Based on observations, interviews, and record review, the facility failed to assure staff provided catheter (a sterile tube inserted into the bladder to drain urine) care in a manner to prevent a urinary tract infection(UTI) or the possibility of a UTI for one of the 12 sampled residents, (Resident #1). The facility census was 37. Review of the facility's undated policy for indwelling urinary catheter, showed, in part: - Position the resident on their back; - Wash around the catheter insertion site and then from the tip of the skin fold down to the body, including all skin folds; - Cleanse approximately 1/3 of catheter tubing from the insertion site. 1. Review of Resident #1's care plan, revised 5/28/24 showed: - The resident had an indwelling catheter related to obstructive uropathy (a urinary tract condition that occurs when urine flow is blocked, causing urine to back up into the kidneys). Position the catheter bag and tubing below the level of the bladder and away from entrance room door. Change the 18 french (fr.) catheter monthly. Monitor, record, report to physician for signs and symptoms of a UTI; Focus: bowel and bladder. Change catheter monthly and as needed. The resident is dependent on staff for all toileting needs. The resident is incontinent of bowel and wears incontinent briefs. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/25/24 showed: - Cognitive skills for daily decision making severely impaired; - Dependent on the assistance of staff for toilet use, dressing, personal hygiene and transfers; - Always incontinent of bowel; - Diagnoses included cancer, renal insufficiency (when the kidneys are not functioning properly and may need treatment or further evaluation), obstructive uropathy, dementia (inability to think), and depression. Review of the resident's physician order sheet (POS), dated August, 2024 showed: - Order date: 8/12/24 - Urinalysis (UA) reflux to culture (a test that includes a dipstick urinalysis, microscopic examination, and culture); - Order date: 5/30/24 - urinary catheter care every shift. Review of the resident's UA, dated 8/13/24 showed: - The presence of bacteria indicative of a possible UTI; - Keflex (antibiotic used to treat UTIS), 500 milligrams (mg.) three times daily for ten days per the physician. Observation on 8/27/24 at 1:39 P.M., showed: - Certified Nurse Aide (CNA) A and Nurse Aide (NA) A removed the residents pants and unfastened the incontinent brief; - CNA A did not separate and clean all areas of the front skin folds and used the same area of the wipe to clean different areas of the front skin folds; - CNA A and NA A turned the resident on his/her side; - CNA A wiped from front to back multiple times with fecal material on each wipe; - CNA A did not clean the catheter tubing. During an interview on 8/28/24 at 10:52 A.M., NA A said: - We should separate and clean all the skin folds; - We should not use the same area of the wipe to clean different areas of the skin; - The catheter tubing should be cleaned with catheter care. During an interview on 8/28/24 at 10:55 A.M., CNA A said: - He/she should not have used the same area of the wipe to clean different areas of the skin; - He/she should have separated and cleaned all the skin folds; - He/she should have cleaned the catheter tubing with catheter care. During an interview on 8/29/24 at 11:30 A.M., the Director of Nursing (DON) said; - Staff should not use the same area of the wipe to clean different areas of the skin. It should be one wipe, one swipe; - Staff should separate and clean all the skin folds; - The catheter tubing should be cleaned during catheter care.

Based on observations, interviews and record review, the facility failed to follow their policy for storage of medications when they stored food and medication in the medication refrigerator. This had the potential to affect all the residents in the facility. The facility census was 37. Review of the facility's undated policy for storage of medications showed, in part: - The facility shall store all drugs and biologicals in a safe, secure, and orderly manner; - Medications requiring refrigeration must be stored in a refrigerator per the manufacturer recommendation and located in the drug room at the nurse's station or other secured location; - Medications must be stored separately from food and must be labeled accordingly. 1. Observation and interview on 8/27/24 at 11:46 A.M., of the medication room showed: - The medication refrigerator had at least 15 containers of applesauce and nine containers of Med Pass (oral nutritional supplement) and two small containers of tomato juice; - Licensed Practical Nurse (LPN) A said it was used for medication pass. During an interview on 8/29/24 at 11:30 A.M., the Director of Nursing (DON) said the Med Pass, applesauce and tomato juice could be in the refrigerator as long as it is separated from the medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3.Review of Resident #31's Quarterly MDS, dated [DATE] showed: - admission to the facility on 1/13/23 - BIMS score of 15, indicating no cognitive deficit. - Diagnoses include: Parkinson's Disease (a brain disorder that affects balance and coordination), Hypertension (high blood pressure), Diverticulosis of Intestine (infection that affects the colon) Review of the resident's medical record showed: - No orders on the POS (Physician Order Sheet) were present as of 8/27/24 for resident to self-administer medications. - Physician orders for Refresh Ophthalmic Solution- staff to instill 3 drops in both eyes every 4 hours as needed for dry eyes. - Sinemet Oral Tablet give 1.5 tablets by mouth four times a day for Parkinsons. - The facility staff had not documented a resident medication self-administration assessment. Review of 8/24 ADL (Activities of Daily Living) care plan showed no care plan completed for the resident to self-administer of medications. During an observation and interview on 8/26/24 at 9:18 A.M. showed: - A medicine cup of pills, one pink and one blue pill on the resident's bedside table. One 1.5 oz bottle of Equate brand nasal spray and one bottle of Refresh Tears 15 ml on the bedside table. - The resident said the staff left the medicine cup on his/her bedside table to take at 9:00 A.M. for Parkinson's Disease. The Refresh Tears need to be administered by the staff on Resident's request since he/she cannot self-administer the eye drops. The nasal spray is administered by the resident as needed without staff assistance. During an interview on 8/29/24 at 9:10 A.M., the Administrator said Resident #31 was the only resident that self-administers his/her own medications. During an interview on 8/29/24 at 9:23 A.M., the Director of Nursing said Resident #31 had eye drops that he/she could self-administer; During an interview on 8/29/24 at 11:30 A.M. the Director of Nursing (DON) said he/she expects that all medications held by a resident in their room are to be care planned and authorized by a Doctor's order. Based on observation, interview, and record review, the facility failed to ensure three sampled residents (Resident #6, #34, and #31) were assessed as safe to self-administer medications when medications were left at bedside table unattended by licensed staff. This affected three of the twelve sampled residents. The facility census was 37. Review of facility policy, self-administration of medications, dated March 2017, showed: -Staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. -In addition to general evaluation of decision-making capacity, the staff and practitioner will perform a more specific skill assessment, including the resident's: -ability to read and understand medication labels; -comprehension of the purpose and proper dosage and administration time of his or her own medications; -ability to remove medications from a container and to ingest and swallow (or otherwise administer) the medication; -ability to recognize risks and major adverse consequences of his or her medications. -Self-administered medications must be stored in a safe and secure place, which is not accessible by other residents. -Staff and practitioner will periodically (for example, during quarterly MDS reviews) reevaluate a resident's ability to continue to self-administer medications. 1. Review of Resident #6's Quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 5/30/24, showed: -He/She was cognitively intact; -He/She had a hearing aide, minimal difficulty with hearing; -He/She had clear speech; -He/She made self understood and usually understood others; -He/She required partial/moderate assistance with all activities of daily living, -Diagnoses included: High blood pressure, heart failure, diabetes (too much sugar), depression, asthma (condition making it difficult to breathe, neuropathy (condition resulting in nerves that are damaged resulting in pain, numbness, weakness, or tingling in one or more parts of the body), generalized muscle weakness, hearing loss, gastroparesis (a chronic condition that affects the stomach's motility), aphasia (inability to swallow) Review of care plan, dated 3/29/24, showed: -Be alert for any drug or medication interactions including over the counter medications; -Observe for signs of confusion, drowsiness, poor coordination due to low fluid intake; -Nurse to give medication as ordered by physician; -Medications at bedside were not care planned. Review of the physician's orders, dated 8/27/24, showed: -Ordered 1/22/24, Biofreeze Professional Gel 5%, a menthol topical analgesic), apply to affected area topically as needed for pain, may keep at bedside. -Ordered 10/17/23, Spray to clean eyelids/lashes two times per day for eyes; -No physician orders for vapor rub; -No physician orders for cough drops. Review of the resident's electronic medical record showed no assessment completed by the facility staff for the safety of self-administration of medications. Observation on 8/27/24 at 4:41 P.M. showed resident had medications at bedside including biofreeze, halls cough drops, and vapor rub. During an interview on 8/27/24 at 4:41 P.M. resident said: -He/She did not do his/her own medications; -His/Her right elbow had been hurting for some time and the biofreeze helped relieve his/her pain; -He/She applied biofreeze when he/she went to bed. Observation on 8/28/24 at 11:17 A.M., showed that the resident had a container of vapor rub by side of bed, saline adhesive for sting free skin barrier to prevent skin friction and protective barrier. During an interview on 8/29/24 at 9:23 A.M., the Director of Nursing said he/she was not sure if Resident #6 self-administered medications. 2. Review of Resident #34's Quarterly MDS, dated [DATE], showed: -He/She was cognitively intact; -He/She felt down or depressed or hopeless 2-6 days per week; -He/She required set up or clean up assistance with eating; -He/She was independent with oral care, toileting, upper and lower body dressing, -Diagnoses included: Dementia (condition that causes a decline in brain function and impairment of a person's ability to think, remember, and make decisions), Parkinson's disease (a chronic, progressive brain disorder that causes movement problems), malnutrition, depression, muscle weakness, and need for assistance with personal care. Review of care plan, dated 2/13/24, showed administer medications as ordered by physician. Review of physician's orders, dated 8/27/24, showed: -Ordered 2/22/24, artificial tears ophthalmic solution 1.4%, polyvinyl alcohol, instill 2 drops in both eyes every 8 hours as needed for dry eyes both eyes; -No orders for any medications at bedside. Review of the resident's electronic medical record showed no assessment completed by facility staff for the self-administration of medications by the resident. Observation on 8/26/24 at 9:53 A.M. showed xlldra eye drops at bedside, 10 vials of unmarked clear tubes that appeared like breathing treatments vials were sitting in a metal tin container beside resident's chair, open container of Vaseline, and nasal spray. During an interview on 8/29/24 at 9:23 A.M., Director of Nursing said Resident #34 did not self-administer medications. During an interview on 8/28/24 at 11:14 A.M., LPN A said: -Medications were not allowed to be left at residents bedside unless a doctor gave facility an order; -Residents who have medications at bedside should have a self-administration of medication assessment completed; -He/She was not aware of any resident who had an order to keep his/her medications at bedside or who had been assessed. During an interview on 8/29/24 at 9:10 A.M., Administrator said: -There was one or two residents who self-administer medications; -He/She was not sure which residents were able to self-administer medications; -He/She did not know if self-administration assessments were done on those residents; -Self-Administration assessments were to be done on residents who self-administer their medications on a quarterly basis; -Assessments for self-administration of medications would be found on the assessments tab in the electronic medical record; -Resident #31 was the only resident that self-administers his/her medications. During an interview on 8/29/24 at 9:23 A.M., Director of Nursing said: -He/She was aware of a couple of residents who self-administer mediations; -Resident #31 had eye drops that he/she could self-administer; -He/She had not completed any self-administration of medication assessments on those residents; -He/She did not know if self-administration of medications had been done prior to his/her taking on Director of Nursing role.

Based on interviews and record review, the facility failed to consider the views of the resident council and act promptly upon grievances and recommendations made by the group concerning issues of resident care and life in the facility when the facility failed to demonstrate their response and rationale for such responses. The facility additionally failed to maintain documentation of attempts to resolve concerns, or the facility's communication to the council on follow up actions. This affected eight of eight residents serving on the resident counsel and potentially other residents of the facility. The facility census was 37. Review of facility policy, Resident Council, 4/2017, showed: - A Resident Council Response Form will be utilized to track issues and their resolution. The facility department related to any issues will be responsible for addressing the item(s) of concern. The Quality Assurance and Performance Improvement (QAPI) Committee will review information and feedback from the Resident Council as part of their quality review. Issues documented on council response forms may be referred to the QAPI Committee, if applicable. Review of facility policy, Resident Rights, undated, showed: - Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: voice grievances to the facility, or other agency that hears grievances, without discrimination or reprisal and without fear of discrimination or reprisal; have the facility respond to his or her grievances. 1. During a group interview on 8/28/24 at 2:00 P.M., eight of eight residents stated: -They did not have access to grievance forms or know about the Council Response Form for receiving feedback on grievances. - They did not know who the Grievance Officer was at the facility. - They did not receive formal feedback between meetings or at the start of next month's meeting about each of their past grievances. Review of resident council minutes, dated June 2024- August 2024, showed: -On 6/5/24: Old minutes were read with no concerns noted. No council president assigned, and the meeting was led by the Activity Director. New Business showed: request for Adult Daily Living (ADL) support with glasses, complaint about staff member being rude and not helping with ADL toileting, complaint regarding the lack of clean towels and trash not being emptied. - There is no facility responses to review for past complaints or requests. -On 7/3/24: Old minutes were read with no concerns noted. No council president assigned, and the meeting was led by the Activity Director. New Business showed: two food item suggestions for the menu. - There is no facility responses to review for past complaints or requests. -On 8/6/24: Old minutes were read with no concerns noted. No council president assigned, and the meeting was led by the Activity Director. New Business showed: one complaint about medications not being administered in a timely manner and a resident feeling that they are treated differently by staff if he/she makes a staff complaint, two complaints about food being overcooked or burnt. - There is no facility responses to review for past complaints or requests. During an interview on 8/28/24 at 3:30 P.M., Activity Director said the facility does not formally reply to the resident council on resolutions or steps the facility took to address resident issues. The feedback process is informal and not tracked by the facility.

Based on interview and record review, the facility failed to obtain a signature from the resident or or resident's legal representative on the Notice of Medicare Non-Coverage (NOMNC) and the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) forms prior to discharging from Medicare services for two residents (Resident #23 and #13) out of three sampled residents. The facility census was 37. Review of form instructions skilled nursing facility advance beneficiary notice of non-coverage (SNFABN) Form CMS-10055, dated 4/8/2014, showed: -Signature and date: The beneficiary or their authorized representative must sign the signature box to acknowledge that they read and understood the notice. The skilled nursing facility may fill in the date if the beneficiary needs help. The date should reflect the date the SNF gave therm notice to the beneficiary in-person or when appropriate, the date contact was made with the beneficiary's authorized representative by phone. If an authorized representative signs for he beneficiary, write 'rep' or representative next to the signature. If the authorized representatives signature is not clearly legible, the authorized representative's name bust be printed. If the beneficiary refuses to choose an option and/or refuses to sign the SNFABN when required, the SNF should annotate the original copy of the SNFABN indicating the refusal to sign and may list a witness to the refusal. -Basic delivery requirements: -Who may sign: Beneficiary, Beneficiary's authorized representative, legally appointed representative or guardian of the beneficiary, in case of emergency, a disinterested third party/ -Delivery requirements: Must be signed 1. Review of Resident #23's NOMNC and SNF ABN forms showed: -The resident discharged from skilled Medicare services on 8/9/24, however remained in the facility. -The NOMNC form showed documentation of a phone call to resident's durable power of attorney on 8/7/24 and a letter was mailed on 8/7/24. -The SNF ABN form showed documentation of a phone call to resident's durable power of attorney on 8/7/24 and a letter was mailed on 8/7/24. -The facility failed to get the legal representative's signature on the forms. 2. Review of Resident #13's NOMNC and SNF ABN forms showed: -The resident discharged from skilled Medicare services on 6/17/24, however remained in the facility. -The NOMNC form showed documentation of a phone call to resident's durable power of attorney on 6/12/24 and a letter was mailed on 6/12/24. -The SNF ABN form showed documentation of a phone call to resident's durable power of attorney on 6/12/24 and a letter was mailed on 6/12/24. -The facility failed to get the legal representative's signature on the forms. During an interview on 8/30/24 at 11:30 A.M., Administrator said he/she expected the beneficiary notices to be signed by the responsible party.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #17's Significant Change MDS, dated , 8/15/24, showed: - Brief interview for mental status (BIMS) score of 2, indicating the resident was severely cognitively impaired; - Diagnoses included: Reduced mobility, Amnesia (Memory Loss), Hypertensive Heart Disease with Heart Failure, Malignant Neoplasm of Uterus (Cancer). - Dependent upon staff for toileting, shower/bath, dressing, personal hygiene, and mobility. Review of Resident #17's Consent for Photo Release agreement signed by DPOA dated, 11/29/22, showed in part: - Consent to photograph which included video, still photography and any other means of recording or reproducing images for the purpose of marketing, public relations, news media, social media and employee training to promote services provided by [NAME] Heights. -There is no statement of full-time installation of a camera with sound to be placed in the Resident's room. Review of the resident's care plan dated, 8/26/24, showed: -Activities of daily living deficit and dependent on 2 staff for care. - Terminal prognosis for cancer requiring staff to provide maximum comfort for resident. - Indwelling urinary catheter which staff will change monthly, monitor and document intake and output. - Cognitive deficit of which staff will be respectful and treat resident as an adult. - Fall risk with interventions for keeping a call light within reach and for staff to keep pathways clear. -The care plan did not indicate that surveillance was being used in the resident's room. Review of the resident's medical record did not show the resident or his/her responsible party gave consent to 24 hour video monitoring with sound in the resident's room. Observation on 8/26/24 at 10:30 A.M. showed no signage that the resident's room was under 24 hour camera surveillance. Observation at 8/28/24 at 12:06 P.M. showed a video monitor at the Nurse's station displaying the resident's room with sound which could be turned up. Resident was observed in bed pulling at his/her brief and a conversation between the resident and staff could be heard from the room through the monitor at the nurses desk. Monitor is VTECH Model VM5255-22. During an interview on 8/29/24 at 11:30 A.M., the Director of Nursing (DON) said: -There is no video recorded in the resident's room, so no signs indicating camera coverage are needed. The DON also stated, that the family had requested the cameras and that it is care planned. - She did not feel there should be signs posted to indicate the use of a camera with audio surveillance in the residents room. Based on observations, interviews and record review, the facility failed to maintain the privacy of three of the 12 sampled residents, (Resident #10, #17 and #32), when staff failed to post signage at the front door or outside each sampled resident's rooms to indicate 24 hour camera surveillance was in progress and failed to obtain consents from the responsible parties of the sampled residents. The facility census 37. Review of the facility's policy for videotaping, photographing, and other imaging of residents, revised April, 2027, showed, in part: - Residents will be protected from invasion of privacy and/or abuse that might occur from photographs, videotapes, digital images, and recordings during resident care or other facility activities; - For the purpose of this policy, resident image means the likeness of a resident captured through still digital images, and recordings during resident care or other facility activities; - The facility policy did not address the use of camera surveillance, posting of camera surveillance or consents required. 1. Review of Resident #10's consent for photo release, dated 10/30/23 showed: - Consent was given to the facility to be photographed while living or visiting the facility; - The term photograph includes video, still photography (in digital or any other format) and any [NAME] means of recording or reproducing images; - The purpose of these images will be used for marketing, public relations, news media, social media and employee training to promote the services by the facility; - The consent did not address the use of camera surveillance with audio capabilities. Review of the resident's care plan, revised 4/26/24, showed: - The resident was at risk for falls. Per family request, a camera is in the room to monitor the resident for frequent falls at home; - The resident had cognitive fluctuation /dementia (inability to think); - Activities of daily living (ADL) - the resident required moderate assistance with walking with the walker in his/her room. The resident used a wheelchair most of the time and was able to propel him/herself. The resident required maximum assistance of one staff for toileting and is incontinent of bowel and bladder. The resident required moderate assistance of one staff for transfers. Review of the resident's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/29/24 showed: - Cognitive skills moderately impaired; - Required partial to moderate assistance of staff for transfers; - Dependent on the assistance of staff for toilet use and personal hygiene; - Occasionally incontinent of bowel and bladder; - Diagnoses included seizure disorder (a brain condition that causes recurring seizures), renal insufficiency (poor function of the kidneys that may be due to a reduction in blood flow to the kidneys caused by renal artery disease), and depression; - Had one fall and no injury. Review of the resident's medical record showed: - Did not have a consent signed by the responsible party for 24 hour camera surveillance. Observation on 8/26/24 at 10:59 A.M., showed: - There was a baby monitor on the resident's dresser; - Did not have a sign outside the resident's room to indicate there was camera surveillance. Observation on 8/28/24 at 12:09 P.M., showed: - There was a monitor at the nurse's desk which showed the resident in his/her room; - It was a VTECH monitor Model L:VM818HD PU. - The volume on the monitor was able to be adjusted and staff could be heard talking in the resident's room; During an interview on 8/28/24 at 12:21 P.M., Licensed Practical Nurse (LPN) said: - They had two baby monitors at the nurse's station and they used them for the resident's who were a fall risk; - The monitors had audio and staff can hear what is being said in the resident's room. 2. Review of Resident #32's consent for photo release, doted 9/26/23, showed: - Consent was given to the facility to be photographed while living or visiting the facility; - The term photograph includes video, still photography (in digital or any other format) and any [NAME] means of recording or reproducing images; - The purpose of these images will be used for marketing, public relations, news media, social media and employee training to promote the services by the facility; - The consent did not address the use of camera surveillance with audio capabilities. Review of the resident's admission MDS, dated [DATE] showed: - Cognitive skills severely impaired; - Required partial to moderate assistance with toilet use, dressing and transfers; - Diagnoses included dementia (inability to think), anxiety, depression, and renal insufficiency. Review of the resident's care plan, revised 8/26/24 showed: - The resident's ADL function showed the resident required moderate assistance of one staff for transfers and toilet use; - The care plan did not address the room mate having 24 hour camera surveillance with audio capabilities. Review of the resident's medical record showed no consent from the responsible party to indicate they were aware of the roommate having 24 hour camera surveillance with audio in the shared room. Observation on 8/26/24 at 10:59 A.M., showed: - The resident's roommate had a baby monitor on the resident's dresser; - Did not have a sign outside the resident's room to indicate there was camera surveillance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop individualized person centered comprehensive care plans for five residents when the care plan failed to address five resident's code status wishes (Resident #18, #34, #6, #8, and #25). This affected five of twelve sampled residents. The facility census was 37. Review of facility policy, care plans, comprehensive person-centered, undated, showed: -A comprehensive, person centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. -The interdisciplinary team, in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. -The care planning process will incorporate the resident's personal and cultural preferences in developing the goals of care. -Reflect on the resident's expressed wishes regarding care and treatment goals. -Identify the professional services that are responsible for each element of care. 1. Review of code status book, showed an Resident#18 had an Out of hospital do not resuscitate sheet was signed 6/23/23. Review of Resident #18's Quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 6/20/24 showed: -No cognitive status available; -He/She had unclear speech and was rarely or never understood; -He/She had highly impaired vision and wore corrective lenses; -He/She had impairment on both sides of upper extremities; -He/She was dependent on a wheelchair; -He/She was dependent for eating, oral care, toileting, bathing, upper and lower body dressing, hygiene, and all mobility; -He/She was on hospice care; -Diagnoses included: Heart failure, high blood pressure,, anxiety disorder, depression, , tendency to fall, heart disease, corneal transplant status, overactive bladder, urinary tract infections Review of physician's orders, dated 8/27/24, showed: -Ordered 3/19/24, Hospice to evaluate and treat; -Ordered 1/4/24, Do Not Resuscitate; Review of care plan, revised 6/12/24, showed: -He/She planned to stay in facility for long term care; -He/She had a terminal prognosis due to senile degeneration of brain; -His/Her comfort will be maintained through the review date; -Work with nursing staff to provide maximum comfort for resident; -Care plan did not address resident's do not resuscitate orders. 2. Review of code status book showed Resident #34 with an Out of hospital do not resuscitate sheet signed 11/22/23. Review of Resident #34's Quarterly MDS, dated [DATE], showed: -He/She was cognitively intact; -He/She felt down or depressed or hopeless 2-6 days per week; -He/She was dependent on walker or wheelchair; -Diagnoses included: Peripheral vascular disease (a condition that can cause blood vessels to narrow, block or spasm), dementia (condition that causes a decline in brain function and impairment of a person's ability to think, remember, and make decisions), Parkinson's disease (a chronic, progressive brain disorder that causes movement problems), malnutrition, depression, inflammation of gallbladder, acute cardiovascular insufficiency (a condition that occurs when there is deficiency in blood flow to the brain), restless leg syndrome (uncomfortable feeling in legs and an irresistible urge to move them), gastroesophageal reflux disease, muscle weakness, need for assistance with personal care. Review of physician's orders, dated 8/27/24, showed a physician order dated 11/22/23 to Do Not Resuscitate. Review of care plan, revised 2/13/24, showed: -He/She planned to stay in facility for long term care. -His/Her code status was not addressed. 3. Review of code status book showed Resident #6 with an Out of Hospital Do Not Resuscitate sheet signed 9/15/22. Review of Resident #6's Quarterly MDS, dated [DATE], showed: -He/She was cognitively intact; -He/She had clear speech; -He/She made self understood and usually understood others; -He/She was dependent on a wheelchair; -Diagnoses included high blood pressure, heart failure, diabetes (too much sugar in the blood), depression, asthma (condition making it difficult to breathe), neuropathy (condition resulting in nerves that are damaged resulting in pain, numbness, weakness, or tingling in one or more parts of the body), and muscle weakness. Review of physician's orders, dated 8/27/24, showed an order dated 11/19/22 to Do Not Resuscitate. Review of care plan, revised 3/29/24, showed: -He/She planned to remain in facility for long term care; -Care plan did not address resident's do not resuscitate orders. During an interview on 8/28/24 at 11:14 A.M., LPN A said the care plan should address resident's code status. During an interview on 8/28/24 at 2:58 P.M., MDS Coordinator said: -He/She had been in position a couple of months; -He/She had not written any actual care plans; -Care plans should address resident's code status. During an interview on 8/29/24 at 9:10 A.M., Administrator said: -He/She expected the care plan to be updated with significant changes, when desired outcomes were not met, when a resident was readmitted the facility, and quarterly with MDS; -If a resident's code status is in resident's chart then the resident's chart was considered part of his/her care plan; -Code status was reviewed at every care plan meeting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure they developed a comprehensive person-centered plan of care consistent with measurable objectives and timeframe's to meet the residents medical, nursing, mental, and psychosocial needs for six residents (#7, #27, #34, #17, #18,#6) of the12 sampled residents. The facility census was 37. Review of the facility's undated Care Plan Policy showed: - Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. - The Interdisciplinary Team must review and update the care plan: a. When there has been a significant change in the resident's condition; b. When the desired outcome is not met; c. When the resident has been readmitted to the facility from a hospital stay; and -The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. -The comprehensive, person-centered care plan will: Reflect the resident's expressed wishes regarding care and treatment goals. -Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. 1.Review of Resident #7's Quarterly MDS dated [DATE] (a federally mandated assessment tool completed by facility staff) showed: -Resident is cognitively intact. -Diagnoses included: Heart failure; hypertension (high blood pressure), dementia; anxiety disorder; depression; non-traumatic spinal cord dysfunction. Review of the resident's physician's orders, 12/14/2023 showed the resident had an order of DNR (Do Not Resuscitate), No life saving measures, code status. Review of the resident's undated care plan on 8/29/24., showed the facility did not care plan the resident's code status wishes. 2.Review of Resident #27's Annual MDS dated [DATE] showed: -Resident has significant cognitive decline impairment, and unable to make needs known. -Diagnoses include: Non-traumatic brain dysfunction(what is that-put that here); hypertension (high blood pressure); end-stage renal disease(kidney failure) diabetes mellitus; Alzheimer's disease; malnutrition or at risk for malnutrition; depression; impaired vision. Review of the resident's undated care plan on 8/29/24., showed the facility did not care plan the resident's code status wishes, nor did the facility care plan the risk for resident falling. Review of the resident's physician's orders, 11/19/22 showed the resident had an order of DNR (Do Not Resuscitate) code status. Review of electronic medical record progress notes showed on 7/10/2024 at 9:13 P.M.: -Res was observed walking up hallway with quilt draped over him/her and dragging part of it on floor. He/She did not have walker. NA B told him he needed walker and walked back to room with res. Review of Fall assessment dated [DATE] showed Resident was a fall risk of 12, which indicates a high-risk for falls score. Review of the resident's care plan, dated 7/4/24.,showed: -Resident has history of Falls. -Resident will be free of falls through the review date. -Staff are to anticipate and meet Resident's needs. -Be sure Resident's call light is within reach and encourage him to use it for assistance as needed. -Ensure that Resident is wearing appropriate footwear when ambulating with his walker. -Follow facility fall protocol. -Resident has very poor vision. Assist him/her throughout the facility as needed. -Resident needs a safe environment with: even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night and his walker within his reach. 3. Review of Resident #17's Significant Change Minimum Data Set, dated [DATE], showed: - Brief interview for mental status (BIMS) score of 2, indicating the resident was severely cognitively impaired; - Diagnoses included: Reduced mobility, Amnesia (Memory Loss), Hypertensive Heart Disease with Heart Failure, Malignant Neoplasm of Uterus (Cancer). - Dependent on staff for toileting, shower/bath, dressing, personal hygiene, and transferring. Review of the resident's care plan dated, 8/26/24, showed: - Activities of daily living deficit and dependent on 2 staff for care. - Terminal prognosis for cancer requiring staff to provide maximum comfort for resident. - Indwelling urinary catheter for bladder draining, staff will change monthly, monitor and document intake and output. - Cognition deficit of which staff will be respectful and treat resident as an adult. - No interventions documented for 24 hour video and audio surveillance of resident's room. Observation at Nurse's station showed a video monitor of resident's room with sound which could be turned up. Resident was observed in bed pulling at his/her brief and conversation between resident and staff could be heard from the room from the monitor. Monitor as VTECH Model VM5255-22. 4. Review of Resident #6's Quarterly minimum data set (MDS), dated [DATE], showed: -He/She was cognitively intact; -He/She had a hearing aide, minimal difficulty with hearing; -He/She had clear speech; -He/She made self understood and usually understood others; -He/She was dependent on a wheelchair; -He/She required partial/moderate assistance with toileting, bathing, upper and lower body dressing, personal hygiene, sit to lying rolling left and right, transitioning from lying to sitting on side of bed, sit to stand, chair to bed transfers, toilet/tub transfers, -Diagnoses included neuropathy (condition resulting in nerves that are damaged resulting in pain, numbness, weakness, or tingling in one or more parts of the body), and generalized muscle weakness. Review of physician's orders, dated 8/27/24, showed: -Ordered 6/30/23, side rails if indicated, no directions specified with order. Review of care plan, dated 8/21/24, showed: -Bed Mobility: He/She required extensive assistance by 1 staff to turn and reposition in bed and as necessary. -Care plan did not address use of side rails. Observation on 8/26/24 at 10:19 A.M. showed u shaped cane rails on both sides of bed. During an interview on 8/26/24 at 10:19 A.M. resident said: -He/She used cane rail when he/she got up during the night to get back into his/her bed. Review of bed rail assessment showed: -Quarterly assessment completed 8/18/24 showed side rails were not indicated at that time; -Quarterly assessment completed 5/24/24 showed side rail placement side rails/assist bar were not indicated at that time; -Quarterly assessment completed 3/19/24 showed the resident had expressed a desire to have side rail/assist bar, side rails / assist bar were indicated and served as enabler to promote resident's independence. The side rail placement was bilateral to provide assist with toileting for the resident at night. -Quarterly assessment completed 6/1/23 showed Resident had expressed a desire to have side rails/assist bar, side rails/assist bar were indicated and served as an enabler to promote independence and the recommended placement was bilateral. 5. Review of Resident #18's Quarterly MDS, dated [DATE], showed: -No cognitive status available; -He/She had unclear speech and was rarely or never understood; -He/She had highly impaired vision and wore corrective lenses; --He/She had impairment on both sides of upper extremities; -He/She was dependent on a wheelchair; -He/She was dependent for eating, oral care, toileting, bathing, upper and lower body dressing, hygiene, and all mobility; -Diagnoses included tendency to fall, corneal transplant status, and anxiety disorder. Physician's orders, dated 8/27/24, showed: -He/She had no orders for side rails. -Ordered 6/30/23, side rails if indicated, was discontinued 12/13/23 by physician. Observation on 8/26/24 at 9:23 A.M. showed side rail up on the right side of the bed. Observation on 8/26/24 at 3:28 P.M. showed side rail up on the right side of the bed. Review of bed rail assessment showed: -No assessments found. 6. Review of Resident #34's Quarterly MDS, dated [DATE], showed: -He/She was cognitively intact; -He/She was dependent on walker or wheelchair; -He/She required partial to moderate assistance with mobility; -He/She had 2 or more falls with no injuries since prior assessment -Diagnoses included peripheral vascular disease (a condition that can cause blood vessels to narrow, block or spasm), dementia (condition that causes a decline in brain function and impairment of a person's ability to think, remember, and make decisions), Parkinson's disease (a chronic, progressive brain disorder that causes movement problems), restless leg syndrome (uncomfortable feeling in legs and an irresistible urge to move them), muscle weakness, need for assistance with personal care. Review of physician's orders, dated 8/27/24, showed: -He/She had no orders for side rails. -Ordered 7/24/24, Immobilizer to right arm on at all times except showers. Review of care plan, revised 7/30/24, showed: -Bed Mobility: He/She was able to independently move self in bed (Revised 12/6/23); -Transfer: He/She required limited assistance of 1 staff to move betwen surfaces (Revised 12/6/23); -He/She was at risk for falls (revised 11/24/23); -He/she will be free from injury resulting from a fall through the next review date (Revised 2/13/24); -A fall risk assessment is completed quarterly (Initiated 11/24/23); -Assist him/her to the bathroom and with peri cares often (initiated 11/24/23); -At times resident will crawl to the bathroom when feeling unsteady with walking or his/her Parkinson's symptoms are worse so he/she does not fall. Educate and remind [NAME] to use her call light to allow staff to assist her with going to the bathroom so she does not have to crawl (Revised 8/11/24); -He/She needed limited assistance of 1 staff member with transfers and walking. Staff to educate and remind her to use her call light for assistance (Revised 3/29/24); -Keep call light within reach and encourage [NAME] to use it (Initiated 11/24/23); -Keep pathways clear and free from clutter to allow for safe passage (Initiated 11/24/23); -Per family request there will be a monitor placed in Joys room to assist in alerting staff to falls (Initiated 7/30/24); -Respond to resident's needs and/or wants promptly (Revised 3/29/24); -Resident had a bone fracture of right clavicle (Initiated 7/24/24) -Resident will be free from signs and symptoms of pain, or will express/exhibit relief of pain after administration of ordered meds, alternative comfort measures. -Resident will not develop complications or permanent loss of mobility related to fracture through review date. -Give pain, anti-inflammatory medications as ordered. Monitor/document side effects and effectiveness. -Handle gently when moving or positioning. Maintain body alignment. -If orthopedic fixation device or traction is present, follow MD orders for monitoring, maintaining device and providing skin care. -Instruct resident regarding fracture healing process, diagnostic procedures, treatments and its complications, home care, daily activities, diet, restrictions, and follow-up. - Parkinson's Disease: Monitor for risk of falls (initiated 12/6/23); -Side rails were not care planned; -No new fall interventions care planned after each fall occurred. Review of fall history in electronic medical record showed: -On 7/24/24 fall with injury resulting in right clavicle fracture; -On 7/20/24 fall with no injuries occurred at 12:35 A.M.; -On 6/29/24 fall with no injuries occurred at 8:50 P.M.; -On 6/27/24 unwitnessed fall with injury at 1:30 P.M. resulting in skin tear on right lower shin and small abrasion on right knee. Review of fall risk assessments showed a score of 10 or greater the resident was considered high risk for potential falls: -On 6/10/24 a quarterly assessment showed he/she was at high risk with score of 10; -On 2/22/24 a quarterly assessment showed he/she was not high risk with score of 8; -On 12/10/23 an admission assessment showed he/she was not at high risk with score of 9. Observation on 8/26/24 at 9:55 A.M. showed resident had a U -shaped cane rail that was up on the right side of his/her bed. During an interview on 8/26/24 at 9:55 A.M. resident said his/her side rail was up to hold his/her call light in place. During an interview on 8/26/24 at 11:32 A.M. resident said he/she had multiple falls due to restless leg and parkinson's and he/she broke his/her collar bone a few weeks ago when a fall occurred. He/She was wearing the immobilizer on his/her arm from the fall with injury. Observation on 8/27/24 at 8:15 A.M. showed resident had bruising to the right side of his/her face. During an interview on 8/27/24 at 2:17 P.M., Director of Nursing (DON) said: -He/She did not know if physicians orders were required for bed rails; -Side rail assessments were completed quarterly and with significant changes; -When side rail assessments showed side rails were not indicated, he/she would expect side rails to be removed; -He/She completed areas of entrapment measurements monthly; During an interview on 8/27/24 at 2:24 P.M., DON said: -Administrator stated facility had physician's orders for residents who had side rails. During an interview on 8/28/24 at 11:14 A.M., Licensed Practical Nurse (LPN) A said: -He/She would assess resident for injuries, obtain vitals, notify family, physician, Director of Nursing (DON), Administrator, and complete risk management form after each fall; -After a resident had falls he/she would get a urinalysis order, have physical therapy evaluate and treat, keep resident's call light close, ensure appropriate footwear was worn, and walker was in reach; -After a resident falls the social service staff, MDS Coordinator, or DON updates residents care plans; -The nurses did not update resident care plans; -Care plans should address new interventions after each time resident has fallen. DON and Administrator on 8/28/24 at 11:30 A.M. said: - It is not regulation to include code status in the care plan and DON said they do not put code status in the care plan because it is documented in resident's chart. During an interview on 8/28/24 at 2:58 P.M., MDS Coordinator said: -New interventions should be added to the care plan after each new fall with dates; -Care plans should address assist bars or side rails and falls. During an interview on 8/29/24 at 9:10 A.M., Administrator said: -When a resident falls the nurse completed an investigation known as the risk management form; -He/She expected care plans to be updated with significant changes, when desired outcome was not met, when resident was readmitted ot the facility, and quarterly with their MDS; -He/She believes the resident's medical record or chart is part of resident's care plan; -He/She expects staff to do side rail assessments; -The side rail assessments are a part of the residents chart so are included in the resident's care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure staff followed professional standards of care for four of the 12 sampled residents when staff installed side rails without a physician's order which affected one sampled resident, (Resident #18); failed to obtain orders for self-administration of drugs for one sampled resident, (Resident #34); failed to follow physician orders for medications (Resident #31) and immobilizer (Resident #34), and left blanks in the documentation on the MAR (Medication Administration Record) for one resident (Resident #6). The facility census was 37. The facility did not provide a policy on professional standards of care. Review of the facility policy regarding documentation of medication administration, showed: - The facility shall maintain a medication administration record to document all medications administered. - Administration of medication must be documented immediately after (never before) it is given. Review of the facility policy regarding storage of medications, showed: - The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Review of the facility policy, Medication Therapy, showed: -The resident's clinical record must contain a written order for all prescription, including over-the-counter medications taken by the resident. 1. Review of Resident #31's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 8/29/24 shows: - admission date of 1/13/23 - BIMS score of 15, indicating no cognitive deficit. - Diagnoses include: Parkinson's Disease (disease of the nervous system), Hypertension (high blood pressure) Diverticulosis of Intestine (inflammation of the intestine) -Requires monitoring and some nursing assistance of one for activities of daily living. - Resident requires a walker for mobility. Review of the resident's physician order sheet (POS), dated, 8/27/24, showed: - Order for Pataday Ophthalmic Solution for allergies, 1 drop in both eyes at bedtime; - Order for Polyethylene Glycol 17 grams by mouth one time a day for Constipation; Review of the resident's medication administration record (MAR), dated, August, 2024, showed: - Pataday Ophthalmic Solution instill one drop in both eyes at bedtime, medication was not documented as administered for 27 days. - Polyethylene Glycol administered only 12 times out of 27 days. Review of the resident's care notes from October 2023 to August 2024, showed no documentation that the resident refused to allow staff to administer eye drops. During an interview on 8/28/24 at 2:25 P.M. the resident said he/she had not received eye drops for months and was told by staff that they were out of the medication. During an observation and interview on 8/28/24 at 3:45 P.M., CMT B stated: - Pataday eye drops are kept in the medication cart. CMT B was not able to find any eye drops and said they were out of stock. CMT B stated that the standard procedure would be to order the medication if they were out. CMT B confirmed there were no eye drops on order and requested a refill of Pataday eye drops during the interview. CMT B stated that resident had refused to take this medication in the past. 2. Review of Resident #18's Quarterly MDS, dated [DATE] showed: -Cognition was not evaluated on the MDS; -He/She had unclear speech and was rarely or never understood; -He/She had impairment on both sides of upper extremities; -He/She was dependent on a wheelchair; -He/She was dependent for all ADL (Activities of Daily Living) assistance; -He/She had no falls since admission; -Diagnoses included heart failure, high blood pressure, anxiety disorder, depression, tendency to fall, heart disease, corneal transplant status, overactive bladder, urinary tract infections Physician's orders, dated 8/27/24, showed: -He/She had no orders for side rails. -Ordered 6/30/23, side rails if indicated, was discontinued 12/13/23 by physician. Observation on 8/26/24 at 9:23 A.M. showed side rail up on the right side of the bed. Observation on 8/26/24 at 3:28 P.M. showed side rail up on the right side of the bed. Review of bed rail assessment showed: -No assessments found. During an interview on 8/27/24 at 2:17 P.M., Director of Nursing (DON) said: -He/She did not know if physician's orders were required for bed rails; During an interview on 8/27/24 at 2:24 P.M., DON said: -He/She checked with administrator and facility had physician's orders for all residents who had side rails. 3. Review of Resident #34's Quarterly MDS, dated [DATE], showed: -He/She was cognitively intact; -He/She felt down or depressed or hopeless 2-6 days per week; -He/She was dependent on walker or wheelchair; -He/She required set up or clean up assistance with eating; -He/She was independent with oral care, toileting, upper and lower body dressing, -Diagnoses included: Dementia (condition that causes a decline in brain function and impairment of a person's ability to think, remember, and make decisions), Parkinson's disease (a chronic, progressive brain disorder that causes movement problems), malnutrition, depression, muscle weakness, need for assistance with personal care. Review of care plan, dated 7/24/24, showed: -Administer medications as ordered by physician. -Resident had a bone fracture of right clavicle; -Resident will not develop complications or permanent loss of mobility related to fracture through review date. -Handle gently when moving or positioning. Maintain body alignment. -If orthopedic fixation device or traction is present, follow MD orders for monitoring, maintaining device and providing skin care. -Instruct resident regarding fracture healing process, diagnostic procedures, treatments and its complications, home care, daily activities, diet, restrictions, and follow-up. Review of physician's orders, dated 8/27/24, showed: -Ordered 2/22/24, artificial tears ophthalmic solution 1.4%, polyvinyl alcohol, instill 2 drops in both eyes every 8 hours as needed for dry eyes both eyes; -No orders for medications at bedside. -Order started 7/24/24, for Immobilizer to be in place to right arm and on at all times except showers. Review of electronic medical record showed: -No assessment for self-administration of medications. -On 7/24/24 an x-ray was completed at the emergency room of resident's right shoulder which showed there was an acute displaced fracture of the right clavicle. Review of facility electronic medical record showed: -On 7/24/24 at 1:18 P.M., Resident returned from the emergency room. His/Her right clavicle was fractured and he/she will be wearing an immobilizer at all times except during showers for 6-8 weeks. Observation on 8/26/24 at 9:53 A.M. showed Xlldra eye drops at bedside, 10 vials of unmarked clear tubes that appeared like breathing treatments vials were sitting in a metal tin container be side resident's chair, along with an open container of Vaseline, and nasal spray. During an interview on 8/26/24 at 11:32 A.M. resident said he/she had multiple falls and he/she broke his/her collar bone. An observation on 8/27/24 at 1:57 P.M. showed resident was sitting in his/her wheelchair in his/her room and did not have immobilizer on. An observation on 8/27/24 at 4:10 P.M. showed resident sitting in front of nurses station with no immobilizer on. During an interview on 8/28/24 at 11:14 A.M., LPN A said: -Medications were not allowed to be left at residents bedside unless a doctor gave facility an order; -Residents who have medications at bedside should have a self-administration of medication assessment completed; -He/She was not aware of any resident who had an order to keep his/her medications at bedside or who had been assessed. During an interview on 8/29/24 at 9:10 A.M., Administrator said: -He/She expected resident's physician's orders to be followed regarding wearing an immobilizer at all times except while showering; -He/She was aware that resident would voluntarily take his/her immobilizer off; -He/She did expect staff to reapply immobilizer when they noticed it was off. During an interview on 8/29/24 at 9:23 A.M., Director of Nursing said: -Resident did not self-administer medications. During an interview on 8/29/24 at 11:30 A.M., Director of Nursing said: -He/She expected resident with orders to have an immobilizer on at all times but showering to have immobilizer on if resident did not refuse; -It was resident's right to refuse to wear immobilizer. 4. Review of Resident #6's Quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 5/30/24, showed: -He/She was cognitively intact; -He/She had a hearing aide, minimal difficulty with hearing; -He/She had clear speech; -He/She made self understood and usually understood others; -He/She was dependent on a wheelchair; -He/She required partial/moderate assistance with ADLS; -Diagnoses included high blood pressure, heart failure, diabetes (too much sugar), depression, asthma (condition making it difficult to breathe), Hypothyroidism (Low functioning thyroid gland hormone). Review of care plan, revised 3/29/24, showed: -Nurse to give medications as ordered; Review of physician's orders, dated 8/27/24, showed: -Order started 12/19/22, Accucheck every Monday 0600 one time a day every Monday related to Type 2 diabetes mellitus without complications; -Order started 12/1/22, Fluticasone Propionate Suspension 50 MCG/ACT, 1 spray in each nostril one time a day related to allergic rhinitis; -Order started 4/12/24, Levothyroxine Sodium Oral Tablet 100 MCG, Give 1 tablet by mouth one time a day for thyroid stimulating hormone (TSH); Review of Medication Administration Record (MAR), dated August 2024, showed: -Accucheck every Monday 0600 one time a day related to Type 2 Diabetes Mellitus without complications -No entry on 8/5, 8/12, and 8/26; -Fluticasone Propionate Suspension 50 MCG/ACT, 1 spray in each nostril one time a day related to Allergic rhinitis at 0600: -No entry on 8/1, 8/12, and 8/15; -Levothyroxine Sodium Oral Tablet 100 MCG (Levothyroxine Sodium), Give 1 tablet by mouth one time a day for TSH at 0600: -No entry on 8/1, 8/12, and 8/15; During an interview on 8/29/24 at 9:10 A.M., Administrator said: -He/She expected there to be no blanks in the MAR; -Facility staff had to chart something in the MAR and were not allowed to lave blanks; -He/She believed the electronic medication administration system did not allow staff to not document something in the MAR, therefore a blank would not be possible in the charting system. During an interview on 8/29/24 at 11:30 A.M., Director of Nursing said: -There should not be blanks in the MAR; -There should be an annotation as to why medication was not given or orders not completed; -He/She did not think it was possible for a blank to be left in the MAR with the electronic medication administration system.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide an ongoing activity program to support residents in their choice of activities designed to meet the interest of and support the physical, mental, and psychosocial well-being of each resident when residents were not offered activities. This affected two residents (Residents #12 and #29) out of 12 sampled residents. The facility census was 37. Review of the facility's Activities policy, revised August 2006, showed, in part: - Activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs; - Activities are scheduled seven days a week and residents are given an opportunity to contribute to the planning, preparation, conducting, cleanup, and critique of the programs; Review of the facility's Activities Documentation policy, revised December 2009, showed, in part: -Recordkeeping is a vital part of the activity programs; - Activity Department personnel will maintain records of: activity assessment with a copy in the medical record of the resident, attendance records, activity progress notes, individualized activity Care Plan or activities portion of the Comprehensive Care Plan, Resident Council minutes and record reviews and updates; -The Activity Director/Coordinator is responsible for obtaining, charting, and filing required reports; Review of the facility's Activities Attendance policy, revised August 2006, showed, in part: - The Activity department records activities attendance and participation of all residents; - Attendance and participation are recorded for every resident in group and individual activities on a daily basis; - Records are reviewed on a regular basis to determine any changes in resident participation that might indicate a change in condition and lead to reassessment and care plan review; - Attendance records are filed for a minimum of three years; Review of the facility's Individual Activities and Room Visit Program policy, revised August 2006, showed, in part: - Individual activities will be provided for those residents whose situation or condition prevents participation in other types of activities, and for those residents who do not wish to attend group activities. Residents who are able to maintain an independent program will have supplies available to them. - The activities offered are reflective of the resident's individual activity interests, as identified in the Activity Assessment, progress notes and the resident's Comprehensive Care Plan. - It is recommended that residents on a full room visit program receive, at a minimum, three room visits per week. Typically, a room visit is ten to fifteen minutes in length. - Residents who choose not to attend group activities will maintain an independent program. It is the responsibility of the facility and the activity staff to make regular contacts and offer supplies, as needed. 1. Review of Resident #12's Significant Change MDS, dated [DATE], showed: - Cognitive skills moderately impaired; - Dependent assistance for eating, oral and personal hygiene, dressing, toileting, mobility, and transfers; - Diagnoses included: Atrial Fibrillation (Irregular rapid heartbeat), Coronary Artery Disease (Heart condition), Thrombosis (Blood cots), Heart Failure, Hypertension (High blood pressure), Peripheral Vascular Disease (Circulation Disorder), Renal Insufficiency (Kidney disease), and Depression. - Staff did not perform an assessment of daily activity preferences for the resident. Review of Resident Care Plan revised 4/12/24 showed: - Encourage resident to participate in group activities - Have resident read his/her own mail - Encourage resident to sit outside and transport on their own - Goal for resident was two activities each day Review of Resident participation in activities from Activity Director logs did not have any documented activities for the last 90 days. 2. Review of Resident #29's quarterly MDS, dated [DATE], showed: - Cognitive skills severely impaired; - Dependent assistance required for toileting and transferring; - Substantial assistance required for bathing, dressing and personal hygiene; - Diagnoses included Alzheimer's Disease (Memory loss), Sjogren syndrome (Immune system disorder), Schizoaffective Disorder (mental health mood disorder), Depressed and Severe Protein-Calorie Malnutrition (Diet deficiency), Hypertension (High blood pressure) Review of Resident Care plan, revised 5/28/24, showed: - Staff will invite and encourage resident to attend activities to improve his/her mood - Resident is expected to participate in two activities daily - Activity Director will continue to read resident his/her mail - Resident will attend the pet therapy activity Review of Resident Activity Preferences dated, 8/7/24 showed: - Pet therapy and family visits with his/her son are very important activities for the resident; - Resident is not interested in group activities; Review of Resident participation in activities from Activity Director logs did not have any documented activities for the last 90 days. 3. Observations from 8/26/24 through 8/29/24 at various times from 7:45 A.M. to 4:30 P.M., showed there were no one on one individualized activities in progress for residents #12 or #29. 4. During an interview on 8/28/24 at 3:30 P.M., the Activities Director stated: - Resident #12 sleeps often and is hard to reach for activities. Mainly activities have consisted of reading the mail to resident and sitting outside when the weather is good. - Activities Director uses only one source for Pet therapy and can only have that activity once every 90 days due to scheduling. The Activity Director could not recall exactly when the last time pet therapy was conducted. During an interview on 8/29/24 at 11:30 A.M., the Administrator stated he/she would expect more than weekly one on one activity engagements for residents that do not want to or cannot engage in group activities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #3's Quarterly Minimum Data Set, dated [DATE], showed: - Cognitive skills intact. - Received PRN pain medication in the last five days. - Diagnoses included: Fractures and other multiple trauma; cancer; heart failure; hypertension; kidney failure; anxiety disorder; depression; lung disease. Review of the Consultant Pharmacist's Medication Regimen Review, dated 6/28/24, showed: - The resident had an order for Xarelto 15 milligrams (mg) daily. - A recommendation to add with food to the instructions on the physician order sheet (POS) and medication administration record (MAR). Review of the POS, dated 7/30/24, showed: -Sertraline 100 mg daily at 8 A.M. one time a day for depression; Cyclobenzaprine HCl Tablet 5 MG Give 1 tablet by mouth every 8 hours as needed for Pain Muscle spasms; oxyCODONE HCl Oral Tablet 5 MG (Oxycodone HCl), give 1 tablet by mouth every 6 hours as needed for moderate to severe pain; ALPRAZolam Oral Tablet 0.25 MG (Alprazolam), give 0.25 mg by mouth two times a day related to GENERALIZED ANXIETY DISORDER; DULoxetine HCl Oral Capsule Delayed Release Sprinkle 60 MG (Duloxetine HCl), give 1 capsule by mouth two times a day related to MAJOR DEPRESSIVE DISORDER. Review of 7/1/24, 6/6/24, 5/6/24, and 4/3/24 Medication Record Review showed: No recommendations noted; consulting pharmacist did not sign; physician did not sign or date to indicate reviewed. Review of Significant Correction, dated 6/28/2024, showed the resident is not prescribed AP (antipsychotics). Resident is prescribed anti-anxiety meds, antidepressant, and opioids. 4. Review of Resident #7's Quarterly Minimum Data Set, dated [DATE], showed: - Cognitive skills intact. - Diagnoses included: non-traumatic spinal cord dysfunction; heart failure; high blood pressure; dementia; anxiety disorder, depression. Review of Pharmacy Consultant Medication Review Reports dated 1/16/24, 2/1/24, and 3/7/24 showed: No recommendations noted; consulting pharmacist did not sign; physician did not sign or date to indicate reviewed. Review of Resident's current Physicians Orders showed: - Take Doxycycline 100 mg BID x 10 days two times a day for redness to outer right thigh and knee for 10 Days Start 6/5/2024. - Doxycycline Hyclate Tablet 100 MG Give 1 tablet by mouth two times a day for infection for 14 Days -Discontinued 04/29/2024. 5. Review of Resident #27's Quarterly Minimum Data Set, dated [DATE], showed: - Cognitive skills are significantly impaired. - Received seven insulin injections in the last seven days. - Diagnoses included: non-traumatic brain dysfunction; hypertension; kidney failure; diabetes; Alzheimer's disease; at risk for malnutrition; depression. Review of 7/4/24 Care Plan Showed: - Resident will be free from discomfort or adverse reactions related to antidepressant therapy through the review date. - Administer ANTIDEPRESSANT medications as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT. - Educate resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms of Mirtazapine. - Monitor/document/report as needed any adverse reactions to ANTIDEPRESSANT therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts. Review of Pharmacy Consultant Medication Review Reports dated 1/16/24, 3/7/24 and 4/2/24 showed: - No recommendations noted; consulting pharmacist did not sign; phys. did not sign or date to indicate reviewed. During an interview on 8/27/24 at 10:16 A.M., Administrator said: -The Director of Nursing (DON) maintained a gradual dose reduction book; -He/She followed the book closely and kept tabs on residents who required a gradual dose reduction; -He/She notified the physician prior to the pharmacist prior to the pharmacist coming in regarding the need for a gradual dose reduction; -The DON got the gradual dose reduction orders signed from the doctor prior to the pharmacist doing his/her reviews. During an interview on 8/27/24 at 1:44 P.M., Director of Nursing (DON) said: -The pharmacist came to facility to do drug regimen reviews; -When resident has no recommended changes to their drug regimen, the reviews were not sent to the physicians; -Physician's do their own reviews of the resident's medical records; In an interview with Director of Nursing, on 08/29/24 at 11:23 AM, he/she said the pharmacist signs a cover sheet and the physicians sign off on orders monthly. During an interview on 8/29/24 at 11:30 A.M., Administrator said: -Drug Regimen Reviews only need to be signed by the physician if there was drug irregularities per their facility policy. During an interview on 8/29/24 at 11:30 A.M., DON said the drug regimen review was handed to him/her by the pharmacist with a cover letter that included a signature from the pharmacist. Based on record review and interview, the facility failed to ensure they obtained a signed and dated statement from the pharmacist when no irregularities were identified during the medication regimen review, and when the pharmacist date of review and name was not listed on any medication regimen reviews. Failed to provide documentation that a monthly medication regimen review was completed, and failed to provide documentation that the medication regimen review was provided to the physician monthly. This affected five of the twelve sampled residents (Resident #6, #18, #3, #7 and #27). The facility census was 37. Review of facility policy, Medication Regimen Review, Revised April 2007, showed: -The consultant pharmacist shall review the medication regimen of each resident at least monthly. -Consultant pharmacist will perform a medication regimen review (MRR) for every resident in the facility. -The Consultant Pharmacist will document his/her findings and recommendation on the monthly drug/medication regimen review report. -The Consultant Pharmacist will provide a written report to physicians for each residents with an identified irregularity. If situation is serious enough to represent a risk to a person's life, health, or safety the consultant pharmacist will contact the physician directly to report the information to the physician and will document such contacts. If the physician did not provide a pertinent response, or the consultant pharmacist identifies that no action had been taken, he/she will then contact the Medical director, or-if the medication director is the physician of record-the administrator. -The Consultant Pharmacist will provide the Director of Nursing Services and Medical Director with a written, signed, and dated copy of the report, listing the irregularities found and recommendations for their solutions. -Copies of the drug/medication regimen review reports, including physician responses, will be maintained as part of the permanent medical record. Review of facility policy, Medication Therapy, revised April 2007, showed: -Each resident's medication regimen shall include only those medications necessary to treat existing conditions and address significant risks. -Upon or shortly after admission, and periodically thereafter, the staff and practitioner (assisted by the consultant pharmacist) will review an individual's current medication regimen, to identify whether: -there is clear indication for treating that individual with the medication. -the dosage is appropriate; -the frequency of administration and duration of use are appropriate, and -potential and suspected side effects are present. -the physician will identify situations where medications should be tapered, discontinued, or changed to another medication, for example: -when a medication is being given in excessive doses, for excessive periods of time, without adequate monitoring, or in the absence of a valid clinical rationale; -when the results of ongoing assessment, or the presence of clinically significant adverse consequences monitoring, suggest that a medication should be reduced or discontinued entirely; and -when a medication is being prescribed to treat, or in anticipation of, an adverse consequence of another prescribed drug. -The Consultant Pharmacist shall review each resident's medication regimen monthly as requested by the staff or practitioner, or when a clinically significant adverse consequence is confirmed or suspected. -The Medical Director and Consultant Pharmacist shall collaborate to address issues of medication prescribing and monitoring with the practitioners and staff. 1. Review of Resident #6's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 5/30/24, showed: -He/She was cognitively intact; -Diagnoses included high blood pressure, heart failure, diabetes (too much sugar), depression, asthma (condition making it difficult to breathe, neuropathy (condition resulting in nerves that are damaged resulting in pain, numbness, weakness, or tingling in one or more parts of the body), and generalized muscle weakness, -He/She had been on schedule pain medications, no PRN pain meds in last 5 days; -He/She was taking an antidepressant, anticoagulant, and diuretic Review of the Resident's care plan showed: -He/She uses antidepressant medication Sertraline for Depression -He/She Will be free from discomfort or adverse reactions related to antidepressant therapy through the review date. -Administer ANTIDEPRESSANT medications as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT. -Educate the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms of Sertraline. ·Monitor/document/report PRN adverse reactions to ANTIDEPRESSANT therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, wt loss, n/v, dry mouth, dry eyes Review of the resident's physician's orders, dated August 2024, showed: -Order started 1/30/24, Sertraline HCL tablet 25MG, give 1 tablet by mouth one time a day for depression, was discontinued on 7/10/24; -Order started 7/11/24, Sertraline HCL Tablet 25mg, Give 1 tablet by mouth one time a day every Monday, Tuesday, Wednesday, Thursday, Friday, Saturday for depression. Review of progress notes from September 2023 to August 2024 showed: -On 9/5/23, the DON wrote the pharmacy consult was received and no irregularities noted. -On 10/25/23, the DON wrote, no new irregularities this month. -On 11/22/23, the DON pharmacy consult received and no irregularities noted. -On 12/7/23, the DON wrote pharmacy consult received and no irregularities noted. -On 1/29/24, the DON wrote pharmacy consult received with no irregularities noted. -On 2/6/24, the DON wrote pharmacy consult notes receives with no new irregularities. -On 3/12/24, the Director of Nursing (DON) wrote pharmacy consult review received with no new irregularities noted. -April 2024 had no drug regimen review; -May 2024 had no drug regimen review; -June 2024 had no drug regimen review; -July 2024 had no drug regimen review; Review of facility provided notes to attending physician from the pharmacist showed: -Documented notes from 9/5/23 through 8/1/24 the following statement: It is my professional judgment that at such time, the resident's medication regimen contained no new irregularities, did not identify name of consultant pharmacist, no signature from pharmacist or physician/prescriber, or date medication regimen review was completed; Review of facility gradual dose reduction tracking form showed: -On 5/29/24 the physician was faxed by the Director of Nursing- That a gradual dose reduction was due on resident's sertraline 25 mg daily. -On 7/3/24 the physician wrote orders and signed to decrease resident's sertraline 25 mg to 6 days per week. 2. Review of Resident #18's Quarterly MDS, dated [DATE], showed: -Cognitive status was not assessed; -He/She took an antipsychotic medication, anticoagulant, and diuretic medications; -He/She had an antipsychotic received, a GDR (Gradual dosage reduction) had been attempted on 5/8/24, -A GDR has not been documented by a physician as clinically contraindicated. -Diagnoses included: Dementia (group of conditions characterized by impairment of at least two brain functions such as memory loss and judgement), anxiety disorder, and depression; Review of care plan, revised 7/11/23, showed: -He/She used psychotropic medications Haloperidol related to behavior management; -He/She would be/remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment through review date. -Administer psychotropic medications as ordered by physician. Monitor for side effects and effectiveness every shift. -Consult with pharmacy, and physician to consider dosage reduction when clinically appropriate at least quarterly. -Discuss with Medical Director, family regarding ongoing need for use of medication. Review behaviors/interventions and alternate therapies attempted and their effectiveness as per facility policy. Review of care conference held 6/27/24, showed: -Reviewed medications with hospice nurse; -Requested to continue decreasing Haloperidol, divalproex sodium and clonazepam; -Hospice nurse agreed with plan to decrease medications. Review of physician's orders, dated August 2024, showed: -Order started 6/20/24, clonazepam oral tablet .5 mg, give .5 tablet by mouth in evening related to anxiety disorder; -Order started 6/20/24, divalproex sodium oral capsule delayed release sprinkle 125mg, Give 2 capsule by mouth in the evening for behavior management. -Order started 6/27/24, haloperidol oral tablet .5 mg, give .5 mg by mouth one time a day related to anxiety disorder; Review of facility provided notes to attending physician from the pharmacist showed: Documented notes from 9/5/23 through 8/1/24 the following statement: It is my professional judgment that at such time, the resident's medication regimen contained no new irregularities, did not identify name of consultant pharmacist, no signature from pharmacist or physician/prescriber, or date medication regimen review was completed. Review of facility gradual dose reduction tracking showed: -On 5/6/24 the physician was faxed by the Director of Nursing that resident had been doing much better in the afternoon and evening but became very tired when taking the 2:00 P.M. dose of Haloperidol .5mg three times a day and clonazepam .25mg three times a day. Would it be acceptable to go down to twice daily to encourage activity and interaction with family in the afternoon; -On 5/7/24 the physician wrote orders to decrease haloperidol .5mg to twice a day and clonazepam to .25 twice a day. Review of progress notes from September 2023 to August 2024 showed: -On 1/29/24, DON wrote the pharmacy consult received and no irregularities noted. -On 2/6/24, DON wrote the pharmacy consult notes received with no new irregularities. -On 3/12/24, DON wrote the pharmacy consultant notes showed based upon the information available at the time of the review, and assuming the accuracy and completeness of such information, it is my professional judgment that at such time, the resident's medication regimen contained no new irregularities. -April 2024 had no drug regimen review; -May 2024 had no drug regimen review; -June 2024 had no drug regimen review; -July 2024 had no drug regimen review;

Based on observations, interviews and record review, the facility failed to ensure staff maintained a medication error rate of less than five percent. Staff made two medication errors out of 25 opportunities for error, resulting in a medication error rate of 8%. This affected two of the 12 sampled residents, (Resident #16 and #32). The facility census was 37. Review of the facility's undated policy for nasal drops/spray medication administration showed: - Withdraw the medication into the dropper or uncap the spray or squeeze bottle if this is the type of dispenser used; - Ask the resident to breathe through the mouth during the administration. Review of the package leaflet for Flonase nasal spray, revised March 2016, showed, in part: - Shake the bottle gently; - Blow your nose to clear the nostrils; - Close one side of the nostril. Tilt your head forward slightly and carefully insert the nasal applicator into the other nostril; - Start to breathe in through your nose, and while breathing in press firmly and quickly down one time on the applicator to release the spray; - Repeat in the other nostril; - Wipe the nasal applicator with a clean tissue and replace the cap. 1. Review of Resident #32's physician order sheet (POS), dated August, 2024 showed: - Order date: 7/31/24 - Flonase Allergy Relief Nasal Suspension, one spray in both nostrils daily for allergies. Review of the resident's medication administration record (MAR), dated August, 2024 showed: Flonase Allergy Relief Nasal Suspension, one spray in both nostrils daily for allergies. Observation on 8/27/24 at 8:33 A.M., showed: - The resident sat in a chair in the hallway; - Licensed Practical Nurse (LPN) A shook the bottle and handed it to the resident; - LPN A did not give the resident any instructions; - The resident gave him/herself one spray in the right nostril then gave him/herself one spray in the left nostril; - The resident did not close either side of the nares. During an interview on 8/27/24 at 1:18 P.M., LPN A said: - He/she should have given the resident instructions; - He/she just follows the physician's orders. During an interview on 8/29/24 at 11:30 A.M., the Director of Nursing (DON) said: - Staff should give the resident instructions on how to use the medication; - Staff should follow the manufacturer's guidelines unless there are different guidelines. 2. Review of the facility's undated policy for eye drops administration showed: - Prevent tip of the eye dropper from touching the resident; - Ask the resident to look upward if resident is able; - While holding the bottle in a vertical position and slightly to the side of the eye and about one-half inches above the eye, instill the ordered number of drops into the conjunctive sac (the space between the bulbar and palpebral conjunctiva in the eye). Review of the website, https://www.webmd.com for Systane eye drops showed: - Place the dropper directly over the eye and squeeze out one or two drops as needed; - Look down and gently close your eye for one or two minutes; - Place one finger at the corner of the eye near the nose and apply gentle pressure; - This will prevent the medication from draining away from the eye. Review of the resident's POS, dated August, 2024 showed: - Order date: 11/25/22 - Systane solution 0.4-0.3%, instill one drop in both eyes twice daily for dry eyes. Review of the resident's MAR, dated August, 2024 showed: - Systane solution 0.4-0.3%, instill one drop in both eyes twice daily for dry eyes. Observation on 8/27/24 at 8:43 A.M., showed: - LPN A instilled two drops in the left eye and two drops in the right eye; - LPN A did not apply lacrimal pressure (apply pressure to the inner corner of the eye). During an interview on 8/27/24 at 1:18 P.M., LPN A said: - He/she did not know what lacrimal pressure was; - He/she should give the amount of eye drops that was ordered. During an interview on 8/29/24 at 11:30 A.M., the DON said: - Staff should administer the amount of eye drops that were ordered; - Was not aware of lacrimal pressure or for how long.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure staff served food to the residents that was palatable, attractive, and served at a safe and appetizing temperature when cooked foods were not temperature checked and finished products were held on the steam line in excess of three hours for 6 of 8 residents sampled (Resident #6, #7, #17, #27, #34, #36). The facility census was 37. No policy on required temperature checks of cooked food was provided. Review of facility policy, food safety and sanitation, undated, showed: -There was no guidance on how to prepare, distribute, and serve food in accordance with professional standards for food safety. Review of facility policy, assistance with meals, revised September 2013, showed: -For all residents, hot foods shall be held at a temperature of 136 degrees or above until served. Cold foods shall be held at 40 degrees or below until served. Nursing and Dietary Services will establish procedures such that delivery of food to serving areas accommodates this requirement. Direct observation of lunch service on 8/28/24 showed: Cook A completed all the below tasks: -Spinach preparation complete and on the steam line at 9:15 A.M.; Staff observed taking final cook temperature 160 degrees and recording. -Au Gratin potatoes complete and on the steam line at 9:15 A.M.; Staff observed taking final cook temperature 160 degrees and recording. -Ham and Pineapple main course complete and on the steam line at 10:15 A.M.; Ham was medium pink in color coming out of the oven. Staff observed taking final cook temperature 165 degrees and recording. - Banana pudding set up for lunch service from refrigerator to counter 11:30 A.M. -First lunch tray is prepared at 12:16 P.M. with Spinach and Au Gratin potatoes warming for 3 hours and main course Ham warming for 2 hours. -No temperatures were observed taken for any items on the steam line before serving or during their time on the steam line. Banana pudding was served but no temperatures were observed taken to ensure below 41 degrees. Observation of test tray from lunch 8/28/24 at 12:42 P.M., received directly after the last resident was served their meal showed: - Ham and Pineapple 2.5 hours on the steam line before serving is at 118 degrees which is below the appropriate serving temperature of 135 degrees. Observation of meat is dried out, hard, and dark red in color with an overcooked texture. - Spinach 3.5 hours on the steam line before serving is very mushy in texture at 150 degrees. -Au Gratin Potatoes 3.5 hours on the steam line before serving is bland at temperature 156 degrees. -Banana Pudding 1.25 hours sitting on the countertop covered with wax paper is at 57 degrees which is above appropriate serving temperature of 41 degrees. 1. Review of Resident #7's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/6/24 showed: - Resident is cognitively intact. - Diagnoses of heart failure; hypertension (High blood pressure); hyperlipidemia (Excess fats in the blood); dementia (loss of memory); anxiety disorder; depression; non-traumatic spinal cord dysfunction. During an interview on 8/26/24 12:00 P.M., the resident stated: -Food temperatures are appropriate, but the food does not taste good. 2. Review of Resident #27's Quarterly MDS, dated [DATE], showed: - Cognitive skills are significantly impaired. - Received seven insulin injections in the last seven days. - Diagnoses included: Non-traumatic brain dysfunction; hypertension (High blood pressure); renal failure (kidney disease); diabetes (pancreas disorder); Alzheimer's disease (memory loss); depression; During an interview on 8/27/24 at 7:21 A.M., the resident stated: - He/she eats in the dining room and the food is sometimes cold. The vegetables are either overcooked or undercooked. 3. Review of the Resident #17's Significant Change MDS, dated [DATE], showed: - Brief interview for mental status (BIMS) score of 2, indicating the resident was severely cognitively impaired; - Diagnoses included: Reduced mobility, Amnesia (Memory Loss), Hypertensive Heart Disease with Heart Failure, Malignant Neoplasm of Uterus (Cancer). During an interview on 8/26/24 at 1:15 P.M., the resident's responsible party stated: - Resident dislikes the food and thinks it is horrible and does not taste good. Additionally, the temperatures are sometimes cold when the food arrives to the resident's room. 4. Review of Resident #36's quarterly (MDS), dated [DATE], showed: - cognitive skills intact; - Upper/lower extremities no impairment; - Diagnoses included high blood pressure, COPD, hyperlipidemia, and renal insufficiency; - Independent with oral hygiene, dressing, transfers, personal hygiene, and toilet use; During an interview on 8/26/24 at 11:31 A.M., resident stated: -Food could be better, it has a lot of turkey and chicken on the menu and the vegetables are under cooked. She eats in the dining room. 5. Review of Resident #34's Quarterly MDS, dated [DATE], showed: -He/She was cognitively intact; -He/She required set up or clean up assistance with eating; -Diagnoses included: (condition that causes a decline in brain function and impairment of a person's ability to think, remember, and make decisions), Parkinson's disease (a chronic, progressive brain disorder that causes movement problems), malnutrition, depression. Review of care plan, revised 2/13/24, showed: -He/She was not to be served chicken [NAME], Brussel sprouts, lima beans; -He/She came to dining room for meals and fed self; -He/She had full set of dentures; -He/She had no preferences on chicken; -He/She was ordered to be on regular diet; -He/She preferred to have scrambled eggs and bacon and sometimes oatmeal for breakfast; -He/She preferred to have boost, no juice, tea, or coffee; -Monitor his/her food and fluid intake throughout the day; -Offer him/her alternative meal options if he/she did not like what was being served; -Weigh him/her weekly. Review of physician's orders dated 8/27/24, showed an order started on 3/5/24, he/she was on a regular diet with regular texture, regular/thin consistency. During an interview on 8/26/24 at 11:28 A.M. resident stated: -Food is terrible, always having corn, lima beans, green beans, fish and no seasoning to it; -Eggs are supposed to be hot and they are served cold. 6. Review of Resident #6's Quarterly MDS dated [DATE], showed: -He/She was cognitively intact; -He/She had clear speech; -He/She made self understood and usually understood others; -He/She required set up or clean up assistance with eating, -Diagnoses included: Diabetes (too much sugar), neuropathy (condition resulting in nerves that are damaged resulting in pain, numbness, weakness, or tingling in one or more parts of the body), generalized muscle weakness, hearing loss, gastroparesis (a chronic condition that affects the stomach's motility), aphasia (inability to swallow) Review of care plan, revised 3/29/24, showed: -He/She will consume 75% of ordered diet each day; -He/She should not be served fish, sausage patty, coleslaw, lettuce spinach, hot rolls, or beans of any kind; -Monitor and record his/her food and fluid intake throughout the day; -He/She came to dining room for meals and fed self; -He/She liked chocolate but prefers to not have too much; -He/She liked cottage cheese; -He/She did not have a preference on chicken; -He/She preferred to have cranberry juice and hot chocolate with breakfast; -He/She preferred to have oatmeal, bacon, fried egg, and toast for breakfast; -He/She preferred to have only water at lunch and supper; -Offer alternative meal options when he/she did not like what was being served; -Offer snacks and fluid in between meals; -Serve him/her a regular diet with regular fluids; -Weigh resident weekly. Review of physician's orders, dated August 2024, showed an order started 4/11/24, Regular diet, mechanical soft texture, regular/thin consistency, moist ground meat. During an interview on 8/26/24 at 10:30 A.M., resident stated: -The food here is terrible and not fit to eat. [NAME] A prepares a good breakfast and lunch but the evening meal after [NAME] A leaves is crappy. Resident had cold oatmeal this morning and the eggs were just warm. This happens often. -Last week the meatloaf was served black which is the same color as my hair. That cook no longer works here. Today they are serving something I don't feel is fit to eat so I will order a baked potato. During a group interview of the resident council on 8/28/24 at 2:00 P.M., four of eight residents stated: - Food was bad to terrible at times due to being burnt or cold when served in the rooms; - Menu was not varied and served carrots multiple times in one week; - Food suggestions are made for the menu but are slow to be adopted; During an interview on 8/28/24 at 14:28 P.M., Dietary Manager said he/she would expect food to be on the serving line no more than two hours maximum for any meal from start to end of service. During an interview on 8/29/24 at 11:30 A.M., Administrator stated: - They would not expect food to be on a steam line for 3 hours before serving residents; - They would expect temperature checks to be conducted in the kitchen according to facility policy; - They would expect food temperatures to be checked immediately prior to serving the first resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility staff failed to maintain an effective infection control program when staff did not ensure residents with open wounds (Resident #18) and catheters (#17) were placed on enhanced barrier precautions (EBP) and when clean laundry was not covered during transportation in the facility. This affected two of the 12 sampled residents (Residents #18, and #17). The facility census was 37. Review of facility policy, infection control, dated 3/2020, showed: -It was the policy of the facility to protect residents and staff from communicable diseases and infections. -For residents for whom enhanced barrier precautions (EBP) are indicated, EBP is employed when performing the following high -contact resident care activities: -Dressing -Bathing/Showering -Transferring; -Providing Hygiene; -Changing linens -Changing briefs or assisting with toileting; -Device care or use: central line, urinary catheter, feeding tube tracheostomy/ventilator; -Wound care: any skin opening requiring a dressing -Residents are not restricted to their room or limited from participation in group activities. Because EBP do not impose the same activity and room placement restrictions as contact precautions, they are intended to be in place for the duration of a resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. 1. Review of Resident #18's Quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 6/20/24, showed: -He/She had impairment on both sides of upper extremities; -He/She was dependent on a wheelchair; -He/She was dependent for eating, oral care, toileting, bathing, upper and lower body dressing, hygiene, and all mobility; -He/She had one stage 3 pressure ulcer -He/She used a pressure reducing device for chair, bed, turning and repositioning program, pressure ulcer care, application of nonsurgical dressings, applications of ointments/medications other than to feet. -Diagnoses included heart failure, high blood pressure, anxiety disorder, depression, , tendency to fall, heart disease, corneal transplant status, overactive bladder, and urinary tract infections Review of care plan, revised 6/20/24, showed: -He/She had actual impairment to skin integrity of the coccyx suspected deep tissue injury; -He/She needed pressure reducing wedge allowing for healing and relief from deep tissue injury. Staff was to use the pressure reducing wedge at all times while he/she was in bed. Review of physician's orders, dated 8/27/24, showed: -Order started 7/23/24, clean coccyx (tailbone), cut calcium alginate to size, and cover with padded dressing two times a day. Observation on 8/26/24 at 8:22 A.M. showed resident did not have any EBP signage on his/her door or Personal protective equipment for EBP in his/her room or outside room. Observation on 8/27/24 at 1:41 P.M. showed resident did not have any EBP signage on his/her door or personal protective equipment for EBP in his/her room or outside room. Observation on 8/28/24 at 11:34 A.M. showed resident did not have an EBP signage on his/her door or personal protective equipment for EBP in his/her room or outside room. 2. The facility did not provide a policy of transportation of laundry in regards to infection control. Observation on 8/27/24 at 8:35 A.M. showed Laundry Aide A was transporting clean laundry containing bed pads and towels in a rolling cart that was uncovered. Observation on 8/27/24 at 1:54 P.M. showed Laundry Aide A was transporting clean laundry cart with shelves full of towels, gowns, blankets, sheets, and towels that was uncovered. Observation on 8/28/24 at 11:27 A.M. showed Laundry Aide A was transporting clean laundry on 3 tiered tall laundry cart with no covering. The cart contained gowns, blankets, bed pads, sheets, and pillows. During an interview on 8/28/24 at 10:40 A.M., Laundry Aide A said: -He/She should cover clean laundry when transporting laundry in facility; -He/She did not have anything big enough to cover the large 3 tiered laundry cart when he/she transported the clean laundry. 3. Review of Resident #17's Significant Change MDS, dated , 8/15/24, showed: -re-admission on [DATE] ; -Severely cognitively impaired; -Set-up and clean-up assistance for eating; -Substantial staff assistance for oral hygiene; -Dependent on staff for toileting, bathing, dressing, personal hygiene, positioning, and transferring; -Indwelling urinary catheter, always incontinent of bowel; -Diagnoses included cancer, anemia (red blood cell deficient), heart failure, high blood pressure, neurogenic bladder (lack of bladder control), arthritis, osteoporosis (lack of bone density), dementia (memory loss), depression; Review of resident's care plan, dated 8/26/24, showed: - Resident has an indwelling urinary catheter and staff completes all catheter cares; - Catheter changed monthly, monitor intake and output as per facility policy; Observation from 8/26/24 to 8/29/24 during room visits showed no enhanced barrier precautions in place for resident with indwelling urinary catheter and no signage; During an interview on 8/28/24 at 7:58 A.M., LPN B said: -He/She did not know what enhanced barrier precautions meant; -He/She had no residents that were on enhanced barrier precautions; -He/She had two residents with catheters including resident # (Gene Young and [NAME]); -He/She had a few residents with wound cares but had no precautions in place in regards to those residents wounds; -He/She had not received any training in regards to enhanced barrier precautions. During an interview on 8/28/24 at 9:05 A.M., Infection Preventionist said he/she completed his/her infection preventionist training on 7/31/24; During an interview on 8/28/24 at 9:05 A.M., the Administrator said: He/She completed his/her infection preventionist training on 11/1/23; -He/She expected that the facility should have enhanced barrier precautions in place; -The facility had not put precautions in place yet for enhanced barrier precautions; -The facility had ordered materials to ensure signage was in place but had not yet put signs up on resident rooms; -The facility had ordered personal protective equipment (PPE) holders for residents rooms who should be on enhanced barrier precautions but the containers ordered did not fit facility doors so the PPE containers had not yet been hung on resident rooms; -He/She had identified two residents with catheters and three residents with wounds that should be placed on enhanced barrier precautions; During an interview on 8/28/24 at 9:19 A.M., Director of Nursing (DON) said: -He/She tried to implement EBP last month but he/she had not been able to get door hangers long enough to go over facility doors for the PPE containers that were ordered. During an interview on 8/29/24 at 11:30 A.M., DON said Residents with catheters and wounds should have enhanced barrier precautions in place.

Based on observation, record review and interview, the facility failed to store food in a sanitary manner. This had the potential to affect all residents in the facility. The facility census was 42. Review of the facility's Labeling/Dating Foods policy, dated 2011, showed: -All foods stored will be properly labeled according to the following guidelines -Date marking for dry storage items: Unopened cases of dry food items will be dated with the date the case was received into the facility and will be using first in-first out method of rotation. 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. The Exception: to date individual dry storage items includes individually packaged food items stored in bulk containers such as packets of hot chocolate, tea bags, saltine crackers, packets of individual cookies, etc. The Dining Services Manager is to ensure that these bulk items are rotated with old items used first. New product is never placed on top of old product. Expiration dates on commercially prepared, dry storage food times will be followed. -Date marking for refrigerated storage items: Unopened cases of refrigerated food items will be dated with the date the time was received into the the facility and will be stored using the first in-first out method of rotation. Once a case is opened, the individual, refrigerated food items are dated with the date the item was received into the facility and placed in/on the proper storage location utilizing the first in-first out method of rotation. Once opened, all ready to eat, potentially hazardous food will be re-dated with a use by date according to safe food storage guidelines or by the manufacturer's expiration date. -Date marking for freezer storage food items: Unopened cases of frozen food items will be dated with the date the item was received into the facility and will be stored using the first in-first out method of rotation. Frozen food packages removed from the case will be dated with the date the item was received into the facility and will be stored using the first in-first out method of rotation. Once a package is opened, it will be re-dated with the he date the item was opened and shall be used by the safe food storage guidelines or by manufacturer's expiration date. -Prepared food or opened food items shall be discarded when: The food item does not have a specific manufacturer expiration date and has been refrigerated for 7 days. The food item is left over for more than 72 hours. The food item is older than the expiration date. Review of the facility's Food Storage policy, dated 2011, showed: -Food shall be stored on shelves in a clean, dry area, free from contaminants. -Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety. -General Storage Guidelines: All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed or discarded. 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. Leftover contents of cans and prepared food will be stored in covered, labeled and dated containers in refrigerators and/or freezers. Observation on the kitchen on 2/14/23 at 12:24 P.M., showed: -Two door refrigerator: Eleven small Styrofoam containers with resident names written on the top, no date or label regarding contents. Ziploc bag containing sliced meat, no label or date. Two open bag of shredded cheese, no label or date. One open bag of chocolate chips, no label or date. Plastic container with green lid containing unknown food, no label or date. Open bag of hot dog buns, dated 01/03. Ziploc bag of sliced cheese, no label or date. -Three door refrigerator: Open bag of tortillas, no date. Open bottle of cranberry juice, no date. Open bottle of fruit punch, no date. Open container of french onion dip, no date. -Freezer: Open bag of blueberries, no label or date. Open bag of breaded chicken pieces, no label or date. Open bag of chicken wings, no label or date. During an interview on 2/14/23 at 12:40 P.M., [NAME] A said: -The small Styrofoam containers in the refrigerator with no label or date are the 3:00 P.M. supplements for residents. They are always made up the day before. -Open foods in the refrigerator and freezer should be labeled and dated with the date the food was opened. -Food left over from a meal should be thrown away after three days. -Open food, like ingredients, should be thrown away after the expiration date. During an interview on 2/14/23 at 12:47 P.M., [NAME] B said: -Food that has been opened or left over from a meal should be stored in the refrigerator and be labeled and dated with the day the food went in the refrigerator. -Food that is left over from a meal and stored should be thrown away after three days. -Other food, like bread or cheese, should be thrown away after 7 days or the expiration date. During an interview on 2/14/23 at 12:57 P.M., the Dietary Manager said: -All open items placed in the refrigerator or freezer should be labeled and dated with the day the item was stored in the refrigerator or freezer. -The facility uses the first in-first out system of using their supplies. Items with the closest expiration date should be used first. -Food left over from a meal should always be labeled with what the food is and what date it was put in the refrigerator. It can then be stored for three days and then thrown away. -Other foods stored in the refrigerator, like ingredients, bread, cheese, must be labeled and dated with the date the items were opened. This food must be thrown out after the manufacture's expiration date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the Resident #29's care plan, revised on 4/4/19, showed: - Significant change in status: resident is now on hospice caseload per family request; - The care plan did not address what additional services hospice staff would provide; - The care plan did not include the admitting diagnosis or any interventions related to hospice care including daily weights; - The care plan did not include how and when staff should perform catheter care. Review of resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/27/19, showed: - Moderate cognitive impairment; - Extensive assistance of one staff for bed mobility, transfer, and toilet use; - Indwelling urinary catheter and always continent of bowel; - Diagnosis of neurogenic bladder (is the name given to a number of urinary conditions in people who lack bladder control due to a brain, spinal cord or nerve problem); - Hospice care. Review of the resident's August 2019, physicians' order sheet (POS), showed: - Hospice care related to congestive heart failure (CHF) start date 3/26/19; - Daily weight start date 3/28/19; - Urinary catheter care three times daily for a diagnosis of neurogenic bladder. 3. During an interview on 8/22/19, at 11:15 A.M., the DON said: - The care plan is like a book that directs staff with individualized care for each resident; - Resident #29 is on hospice related to a diagnosis CHF; his/her care plan should include interventions related to these services. - MRSA should included in the care plan; she expected staff to follow standard infection control practices; the wounds should not be dangers if staff are using those. Based on observation, record review and interviews, the facility failed to ensure they used residents' comprehensive Resident Assessment Instruments (RAI) to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs which included residents' personal preferences as well as services and interventions that are designed to help the resident achieve goals for care, and which addressed reasons for admission. This effected two of 15 sampled residents (Resident #16 and #29). The facility's census was 43. Review of the facility's Policy for Use of the RAI (Resident Assessment Instrument) Minimum Data Set (MDS) Process, a federally mandated assessment instrument completed by facility staff, dated November 2017, showed: - It is the policy of the facility to utilize the RAI MDS to assist staff in gathering definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan. - It also assists staff with evaluating goal achievement and revising care plans accordingly by enabling the facility to track changes in resident status; - Used of the RAI allows for an interdisciplinary approach to foster a more holistic to resident care that assess residents' needs, strengths, goals, life history and preferences; - The Care Area Assessments (CAA) Process is designed to assist the assessor to systematically interpret the information on the MDS; helps to focus on key issues identified during the assessment so that decision as to whether or how to intervene can be explored with the resident. CAAs help identify social, medical and psychological problems and are the basis for individualized care planning; - The CAA process provides a framework for guiding the review of triggered areas, and clarification of a resident's functional status and related causes of impairment; provides a basis for additional assessment of potential issues, including related risk factors; may help the team begin to develop an individualized care plan with measurable objectives and timetables to meet a resident's medical, functional, mental and psychosocial needs as identified through the comprehensive assessment; - The plan of care, based on the MDS and identification of resident problems through the CAA process, reflects the strengths and areas for improvement for residents admitted to the facility; - The full plan of care is developed during the interdisciplinary care planning team (IDT) meeting where the CAAs and other data are shared with the entire team including the resident and caregivers; - The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs; - The plan includes residents' personal preferences as well as services and interventions that are designed to help the resident achieve goals for care, address reasons for admission and if appropriate, for discharge to the next appropriate setting including home and community based services. 1. Review of Resident #16's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/4/19, showed: - A Brief Interview for Mental Status (BIMS) score of 15, indicating the resident as no cognitive impairment; - Extensive assistance of two or more staff for bed mobility, transfers, moving throughout the facility, dressing and personal hygiene; - Diagnoses included: paraplegia, thoracic spina bifida with hydrocephalus (a birth defect that causes permanent damage to the spinal cord where excess spinal fluid builds up within the brain); neuromuscular dysfunction of the bladder; and sepsis (a potentially life-threatening condition caused by the body's response to an infection); - At risk for pressure ulcers; - One Stage 3 pressure ulcer (full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of the adjacent tissue); - One Unstageable pressure ulcer (known but not stageable due to coverage of the wound bed by slough and/or eschar; - Pressure reducing device for bed; turning/repositioning program; pressure ulcer care; application of nonsurgical dressing other than to feet. - Did not take an antibiotic during the seven days prior to the assessment. Review of the care plan, developed on 1/11/19, showed: - Problem: At risk for pressure ulcers; approaches included assist with repositioning; peri-care after toileting or incontinent episodes; observe for signs and symptoms of skin break down (redness, swelling, bruising and open areas) and report to charge nurse; elevate calves on a pillow while in bed to reduce pressure on heals; encourage food and fluid intake; contracted wound care team will evaluate and treat a developed pressure ulcer weekly; - Problem: Left back wound: approaches included treatments carried out as ordered; wound care team will evaluate and treat weekly; assist with repositioning often; observe wound for signs of infection; mechanical lift sling removed from chair after transfers; encourage an increase in protein intake; encourage him/her to lay down between meals; encourage to not sit for long periods of time; to be up for one hour a day per physician's orders; - 1/17/19: Wound care team in facility and evaluated wound; - 1/31/19: Wound care team in facility and wound has improved; - 2/14/19: Wound care team in facility and would has gotten worse. Review of the care plan, dated 6/6/19, showed: - Problem: Wound to the medial back: approaches included: licensed nurse will complete treatments as ordered; monitor for signs of infection (redness, warmth, swelling, fever and pain) and report to charge nurse; wound care team will evaluate and treat weekly; encourage to eat protein at meals; encourage to get up out of bed for meals and activities; - Addendum 6/13/19: wound care team in facility and wound has improved; - Addendum 6/20/19: wound care team in facility and would has gotten worse. Review of the wound culture results showed the following: - Collected 6/20/19; received 6/21/19; results finalized 6/25/19; - Final Report: Moderate Methicillin-Resistant Staph aureus (MRSA, an infection caused by a type of Staphylococcus (staph) bacteria that's resistant to many antibiotics); - The physician ordered Bactrim (an antibiotic which showed to be resistant to the MRSA) 800-160 milligrams (mg), one tablet twice a day for 10 days. Review of the nurses' progress note, dated 6/26/19 at 9:02 A.M., showed staff documented the received the antibiotic order for Bactrim 800-160 due to wound culture results; notified the resident's guardian and the resident. Review of the quarterly MDS, dated [DATE], showed: - Resident rejected care four to six days during the assessment period; - One Stage 3 pressure ulcer; - Two unstageable pressure ulcers; - Pressure reducing device for bed; turning/repositioning program; pressure ulcer care; application of nonsurgical dressing other than to feet. - Received an antibiotic two of the previous seven days; - Diagnoses did not include MRSA. Review of the wound care team's notes, date 6/27/19, showed: - Noted areas unchanged/worse - Wound team inquired with resident if he/she moves in his/her bed due to area to upper medial back looked sheered; - Resident denied; - Writer reports resident repositioned by staff, then will wiggle pull self back to a position he/she prefers; - Also reported resident refusing a protein supplement. Review of the resident's care plan showed the following addendums dated 6/27/19: - Wound care team in facility and wound has gotten worse; - Resident will be free from skin breakdown over the next 90 days; - Repeated all of the interventions previously listed in the care plan; - Did not add any interventions related to the results of the wound culture. Review of the care plan showed the following addendums: - 7/5/19: wound care team in facility and wound has gotten worse; - 7/11/19: Wound care team in facility and wound has improved; - 7/15/19: wound care team in facility and wound has gotten worse; - 7/22/19: Wound care team in facility and wound has improved; - 7/29/19: Wound care team in facility and wound has improved; - 8/5/19: Wound care team in facility and wound has improved; - 8/12/19: wound care team in facility and wound has gotten worse; - None of the addendums mentioned the MRSA. Review of the wound culture results showed: - Collected 8/12/19; received 8/13/19; results finalized 8/18/19; - Many MRSA; - The physician marked on the lab results he wanted staff to give trimethoprim/sulfa twice a day for 10 days; - Re-culture five days after antibiotic. Review of the nurses' progress note, dated 8/19/19, showed staff documented: - Physician here to see resident on rounds; - Reported C&S (culture & sensitivity) from wound and inquired if he wanted wound care team to address or order himself; - Antibiotic order of trimethoprim/sulfa twice a day for 10 days ordered; - Follow up culture five days after antibiotic completed. Review of the resident's care plan on 8/21/19, showed staff did not include any interventions for the MRSA infection in the resident's wound. During an interview on 8/21/19, at 7:25 A.M., the Director of Nursing (DON) said the resident refuses a lot of things, and will not get up. The area on his/her back has been there for a very long time. The wound care team comes to see him/her on a weekly basis. She spent several months in the hospital because of one wound but the other areas are new. She believed they were from shearing in his/her bed. He/she scoots around and causes the areas because he/she will not always allow staff to reposition him/her. The resident wants to control things, and will not get up anymore. They have the wheelchair for him/her but he/she refuses, saying it hurts. He/she does not promote the healing of the wounds by not getting up. He/she does take ensure 3 times a day for the protein value but will refuse at times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to update one of 15 sampled residents' (Resident #13) care plan with new interventions that included measurable objectives and timeframes to meet his/her needs after the resident's pressure ulcer located on his/her ankle healed. The facility's census was 43. Review of the facility's Policy for Use of the RAI (Resident Assessment Instrument) Minimum Data Set (MDS) Process, a federally mandated assessment instrument completed by facility staff, dated November 2017, showed: - It is the policy of the facility to utilize the RAI MDS to assist staff in gathering definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan. - It also assists staff with evaluating goal achievement and revising care plans accordingly by enabling the facility to track changes in resident status; - Used of the RAI allows for an interdisciplinary approach to foster a more holistic to resident care that assess residents' needs, strengths, goals, life history and preferences; - The Care Area Assessments (CAA) Process is designed to assist the assessor to systematically interpret the information on the MDS; helps to focus on key issues identified during the assessment so that decision as to whether or how to intervene can be explored with the resident. CAAs help identify social, medical and psychological problems and are the basis for individualized care planning; - The CAA process provides a framework for guiding the review of triggered areas, and clarification of a resident's functional status and related causes of impairment; provides a basis for additional assessment of potential issues, including related risk factors; may help the team begin to develop an individualized care plan with measurable objectives and timetables to meet a resident's medical, functional, mental and psychosocial needs as identified through the comprehensive assessment; - The plan of care, based on the MDS and identification of resident problems through the CAA process, reflects the strengths and areas for improvement for residents admitted to the facility; - The full plan of care is developed during the interdisciplinary care planning team (IDT) meeting where the CAAs and other data are shared with the entire team including the resident and caregivers; - The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs; - The plan includes residents' personal preferences as well as services and interventions that are designed to help the resident achieve goals for care, address reasons for admission and if appropriate, for discharge to the next appropriate setting including home and community based services. 1. Review of Resident #13's annual MDS, dated [DATE], showed: - a Brief Interview for Mental Status score of seven, which indicated severe cognitive impairment; - Limited assistance of one staff for transferring, walking in his/her room and the corridor, dressing and toilet use; supervision only with personal hygiene; - Diagnoses included dementia, anxiety, and depression; - Not assessed as at risk for developing pressure ulcers; no skin issues and no treatments; - The CAAs indicated the resident triggered a care area for pressure ulcers based on information provided in the MDS; - Staff indicated they addressed pressure ulcer risk in their care plan. Review of the resident's care plan, developed on 1/3/19, showed a problem of at risk for pressure ulcer. Staff listed the following approaches: - Assist with repositioning throughout the day and night; - Assist with peri-care after toileting and incontinent episodes; - Observe for signs and symptoms of skin breakdown: redness, swelling, bruising and open areas; report to charge nurse; - Braden score performed quarterly; - Elevate calves on a pillow while in bed to reduce pressure to heels; - Encourage increase food and fluid intake; - Contracted wound care to evaluate and treat a developed pressure ulcer weekly at facility. Review of the electronic medical record (e-MR) showed: - Wound to ankle; will heal without complication over the next 90 days; Licensed nurse will completed treatment as per physician's orders; monitor for signs of infection and report to charge nurse; contracted wound care team will evaluate and treat wound weekly on facility rounds; encourage proteins at meals; - 2/14/19: wound care team to evaluate wound. Review of the resident's care plan showed: - 3/29/19 addendum: Reviewed and no changes at this time; - No other addendums listed with additional updates. Review of the resident's quarterly MDS, dated [DATE], showed: - Has a Stage I pressure ulcer (Intact skin with a localized area of non-blanchable erythema or redness); or greater, a scar over bony prominence, or non- removable dressing/device; - At risk of developing pressure ulcers; - One Stage II (partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater) pressure ulcer; - Pressure reducing device for bed; turning/repositioning program; pressure ulcer care; application of nonsurgical dressing other than to feet. Review of the quarterly MDS, dated [DATE], showed: - At risk of developing pressure ulcers; - One Stage 3 pressure ulcer (full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of the adjacent tissue); - No healed pressure ulcers; - Pressure reducing device for bed; turning/repositioning program; pressure ulcer care; application of nonsurgical dressing other than to feet. - Wound care team documented on 7/8/19, the resident continued with a right lateral ankle wound, and gave orders for a dry dressing change only; - 7/29/19, Wound care team documented the wound was resolved. Right off-loading device in use, resident refuses offloading boot in bed. Review of the resident's care plan showed staff made no other addendums with additional updates after the resident's ankle wound healed. Staff did not update the care plan with new interventions to keep the resident from re-developing another pressure ulcer to his/her ankle once the wound healed. During an interview on 8/21/19, at 7:25 A.M., the Director of Nursing (DON) said the resident developed a pressure ulcer to his/her ankle from the shoes he/she wore. They rubbed an area which is now healed. Staff are using skin prep (used to toughen the skin) to the area now. She knew the family had cut the sides out of the resident's shoes to keep them from rubbing on the area, but did not see that they had updated the care plan once the wound healed. The Social Services Designee (SSD) adds a line on the dashboard (a screen on the facility's eMR) each time the wound care team assesses the wounds. There are not specific interventions included with those entries, only the status of the wound. During an interview on 8/22/19 at 11:12 A.M., the DON said: - Care Plans are like a book that tells staff how to care for people with instructions and guidelines; - There should be new interventions put into place to be sure wounds do not reopen if they are healed; - The SSD updates the care plans and develops the interventions; she tries to look at them but does not always get them reviewed.

Based on observation, interview and record review, the facility failed to ensure staff followed appropriate techniques to prevent the development of urinary tract infections (UTIs) for one of 15 sampled residents (Residents #29) with an indwelling urinary catheter (a sterile tube inserted into the bladder to drain urine) who was currently on an antibiotic for a UTI. The facility census was 43. Review of the facility's policy on Hand Hygiene, dated January 2017, showed: - Effective hand hygiene reduces the incidence of healthcare-associated infections; - Hand hygiene is the most important way to prevent the spread of bacteria which cause infections; - Improving healthcare personnel adherence to hand hygiene practices can reduce both infection and the spread of antibiotic-resistant bacteria; - Proper hand hygiene must be understood by all people working in a healthcare facility; - All members of the healthcare team will comply with current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines; -The policy did not direct staff to wash hands before and after gloving and when going from a dirty task to a clean task. Review of the facility's policy on Urinary Catheter Care, dated October 2016, showed: - Purpose: To ensure any resident with a catheter will be maintained to prevent infection; - Wash hands and put on clean gloves; - Perform perineal care gently washing around the opening of the urethra; - Cleanse the insertion site down the tubing of the urinary catheter outward (away from the body) four inches or farther if needed; repeat if necessary with a clean cloth or wipe, do not pull on the catheter; - A leg bag may be used when a resident is out of bed. Review of the facility's undated policy on Emptying Catheter Bag/Recording Intake and Output, showed: - Purpose: To measure output and visibly check color, amount, and consistency of urine; - Wash hands and put on gloves; - Open drainage port and allow urine to flow into container; - Wipe port with alcohol swab in a circular motion ensuring the drainage port does not touch the side of the container; - Empty the urine after reading output; - Rinse container in dirty utility room; - Remove gloves, wash hands, and put on clean gloves and proceed to next step; - Place the catheter or leg bag in a clean trash bag and take to the dirty utility room for cleaning; - Replace container bag nightly and the urine container every Sunday night; - The policy did not instruct staff to not place the container directly on the floor when emptying the catheter. 1. Review of the Resident #29's care plan revised on 4/4/19, showed: - Staff assistance with peri care after toileting and incontinent episodes; - Change catheter monthly and as needed; - Use leg bag when out of bed; - Goal to be free of any infection from his/her catheter; - The care plan did not include how and when staff should perform catheter care. Review of resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/27/19, showed: - Moderate cognitive impairment; - Extensive assistance of one staff for bed mobility, transfer, and toilet use; - Indwelling urinary catheter and always continent of bowel; - Diagnoses included neurogenic bladder (is the name given to a number of urinary conditions in people who lack bladder control due to a brain, spinal cord or nerve problem). Review of the resident's August 2019, physicians' order sheet (POS), showed: - Urinary catheter care three times daily for a diagnosis of neurogenic bladder. Review of the resident's urinalysis (UA, a test to detect bacteria indicative of a UTI), dated 8/16/19, showed bacteria in the urine indicative a UTI. Review of the resident's electronic physicians' order, dated 8/16/19, at 1:00 P.M., showed: - Macrobid (antibiotic), 100 milligrams (mg), one tablet orally, twice daily for seven days for UTI. Review of the nurses' notes, dated 8/19/19, at 11:08 A.M., showed: - Resident continues on antibiotic for UTI; - Denies complaints; voices feeling lost my mind. Review of the resident's culture and sensitivity (C&S, a test to determine which antibiotic should be used), dated 8/20/19, showed: - Faxed to the resident's physician who ordered to stop the Macrobid on 8/21/19,; - Ordered staff to start Bactrim DS 800 mg/160 mg (a combination of two antibiotics used to treat a UTI), twice daily for five days. Observation on 8/20/19, at 10:35 A.M., showed Certified Nurse Aide (CNA) A entered the resident's room to assist him/her to the bathroom to provide catheter care and did the following: - Did not wash his/her hands upon entering the resident's room; - Applied a gait belt snugly around the resident's waist and assisted the resident to transfer from the recliner to his/her wheelchair; - Pushed him/her into the bathroom and assisted the resident to transfer from the wheelchair to the commode; - Pulled the resident's pants and brief down with his/her bare hands; - Did not wash his/her hands and reached into the box of gloves located in the resident's bathroom and applied clean gloves; - Obtained a graduate from a clear plastic bag tied to the bar in the bathroom, did not place a barrier down on the floor and set the graduate directly onto the floor; - Obtained a disposable wipe with dirty gloves, picked up the graduate from the floor, opened the drainage port, drained the urine into the graduate and cleaned the drain port with a disposable wipe; - Placed the graduate with urine on the back of the commode balancing it on a package of disposable wipes as the resident continued to sit on the commode; - Did not remove his/her gloves and wash his/her hands then with the same gloves used for emptying the catheter, he/she obtained additional disposable wipes from another package of disposable wipes; - With dirty gloves, he/she held the catheter at the insertion site and used one wipe to wipe downwards towards the resident's leg bag; - Did not remove his/her gloves and wash his/her hands; - With dirty gloves, he/she assisted the resident to stand up from the commode; - Used three wipes to remove fecal material from the resident's rectum; - Did not remove his/her gloves and wash his/her hands before he/she pulled up the resident's brief and pants, then assisted him/her back to his/her wheelchair; - Picked up the graduate from the back of the commode, dumped the urine in the commode, rinsed it in the sink dumping the water in the commode, then placed it in a plastic bag tied to the bar in the resident's bathroom; - Removed his/her gloves, did not wash his/her hands; pulled the trash from the trash can and set the bag of trash directly on the floor; - Washed his/her hands in the bathroom, pushed the resident in his/her wheelchair from the bathroom to his/her bedside and transferred him/her back to the recliner; - Removed the gait, picked up the trash from the floor, and exited the resident's room without washing his/her hands. During an interview on 8/20/19, at 1:54 P.M., CNA A said: - Staff should wash their hands upon entering a resident's room, when going from a dirty task to clean task, after glove removal, and before exiting a resident's room; - When providing catheter care, it is acceptable to empty the catheter first; - The floor is considered to be dirty, but he/she did not know the graduate for emptying a catheter should not be placed directly on the floor; - It is acceptable to clean the catheter drain port with a disposable wipe; he/she did not know that an alcohol swab should be used; - Catheter care includes cleaning the tubing, holding it at the insertion site with clean gloves; - He/she should have also cleaned the resident's front perineal skin folds; - When staff go from a dirty task to clean task, they should remove their gloves and wash their hands; - After providing peri care, staff should remove their gloves, wash their hands and put on clean gloves; - It is acceptable to set the trash directly on the floor; - A person's hands may be considered dirty if they pick an item up from the floor. During an interview on 8/22/19, at 11:15 A.M., the Director of Nursing (DON) said: - Resident #29 is currently on an antibiotic for a UTI; - Staff should ensure they use good infection control practices when providing catheter care for residents to prevent UTIs; - Catheter care includes cleansing the front perineal skin folds and catheter tubing; - This should be done by holding the catheter tubing at the insertion site with a clean glove and cleansing the tubing approximately 6 inches down the tubing, wiping downwards; - Staff should wash their hands upon entering a resident's room, when going from a dirty task to clean task, after glove removal, and before exiting a resident's room; - Staff should not touch clean items with dirty hands; - The floor is considered dirty and the graduate used for emptying should not be placed directly on the floor; - Staff should empty a resident's catheter after peri-care has been provided; - After emptying a catheter, the drain port should be cleaned with an alcohol swab.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to ensure staff used proper techniques to reduce the possibility of accidents and injuries when facility staff failed to apply a gait belt during a transfer and failed to use the gait belt appropriately when transferring residents for three of 15 sampled residents (Resident #27, #29, and #42). The facility census was 43. Review of the facility's policy titled Gait Belt, revised on December 2014, showed: - The purpose of the gait belt is to provide increased security for the resident and staff and prevent injury during gait training and transferring of the resident; - Apply the belt around the resident's waist snugly to eliminate the possibility of gait belt movement; - Bring the resident to a standing position by grasping the belt with both hands while remaining upright yourself. Staff should place feet apart, one more forward than the other and slightly bend knees to assure solid posture and good body mechanics during lift/transfer. 1. Review of the Resident #42's care plan revised on 2/7/19, showed: - Staff assistance with transfers, mobility, dressing, toileting, and hygiene needs; -At risk for falls; goal to remain free from injury resulting from a fall. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/1/19, showed: - Moderate cognitive impairment; - Extensive assistance of one staff for bed mobility, transfer, and toilet use; - Balance during transitions and walking not steady; only able to stabilize with staff assistance. Observation on 8/19/19, at 10:01 A.M., showed Certified Nurse Aide (CNA) A entered the resident's room to assist the resident to the bathroom and did the following as the resident sat in his/her wheelchair: - The resident self-propelled his/her wheelchair to the bathroom and stood up unassisted; - CNA A did not inform the resident that he/she needed to apply a gait belt and assisted the resident to sit on the commode holding his/her arm; - CNA A informed the resident he/she would stand near the door and he/she exited the bathroom closing the door behind him/her; - After a few minutes, CNA A re-entered the bathroom, did not apply a gait belt before he/she assisted the resident to stand up from the commode by putting his/her arms under the resident's arm pits causing the resident's shoulders to raise upwards as he/she assisted the resident to stand; - After CNA A provided care, he/she assisted the resident back to his/her wheelchair, putting his/her arms under the resident's arm pits. 2. Review of the Resident #29's care plan revised on 4/4/19, showed: - At risk for falls; - Goal to remain free from injury resulting from a fall. Review of resident's quarterly MDS, dated [DATE], showed: - Moderate cognitive impairment; - Extensive assistance of one staff for bed mobility, transfer, and toilet use; - Diagnoses included depression. Observation on 8/20/19, at 10:35 A.M., showed CNA A entered the resident's room to assist him/her to the bathroom to provide catheter care and did the following: - Applied a gait belt snugly around the resident's waist as the resident sat in his/her recliner and assisted the resident to stand by putting one hand under the resident's arm pit causing the resident's shoulder to rise upwards as he/she held the gait belt with the other hand and assisted the resident to transfer to the wheelchair; - Pushed him/her into the bathroom and assisted the resident to transfer to the commode by putting one hand under the resident's arm pit causing the resident's shoulder to rise upwards as he/she held the gait belt with the other hand; - After CNA A provided catheter care, he/she assisted the resident to transfer from the commode back to the wheelchair by putting one hand under the resident's arm pit causing the resident's shoulder to rise upwards; - Pushed the resident in his/her wheelchair from the bathroom to his/her bedside and transferred him/her back to the recliner by putting one hand under the resident's arm pit causing the resident's shoulder to rise upwards; - CNA A removed the gait and exited the resident's room. 3. Review of Resident #27's 30-day MDS, dated [DATE], showed: - A Brief Interview for Mental Status (BIMS) score of five, which indicated severe cognitive impairment; - Limited physical assistance by one staff for transferring; - Not steady when moving from a seated to standing position; not steady, only able to stabilize with human assistance; - Diagnoses included: pneumonia, dementia and generalized muscle weakness; - Received as needed (PRN) pain medications; no presence of pain at the time of the assessment. Review of the resident's care plan, updated 6/21/19, showed: - Problem: Risk for falls; assist with transfers to wheelchair; - Problem: ADL (activities of daily living)/incontinence; assist with toileting, transfers, hygiene and dressing; - Did not indicate what type of assistance staff needed to provide for transfers. Observation and interview on 8/19/19, at 1:45 P.M. showed the resident sat in his/her wheelchair moaning and saying his/her back hurt so bad. CNA A entered the room to transfer the resident from the wheelchair to the recliner. CNA A put the gait belt around the resident's waist, grabbed the back of the gait belt with one hand then used his/her other hand and grabbed the backside of the resident's arm to assist him/her with standing. The resident's arm raised and he/she cried out in pain as he/she stood. CNA A said the resident was usually independent but lately his/her back has been hurting so bad that he/she needs help. 4. During an interview on 8/20/19, at 1:54 P.M., CNA A said: - He/she should have applied a gait belt on Resident # 42; - It is not acceptable to put your arm under a resident's arm pit. During an interview on 8/22/19, at 11:15 A.M., the Director of Nursing (DON) said: - Staff should always use a gait belt when transferring a resident and the gait belt should be applied snug around the resident's waist; - Staff should never put their arms under a resident's arm pit as this could cause injury.

Based on observations, interview and record review, the facility failed to ensure they documented the administration of their controlled substances to ensure the narcotic count and the Controlled Substance Record were accurate which affected two of 12 sampled residents (Resident #3 and #36) and one additionally sampled resident (Resident #17). The facility census was 43. Review of the facility policy, dated August 2017, titled Accountability of Controlled Medications (medications that are classified into five distinct categories or schedules depending upon the drug's acceptable medical use and the drug's abuse or dependency potential) showed: - The facility will utilize a Controlled Medication Use form to monitor administration of medication. This form will include: Name of resident, medication name, and strength and dosage form of the medications, date dispensed and quantity received; - Immediately after a dose is administered, the licensed nurse or certified medication technician (CMT) administering the medication enters all the required information on the required form. - Any discrepancies in controlled substance medications counts are reported to the Director of Nursing (DON) immediately. 1. Review of the Resident #3's physician order sheet (POS), dated August 2019, showed: - Xanax (medication used to treat used to treat anxiety and panic disorders) Schedule IV tablet 0.25 milligrams (mg), orally twice daily; no diagnosis indicated. Review of the Controlled Substance Record for the resident's Xanax 0.25 mg showed the resident should have four Xanax 0.25 tablets in his/her cassette. Observation on 8/21/19, at 9:28 A.M., showed the resident's medication cassette of Xanax 0.25 mg contained three tablets. 2. Review of the Resident #36's POS, dated August 2019, showed: - Clonazepam (medication used to treat used to treat anxiety and panic disorders) Schedule IV 0.5 mg, orally twice daily for anxiety. Review of the Controlled Substance Record for the resident's Clonazepam 0.5 mg showed the resident should have six Clonazepam 0.5 mg tablets in his/her cassette. Observation on 8/21/19, at 9:30 A.M., showed the resident's medication cassette of Clonazepam 0.5 mg contained five tablets. 3. Review of the Resident #17's POS, dated August 2019, showed: - Norco (narcotic pain medication), Schedule II, 5-325 mg, orally every 12 hours; no diagnosis indicated. Review of the Controlled Substance Record for the resident's Norco 5-325 mg showed the resident should have 15 Norco 5-325 mg tablets in his/her cassette. Observation on 8/21/19, at 9:32 A.M., showed the resident's medication cassette of Norco 5-325 mg contained 14 tablets. 4. During an interview on 8/21/19, on 9:35 A.M., Registered Nurse (RN) A said: - The Controlled Substance Record and the actual controlled medication count do not currently match because he/she needs to sign out the 8:00 A.M., doses of medications for multiple residents; - He/she needed to sign out Resident #3's, # 36's and # 37's 8:00 A.M. medications; - He/she should have completed all documentation immediately after he/she administered their medications. 5. During an interview on 8/21/19, at 10:00 A.M., the DON said: - The Controlled Substance Record and the narcotic count should always match; - Staff are expected to administer the medication then immediately chart the medications as given. - This includes subtracting the medication for the Controlled Substance Record.

Based on observation, interview and record review, the facility failed to ensure they kept the refrigerator that contained residents' medication, located in the medication room, clean and free of debris; failed to ensure staff destroyed and did not store a discontinued bottle of liquid Ativan (often used at end of life and to treat anxiety), a Schedule IV medication (has a low potential for abuse relative to the schedule III medications) for one resident (Resident #29), and failed to ensure a foil package of Brovana (inhalation solutions for nebulized treatments),located in the door of the refrigerator, was labeled, and failed to ensure they dated when they opened applesauce used when staff administer medication. Additionally, staff failed to ensure a foil package of DuoNeb (inhalation solution for nebulized treatments) was labeled and was not stored with residents' oral medications located in the medication cart. The facility census was 42. Review of the facility's policy, titled Disposing of Drugs, dated January 2017, showed: - It is the facility's policy to dispose of medications in compliance with state and federal regulations; - Any medication that has been discontinued by a physician shall be removed from the medication cart and placed in the medication room to be destroyed per facility policy; - Medications shall be destroyed within 30 days of them being discontinued; - Any medication that is destroyed will be logged on a Drug Disposal Record and kept as part of the resident's clinical record. Review of the facility's policy, titled Medication Storage and Labeling, dated August 2017, showed: - All medication will be destroyed upon expiration; - The night nurse will audit the medication room for expired medication and open dates weekly on Saturday night; - The Director of Nursing (DON) will audit the medication room monthly and review the Pharmacy Consultants reports monthly. Review of the facility's undated policy titled Medication Room Refrigerator, showed: - The refrigerator is to be maintained in a clean and safe manner; - Everything in the refrigerator is to be dated. 1. Observation on 8/21/19, at 9:45 A.M., of the medication refrigerator located in the medication room showed: - An opened foil package of Brovana that contained two vials; the foil package was not labeled with a resident's name or dosage instructions; - An opened, individual serving cup of applesauce that was almost empty with no open date; - Multiple dried food particles and dried brown-colored substances on the shelf; - A dead bug laying on a shelf of the door; - Dried food particles and hair in the bottom. 2. Observation on 8/21/19, at 9:50 A.M., of the medication refrigerator located in the medication room showed: - Resident #29's bottle of liquid Ativan give 0.25 milligrams (mg) every two hours as needed (PRN), filled on 5/28/19. Review of Resident #29's physicians' order sheet (POS) dated August 2019, showed: - No active order for liquid Ativan. 3. Observation of the South hall medication cart on 8/21/19, at 9:52 A.M., showed: - An opened package of DuoNeb the foil package not labeled with a resident's name or dosage instructions. 4. During an interview on 8/21/19, at 9:55 A.M., Registered Nurse (RN) A said: - As needed (PRN) psychotropic medications are discontinued after 14 days; ideally Resident #29 liquid Ativan should have been destroyed mid June; - When a resident requires their medication to be crushed, staff frequently use applesauce; the applesauce should have a date when opened; - After opening Brovana, it should be stored in the refrigerator and he/she planned to store the entire box in the refrigerator; - Like medications should be stored together and nebulizer supplies are stored in the bottom of the medication cart. During an interview on 8/21/19, at 10:00 A.M., the DON said: - Discontinued medications should not be stored in the medication refrigerator; - All medications should have dosage instructions and should be in the original container; - It is everyone's responsibility to ensure the medication refrigerator is clean; if something is spilled it should be cleaned up immediately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to assure staff provided care in a manner to prevent infection or the possibility of infection when staff did not use proper hand hygiene when administering medications, when staff did not wash their hands upon entering and exiting a resident's rooms, when providing incontinent care, before putting on clean gloves, before changing gloves between dirty and clean tasks, and did not clean a floor with an disinfecting agent after setting trash directly on the floors of resident rooms, which affected nine of 15 sampled residents (Residents #3, #9, #14, #24, #26, #36, #1, #37 and #42). The facility census was 43. 1. Review of the facility's Hand Hygiene policy, dated January 2017, showed: - Effective hand hygiene reduces the incidence of healthcare-associated infections; - Hand hygiene is the most important way to prevent the spread of bacteria which cause infections; - Improving healthcare personnel adherence to hand hygiene practices can reduce both infection and the spread of antibiotic-resistant bacteria; - Proper hand hygiene must be understood by all people working in a healthcare facility; - All members of the healthcare team will comply with current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines. 2. Observation of medication administration on 8/19/19, at 12:01 P.M., showed Registered Nurse (RN) A did the following: - Without applying hand sanitizer, he/she reached into the medication cart, retrieved medication cassette and popped Resident #3's ropinirole (used to treat restless leg syndrome) into a cup and administered to the resident; - Without applying hand sanitizer, he/she reached into the medication cart, retrieved medication cassette and popped Resident #9's potassium and Demadex (used to treat fluid retention) into a cup and administered to the resident with a spoon; - Without applying hand sanitizer, he/she reached into the medication cart, retrieved medication cassette and popped Resident #36's Sinemet (used to treat Parkinson's symptoms: shakiness, stiffness, difficulty moving) into a cup and administered to the resident with a spoon; - Without applying hand sanitizer, he/she reached into the medication cart, retrieved medication cassette and popped Resident #26's iron into a cup and administered to the resident. During an interview on 8/20/19, at 12:30 P.M., RN A stated: - Hand hygiene should occur between residents if contact occurs; - Eye drop administration requires hand washing afterwards, hand sanitizer is not allowed; - Hand hygiene was not required between every resident when using a spoon to administer when resident contact or resident object contact did not occur. 3. Observation and interview of medication administration on 8/21/19, at 12:11 P.M., showed Social Services Designee/CMT: - Without applying hand sanitizer, he/she reached into the medication cart, retrieved medication cassette and popped Resident #24's Chlorpromazine (used to treat psychotic disorders) into a cup and administered to the resident. - He/she said hand hygiene occurs when resident contact happens. 4. Review of the Resident #42's care plan revised on 2/7/19, showed: - Staff assistance with transfers, mobility, dressing, toileting, and hygiene needs. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/1/19, showed: - Moderate cognitive impairment; - Extensive assistance of one staff for bed mobility, transfer, and toilet use; - Always continent of bowel and bladder. Observation on 8/19/19, at 10:01 A.M., showed Certified Nurse Aide (CNA) A entered the resident's room to assist the resident to the bathroom and did the following as the resident sat in his/her wheelchair: - Did not wash his/her hands upon entering the resident's room; -The resident self propelled his/her wheelchair to the bathroom and stood up unassisted; - CNA A pulled the resident's brief and pants down with his/her bare hands and assisted the resident to sit on the commode; - CNA A informed the resident he/she would stand near the door and he/she exited the bathroom closing the door behind him/her; - After a few minutes, CNA A opened the bathroom door and entered the bathroom; he/she did not wash his/her hands before putting on clean gloves; - CNA A assisted the resident to stand and used disposable wipes to cleanse the resident's front perineal skin folds; - With the same gloves, he/she reached into the package of disposable wipes and cleansed the resident's rectal area; - Did not remove his/her gloves and wash hands before he/she pulled up the resident's brief, pants, and assisted the resident to his/her wheelchair; - Removed his/her gloves but did not wash his/her hands; - Bagged the trash, setting it on the floor, straightened the towels on the rack near the sink then opened the bathroom door wider so the resident could self propel out of the bathroom; - CNA A washed his/her hands, picked up the trash from the floor and exited the resident's room. 5. Review of the Resident #24's care plan revised on 1/17/19, showed: - Staff assistance with hygiene needs due to bowel and bladder incontinence. Review of resident's quarterly MDS, dated [DATE], showed: - Moderate cognitive impairment; - Extensive assistance of two staff for bed mobility, dressing, and hygiene; - Always incontinent of urine and bowel; - Diagnoses included schizophrenia. Observation on 8/19/19, at 10:12 A.M., showed CNA A and CNA B entered the resident's room as the resident lay in is/her bed and did the following: - CNA B washed his/her hands and put on clean gloves; - CNA A walked over to the resident and started gathering supplies; CNA B instructed him/her to wash his/her hands; - CNA A washed his/her hands and put on clean gloves; - Both staff opened the resident's soiled brief and both staff rolled the resident onto his/her left side; - CNA A pulled several wipes from the package, handed them to CNA B as he/she wiped fecal material from the resident's buttock and rectal area; - CNA A informed CNA B that he/she would need to leave the room to obtain an additional package of wipes; - CNA A removed his/her gloves, used hand sanitizer and exited the resident's room; - CNA A returned to the room, did not wash his/her hands upon entering, and placed the new package of wipes on the foot of the bed; - CNA B instructed CNA A to wash his/her hands; CNA A then went to the resident's bathroom, washed his/her hands and put on clean gloves; - CNA A continued to pull multiple wipes from the package, handing them to CNA B to cleanse the fecal material from the resident's buttock and rectal area; - Both staff assisted the resident to roll so they could remove the soiled brief and CNA B discarded the brief in the trash; - CNA B removed his/her gloves that contained fecal material, washed his/her hands, and put on clean gloves; - CNA A obtained wipes and cleaned the resident's frontal perineal skin folds, removing fecal material; - CNA A did not remove his/her gloves and wash his/her hands before assisting CNA B with securing a clean brief on the resident; - With the same dirty gloves, CNA A obtained a pair of pants that lay in the resident's wheelchair and both staff put the pants on the resident; - With the same dirty gloves, CNA A obtained the lift seat that lay in the resident's wheelchair and both staff rolled the resident side to side as they slid the lift seat under the resident; - Both staff then used the mechanical lift and transferred the resident from his/her bed to the wheelchair; - With dirty gloves, CNA A touched the lift that is used on multiple residents and the resident's wheelchair; - CNA A removed his/her gloves, did not wash did not wash his/her hands and bagged the trash, setting it on the floor; - CNA B removed his/her gloves; CNA A followed him/her to the bathroom and both staff washed their hands; - CNA A picked up the bag of trash from the floor and exited the resident's room. 6. Review of the Resident #14's care plan revised on 3/28/19, showed: - Staff assistance with perineal care after toileting and incontinent episodes. Review of resident's quarterly MDS, dated [DATE], showed: - Severe cognitive impairment; - Extensive assistance of two staff for bed mobility, dressing, and hygiene; - Always incontinent of urine and frequently incontinent of bowel; - History of urinary tract (UTI) within the last 30 days. Review of the resident's August 2019, physicians' order sheet (POS), showed: - Dietary supplement Glucernia (shakes designed specifically for people with diabetes), twice daily at 10:00 A.M., and bedtime. Observation on 8/19/19, at 10:52 A.M., showed CNA A and CNA C entered the resident's room as the resident lay in is/her bed and did the following: - Both staff washed their hands and put on clean gloves; - CNA A pulled disposable wipes from the package and CNA C used multiple wipes to remove fecal material from the resident's frontal perineal skin folds; - CNA C did not remove his/her gloves and wash his/her hands before he/she assisted CNA A to roll the resident onto his/her side; - CNA A pulled disposable wipes from the package and CNA C used wipes to remove fecal material from the resident's buttock and rectal area; - As CNA C was cleansing the resident's rectum, the resident started to have another bowel movement; - CNA A pulled disposable wipes from the package and CNA C used multiple wipes to remove the fecal material from the resident's buttock and rectal area; - CNA C did not remove his/her gloves before he/she assisted CNA A with securing a clean brief on the resident; - CNA C removed his/her gloves, did not wash his/her hands and with dirty hands obtained the resident's pants and lift seat which set in the resident's wheelchair; - As care was being provided, staff knocked on the door and said they had the resident's Glucerna; CNA A directed them to set it on the bedside table which staff did and then they exited the room; - Both staff put the resident's pants on and rolled the resident back and forth positioning the lift seat under the resident; - With dirty hands, CNA C touched the mechanical lift and assisted CNA A to transfer the resident from his/her bed to the wheelchair; - With dirty hands, CNA C picked up the straw that set next to the glass of Glucerna on the bedside table, put the straw in the glass and handed the glass to the resident; - CNA A removed his/her gloves, did not wash his/her hands, bagged the trash, placed the trash on the floor, put a new plastic liner in the trash can, picked up the trash from the floor, and both staff exited the resident's room without washing their hands. During an interview on 8/19/19, at 1:30 P.M., CNA C said: - When staff go from a dirty task to clean task, they should remove their gloves and wash their hands; - Perineal care is considered a dirty task; staff should remove their gloves and wash their hands before continuing with care; - Staff should not touch clean items with dirty hands. During an interview on 8/20/19, at 1:54 P.M., CNA A said: - Staff should wash their hands upon entering a resident's room, when going from a dirty task to clean task, after glove removal, and before exiting a resident's room; - When staff go from a dirty task to clean task, they should remove their gloves and wash their hands; - After providing peri care, staff should remove their gloves, wash their hands and put on clean gloves; - It is acceptable to set the trash directly on the floor; - A person's hands may be considered dirty if they pick an item up from the floor. 7. Review of the Resident #1's August 2019 POS, showed: - Timolol (used to treat glaucoma, a condition in which increased pressure in the eye can lead to gradual loss of vision), 0.5 % ophthalmic solution, instill one drop to both eyes twice daily. Observation of medication administration on 8/20/19, at 8:37 A.M., showed RN A did the following: - Pushed the medication cart outside of Resident #1's room, obtained a bottle of Timolol 0.5% from the medication cart, entered the resident's room, and placed the bottle on the resident's bedside table; - Washed his/her hands, put on clean gloves and administered one drop in each eye; - Applied lacrimal pressure (nasal cavity, pressure on the tear drainage duct avoids unwanted systemic side effects) with a tissue; - Removed his/her gloves, did not wash his/her hands, exited the resident's room, reached into his/her pocket to obtain the keys to the medication cart, unlocked the cart and returned the bottle of Timolol; - Charted the administration of the medication and pushed the medication cart across the hall outside Resident #37's room. 8. Review of the Resident #37's August 2019, POS showed: - Restasis (is used to treat chronic dry eye) ophthalmic solution, instill one drop to both eyes twice daily. - Erythromycin (antibiotic) 0.5% ophthalmic ointment daily for blepharitis (inflammation of the eyelids); start date 8/19/19. Observation of medication administration on 8/20/19, at 8:42 A.M., showed RN A did the following; - Entered Resident #37's room, washed his/her hands, returned to the medication cart and prepared the resident's Restasis, pulling a single use vial from the box; - Entered the resident's room again, did not wash his/her hands before putting on clean gloves and he/she administered the Restasis, placing one drop in each eye; - Applied lacrimal pressure with a tissue; - Removed his/her gloves, did not wash his/her hands, exited the resident's room, and charted the administration of the eye drops without washing his/her hands. 9. During an interview on 8/22/19 at 11:12 A.M., the Director of Nursing (DON) said: - Hand hygiene should occur with medication administration; - Hand hygiene should occur between residents, regardless of resident contact; - Staff should wash their hands before starting medication pass; - Staff should follow CDC guidelines for handwashing; - Staff should wash their hands upon entering a resident's room and prior to exiting; - Staff should wash their hands before and after providing care; - Staff should wash their hands and change gloves between dirty and clean tasks; - Staff should not touch clean items with dirty hands; - Staff should always wash their hands after glove removal; - The trash can is considered a dirty item; staff should remove their gloves and wash their hands after touching the trash can; - Trash should not placed on the floor after they remove it from the can; it should be taken directly to the dirty utility room.