the resident to remove his/her gown and place a sweater on. CNA B placed several rags into the sink basin under running water and placed soap on the rags. He/She then assisted the resident to stand with the use of the sit to stand lift. CNA B moved the lift with the resident to the center of the room, in front of the resident's wheelchair. CNA B removed the resident's brief and dropped it on the floor. The brief was saturated with urine and hit the floor with a loud thud and splat sound. Droplets of urine were observed to be splattered on the floor around where the brief lay. CNA B obtained a handful of rags from the sink basin and used one to wipe the resident in a front to back motion up the buttocks crease, and then a towel was used to dry the same area. CNA B picked up the saturated brief from the floor and placed it on top of the wheelchair pedals that lay on the resident's bed, on top of the resident's blanket. While wearing the same soiled gloves, CNA B placed a clean brief on the resident, moved behind the wheelchair and grabbed the handles before placing the wheelchair directly under the resident. CNA B then used the same soiled gloves to touch the mechanical lift controllers to lower the resident to the wheelchair. CNA B removed the lift sling and draped it over the mechanical lift. The resident's sweater had a zipper on the top half of the shirt. CNA B used the same gloved hands to zip up the residents shirt to his/her chin before he/she grabbed a blanket from across the room on a chair and used the blanket to cover the resident. CNA B obtained another washcloth from the sink basin, while wearing the same soiled gloves and handed it to the resident. CNA B instructed the resident to wash his/her face. The resident appeared to have difficulty understanding, so the CNA grabbed the wash cloth and wiped the residents face, eyes and lips. While wearing the same gloves, CNA B propelled the resident to the bathroom. CNA B obtained another wash cloth and wiped the corners of the resident's eyes as he/she continued to wear the same gloves used to provide perineal care and pick up the soiled brief. CNA B placed the rag on the resident's sink, grabbed the resident's toothbrush, place toothpaste on it, filled a cup with water, and handed the toothbrush to the resident. The resident appeared to struggle to brush his/her teeth, so CNA B grabbed the toothbrush and brushed the resident's teeth. Once done brushing the resident's teeth, while wearing the same gloves, CNA B handed the resident the cup of water and set the toothbrush on the sink. The resident took a drink. CNA B then grabbed the resident's hair brush and brushed the resident's hair. He/she then rinsed off the resident's toothbrush and put it away. While wearing the same soiled gloves, CNA B propelled the resident out of the bathroom. He/she then grabbed the soiled brief and linen and threw them into the trash can. CNA B grabbed the wheelchair foot pedals from off of the resident's bed and attached them to the wheelchair. At this time, CNA B removed his/her gloves, and without washing or sanitizing his/her hands, grabbed his/her work phone from his/her pocket and looked at it. After placing the phone back in his/her pocked, he/she opened the room door by touching the door handle and propelled the resident out of the room and into the dining room. No hand hygiene was offered to the resident. CNA B walked into the kitchenette, grabbed a new pair of gloves and placed them on. He/She then reentered the resident's room, grabbed rags from the trash can and placed them into a separate bag. He/She then exited the room, while wearing the same glove used to pick the soiled linen out of the trash can, and entered the soiled utility room with the bags in one hand. He/she exited the room after disposing of the bags and continued to wear the soiled gloves. He/She then removed his/her gloves and entered the dining room where he/she disposed of the gloves and washed his/her hands. The sit to stand lift remained in the resident's room and not cleaned after being contaminated with urine. The sit to stand lift remained in the resident's room until 11:45 A.M., when CNA D entered the room, obtained the lift by holding the same handles touched by CNA B with soiled gloves, and placed it in the lift storage closet. The lift was not cleaned. Observation of the storage closet at this time, showed no cleaning supplies available. During an interview on 5/11/23 at 9:36 A.M., the Director of Nursing (DON) said her preference would be for staff to provide incontinence care while the resident was still in bed. Gloves should be changed after touching soiled items and before touching clean items. Hands should be sanitized between glove changes. The resident or resident surfaces should not be touched with soiled gloves. Soiled linen should not be thrown on the floor. 5. Review of Resident #1's medical record, showed diagnoses included neuromuscular disorder of the bladder (difficulty controlling the bladder) and multiple sclerosis (an autoimmune disease where the body attacks its own nervous system). Review of the resident's care plan, in use at the time of the survey, showed: -Need initiated 5/30/20: The resident is incontinent of bowel movement and bladder/urine; -Goal: Incontinence will be managed by staff without evidence of skin breakdown; -Interventions included: Check for incontinence. Clean and dry skin if wet or soiled. Use pads, briefs to maintain incontinence. Observation on 5/10/23 at 1:23 P.M., showed Nursing Supervisor A and Licensed Practical Nurse (LPN) E completed a skin assessment of the resident. Staff assisted the resident to the left side and unsecured the resident's brief. The resident was wet with urine. Staff assisted the resident to his/her back and Nursing Supervisor A provided care. Staff assisted the resident to his/her left side and a large soft stool was observed. LPN E attempted several wipes to remove to stool, folding the rag with each wipe. The stool started to smear from the rag and back onto the residents buttocks as the amount of stool on the rag increased. Nursing Supervisor A told LPN E to stop and get a new rag. LPN E removed his/her gloves and entered the resident's bathroom. When LPN E returned to the room, he/she placed new gloves on and wiped the resident's buttocks in a back to front motion, in the direction of the urinary opening. The resident continued to actively have a bowel movement. Nursing Supervisor A directed LPN E to remove the soiled pad and rags, and allow the resident privacy to finish going to the bathroom. LPN E removed the soiled pad and rags from under the resident and threw them directly on the floor. He/She then used the same gloved hands to roll the resident to the side to place a new pad under him/her. With the same gloves on, LPN E adjusted the resident's pillow, then covered the resident with a blanket. Once the resident was covered, LPN E grabbed the bed controller and positioned the bed to the resident's preference. He/She then tied the trash bag, obtained a new bag from the trash can and put the linen from the floor into the new bag before removing one glove and exiting the room. He/she failed to wash or sanitize his/her hands. During an interview on 5/10/23 at 1:23 P.M., the DON said gloves should be changed after touching soiled items and before touching clean items. Hands should be sanitized between glove changes. The resident or resident surfaces should not be touched with soiled gloves. Soiled linen should not be thrown on the floor. 6. Review of Resident #21's medical record, showed: -Diagnoses included history of falls and left leg fracture; -An occupational therapy Discharge summary, dated [DATE], showed patient has not made a significant progress with recent fall. Remains a Hoyer lift (full body mechanical lift). Observation on 5/9/23 at 11:35 A.M., showed CNA D propelled a Hoyer lift down the hall, towards the resident's room and said staff are getting ready to get the resident up. CNA B was already in the room. The Hoyer lift battery was dead. CNA B exited the room with the lift and returned with a different Hoyer lift. Staff then transferred the resident from bed to a Broda chair (medical reclining chair). At 11:45 A.M., CNA D exited the resident's room with the Hoyer lift and a bag of soiled linen that had been picked up from the floor in the resident's room. The soiled linen bag pressed against the bars on the lift as the lift was transported down the hall. CNA D placed the Hoyer lift in the shower room, exited the shower room, placed the soiled linen in the soiled utility room, and walked back down the hall. The lift was not cleaned. Observation at this time, showed no cleaning supplies in the shower room. 7. During an interview on 5/10/23 at 11:50 A.M., CNA B said he/she believes night shift is responsible to clean the mechanical lifts. Shared medical equipment should be cleaned after use with Lysol. Mechanical lifts should be cleaned right after use, before they are put away, so it is ready for the next time. Gloves should be changed after touching urine or stool and sanitized at that time. 8. During an interview on 5/10/23 at 11:57 A.M., CNA D said cleaning shared medical equipment, such as lifts, is done between resident uses. Staff wipe down the lifts both before use and before putting the lift away. 9. During an interview on 5/11/23 at 9:36 A.M., the DON said shared medical equipment, such as mechanical lifts, are sprayed or wiped down, between each resident use with approved products available on the floors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow their policy to complete a prompt and thorough investigation, to ensure interventions are implemented to prevent further incidents, regarding two resident to resident altercations involving two of 12 sampled residents (Residents #9 and #27). The census was 47. Review of the facility's Resident Abuse and Neglect Policy, revised 1/14/17, showed: -Investigating and reporting of abuse and neglect: -The internal reporting procedures are distinct and based on the facility's reporting procedures. The investigation will consist of: -A. An interview with the person(s) reporting the incident; -B. Interviews with any witnesses to the incident; -C. An interview with the resident; -D. A review of the resident's medical record; -E. An interview with staff members (on all shifts) having contact with the resident during the period of the alleged incident; -F. Interviews with the resident's roommate, family member, and visitors; -G. A review of circumstances surrounding the incident; -Staff roles and responsibilities include: -Immediately report any witnessed, suspected, or alleged abuse to a supervisor, Executive Director (ED) and/or their designee; -The ED will obtain a factual note containing information pertinent to the alleged incident from the staff member(s); -Management roles and responsibilities: -Nursing supervisor/charge nurse or senior manager on duty is to immediately notify the Director of Nursing (DON) who notifies the ED and/or their designee or DON/designee or senior manager on duty immediately upon receipt of the report of the alleged abuse or neglect witnessed or unwitnessed resulting in serious bodily injury; -The ED and/or their designee will immediately initiate an investigation into the alleged incident. 1. Review of Resident #9's annual Minimal Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/28/19, showed: -Diagnoses of dementia, high blood pressure, anxiety and depression; -Short/long term memory loss; -Verbal behaviors 3 days per week; -Rejects care 4-6 days per week; -Extensive staff assistance for bed mobility, transfers, personal hygiene, dressing, eating and toilet use; -Total staff assist with bathing. Review of the resident's nurse's notes, dated 9/28/19 at 6:10 P.M., showed the resident hit another resident when he/she approached him/her in the television room. Review of the resident's care plan, dated 9/30/19, showed: -Quarterly review: Resident continues with cognitive impairment and behaviors. At times yelling out without purpose and rejecting cares or medications. Currently receives psychoactive medications. No adverse reactions noted; -Problem: Long standing history of psych issues, including major depressive disorder, dementia with behaviors, takes anti-psychotic daily. Hallucinations and talks to self. Refuses medications; -Interventions: Psych medications as ordered. Monitor for adverse reactions. Monitor and document behaviors when escalates. Observation on 11/7/19 at 9:49 A.M., showed the resident leaned forward in his/her wheelchair in the dining room, picking up dry cereal off the floor. Staff redirected the resident to the dining table. During an interview on 11/13/19 at 11:35 A.M., the administrator said there was no report made regarding the resident to resident incident. She would expect staff to follow the facility's policy. The facility would investigate and call in to the state agency within the reporting time frame. 2. Review of Resident #27's annual MDS, dated [DATE], showed: -Severe cognitive impairment; -Verbal behaviors occur 1-3 days per week; -Physical behaviors not exhibited; -Behavioral symptoms do not impact others; -Supervision of one staff required for locomotion on unit. Review of Resident #27's care plan, updated 7/1/19, showed: -Diagnoses include dementia without behavioral disturbance, dementia with behavioral disturbance, wandering, major depressive disorder and anxiety disorder; -Problem: Behavioral symptoms. Has verbal and physical behavioral symptoms directed at others at times, placing him/her at risk for injury or isolation; -Interventions: If physical confrontation occurs between resident and another resident, staff will separate from each other immediately until both parties are in calmer state. Staff will monitor for changes in mood or regression after any episode for behaviors returning. After residents are calm, then staff will attempt to converse with both parties to determine cause of verbal or physical behaviors. Update family, physician, and DON after every confrontation. Monitor for side effects of confrontation both mentally or physically adverse reactions. Review of Resident #34 annual MDS, dated [DATE], showed: -Severe cognitive impairment; -Behavioral symptoms not exhibited; -Total dependence of one staff required for locomotion on and off the unit; -Extensive assistance of one staff required for bed mobility and two staff required for transfers. Review of the Resident #34's face sheet, showed diagnoses include dementia without behavioral disturbance, Alzheimer's disease, major depressive disorder, muscle weakness, difficulty walking, and unsteadiness on feet. Review of the facility's self-report, submitted to the Department of Health and Senior Services (DHSS) on 6/30/19, showed: -Summary of alleged incident: On 6/30/19 at 10:00 A.M., nursing management and administrator were notified of a resident to resident verbal and physical altercation that occurred on 6/30/19 at 9:30 A.M. between Residents #27 and #34. It was reported that Resident #27 hit Resident #34 in the face on above date and time. Both residents have confusion and disorientation noted. Resident #27 is on one on one observation; no behaviors since incident have been noted. Currently investigating incident and will send a complete review of the incident and investigation, with appropriate documentation; -No additional documentation provided. Review of Resident #27's clinical note, dated 6/30/19 at 4:39 P.M., showed Nurse C documented on 6/30/19 at 9:30 A.M., the resident was leaving the unit by him/herself and was redirected by staff. The resident started hitting the staff member and was agitated. He/she propelled himself/herself in his/her wheelchair to the dining room and saw another resident sitting at the table and approached him/her, stating, I'm going to kill you. Resident #27 went up to the other resident and struck them on the right side of the face. Resident #27 was removed from the other resident and stated the other resident was trying to kill him/her, and that is why Resident #27 hit him/her. During an interview on 11/12/19 at 1:09 P.M., Nurse C said his/her note from 6/30/19 pertained to Residents #27 and #34. Resident #27 thought Resident #34 wanted to kill him/her, and Nurse C witnessed him/her punch Resident #34 in the face. Resident #34 would not be able to do anything back because he/she does not move or talk anymore. Following the incident, the residents were separated and they eat at separate tables in the dining room. Residents #27 and #34 remain roommates. Observations on 11/7/19 at 11:46 A.M., 11/12/19 at 7:11 A.M., 11/12/19 at 12:51 P.M. and 11/13/19 at 8:13 A.M., showed Resident #27 propelled himself/herself in a wheelchair throughout the facility unit, without difficulty or staff assistance. Observation on 11/13/19 at 8:30 A.M., showed Residents #27 and #34 share a room at one end of the unit's hall. The resident's beds are within sight of each other, with curtains hung from the ceiling to distinguish separate living spaces. Further review of the facility's self-report, provided to DHSS on 11/13/19 at approximately 9:00 A.M., showed: -Written statements, dated 7/1/19, from two employees who worked the day shift on 6/30/19. Neither employee witnessed the altercation between Residents #27 and #34; -No documentation of interviews with witnesses to the incident; -No documentation of interviews with the residents involved; -No documentation of interviews with staff on other shifts; -No documentation of a review of circumstances surrounding the incident; -No documentation of facility interventions, following the incident. During an interview on 11/13/19 at 7:23 A.M., the DON said Resident #27 has flashbacks from the war. Yelling triggers his/her flashbacks and he/she needs a lot of one on one attention. The resident yells and gets in the personal space of others, but he/she is not physically aggressive. The DON recalled hearing about the incident in which Resident #27 punched Resident #34. She believed the incident had to do with dining, so the residents have been moved to separate tables in the dining room. This should be documented on the resident's care plan. During an interview on 11/13/19 at 10:45 A.M., the administrator said until that day, she did not know Residents #27 and #34 remained roommates, following a physical altercation between them on 6/30/19. The residents sit at separate tables during meal times. She was told by other staff that the residents were not moved to separate rooms because neither of them could remember the altercation after it occurred. Decisions to separate the residents during meal times and to maintain their room assignments should have been documented in the facility's investigation and reflected on the resident's care plans. The facility's investigation included two interviews with staff who did not witness the altercation. The investigation should have followed the facility's policy by including additional interviews, and an investigative summary or outcome.

Based on observation, interview and record review, the facility failed to ensure staff tracked and monitored one resident's pressure ulcers and ensure the resident received treatments as ordered. The facility identified three residents with pressure ulcers, two were sampled and problems were found with one (Resident #140). The census was 47. Review of the resident's admission Minimum Data Set, a federally mandated assessment instrument completed by facility staff, dated 10/20/19, showed: -admission date of 10/15/19; -Clear speech - distinct intelligible words; -Usually understood; -Understands; -Extensive assistance of one person required for bed mobility and personal hygiene; -Total dependence of two (+) persons required for transfers and walking in room; -Total dependence of one person required for dressing and toilet use; -Wheelchair primary mode of transportation; -Frequently incontinent of bladder; -Diagnoses of anemia, high blood pressure, renal insufficiency and diabetes mellitus; -Risk of pressure ulcers - Yes; -Unhealed pressure ulcer - Yes; -One Stage III pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough (dead tissue) may be present but does not obscure the depth of tissue loss. May include undermining and tunneling). Review of the resident's undated care plan, showed: -Skin: Does this resident have a pressure ulcer? No; -Frequently incontinent of bladder. Review of the facility Pressure Wound Report form (an assessment and description of a wound, completed weekly by facility staff), showed the following information should be documented: -Resident name and room number; -Was the pressure ulcer acquired or was the resident admitted with the pressure ulcer; -Date the pressure ulcer was first identified; -Stage of the pressure ulcer; -Location of the pressure ulcer; -Measurement of the pressure ulcer (length, width, depth) for both the week the form is being completed and the measurement of the pressure ulcer from the previous week; -Exudate (drainage) or tunneling (a cavity that develops in the pressure ulcer); -Status: Is the pressure ulcer healing or declining; -Resident representative notified; -Physician notified. Review of the resident's clinical note, dated 10/15/19 at 9:00 P.M., showed he/she arrived at 4:30 P.M. Left inner buttock has two small 2 centimeter (cm) open areas. Resident's physician in facility at this time and report given. The clinical note did not identify the stage of the areas. Review of the facility's weekly Pressure Wound Report, dated 10/14/19 through 10/18/19, showed no information regarding the resident. Review of the resident's treatment administration record (TAR), dated 10/1/19 through 10/31/19, showed an order dated 10/15/19, for barrier cream (a protectant cream applied to keep bodily fluids from the skin) three times a day to the right and left inner buttocks. The order did not specify the barrier cream was to be applied to the open areas. Review of the resident's clinical note, dated 10/22/19 at 2:19 P.M., showed the resident had an area on the left buttock, approximately 6.0 cm by 2.0 cm. A 4 x 4 (gauze) was placed on the area with tape. Physician made aware. Area on right buttocks appear to be healing. Resident of the resident's clinical note, dated 10/23/19 at 2:26 P.M., showed an order received for calcium alginate (an absorbent dressing) to left buttock, change daily. Supervisor made aware. Review of the facility's weekly Pressure Wound Report, dated 10/21/19 through 10/25/19, showed no information regarding the resident. Review of the resident's TAR, dated 10/23/19 through 10/29/19, showed no order for calcium alginate to the left buttock. Review of the facility Pressure Wound Report, dated 10/28/19 through 11/1/19, showed no information regarding the resident. Review of the resident's TAR, dated 10/1/19 through 10/31/19, showed an order dated 10/30/19, for calcium alginate two times a day (day shift and evening shift). The first treatment administered was documented on 10/30/19, on the evening shift. Review of the resident's TAR, dated 11/1/19 through 11/30/19, showed: -An order dated 10/15/19, for barrier cream to the left and right inner buttocks three times a day; -An order dated 10/30/19, for calcium alginate to the left buttock on the day and evening shift; -An order dated 11/2/19, to discontinue the calcium alginate two times a day and begin the treatment one time a day. Review of the facility's weekly Pressure Wound Report, dated 11/4/19 through 11/8/14 (the most recent report), showed no information regarding the resident. Observation on 11/7/19 at 9:53 A.M., showed the resident sat in a wheelchair in his/her room. The resident said he/she had a sore on his/her bottom and he/she had it at home. Observation on 11/12/19 at 7:27 A.M., showed the resident lay in bed. During an interview, the facility Wound Nurse said she had started at the facility last Monday. This was the first time doing the resident's treatment. The Assistant Director of Nurses (ADON) said the previous Wound Nurse quit about a month ago. Since that time, she was responsible for completing the weekly Pressure Wound Reports and the floor nurses are responsible for the daily treatments. She was not aware the resident had pressure ulcers, no one had told her. That's why the resident has not been monitored and did not have an assessments on the weekly Pressure Wound Reports. The resident was positioned onto his/her right side, revealing two pressure ulcers, neither of which had a dressing in place. The Wound Nurse and ADON said they did not know why there was no dressing in place. If a dressing was soiled or removed, staff should notify the nurse so a new dressing could be applied. The Wound Nurse identified both pressure ulcers as Stage IIs (Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as intact or open/ruptured blister). The pressure ulcer, on the coccyx, measured 0.7 cm by 0.4 cm and the one on the left inner buttock measured 2.8 cm by 1.3 cm. During an interview on 11/13/19 at 10:31 A.M., the Director of Nurses (DON) said the nurses that documented the pressure ulcers in the clinical notes should have notified the ADON so they could be assessed and monitored on a weekly basis. She did not know why the treatment order for the pressure ulcer on the left buttock was obtained on 10/23/19, but did not start until 10/30/19.

Based on observation, interview and record review, the facility failed to document one resident's behaviors (Resident #9). The census was 47. Review of Resident #9's nurse's note, dated 8/6/19 at 8:13 P.M., showed: -New order from the physician to discontinue quetiapine (Seroquel, an anti-psychotic) 25 milligram (mg) by mouth at bedtime; -Increase dose of quetiapine to 50 mg by mouth at bedtime starting 8/6/19; -No documentation regarding the resident's behaviors. Review of the resident's annual Minimal Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/28/19, showed: -Diagnoses of dementia, high blood pressure, anxiety and depression; -Short/long term memory loss; -Verbal behaviors 3 days per week; -Rejects care 4-6 days per week; -Extensive staff assistance for bed mobility, transfers, personal hygiene, dressing, eating and toilet use; -Total staff assistance with bathing. Review of the resident's care plan, dated 9/30/19, showed: -Quarterly review: Continues with cognitive impairment and behaviors. At times yelling out without purpose and rejecting cares or medications. Currently receives psychoactive medications. No adverse reactions noted; -Problem: Long standing history of psych issues, including major depressive disorder, dementia with behaviors, takes anti-psychotic daily. Hallucinations and talks to self. Refuses medications; -Interventions: Psych medications as ordered. Monitor for adverse reactions. Monitor and document behaviors when escalates. Review of the resident's physician's order sheet, dated 11/2019, showed the following: an order dated 8/6/19, for quetiapine (an anti-psychotic medication used to treat schizophrenia, bipolar and depression) 50 mg once a day. During an interview on 11/13/19 at 12:35 P.M., the Director of Nurses (DON) said staff failed to document the resident's behaviors, that would support the need for an increase in the anti-psychotic medication. She would expect staff to document behaviors in the nurse's notes and report them to the supervisor, Assistant Director of Nurses and DON.

Based on observation, interview and record review, the facility failed to ensure staff followed the facility policy and acceptable professional standards for labeling and discarding insulin vials and eye drops. The facility had three medications carts, two were inspected and problems with insulin were found in one and problems with eye drops were found in both. The census was 47. Review of the facility's insulin storage policy, revised on 2/2019, showed: Purpose: To assure resident medication safety; -Unopened, not-in-use insulin should be stored in a refrigerator at a temperature of 36 - 46 degrees Fahrenheit (F); -Open, in-use insulin may be stored at room temperature below 86 degrees F, unless manufacturer's instructions state otherwise; -Never use insulin beyond the expiration date stamped on the vial, pen, or cartridge that is supplied from the drug manufacturer; -Insulin is to be dated after opening and disposed of in accordance with manufacturer's recommendations. Review of the facility Beyond-Use, Dating/Storage of refrigerated Items, undated but obtained from the facility pharmacy on 11/13/19, showed insulin should be discarded after opening, anywhere from 28 to 42 days, depending on the type of insulin. Eye drops should be discarded after opening depending on the manufacturers guidelines. Observation on 11/7/19 a 5:51 P.M., showed the third floor medication cart contained five bottles of eye drops. Three of the five eye drop bottles had been opened for use with no date printed on them as to when they had been opened. During an interview on 11/7/19 at 5:55 P.M., Nurse A said eye drop bottles should have the date they were opened written on them and they are to be discarded within 30 days if not empty. He/she had no idea when the three bottles had been opened and had no idea when they should be discarded. Observation 11/7/19 at 6:04 P.M., showed the second floor medication cart contained two opened insulin vials and 13 opened eye drop bottles. One insulin vial had been dated 9/24/19 (45 days since being opened), and one had no date as to when it was opened. Four of the 13 eye drop bottles had been dated and opened within the past 30 days. Two were opened on 9/9/19, one was opened on 9/24/19 and three were opened on 9/27/19. Three had been opened with no date. During an interview on 11/7/19 at 6:15 P.M., Nurse B said the nurse that opens the insulin or eye drops is responsible to write the date they opened it on the vial or bottle. He/she thought eye drops should be discarded after 30 days if not used, and insulin was 28 days. During an interview on 11/8/19 at 11:24 A.M., the Executive Director said she expects staff to follow the policy the facility provided. During an interview on 11/13/19 at 9:05 A.M., the Director of Nurses said the facility does not have a policy of when to discard eye drops, but she would expect staff to discard eye drops no more than 30 days after opening.