Based on interview and record review, the facility failed to provide for the rights of one resident (Resident #1), in a review of five sampled residents, when the facility performed a urinary catheterization (a procedure that involves inserting a flexible tube called a catheter into the bladder to drain urine) and obtained a urine drug screen (used to detect illegal and some prescription drugs in the urine) without notification and permission from the resident or his/her emergency contact. The facility census was 54. Review of the facility policy, Resident Rights, undated, showed the following: -It is the goal of the facility to promote and protect the rights as a resident in the facility. The resident has a right to a dignified existence, self-determination and communication with and access to persons and services inside and outside the facility. Therefore, as a resident, you have: -The right to be fully informed, orally and in writing, of your rights; -The right to be fully informed or your total health status, including your medical condition; -The right to refuse your nursing care and medical treatment and to refuse to participate in any experimental research; -The right to have your family and physician promptly notified of significant changes in your medical condition and/or status; -The right to be fully informed in advance of your medical care and treatment and any changes in such care and treatment. 1. Review of Resident #1's face sheet showed the following: -The resident was his/her own person; -Three emergency contacts were listed; -Diagnoses included chronic pain, post-traumatic stress disorder (PTSD, a mental health condition that can develop after experiencing or witnessing a traumatic event), and chronic kidney disease (CKD, a longstanding disease of the kidneys which can lead to kidney failure). Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 01/27/25, showed facility staff documented the following: -Cognitively intact; -Required substantial to maximal assistance with mobility and toileting; -Continent of bladder most of the time; -Did not have a urinary catheter. Review of the resident's February 2025 physician order sheet (POS), showed an order allowing staff to straight cath (a procedure that involves inserting a flexible tube called a catheter, or cath, into the bladder to drain the urine) the resident PRN (as needed) for urinary retention (inability to empty the bladder), start date 08/08/22, open ended (no stop date). There was no order for urine collection for any type of testing. Review of the resident's care plan, updated on 02/06/25, showed the following: -The resident will have positive experiences in daily routine without overly demanding tasks and without becoming overly stressed; -Respect resident's rights to make decisions. Review of the resident's nursing progress notes, dated 02/08/25 at 10:10 A.M., showed staff documented the resident was alert and oriented times three (cognitively aware of person, place and time). Review of the resident's nursing progress notes, dated 02/14/25 at 3:10 A.M., showed the DON documented the following: -Resident's urine in urinal is dark yellow, has sediment (particles that settle in the urine and creates a cloudiness to the appearance) and foul odor. Urine specimen obtained by straight catheter per clean technique. Dipped here (a urine dipstick test, a quick and simple test using a thin, plastic stick with chemical strips that change color when dipped into a urine sample to detect various substances and potential problems in the urinary tract). Also due to resident's behaviors tested resident's urine for drugs. The results seen show positive results for opioids, tetrahydrocannabinol (THC, the substance that is primarily responsible for the effects of marijuana on a person's mental state) and benzodiazepines (a class of depressant drugs that treat anxiety, insomnia, and seizures). Resident is currently on opioids. Will update the resident's primary care physician (PCP) before the courier is here to pick up the labs. The record showed no documentation the resident had urinary retention or documentation to show staff notified the physician prior to the urine specimen collection per strait catheterization. There was no documentation to show the DON obtained consent from the resident prior to the catheter procedure and/or testing. Review of the resident's nursing progress notes for 02/14/25 showed no documentation that the facility staff called the PCP for an order to perform a straight catheterization of the bladder on the resident, or that staff received an order to perform a urine drug screen. Review of the resident's nursing progress notes for 02/14/25 showed no documentation that the staff obtained permission to perform a urine drug screen from the resident or his/her first emergency contact. During an interview on 03/03/25 at 11:30 A.M., the resident said he/she remembered he/she got really sick a few weeks ago and had to go to the hospital, he/she did not recall any details about that time. During an interview on 03/03/25 at 5:35 P.M. and 03/04/25 at 1:32 P.M., the DON said the following: -She obtained a urine sample by a straight catheterization (cath) method from the resident due to his/her changes in his/her condition; -She did not get an order for a straight cath urine drug screen on the resident from the resident's physician; -She checked the resident's urine sample for drugs because the resident acted high, his/her demeanor was different, and he/she was joking and smiling even though he/she had changes in his/her physical condition and was possibly getting ill; -There had been reports that the resident's family had brought in marijuana gummies to the resident in the past, so that was also why she did a urine drug screen; -She did not get the resident's permission for a urine drug screen, and she did not notify his first emergency contact for permission either; -She should have asked the resident's permission before doing a urine drug screen, or contact his first emergency contact if the resident was unable to respond; -The facility did not have a policy for obtaining a drug screen on a resident or following physician orders. During an interview on 03/04/25 at 1:32 P.M., the facility Administrator said the following: -She would expect facility staff to get a physician order and a resident's permission, or the resident's first emergency contact's permission if the resident is unable to speak for themselves, before obtaining a urine drug screen; -The facility did not have a policy for obtaining a urine drug screen on a resident or following physician orders. During an interview on 03/03/25 at 4:30 P.M., the resident's physician said the following: -The facility had the capability to test a urine sample for drugs, including marijuana; -Facility staff should probably get the resident's or family's permission to perform a urine drug screen. MO00249915

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assess the use of pressure alarms used in a resident's bed and chair as a restraint for one resident (Resident #48), in a review of 22 sampled residents. The facility implemented the pressure alarms upon the resident's admission to the facility as an intervention to prevent falls. Staff documented the alarms caused the resident to become agitated. The resident expressed he/she hated the alarms and felt restrained to his/her chair and trapped. The facility census was 59. 1. Review of Resident #48's undated Continuity of Care Document (CCD), showed the following: -Diagnoses included dementia with behavioral disturbances, Parkinsonism (a clinical syndrome characterized by tremors (involuntary shaking), bradykinesia (slowness of movement), rigidity (stiffness), difficulty maintaining balance), delusional disorders, need for assistance with personal care, weakness, abnormalities of gait and mobility, repeated falls, muscle weakness, major depressive disorder, and restless leg syndrome; -The resident has a durable power of attorney for healthcare decisions. Review of the resident's Progress Notes, dated 6/8/24 at 10:10 A.M., showed the resident required two staff with a gait belt and walker to transfer. He/She did not remember to use the call light, so a pressure alarm was in place on both his/her bed and chair. It was noted that when the pressure alarm was going off, the resident was found up and walking without assistance. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 6/13/24, showed the following: -Severe cognitive impairment; -No inattention, disorganized thinking, or altered level of consciousness; -No behaviors, rejection of care, or wandering; -Utilized a walker and wheelchair for mobility; -Dependent on staff for ambulation and wheelchair mobility; -Had one fall within a month of admission; -Bed alarm and chair alarm used daily. Review of the resident's Progress Notes, dated 6/25/24 at 6:05 P.M., showed the resident was found standing and going through his/her closet without assistance. His/Her pressure alarm was sounding. Staff redirected the resident back to his/her recliner and put the pressure alarm back in place for safety. Review of the resident's Progress Notes, dated 7/2/24 at 12:43 P.M., showed the resident had behaviors of moodiness. Reported behaviors included shutting off his/her pressure alarm and throwing it onto the other bed in the room. Staff replaced the pressure alarm in his/her chair resulting in the resident becoming agitated and saying his/her spouse said he/she did not need that. Staff explained to the resident that his/her spouse wanted the pressure alarm for safety due to being a fall risk, his/her lack of safety awareness, and not using the call light. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -No inattention, disorganized thinking, or altered level of consciousness; -No behaviors, rejection of care, or wandering; -Utilized a walker and wheelchair for mobility; -Supervision or touching assistance for ambulation; -Independent for wheelchair mobility; -Bed alarm and chair alarm used daily. Review of the resident's care plan, updated on 12/6/24, showed the following: -He/She required limited to extensive assistance with activities of daily living; -He/She walked with a walker and assist of one or two staff with a gait belt; -Pressure alarm at all times; -Potential for falls related to weakness, decreased mobility, poor safety judgement, antidepressant therapy and history of falls; -Encourage the resident to wait for assistance and answer call light promptly; -The resident had periods of confusion/forgetfulness, which caused difficulty thinking and decision making. Review of the resident's medical record showed no evidence staff evaluated the use of the bed alarm and chair alarm as a restraint prior to implementing the alarms or after the resident became agitated and upset after the alarms were utilized. Observation on 1/21/25 at 12:57 P.M. showed the resident sat on a pressure alarm in his/her recliner in his/her room. During an interview on 1/21/25 at 12:57 P.M., the resident and his/her spouse said the following: -The resident admitted to the facility due to falls at home; -He/She had not had any falls since admission; -He/She had a bed and chair alarm due to a history of falling. Observation on 1/22/25 at 1:07 P.M. showed the resident sat in his/her recliner chair in his/her room with a pressure alarm in place in the recliner. Observation on 1/23/25 at 5:26 A.M. showed the resident lay on a pressure alarm in bed. Observation on 1/23/25 at 6:17 A.M. and 2:52 P.M. showed the resident sat in his/her recliner chair in his/her room with a pressure alarm in place in the recliner. During an interview on 1/24/25 at 1:12 P.M., the resident's spouse said the following: -The resident had the bed and chair alarms since he/she was admitted ; -The resident did not like the alarms; -The resident had a lot of falls at home and didn't remember to use the call light, which was why he/she needed the alarms. During interviews on 1/24/25 at 1:12 P.M. and 4:46 P.M., the resident said the following: -He/She hates the alarms; -The alarm made him/her afraid to get up, because when it goes off, everyone came running; -He/She felt restrained to the chair; he/she just wanted to be able to get up and use the bathroom; -He/She thought it was ridiculous to be trapped in the chair and almost pee yourself, because sometimes it took staff a while to answer the call lights; -He/She felt trapped, which made him/her mad because all he/she wanted was some freedom; -He/She wanted to do better and be safe, but did not want to be trapped in the same spot all day. During an interview on 1/28/25 at 3:29 P.M. the Director of Nursing (DON) said the following: -The facility did not currently have any restraints in use; -A restraint was something that prevented a resident from doing something. She did not feel the chair or bed alarms prevented residents' movement. During an interview on 1/28/25 at 4:45 P.M. the Administrator said she did not consider an alarm to be a restraint.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure two residents (Resident #42 and #1), a review of 22 sampled residents, received care and treatment to promote healing and prevent new pressure ulcers (a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) from developing. Facility staff failed to update Resident #42's care plan, implement identified interventions needed to promote healing and prevent worsening of a wound, prevent direct pressure to a pressure wound, or provide pressure reducing surfaces to promote healing of his/her unstageable pressure ulcer to his/her right heel. The facility failed to implement a system to ensure low air loss mattresses, utilized for one resident with pressure ulcers (Resident #1) was maintained on the correct weight setting to promote healing. The facility census was 59. Review of the facility's policy, Pressure Ulcers/Skin Breakdown Clinical Protocol, last revised 2007, showed the following: -The nurse shall assess and document/report a full assessment of pressure ulcers including location, stage, length, width and depth, presence of exudates or necrotic tissue. The nurse shall document a pain assessment and the resident's current treatments, including support surfaces; -The physician will authorize pertinent orders related to wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.) and application of topical agents; -The physician will help identify medical interventions related to wound management; for example, treating soft tissue infection surrounding an ulcer, removing necrotic tissue, addressing comorbid medical conditions, managing pain related to the wound or to wound treatment, etc.; -During resident visits, the physician will evaluate and document the progress of wound healing-especially for those with complicated, extensive or non-healing wounds; -The physician will help the staff review and modify the care plan as appropriate, especially when wounds are not healing as anticipated, or new wounds develop, despite existing interventions. Review of the facility's policy, Prevention of Pressure Ulcers, last revised March 2005, showed the following: -Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area and subsequent destruction of tissue; -The most common site of a pressure ulcer is where the bone is near the surface of the body, including the back of the head, around the ears, elbows, shoulder blades, backbone, hips, knees, heels, ankles and toes; -Pressure ulcers are often made worse by continual pressure, heat, moisture, irritating substances on the resident's skin (i.e., perspiration, feces, urine, wound discharge, soap residue, etc.), decline in nutrition and hydration status, acute illness and/or decline in the resident's physical and/or mental condition; -The facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician and family and addressed; -Identify risk factors for pressure ulcer development; -For a person in bed, determine if the resident needs a special mattress. If a special mattress is needed, use one that contains foam, air, gel, or water as indicated; -Ensure the resident drinks plenty of fluids and eats a well-balanced diet; -Routinely assess and document the condition of the resident's skin, per facility wound and skin care program, for any signs and symptoms of irritation or breakdown; -Immediately report any signs of a developing pressure ulcer to the supervisor; -The care process should include efforts to stabilize, reduce or remove underlying risk factors; to monitor the impact of the interventions; and to modify the interventions as appropriate; -Use pillows or wedges to keep bony prominences, such as knees or ankles, from touching each other; -When in bed, every attempt should be made to float heels (keep heels off of the bed) by placing a pillow from knee to ankle or with other devices as recommended by therapist and prescribed by the physician; -Dietitian will assess nutrition and hydration and make recommendations based on the individual resident's assessment. Monitor nutrition and hydration status. Monitor laboratory values notify physician when appropriate. Encourage proper dietary and fluid intake. If a normal diet is not possible, talk to physician about supplements. Administer vitamins, mineral and protein supplements in accordance with physician orders and dietitian recommendations; 1. Review of Resident #42's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 02/02/24, showed the following: -Severe cognitive impairment; -Diagnosis of diabetes mellitus (inability to regulate blood sugar), osteoporosis (decrease in bone mass causing bones to be fragile) and dementia; -Independent with roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed to chair transfer, toilet transfer, tub/shower transfer and ambulation with a walker; -Requires partial/moderate assistance from staff for lower body dressing and putting on/taking off footwear; -Requires substantial/maximal assistance from staff for to shower/bathe self, -Receives insulin (medication to treat diabetes); -No pressure ulcers present. Review of the resident's care plan, dated 02/05/24, showed the following: -The resident will be free from skin breakdown with good skin integrity; -Assist resident out of bed three to four times a day; -Encourage and assist resident with turning and repositioning every two hours and as needed; -Inspect skin at least weekly during showers and as needed; -Report any reddened or open areas to the physician. (The care plan did not include any identified wounds.) Review of the resident's care plan, updated on 03/01/24, added feather tic mattress (a mattress made of strong, stiff, tightly woven material (ticking) that was filled to make a mattress. Typically then laid over a firmer, non-feather mattress) on bed. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Required supervision/touching assistance from staff members for sit to lying, lying to sitting on side of bed, sit to stand and tub/shower transfer; -Required substantial/maximal assistance from staff for lower body dressing; -Dependent on staff for putting on/taking off footwear. -No pressure ulcers present. Review of the resident's Nurses Progress Notes, dated 12/23/24 at 9:30 A.M., documented by the Wound Care Nurse, showed the following: -Skin inspection during a shower showed an open area noted to the resident's right heel; -The open area measured 2 centimeters (cm) in length by 1.5 cm in width, with a depth of 0.2 cm; -The tissue was 100% dark, soft tissue; the wound margins were not attached to the wound bed; -The resident's heel was soft and boggy to touch; -Peri-wound (area around the wound) is white in coloration (also known as macerated skin (macerated skin appears soft, wrinkled, white or gray and may feel soggy or spongy. The skin may also be translucent or waterlogged, and is caused by too much moisture to the skin.) that extends out 0.5 cm around the wound with heel being tender to touch; -Physician notified and requested a treatment order; -Nursing intervention will be in place to float the resident's heels while in bed; -Power of attorney notified of resident's skin condition. Review of the resident's Nurses Progress Notes, dated 12/23/24 at 3:11 P.M., documented by the Wound Care Nurse, showed physician's office notified of right heel; new order received to startbetadinee (germicide used to prevent infection in wounds) paint to the resident's right heel two times daily until healed, ordered by the nurse practitioner. Review of the resident's Physician's orders, dated 12/23/24, showed Betadine paint to the resident's right heel two times daily until healed. Review of the resident's care plan did not show an update that a wound was found or of the intervention to float the resident's heels. Review of the resident's Nurses Progress Notes, dated 12/31/24 at 12:03 P.M., documented by the Wound Care Nurse, showed the following: -Wound Assessment, measurements obtained on 12/30/24; -Resident lay in bed with his/her bilateral heels floating on a pillow; -Assessment completed to bilateral heels with no open areas noted to left heel with tissue being pink-blanchable and non-tender to touch; -The right heel open area measured 1 cm in length, 1.8 cm in width, with wound bed being 100% soft, dark-black eschar, with periwound being white in coloration (unstageable), tender to touch; -Goal will be to continue to relieve site of pressure with floating heels when in bed; -Resident has not been wearing his/her shoes to ambulate, instead, slip socks worn due to his/her shoes causing him/her discomfort and rubbing at site; -Treatment remains appropriate, slight improvement noted. Review of the resident's Nurses Progress Notes, dated 01/08/25 at 4:42 P.M., documented by the Wound Care Nurse, showed the following: -Wound Assessment: Resident lay in bed with bilateral heels floating on a pillow; -Area to right heel measures 1.2 cm in length, and 1.7 cm in width with wound margins well defined and attached to wound bed; -Resident yelled ouch upon the slightest touch; -No depth present; wound bed is 100% black eschar (unstageable; obscured full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar); -Peri wound is dry, no longer macerated to surrounding site; -Continuing all pressure relieving interventions which are heels floating when in bed, feather tic mattress in place; -Resident no longer wearing his/her shoes as the back was rubbing, causing resident to have sore feet; the resident prefers slip socks at this time; -Treatment remains appropriate as improvement was noted; -(The assessment showed a new finding of the left heel being soft and boggy.) Review of the resident's Nurses Progress Notes, dated 01/15/25 at 3:30 P.M., documented by the Wound Care Nurse, showed the following: -Wound Assessment: resident lay in bed with bilateral heels floating on a pillow; -Right heel has an area that measures 2.5 cm in length, and 2.3 cm in width, the tissue is dry with all aspects of wound margins lifting; -Resident denies tenderness; -Surrounding tissue pink, healthy and blanches upon touch. -(The assessment showed an increase in the size of the right heel wound, and no documentation to evaluate what caused the increase in dimensions.) Review of the resident's annual MDS, dated [DATE], showed the following: -Required supervision/touching assistance from staff members to roll left and right; -Required substantial/maximal assistance from staff for tub/shower transfer, (worsening activities of daily living (ADL)'s); -New, as needed pain medication and non-pharmacological interventions for pain; -Vocal complaints of pain, one to two days in the last five days; -New pressure ulcer, unstageable and new pressure ulcer care. Observation on 01/23/25 at 2:05 P.M., showed the following: -The Wound Care Nurse entered the resident's room; -The resident lay in his/her bed; -When the Wound Care Nurse pulled the resident's covers back, the resident's heels were pressed against a pillow and not floated on the pillow as the Nurses Progress Notes, dated 12/23/24, directed (pressing against the pillow would cause increased pressure); -The resident's bed did not have a pressure reducing mattress or the feather tic mattress as documented on the resident's updated, 03/01/24, care plan as being added; -The resident grimaced and moaned in pain when the Wound Care Nurse moved his/her leg; -The resident said his/her heels really hurt bad; -The Wound Care Nurse measured the area to the resident's right heel as 1.2 cm in length, 1.5 cm in width total area of the skin alteration; -The eschar dark area measured 0.5 cm in length, and 0.8 cm in depth, without being able to visualize if any depth was present, obscured view because eschar intact; -The resident's wound was not stained with Betadine; the resident's surrounding wound was normal skin color and no area had discoloration or the color of Betadine painting was present. 2. Review of Resident #1's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Diagnoses of Alzheimer's disease, dementia and anxiety disorder; -Lower extremity impairment on both sides; -Always incontinent of bowel and bladder; -Two Stage I pressure ulcers; -Application of ointments/medications other than to feet. Review of the resident's care plan, revised 11/14/24, showed the following: -Resident has periods of confusion/forgetfulness, which causes him/her to have difficulty thinking and making decisions; -Potential for skin breakdown related to decreased mobility, bowel and bladder incontinence; -Feather tick mattress on bed. Review of the resident's physician's orders, dated January 2025, showed the following: -Left buttocks: apply barrier cream twice daily and upon cares to protect tissue from urinary incontinence; -No treatment order for the right buttocks. Review of the resident's weight record, dated 01/01/25, showed the resident's weight was 159 pounds (72 kilograms). Review of the resident's wound assessment, dated 01/05/25 at 3:11 P.M., showed the following: -No open areas are noted on left buttocks; -Right buttocks at upper aspect of cleft, open area measures 2.4 cm by 1.5 cm with area having a depth of 0.1 cm with wound margins attached to wound bed (depth now noted - a new finding); -Wound is 100% pink, shiny tissue, with no drainage noted at this time-open area not directly attached to wound as tissue between is pink and healthy measures 0.6 cm by 0.5 cm that is circular in shape with wound bed being 100% pink healthy tissue with wound margins attached to wound bed. Review of the resident's wound assessment, dated 01/06/25 at 11:43 A.M., showed the following: -Areas reported at this time that were not present on yesterdays (01/05/25) assessment to right elbow, outer aspect; -Resident has two open areas proximal (nearer to the center or point of attachment to the body) site measures 1.3 cm by 0.8 cm that has no depth-wound bed is pink, shiny and moist with wound margins attached at the wound bed-distal area measures 0.4 cm by 0.5 cm with no depth, circular in shape and wound margins attached to wound bed-wound bed is 100% pink, shiny tissue; -Resident lays on a feather tick mattress with lamb's wool between arms; -Intervention: feather tick mattress will be removed from bed and air mattress (an alternating pressure mattress system used for the treatment of developed pressure ulcers as well as prevention of them) will be provided. Review of the resident's care plan showed no documentation regarding the development of open areas on the resident's right outer elbow and right buttock or the discontinuation of the feather tick mattress or the addition of an air mattress. Review of the resident's physician's orders, dated 01/06/25, showed no evidence of an order for an air mattress. Review of the resident's wound assessment, dated 01/16/25 at 7:14 P.M., showed the following: -Inner aspect of left elbow to anterior (front) aspect of the forearm tissue is pink and shiny, measures 6.5 cm by 2.5 cm that has an appearance of superficial tissue loss, surrounding tissue is pink and blanchable; -Posterior aspect of elbow to bony prominence site that is scabbing over, measuring 3.7 cm by 1.5 cm; (a noted worsening in measurements of the elbow areas); -Left buttocks dark pink tissue that blanches slowly to touch measures 8.5 cm by 3 cm and to right buttocks dark pink tissue that blanches slowly measuring 4.8 cm by 5.6 cm; -Open area to right buttocks measures 0.5 cm by 0.5 cm with wound bed being pink shiny epithelial tissue with wound margins attached to wound bed; -Noted that upon touch, wound bed is 100% firm with surrounding tissue being firm to touch-tender to touch; -All interventions will remain in place as resident has an air mattress in place and wedge pillow in place for positioning. Observation on 01/21/25 at 12:23 P.M., in the resident's room, showed the following: -The resident lay in bed on his/her back with his/her eyes closed; -A lowaire loss mattress was present on the resident's bed; -The mattress was set at 110-130 kg (242-286 pounds) (over inflated and too firm for the resident's weight). Review of the resident's weight record, dated 01/22/25, showed the resident's weight was 147 pounds (67 kg). Observation on 01/22/25 at 8:46 A.M., in the resident's room, showed the following: -The resident lay on his/her left side in bed with his/her eyes closed; -A low air loss mattress was present on the resident's bed; -The mattress was set at 110-130 kg (242-286 pounds) and overinflated Observation on 01/22/25 at 12:04 P.M., in the resident's room, showed the following: -The resident lay on his/her back in bed; -The resident was awake; -A low air loss mattress was present on the resident's bed; -The mattress was set at 110-130 kg (242-286 pounds) and over inflated. Observation on 01/23/25 at 12:26 P.M., in the resident's room, showed the following: -The resident lay in bed; -Staff provided pericare and changed the resident's gown; -A low air loss mattress was present on the resident's bed; -The mattress was set at 110-130 kg (242-286 pounds) and over inflated. Review of the resident's wound assessment, dated 01/24/25 at 9:58 A.M., showed the following: -Right great toe at distal end with a small blackened circular area that has appearance of a blood blister, measurements are 0.5 cm by 0.8 cm with peri wound being pink and blanchable and non-tender; -Wound bed is 100% soft, not boggy, black eschar with wound margins well defined and area being circular in shape; -Left elbow tissue overall is dry. Medially (towards the middle) is a scabbed area that measures 0.5 cm by 0.5 cm that is circular in shape and firm to touch. Wound bed is 100%, dull, rust coloration with peri-wound being pink and blanchable surrounding the site-no warmth noted, non-tender; -Right buttocks tissue does blanch, measures 4.4 cm by 5.0 cm and left buttocks is pink, blanchable tissue that measured 5.0 cm by 3.0 cm. During an interview on 01/23/25 at 8:40 A.M., Certified Nurse Aide (CNA) P said the following: -He/She did not know who monitored the settings on the low air loss mattresses; -CNA staff do not adjust the settings on the low air loss mattresses. During an interview on 01/23/25 at 3:12 P.M., the Wound Care Nurse said low air loss mattresses were set when first placed on the resident's bed. During an interview on 01/23/25 at 12:26 P.M. and 3:15 P.M., the DON said the following: -The resident weighs approximately 140 pounds; -The low air loss mattress was set too high for the resident's weight; -Staff should set the mattress by the resident's weight. During an interview on 01/23/25 at 2:20 P.M. the Wound Care Nurse said the following: -She oversees wound care, quality measures and various other areas; -If a resident has a pink area, she will add interventions, then place the resident on her list to monitor; -She notifies the MDS Coordinator, so the MDS Coordinator can update the care plan with all the interventions that added; -She implements a feather tick mattress if the resident needs one; -If a resident had chronic wounds, or many wounds, the resident will get a low air loss mattress; -She expected the CNAs or nursing staff to do the interventions that have been added; -Resident #42's heels were against the pillow during the observed assessment on 01/23/25; -She thought she had asked for a feather tic mattress for Resident #42, but she may have missed asking them to put one on; -If the feather tic mattress was on Resident #42's bed, and staff removed it, staff are expected put it back on; -She expects staff to let her know if they took off an intervention for any reason; -If a resident is getting a betadine paint to a wound, the skin was usually yellow, and Resident #42's was not; -Resident #42 should have had a feather tick mattress and his/her heels floated, not against the pillow. During an interview on 01/23/24 at 3:15 P.M. and 01/28/24, at 3:33 P.M., the Director of Nursing said the following: -Any resident with a pressure ulcer should have a feather tic mattress; she did not have information on the brand or where they purchased the feather tic mattress overlays; -She expected low are loss mattresses to be set to a resident's weight; -She expected staff to ensure a resident's heels do not have direct pressure with a pillow under the heels; the heels should be off the pillow and mattress if heels are to be floated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide restorative nursing services to assist one resident (Resident #28), in a review of 22 sampled residents to attain or maintain his/her their highest level of functioning. The resident admitted to the facility free of contractures and had no limits in range of motion. The facility did not have a system to identify residents at risk for a decrease in range of motion or prevent development of contractures (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). The facility failed to develop restorative nursing plans with goals to prevent the development of contractures, improve or maintain functional range of motion, or direction to staff to meet the resident's needs. Resident #28 had a decrease in her range of motion abilities. The facility census was 59. During an interview on 01/24/25, the Director of Nursing (DON) said the facility does not have a policy for range of motion, contractures, or prevention/improvement of contractures. Review of the list of resident's on a restorative nursing program in the facility did not include Resident #28. Review of Resident #28's admission Minimum Data Set (MDS's), federally mandated assessment instruments to be completed by facility staff, from 10/22/18 (first admission to facility) to 03/18/24, showed the facility assessed the resident with no limits in range of motion. Review of the resident's Nurses Progress Notes, dated 03/07/24, at 7:05 P.M., showed the resident was found on the floor leaning towards his/her left side. Staff assisted the resident to a partial standing stance (due to contracted knees). Review of the resident's annual MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Diagnoses included heart dysrhythmia (abnormal heart beat), and diabetes mellitus (inability to control blood sugar); -Independent with eating, oral hygiene, toilet hygiene, putting on/taking off footwear, personal hygiene, roll left and right, sit to lying, lying to sitting, sit to stand, chair/bed to chair transfer, and toilet transfer; -Set up or clean up assistance from staff for upper and lower body dressing; -Required partial/moderate assistance from staff for tub/shower transfer; -Required substantial/maximal assistance from staff for shower/bathe; -Used a wheelchair independently; -Two or more no injury falls and one injury fall; -No limitation in functional range of motion (ROM); -Restorative range of motion and walking one day. Review of the resident's Nurses Progress Notes, dated 3/25/24, at 4:00 P.M. showed the resident had a lack of safety awareness and still believed at times he/she can walk. Resident's knees were contracted, but was still able to transfer self. Review of the resident's significant change in status MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Diagnoses included new dementia, and contractures of the right knee and left knees; -No behavior or rejection of care; -Independent with roll left and right, sit to lying, lying to sitting; -New limited ROM to both lower extremities; -Requires substantial/maximal assistance from staff for toilet hygiene, lower body dressing, putting on/taking off footwear; -Dependent on staff for sit to stand, chair/bed to chair transfer, toilet transfer, tub/shower transfer, and wheelchair mobility; -Two or more non injury falls; -No therapy or restorative nursing services; -Bed alarm and chair alarm used daily. Review of the resident's Physician's Orders, dated 12/24/23 to 01/24/25, showed the resident did not have an order for physical therapy to evaluate or treat. Review of the resident's quarterly MDS, dated [DATE], showed limited range of motion both lower extremities. Review of the resident's MDS's showed he/she admitted without contractures at the facility. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Independent with wheelchair mobility; -Limited ROM in both lower extremities; -Required partial/moderate assistance from staff for roll left and right -Dependent on staff for toilet hygiene, shower/bathe, lower body dressing, putting on/taking off footwear, -New pain medication and non pharmacological interventions for pain. Observation on 01/22/25, at 10:23 A.M., showed the following: -The resident lay in a low bed; -The resident wore no pants and was partially covered with a sheet; -The resident's legs were drawn up in a fetal position with his/her head leaning to the right side; -The resident had contractures at the knee and hip; -Staff came into the resident's room and assisted him/her to move, the resident was unable to straighten his/her legs. During an interview on 01/23/25, at 8:00 A.M., Certified Nurse Assistant (CNA)/Certified Medication Technician (CMT) M said the resident was contracted at the knees and hips. During an interview on 01/24/25, at 12:08 P.M., the Director of Nursing (DON) said the following: -The facility does not have a policy for range of motion, contractures or prevention/improvement of contractures; -She ensured residents who have a restorative program are appropriate, re-evaluated their programs and oversees the restorative aide; -Therapy can refer residents to restorative when they discontinue therapy services; -Residents get some range of motion with daily cares, getting dressed and taking showers; -The facility did not put residents on a restorative program because of limits with range of motion; -There was nospecific care program for residents with or at risk for contractures; -Resident #28 was not on a restorative program and had contractures.

Based on observation, interview, and record review, the facility failed to have a system in place to ensure residents, including one resident (Resident #13), with diagnosis of post traumatic stress disorder (PTSD - a mental health condition triggered by a terrifying event, either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event), were assessed and received trauma informed care to mitigate or eliminate triggers that may cause retraumatization of the resident. The facility's census was 59. Review of email communication, dated 02/05/25 at 4:52 P.M., showed the Director of Nursing (DON) wrote the facility did not have a policy for trauma informed care or care for residents with PTSD. 1. Review of the resident's face sheet showed the following: -Current admission date of 08/08/22; -Diagnoses of PTSD and major depressive disorder. Review of the resident's care plan, updated 08/15/23, showed the following: -Resident has verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others); -Resident will not threaten, scream at, or curse at other residents, visitors, and/or staff; -Avoid power struggles with resident. Leave the room. Do not argue with resident; -Inform the Charge Nurse and Management of resident's behaviors. Set expectations and limits for resident; -Investigate the reasoning for the behavior; -Maintain a calm environment and approach to the resident. Review of the resident's care plan, last reviewed/updated 11/6/24, did not include information about the resident's PTSD triggers or interventions to prevent the resident from experiencing further re-traumatization related to his/her diagnosis of PTSD. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 01/26/24, showed the following: -Moderate cognitive impairment; -Diagnosis of PTSD, anxiety, and depression; -The resident did not have a PASARR screening completed; -No difficulties hearing; -No behaviors or rejection of care; -Very important to the resident to have activities involving pets and keeping up with the news; -Somewhat important to the resident to have activities and to go outside when the weather was nice. Review of the resident's medical record, including physician notes and social service notes, showed no documentation regarding the resident's PTSD. The resident's record contained no trauma informed care assessment, and did not address how to care for the resident related to the resident's PTSD. Review of the resident's electronic medical record, under the document tab labeled social services, a document was saved as the DA124C (the states Level I screening form), when the document opened it showed a face sheet and hand written at the top of the face sheet a staff member wrote not needed a VA resident. During an interview on 01/21/25 at 1:43 P.M. and 01/24/25 at 2:00 P.M., the resident said the following: -He/She was in the military during the war and laid on the battle field for four hours with 14 holes in him/her from shrapnel. The shrapnel hit the artery behind his/her knee and he/she thought he/she was would die. The resident shared how much this experience had affected him/her. His/Her spouse was a retired nurse and had helped him/her deal with the PTSD. The resident said he/she did not receive counseling at the facility, his/her spouse was a retired nurse and helped him/her deal with the PTSD; -He/She cannot take the commotion in the dining room, just stays in his/her room and eats all meals in his/her room. If there was too much going on, he/she felt overwhelmed. He/She did not want to go to group activities and the facility did not offer any in room activities so he/she watched television with his/her spouse. Observations throughout survey, from 01/21/25 to 01/24/25, showed the resident did not leave his/her room for activities or meals. During an interview on 01/28/25 at 12:59 P.M., the MDS Coordinator said the following: -The resident did not have a Level I screening that she could find; -She was not sure if the resident had triggers with his/her PTSD; -The care plan should include any special care needs for behaviors or triggers for PTSD for staff to follow; -She was not sure if the care plan included those behavioral issues or if the resident's PTSD was included in the resident's care plans. During an interview on 01/28/25 at 3:33 P.M., the DON said the following: -There were no specific interventions related to residents with PTSD: -Triggers that might cause the resident to remember or have flash backs of their trauma were probably not in the care plan, but staff knew these by word of mouth; -Staff were still learning some of the residents' triggers; -The facility only knew what a resident's triggers were when family shared these with facility staff; -Once staff knew the residents, this would be added to information on the report sheet; -New staff would be told by current staff; -Triggers and behaviors would be good to have on the care plan, but they may not be on the care plan; -The facility did not monitor triggers or specific behaviors as much as the staff were monitoring for side effects of medications. During an interview on 01/28/25 at 3:33 P.M., the Administrator said the facility took care of veterans. Every resident was treated as if they had PTSD.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to complete a significant change status assessment (SCSA) Minimum Data Set (MDS), a federally mandated assessment, required to be completed by facility staff, for four residents (Residents #18, #8, #13 and #28), in a review of 22 sampled residents. This assessment should have been completed within 14 days after the facility determined, or should have determined, there had been a significant change (major decline or improvement in the resident's status) in the resident's physical or mental condition which had an impact on more than one area of the resident's health status and required interdisciplinary review and/or revision of the care plan. The facility census was 59. Review of the Long Term Care Facility RAI User's Manual, version 3.0 showed a significant change is a decline or improvement in a resident's status that: -Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, is not self-limiting; -Impacts more than one area of the resident's health status; -Requires interdisciplinary review and/or revision the care plan. -Significant Change in Status Assessment (SCSA) was appropriate if there was a consistent pattern of changes, with either two or more areas of decline, or two or more areas of improvement. This may include two changes within a particular domain (e.g., two areas of Activity of daily living (ADL) decline or improvement). -significant change is a major decline or improvement in a resident's status that: -Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self limiting; -Impacts more than one area of the resident's health status; and -Requires interdisciplinary review and/or revision of the care plan. 1. Review of Resident #18's quarterly MDS, dated [DATE], showed the following: -Supervision required for oral hygiene; -Supervision assistance with upper body dressing; -Independent when moving from sitting on the side of the bed to lying flat in bed and when moving from lying on his/her back to sitting on the side of the bed; -Supervision required to move from a sitting to a standing position, for chair to bed transfers and for toilet transfers; -Independent to walk 50 and 150 feet; -Always continent of bowel; -Pain rarely interferes with day to day activities. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Maximum assistance required for oral hygiene and upper body dressing; -Moderate assistance required when moving from sitting on the side of the bed to lying flat in bed and when moving from lying on his/her back to sitting on the side of the bed; -Moderate assistance required for chair to bed transfers and toilet transfers; -Maximum assistance when moving from a sitting to a standing position; -Did not complete walking up 50 or 150 feet; -Occasionally incontinent of bowel; -Pain occasionally interferes with day to day activities. Review of the resident's medical record showed no documentation staff completed a significant change assessment when the resident had a decline in two or more activities of daily living (ADL). During an interview on 1/22/25 at 9:58 A.M., the resident's family member said the resident had a major decline in his/her ADL function in the last three months. 2. Review of Resident #8's annual MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Diagnoses included arthritis, stroke, seizure, and mild cognitive impairment; -Independent with eating, oral hygiene, roll left and right, sit to lying, lying to sitting on side of bed and wheel 150 feet; -Required set up assistance from staff for upper body dressing and personal hygiene; -Required supervision/touch assistance from staff for toileting hygiene, lower body dressing, sit to stand, chair/bed-to-chair transfer, and toilet transfer; -Required partial/moderate assistance from staff for putting on/taking off footwear, and tub/shower transfer; -Required substantial/maximal assistance from staff to shower/bathe; -Frequently incontinent of bladder, continent of bowel; -Scheduled pain medication regimen and non-medication interventions for pain; -Pain occasionally at a three (on a scale of one to ten, with ten being the worst pain possible); -Resident weighed 287 pounds (lbs); -Therapeutic diet; -Edentulous. Review of the resident's quarterly MDS, dated [DATE], showed the resident weighed 283 lbs. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Required partial/moderate assistance from staff for eating, and toilet transfer; (a change from eating independently and supervision/touch assist for toileting transfer); -Required substantial/maximal assistance from staff for toileting hygiene, upper body dressing, lower body dressing, putting on/taking off footwear, sit to lying, lying to sitting on side of bed, and personal hygiene, sit to stand, chair/bed-to-chair transfer, and tub/shower transfer; (all changes from either independent, set up assistance, supervision/touch assistance or partial/moderate assistance); -Dependent on staff for oral hygiene, shower/bathe, roll left and right, and wheel 150 feet; (all changes from either independent or substantial/maximal assistance); -Occasional bowel incontinence; (change from continent of bowel); -New as needed (PRN) pain medication; -One fall since prior assessment; -New swallowing disorder; -252 lbs (31 lb weight loss since August), significant wt loss not on a program. Review of the resident's medical record showed no documentation staff completed a significant change assessment within 14 days when the resident had a decline in two or more ADL areas. 4. Review of Resident #13's annual MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Diagnosis of dementia, post traumatic stress disorder, (PTSD - a mental health condition triggered by a terrifying event, either experiencing it or witnessing it; symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event) and Parkinson's (a progressive brain disorder that causes movement problems and is characterized by tremors, stiffness and difficulty with balance and coordination); -No difficulties hearing; -No functional range of motion (ROM) limitations; -Required setup or clean up assistance from staff for personal hygiene; -Required partial/moderate assistance from staff for roll left and right; -Required substantial/maximal assistance from staff for toilet hygiene and upper body dressing; -Dependent on staff for shower/bathing and to put on/take off footwear. Review of the resident's quarterly MDS, dated [DATE], showed the following: -New moderate hearing difficulty, speaker has to increase the volume and speak distinctly; -Limits to functional ROM in both lower extremities; (change from no functional range of motion); -Required partial/moderate assistance from staff for toilet hygiene and upper body dressing; (change from either set up or substantial/maximal assistance); -Required substantial/maximal assistance from staff for shower/bathing, put on/take off footwear, personal hygiene, roll right and left; (all changes from either dependent, set up assistance or partial/moderate assistance); -New swallowing disorder, loss of liquids/solids from mouth, when eating or drinking; -New mechanically altered diet. Review of the resident's medical record showed no documentation staff completed a significant change assessment within 14 days when the resident had a status change in two or more ADL areas. 3. Review of Resident #28's significant change in status MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Diagnoses included dementia and contracture (tightening of muscles) of right knee and left knee; -New limitation in ROM both lower extremities; -Independent with roll left and right, sit to lying, lying to sitting; -Required partial/moderate assistance from staff for eating, upper body dressing; -Required substantial/maximal assistance from staff for oral hygiene, toilet hygiene, lower body dressing, shower/bathe, and putting on/taking off footwear; -Dependent on wheelchair for mobility; -Weighed 160 lbs., significant weight loss (not planned); -No mechanically altered diet; -No signs or symptoms or pain management medications or interventions; -No antidepressant medication. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Required supervision/touching assistance from staff members for eating; (change from partial/moderate assistance); -Weighed 164 lbs.; -New antidepressant medication. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Independent with wheelchair mobility; (change from dependent status); -Required partial/moderate assistance from staff for roll left and right; (change from independent status); -Required substantial/maximal assistance from staff for upper body dressing; (change from partial/moderate assistance); -Dependent on staff for oral hygiene, toilet hygiene, shower/bathe, lower body dressing and putting on/taking off footwear; (all changes from substantial/maximal assistance); -New pain medication and non-pharmacological interventions for pain; -Weighed 147 lbs (10% significant weight loss since 09/04/24 assessment); -New mechanically altered diet; -Continued on antidepressant medication since the 09/04/24 assessment. Review of the resident's medical record showed no documentation staff completed a significant change assessment within 14 days when the resident had a status change in two or more ADL areas. During an interview on 01/24/25 at 11:04 A.M., the MDS coordinator (MDSC) said the following: -When completing the MDS, staff used residents' charts and Certified Nurse Assistants (CNA's) chart on specific areas during the look back period; -The facility had an interdisciplinary team (IDT) meeting and reviewed the results of the residents' assessments; -A SCSA was completed if a resident had two or more changes to the resident's condition; -Staff compared the MDS to the last MDS if it was a quarterly or a comprehensive; --A significant change occurred when there were two changes, for example a resident goes from one assist to two assist. She goes back to last quarterly assessment and did not know to go back to last comprehensive assessment; -She did not use the Resident Assessment Manual (RAI) manual much, as she thought the manual was for ICD10 codes. During an interview on 01/24/25 at 3:33 P.M., the Director of Nursing said the following: -She expected staff to complete a SCSA when the resident has had a change and demonstrated they would not return to their previous level of function; -She expected the SCSA to be initiated within two to three days of a change in condition; -Staff are expected to complete the SCSA as defined by the MDS criteria in the RAI manual; -The MDSC was responsible to complete the SCSA MDS.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow proper technique for medication administration of insulin pens and eye drops for three residents (Resident #2, #58, and #21), in a review of 22 sampled residents. The facility census was 59. 1. Review of resident #58's Continuity of Care Document (CCD) showed a diagnosis of diabetes mellitus (too much sugar in the blood stream). Review of the resident's care plan, dated 12/26/24, showed the following: -The resident had diabetes; -Administer insulin as ordered. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 01/22/25, showed the resident received seven insulin injections in the last seven days. Observation on 01/23/25 at 7:00 A.M., showed the following: -Registered Nurse (RN) B administered 40 units of Tresiba (an injectable long-acting insulin used to treat diabetes mellitus) insulin via pen to Resident #58; -Immediately after administering the dose, RN B removed the needle and did not wait for a count of five or six after administration. Review of the Tresiba administration instructions for use on Tresiba.com showed to give an injection, wipe the skin with an alcohol swab and let dry, insert the needle in desired spot, press and hold the dose button, after the dose counter reaches zero, slowly count to six. 2. Review of Resident #2's CCD showed a diagnosis of diabetes mellitus. Review of the resident's quarterly MDS, dated [DATE], showed the resident has a diagnosis of diabetes mellitus and received seven insulin injections in the last seven days. Observation on 01/23/25 at 6:50 A.M., showed the following: -RN B administered eight units of Humalog (an injectable fast-acting insulin used to treat diabetes) insulin via Kwikpen to Resident #2 ; -Immediately after administering the dose, RN B removed the needle and did not wait for a count of five after administration. Review of the Humalog KwikPen administration instructions, for use on [NAME] Lilly and Company website (maker of Humalog KwikPen), showed to give an injection, wipe the skin with alcohol swab and let dry, insert the needle into the skin, push the dose knob in and slowly count to five before removing the needle. During an interview on 01/24/25 at 11:56 A.M., RN B said he/she usually held the insulin pen for a count of five or six and thought he/she did with both of the injections. 3. Review of Resident #21's CCD showed an order for ketotifen/an eye drop used to treat itchy eyes and discomfort caused by allergies) 0.025% drops, instill one drop into both eyes two times a day for allergic conjunctivitis (eye inflammation caused by allergies). Observation on 01/23/25 at 6:07 A.M. showed the following: -Certified Medication Technician (CMT) C explained to the resident he/she had the resident's eye drops to administer; -CMT C pulled the resident's lower eye lid down and administered one drop of ketotifen to the left eye and then repeated the process with the right eye; -CMT C then wiped the excess from the resident's face with a tissue and walked away from the resident; -CMT C did not hold any pressure to the lacrimal gland or encourage the resident to keep his/her eyes closed for any period of time. Review of administration of Ketotifen ophthalmic eye drops, on Medlineplus.gov, showed to instill the eye drops, pull down the lower lid of the eye to form a pocket, instill the ordered about of drops, close the eye for two to three minutes, place a finger on the tear duct and apply gentle pressure and wipe any excess liquid from they face with a tissue. During an interview on 01/24/25 at 1:28 P.M., CMT C said the following: -When administering eye drops, pressure should be held for a couple of seconds to make sure the medication gets into the eye appropriately; -He/She did not hold pressure when administering the resident's eye drops and should have. During an interview on 01/24/25 at 3:30 P.M., the Director of Nurses (DON) said she would expect medication to be administered following professional standards of practice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to propel three residents (Resident 28, #17, and #11), in wheelchairs equipped with foot pedals, in a review of 22 sampled residents. The facility census was 59. 1. Review of Resident #28's significant change in status Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/14/24, showed the following: -Severe cognitive impairment; -Diagnoses included new dementia and contractures (muscle tightening restricting range of motion due to non use) right knee and left knee, -Dependent on wheelchair mobility; -Two or more non injury falls. Review of the resident's Social Services progress note, dated 12/03/2024, at 8:24 A.M., shoed the Social Services Director documented when up in his/her wheelchair, the resident will at times propel himself/herself. Observation on 01/23/25, 6:30 A.M., showed Certified Nurse Assistant (CNA)/Certified Medication Technician M propelled the resident in his/her wheelchair from his/her bedside, out of his/her room and approximately 20 feet down the hall. The resident's feet slid on the floor, making a sliding sound. The resident did not have foot pedals on his/her wheelchair. The staff did not apply foot pedals, cue the resident, or ensure the resident's feet were safe when there was audible sliding sounds while CNA/CMT M propelled the resident. During an interview on 01/23/25, at 8:05 A.M., CNA/CMT M said staff have been instructed to always make sure residents in wheelchairs have foot pedals before propelling their wheelchairs. Propelling a resident without foot pedals could cause injury to the resident's feet, or if the resident puts his/her feet down while the chair was moving it could eject them from their wheelchair. 2. Review of Resident #17's Care Plan, dated 06/08/23, showed the following: -Resident has potential for falls related to weakness, decreased mobility, poor safety judgment, and history of falls; -Resident uses wheelchair for long distances propelled by the resident. Review of the resident's, quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Dependent on staff for putting on/taking off footwear, to wheel his/her wheelchair 50 feet and make two turns, and dependent on staff to wheel his//her wheelchair 150 feet. The resident's care plan did not show evidence staff identified the resident required staff to propel his/her wheelchair long distances as reflected on his/her MDS 11/18/24. Observation on 01/22/25, at 09:45 A.M., showed the resident sat in his/her wheelchair. The wheelchair did not have foot pedals. Observation on 01/23/25, at 11:58 A.M., showed CMT N propelled Resident #17 from his/her room down the hall and into the dining room. The resident tried to hold his/her feet up. His/Her feet were barely off of the ground. Two times the resident could not hold his/her feet up and the wheelchair stopped when the resident's feet hit the floor. CMT N asked the resident to hold up his/her feet and continued down the hall. Observation on 01/23/25, at 03:19 P.M., showed the following: -The Wound Nurse and CNA/CMT M assisted the resident to the bathroom with a wheeled walker; -While in the bathroom the resident became unsteady; -CNA/CMT M assisted the resident to his/her wheelchair while in the bathroom; -CNA/CMT M propelled the resident from the bathroom back to his/her bed with no foot pedals on the wheelchair. The resident's feet touched the floor while CNA/CMT M pushed the resident's wheelchair. During an interview on 01/25/25, at 1:35 P.M., CMT N said he/she propelled residents without foot pedals in their wheelchair slowly while she walked behind the wheelchair. All residents have foot pedals for their wheelchairs, and staff should use foot pedals when propelling residents in the wheelchair to prevent injuries. Staff get busy and do not get the wheelchair foot pedals. 3. Review of Resident #11's face sheet showed the resident had a diagnosis of rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein into the blood and can cause muscle weakness and muscle aches). Review of the resident's quarterly MDS, dated [DATE], showed the following: -Used a wheelchair for mobility; -Independently with wheelchair mobility. Review of the resident's care plan, revised 11/18/24, showed the following: -Potential for falls related to weakness, decreased mobility, poor safety judgment and history of falls; -Propels self in wheelchair. Will ask for assistance as needed. Observation on 01/22/25, at 12:09 P.M., showed the Social Services Director (SSD) pushed the resident from his/her room down the hallway, approximately the distance of ten rooms. The resident did not have foot pedals on his/her wheelchair. The resident's right foot was crossed over his/her left foot and drug the floor approximately half the distance as staff pushed the resident in the chair During an interview on 1/24/25 at 4:14 P.M., the Social Services Director said the following: -If a resident was able to self-propel in a wheelchair, staff do not put foot pedals on the wheelchair; -Resident #11 typically self-propelled himself/herself in the wheelchair; -On 1/22/25, he/she thought the resident held his/her feet up and did not realize the resident's foot dragged on the floor. 4. During an interview on 01/28/25, at 3:29 P.M., the Director of Nursing (DON) said the following: -If staff pushed a resident a short distance in a wheelchair, staff could tell the resident to hold up their feet and staff could safely push them; -If staff pushed a resident in a wheelchair a long distance, the wheelchair should have foot pedals; -If staff pushed a resident and the resident's feet dragged on the floor, staff should no longer push the resident to avoid injury. During an interview on 01/28/25, at 4:45 P.M., the Administrator said the following: -Staff should not propel the residents in a wheelchair without foot pedals on the chair; -At times, it can be hard for staff to determine who should have foot pedals because some residents can propel themselves; -There were bags on the wheelchairs for the foot pedals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to complete a side rail assessment for one resident, (Resident #17) or assess three residents' (Resident #17, #54 and #18) risk for entrapment prior to use of side rails, in a review of 22 sampled residents. The facility failed to obtain consent from one resident (Resident #54) or his/her family for use of the side rails prior to use. The facility census was 59. Review of the undated facility policy, Quarter Side Rail Policy, showed the following: -The purpose is to ensure the appropriate use of quarter bed rails and to ensure the safety for a resident who requests quarter bed rails. -Any resident who is admitted to the facility, that has a history of using bed rails, fall risks and compromised mobility, shall be reassessed for appropriate use; -Bed rails are used for: transferring, enhancing mobility, assisting with turning/reposition, and emotion support per request after nursing assessment and agreement by the Quality Assurance (QA) committee; -A resident who uses bed rails shall be screened or assessed monthly according to the monthly assessment scheduled; -The care plan shall reflect the use of bed rails; -A resident who requests to have bed rails shall be educated on risks and benefits; -The QA committee shall assess and decide for the continuity of use; -The procedure is to assess the residents mobility level, assess the residents emotional comfort, send the communication regarding this to the QA committee, QA committee meets briefly in the morning to discuss and approve side rail use after assessment, explain risk for use to resident and family members, obtain signed consent, monitor for entrapment, risk of injury, footboards and headboards, and documentation for risk assessment and evaluation monthly and as needed (especially with change of condition, mobility levels and fall risks). 1. Review of Resident #17's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, dated 11/18/24, showed the following: -Severe cognitive impairment; -Independent when rolling left and right; -Required partial to moderate assistance to move from sitting on the side of the bed to lying flat on the bed; -Required partial to moderate assistance lying on his/her back to sitting on the side of the bed with feet flat on the floor; -Required partial to moderate assistance to stand from a sitting position on the bed. Review of the resident's Care Plan, last reviewed 11/21/24, showed the following: -The resident had the potential for falls related to weakness, decrease mobility, poor safety judgement, and history of falls; -On 12/4/24, the resident slid out of bed; -On 12/19/24, the resident rolled out of bed. Staff provided safety awareness education about being aware of where he/she is in bed; -Transfer with assist of one staff at times. He/She transferred himself/herself between the chair and bed; -On 1/3/25, the resident liked side rails up on his/her bed so he/she was able to reposition himself/herself while in bed. Review of the resident's Physician's Orders, dated 12/23/24 through 1/23/25, showed the following: -The resident's diagnoses included history of repeated falls, altered mental status, muscle weakness, need for assistance with personal care, and lack of coordination; -An order dated 1/3/25 for one-fourth side rails for assistance with bed positioning. Review of the resident's medical record showed no documentation staff completed a side rail assessment or assessed the resident's risk for entrapment prior to use of the side rails on 1/3/25. Observation on 01/22/25 at 3:51 P.M., showed the resident lay in bed. The resident had a one-fourth side rail in the raised position on the left side of his/her bed. During interview on 01/23/25 at 1:05 P.M., the Director of Nursing (DON) said she completed a side rail assessment for the resident, but did not fill out a form with the assessment. She made a mental note to complete the assessment form at the end of the month. 2. Review of Resident #54's Side Rails Monthly Assessment, dated 12/5/23, showed the following: -Type of side rails: One-fourth side rails up times two; -Reason for side rail usage: Assist with bed mobility (turning side to side) and boundary limitations; -The side rail was an enabler; -The resident was alert and oriented and requests (side rails); -Risks and benefits were explained to the resident/family. Review of the resident's medical record showed no evidence staff assessed the resident's risk for entrapment prior to use of the bed rails. Review showed no evidence staff obtained consent from the resident/family for use of the side rails. Review of the resident's annual MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Required substantial/maximal assistance to roll left and right in bed, to change position from sitting to lying in bed and from lying to sitting on the side of the bed, and to stand from a sitting position on the bed. Review of the resident's Care Plan, last reviewed 11/26/24, showed the following: -The resident required maximum assistance to dependent on staff of cares. He/She used one to two staff assist with Sara Steady (a transfer aide used to assist an individual from a sitting to a standing position) for transfers; -The resident was alert with moments of confusion. He/She had episodes of hallucinations at times. He/She required orientation to his/her surroundings. -The resident liked to have bed rails so he/she was able to reposition himself/herself while in bed. Review of the resident's Physician's Orders, dated 12/23/24 through 01/23/24, showed the following: -The resident's diagnoses included Parkinson's disease, dementia with behavioral disturbances, hallucinations, and muscle weakness; -One-fourth side rails for positioning. Observation on 01/21/25 at 2:15 P.M., showed the resident lay in bed. The right side of the resident's bed was against the wall. The resident had a one-fourth side rail in the raised position on the left side of his/her bed. During interview on 01/23/25 at 1:10 P.M., the DON said the following: -She could not find a side rail consent form for the resident; -The resident used the side rail to know where the edges of the bed were located and to sit on the side of the bed. 3. Review of Resident #18's undated Face Sheet showed the following: -Diagnoses of history of falls, muscle weakness, hypertension (elevated blood pressure), gout (a form of arthritis that causes pain and swelling of the joints), chronic fatigue (tiredness), pain, osteoarthritis, and macular degeneration (a progress eye disease that causes vision loss); -Did not identify a responsible party, power of attorney, or health care proxy. Review of the resident's Resident Quarter Bed Rail Consent Form, dated 7/6/23, showed the resident's family member signed and gave consent for side rails on 7/6/23. Review of the resident's medical record showed no documentation staff assessed the resident's risk for entrapment prior to use of the side rails. Review of the resident's Physician Orders, dated 7/1/24 through 1/23/25 showed an order dated 7/11/23 for one-fourth side rail for positioning. Review of resident's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Impairment of bilateral lower extremities; -Independent in rolling left to right in bed; -Required partial to moderate assistance to move from sitting on the side of the bed to lying flat on the bed; -Required partial to moderate assistance to move from lying on his/her back to sitting on the side of the bed; -Required substantial to maximum assistance to move from sitting on the side of the bed to standing. Review of the resident's care plan, last reviewed 10/25/24, showed the following: -The resident required limited to extensive assist with activities of daily living (ADLs); -The resident transferred with one or two assist but did not always remember to ask for help; -The resident had the potential for falls related to weakness, decreased mobility, poor safety judgement and history of falls; -One-fourth side rails applied to the resident's bed for assistance and to help the resident determine the edge of the bed (implemented on 7/6/23); -The resident liked to have side rails up so he/she was able to reposition self while in bed (implemented 7/7/23). Review of the resident's Side Rails Monthly Assessment, dated 12/30/24, showed the following: -Type of side rails: one-fourth side rails up times two; -Reason for side rail usage: boundary limitations; -The side rail was an enabler; -The resident was alert and oriented and requests side rails; -The risks and benefits were explained to the resident/family on 7/6/23; -There was no change in condition; -Appropriate and continue use of side rails. Review of the resident's medical record showed no evidence staff assessed the resident's risk for entrapment from the bed rails. Observation on 1/22/25 at 8:49 A.M. showed quarter side rails in the raised position on both sides of the resident's bed. Observation on 1/24/25 at 1:07 P.M. showed quarter side rails in the raised position on both sides of the resident's bed. During an interview on 1/24/25 at 1:07 P.M., the resident said he/she used the side rails to roll over and get up out of bed. During interview on 01/23/25 at 1:10 P.M., the DON said the following: -Staff should obtain consent prior to initiating the bed rails; -She was responsible for completing the bed rail assessments. The assessments should be completed prior to using the side rails.

Based on observation and interview, the facility failed to ensure insulin (a medication used to treat diabetes) vials/pens for two residents (Residents #2 and #58), were dated when opened or discarded within the designated time frame after opening. The facility failed to secure a schedule IV controlled substance (a medication subject to abuse) in a separately locked compartment, failed to timely destroy expired medications, and failed to destroy one expired resident's (Resident #300's) medications. The facility census was 59. 1. Review of the Drugs.com showed the following: -Use Humalog (a rapid acting injectable insulin used to treat diabetes) within 28 days of opening; -Use Basaglar (a long-acting injectable insulin used to treat diabetes) within 28 days of opening. Observation of the east hall medication room and east hall nurse's medication and treatment cart on 01/23/25 at 5:16 A.M., showed the following: -One bottle containing 29 milliliters (ml) of liquid Ativan (a medication used to treat anxiety), labeled for Resident #1, was located in the unlocked refrigerator in the medication room; -One Basaglar Kwikpen, in use and labeled for Resident #2, was 1/2 full and was not labeled with an open date; -One vial of Humalog insulin, in use and labeled for Resident #58, was 3/4 full and was dated as opened 12/01/24 (opened 54 days, the medication was not discarded within 28 days after opening); -One card containing ten tablets of Xanax (a medication used to treat anxiety) 0.25 milligrams was in the locked emergency narcotic box and had an expiration date of 12/20/24. 2. Observation of the west medication room on 01/23/25 at 10:41 A.M., showed the following: -Two unopened boxes of albuterol sulfate (medication used to treat wheezing and shortness of breath) inhalation solution 0.5 mg/3 mg per 3 ml labeled with Resident #300's name. (Resident #300 expired on 10/20/24); -One opened bottle of nystatin topical powder (antifungal medication) expired 02/24; -One opened box of albuterol sulfate inhalation solution 0.083% 2.5 mg/3 ml expired 09/24. During an interview on 01/23/25 at 10:50 A.M., the Infection Preventionist/MDS Coordinator said certified medication technicians (CMTs) were to notify a nurse as soon as possible after a resident expired so the medication could be destroyed. 3. During an interview on 01/23/25, at 5:41 A.M., Licensed Practical Nurse (LPN) F said the following: -He/She was usually responsible for checking the medication rooms and carts for expired medications when he/she had time; -Ultimately, every nurse and certified medication technician (CMT), was responsible to check the medication room and carts for expired medications; -Staff should date insulin vials and pens when opened; -Insulin was good for 28 days once opened; -Two nurses should destroy expired medications; -Resident #1's Ativan was stored in the refrigerator in the medication room, and the refrigerator did not lock. During an interview on 01/28/25, at 3:29 P.M., the Director of Nursing (DON) said the following: -All licensed nursing staff had access to the medication rooms and carts and should check for expired medications; -The pharmacist also checked for expired medications on their monthly reviews; -Staff should check the emergency kits for expired medications; -Liquid Ativan should be stored in the refrigerator. The refrigerator did not lock; -Liquid Ativan should be under double lock.

Based on observation, interview, and record review, the facility failed to label food items, discard food that was past the expiration/remove by date in dry storage, and discard prepared food after the labeled use by date in the walk-in cooler. The facility also failed to ensure food service equipment and surfaces were appropriately cleaned and maintained. The facility census was 59. Review of the facility's policy, Food Storage (Dry, Refrigerated, and Frozen), dated 2020, showed the following: -Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety; -Discard food that has passed the expiration date, and discard food that has been prepared in the facility after seven days of storing under proper refrigeration; -Date marking for dry storage food items - once a case is opened, the individual food items from the case are dated with the date the item was received into the facility and placed in/on the proper storage unit utilizing the first in-first out method of rotation. Expiration dates on commercially prepared, dry storage food items will be followed; -Date marking for refrigerated storage food items - once opened, all ready to eat, potentially hazardous food will be re-dated with a use by date according to current safe food storage guidelines or by the manufacturer's expiration date; -Prepared food or opened food items should be discarded when the food item does not have a specific manufacturer expiration date and has been refrigerated for seven days, the food item is leftover for more than 72 hours, or the food item was older than the expiration date. 1. Observations on 1/21/25 between 10:30 A.M. and 5:00 P.M., in the dry food storage room showed the following: -An opened/resealed plastic bag of cornflakes unlabeled with an opened date and did not have an expiration date; -An opened/resealed 11.3-ounce package of pork gravy mix unlabeled with opened date and did not have an expiration date; -An opened/resealed 24-ounce package of cheddar cheese sauce mix, unlabeled with opened date and did not have an expiration date. Observations on 1/21/25 between 10:30 A.M. and 5:00 P.M., in the walk-in cooler, showed the following: -An approximate 10-inch by 8-inch stainless steel container of egg salad labeled 'Saturday supper, use by 1/10'; -An approximate 6-inch by 6-inch glass container of tomato sauce labeled 'Saturday supper, use by 1/13'. During an interview on 1/22/25 at 9:15 A.M., the Dietary Manager said the following: -Dietary staff should ensure food items were labeled correctly and removed when required from the walk-in cooler/freezer and the dry food storage room; -Dietary staff should monitor the walk-in cooler/freezer and dry food storage room daily to identify products to ensure they were labeled and not expired; -She expected food items to be labeled correctly and to be removed after the use by/expiration dates. During an interview on 1/22/25 at 11:00 A.M., the Dietary Supervisor said the following: -All dietary staff were responsible for ensuring food items were labeled properly and any outdated items were removed from the dry storage and walk-in cooler/freezer areas. -She expected dietary staff to monitor the food items in the dry storage and walk-in cooler/freezer daily correct labeling, rotation of stock and removal of products past the use by/expiration dates. During an interview on 1/22/25 at 3:00 P.M., the Administrator said the following: -All dietary staff and the dietary supervisor were responsible in making sure food items were labeled correctly in the dry storage room and walk-in cooler and freezer; -Staff should monitor these areas on an ongoing basis; -She expected staff to label the food items when opened. Any items with past use by dates were to be removed. 2. Observations on 1/21/25 between 10:30 A.M. and 5:00 P.M., of the ice machine in the kitchen, showed the following: -An approximate 4-foot long by 0.25-inch-wide white scaly material on the outside of the machine at the top front and around both corners above the door; -White scaly and rust-colored run marks on both left and right sides of the front corners; -A buildup of a white, scaly material was on the inside of the machine at the right side of the stainless-steel panel to the ice dump; -A crack around the circumference of the plastic underside of the door; -The crack was filled with a sealant, and the sealant was separating from the repaired area. Observations on 1/21/25 between 10:30 A.M. and 5:00 P.M., of the dishwasher in the kitchen, showed the following: -A buildup of debris on the top surface of the dishwasher and around the temperature box area; -A buildup of debris behind the temperature box area and the piping below; -A buildup of debris located below the power/motor switches and wash/rinse temperature gauge area; -A buildup of a blackened material located below the dirty dish entrance side (right side of dishwasher), plastic piping, and baseboard. During an interview on 1/22/25 at 9:15 A.M., the Dietary Manager said the following: -Dietary staff were responsible for cleaning the ice machine, the dish washing machine and the areas around them; -She was not sure how often staff cleaned the machines; -She expected staff to clean the outside surfaces of the ice machine weekly and to clean inside the machine monthly; -She expected staff to clean the surfaces of the dishwasher daily. During an interview on 1/22/25 at 11:00 A.M., the Dietary Supervisor said the following: -The dietary department was responsible for cleaning the outside surface of the ice machine daily, and the maintenance department was responsible for cleaning inside the ice machine; -Dietary staff were responsible for cleaning the surfaces of the dishwasher daily and should clean the piping weekly; -She expected the outside/inside areas of the ice machine and the dishwasher surfaces, piping, and area to be clean and sanitized. During an interview on 1/22/25 at 12:20 P.M., the Maintenance Technician said the maintenance department was responsible for cleaning inside the ice machine. He was not aware of the white scaly material inside the machine. Maintenance cleaned the ice machine bi-annually, and it was due to be cleaned this month. During an interview on 1/22/25 at 3:00 P.M., the Administrator said the following: -The dietary department was responsible for cleaning the outside surfaces of the ice machine and the dishwasher weekly; -The maintenance department was responsible for cleaning/deep cleaning the interior of the ice machine and the dishwasher monthly; -She expected the ice machine, dishwasher, and equipment areas to be cleaned and sanitized.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow current infection control standards for three residents (Residents #25, #17, and #21), in a review of 22 sampled residents, and for two additional residents (Resident #20 and #55). The facility failed to follow infection control practices while performing blood glucose monitoring (a procedure where a drop of blood is obtained to test the amount of sugar in the blood) for three residents (Resident #25, #20, and #17) when staff failed to appropriately sanitize the glucometer (a machine that tests a drop of blood for the amount of sugar it contains) after use and use a barrier to protect against contamination. The facility failed to store oxygen tubing and nebulizer equipment (equipment used to give aerosol breathing treatments) when not in use in a way to prevent potential contamination for three residents (Resident #25, #21 and #55). The facility failed to develop a policy to address Legionella (a bacterium that can cause a serious type of pneumonia called Legionnaires' Disease (a bacterial disease commonly associated with water-based aerosols) in persons at risk) control that included specific control parameters based on Center for Disease Control and Prevention (CDC) and American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) standards, and failed to complete a facility water assessment to identify potential sources of Legionella growth. The facility's policy did not include a water management team, a water flow map, parameters for findings related to water monitoring, and did not include how staff were to monitor residents for Legionnaire's Disease. The facility census was 59. Review of the Centers for Disease Control (CDC), Considerations for Blood Glucose Monitoring, showed the following: -Assign blood glucose meters to a person unless the device is designed for use in professional settings and is cleaned and disinfected after every use; -Clean and disinfect blood glucose meters after every use per the manufacturer's instructions, to prevent the spread of blood and infectious agents. Review of the Easy Touch Glucose Monitoring System User Manual, revised 12/2011, showed the following: -When cleaning meter, gently wipe the exterior surface using a damp soft cloth; -For healthcare professionals using this system on multiple residents, please be aware that all items that come in contact with human blood should be handled as potential biohazards. Users should follow the guidelines for prevention of blood-borne transmittable diseases in a healthcare setting for potentially infectious human blood specimens as recommended in the National Committee for Clinical Laboratory Standards, Protection of Laboratory Workers from Instrument Biohazards and Infectious Disease Transmitted by Blood, Body Fluids and Tissue: Approved Guideline. Review of the National Committee for Clinical Laboratory Standards, Protection of Laboratory Workers from Instrument Biohazards and Infectious Disease Transmitted by Blood, Body Fluids and Tissue: Approved Guideline website, that provides guidance on how to protect workers from bloodborne infections, instructs for safety, appropriate disinfectants should be used. Review of the website for Clorox Healthcare Hydrogen Peroxide Cleaner Disinfectant Wipes (green top) showed the following: -Wipe surface until completely wet; -30 seconds to 1 minute contact times on most bacteria and viruses. -The product protects against hepatitis B (virus commonly spread by exposure to infected bodily fluids), hepatitis C (virus that is spread by contact with contaminated blood) and human immunodeficiency virus (HIV) (virus that is transmitted by contact with infected blood. Review of the National Heart, Lung, and Blood Institute, National Institute of Health: How to Use a Nebulizer, dated October 2021, showed the following: -After each treatment wash the medicine cup and mouthpiece or mask with warm water and mild soap, rinse well and shake off excess water, air dry parts on a paper towel; -Between uses store nebulizer parts in a dry, clean plastic storage bag. 1. Review of Resident #25's undated Face Sheet, showed the resident's diagnoses included chronic obstructive pulmonary disease (COPD; a lung disease that blocks airflow and makes it difficult to breath), chronic respiratory failure with hypoxia (a long-term condition that occurs when there is not enough oxygen in the blood), dependence on supplemental oxygen, asthma, and diabetes mellitus with diabetic chronic kidney disease (too much sugar in the blood stream and affects the ability of the kidney's for function correctly). Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument, dated 11/15/24, showed the following: -Cognitively intact; -Received oxygen therapy. Review of the resident's Care Plan, revised 11/15/24, showed the following: -The resident had a potential for impaired air exchange related to COPD and chronic respiratory failure; -Administer oxygen as ordered; -The resident used oxygen at 2 liters via nasal cannula (a medical device that provides supplemental oxygen to a patient through their nose) as needed. The resident will remove oxygen for shower, activities, and meals. Review of the resident's Physician Orders, dated 12/23/24 through 1/23/24, showed orders for the following: -Continuous oxygen at 2 to 4 liter via nasal cannula. May be off for meals, activities, shower, and transportation; -Blood glucose (level of sugar in the blood stream) checks for times a day as needed for signs and symptoms of hyperglycemia (high blood sugar); -Fasting blood sugar check weekly on Mondays. Observation on 1/21/25 at 1:25 P.M. showed the resident lay in bed. The resident received oxygen via nasal cannula. The oxygen tubing was dated 12/2/24. There was no bag in the resident's room for the oxygen nasal cannula and tubing when not in use. During an interview on 1/21/25 at 1:25 P.M., the resident said the following: -He/She wore continuous oxygen and only took it off when he/she was out of bed or left the room; -When he/she took off the oxygen, he/she laid the oxygen tubing on his/her bed and did not put it in a bag; -The staff did not change the tubing very often, maybe a couple times each year. Observation on 1/22/25 at 9:00 A.M. showed the resident lay in bed and received oxygen via nasal cannula. The oxygen tubing was dated 1/21/25. Observation on 1/22/25 at 11:03 A.M. showed the resident was not in his/her room. The resident's oxygen nasal cannula and tubing lay on the resident's bed and was not stored in a bag. There was no storage bag for the oxygen tubing available in the resident's room. Observation on 1/23/25 at 6:31 A.M. and 2:49 P.M. showed the resident was not in his/her room. The resident's oxygen nasal cannula and tubing lay on the bed and was not stored in a bag. There was no storage bag for the oxygen tubing available in the resident's room. Observation on 01/23/24 at 8:25 A.M., showed the following: -Registered Nurse (RN) B prepared to obtain a blood sugar sample for the resident; -A container of Clorox Healthcare Hydrogen Peroxide Cleaner Disinfectant Wipes (green top) sat on top of the treatment cart, available for use (an approved disinfectant wipe); -RN B took an Easy Touch glucometer (used for multiple residents) out of the treatment cart and placed it directly on top of the treatment cart without a barrier; -RN B went into the resident's room and placed the glucometer directly on the resident's bedside table without a barrier; -RN B obtained the blood sample from the resident's finger, performed the blood glucose check procedure by placing a blood filled test strip in the glucometer, obtaining the result and then removing the blood filled test strip; -RN B returned the glucometer to the treatment cart, cleaned the glucometer with an alcohol swab and placed the glucometer back into the treatment cart drawer; -RN B did not use the Clorox Healthcare Hydrogen Peroxide Cleaner Disinfectant Wipes to disinfect the glucometer. During an interview on 01/24/25 at 11:56 A.M. and 1:16 P.M., RN B said on 01/23/24, he/she cleaned the glucometer with alcohol wipes after taking the resident's blood sugar because that was how the nurse managers told him/her to clean the glucometer. 2. Observation on 01/23/25 on 6:08 A.M., showed the following: -Certified Medication Technician (CMT) N placed the glucometer (used for multiple residents) on the medication cart without a barrier; -CMT N put a test strip in the glucometer, entered Resident #20's room, obtained a blood sample from the resident's finger an placed it on the test strip; -CMT N returned to the medication cart, placed the glucometer on the cart without a barrier, removed his/her gloves and washed his/her hands; -CMT N quickly cleaned the glucometer (less than 30 seconds) with a Clorox Healthcare Hydrogen Peroxide Cleaner Disinfectant wipe and placed the glucometer directly on top of the medication cart without a barrier; -CMT N sanitized his/her hands and placed the glucometer back into the drawer. Observation on 01/23/25 6:15 A.M., showed the following: -CMT N put gloves on, took the glucometer (he/she used to check Resident #20's blood sugar) and placed the glucometer on the medication cart without a barrier; -CMT N put the test strip in the monitor, entered Resident 17's room, and obtained a blood sample from the resident's finger onto the test strip; -CMT N returned to the medication cart, placed the glucometer directly on the cart without a barrier, removed his/her gloves and washed his/her hands; -CMT N quickly cleaned the glucometer (less than 30 seconds) with a Clorox Healthcare Hydrogen Peroxide Cleaner Disinfectant wipe and placed the glucometer directly on top of the medication cart without a barrier; -CMT N sanitized his/her hands and placed the glucometer back into the drawer. During an interview on 01/28/25 at 03:33 P.M., the Director of Nurses (DON) said the following: -Staff should clean the glucometers using the manufacturer's directions; - 70% alcohol is not recommended for multi-use glucometers; -There was some discrepancy with the information that was given from the manufacturer when they called; -She educated staff on how to clean glucometers using Clorox Healthcare Hydrogen Peroxide Cleaner Disinfectant wipes. During an interview on 01/28/25 at 4:45 P.M., the Administrator said the manufacturer said to clean the glucometers with alcohol. 3. Review of Resident #21's undated Face Sheet showed he/she had a diagnoses of COPD. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -No rejection of cares; -Received oxygen therapy. Review of the resident's Care Plan, revised 11/04/24, showed the following: -The resident had the potential for impaired air exchange related to COPD and chronic respiratory failure; -Monitor the resident's oxygen saturations due to him/her removing his/her oxygen. He/She removes the oxygen and throws it on the floor at times; -Administer oxygen as ordered by the physician. Review of the resident's January 2025 POS showed the following: -An order for continuous oxygen at 2 to 5 liters per nasal cannula. May be off for meals, activities, showers and transporting between; -An order for ipratropium-albuterol (an inhaled solution administered by nebulizer for treatment of COPD symptoms) 0.5 milligrams (mg) -3 mg/3 milliters (ml) 1 vial by inhalation three times a day between 6:00 A.M. to 10:00 A.M., 11:00 A.M. to 2:00 P.M. and 4:00 P.M. to 7:30 P.M. Observation on 1/21/25 at 11:55 A.M., showed the following: -An oxygen concentrator was against the wall in the dining room; -Undated oxygen tubing was connected to the concentrator. The oxygen tubing and the nasal cannula lay on the floor; -There was no storage bag attached to the concentrator; -Certified Nursing Assistant (CNA) E pushed the resident into the dining room and sat him/her at the table closest to the oxygen concentrator; -CNA E placed the nasal cannula, that had been on the floor, inside the resident's nares and turned on the oxygen at 2 liters. Observation on 01/21/25 at 12:40 P.M. showed CNA E removed the nasal cannula from the resident's nares, gathered the oxygen tubing and tucked it in the handle of the oxygen concentrator and took the resident from the dining room. CNA E did not store the oxygen tubing in a bag. During an interview on 01/24/25 at 1:35 P.M., CNA E said the following: -Oxygen tubing should be stored in the blue bag when not in use; -Oxygen tubing that touched the floor should never be used for a resident; -He/She was unaware on 01/21/25 that the oxygen tubing for the resident touched the floor prior to him/her putting it on the resident. Observation on 01/21/25 at 2:12 P.M. showed a nebulizer (a machine used to administer inhaled breathing treatments) machine was at the resident's bedside. The nebulizer tubing was connected and uncovered. A nebulizer set-up (the mechanism to administer the breathing treatment) was disassembled and sat on a washcloth by the handwashing sink. The set-up was uncovered and no storage bag was present in the room. Observation on 01/22/25 at 10:22 A.M., showed a nebulizer machine was at the resident's bedside. The nebulizer tubing was connected and uncovered. The nebulizer set-up was disassembled and sat on a paper towel turned upside down by the handwashing sink. The nebulizer set-up was uncovered and no storage bag was present in the room. Observation on 01/23/25 at 6:05 A.M., showed a nebulizer machine was at the resident's bedside. The nebulizer set-up was connected to the machine and lay uncovered on the resident's bedside table. Observation on 01/23/25 at 6:25 A.M., showed Certified Medication Technician (CMT) C removed the nebulizer treatment mask from the resident's face after administering a breathing treatment. He/She rinsed the nebulizer set up and placed it open side down on a clean washcloth on the counter by the handwashing sink. CMT C did not cover the set up with a drape or towel and did not place the set-up in a bag. Observation on 01/23/25 at 10:43 A.M. showed the resident's nebulizer treatment equipment was dry and continued to sit open side down on a clean washcloth on the counter by the handwashing sink. The equipment sat uncovered and was not placed in the equipment bag. During an interview on 01/24/25, at 1:28 P.M., CMT C said the following: -Oxygen supplies such as nasal cannulas and nebulizer treatments should be stored in the bag when not in use; -If the nebulizer treatment has been used and was drying after washing, it should be covered with a paper towel or clean washcloth so germs from the sink do not get splashed on it. During an interview on 01/24/25 at 11:56 A.M. and 1:16 P.M., Registered Nurse (RN) B said the following: -When oxygen supplies are not being used, such as tubing and nebulizer treatments, they need to be stored in the blue bag; -If a nasal cannula touches the floor, it needs to be thrown away and a new one obtained; -Nebulizer treatment equipment should not be left uncovered on the counter or on the bedside table. During an interview on 1/28/24 at 3:33 P.M. the DON said the following: -When oxygen tubing is not in use, it should be stored in the blue bags; -Staff should change oxygen tubing monthly and as needed; -Nebulizer tubing, reservoir and mask are to be cleaned and put on a clean surface to dry; -Placing the nebulizer parts in a clean area, on a clean surface, uncovered, would be appropriate, next to the sink would not be appropriate. 4. Review of Resident #55's undated Face Sheet showed the resident's diagnoses included aortic valve stenosis (narrowing of the valve in the large blood vessel branching off the heart, can cause chest pain, fatigue, and shortness of breath) and dependence on supplemental oxygen. Review of resident's annual MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Received oxygen therapy. Review of resident's care plan, revised 12/27/24, showed no documentation the resident used supplemental oxygen. Review of the resident's Physician Orders, dated January 2025, showed an order for continuous oxygen at 3 liter via nasal cannula at bedtime. May be off for meals, activities, showers and transportation. Observation on 1/21/25 at 1:39 P.M. showed the resident sat in a chair in his/her room. The resident's oxygen nasal cannula and tubing lay on the floor and were not stored in a bag. A storage bag hung on the oxygen concentrator. The oxygen tubing was labeled with the date 12/2/24. During an interview on 1/21/25 at 1:39 P.M., the resident said he/she only wore oxygen at night and not during the day. Observation on 1/22/25 at 8:47 A.M. showed the resident sat in a chair in his/her room. The resident's oxygen nasal cannula and tubing lay on the floor and were not stored in a bag. A clear bag hung on the oxygen concentrator in the room. The oxygen tubing was labeled with the date 1/21/25. Observation on 1/23/25 at 7:39 A.M. and 2:42 P.M. showed the resident sat in a chair in his/her room. The resident's oxygen nasal cannula and tubing lay on the floor and were not stored in a bag. Observation on 1/24/25 at 1:09 P.M. showed the resident sat in a chair in his/her room. The resident's oxygen nasal cannula and tubing lay on the floor and were not stored in a bag. 5. Review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification (S&C) letter 17-30, dated 06/02/17 and revised on 06/09/17, showed the following: -The bacterium Legionella can cause a serious type of pneumonia called Legionnaires' Disease (LD) (a bacterial disease commonly associated with water-based aerosols and often a result of poorly maintained air conditioning cooling towers and potable water systems) in persons at risk. Those at risk include persons 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, cooking towers, hot tubs and decorative fountains; -Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water; -CMS expects Medicare certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. An industry standard calling for the development and implementation of water management programs in large or complex building water systems to reduce the risk of legionellosis was published in 2015 by American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE). In 2016, the CDC and its partners developed a toolkit to facilitate implementation of this ASHRAE Standard (https://www.cdc.gov/Legionella/maintenance/wmp-toolkit.html). Environmental, clinical, and epidemiological considerations for healthcare facilities are described in this toolkit; -Surveyors will review policies, procedures, and reports documenting water management implementation results to verify that facilities: -Conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system; -Implement a water management program that considers the ASHRAE industry standard and the CDC toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens; -Specify testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained. Review of the Centers for Disease Control and Prevention Legionella Environmental Assessment Form, undated, showed Legionella generally grows well between 77 degrees Fahrenheit (F) and 113 degrees F. The optimal growth range for Legionella is between 85 degrees F and 108 degrees F. Growth slows between 113 degrees F and 120 degrees F, and Legionella begin to die above 120 degrees F. Growth also slows between 68 degrees F and 77 degrees F, and Legionella become dormant below 68 degrees F. Review of the undated facility policy, titled Legionella Prevention, showed the following: -Employee and resident exposure to Legionnaires' Disease; -It (Legionnaires' Disease) can occur where water, contaminated with the legionella organism, is aerosolized and then breathed in by workers or residents; -Legionnaires' Disease is not contagious, but is of environmental origin. Consequently, only those who are directly exposed to the contaminated aerosolized water source can get the disease; -Exposure to the legionella bacteria could occur in the shower or whirlpool area, or areas that use spray nozzles. Cooling towers, evaporative condensers, fluid coolers, and domestic hot-water systems are water sources that frequently provide optimal conditions for growth of the legionella organism; -Exposure to the legionella bacteria can cause a mild respiratory illness (that may not require treatment), or severe pneumonia-like symptoms two to 10 days after exposure; -If not detected and treated promptly with appropriate antibiotics, can lead to death; -The risk for the facility is deemed low, as the infrastructure affected by potential Legionella outbreaks is modern, up to date and well maintained; -The water supply for the facility enters from the south end of the facility via a 3 PVC main from the city municipal water supply; -Backflow protection is in place at the entrance to the facility and after the water softening system; -Cold water is distributed directly to appropriate end-user locations; -Hot water is constantly circulated throughout the building via circulating pumps in each mechanical room; -Indirect water boilers supply two, 119 gallon holding tanks, that are a part of the circulating system; -On the [NAME] End, two, 80 gallon water heaters, distribute to all areas in this portion of the building, also constantly circulating; -Detection: a. Multiple commercial devices are available to detect legionella contamination; b. These devices include a validation line to ensure the test sample was adequate; c. While no brand is endorsed by this plan, options include: 1. Accepta Legionella Detection Kit; 2. Hydrosense Legionella Test Kit; 3. Nova-Tech Legionella Detection Kit; 4. Orbeco Legionella Test Kit; 5. And other; -Testing, in accordance with the selected test kit will be done when a possible outbreak is being investigated; -Prevention Solutions: a. Maintenance of water systems - specific recommendations: 1. Water will be stored at 140 degrees F and delivered at a minimum of 122 degrees F to all outlets; 2. To prevent scalding problems, scald protection equipment, such as preset thermostatic mixing valves may be installed if outlet temperature exceeds 130 degrees F.; 3. Where building cannot be retrofitted, consider periodically increasing the temperature to at least 158 degrees for chlorination followed by flushing; 4. Inspect systems annually to ensure equipment functions properly; b. Domestic cold-water systems: 1. Eliminate water tanks that allow water to remain uncirculated for long periods or design them to reduce storage time to a day or less. They should also be covered and protected from temperature extremes; 2. Prevent cross-contamination of the domestic cold-water system with other systems; 3. Use hyperchlorination to eradicate legionella if the cold-water lines have significant contamination; -References: a. OSHA Technical Manual, also provides Controls, and Source Identification; b. Appendix Ill: 7-5. OSHA Technical Manual, Water Treatment Protocols for Facilities that have experienced a Legionnaires' Outbreak; c. Appendix Ill: 7-1. Employee Awareness Program, to inform employees of any potential outbreaks, and to educate about the disease, and provide early recognition of the disease. Sample forms and questions and answers about Legionnaires' disease are provided; VI. Medical Awareness of Physicians and Health Care Workers (HCWs): a. HCWs need to be aware that the bacteria can be present in water systems and promptly test vulnerable and/or symptomatic residents and use appropriate antibiotics quickly; b. Legionnaires' Disease most frequently attacks individuals who have an underlying illness or weakened immune system. The most susceptible include persons who are elderly, smokers and immunosuppressed; c. Symptoms include: i. dry cough, high fever, chills, muscle aches, diarrhea, fatigue, headache, and abdominal pain; d. Treatment: i. Usually treated with erythrornycin or a combination of erythromycin and Rifampin (antibiotics). VII. Additional Information: a. Legionnaires' Disease. OSHA eTool. This tool was designed to assist industrial hygienists in the assessment of worksites for potential legionnaires' disease. It provides information on disease recognition, investigation procedures to identify probable water sources, and control strategies; b. Environmental Care; Utility System and Acquired Illness. Joint Commission, Environment of Care Standards, (2008, November 24). Address issues of improperly designed and maintained aerosolizing water systems (controlling pathogenic biological agents such as legionella in cooling towers, domestic hot water systems, etc); c. Patient Facts: Learn More about Legionnaires' disease. Centers for Disease Controland Prevention (CDC), (2008, June 27). -The facility did not reference the ASHRAE standards developed in 2015, including a facility water management team, it's required members, meetings or a facility water flow map, or the CDC toolkit developed in 2016 as directed in the 2017 S&C letter in their policy, they referenced resources from 2008; -The policy states water will be delivered at a minimum of 122 degrees F to all outlets, but temperatures over 120 degrees F contradicts state regulation for temperature. Review of the facility's water temperature log, dated 10/28/24, showed the following: -Men's east shower room, 106.5 degrees F; -Women's east shower room, 104.2 degrees F; -room [ROOM NUMBER], 107.8 degrees F; -room [ROOM NUMBER], 108.1 degrees F.; -The specific location that the water temperature was taken from was not specified; -The log did not include cold water temperatures or any actions taken for low hot water temperatures. Review of the facility's water temperature log, dated 11/08/24, showed the following: -East shower room, 106.7 degrees F; -Chapel, 107.1 degrees F; -room [ROOM NUMBER], 109.6 degrees F. -West spa/shower, 109.7 degrees F; -400 hall shower, 107.9 degrees F; -room [ROOM NUMBER], 107.7 degrees F.; -The specific location that the water temperature was taken from was not specified; -The log did not include cold water temperatures or any actions taken for low hot water temperatures. Review of the facility's water temperature log, dated 11/11/24, showed the following: -East shower room, 108.9 degrees F; -The specific location that the water temperature was taken from was not specified; -The log did not include cold water temperatures or any actions taken for low hot water temperatures. Review of the facility's water temperature log, dated 12/02/24, showed the following: -East shower room, 108.9 degrees F; -East spa, 108.7 degrees F; -room [ROOM NUMBER], 108.3 degrees F; -The specific location that the water temperature was taken from was not specified; -The log did not include cold water temperatures or any actions taken for low hot water temperatures. Review of the facility's water temperature log, dated 12/23/24, showed the following: -East spa, 106.8 degrees F; -The specific location that the water temperature was taken from was not specified; -The log did not include cold water temperatures or any actions taken for low hot water temperatures. Review of the facility's water temperature log, dated 12/31/24, showed the following: -room [ROOM NUMBER], 108.9 degrees F; -West spa/shower, 109.6 degrees F; -400 hall shower, 106.7 degrees F; -room [ROOM NUMBER], 108.7 degrees F; -The specific location that the water temperature was taken from was not specified; -The log did not include cold water temperatures or any actions taken for low hot water temperatures. The facility did not provide water temperature logs from 01/01/25 to 01/24/25. During an interview on 01/24/25 at 11:02 A.M. and 12:28 P.M., the Environmental Services Supervisor, said the following: -The facility does not test for legionella; -Every open or closed loop was moving; -The facility did not have stagnant water; -He flushed empty rooms by turning on the water for a couple minutes once a month, sometimes every two weeks; -The facility has not completed a CDC tool kit that he knew of and he had not heard of the ASHRAE guidelines; -He made sure there were no breaks in the water lines; -The facility tested for hard water but does not test for legionella; -The facility does not have a water flow map; -The facility does not have a water management team; -He monitored hot water temperatures weekly to make sure they were above 120 degrees Fahrenheit. If they were below, he turned the water heater temperature up; -He does not monitor cold water temperatures, chlorine levels, water sediment or biofilm; -The hard water test has a pH (measure of alkalinity/acidity) component but they do not have any actions or specifications of what the pH needed to be so they do not do anything with that value. During an interview on 01/24/25 at 11:02 A.M., the Infection Preventionist (IP), said the following: -She does not serve on a water management committee or any committee that discussed water or Legionella; -The facility does chest x-rays for people with pneumonia; -She does not screen anyone for legionella, she thought the hospital would have to do that if the resident was sick enough to go to the hospital; -She does not know the signs or symptoms of legionella, or Legionnaire's disease or how to check for legionella. During an interview on 01/23/25 at 1:45 P.M., the Administrator said the following: -The facility tests the water for legionella; -She did not have documentation of a facility water assessment; -She did not know what a water flow map was; -The Maintenance Director monitored water temperatures and can get the water management program and any testing completed; -The Maintenance Director was expected to follow the policy and guidelines for monitoring water; -The facility did not have a water management team.

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #54) with a diagnosis of severe coronary obstructive pulmonary disease (COPD), a chronic lung disease that caused hypoxia (low oxygen levels), in a review of 19 residents wore his/her oxygen continuously as ordered. Staff failed to ensure the resident had supplemental oxygen when staff transported the resident from his/her room to the dining room, and back to his/her room. The resident had increased respiratory effort and critically low oxygen saturation levels after staff transported the resident without oxygen. The facility census was 59. During an interview on 5/5/2 at 1:00 P.M., Registered Nurse (RN) A said the facility did not have a policy regarding oxygen use. 1. Review of Resident #54's physician's progress note dated 1/25/23 showed his/her past medical history included severe COPD and chronic hypoxemia (low blood oxygen level) which required O2 dependence and dementia Review of resident's quarterly Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility dated 3/13/23 showed the following: -His/Her cognition was severely impaired; -He/She had a chronic lung disease; -He/She required the use of oxygen (O2) therapy. Review of resident's care plan last reviewed on 3/23/23, showed the following: -He/she had potential for impaired air exchange related to COPD and chronic respiratory failure; -Staff were to administer oxygen as ordered by the resident's physician; -Staff would propel the resident when in wheelchair due to respiratory problems. Review of resident's Physician's Order Report dated 4/1/23 to 5/3/23, showed an open ended order, dated 12/26/22, for the administration of O2 per nasal cannula at 3-6 liters continuously, MUST WEAR AT ALL TIMES EVEN DURING SHOWERS. Review of resident's nursing progress note dated 4/13/2023 7:47 P.M. showed the following: -Resident's O2 saturation level was 95% on 5 Liters of O2 (normal level was 95-100%); -Resident was barrel chested and had significant breathing issues noted. Review of resident's monthly Summary completed by nursing staff on 4/29/2023 at 6:44 P.M. showed the following: -O2 saturation level was 95% at 5 liters; -Propelled by staff in w/c. Observation of the resident on 5/1/23 at 7:40 A.M., showed nursing assistant (NA) E transported the resident to the dining room from his/her room without oxygen connected. NA E brought the resident's oxygen concentrator and plugged it in when the resident was at the dining room table. There was no portable oxygen noted on the resident's wheelchair. The resident had some increased respiratory effort when he/she arrived to the dining room without the oxygen. Review of facility's Certified Nurse Aide (CNA) sheet dated 5/2/23 showed resident WAS TO WEAR O2 AT ALL TIMES. Observation on 5/2/23 at 12:03 P.M., showed Certified Medication Technician (CMT) D, pushed the resident in the wheelchair to the resident's room with no oxygen in place. CMT B pushed the oxygen concentrator alongside of resident but the concentrator was not turned on. There was no portable O2 used during the transport from the nurse's station to the resident's room. Observation on 5/2/23 at 1:55 P.M., showed CMT B pushed the resident in the wheelchair to the resident's room without oxygen in place. CMT B pushed the O2 concentrator alongside the resident, but the concentrator was not turned on. There was no portable O2 used during the transport. The resident had increased respiratory effort after transport without O2. Observation on 5/2/23 at 2:10 P.M. showed CMT B pushed the resident in a wheelchair back to the nurse's station from the resident's room without use of O2. There was no portable O2 noted on the resident's wheelchair. the resident was noted to have increased respiratory effort. observation on 5/2/23 at 3:39 P.M., showed CMT C pushed the resident in a wheelchair to the resident's room from the nurse's station without O2 in place. CMT C pushed an oxygen concentrator down the hall alongside resident, but the concentrator was not in use during the transport. There was no portable O2 noted on the back of the resident's wheelchair. The resident was noted to have increased respiratory effort. Review of the resident's vital signs record dated 5/3/23 at 6:21 A.M. showed the resident's O2 saturation was 94%. Observation on 5/3/23 at 7:45 A.M. showed CNA D pushed the resident in a wheelchair from his/her room to the dining room without oxygen. There was no portable oxygen noted on the back of resident's wheelchair. Observation on 5/3/23 AT 7:50 A.M. showed the resident with increased respiratory effort. CNA D and CMT B checked the resident's oxygen saturation (at the request of state surveyor), and noted an abnormally low level of 78% (normal saturation levels was 95-100%) with oxygen in place at 5 liters per nasal cannula approximately five minutes after transport. During an interview on 5/3/23 at 7:45 A.M., CNA D said resident could not be off of oxygen for very long because his/her oxygen level would decrease. That was why they transported him/her quickly from his/her room to the dining room. The resident seemed to do fine when when transported, but staff would have to encourage him/her to breathe through his/her her nose when oxygen was started again. During an interview on 5/3/23 at 7:50 A.M., CMT B said resident's O2 saturation had come up to 89% after encouragement to breathe through his/her nose. There were portable O2 tanks that could be used, but he/she was unable to provide an answer as to why they were not used. During an interview on 05/3/23 at 11:50 A.M., the resident's physician said resident required constant oxygen due to severe COPD. Staff should probably use portable oxygen for transport from the resident's room to the dining room. He identified that 79% was a significantly low oxygen level. During an interview on 5/4/23 at 3:12 P.M. the Director of Nursing (DON) said she would expect staff to ensure the resident had continuous oxygen on, if that was what was ordered. This included time during transport from resident's room to dining room and vice versa. There were portable O2 tanks that could be used.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Review of Resident #57's face sheet showed the resident's diagnoses included lobar pneumonia (infection of one lobe of a lung), chronic obstructed pulmonary disease (COPD) (chronic inflammatory lung disease that causes obstructed airflow from the lungs), and dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). Review of the resident's nurse note, dated 1/22/23 at 2:40 P.M., showed the following: -The resident had a wet congestive cough with audible congestion that clears with cough for short periods and lungs have rhonchi (continuous low-pitched, rattling lung sounds that often resemble snoring) throughout; -Upon conversation, the resident seemed paranoid (unreasonably or obsessively anxious, suspicious, or mistrustful); -The resident had edema to right hand and bilateral lower extremities up to knee-pitting edema (when a swollen part of your body has a dimple (or pit) after you press it for a few seconds) with plus 3 pitting edema present; -The resident said the edema was why he/she couldn't walk; his/her legs felt too heavy; -The resident became very emotional upon conversation and even began crying; -One-on-one was provided. Review of the resident's nurse note, dated 1/23/23 at 12:00 P.M., showed the resident continued to have plus 3 pitting edema to bilateral lower extremities and right hand had plus one pitting edema. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/26/23, showed the following: -The resident had moderately impaired cognition; -No delirium, mood issues, or behaviors; -He/She didn't reject care or wander. Review of the resident's nurse note, dated 2/5/23 at 2:10 P.M., showed the following: -The resident attempted to become combative, which is not like this resident; -The resident's family member said the resident had some personality changes; -Conversation held between the family member and the resident, then the family member said the resident has been emotional with the transition from residential care facility (RCF) to skilled nursing facility. Review of the resident's nurse note, dated 2/11/23 at 7:30 P.M., showed the resident tried to elope. He/She went through the doors going to the RCF (that was attached). He/She had the code for the door on his/her walker and used it. Review of the resident's nurse note, dated 2/14/23 at 5:45 A.M., showed the following: -The resident refused to sleep in his/her room; -The staff assisted the resident to his/her room and the resident stopped at the doorway, and said, I am not going in that room and if you make me I will call the police on you; -The staff offered the resident to sleep in a recliner across from the nurses station. He/She agreed and slept all night in the recliner. Review of the resident's nurse note, dated 2/14/23 at 10:29 A.M., showed the resident had a chest x-ray performed resulting in hyperinflated lungs compatible with COPD and possible infectious process. Review of the resident's nurse note, dated 2/15/23 at 3:13 P.M., showed the resident was prescribed Levaquin (an antibiotic) for an upper respiratory infection. Review of the resident's nurse note, dated 2/16/23 at 10:25 P.M., showed the resident was hallucinating. He/She saw men coming through the wall and blood coming out between his/her toes, so staff redirected the resident. Review of the resident's nurse note, dated 2/24/23 at 7:15 P.M., showed the following: -The resident finished antibiotic therapy; -The staff encouraged the resident to cough as he/she doesn't do so and will have audible congestion. Review of the resident's care plan, last updated 3/17/23, showed the following: -The resident may be confused at times, but still had a strong opinion; -He/She wanted to control some decision making and felt his/her opinion mattered; -Allow to express feelings of frustration and inadequacy; -The resident was not an elopement risk; -The care plan did not address resident specific non-pharmacological interventions for behaviors or problems with edema and lung infections/congestion. Review of the resident's nurse note, dated 4/21/23 at 3:43 P.M., showed the following: -The resident refused to sleep in his/her bed the previous night and removed the dressing on his/her buttocks; -The resident refused to go to the dining room for breakfast, said he/she was left in water, stubborn and argumentative and refused cares wanting to do all activities of daily living for himself/herself, and lacked safety awareness. A staff member stayed with the resident for safety. Review of the resident's nurse notes, dated 4/25/23 at 4:01 P.M., showed the following: -The resident complained of not feeling well; -Lungs have crackles (clicking, rattling, or crackling noises that may be made by one or both lungs of a human with a respiratory disease during inhalation) throughout; -The nurse asked the resident to cough to clear his/her airway and his/her cough was extremely congested but unable to clear. Review of the resident's nurse notes, dated 4/27/23 at 9:12 A.M., showed the following: -Increase Lasix (diuretic) 20 mg orally twice a day for two weeks; -Use DuoNeb (bronchodilator) per nebulizer machine as needed for shortness of breath. During an interview on 5/3/23 at 2:20 P.M., the Quality Assurance Nurse said the following: -The resident was confused at times and was stubborn regarding assistance with ADLs, interventions for pressure ulcers, and dietary interventions; -He/She thought the resident had negative behaviors when he/she was not feeling well or when something was not going the way he/she expected; -The staff were told not to argue with the resident when he/she had behaviors, but keep him/her safe; -The staff should remain calm and allow him/her to voice frustrations; -Sometimes the family talked to him/her before the resident would calm down; -The resident had edema and took Lasix (diuretic) to reduce it; -The resident was admitted from a hospital with pneumonia on 1/19/23; -He/She was susceptible to respiratory infections because of the COPD and being sedentary; -The resident had nebulizer medication as needed for shortness of breath, but didn't need oxygen. 2. Review of Resident #44's care plan, last updated 4/4/22, showed the following: -Provide toileting assist daily; -Remind the resident that he/she is unable to ambulate on his/her own any longer; -Provide incontinence care after each incontinence. Review of the resident's quarterly MDS, dated [DATE], showed the following: -The resident had severely impaired cognition; -He/She required extensive assistance from two staff for bed mobility, dressing, and toilet use; -He/She was dependent on two staff for transfers; -He/She was dependent on one staff for locomotion, eating, personal hygiene, and bathing; -He/She had limited range of motion on one side of the upper and lower extremities; -He/She was always incontinent of bladder and bowel. Observation on 5/1/23 at 8:03 A.M., showed the following: -The resident sat up in geri-chair (specialized wheelchair) at the dining room table and leaned to the right side of his/her chair; -The resident's right hand was in a closed, fist position; -Certified Nurse Aide (CNA) F assisted the resident to eat his/her breakfast; -CNA F attempted to reposition the resident in the geri-chair, but was unsuccessful so CNA F raised the feet on the geri-chair and took the resident back to his/her room. Observation on 5/1/23 at 8:35 A.M., showed the resident sat up in the geri-chair and continued to lean to the right. During an interview on 5/1/23 at 11:30 A.M., CNA F said the following: -The resident is unable to walk, and transfers with a mechanical lift and two staff; -He/She needed assistance with all the care provided. Observation on 5/3/23 at 7:20 A.M., showed CNA J and CNA K transferred the resident with the mechanical lift from the resident's bed to the geri-chair. During an interview on 5/4/23 at 8:50 A.M., CNA J said the following: -The resident required assistance with all of his/her activities of daily living; -The resident required assistance of two with transfers, bed mobility, incontinence care, but only one person with personal hygiene and eating. During an interview on 5/4/23 at 10:10 A.M., the Restorative Aide/CNA said she worked on the resident's hand that has limited movement and places a cushion in the resident's hand because it draws up, preventing use of the hand. Review of the resident's care plan showed it was not updated to show the resident's current needs of needing assistance with eating, need of two staff members with bed mobility and dressing, dependence of one staff member with personal hygiene and bathing, and transfers with mechanical lift. 3. Review of Resident #162's face sheet showed the resident's diagnoses included dementia with Lewy bodies (a type of progressive dementia that leads to a decline in thinking, reasoning and independent function. Review of the resident's fall event report, dated 03/29/23 at 2:43 A.M., showed the following: -The resident's bed alarm was sounding and staff found the resident sitting on his/her buttocks next to his/her bed; -No injuries noted; -Immediate intervention of floor mat placed; -Care plan was not reviewed. Review of the resident's care plan showed no evidence staff updated the care plan to include the floor mat. Review of the resident's fall event report, dated 04/9/23, at 1:30 A.M., showed the following: -The resident's bed alarm was sounding and staff found the resident sliding out of bed saying he/she was trying to clean up a spill; -No injuries noted; -No immediate interventions indicated; -Care Plan was not reviewed. Review of the resident's care plan, revised 05/01/23, showed the following: -Potential for falls related to weakness, decreased mobility, poor safety judgment and history of falls; -No indication of floor mat use; -No indication of bed alarm use; -No indication of side rail use; -No indication of 03/29/23 or 04/09/23 falls or interventions implemented following these falls. Observation on 05/01/23, at 6:17 A.M., showed the resident's bed alarm was sounding. The resident lay in bed sleeping with his/her feet hanging to the side. The half side rail located on the right side of the resident's bed was raised. A fall mat was on the floor at the resident's right side of bed. 4. Review of Resident #9's quarterly MDS, dated [DATE], showed the following: -Severely impaired cognition; -Require extensive assistance from one staff for transfers and bed mobility; -Bed rails not used; -Bed and chair alarm used daily. Review of the resident's care plan, revised on 03/22/23, showed the following: -Diagnoses include dementia with behavior disturbance (a group of thinking and social symptoms that interferes with daily functioning, exhibiting physical or verbal aggression), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with daily activities). -Potential for falls related to weakness, decreased mobility, poor safety judgement, anti-depressant therapy and history of falls; -No indication of side rail use or bed or chair alarm use. Observation on 05/01/23, at 7:08 A.M., showed the resident sat awake in his/her recliner. The resident sat on a pressure chair alarm that was not connected to the alarm box. Observation on 05/03/23, at 5:32 A.M., showed the resident lay awake in bed with the right side upper 1/2 side rail in the raised position. The resident had a bed alarm. 5. Review of Resident #18's annual MDS, dated [DATE], showed the following: -Severely impaired cognition; -Required extensive assistance from two staff for bed mobility and transfers; -No bed side rails used. Review of the resident's care plan, revised on 03/02/23, showed the following: -Diagnoses include cerebral infarction (also called ischemic stroke, occurs as a result of disrupted blood flow to the brain that can cause paralysis), Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), left sided hemiplegia (paralysis of left side) and left sided hemiparesis (muscle weakness of the left side). -The resident has potential for falls related to anti-depressant therapy, weakness, decreased mobility, poor safety judgment and history of falls; -He/She thinks he/she can transfer himself/herself. Remind the resident to use call light for help; -No indication of side rail use; -No indication of bed alarm use. Observations on 05/01/23 at 10:09 A.M., on 5/2/23 at 9:18 A.M., and on 5/3/23 at 5:30 A.M. showed the resident lay awake in bed. The resident had half side rails raised on both sides of his/her bed. The resident had a bed alarm. 6. Review of Resident #34's annual MDS, dated [DATE], showed the following: -Severely impaired cognition; -Total dependence on one staff for bed mobility; -Total dependence on two staff for transfers; -No bed side rails used. Review of the resident's care plan, revised on 03/10/23, showed no indication of side rail use. Observations on 05/01/23 at 10:12 A.M., 5/2/23 at 9:12 A.M., and on 5/3/23 at 5:28 A.M. showed the resident lay in bed. The resident had half side rails raised on both sides of his/her bed. 7. During interview on 05/04/23, at 1:15 P.M., the Quality Assurance (QA) Nurse said the following: -Nurses can update the care plans, but she has not asked them to do so since they are very busy; -Side rails and alarms have not been put on the care plans, but would probably be beneficial to do so; -Lack of staff and nurses, and too many things going on made it difficult to get the updates done. During interview on 05/04/23, at 2:30 P.M., the MDS Coordinator said the following: -She or the QA nurse were responsible for updating the care plans and they had gotten behind on updates; -Things like falls, infections, oxygen use, alarms and side rails should be updated on the care plans. During interview on 05/04/23, at 3:12 P.M., the Director of Nursing (DON) said the following: -She would expect oxygen use, falls, side rails and alarms to be included on the care plan; -She would expect interventions to be listed on the care plan; -The MDS coordinator is responsible for the care plans and updates. Based on interview and record review, the facility failed to update interventions in the resident's care plan to reflect current care needs for six residents (Residents #9, #18, #34, #44, #57, and #162), in a review of 19 sampled residents. The facility census was 59. 1. During interview on 05/04/23, at 1:00 P.M., the Quality Assurance (QA) Nurse said the facility did not have a policy in place for care plans timing and revisions. Review of the Centers for Medicare and Medicaid Services (CMS), Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.17.1, Chapter 4, revised October 2019, showed the following: -The care plan is driven not only by identified resident issues and/or conditions but also by a resident's unique characteristics, strengths, and needs; -A care plan that is based on a thorough assessment, effective clinical decision making, and is compatible with current standards of clinical practice can provide a strong basis for optimal approaches to quality of care and quality of life needs of individual residents; -A well developed and executed assessment and care plan: 1. Looks at each resident as a whole human being with unique characteristics and strengths; 2. Views the resident in distinct functional areas for the purpose of gaining knowledge about the resident's functional status (MDS); 3. Gives the interdisciplinary team (IDT) a common understanding of the resident; 4. Re-groups the information gathered to identify possible issues and/or conditions that the resident may have (i.e., triggers); 5. Provides additional clarity of potential issues and/or conditions by looking at possible causes and risks (CAA process); 6. Develops and implements an interdisciplinary care plan based on the assessment information gathered throughout the RAI process, with necessary monitoring and follow- up; 7. Reflects the resident's/resident representative's input, goals, and desired outcomes; 8. Provides information regarding how the causes and risks associated with issues and/or conditions can be addressed to provide for a resident's highest practicable level of well- being (care planning); 9. Re-evaluates the resident's status at prescribed intervals (i.e., quarterly, annually, or if a significant change in status occurs) using the RAI and then modifies the individualized care plan as appropriate and necessary; 10. Reviews and revises the current care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Review of Resident #47's Morse Fall Scale (a rapid and simple method of assessing a patient's likelihood of falling), dated 1/5/22, showed the resident was at high risk for falls. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 1/12/22, showed the following: -His/Her cognition was severely impaired; -He/She was independent with transfers and ambulation on and off of the unit; -He/She required supervision with locomotion on and off of the unit; -He/She had fallen in the previous month prior to admission. Review of the resident's event report, dated 1/25/22, showed the following: -At 3:15 P.M., staff found the resident sitting on his/her buttocks near the end of his/her bed; -Care plan was not reviewed. (There was no documentation to show interventions were reviewed/revised to prevent further falls.) Review of the resident's care plan, dated 1/27/22, showed the following: -He/She was at risk for falls due to his/her cognitive status; -He/She required increased staff supervision with intensity based on his/her needs; -Staff were to provide individualized toileting interventions based on needs/patterns. Review of the resident's Morse Fall Scale, dated 4/11/22, showed the resident was at high risk for falls. Review of the resident's quarterly MDS, dated [DATE], showed the following: -His/Her cognition was severely impaired; -He/She was independent with transfers and ambulation; -His/Her balance was unsteady, but able to transfer without human assistance. Review of the resident's event report, dated 6/18/22, showed the following: -At approximately 10:40 A.M., the resident was walking out of his/her room while holding the hand rail when he/she appeared to have lost his/her balance and fell forward onto his/her knees; -A small skin tear was noted on the inner left thumb; -Care plan was not reviewed. Review of the resident's care plan showed no documentation of the resident's fall on 6/18/22 or evidence interventions were implemented after the resident fell. Review of the resident's Morse Fall Scale, dated 10/10/22, showed the resident was at high risk for falls. Review of the resident's annual MDS, dated 12/29//22, showed the following: -His/Her cognition was severely impaired; -He/She was independent with transfers and ambulation; -His/Her balance was unsteady, but able to transfer without human assistance. Review of the resident's event report, dated 1/2/23 at 7:38 P.M., showed the following: -The resident was wandering around the facility per his/her normal gait and pacing pattern; -He/She ambulated into the dining room where upon a loud noise was heard. Upon entering the dining room, staff noted the resident's legs on the floor in the back of the dining room where a stack of folding chairs on a rack were located. Upon moving the rolling chair rack, a bright red pool of blood was noted which was determined coming from the resident's left hand. Pressure was applied with an ice pack. Staff positioned the resident on his/her left side and immediately stabilized his/her head because it was obvious he/she had hit his/her head as there was a hematoma to the left eyebrow and cheek. There was a copious amount of blood coming from the resident's left thumb. The ambulance was notified, and the resident was sent to the hospital for evaluation and treatment of injuries; -At 6:10 P.M., report was received that the resident was returning to facility without evidence of fractures. -Care plan was not reviewed. Review of resident's care plan showed no documentation of the resident's fall on 1/2/23 or evidence interventions were implemented to prevent additional falls. During an interview on 5/3/23 at 5:30 A.M., Certified Nurse Assistant (CNA) N said the resident didn't have any specific interventions in place to prevent him/her from falling. He/She knew to monitor the resident's location and perform a room check every two hours and as needed. Fall interventions utilized for residents were communicated on the resident's care plans, CNA worksheet, and with verbal report. Review of facility's CNA worksheet, dated 5/4/23, showed the following: -The resident wandered; -The resident was independent with ambulation, but required help with finding the bathroom frequently. (Review showed no documentation the resident was at risk for falls with interventions to prevent falls.) 2. Review of Resident #54's admission MDS, dated [DATE], showed the following: -Severely impaired cognition; -Required limited assistance from one staff for transfers and toilet use; -Required extensive assistance from one staff with locomotion on the unit; -Balance during transitions was unsteady and only was able to stabilize with staff assistance; -His/Her triggered care areas included falls which was to be addressed on the resident's care plan. Review of the resident's event report, dated 3/8/23, showed the following: -The resident's pressure alarm was sounding. Upon entering the resident's room, staff found the resident sitting on his/her buttocks; -The resident sustained a skin tear to the left forearm; -Staff documented the care plan was not reviewed after the fall. Review of the resident's Morse Fall Scale (scale used to determine resident's risk for falls), dated 3/9/23, showed he/she was at high risk for falls. Review of the resident's event report, dated 3/15/23, showed the following: -Certified nurse assistant (CNA) responded to the resident's alarm sounding. Upon entering the room, staff found the resident sitting on the floor between the bed and heat register by the window; -He/She sustained a skin tear to the right wrist; -Staff documented the care plan was not reviewed. Review of the resident's care plan, revised on 3/24/23, showed the following: -His/Her diagnoses included dementia with behavioral disturbances, anxiety disorder, and coronary obstructive pulmonary disease (chronic lung disease characterized by shortness of breath); -He/She ambulated with walker and assist of one staff; -He/She used a pressure alarm in his/her chair and on the bed due to he/she was forgetful that he/she needed assistance with ambulation because he/she would fall; -There were no documentation of resident's falls on 3/8/23 and 3/15/23. Review of the resident's event report, dated 4/5/23, showed the following: -At 6:01 P.M., the resident fell in his/her room while ambulating without his/her walker or assistance; -Staff documented the care plan was not reviewed after the fall. Review of the resident's care plan showed staff failed to address his/her fall on 4/5/23 with interventions to prevent future falls. Review of the resident's event report, dated 4/12/23, showed the following: -At 3:15 P.M., the resident was found on floor between his/her bed and heat register; -The resident stood up beside his/her bed and then sat down to the floor; -Staff documented the care plan was not reviewed after the fall. Review of the resident's progress notes, dated 4/12/23 at 3:29 P.M., showed the resident said he/she was too weak to walk to the bathroom by himself/herself. There was discussion about positioning the resident's bed against the wall. Review of the resident's nursing progress notes, dated 4/15/23 at 10:50 A.M., showed the following: -He/She remained on follow-up after he/she fell on 4/12/23; -He/She had been on one-on-one observation all throughout the morning; -He/She repeatedly attempted to stand while his/her pressure alarm sounded, and attempted to walk; -He/She displayed a complete lack of safety awareness and impulsive behaviors of which staff were unable to redirect; -Offering food, fluids, toileting, and other distractions had been attempted and were successful for a very short interval. Review of the resident's nursing progress notes, dated 4/16/23 at 7:41 P.M., showed the following: -He/She required one-on-one observation and was brought to the nurse's desk; -He/She lacked safety awareness, would stand, and attempt to walk without assist; -He/She was impulsive and believed that he/she could do things that he/she was no longer able to do. Review of the resident's care plan showed no documentation of resident's impulsivity and lack of safety awareness or interventions to address this, increased risk for falls and/or any interventions, including one-on-one observation, need for redirection with food or fluids, change in position, and/or any other intervention pertinent to the resident's increased fall risk. During an interview on 5/3/23 at 5:30 AM., CNA N said the resident had a body alarm and was monitored every two hours and as needed. Staff were aware to get to the resident quickly when the alarm sounds because the resident was quick. 3. Review of Resident #25's annual MDS, dated [DATE], showed the following: -Severely impaired cognition; -Walked independently with a walker; -One fall without injury since last assessment; -Administered antipsychotic, anti-depressant, and anti-anxiety seven out of seven days during observation period. Review of the resident's fall event report, dated 02/07/23, at 3:03 P.M., showed the following: -The resident was walking down the hallway when staff heard a loud crash; -The resident had fallen on his/her left side in the doorway of a room. The resident's walker had tipped and lay on the floor; -The resident's left calf appeared darker in color and slightly swollen but not caused by the fall; -No immediate interventions indicated; -Care Plan was not reviewed. Review of the resident's fall event report, dated 02/17/23, at 3:50 A.M., showed the following: -The resident was found on the floor in the doorway across the hall from his/her room; -The resident had a blanket under part of him/her and no walker; -The resident complained of pain in the left lower extremity; -Staff noted swelling with purple bruising, and pain with weight/moving; -The resident was sent to the hospital for evaluation; -No immediate interventions indicated; -Care Plan was not reviewed. Review of the resident's fall event report, dated 03/12/23, at 5:50 A.M., showed the following: -The resident was walking back from the closet without his/her walker and fell by the front of the bed; -The resident received a skin tear to his/her left forearm, bruising below elbow, and abrasion on left lower back; -Immediate intervention of first aid; -Care Plan was not reviewed. Review of the resident's care plan, revised 04/24/23, showed the following: -Diagnoses include panic disorder (sudden episode of intense fear or anxiety), dementia (a group of thinking and social symptoms that interferes with daily functioning) and delusional disorders (a belief or altered reality that is persistently held despite evidence or agreement to the contrary). -The resident has a potential for falls related to poor safety judgement, anti-depressant therapy and cognitive decline; -Interventions included continue to remind the resident to use call light, ambulates with walker independently, answer call light promptly, remind resident to use his/her walker when he/she forgets, wear proper foot wear with non-slippery soles; -No indication fall or interventions evaluated after falls on 02/07/23, 02/17/23, and 03/12/23. 4. Review of Resident #9's quarterly MDS, dated [DATE], showed the following: -Severely impaired cognition; -Required extensive assistance from one staff for transfers; -Required extensive assistance from one staff for locomotion on the unit; -Total dependence on one staff for locomotion off the unit. -Balance during transitions was unsteady and only able to stabilize with staff assistance; -Bed and chair alarm used daily. Review of the resident's care plan, revised on 03/22/23, showed the following: -Diagnoses included dementia with behavior disturbance (a group of thinking and social symptoms that interferes with daily functioning, exhibiting physical or verbal aggression), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with daily activities). -Potential for falls related to weakness, decreased mobility, poor safety judgement, anti-depressant therapy and history of falls; -Interventions include call light within easy reach at all times, keep bed at lowest level convenient to resident, transfer with [NAME] steady (manual sit-to-stand lift) and/or walker with assist of staff; -Wear proper footwear and or non-slippery socks; -Wheelchair for long distances, propelled by staff and sometimes by resident. Review of the resident's fall event report, dated 03/23/23 at 5:18 A.M., showed the following: -The resident was found on the floor in front of his/her recliner with the recliner in the fully raised position. The chair alarm was sounding; -No injuries noted; -No immediate interventions indicated; -Care plan was not reviewed. Review of the resident's fall event report, dated 04/03/23 at 6:21 P.M., showed the following: -The resident was found on the floor in front of his/her recliner with the recliner in the fully raised position. The chair alarm was sounding; -No injuries noted; -No immediate interventions indicated; -Care Plan was not reviewed. Review of the resident's fall event report, dated 04/30/23 at 8:34 P.M., showed the following: -The resident was found on the floor in front of his/her recliner with the recliner in the fully raised position. The chair alarm was not sounding; -No injuries noted; -Immediate intervention of rest and moved to bed; -Care Plan was not reviewed. Review of the resident's care plan showed no indication of updating with the 03/23/23, 04/03/23, and 04/30/23 falls or interventions after falls. Observation on 05/01/23, at 7:08 A.M., showed the resident sat awake in his/her recliner. The resident sat on a pressure chair alarm that was not connected to the alarm box. Observation on 05/03/23, at 7:08 A.M., showed the following: -CNA G propelled the resident in a wheelchair out of his/her room and up the hall to the dining room. The resident's wheelchair did not have foot rests; -During transport, both of the resident's feet slid on the floor making a rubbing sound at least half the distance to the dining room. Observation on 05/01/23, at 7:44 A.M., showed the following: -CNA G propelled the resident in a wheelchair from the dining room table out of the dining room to provide personal care; -During transport from the table out of the dining room, the resident's feet slid on the floor making a rubbing sound. During interview on 05/04/23, at 12:05 P.M., CNA G said the following: -Foot rests were available for the residents and located in the storage room; -He/She had also seen some in resident rooms recently; -Foot rests should be used if the resident does not propel themselves; -Resident #9 will kick the foot rests out of the way and does not like them; -Foot rests should be used if residents are not propelling themselves to prevent jerking the feet back and causing injuries. 5. Review of Resident #13's care plan, last updated 1/30/22, showed the following: -The resident propelled himself/herself via wheelchair and will ask for assist if needed; -The staff will assist the resident into his/her wheelchair reminding of safe transfer and allowing the resident to do what he/she can. Review of the resident's annual MDS, dated [DATE], showed the following: -The resident had severely impaired cognition; -He/She required limited assistance of one staff for transfers; -He/She was independent with locomotion on the unit. Observation on 5/1/23 at 7:13 A.M., showed CNA F propelled the resident in a wheelchair into the dining room. The resident's wheelchair did not have foot rests. The resident's socked feet dragged along the floor during the transport. Observation on 5/1/23 at 8:15 A.M., showed CNA F propelled the resident in a wheelchair from the dining room to the resident's room. The resident's socked feet dragged along the floor during the transport. Observation on 5/1/23 at 8:19 A.M., showed the following: -CNA F and CNA G transferred the resident from his/her wheelchair to the toilet; -CNA F and CNA G lifted the resident under his/her armpits up from the wheelchair to the toilet; -CNA F and CNA G lifted the resident up from under his/her armpit to transfer him/her from the toilet back to the wheelchair; -CNA F and CNA G then lifted the resident up from under his/her armpits to transfer him/her from the wheelchair to the bed; -Both CNA F and CNA G had gait belts on their person, but did not put them on the resident or utilize them during the transfers. During an interview on 5/1/23 at 8:27 A.M., CNA F said the following: -The resident's feet did drag on the floor because the resident was too tired to assist with the transport; -The resident didn't have foot rests to put on his/her wheelchair; -He/She was in a hurry, so he/she forgot to put the gait belt on the resident during the transfer. During an interview on 5/4/23 at 8:43 A.M., CNA H said foot rests were supposed to be on wheelchairs unless the resident propelled themselves with their feet. During an interview on 5/4/23 at 8:50 A.M., CNA J said the following: -The resident was supposed to have foot rests on his/her wheelchair when the resident was lethargic and not able to lift his/her feet; -All residents with a wheelchair were supposed to have foot rests available; -If a resident was able to propel himself/herself, then the foot rests can be left off. 6. Review of Resident #34's annual MDS, dated [DATE], showed the following: -Severely impaired cognition; -Total dependence on one staff for locomotion on the unit; -Required extensive assistance from one staff for locomotion off the unit; -Used a wheelchair for mobility. Review of the resident's care plan, revised on 03/10/23, showed the following: -Diagnoses include dementia (a group of thinking and social symptoms that interferes with daily functioning), legal blindness, and generalized muscle weakness; -Staff propelled the resident when he/she was in a wheelchair for long distances. The resident can propel himself/herself in wheelchair for short distances; Observation on 05/01/23, at 8:04 A.M., showed the following: -CNA F propelled the resident in a wheelchair out of the dining room. The resident did not have foot rests on his/her wheelchair; -During transport, the resident's right foot slid on the floor making a rubbing sound. Observation on 05/01/23, at 12:28 P.M., showed the following: -CNA G propelled the resident in a wheelchair from his/her room to the dining room. The resident's wheelchair did not have foot rests; -During transport, the toes on the resident's right foot slid on the floor making a rubbing sound. 7. During interview on 05/03/23, at 3:09 P.M., Registered Nurse A said the following: -After a fall, staff complete an incident check list and slide it under the Director of Nursing's (DON's) door or administrator's door; -The check list indicates for the DON to add the fall to the care plan and adds interventions; -Nursing staff is probably able to update care plans, he/she just never has; -The interdisciplinary team identifies interventions for falls, but if there is an immediate concern, nursing addresses the concern and lets management know what was done. During interview on 05/04/23, at 1:15 P.M., the Quality Assurance (QA) Nurse said the following: -She is in charge of initiating interventions after falls on the care plans; -Nurses can update the care plans but she has not asked them to do so since they are very busy; -Lack of staff and nurses, and too many things going on has made it difficult to get the updates done. During interview on 05/04/23, at 2:30 P.M., the MDS Coordinator said the following: -She or the QA nurse were responsible for updating the care plans and they had gotten behind on updates; -Falls should be updated on the care plans. During interview on 05/04/23, at 3:12 P.M., the Director of Nursing (DON) said the following: -She expected intervention be reviewed and/or revised as needed after falls; -The MDS Coordinator was responsible for the review of care plans and updates as needed. -Staff should use foot rests when pushing a resident in a wheelchair if the resident is unable to hold up his/her feet; -If foot rests are not used, it could potentially cause the resident to drag their feet and go out of the wheelchair face first or could damage the resident's feet; -Foot rests should be used if a resident's feet drag on the floor; -Nursing staff should use a gait belt when transferring a resident and not lift under the resident's arms. During interview on 05/04/23, at 3:25 P.M., the administrator said the following: -The residents who can propel themselves do not have foot rests; -Residents #9 and #34 have self propelled themselves recently; -Staff should not propel a resident in a wheelchair without foot rests if the resident cannot hold up their feet. Based on observation, interview, and record review, the facility failed to review and/or revise interventions to prevent falls for four residents (Residents #9, #25, #47, and #54), in a review of 19 sampled residents. The facility failed to use proper technique when transferring one resident (Resident #13) when staff lifted under the resident's armpits during transfer and did not use a gait belt (a canvas belt placed around the resident's waist to assist with ambulation and transfers). The facility failed to safely transport three residents (Residents #9, #13, and #34) in wheelchairs with footrests. The facility census was 59. During interview on 05/04/23, at 1:00 P.M., the Quality Assurance (QA) Nurse said the facility did not have a policy in place for transporting residents in wheelchairs. Review of facility's policy for management of falls, dated December 2007, showed the following: -Based on previous evaluations and current data, the staff would identify interventions related to resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling; -Staff with the input of the attending physician, would identify appropriate interventions to reduce the risk of falls. If a systematic evaluation of a resident's fall risk identified several possible interventions, the staff could choose to prioritize interventions; -Examples of initial approaches might include exercise and balance training or a rearrangement of room furniture. If a medication was suspected a a possible cause of a resident's falling, the initial intervention might be to taper or stop that medication; -If falling recurred despite initial interventions, staff would implement additional or different interventions, or indicate why the current approach remained relevant; -If underlying causes could not be readily identified or corrected, staff would try various interventions, based on assessment of the nature or category of falling, until falling was reduced or stopped, or until the reason for the continuation of the falling was identified as unavoidable; -In conjunction with the attending physician, staff would identify and implement relevant interventions to try to minimize serious consequences of falling. Review of the facility's undated policy for gait belt transfers showed the following: -Gait belts were required for all residents when performing transfers, ambulation, or repositioning in a chair; -The belt was to be applied snugly around the resident's waist over clothing below the ribs so that the nurse assistant fingers may grasp the belt securely; -The nurse assistant grasps the belt on both sides of the resident's wait. Palms should be inserted between the belt and resident with fingertips pointing upward; -The nurse assistant should not transfer or ambulate residents by grasping their upper arms or under their arms. Such a transfer could result in skin tears, damage to the nerves and arteries, and possible dislocation of the shoulder. The gait belt increased the comfort and safety of the resident during the transfer procedure and prevented injury to the resident that could be caused by pulling on his/her arms, shoulders, or wrist.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of Resident #13's face sheet showed the resident was admitted to the facility on [DATE] with diagnosis of dementia and he/she had a responsible party for decision making. Review of the resident's medical record did not include informed consent or education of the responsible parties on the risk of bed rail use and failed to document attempted alternatives prior to installing the bed rails. Review of the resident's care plan, last updated on 1/30/22, showed the following: -The resident was at risk for falls related to weakness, decreased mobility, poor safety judgement and history of falls; -Increased staff supervision with intensity based on resident need; -Ambulates with walker and assist of one or two staff with gait belt, goes back and forth to the bathroom, at times; -Staff will assist the resident into wheelchair reminding of safe transfers, -The care plan did not include the use of bed rails. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/5/23, showed the following: -The resident had severely impaired cognition; -He/She required extensive assistance of one staff member for bed mobility; -He/She required limited assistance of one staff member for transfers; -Diagnosis of dementia; -He/She had a fall without injury; -He/she took an antianxiety, antidepressant, and diuretic medication. Observation on 5/1/23 at 8:15 A.M., showed the resident lay on his/her back in bed with quarter bed rails up on both sides of the bed. Observation on 5/3/23 at 5:20 A.M., showed the resident lay on his/her back in bed. The quarter bed rail on the left side of the resident's bed was raised. 5. Review of Resident #18's annual MDS, dated [DATE], showed the following: -Severely impaired cognition; -Extensive assistance of two staff members for bed mobility and transfers; -Limited range of motion one upper and lower extremity; -No falls since last assessment; -No bed bed rails used. Review of the resident's care plan, revised on 03/02/23, showed the following: -The resident has potential for falls related to anti-depressant therapy, weakness, decreased mobility, poor safety judgment and history of falls; -He/She thinks he/she can transfer himself/herself, remind to use call light for help; -Keep bed in lowest level; -No indication of bed rail use. Review of the resident's May 2023 physician orders showed no order for bed rail use. Review of the resident's electronic health record showed no initial or routine bed rail assessment, informed consent for bed rail use or initial or routine measurements of entrapment zones. Observation on 05/01/23, at 10:09 A.M., showed the resident lay awake in bed with bilateral 1/2 upper bed rails in the raised position. Observation on 05/02/23, at 9:18 A.M., showed the resident lay in bed with eyes closed and bilateral 1/2 upper bed rails in the raised position. During interview on 05/02/23, at 9:20 A.M. the resident said he/she uses the bed rails for bed mobility. He/She did not recall signing consent for use of bed rails. Observation on 05/03/23, at 5:30 A.M., showed the resident lay in bed awake. The bed was in a low position. Bilateral 1/2 upper bed rails in the raised position. 6. Review of Resident #34's annual MDS, dated [DATE], showed the following: -Severely impaired cognition; -Total dependence on one staff member for bed mobility; -Total dependence on two staff members for transfers; -Limited range of motion bilateral lower extremities; -No bed side rails used. Review of the resident's care plan, revised on 03/10/23, showed the following: -The resident has potential for falls related to weakness, poor safety judgment and falling asleep in wheelchair; -Keep bed in lowest level, convenient to resident; -Transfer with assist of two per mechanical lift; -No indication of bed rail use. Review of the resident's May 2023 physician orders showed no order for bed rail use. Review of the resident's electronic health record showed no initial or routine bed rail assessment, informed consent for bed rail use or initial or routine measurement of entrapment zones. Observation on 05/01/23, at 10:12 A.M., showed the resident lay in bed asleep with bilateral 1/2 upper bed rails in raised position. Observation on 05/02/23, at 9:12 A.M., showed the resident lay in bed awake with bilateral 1/2 upper bed rails in raised position. During interview on 05/02/23, at 9:12 A.M., the resident said he/she uses the bed rails to help him/her turn in bed. He/She did not recall signing consent for use of bed rails. Observation on 05/03/23, at 5:28 A.M., showed the resident lay in bed sleeping with bilateral 1/2 upper bed rails in the raised position. 7. Review if the Resident #162's face sheet showed the following: -admission to the facility on [DATE]; -Diagnoses include malignant neoplasm of unspecified bronchus or lung (lung cancer) and dementia with Lewy bodies (a type of progressive dementia that leads to a decline in thinking, reasoning and independent function. Review of the resident's May 2023 physician orders noted no order for bed rail or bed alarm use. Review of the resident's care plan, revised 05/01/23, showed the following: -Potential for falls related to weakness, decreased mobility, poor safety judgment and history of falls; -Keep bed in lowest level, convenient to resident; -No indication of bed alarm use; -No indication of bed rail use. Review of the resident's electronic health record showed no initial or routine bed rail assessment, informed consent for bed rail use or initial or routine measurement of entrapment zones. Observation on 05/01/23, at 6:17 A.M., showed the resident's bed alarm was sounding. The resident lay in bed sleeping with his/her feet hanging to the side, bed in low position and right upper 1/2 bed rail in the raised position. Observation on 05/03/23, at 5:26 A.M., showed the resident lay in bed sleeping, bed in low position, right upper 1/2 bed rail in the raised position. During interview on 05/03/23, at 8:45 A.M., the administrator said the facility did not have bed rail assessments or consents for bed rail use. Based on observation, interview, and record review, the facility failed to have a system in place to obtain informed consent and educate residents and their responsible parties about the risks of bed rail use prior to use, and failed to assess for continued safe use of bed rails for five residents (Resident #9, #13, #18, #34, #162), in a review of 19 sampled residents. The facility census was 59. 1. During interview on 05/04/23, at 1:00 P.M., the Quality Assurance (QA) Nurse said the facility did not have a policy in place for bed rail assessments or use. 2. Review of the Food and Drug Administration (FDA) Guide of Bed Safety, Bed Rails in Hospitals, Nursing Homes and Home Health Care: The Facts, revised April 2010, showed the following: -Patients who have problems with memory, sleeping, incontinence, pain, uncontrolled body movement, or who get out of bed and walk unsafely without assistance, must be carefully assessed for the best ways to keep them from harm, such as falling; -Assessment by the patient's health care team will help to determine how best to keep the patient safe; -Potential risks of bed rails may include strangling, suffocating, bodily injury or death when patients or part of their body are caught between rails or between the bed rails and mattress, more serious injuries from falls when patients climb over rails, skin bruising, cuts, and scrapes, feeling isolated or unnecessarily restricted, and preventing patients, who are able to get out of bed, from performing routine activities such as going to the bathroom or retrieving something from a closet; -When bed rails are used, perform an on-going assessment of the patient's physical and mental status and closely monitor high-risk patients; -Use a proper size mattress or mattress with raised foam edges to prevent patients from being trapped between the mattress and rail; -Reduce the gaps between the mattress and side rails; -A process that requires ongoing patient evaluation and monitoring will result in optimizing bed safety; -Reassess the need for using bed rails on a frequent, regular basis. 3. Review of Resident #9's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, dated 03/09/23, showed the following: -Severely impaired cognition; -Extensive assistance of one staff member for transfers and bed mobility; -Balance during transitions is unsteady and only able to stabilize with staff assistance; -No range of motion impairments; -No falls since last assessment; -Bed rails not used; -Bed and chair alarm used daily. Review of the resident's care plan, revised on 03/22/23, showed the following: -Potential for falls related to weakness, decreased mobility, poor safety judgement, anti-depressant therapy and history of falls; -Interventions included call light within easy reach at all times, keep bed at lowest level convenient to resident, transfer with manual sit to stand lift and or walker with assist of staff; -Wear proper footwear and or non-slippery socks; -No indication of bed rail use; -No indication of bed or chair alarm use. Review of the resident's May 2023 physician order sheet showed no orders for bed rails, bed alarm or chair alarm use. Review of the resident's electronic health record showed no initial or routine bed rail assessment, no informed consent for bed rail use, and no education of risks or benefits related to bed rail use or initial or routine measurement of entrapment zones. Observation on 05/03/23, at 5:32 A.M., showed the resident lay awake in bed with the right side upper 1/2 bed rail in the raised position. During interview on 05/01/23, at 7:08 A.M., the resident said he/she used the bed rail to help him/her turn in bed. He/She did not recall signing consent for bed rail use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #13's care plan, last updated 1/30/22, showed the following: -The resident required limited to extensive assist with activities of daily living (ADLs) at times; -Assist with peri care as needed. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/5/23, showed the following: -The resident had severely impaired cognition; -He/She required extensive assistance of one staff member for toilet use; -He/She had occasional urinary incontinence. Observation on 5/1/23 at 8:19 A.M., showed the following: -Certified Nurse Aide (CNA) F and CNA G entered the resident's room, washed their hands and put on gloves; -CNA F assisted CNA G to transfer the resident from the wheelchair to the toilet; -CNA F pulled down the resident's wet incontinence brief; -CNA F and CNA G assisted the resident to stand, and CNA F provided perineal care for the resident with toilet paper; -CNA F did not remove his/her gloves or wash his/her hands after providing perineal care to the resident; -CNA F assisted to pull up the resident's clean incontinence brief and pants, transferred the resident to the wheelchair and then to bed, and placed a blanket on the resident. During an interview on 5/1/23 at 8:27 A.M., CNA F said the following: -He/She didn't wash hands or change gloves between handling dirty items, because he/she was the one who was performing the dirty tasks, while CNA G performed the clean tasks; -He/She didn't think about how he/she had to touch the resident with dirty gloves when transferring the resident back from the toilet to wheelchair and again from wheelchair to bed. 4. Review of Resident #11's annual MDS, dated [DATE], showed the following: -The resident had moderately impaired cognition; -He/She required limited assistance of one staff member for toilet use; -He/She was always incontinent of bladder. Review of the resident's care plan, last updated, 1/3/23, showed the resident required assistance with peri care. Observation on 5/3/23 at 6:23 A.M., showed the following: -Nurse Aide (NA) I washed his/her hands and put on gloves; -NA I removed the resident's urine soiled clothes and performed perineal care for the resident; -Without removing his/her gloves and washing his/her hands after providing perineal care, NA I assisted the resident to transfer from the bed to the wheelchair and then from the wheelchair to the toilet. During an interview on 5/3/23 at 6:42 A.M., NA I said the following: -He/She made a mistake when the resident was in the restroom, because he/she was assigned the clean tasks; -He/She performed the peri care, pulled up the resident's clean clothes, and assisted with the transfer without changing his/her gloves or washing his/her hands. 5. Review of Resident #19's care plan, revised on 12/20/22, showed the resident was incontinent of bowel and bladder and needed assistance with perineal care and toileting. Review of the resident's annual MDS, dated [DATE], showed the following: -Moderately impaired cognition; -Required extensive assistance from one staff for toileting and personal hygiene; -Always incontinent of bowel and bladder. Observation on 05/01/23, at 8:25 A.M., showed the following: -The resident was incontinent of urine and his/her pants were wet with urine; -NA L did not wash his/her hands or put on gloves; -NA L took the resident to the bathroom and removed the resident's pants and urine soaked incontinence brief; -CNA G entered the resident's room, and without washing his/her hands or performing hand hygiene, he/she put on gloves; -CNA G removed the resident's soiled pants and placed them directly on the floor; -Without washing his/her hands, NA L put on gloves and wiped the resident's buttocks with toilet paper; -Without removing their gloves, CNA G and NA L applied a new incontinence brief and pants on the resident; -CNA G placed the resident's soiled pants in a bag, removed one of his/her gloves, and left the resident's room. During interview on 05/04/23, at 1:45 P.M., NA L said the following: -Staff should wear gloves any time they are providing resident care, such as toileting; -Staff should change their gloves between dirty procedures and after providing peri-care; -He/She did not remember not using gloves while caring for Resident #19. During interview on 05/04/23 at 12:05 P.M., CNA G said the following: -Staff should wear gloves when providing care for the residents; -Staff should wash their hands or use hand sanitizer prior to putting on gloves and after removing gloves; -He/She used hand sanitizer outside Resident #19's room prior to coming into the room to assist NA L with the resident's care. 6. Review of Resident #163's care plan, revised 04/06/23, showed the resident needed moderate to extensive assist of one staff member with toileting. Observation on 05/02/23, at 1:26 P.M., showed the following: -The resident was incontinent of bladder and bowel; -CNA D washed his/her hands and put on gloves; -CNA D performed perineal care to the resident's buttocks and rectal area; -Without removing his/her gloves, CNA D picked up a basin from the sink counter, turned on the water, turned off the water, returned to the resident's bedside, and wet a clean washcloth and rinsed the soap from the resident's buttocks; -Without removing his/her gloves, CNA D assisted the resident to turn to his/her side. During interview on 05/11/23, at 6:00 P.M., CNA D said the following: -Staff should wash their hands before and after providing resident care and applying gloves; -Staff should changed gloves when they become soiled; -He/She provided peri-care for the resident and forgot to get a basin of clean water; -He/She did not remove his/her gloves when he/she got the basin of clean water; -He/She should have removed his/her gloves, washed his/her hands and applied new gloves before getting the clean basin. 7. During an interview on 5/4/23 at 3:12 P.M., the Director of Nursing said the following: -She expected staff to wash their hands before and after direct resident care, and after changing gloves; -She expected staff to wear gloves when providing resident care and helping the resident to the bathroom; -Nebulizer masks/oxygen equipment should be covered when not in use. During an interview on 5/4/23 at 3:12 P.M., the Administrator said the following: -She expected staff to wear gloves when providing resident care to wash their hands before putting on gloves and after removing gloves; -Hand sanitizer was located in the hallway for staff to use as needed prior to entering a resident's room. Based on observation, interview, and record review, the facility failed to ensure nursing staff performed acceptable infection control practices to prevent contamination when staff failed to protect nebulizer masks while not in use for two residents (Residents #22 and #54), in a review of 19 sampled residents. The facility failed to follow the facility's policy for hand washing and gloving during perineal care for one sampled resident (Resident #13) and for three additional residents (Residents #11, #19 and #163). The facility census was 59. Review of facility's undated handwashing policy showed the following: -Handwashing remained the single most effective means of preventing disease transmission; -Washing hands often and well, paying particular attention to around and under fingernails and between the fingers; -Staff were expected to wash hands when they were soiled with body substances, before food preparation, before eating, after using the toilet, before performing invasive procedures, and upon completion of resident's care; -Waterless antiseptic hand cleaners or towelettes may be used if hands could not be washed right after being soiled, but soap and water must be used as soon as feasible; -The use of alcohol based rinses or foams with non-drying emollients were occasionally used as an adjunct to handwashing. During interview on 05/04/23, at 1:00 P.M., the Quality Assurance (QA) Nurse said the facility did not have a policy in place for oxygen or nebulizer equipment storage when not in use. 1. Review of Resident #54's care plan, last reviewed/revised on 3/23/23, showed the following: -He/She had potential for impaired air exchange related to chronic obstructive pulmonary disease (COPD, chronic lung disease characterized by shortness of breath) and chronic respiratory failure; -He/She would have minimal dyspnea (shortness of breath) and free from respiratory infection; -Administer medications and oxygen as ordered by his/her physician. Review of the resident's physician's orders, dated 4/1/23 to 5/3/23, showed the following: -His/Her diagnoses included COPD and hypoxemia (low levels of oxygen in the blood); -An order for ipratropium-albuterol (inhaled medication used to relax muscle and open air passages to the lungs to make breathing easier) to be administered per nebulizer (a small machine that turns liquid medicine into a mist that can be easily inhaled) four times a day. Observation on 5/1/23 at 10:00 A.M. showed the resident's nebulizer mask was uncovered on the resident's bedside table. Observation on 5/2/23 at 11:55 A.M. showed the resident's nebulizer mask was uncovered on the resident's bedside table. Observation on 5/2/23 at 3:36 P.M. showed Certified Medication Technician (CMT) C administered a nebulizer treatment to the resident via the nebulizer machine/mask. 2. Review of Resident #22's undated continuity of care document (CCD) showed the following: -His/Her diagnoses included COPD; -An order for ipratropium-albuterol to be administered via nebulizer four times a day. Review of resident's care plan, last reviewed on 3/14/23, showed the following: -He/She had the potential for impaired air exchange related to COPD and chronic respiratory failure; -Staff were to administer inhalers/medications per physician's orders. Observation on 5/1/23 at 6:30 A.M. showed the resident's nebulizer mask was uncovered on the resident's bedside table. Observation on 5/2/23 at 10:00 A.M. showed the resident's nebulizer mask was uncovered on the resident's bedside table. Review of resident's Treatment Administration Record (TAR), dated 5/2/23, showed staff administered ipratropium-albuterol on 5/2/23 at 12:08 P.M. Observation on 5/2/23 at 1:16 P.M. showed the resident's nebulizer mask was uncovered on the resident's bedside table. During an interview on 5/16/23 at 10:35 A.M., Certified Medication Technician (CMT) C said some of the residents' nebulizer masks were located on their night stands. Staff were to place the masks on the holder located on the nebulizer machine when not in use. He/She was not aware of ever covering nebulizer masks with any sort of bag.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop policies and procedures regarding the provisions of pneumococcal (lung inflammation caused by bacterial or viral infection) vaccinations in accordance with the Centers for Disease Control and Prevention (CDC) recommendations. The facility failed to provide pneumococcal vaccine for one additional resident (Resident #163), who had a signed consent requesting the vaccine, and failed to follow CDC recommendations to administer the PCV15 (15-valent pneumococcal conjugate vaccine) or PCV20 (20-valent pneumococcal conjugate vaccine) when one resident's (Resident #8's), vaccination history was unknown. The facility failed to provide five residents (Resident #2, #8, #22, #54, and #57) in a sample of 19 residents and one additional resident (Resident #59), education of risks and benefits of receiving a pneumococcal vaccine. The facility census was 59. During interview on 05/04/23, at 1:00 P.M., the Quality Assurance (QA) Nurse said the facility did not have a policy in place for monitoring residents' vaccination status, including pneumococcal vaccination status and administration. During an interview on 5/18/23 at 2:00 P.M., the administrator said the facility did not have a policy for pneumococcal vaccinations. Review of the CDC recommendations for pneumococcal vaccine timing, dated 4/1/22, showed the following: -CDC recommends pneumococcal vaccination for adults [AGE] years old or older, and for adults 19 through [AGE] years old with certain underlying medical conditions including cigarette smoking; -For adults who have never received a pneumococcal vaccine, or those with unknown vaccination history, one dose of PCV15 (15-valent pneumococcal conjugate vaccine) or PCV20 (20-valent pneumococcal conjugate vaccine) should be administered; -If PCV 20 is used, their pneumococcal vaccinations are complete; -If PCV 15 is used, follow with one dose of PPSV23 (23-valent pneumococcal polysaccharide vaccine) with a recommended interval of at least one year; -For adults who have previously received PPSV23 but who have not received any pneumococcal conjugate vaccine (PCV), one does of PCV15 or PCV20 may be administered with an interval of at least one year; -For adults 65 years or older without an immunocompromising condition, cerebrospinal fluid leak, or cochlear implant, who have previously received PCV13 at any age, it is recommended to receive one dose of PPSV23 at or after [AGE] years of age (at least one year after PCV13 was received). Their pneumococcal vaccinations are complete; -For adults 19 years or older with an immunocompromising condition who have previously received a PCV13 at any age, CDC recommends two doses of PPSV 23 before age [AGE] years and one dose of PPSV23 at the age of 65 or older: -Administer a single dose of PPSV23 at least 8 weeks after the PCV13 was received; -If the patient was younger than [AGE] years old when the first dose of PPSV23 was given and has not turned [AGE] years old yet, administer a second dose of PPSV23 at least five years after the first dose of PPSV23. This is the last dose of PPSV23 that should be given prior to [AGE] years of age; -Once the patient turns [AGE] years old and at least five years have passed since PPSV23 was last given, administer a final dose of PPSV23 to complete their pneumococcal vaccinations. 1. Review of Resident #163's face sheet showed the following: -The resident's diagnoses included dementia (a group of thinking and social symptoms that interferes with daily functioning), atrial fibrillation (an irregular, often rapid heart beat that causes poor blood flow), and heart disease (heart condition that includes diseased blood vessels, structural problems and blood clots); -The resident was over the age of [AGE] years old. Review of the resident's pneumonia vaccine consent form, dated 10/03/22, indicated the resident checked 'yes' to receive the pneumococcal vaccine. Review of the resident's medical record showed no evidence the resident received the pneumococcal vaccine after providing consent on 10/03/22. During interview on 05/09/23, at 9:16 A.M., the resident's legal representative said he/she would have expected the pneumococcal vaccine to be given if the resident signed a consent form requesting the vaccine. 2. Review of Resident #8's face sheet showed the following: -The resident was over age [AGE]; -Diagnoses included acute respiratory failure (serious condition that happens when your lungs cannot get enough oxygen into your blood or remove enough carbon dioxide) with hypoxia (low levels of oxygen in your body tissues). Review of the resident's pneumonia vaccine consent, dated 3/7/23, showed the family reported the resident had received a pneumococcal vaccination in the past, but was unsure of the date. Review of the resident's medical record showed no documentation the resident received the PCV15 nor PCV20 pneumonia vaccine per CDC recommendations when the resident's vaccination history was unknown. During an interview on 5/3/23 at 1:23 P.M., the resident's responsible party said the resident had a pneumococcal vaccination in the past but couldn't remember when. He/She would prefer the resident be up-to-date on pneumococcal vaccinations, and would want the facility to give the vaccine if ordered by the physician. 3. Review of Resident #54's undated face sheet showed the following: -He/She was over the age of 65; -His/Her family made medical decisions for him/her; -His/Her diagnoses included chronic obstructive pulmonary disease (COPD) (chronic inflammatory lung disease that causes obstructed airflow from the lungs), hypoxemia (low blood oxygen level), and history of nicotine dependence. Review of the resident's pneumonia vaccine consent, dated 9/8/22, showed the family refused the pneumococcal vaccination. Review of the resident's medical record showed no documentation the facility provided the resident and/or his/her responsible party with education regarding the risks and benefits of the pneumococcal vaccination. 4. Review of Resident #22's pneumonia vaccine consent, dated 6/6/22, showed he/she refused the pneumococcal vaccination as evidenced with his/her signature. Review of the resident's medical record showed no documentation the facility provided the resident and/or his/her responsible party with education regarding the risks and benefits of the pneumococcal vaccination. Review of the resident's quarterly MDS, dated [DATE], showed the following: -He/She was over the age of 65; -His/Her diagnoses included COPD/chronic lung disease, heart failure, and dementia; -Pneumococcal vaccine was up to date. Review of the resident's physician progress note dated 2/1/23 showed the resident was due for the pneumococcal vaccine. Review of the resident's medical record showed no documentation the resident was offered or received the pneumococcal vaccination after the physician's progress note dated 2/1/23, and no evidence staff provided the resident with education regarding the risk and benefits of the pneumococcal vaccination when the resident refused on 6/6/22. 5. Review of Resident #2's face sheet showed the following: -The resident was over age [AGE]; -Diagnoses included congestive heart failure (CHF; weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs and can't pump enough oxygen-rich blood to meet your body's needs) and pulmonary hypertension in chronic thromboembolic disease (abnormally high pressure in a lung's small blood vessels as a result of prior blood clots in the lungs). Review of the resident's pneumonia vaccine consent form, dated 2/10/23, showed the resident doesn't take the pneumococcal vaccine. Review of the resident's medical record showed no documentation the facility provided education to the resident and/or resident representative regarding the risks and benefits of the vaccination. 6. Review of Resident # 57's face sheet showed the resident was over age [AGE]. Review of the resident's pneumonia vaccine consent, dated 9/9/22, showed the family declined the vaccination. Review of the resident's medical record showed no documentation the facility provided education to the resident and/or resident representative regarding the risks and benefits of the vaccination. 7. During interview on 05/03/23, at 12:45 P.M., the Quality Assurance nurse said the following: -If a pneumococcal vaccination was not documented in the preventative health record, it more than likely had not been given; -If consent was obtained from a resident requesting a vaccine, it should be administered; -There is no specific place where staff document when education was provided to a resident or resident representative regarding the vaccine; -She was not aware of the current CDC recommendations for pneumococcal vaccinations. During interview on 05/04/23, at 3:12 P.M., the Director of Nursing said the following: -She expected residents to be up-to-date on vaccinations if that was what the resident wanted; -She expected vaccinations to be given in a timely manner if consent to administer was obtained; -She expected nursing staff to provide education to the resident or resident representative if the resident refused a recommended vaccine. During an interview on 5/3/23 at 8:45 A.M., the administrator said the QA nurse had been working to ensure pneumonia vaccinations were up to date, but she was unsure on his/her progress with the review. She expected staff to provide education about the pneumococcal vaccinations per the CDC to residents and/or resident representatives with all consents. She expected staff to administer vaccinations if consent was granted and per CDC guidelines. During interview on 05/03/23, at 12:30 P.M., the medical director said the following: -He expected residents' immunizations to be up-to-date; -He expected the facility to follow the current CDC recommendations for administration of pneumococcal vaccinations; -He expected staff to screen for vaccination status on admission to determine if the resident was up-to-date on all vaccinations; -If the facility was unable to determine a resident's vaccination status, he expected the facility to administer vaccinations to bring the resident up-to-date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #13's annual MDS, dated [DATE], showed the resident had severely impaired cognition. Observation on 5/1/23 at 8:15 A.M., showed the resident lay in bed. The 1/2 bed rails on both sides of the resident's bed were in the raised position. Observation on 5/3/23 at 5:20 A.M., showed the resident lay in bed. The 1/2 bed rail on the left side of the resident's bed was in the raised position. Review of the resident's medical record showed no evidence of measurements or an evaluation for entrapment zones on the resident's bed. 3. Review of Resident #18's annual MDS, dated [DATE], showed the following: -Severely impaired cognition; -Require extensive assistance from two staff for bed mobility; -Limited range of motion one upper and lower extremity. Review of the resident's care plan, revised on 03/02/23, showed the following: -The resident has potential for falls; -He/She thinks he/she can transfer himself/herself. Observations on 05/01/23 at 10:09 A.M., on 5/3/23 at 9:18 A.M., and on 5/3/23 at 5:30 A.M. showed the resident lay in bed. The 1/2 bed rails on both sides of the resident's bed were in the raised position. Review of the resident's medical record showed no evidence the facility obtained measurements or completed an evaluation for entrapment zones on the resident's bed. 4. Review of Resident #34's annual MDS, dated [DATE], showed the following: -Severely impaired cognition; -Total dependence on one staff member for bed mobility; -Limited range of motion bilateral lower extremities. Review of the resident's care plan, revised on 03/10/23, showed the following: -The resident has potential for falls. -Keep bed in lowest level, convenient to resident. Observations on 05/01/23, at 10:12 A.M. and on 5/2/23 at 9:12 A.M. showed the resident lay in bed. The 1/2 bed rails on both sides of the resident's bed were in the raised position. Review of the resident's medical record showed no evidence the facility obtained measurements or completed an evaluation for entrapment zones on the resident's bed. 5. Review of Resident #162's face sheet showed the resident's diagnoses included dementia with Lewy bodies (a type of progressive dementia that leads to a decline in thinking, reasoning and independent function). Review of the resident's care plan, revised 05/01/23, showed the following: -Potential for falls related to weakness, decreased mobility, poor safety judgment and history of falls; -Keep bed in lowest level, convenient to resident. Observation on 05/01/23, at 6:17 A.M., showed the resident lay in bed sleeping with his/her feet hanging to the side. The 1/2 bed rail on the right side of the resident's bed was in the raised position. Observation on 05/03/23, at 5:26 A.M., showed the resident lay in bed. The 1/2 bed rail on the right side of the resident's bed was in the raised position. Review of the resident's medical record showed no evidence the facility obtained measurements or completed an evaluation for entrapment zones on the resident's bed. 6. During interview on 05/03/23, at 8:45 A.M., the administrator said staff had not measured entrapment zones for any bed with bed rails presently in use. 1. Review of Resident #9's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 03/09/23, showed the following: -Severely impaired cognition; -Required extensive assistance from one staff for bed mobility. Observations on 05/01/23, at 6:17 A.M., showed the resident lay in bed sleeping with his/her feet hanging to the side. The 1/2 bed rail on the right side of the resident's bed was in the raised position. Observation on 05/03/23, at 5:26 A.M., showed the resident lay in bed. The 1/2 bed rail on the right side of the resident's bed was in the raised position. Review of the resident's medical record showed no evidence the facility obtained measurements or completed an evaluation for entrapment zones between the resident's bed and the bed rail. Based on observation, interview, and record review, the facility failed to complete inspections of bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for five residents (Resident #9, #13, #18, #34 and #162), who used bed rails, in a review of 19 sampled residents. The facility census was 59. During interview on 05/04/23, at 1:00 P.M., the Quality Assurance (QA) Nurse said the facility did not have a policy in place for measuring the entrapment zones or a regular maintenance program to identify areas of possible entrapment. Review of the Food and Drug Administration's (FDA) Guide to Bed Safety, Bed Rails in Hospitals, Nursing Homes and Home Health Care: The Facts, revised April 2010, showed the following: -Between 1985 and 1/1/09, 803 incidents of patients caught, trapped, entangled or strangled in beds with rails were reported to the U.S. FDA; -Of those reported, 480 died and 138 had non-fatal injuries; -Most patients were frail, elderly or confused; -Potential risks of bed rails may include strangulation, suffocation, bodily injury or death when patients or parts of their body are caught between rails and mattress, more serious injury from falls when patients climb over rails, skin bruising, cuts and scrapes, feeling isolated or unnecessarily restricted, and preventing patients, who are able to get out of bed, from performing routine activities such as going to the bathroom or retrieving something from a closet.

Based on observation, interview, and record review, the facility failed ensure food items were labeled, dated, covered or discarded when expired; failed to ensure staff utilized sanitary practices when handling ready to eat food items; and failed to ensure staff wore hair restraints to cover exposed hair. The facility census was 59. 1. Review of the undated facility policy, Food Labeling and Dating and Closure, showed the following: -All foods placed in dry storage, refrigerated and freezer units must be dated with date opened/placed, use by date (UBD) and initials and sealed with an approved tie; -Dietary staff and/or any staff member placing items for dietary or resident must follow this procedure; -Dietary staff and/or any staff member receiving food from family for a resident must follow this procedure and inform the family that the item will only be kept for three days; -Any item placed in dry storage, refrigerated and freezer units that has been opened must be sealed (not just folded over) to ensure freshness and have a label (you may write with marker if packaging allows) with the date opened/placed, UBD and your initials. Day 1 is the day opened or made-add six days. Example: 3/15 you opened pears UBD would be 3/21; - Items will be discarded the day after the UBD or label is not properly filled out. Observation on 5/1/23 at 10:31 A.M. of the walk-in cooler showed the following: -A plastic container appeared to contain shredded carrots and was dated 4/19, and labeled Friday supper; -An open package of raisins was undated. The open edge of the package was folded over but unsealed; -A large plastic bag containing two bagels was sealed and undated; -A container of pancake batter was dated 4/28. Observation on 5/1/23 at 10:34 A.M. of the dry storage room in the kitchen showed an individual plastic bag of white cheddar popcorn was open to air and sat on the bottom shelf of a silver cart. The popcorn was not dated or sealed. Observation on 5/1/23 on 10:40 A.M. of the refrigerator located in the east dining room showed two clear round containers sat in the refrigerator door and were labeled Fr bar (fruit bar) and were dated 4/22. Observation on 5/2/23 at 9:57 A.M. in the refrigerator and on counter tops located in the west dining room kitchenette, showed the following: -A clear plastic container held meat, green beans and potatoes and was labeled with a resident's name and was undated; -A large pizza box contained half of a pizza and was labeled with a first name and was undated; -A large plastic container with a label that read Baby Spinach contained five chocolate chip cookies. The container was labeled with a resident name and was undated; -A pink rectangular box of almond macaroon cookies contained three cookies inside and was open to air and unsealed. The box was undated; -One hot dog bun sat inside a zippered plastic bag on top of a container of chocolate chip cookies. The hot dog bun was undated. 2. Review of the undated facility policy, Read to Eat Food, showed the following: -Guideline: To ensure ready to eat food is handled properly to avoid cross contamination; -Definition: Ready to eat food is defined as food that will not be cooked or reheated before serving; -Examples: bread items, cookies, donuts, fresh vegetables, and many more; -Dietary staff preparing, serving or delivering food to residents must use utensils, tongs, deli paper or sanitary gloves when dealing with a ready to eat food item. -Nursing staff or any other person helping to prepare, serve, deliver, or assist with feeding must use utensils, tongs, deli paper or sanitary gloves when dealing with a ready to eat food item; -All staff assisting a resident with cutting their food must use utensils, tongs, deli paper or sanitary gloves. No bare hands may touch the food a resident will be eating. Observation in the kitchen on 05/01/23 at 6:15 A.M., showed the following: -Dietary Staff O did not wear gloves while preparing the donuts for breakfast; -As he/she put icing on the donuts, three of the donuts slid towards the end of the plate. He/She touched and moved the donuts back onto the plate with this/her bare fingers. Observation on 05/01/23, at 7:40 A.M., showed the following: -Nursing Assistant (NA) L fed Resident #44 his/her breakfast; -NA L picked up half the donut with his/her bare hand, and gave it to the resident to eat; -NA L coughed into his/her left hand and he/she assisted the resident to eat. He/She did not perform hand hygiene; -NA L picked up the other half of the donut with his/her bare hand, and gave it to the resident to eat. -NA L did not perform hand hygiene as he/she fed the resident. Observation on 05/01/23, at 12:24 P.M., showed the following: -Activity Aide M fed Resident #44 his/her lunch; -Activity Aide M touched the resident's biscuit with his/her bare hand as he/she put butter and jelly on the biscuit; - Activity Aide M did not perform hand hygiene prior to or during assisting the resident to eat. During interview on 05/04/23, at 1:45 P.M., NA L said the following: -He/She fed the resident breakfast on 5/1/23; -He/She was not wearing gloves when feeding the resident; -He/She did not perform hand hygiene when feeding the resident; -He/She should not touch resident's food with bare hands. During interview on 05/11/23, at 6:12 P.M., Activity Aide M said he/she should not touch resident's food with a bare hand. During an interview on 5/2/23 at 10:08 A.M., Dietary Staff O said he/she would use tongs when handling ready to eat food and denied touching the donuts with his/her bare hands. 3. Review of the undated facility policy, Hair Restraints, showed the following: -Guideline: Hair restraints shall be worn by all dietary staff when in food production areas, dishwashing areas or when serving food; -Procedure: -1. Dietary staff shall wear hair restraints in all food production areas, dishwashing areas or when serving food; -2. Hair restraints, hats, and/or beard guards shall be used to prevent hair from contacting exposed food. Facial hair is discourage. Any facial hair that is longer than the eyebrow shall require coverage with a beard guard in the food production areas, dishwashing areas or when serving food; -3. Non-dietary staff must follow guidelines and red lines when entering the kitchen. Observation on 5/1/23 between 11:54 A.M. and 1:03 P.M. during the lunch meal service showed Dietary Staff P stood over the steam table and plated desserts and a biscuit on residents' meal trays. His/Her hair bangs were not covered with a hair restraint and were on the outside of the hair net. During an interview on 5/2/23 at 8:55 A.M., the dietary manager said the following: -The date on the item was the use by date. The item should be discarded by the following day; -The food items prepared for the next day should have been discarded if not used; -The bag of raisins should have been sealed and dated when opened; -The opened popcorn bag on the cart shouldn't have been stored there and most likely belonged to staff and should have been discarded; -The container labeled fruit bar should have been discarded on 4/22; -The pizza in the west dining room refrigerator had been there since 4/28; -Staff go through the kitchen refrigerators and refrigerators outside of the kitchen either weekly or biweekly; -Any dietary staff member that handled ready to eat food should wear gloves or use a utensil; -He/She was unaware there were items that needed to be discarded in these areas; -Hair nets should cover all hair on a person's head. Dietary Staff P tended to leave his/her bangs outside the hair net and his/her bangs needed to be covered with a hair net.

Based on observation, interview, and record review, the facility failed to administer insulin according to the manufacturer's recommendations for one resident (Resident #4), in a review of 13 sampled resident. The failure had the potential to result in the resident not receiving the full dose of ordered insulin. The facility census was 65. 1. Review of the Novolog FlexPen information, provided by the director of nursing (DON), showed the following: -For prefilled pen injectors, prime the needle before each injection with two units of insulin; -Once injected, hold the pen device in the skin for a count of six after the dose dial has returned to zero units before the needle is removed to ensure the full dose has been administered. 2. Review of Resident #4's physician orders for September 2019, showed the following: -Novolog 100 units/milliliter (ml) 10 units subcutaneously (under the skin) twice a day at 6:00 A.M. and 11:00 A.M.; -Novolog 100 units/ml 15 units subcutaneously once daily in the evening at 4:00 P.M.; -Novolog 100 units/ml subcutaneously before meals if blood sugar result was between 150-199 milligrams(mg)/deciliter(dl), give two units subcutaneously. Observation on 9/16/19 at 4:30 P.M. showed the following: -Registered Nurse (RN) C checked the resident's blood sugar which was 181 mg/dl; -RN C dialed the dose selector of the resident's Novolog FlexPen to 17 units (15 scheduled units and two units per the sliding scale); -RN C did prime the needle of the Novolog FlexPen with 2 units on insulin prior to selecting the desired dose; -RN C administered the Novolog he/she prepared into the resident's abdomen without priming the insulin pen. Observation on 9/18/19 at 6:10 A.M., showed the following: -RN C checked the resident's blood sugar which was 194 mg/dl; -RN C dialed the dose selector of the resident's Novolog FlexPen to 12 units (10 scheduled units and two units per the sliding scale); -RN C did prime the needle of the Novolog FlexPen with 2 units on insulin prior to selecting the desired dose; -RN C administered the Novolog he/she prepared into the resident's abdomen without priming the insulin pen. During interview on 9/18/19 at 6:12 A.M., RN C said the Novolog FlexPen primes itself when he/she pushed it up against the skin. The pen clicks and then she/he administers the insulin. He/She has been doing it this way the past three years. If he/she dialed up a couple of units to waste it, then they wouldn't know how much was left in the insulin pen. During interview on 9/19/19 at 11:15 A.M., the DON said she was unaware of any instructions with priming the Novolog flex pen before administration. She had not received any updates which said to prime before the beginning of each administration. She said she did prime a new flex pen when opened because there was a definite bubble at the tip.

Based on interview and record review, the facility failed to maintain a comprehensive infection control program designed to help prevent the development and transmission of water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease), by failing to implement their policy or to complete a risk assessment to determine susceptible locations for the growth of such organisms. The facility census was 65. 1. Review of the facility's Legionella Prevention Policy, dated 2017, showed the following: -Legionnaire's disease is a bacterial disease commonly associated with water-based aerosols and often a result of poorly maintained air conditioning cooling towers and potable water systems; -Only those who are directly exposed to the contaminated aerolized water source can get the disease; -Exposure to Legionella bacteria can cause mild respiratory illness, or severe pneumonia-like symptoms, and if not treated promptly with the appropriate antibiotics, can lead to death; -The risk for the facility is deemed low, as the infrastructure affected by potential Legionella outbreaks is modern, up to date, and well maintained; -Multiple commercial devices are available to detect Legionella contamination. These devices include a validation line to ensure the test sample was adequate; -Testing, in accordance with the selected test kit, will occur semiannually, or when a possible outbreak is being investigated; -Water will be stored at 140 degrees F and delivered at a minimum of 122 degrees F to all outlets; -Where the building cannot be retrofitted, consider periodically increasing the temperature to 158 degrees F or chlorination followed by flushing; -Inspect systems annually to ensure equipment functions properly; -Maintain cold water lines at 68 degrees F; -Eliminate water tanks that allow water to remain uncirculated for long periods or design them to reduce storage time to a day or less. They should also be covered and protected from temperature extremes; -Prevent cross contamination of the domestic cold water system with other systems; -Use hyperchlorination to eradicate Legionella if the cold water lines have significant contamination. 2. Review of the Centers for Medicare and Medicaid Services (CMS), Survey and Certification memo, revised 7/6/18, showed the following: -CMS expects certified healthcare facilities to have water management policy and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems; -Facilities must have water management plans and documentation that, at a minimum, ensure each facility: -Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility water system; -Develops and implements a water management program that considers The American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) industry standard and the Centers for Disease Control (CDC) toolkit; -Specify testing protocols and acceptable ranges for control measures. 3. During interview on 9/19/19 at 9:00 A.M., the administrator said they had not implemented their policy for Legionella prevention. The facility had not completed a risk assessment to identify susceptible locations for Legionella.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the necessary care and services based on professional standards of practice for three residents (Residents #35, #33 and #62), in a review of 13 sampled residents, to maintain or improve their highest practicable physical and mental well-being, by failing to monitor and document bowel movements and administer medications as appropriate to prevent constipation. The facility census was 65. 1. Review of an email received by the facility's assistant administrator on 9/24/19, regarding the facility's Bowel Protocol, showed the following: -Day three without a bowel movement: Milk of Magnesia (laxative to relieve occasional constipation); -Day four without a bowel movement: Suppository; -Day five without a bowel movement: Enema. 2. Review of Resident #35's Care Plan, with an onset date of 11/7/18, showed the following: -The resident required extensive assistance with most activities of daily living; -Assist the resident to toilet routinely every two hours. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 4/25/19, showed the following: -Diagnoses included Alzheimer's and dementia; -Cognition was severely impaired; -Required extensive assistance of two or more staff for transfers; -Dependent on two or more staff for locomotion and toilet use; -Always incontinent of bowel. Review of the resident's physician order sheet (POS) for July 2019 showed the following: -Milk of Magnesia 30 milliliters (ml) by mouth daily as needed (PRN) for constipation; -Polyethylene glycol (laxative used to treat occasional constipation or irregular bowel movements), take half a capful by mouth daily. Review of the resident's bowel movement log for July 2019 showed there were no bowel movements documented between 7/1/19 and 7/6/19 (six days). The resident had a bowel movement on 7/7/19. Review of the resident's Medication Administration Record (MAR) for July 2019 showed the following: -Staff did not administer as needed MOM between 7/1/19 and 7/6/19; -On 7/17/19, staff administered the PRN MOM for complaints of constipation. There was no follow up documentation found in the resident's record regarding the effectiveness of the PRN MOM. Review of the resident's bowel movement log for July 2019 showed the following: -On 7/17/19 at 4:37 P.M., the resident had a small formed bowel movement; -No bowel movement documented 7/18/19 through 7/24/19 (seven days). Review of the resident's MAR for July 2019 showed no evidence staff administered PRN MOM 7/18/19 through 7/24/19. Review of the resident's bowel movement log for July 2019 showed the following: -On 7/25/19 at 10:44 A.M., the resident had a medium sized, loose bowel movement; -On 7/25/19 at 7:49 P.M., the resident had an extra-large, formed bowel movement; -There were no bowel movements documented for the resident for July after 7/25/19. Review of the resident's nurse's note, dated 7/29/19 at 1:26 P.M., showed the resident had been overly fatigued throughout the morning. The resident slept through breakfast and got up for lunch but was still sleeping. Staff said the resident was fatigued yesterday as well. Staff would continue to monitor the resident. Review of the resident's bowel movement log for August 2019 showed the following: -No bowel movement documented on 8/1/19; -On 8/2/19 at 10:55 P.M., the resident had an extra-large, watery, stool. Review of the resident's nurse's notes, dated 8/2/19, showed the following: -At 9:26 A.M., the Certified Nurse Assistant (CNA) called the nurse to check on the resident. Upon entering the resident's room, the nurse noted the resident's abdomen was very distended. The resident was pale in color. The resident had a large emesis at 12:00 A.M. The nurse inserted a urinary catheter in the resident due to his/her distended abdomen and obtained a 100 ml of urine. The resident's lower left abdominal quadrant had bowel sounds present. All other abdominal quadrants had sluggish bowel sounds. The resident denied pain or discomfort. The nurse would wait for the administrator and director of nursing (DON) to come to the facility to talk over what to do. After talking with everyone, it was decided to draw blood for laboratory testing and obtain an abdominal X-ray (imaging using electromagnetic waves to show pictures of the inside of the body), as ordered by the physician. The resident had another emesis at 6:15 A.M. New orders were received for magnesium citrate due to the resident not having a bowel movement for multiple days. The nurse began administering the magnesium citrate as ordered and awaiting the abdominal X-ray; -At 4:51 P.M., the nurse continued to administer the magnesium citrate to the resident throughout the shift. The abdominal X-ray results were received with impression being distended loops of small bowel with a small bowel obstruction not entirely excluded. The physician was notified and an order was received to make the resident nothing by mouth (NPO) status with only sips of water and ice chips. The resident could follow-up at the emergency room for decompression. The nurse called the resident's responsible party about the resident's condition. The resident's responsible party said if the resident has not had adequate results by tomorrow, then he/she would like the resident to go to the emergency room for evaluation and treatment. The nurse notified the DON; -At 5:19 P.M., the nurse administered an enema to the resident, as protocol allowed, per the DON, to assist with constipation as the resident had only small results from the magnesium citrate; -At 8:40 P.M., the resident had several large bowel movements after a hard feces mass was expelled. The resident had several loose watery stools. The resident's abdomen was less distended and the resident denied any discomfort. Review of the resident's MAR for August showed staff administered magnesium citrate on 8/2/19. There was no documentation on the MAR regarding the administration of the enema. Further review of the resident's bowel movement log for August 2019 showed the following: -No bowel movement documented on 8/4/19 through 8/10/19 (seven days); -On 8/11/19 at 2:27 P.M., the resident had a large watery stool; -On 8/12/19 at 3:51 A.M., the resident had a large watery stool. Further review of the resident's MAR showed no documentation staff administered the PRN MOM during the month of August 2019. Review of the resident's bowel movement log for September 2019 showed the following: -On 9/4/19 at 11:12 P.M., the resident had a large watery stool (previous bowel movement on 8/29/19, four days prior); -On 9/5/19 at 12:03 P.M., the resident had a large loose stool. Review of the resident's MAR for September 2019 showed on 9/5/19, staff held the resident's daily scheduled dose of polyethylene glycol due to the resident having diarrhea. Review of the resident's bowel movement log for September 2019 showed no bowel movement documented on 9/6/19 through 9/11/19 (six days). Review of the resident's bowel movement log for September 2019 showed no evidence staff administered the PRN MOM from 9/1/19 to 9/19/19. 3. Review of Resident #33's physician order sheet (POS) for July 2019 showed the following: -Polyethylene glycol (laxative used to treat occasional constipation or irregular bowel movements), one capful with water or juice every Sunday, Tuesday, Thursday, and Saturday; -May remove fecal impactions as needed (PRN); -Sodium phosphate enema PRN. Review of the resident's bowel movement log for July 2019 showed no documented bowel movement on 7/8/19 through 7/15/19 (eight days). Review of the resident's quarterly MDS, dated [DATE], showed the following: -Diagnoses included dementia, anxiety, and depression; -Short-term and long-term memory problems; -Dependent on two or more staff for transfers and toilet use; -Always incontinent of bowel. Further review of the resident's bowel movement log for July 2019 showed no documented bowel movement on 7/18/19 through 7/24/19 (seven days). Review of the resident's MAR for July 2019 showed staff did not administer the sodium phosphate enema, or any PRN medications to address constipation. Review of the resident's bowel movement log for August 2019 showed on 8/6/19 the resident had a medium formed stool. Review of the resident's MAR for August 2019 showed staff held the resident's polyethylene glycol on 8/6/19 due to loose stool. Review of the resident's bowel movement log for August 2019 showed no documented bowel movement from 8/8/19 through 8/14/19 (seven days). Review of the resident's MAR for August 2019 showed staff did not administer the sodium phosphate enema or any PRN medication to address constipation. Review of the resident's bowel movement log for August and September 2019 showed no documented bowel movement on 8/29/19 through 9/11/19 (13 days). Review of the resident's MAR for 9/1/19 through 9/19/19 showed staff did not administer the sodium phosphate enema, or any PRN medication to address constipation. 4. Review of Resident #62's annual MDS, dated [DATE], showed the following: -Diagnoses included dementia, anxiety, and depression; -Cognition was severely impaired; -Required limited assistance of one staff for transfers; -Required extensive assistance of one staff for toilet use; -Always continent of bowel. Review of the resident's physician order sheet (POS) for July 2019 showed no orders for scheduled or as needed stool softeners or laxatives. Review of the resident's bowel movement log for July 2019 showed the following: -No documented bowel movement on 7/7/19 through 7/14/19 (eight days); -No documented bowel movement on 7/23/19 through 7/29/19 (seven days). Review of the resident's medication administration record (MAR) for July 2019 showed no documentation staff administered any stool softeners or laxatives for the month. Review of the resident's POS for August 2019 showed no orders for scheduled or as needed stool softeners or laxatives. Review of the resident's bowel movement log for August 2019 showed no documented bowel movements from 8/15/19 through 8/25/19 (11 days). Review of the resident's MAR for August 2019 showed no documentation staff administered any stool softeners or laxatives for the month. Review of the resident's POS for September 2019 showed no orders for scheduled or as needed stool softeners or laxatives. Review of the resident's bowel movement log for 9/1/19 through 9/19/19 showed no documented bowel movements from 9/2/19 through 9/6/19 (five days). Review of the resident's MAR for 9/1/19 through 9/19/19 showed no documentation staff administered any stool softeners or laxatives during that time frame. 5. During an interview on 9/19/19 at 9:52 A.M., Registered Nurse (RN) A said the nurse aides, or any nursing staff who assisted a resident, could document a bowel movement in the electronic record. RN A looked up the bowel movement logs on each resident in the morning to see who had not had a bowel movement. Sometimes, the night shift nurse would make a list of residents who had not had a bowel movement, but not consistently. RN A would ask a resident who was alert and oriented and had no documented bowel movement for two or three days if they were having any issues with constipation and tried to remind the aides to monitor for and document bowel movements. If a resident had not had a bowel movement in three days, staff should start by giving prune juice, MOM, or polyethylene glycol if the resident had an order to do so. If the resident did not have a PRN order for constipation in place, staff should call the physician and get something. If the resident still had not had a bowel movement by the following day, staff should try something more powerful like an enema, a suppository, or magnesium citrate. RN A thought there were standing physician orders in place for residents for these medications. Resident #35 had issues with constipation in the past and it would come and go. The resident seemed to go from one extreme of being constipated to the other extreme of having diarrhea. During an interview on 9/19/19 at 10:10 A.M., Certified Medication Technician (CMT) B said the charge nurse usually printed out the residents' bowel movement logs and gave them to the CMTs. If the resident had not had a bowel movement in three days, he/she would look to see if the resident had an order in place for a PRN laxative. If there was no order, he/she would start by giving the resident prune juice. If the resident did not have any results, staff should let the charge nurse know. During an interview on 9/19/19 at 1:15 P.M., the director of nursing (DON) said CNAs documented resident bowel movements in the electronic record. Every morning, the charge nurse should print out a bowel movement list and work on it together with the CMTs. Staff should first check with the CNAs and the resident if able to see if a bowel movement had missed being documented. If a resident had no bowel movement for three days, staff should administer MOM or a different PRN if there was an order in place. If there were no results by the next day, staff should administer a suppository and if there were still no results, administer an enema. The DON would expect staff to follow up with documentation after any PRN medication was administered.