**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and document review, the facility failed to ensure a resident was appropriately discharged for 1 of 6 sampled residents (Resident (R) 6). This failure could potentially lead to medical complications or adverse events which could result in rehospitalization.Findings include:Resident 6 (R6) was admitted to the facility on [DATE] with diagnoses including spondylosis, type 2 diabetes mellitus, hypothyroidism, and hypertension.A care plan dated 6/12/2025 documented the need for discharge planning. R6 was to be discharged from the facility with a safe and coordinated discharge to R6's home with family. The facility was to assist R6 and/or support person in locating and coordinating post discharge services and to plan for specific resident needs and continuing care needs after discharge such as home health care, durable medical equipment, oxygen (if needed), prescriptions, and other support services.On 07/24/2025 at 9:02 AM, a Case Manager (CM) stated a new resident assessment was completed within 48 hours of a resident's admission to the facility. This Assessment included finding out if the resident had a previous home health provider, or if the resident planned to go to a group home which may have had a preferred home health care provider. The CM affirmed the facility preferred to use the facility's own home health care agency when a referral for home health care was needed. The CM stated the facility had a form the resident could fill out on admission to the facility which documented the resident had allowed the facility to use the facility's home health agency as the resident's preferred choice for home health care services. The CM expressed when the resident did not fill this form out, discharge planning was completed by giving the resident other home health agency options. If the resident had already filled out the form, then the facility would have used their home health agency for care continuity when able. The CM affirmed the facility had no list of home health agency providers for case management to give to residents.On 07/24/2025 in the afternoon, R1, R2, R3, and R4 had a signed referral form to use the facility's preferred home health agency, however, explained had no recollection of signing the form. R5 had a signed referral form to use the facility's preferred home health agency and stated wanted to try the facility's home health agency.The facility failed to produce documented evidence R6 was presented with options and assisted to choose a post-acute care provider which was best suited to the resident's goals, preferences, needs and circumstances.On 07/23/2025 at 12:00 PM, the Director of Nursing stated there was nothing in writing, but case management had told the residents they had other options besides the facility's home health agency.On 07/23/2025 at 03:28 PM, the Administrator stated case management documentation of resident discharge planning was not always in the notes, but the results of the discharge planning were documented in the resident's discharge summary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure proper Medicare Notice of Medicare Non-Coverage letter was completed and provided for 1 of 3 unsampled residents selected for beneficiary notification review. The deficient practice resulted in non-compliance with Medicare requirements, that could hinder the resident's ability to make informed decisions regarding their coverage and care. Findings include: Resident #99 (R99) R99 was admitted to the facility on [DATE], with diagnoses including fall, right hip fracture and syncope. Review of R99 S's CMS (Centers for Medicare and Medicaid Services) SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review form provided by the Case Manager on 03/19/2025, revealed R99's Medicare Part A skilled services episode started on 08/30/2024 and the last covered day for Part A services was on 09/18/2024. R99 was discharged home on [DATE]. The medical record lacked documented evidence the Notice of Medicare Non-Coverage letter was provided to R99 or to resident's representative. On 03/19/2025 at 11:00 AM, the facility's Case Manager could not produce evidence the Notice of Medicare Non-Coverage letter was provided to R99. On 03/20/2025 at 9:45 AM, the facility's Administrator stated it was the expectation the facility followed the CMS guidelines and provide the Notice of Medicare Non-Coverage letter to resident and/or resident representative three days prior to the end of the benefits. The facility's undated policy titled Notice of Medicare Non-Coverage (NOMNC) documented the facility would provide a NOMNC letter to eligible beneficiaries, even if they agree to terminate services. The NOMNC would be delivered at least two days before Medicare covered services end, or the last day of service if care is not provided daily, and the original signed document must be retained in the beneficiary's file.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and document review, the facility failed to implement care plan interventions for 4 of 13 sampled residents and one unsampled resident (Resident #11), for pressure reducing device (Resident #92), intravenous midline care (Residents #17 and 21), feeding assistance (Resident #11 and 21), and constipation care (Resident #39). The deficient practice had the potential to compromise the quality of care, disrupt continuity in treatment, and may lead to negative outcomes, including deterioration in residents' overall health. Findings include: Resident #92 (R92) R92 was admitted on [DATE] with diagnoses including dementia, benign prostatic hyperplasia (BPH), chronic hypoxic respiratory failure, diabetes mellitus, and bed-bound status. The admission skin assessment dated [DATE], revealed an unspecified open area in coccyx. Skin assessment dated [DATE], documented R92 had a deep tissue injury (DTI) with moisture-associated skin damage (MASD) in the coccyx area. [NAME] risk observation for the prediction of pressure ulcer dated 03/12/2025, documented R92 was at moderate risk for pressure ulcers and the care plan included air mattress. A physician's order dated 03/11/2025 documented place air mattress and verify placement every shift. A care plan dated 03/11/2025 for pressure ulcer revealed interventions including pressure reducing devices as indicated. On 03/18/2025 at 8:46 AM, R92 was in bed and no air mattress was observed. On 03/18/2025 at 2:15 PM, a Certified Nursing Assistant (CNA) confirmed R92 was not on an air mattress. Treatment administration record (TAR) revealed nurses documented air mattress placement was verified every shift, from 03/11/2025 through 03/18/2025. On 03/18/2025 at 2:27 PM, the wound care nurse explained air mattresses were ordered based on the wound conditions and the prediction of wound progress based on the risk assessment and resident's condition. The wound care nurse confirmed a request for air mattress was transmitted to a vendor the same day the physician order was obtained on 03/11/2025. The wound care nurse acknowledged did not follow the order to ensure the air mattress was delivered and placed on R92's bed. The wound care nurse indicated nurses would verify the placement of the air mattress and notify the Wound Care Nurse if the resident had not received the mattress. The wound care nurse acknowledged did not verify the placement of the air mattress when performed the wound care on 03/17/2025. On 03/18/2025 at 2:40 PM, a Registered Nurse stated being not aware R92 had an order for an air mattress. The RN when to R92's room and confirmed the air mattress was not in place. After revising the TAR, the RN acknowledged had documented the air mattress placement without verifying. On 03/20/2025 at 7:40 AM, the wound care Nurse Practitioner (NP) explained R92 was at risk to develop pressure ulcers due to the several co-morbidities that included diabetes, hypoxia, anemia, poor mobility and bed bound. The NP indicated R92 had a deep tissue injury in the coccyx area, a lesion that the extent of the damage could not be superficially observed until the skin was open. The NP verbalized as protocol, residents with DTI, unstageable pressure ulcers and pressure ulcers stage 3 and above were required to be placed on an air mattress to prevent the development and worsening of pressure ulcers. The NP explained the mattress uses inflatable air tubes to inflate and deflate, mimicking patient movement, to relieve pressure and ensure proper air circulation, preventing pressure wounds and preventing pressure in areas with less padding. The NP confirmed had signed the order for low air loss mattress for R92 on 03/11/2025 and expected the nurses to follow the order as standard of practice. Resident 17 (R17) R17 was admitted on [DATE], with diagnoses including hemiplegia hemiparesis following cerebral infarction and sepsis. R17's care plan for midline care initiated 02/18/2025, documented an intervention to receive treatment in accordance with physician's order. Site care and dressing changes per protocol. On 03/18/2025 at 9:32 AM, R17's right upper arm midline dressing was dated 03/10/2025 with ends coming loose. A Registered Nurse (RN) confirmed the observation and indicated midline dressing changes were done weekly on Sundays. A physician's order dated 02/18/2025, documented to change midline dressing weekly. Clean with alcohol stick or chloraprep at insertion site, air dry, apply skin prep to area and air dry. Apply bio-patch to insertion site. Cover with transparent dressing. The observation revealed R17's midline dressing change had not been performed since 03/10/2025 (eight days). Resident 21 (R21) R21 was admitted on [DATE], with diagnoses including metabolic encephalopathy, dementia and history of craniotomy. R21's care plan for midline care initiated 03/04/2025, documented an intervention to receive treatment in accordance with physician's order. Site care and dressing changes per protocol. On 03/18/25 at 10:12 AM, R21's right upper arm midline dressing was dated 03/09/2025 with ends coming loose. The Clinical Nurse Manager (CNM) confirmed the observation and indicated midline dressing changes were done weekly on Sundays. The observation revealed R21's midline dressing change had not been performed since 03/09/2025 (nine days). R21's nutrition care plan initiated on 03/10/2025, documented an intervention to provide R21 with one-on-one (1:1) feeding assistance due to a diagnosis of protein calorie malnutrition. Two meal observations on 03/19/2025 (breakfast) and 03/20/2025 (breakfast) revealed there was no staff member providing feeding assistance to R21. Resident 11 (R11) R11 was admitted on [DATE], with diagnoses including unspecified dementia and severe protein calorie malnutrition. R11's nutrition care plan initiated on 03/10/2025, documented an intervention to provide R11 with one-on-one (1:1) feeding assistance due to risk in alterations in nutritional status. One meal observation on 03/19/2025 (breakfast) revealed there was no staff member providing feeding assistance to R11. Resident 139 (R139) R139 was admitted on [DATE], with diagnoses including ulcerative colitis and diverticulitis. R139's Bowel and Bladder care plan initiated on 03/06/2025, documented interventions to follow the bowel brigade. Review of medical record revealed R139's last bowel movement was on 03/11/2025 and the bowel brigade was not followed. Specifically, the bowel brigade called for enema administration on 03/16/2025 (Day 5 of no BM) but this was not administered until 03/20/2025 (nine days of no BM). The Comprehensive Care Plan policy (undated) documented, the facility would develop person-centered care plan. The care plan should be evaluated to determine if current interventions were being followed and effective in attaining identified goals. Outcomes were monitored and interventions evaluated after implementation of the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and document review, the facility failed to ensure care not provided to residents, were not documented in the medical record as completed for the application of antimicrobial wipes for 1 of 13 sampled residents (Resident #92), and for wound care and intravenous midline dressing change for 2 of 13 sample residents (Resident #17 and 21). Failure to accurately document care in the medical record had the potential to compromise patient safety by leading to gaps or errors in care, delay necessary interventions, and hinder continuity of treatment that could lead to deterioration of resident's health due to unmet care needs. Findings include: Resident #92 (R92) R92 was admitted on [DATE] with diagnoses including included dementia, benign prostatic hyperplasia (BPH), chronic hypoxic respiratory failure, diabetes mellitus, and bed-bound status. A physician order dated 03/15/2025 documented to wipe down resident's entire body with Chlorhexidine (CHG) wipes once daily to be applied in between 6:00 AM to 2:00 PM, related to Candida auris infection. (CHG is an antimicrobial agent used as a topical antiseptic and disinfectant, effective against bacteria, yeasts, and some viruses). On 03/19/2025 at 9:00 AM, the treatment administration record (TAR) was reviewed. The TAR revealed the CHG wipes were applied from 03/15/2025 through 03/19/2025 as ordered and signed by a Registered Nurse (RN). On 03/19/2025 at 9:30 AM, the RN who signed the TAR for the application of CHG wipes, explained the Certified Nursing Assistants (CNAs) were responsible to execute the order for wiping down R92 and was not sure if the CNAs already did it. On 03/19/2025 at 10:00 AM, the CNA assigned to provide care to R92 confirmed the the wiping procedure was not performed at that time. On 03/19/2025 at 11:45 AM, an observation of the application of CHG wipes was conducted with two Certified Nursing Assistances (CNAs). One of the CNAs verbalized it was the first time these wipes were used. The CNA confirmed on 03/17/2025 and 03/18/2025, regular wipes and soap and water were used to wipe the resident down. On 03/19/2025 at 2:00 PM, a second review of the TAR revealed new charting entries which were not documented when the record was reviewed in the morning. The new charting indicated CHG wipes were not applied on 03/17/2025, since the Certified Nursing Assistant did not wipe the resident with the CHG. The information was documented in the TAR as charted on 03/17/2025 at 7:52 AM by an RN. The TAR also documented new charting entry stating the wipes were applied on 03/18/2025 at 4:30 PM, after changed bed to air mattress. This information was documented in the TAR as charted on 03/19/2025 at 12:16 PM by the same RN. The TAR revealed another new charting entry explaining the wipes were applied on 03/19/2025, however the CNA stated had not wiped the resident with CHG in the morning. This information was documented in the TAR as charted on 03/19/2025 at 12:20 PM by the same RN. These three administration entries were not documented on the TAR when it was revised in the morning. On 03/19/2025 at 1:30 AM, the RN confirmed the TAR comments were documented extemporaneously after knowing the CNAs did not apply the CHG wipes to R92. The RN acknowledged had documented and signed the administration of the CHG wipe without verifying the application. The RN confirmed a new order for wiping down the resident was obtained to extend the treatment since the wipes were not applied as ordered. On 03/19/2025 at 2:00 PM, the Director of Nursing (DON) explained the RN should not have documented extemporaneous comments in the TAR since it could be considered alteration of medical records. The DON indicated it was the expectation that nurse did not chart care as provided, when it did not occur. Wound Care Resident 17 (R17) R17 was admitted on [DATE], with diagnoses including hemiplegia hemiparesis following cerebral infarction and sepsis. A physician's order dated 02/19/2025, documented to provide wound care to coccyx pressure ulcer: clean with wound cleanser, pat dry, apply Triad cream and cover with foam dressing daily. Change dressing as needed. A physician's order dated 02/19/2025, documented to provide wound care to left heel pressure ulcer: clean with wound cleanser, pat dry, apply Sure prep and cover with foam dressing every Tuesday and Friday, change dressing as needed. A physician's order dated 02/19/2025, documented to provide wound care to right heel pressure ulcer: clean with wound cleanser, pat dry, apply Sure prep and cover with foam dressing every Tuesday and Friday, change dressing as needed. On 03/18/2025 at 9:47 AM, a Registered Nurse (RN) and a Certified Nursing Assistant (CNA) entered R17's room and removed the resident's blue socks. The resident's right and left heel each had a beige foam dressing dated 03/13/2025. The treatment administration record (TAR) reflected treatments were administered to R17's bilateral heels on 03/14/2025 and 03/18/2025. On 03/18/2025 in the afternoon, the Registered Nurse (RN) and wound care nurse confirmed the observation of R17's bilateral heel dressings which were dated 03/13/2025 did not align with documented care which was supposedly provided on 03/14/2025 and 03/18/2025. Resident 21 (R21) R21 was admitted on [DATE], with diagnoses including metabolic encephalopathy, dementia and history of craniotomy. On 03/18/25 at 10:12 AM, R21 laid in bed appearing weak and lethargic. R21 responded with singular words or nodding head. The wound care nurse and a CNA lifted the resident's blanket which revealed R21's right and left heel each had a beige foam dressing dated 03/13/2025. A physician's order dated 03/04/2025, documented to provide wound care to left heel pressure ulcer: clean with wound cleanser, pat dry, apply Sure prep and cover with foam dressing every Tuesday, Thursday and Saturday, change dressing as needed. A physician's order dated 03/04/2025, documented to provide wound care to right heel pressure ulcer: clean with wound cleanser, pat dry, apply Sure prep and cover with foam dressing every Tuesday, Thursday and Saturday, change dressing as needed. R21's TAR reflected wound care to R21's bilateral heels were signed as having been administered on 03/15/2025 and 03/18/2025. On 03/18/2025 in the afternoon, the RN and wound care nurse confirmed the observation of R21's bilateral heel dressings which were dated 03/13/2025, did not align with documented care which was supposedly provided on 03/15/2025 and 03/18/2025. On 03/18/2025 at 10:25 AM, the wound care nurse acknowledged R21's TAR reflected R21's coccyx wound treatments were not administered on 03/06/2025, 03/08/2025 and 03/11/2025. The wound care nurse acknowledged there was no documented evidence the wound care nurse provided the service on the above-mentioned dates, because the wound care nurse was under the impression the RN's comments of not-administered wound care nurse to perform was sufficient to convey treatment had been administered by the wound care nurse. The wound care nurse indicated there was no other place in the EHR to reflect the missed treatments were indeed provided by the wound care nurse. On 03/18/2025 at 10:30 AM, the wound care nurse explained having the habit of pre-signing all wound care treatments before actual administration because the tasks were scheduled to be performed for the rest of the day. The wound care nurse acknowledged signing R17's and R21's wound treatment services on 03/18/2025 even if wound care had not been performed. On 03/19/2025 at 3:19 PM, the Director of Nursing (DON) indicated wound care services should be signed off after the administration of the task and not ahead of time. The DON acknowledged observation of R17 and R21's foam dressings dated 03/13/2025 did not align with documented care in the TAR, which went against the [NAME] standards of practice which the facility adopted to follow. Midline Dressing Changes Resident 17 (R17) R17 was admitted on [DATE], with diagnoses including hemiplegia hemiparesis following cerebral infarction and sepsis. On 03/18/2025 at 9:32 AM, R17 laid awake and alert in bed. A single lumen midline was observed on R17's right upper arm with dressing dated 03/10/2025 with ends coming loose. A Registered Nurse (RN) confirmed the observation and indicated midline dressing changes were done weekly on Sundays. The RN indicated R17's the midline had not been used in the facility. A physician's order dated 02/18/2025, documented to change midline dressing weekly. Clean with alcohol stick or chloraprep at insertion site, air dry, apply skin prep to peri-cath area and air dry. Apply bio-patch to insertion site. Cover with transparent dressing. The Medication Administration Record (MAR) for March 2025, documented a nurse performed dressing change to R17's midline on 03/16/2025. On 03/18/2025 in the afternoon, an RN and Clinical Nurse Manager (CNM) confirmed observation of R17's midline dressing which was dated 03/10/2025 did not align with documented care supposedly provided on 03/16/2025. On 03/18/2025 at 12:29 PM, the Infection Preventionist (IP) could not speak to why the nurse assigned to R17 on 03/16/2025, had signed for the dressing change administration when the actual midline dressing was labeled 03/10/2025. Resident 21 (R21) R21 was admitted on [DATE], with diagnoses including metabolic encephalopathy, dementia and history of craniotomy. On 03/18/25 at 10:12 AM, R21 laid in bed appearing weak and lethargic. The Clinical Nurse Manager (CNM) extended R21's right arm which revealed a double lumen midline with dressing dated 03/09/2025 with ends coming loose. The CNM explained R21's midline was being used for IV banana bag (electrolytes) administration. On 03/18/2025 at 10:15 AM, the CNM reviewed R21's MAR and confirmed there was documented care for R21's midline on 03/16/2025 which did not align with the actual observation of the midline dressing dated 03/09/2025. The CNM described R21's midline dressing as not appearing new and edges were coming loose. On 03/19/2025 at 3:04 PM, the DON indicated being made aware actual observations of R17's and R21's midline dressing dates did not align with documented care in the residents' MAR which went against professional standards of practice for documenting care. On 03/19/2025 in the afternoon, the DON indicated nurses were not permitted to sign off on a medication or treatment without administering or providing the service. The DON indicated nurses were not permitted to document administration of a medication or treatment service prior to actual administration. The DON indicated the facility followed the [NAME] standards of practice and provided the following: The Lippincott Nursing Procedure (ninth edition) indicated, documentation was a valuable method for demonstrating a nurse had applied knowledge, skills and judgement according to professional standards of practice. Document only care, treatments and medications which the nurse themselves had provided or administered. Nurses must never chart in advance and must ensure documentation reflected ongoing care. Delayed documentation increased the potential for omissions, errors, and inaccuracies due to memory lapses.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and document review, the facility failed to ensure assistance was provided for residents who were assessed or evaluated to require one-on-one (1:1) feeding assistance for 1 of 13 sampled residents (Resident 21) and one unsampled resident (Resident 11). The deficient practice placed the residents at risk for significant weight loss and malnutrition. Findings include: Resident 21 (R21) R21 was admitted on [DATE], with diagnoses including metabolic encephalopathy, dementia and history of craniotomy. On 03/19/2025 at 9:18 AM, R21's head of bed was elevated approximately 30 degrees, R21 appeared weak and lethargic and responded with singular words or nodding head. A signage on the wall read 1:1 feeding assistance. Sit resident up in chair during mealtimes. A meal tray was observed on the resident's bedside table and contained a bowl of cream of wheat covered in plastic wrap and an Ensure supplement. The meal ticket read regular pureed diet with thin liquids. There were no staff members observed in the room. A physician's order dated 03/05/2025, documented to provide R21 with 1:1 feeding assistance. The five-day minimum data set (MDS) dated [DATE], revealed R21 was dependent on staff for eating. On 03/19/2025 at 9:25 AM, a Certified Nursing Assistant (CNA1) entered R21's room and stated R21 had refused to eat. CNA1 defined refusal as the resident's failure to respond to the CNA when CNA1 asked R21 if the resident wanted to eat. CNA1 explained having three residents requiring feeding assistance and CNA1 could not transfer R21 from bed to chair by themselves and was too shy to ask for help from other CNAs who were busy as well. The vitals report dated 03/19/2025, revealed R21 consumed 1 percent (%) to 25% of the breakfast meal. On 03/20/2025 at 9:20 AM, R21 laid in bed with eyes closed, head of bed elevated approximately 30 degrees. An untouched breakfast tray was observed on R21's bedside table which contained a bowl of cream of wheat, a bowl of pureed eggs, a cup of apple juice and an Ensure supplement. There were no staff members in the room. On 03/20/2025 at 9:24 AM, CNA2 indicated being assigned to R21 but CNA2 also had two other residents who required feeding assistance, so CNA2 asked CNA3 to assist R21 with breakfast. CNA3 indicated having already attempted to offer R21 breakfast but R21 refused to eat. CNA3 defined refusal as the resident not responding to CNA3 when the CNA3 asked R21 if R21 wanted to eat. CNA2 and CNA3 were inside R21's room and confirmed a signage on the wall read 1:1 feeding assistance, sit resident up in chair during mealtimes. CNA2 and CNA3 confirmed the observation R21 laid in bed and was not seated on chair, and R21's meal tray had been untouched with spoon clean and food bowls still covered with plastic wrap. On 03/20/2025 at 9:28 AM, CNA2 and CNA3 indicated the observation of R21's breakfast service reflected instructions to sit resident up in chair was not followed and the untouched tray reflected the lack of a proactive attempt to feed the resident's breakfast meal. In addition, CNA3 indicated not informing the nurse regarding R21's refusing breakfast. On 03/20/2025 at 9:30 AM, CNA2 recounted a day last week when CNA2 was assisted by another staff member in transferring R21 to the chair for meal service which resulted in a 50% consumption of the meal because the resident was more alert and participative in the meal task. CNA2 indicated personally observing how the intervention of sitting the resident up had a positive impact on the resident's consumption. On 03/20/2025 at 9:32 AM, the Licensed Practical Nurse (LPN) indicated expecting CNAs to inform the nurse of all refused services which included meals. The LPN indicated being informed of resident refusals gave nurses the opportunity to make own attempts with providing the service, identifying the resident's reason for refusal so findings could be documented in the resident's electronic health record (EHR) and communicated with the inter-disciplinary team (IDT) particularly the Registered Dietician (RD), the Director of Nursing (DON) and the physician. On 03/20/2025 at 9:40 AM, the Director of Nursing (DON) entered R21's room and confirmed the signage on the wall which read, 1:1 feeding assistance, sit resident up on chair during mealtimes. The DON confirmed the observation of R21 lying in bed instead of sitting on a chair, and the meal tray having been untouched with food bowls and juice still covered with plastic wrap and spoon clean. Using a loud voice and clear speech, the DON asked R21 if the resident wanted to eat breakfast. The resident responded to the DON, I'll try. The DON asked R21 if the resident preferred to sit in a chair for breakfast, the resident responded to the DON, yes. On 03/20/25 at 9:50 AM, R21 appeared well-groomed with hair combed while seated on a chair. CNA2 pointed to the resident's tray and stated R21 had fully consumed the cream of wheat, 25 % of pureed egg and 120 milliliters (ml) of the Ensure supplement. CNA2 indicated the resident's consumption would be documented as 75%. On 03/20/2025 at 10:00 AM, the DON indicated the intervention to sit R21 up in a chair during meals was an intervention which was expected to be followed. The DON indicated not knowing whether the intervention was a family request, a therapy recommendation or a physician's order, but CNAs who read the signage were expected to follow them. Resident 11 (R11) R11 was admitted on [DATE], with diagnoses including unspecified dementia and severe protein calorie malnutrition. On 03/19/2025 at 9:08 AM, R11 laid awake in bed appearing weak and responded with soft voice. A breakfast tray containing scrambled eggs and pureed bread was observed on a table in front of the resident. A signage on the wall read, Provide 1:1 feeding assistance. There were no staff members in the room. On 03/19/2025 at 9:10 AM, CNA1 indicated R11 did not need assistance with meals because the resident was an independent eater. CNA1 entered R11's room and confirmed there was a signage with instructions to provide the resident with 1:1 feeding assistance, but the CNA verbalized not being aware of this instruction. A five-day MDS dated [DATE], revealed R11 was independent with eating. A physician's progress note dated 03/17/2025, documented R11 was drowsy, slept a lot and was not eating much, put on 1:1 feed. A physician's order dated 03/17/2025, documented to provide R11 with 1:1 feeding assistance. The vital report dated 03/19/2025, revealed R11 consumed 1% to 25% of the breakfast meal. On 03/20/2025 at10:00 AM, the DON explained R11's MDS assessment was completed by a therapy staff member who assessed the resident to be independent with eating from a functional ability standpoint. According to the DON, R11 was evaluated by a provider on 03/17/2025 and ordered to put R11 on 1:1 feeding assistance due to increased fatigue and poor meal intakes. The DON indicated the morning observation of R11's meal service on 03/19/2025, reflected physician's order to provide the resident with feeding assistance was not followed and should have been. On 03/20/2025 at 10:05 AM, the DON indicated expecting 1) CNAs to practice teamwork and seek assistance from one another when there were multiple resident requiring assistance during meals, 2) proactive attempts must be made to be successful with meal service, and 3) resident refusals must immediately be reported to the nurse to give the nurse the opportunity to make own attempts, identify reasons for refusal, document event in the EHR and communicate with the IDT. On 03/20/2025 at 10:19 AM, the RD confirmed R21 and R11 both had orders for 1:1 feeding assistance because both residents had issues with alertness, weakness and poor consumption. The RD explained being sat up in a chair was an intervention in R21's case because the resident was often drowsy and became more alert and participative with meals when seated on chair. According to the RD, R21 had a two-pound weight loss which did not rise to a level of significant weight loss but had the potential to result in significant weight loss if interventions were not being implemented. The RD indicated R11 was also in the RD's focus list due to poor intakes related to weakness, impaired cognition and debility. The RD indicated not being informed R21 and R1 were not being provided 1:1 feeding assistance as ordered, prior to today. On 03/20/2025 in the afternoon, the RD and Dietary Manager indicated residents were no longer transported to the main dining area for meals unlike before. The RD and dietary manager indicated expressing residents such as R21 and R11 would benefit from being transported to the dining room where the residents had a higher chance of being awake, alert and participative with meal service. According to the RD and dietary manager, transporting residents to the dining room would also enable CNAs to assist multiple residents at the same time. The RD and dietary manager indicated not hearing back from leadership regarding transporting dependent residents to the dining area for meals. The Activities of Daily Living (ADL) policy (Undated) documented, a resident unable to carry out ADL would receive necessary services to maintain good nutrition. For these residents, care plan goals may not be stated in terms of what the resident was able to achieve but in terms of the outcome of care and/or services provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and document review, the facility failed to ensure prescribed antimicrobial wipes were used for the treatment of a multidrug resistant fungal infection for 1 of 13 sampled residents (Resident #92). The deficient practice had the potential to increase the risk of complications for the affected resident, compromise the overall quality of care, lead to further spread of the infection, and jeopardizing the health and safety of other residents and staff within the facility. Findings include: Resident #92 (R92) R92 was admitted on [DATE] with diagnoses including included dementia, benign prostatic hyperplasia (BPH), chronic hypoxic respiratory failure, diabetes mellitus, and bed-bound status. A physician order dated 03/10/2025, revealed R92 was on strict contact isolation for Candida auris in the groin area (Candida auris is a multidrug-resistant fungal pathogen that can cause serious infections, particularly in healthcare settings, and is difficult to treat with standard antifungal medication. A physician order dated 03/15/2025 documented to wipe down resident's entire body with Chlorhexidine (CHG) wipes once daily to be applied in between 6:00 AM to 2:00 PM, related to Candida auris infection. (CHG is an antimicrobial agent used as a topical antiseptic and disinfectant, effective against bacteria, yeasts, and some viruses). On 03/19/2025 at 9:00 AM, the treatment administration record (TAR) was reviewed. The TAR revealed the CHG wipes were applied from 03/15/2025 through 03/19/2025 as ordered and signed by a Registered Nurse (RN). On 03/19/2025 at 9:30 AM, the RN who signed the TAR for the application of CHG wipes, explained the Certified Nursing Assistants (CNAs) were responsible to execute the order for wiping down R92 and was not sure if the CNAs had already did it. On 03/19/2025 at 10:00 AM, the CNA assigned to provide care to R92 confirmed the wiping procedure was not performed at that time. On 03/19/2025 at 11:45 AM, an observation of the application of CHG wipes was conducted with two Certified Nursing Assistances (CNAs). One of the CNAs verbalized it was the first time these wipes were used. The CNA confirmed on 03/17/2025 and 03/18/2025, regular wipes and soap and water were used to wipe the resident down. On 03/19/2025 at 2:00 PM, a second review of the TAR revealed new charting entries which were not documented when the record was reviewed in the morning. The new charting indicated CHG wipes were not applied on 03/17/2025, since the Certified Nursing Assistant did not wipe the resident with the CHG. The information was documented in the TAR as charted on 03/17/2025 at 7:52 AM by an RN. The TAR also documented new charting entry stating the wipes were applied on 03/18/2025 at 4:30 PM, after changed bed to air mattress. This information was documented in the TAR as charted on 03/19/2025 at 12:16 PM by the same RN. The TAR revealed another new charting entry explaining the wipes were applied on 03/19/2025, however the CNA stated had not wiped the resident with CHG in the morning. This information was documented in the TAR as charted on 03/19/2025 at 12:20 PM by the same RN. These three administration entries were not documented on the TAR when it was revised in the morning. On 03/19/2025 at 1:30 AM, the RN confirmed the TAR comments were documented extemporaneously after knowing the CNAs did not apply the CHG wipes to R92. The RN acknowledged had documented and signed the administration of the CHG wipe without verifying the application. The RN confirmed a new order for wiping down the resident was obtained to extend the treatment since the wipes were not applied as ordered. On 03/19/2025 at 2:00 PM, the Director of Nursing (DON) explained the RN should not have documented extemporaneous comments in the TAR, since it could be considered alteration of medical records. The DON indicated it was the expectation that nurse did not chart care as provided when it did not occur. The facility undated policy titled Administration of Medication version E1019, documented licensed staff would administer medications in accordance with professional standard.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and document review, the facility failed to ensure a physician order for an air mattress was followed for 1 of 13 sampled residents (Resident #92), and wound care treatment was provided as per physician's order for 2 of 13 sampled residents (Residents #17 and 21). The deficient practice placed the residents at risk to develop new pressure ulcers and had the potential to worsen or delay healing of the existing pressure ulcer and increase patient pain and discomfort. Findings include: Resident #92 (R92) R92 was admitted on [DATE] with diagnoses including included dementia, benign prostatic hyperplasia (BPH), chronic hypoxic respiratory failure, diabetes mellitus, and bed-bound status. The admission skin assessment dated [DATE], revealed an unspecified open area in coccyx. Skin assessment dated [DATE], documented R92 had a deep tissue injury (DTI) with moisture-associated skin damage (MASD) in the coccyx area. [NAME] risk observation for the prediction of pressure ulcer dated 03/12/2025, documented R92 was at moderate risk for pressure ulcers and the care plan included air mattress. A physician's order dated 03/11/2025 documented place air mattress and verify placement every shift. A care plan dated 03/11/2025 for pressure ulcer revealed interventions including pressure reducing devices as indicated. On 03/18/2025 at 8:46 AM, R92 was in bed and no air mattress was observed. On 03/18/2025 at 2:15 PM, a Certified Nursing Assistant (CNA) confirmed R92 was not on an air mattress. Treatment administration record (TAR) revealed nurses documented air mattress placement was verified every shift, from 03/11/2025 through 03/18/2025. On 03/18/2025 at 2:27 PM, the wound care nurse explained air mattresses were ordered based on the wound conditions and the prediction of wound progress based on the risk assessment and resident's condition. The wound care nurse confirmed a request for air mattress was transmitted to a vendor the same day the physician order was obtained on 03/11/2025. The wound care nurse acknowledged did not follow the order to ensure the air mattress was delivered and placed on R92's bed. The wound care nurse indicated nurses would verify the placement of the air mattress and notify the Wound Care Nurse if the resident had not received the mattress. The wound care nurse acknowledged did not verify the placement of the air mattress when performed the wound care on 03/17/2025. On 03/18/2025 at 2:40 PM, a Registered Nurse stated being not aware R92 had an order for an air mattress. The RN when to R92's room and confirmed the air mattress was not in place. After revising the TAR, the RN acknowledged had documented the air mattress placement without verifying. On 03/20/2025 at 7:40 AM, the wound care Nurse Practitioner (NP) explained R92 was at risk to develop pressure ulcers due to the several co-morbidities that included diabetes, hypoxia, anemia, poor mobility and bed bound. The NP indicated R92 had a deep tissue injury in the coccyx area, a lesion that the extent of the damage could not be superficially observed until the skin was open. The NP verbalized as protocol, residents with DTI, unstageable pressure ulcers and pressure ulcers stage 3 and above were required to be placed on an air mattress to prevent the development and worsening of pressure ulcers. The NP explained the mattress uses inflatable air tubes to inflate and deflate, mimicking patient movement, to relieve pressure and ensure proper air circulation, preventing pressure wounds and preventing pressure in areas with less padding. The NP confirmed had signed the order for low air loss mattress for R92 on 03/11/2025 and expected the nurses to follow the order as standard of practice. Resident 17 (R17) Resident # 17 was admitted on [DATE], with diagnoses including hemiplegia hemiparesis following cerebral infarction and sepsis. An admission skin assessment dated [DATE], revealed R17 was admitted with a coccyx (tailbone) deep tissue injury (DTI) measuring 5 centimeters (cm) by 4.6 cm, a left heel DTI measuring 1.5 cm by 2.0 cm and a right heel DTI measuring 2.0 cm by 2.0 cm. On 03/18/2025 at 9:32 AM, R17 laid awake and alert in bed and able to express needs. R17 reported receiving inconsistent care to bilateral heel ulcers and the coccyx wound. On 03/18/2025 at 9:47 AM, a Registered Nurse (RN) and a Certified Nursing Assistant (CNA) entered R17's room and removed the resident's blue socks. The resident's right and left heel each had a beige foam dressing dated 03/13/2025. R17 was then turned to left side which revealed a small light-colored unopened area over the coccyx which was described by the RN as a moisture associated skin damage (MASD). A physician's order dated 02/19/2025, documented to provide wound care to coccyx pressure ulcer: clean with wound cleanser, pat dry, apply Triad cream and cover with foam dressing daily. Change dressing as needed. A physician's order dated 02/19/2025, documented to provide wound care to left heel pressure ulcer: clean with wound cleanser, pat dry, apply Sure prep and cover with foam dressing every Tuesday and Friday, change dressing as needed. A physician's order dated 02/19/2025, documented to provide wound care to right heel pressure ulcer: clean with wound cleanser, pat dry, apply Sure prep and cover with foam dressing every Tuesday and Friday, change dressing as needed. The treatment administration record (TAR) for February 2025 and March 2025, revealed coccyx wound treatments were not administered on 02/21/2025, 02/25/2025, 03/03/2025, 03/10/2025, and 03/17/2025. The TAR reflected wound care was not administered to R17's right and left heel on 02/21/2025, 02/25/2025, and 03/04/2025. Comments for non-administration read, to be done by wound care nurse. The TAR reflected wound care had been administered for R17's coccyx, right heel and left heel pressure ulcers on 03/18/2025 by the wound care nurse. On 03/18/2025 at 10:15 AM, the RN acknowledged routinely signing off on R17's wound care as not administered wound care nurse to perform because the RN expected the wound care nurse to be providing the wound treatment on those days. The RN stated instead of documenting not administered on the resident's TAR, the RN should have left the TAR blank until the wound care nurse themselves provided the service to ensure provision of care and accurate documentation. The RN verbalized the observation of R17's foam dressings on bilateral heels dated 03/13/2025 did not align with the TAR which reflected treatments were administered to R17's bilateral heels on 03/14/2025 and 03/18/2025. On 03/18/2025 at 10:25 AM, the wound care nurse acknowledged R17's TAR reflected R17's coccyx wound treatments were not administered on 02/21/2025, 02/25/2025, 03/03/2025, 03/10/2025, and 03/17/2025 and wound care was not administered to R17's right and left heel on 02/21/2025, 02/25/2025, and 03/04/2025. The wound care nurse acknowledged there was no documented evidence the wound care nurse had provided the service on the above-mentioned dates because the wound care nurse was under the impression the RN's comments of not-administered wound care nurse to perform was sufficient to convey treatment had been administered by the wound care nurse. The wound care nurse indicated there was no other place in the electronic health record (EHR) to reflect the missed treatments were indeed provided by the wound care nurse. On 03/18/2025 at 10:30 AM, the wound care nurse confirmed wound care for R17's coccyx, left heel and right heel wounds had already been signed off as administered by the wound care nurse on 03/18/2025 when in fact the service had not yet been administered. The wound care nurse explained having the habit of pre-signing all wound care which were scheduled to be performed for the rest of the day. The wound care nurse confirmed the observation of R17's foam dressings on bilateral heels dated 03/13/2025 did not align with the TAR which reflected treatments were administered to R17's bilateral heels on 03/14/2025 and 03/18/2025. Resident 21 (R21) R21 was admitted on [DATE], with diagnoses including metabolic encephalopathy, dementia and history of craniotomy. An admission skin assessment dated [DATE], revealed R21 was admitted with a coccyx DTI measuring 5.0 cm by 4.5 cm, a left heel DTI measuring 1.5 cm by 1.5 cm and a right heel DTI measuring 2.0 cm by 2.0 cm. On 03/18/25 at 10:12 AM, R21 laid in bed appearing weak and lethargic. R21 responded with singular words or nodding head. The wound care nurse and a CNA lifted the resident's blanket which revealed R21's right and left heel each had a beige foam dressing dated 03/13/2025. R21's coccyx wound did not have a foam dressing. A physician's order dated 03/04/2025, documented to provide wound care to coccyx pressure ulcer: clean with wound cleanser, pat dry, apply Triad cream and cover with foam dressing daily, change dressing as needed. A physician's order dated 03/04/2025, documented to provide wound care to left heel pressure ulcer: clean with wound cleanser, pat dry, apply Sure prep and cover with foam dressing every Tuesday, Thursday and Saturday, change dressing as needed. A physician's order dated 03/04/2025, documented to provide wound care to right heel pressure ulcer: clean with wound cleanser, pat dry, apply Sure prep and cover with foam dressing every Tuesday, Thursday and Saturday, change dressing as needed. The TAR for March 2025 revealed wound treatments were not administered to R21's coccyx, right heel and left heel pressure ulcers on 03/06/2025, 03/08/2025 and 03/11/2025 Comments for non-administration read, not administered-to be done by wound care nurse. The TAR reflected wound care to R21's bilateral heels were signed off as having been administered on 03/15/2025 and 03/18/2025. On 03/18/2025 at 10:15 AM, the RN acknowledged routinely signing off on R21's wound care as not administered- wound care nurse to perform because the RN expected the wound care nurse to be providing the wound treatment on those days. The RN stated instead of documenting not administered on the resident's TAR, the RN should have left the TAR blank until the wound care nurse themselves provided the service to ensure the provision and documentation of care was accurate. The RN verbalized the observation of R21's foam dressings on bilateral heels dated 03/13/2025 did not align with the TAR which reflected treatments were administered to R21's bilateral heels on 03/15/2025 and 03/18/2025. On 03/18/2025 at 10:25 AM, the wound care nurse acknowledged R21's TAR reflected R21's coccyx wound treatments were not administered on 03/06/2025, 03/08/2025 and 03/11/2025. The wound care nurse acknowledged there was no documented evidence the wound care nurse had provided the service on the above-mentioned dates because the wound care nurse was under the impression the RN's comments of not-administered wound care nurse to perform was sufficient to convey treatment had been administered by the wound care nurse. The wound care nurse indicated there was no other place in the EHR to reflect the missed treatments were indeed provided by the wound care nurse. On 03/18/2025 at 10:30 AM, the wound care nurse confirmed wound care for R21's coccyx, left heel and right heel wounds had already been signed off as administered by the wound care nurse on 03/18/2025 when in fact the service had not yet been administered. The wound care nurse explained having the habit of pre-signing all wound care which were scheduled to be performed for the rest of the day. The wound care nurse confirmed the observation of R21's foam dressings on bilateral heels dated 03/13/2025 did not align with the TAR which reflected treatments were administered to R21's bilateral heels on 03/15/2025 and 03/18/2025. On 03/19/2025 at 3:19 PM, the Director of Nursing (DON) indicated the RN who was documenting R17's and R21's scheduled wound treatments as not administered to be done by wound care nurse should have left the TAR blank and allow the wound care nurse who would be providing the treatments, to sign on wound care services after the administration of the task and not ahead of time. The DON acknowledged observation of R17 and R21's foam dressings dated 03/13/2025 did not align with documented care in the TAR and went against basic nursing documentation guidelines, and this practice was unacceptable. On 03/20/2025 at 7:56 AM, the wound Nurse Practitioner (NP) indicated expecting nurses to follow treatment orders to encourage proper healing and prevent complications of wounds. The NP indicated expecting wound dressings to be signed and dated for accountability purposes and to ensure care was provided to the wound. The Administration of Medications policy (undated) documented, licensed personnel would appropriately administer prescribed medications and immediately chart the administration in the electronic health record. The Treatment of Pressure Ulcers policy (undated) documented, all treatments require a physician's order. The wound care nurse was responsible for ensuring appropriate treatments and protective measures were in place and implemented. The policy indicated interventions for the care of residents with moderated risk for pressure ulcers may benefit from approaches included air mattress.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and document review, the facility failed to ensure the facility's bowel protocol was followed for a resident who was constipated for 1 of 13 sampled residents (Resident 139). The deficient practice placed the resident at risk for bowel complications such as fecal impaction. Findings include: Resident 139 (R139) R139 was admitted on [DATE], with diagnoses including ulcerative colitis and diverticulitis. On 03/20/2025 at 2:12 PM, R139 was seated in wheelchair with family member present. R139 responded slowly to questions using singular words. The family member indicated visiting the resident daily and expressed concern regarding R139 not having a bowel movement (BM) since 03/11/2025. The family member reported R139 had been suffering from stomach issues for 20 years and BMs were very irregular, but the family member had a routine which worked for them at home. R139's family member indicated administering a stool softener and a laxative after two days of no BM. If this was not successful, the family member would administer an enema (a liquid inserted into the rectum to stimulate a BM) after four days of no BM and an enema was effective 100 percent of the time. On 03/20/2025 at 2:18 PM, R139's family member indicated no nurse had discussed the bowel protocol with the family member, but the physician presented some options during a visit on 03/16/2025 however, the physician did not mention an enema which led the family member to think an enema was not among the options available. The family member indicated not being aware R139 had a physician's order for an enema which was to be administered on Day 5 of no BM. A nursing progress note dated 03/18/2025, revealed R139's last recorded bowel movement (BM) was on 03/11/2025. R139's abdomen was distended; bowel sounds present on all quadrants. Physician notified, ordered KUB (non-invasive diagnostic tool which uses radiography imaging to visualize the kidneys, ureter, and bladder). On 03/20/2025 at 2:20 PM, R139's family member indicated being aware a KUB was ordered and carried out on 03/18/2025. The family member claimed to have requested a copy of the results from a nurse on the afternoon of 03/19/2025 and was informed results were not yet available. On 03/20/2025 at 2:27 PM, R139's family member pressed on R139's abdomen and described the resident's abdomen as distended and more rigid than usual. The family member pressed on R139's stomach and asked R139 if there was pain or discomfort from being constipated to which R139 responded, Yes. The Bowel Brigade (bowel protocol) policy (undated), documented to administer Milk of Magnesia on Day three of no bowel movement. Review of R 139's medical record revealed a physician's order dated 03/11/2025, documented to administer Milk of Magnesia 30 cubic centimeters (cc) by mouth in the morning. The medication administration record (MAR) for March 2025, revealed Milk of Magnesia was administered to R139 on 03/13/2025. Result: ineffective. The Bowel Brigade (bowel protocol) policy (undated), documented to administer Dulcolax suppository on Day four of no bowel movement. Review of R 139's medical record revealed a physician's order dated 03/11/2025, documented to administer Dulcolax suppository 10 milligrams (mg) per rectum in the morning on Day four of no bowel movement. The medication administration record (MAR) for March 2025, revealed Milk of Magnesia was administered to R139 on 03/14/2025. Result: ineffective. The Bowel Brigade (bowel protocol) policy (undated), documented to administer Fleet Enema on Day five of no bowel movement. Review of R 139's medical record revealed a physician's order dated 03/11/2025, documented to administer Fleet Enema in the morning on Day five of no bowel movement. The medical record lacked documented evidence Fleet Enema was offered or administered to R139 on 03/16/2025 (day five of no BM) or at any given time until 03/20/2025 (nine days with no BM). On 03/20/2025 at 1:49 PM, the Infection Preventionist (IP) indicated being familiar with the facility's bowel brigade and R139's constipation issues. The IP reviewed R139's medical record and confirmed R139 had orders for Fleet enema but the enema had not been offered or discussed with the family member or administered per facility protocol. The IP indicated no nurse had discussed the bowel brigade with R139's family member or gathered information such the effectiveness of the enema procedure with R139. The IP indicated R139's KUB results were received by the facility at approximately 8:00 AM on 03/19/2025 and a copy of the results should have been provided to the family member upon request on the afternoon of 03/19/2025. On 03/20/25 at 2:37 PM, the Director of Nursing (DON) explained the bowel brigade was entered as a standing order for all residents except when contraindicated. The DON indicated medical record reflected fleet enema was not offered, discussed, refused or administered to R139 on 03/16/2025 and as of 03/20/2025, which was not in accordance with the facility's bowel brigade and physician's orders. The KUB report dated 03/18/2025, revealed R139 had mild increased feces throughout the colon. The Bowel Brigade policy (undated) documented, each resident would receive bowel care per general orders on a routine and consistent basis to ensure adequate bowel evacuation to prevent complications or discomfort which may arise to acute constipation or fecal impaction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and document review, the facility failed to ensure physician's orders to provide one-on-one (1:1) feeding assistance were followed for 1 of 13 sampled residents (Resident 21) and one unsampled resident (Resident 11). The deficient practice placed the residents at risk for significant weight loss and malnutrition. Findings include: Resident 21 (R21) R21 was admitted on [DATE], with diagnoses including metabolic encephalopathy, dementia and history of craniotomy. On 03/19/2025 at 9:18 AM, R21's head of bed was elevated approximately 30 degrees, R21 appeared weak and lethargic and responded with singular words or nodding head. A signage on the wall read 1:1 feeding assistance. Sit resident up in chair during mealtimes. A meal tray was observed on the resident's bedside table and contained a bowl of cream of wheat covered in plastic wrap and an Ensure supplement. The meal ticket read regular pureed diet with thin liquids. There were no staff members observed in the room. A physician's order dated 03/05/2025, documented to provide R21 with 1:1 feeding assistance. The five-day minimum data set (MDS) dated [DATE], revealed R21 was dependent on staff for eating. On 03/19/2025 at 9:25 AM, a Certified Nursing Assistant (CNA1) entered R21's room and stated R21 had refused to eat. CNA1 defined refusal as the resident's failure to respond to the CNA when CNA1 asked R21 if the resident wanted to eat. CNA1 explained having three residents requiring feeding assistance and CNA1 could not transfer R21 from bed to chair by themselves and was too shy to ask for help from other CNAs who were busy as well. The vitals report dated 03/19/2025, revealed R21 consumed 1 percent (%) to 25% of the breakfast meal. On 03/20/2025 at 9:20 AM, R21 laid in bed with eyes closed, head of bed elevated approximately 30 degrees. An untouched breakfast tray was observed on R21's bedside table which contained a bowl of cream of wheat, a bowl of pureed eggs, a cup of apple juice and an Ensure supplement. There were no staff members in the room. On 03/20/2025 at 9:24 AM, CNA2 indicated being assigned to R21 but CNA2 also had two other residents who required feeding assistance, so CNA2 had asked CNA3 to assist R21 with breakfast. CNA3 indicated having already attempted to offer R21 breakfast but R21 refused to eat. CNA3 defined refusal as the resident not responding to CNA3 when the CNA3 asked R21 if R21 wanted to eat. CNA2 and CNA3 were inside R21's room and confirmed a signage on the wall read 1:1 feeding assistance, sit resident up in chair during mealtimes. CNA2 and CNA3 confirmed the observation R21 laid in bed and not seated on chair and R21 meal tray had been untouched with spoon clean and food bowls still covered with plastic wrap. On 03/20/2025 at 9:28 AM, CNA2 and CNA3 indicated the observation of R21's breakfast service reflected instructions to sit resident up in chair, was not followed and the untouched tray reflected the lack of a proactive attempt to feed the resident's breakfast meal. In addition, CNA3 indicated not informing the nurse regarding R21's refusing breakfast. On 03/20/2025 at 9:30 AM, CNA2 recounted a day last week when CNA2 was assisted by another staff member in transferring R21 to the chair for meal service which resulted in a 50% consumption of the meal because the resident was more alert and participative in the meal task. CNA2 indicated personally observing how the intervention of sitting the resident up had a positive impact on the resident's consumption. On 03/20/2025 at 9:32 AM, the Licensed Practical Nurse (LPN) indicated expecting CNAs to inform the nurse of all refused services which included meals. The LPN indicated being informed of resident refusals, gave nurses the opportunity to make own attempts with providing the service, identifying the resident's reason for refusal so findings could be documented in the resident's electronic health record (EHR) and communicated with the inter-disciplinary team (IDT) particularly the Registered Dietician (RD), the Director of Nursing (DON) and the physician. On 03/20/2025 at 9:40 AM, the Director of Nursing (DON) entered R21's room and confirmed the signage on the wall which read, 1:1 feeding assistance, sit resident up on chair during mealtimes. The DON confirmed the observation of R21 lying in bed instead of sitting on a chair, and the meal tray was untouched with food bowls and juice still covered with plastic wrap and spoon clean. Using a loud voice and clear speech, the DON asked R21 if the resident wanted to eat breakfast. The resident responded to the DON, I'll try. The DON asked R21 if the resident preferred to sit in a chair for breakfast, the resident responded to the DON, yes. On 03/20/25 at 9:50 AM, R21 appeared well-groomed with hair combed while seated on a chair. CNA2 pointed to the resident's tray and stated R21 had fully consumed the cream of wheat, 25 % of pureed egg and 120 milliliters (ml) of the Ensure supplement. CNA2 indicated the resident's consumption would be documented as 75%. On 03/20/2025 at 10:00 AM, the DON indicated the intervention to sit R21 up in a chair during meals was an intervention which was expected to be followed. The DON indicated not knowing whether the intervention was a family request, a therapy recommendation or a physician's order but CNAs who read the signage were expected to follow them. Resident 11 (R11) R11 was admitted on [DATE], with diagnoses including unspecified dementia and severe protein calorie malnutrition. On 03/19/2025 at 9:08 AM, R11 laid awake in bed appearing weak and responded with soft voice. A breakfast tray containing scrambled eggs and pureed bread was observed on a table in front of the resident. A signage on the wall read, Provide 1:1 feeding assistance. There were no staff members in the room. On 03/19/2025 at 9:10 AM, CNA1 entered R11's room and confirmed there was a signage with instructions to provide the resident with 1:1 feeding assistance. The CNA confirmed R11 had a meal tray in front with no staff present in the room. A physician's progress note dated 03/17/2025, documented R11 was drowsy, slept a lot and was not eating much, put on 1:1 feed. A physician's order dated 03/17/2025, documented to provide R11 with 1:1 feeding assistance. The vital report dated 03/19/2025, revealed R11 consumed 1% to 25% of the breakfast meal. On 03/20/2025 at 10:00 AM, the DON explained R11 was evaluated by a provider on 03/17/2025 who ordered to put R11 on 1:1 feeding assistance due to increased fatigue and poor meal intakes. The DON indicated the morning observation of R11's meal service on 03/19/2025 reflected the physician's order to provide the resident with feeding assistance was not followed and should have been. On 03/20/2025 at 10:05 AM, the DON indicated expecting 1) CNAs to practice teamwork and seek assistance from one another when there were multiple resident requiring assistance during meals, 2) proactive attempts must be made to be successful with meal service, and 3) resident refusals must immediately be reported to the nurse to give the nurse the opportunity to make own attempts, identify reasons for refusal, document event in the EHR and communicate with the IDT. On 03/20/2025 at 10:19 AM, the RD confirmed R21 and R11 both had orders for 1:1 feeding assistance because both residents had issues with alertness, weakness and poor consumption. The RD explained being sat up in a chair was an intervention in R21's case because the resident was often drowsy and became more alert and participative with meals when seated on chair. According to the RD, R21 had a two-pound weight loss which did not rise to a level of significant weight loss but had the potential to result in significant weight loss if interventions were not being implemented. The RD indicated R11 was also in the RD's focus list due to poor intakes related to weakness, impaired cognition and debility. The RD indicated not being informed R21 and R11 were not being consistently provided 1:1 feeding assistance as ordered, prior to today. On 03/20/2025 in the afternoon, the RD and Dietary Manager indicated residents were no longer transported to the main dining area for meals unlike before. The RD and dietary manager indicated expressing residents such as R21 and R11 would benefit from being transported to the dining room where the residents had a higher chance of being awake, alert and participative with meal service. According to the RD and dietary manager, transporting residents to the dining room would also enable CNAs to assist multiple residents at the same time. The RD and dietary manager indicated not hearing back from leadership regarding transporting dependent residents to the dining area for meals. The Activities of Daily Living (ADL) policy (undated) documented, a resident unable to carry out ADL would receive necessary services to maintain good nutrition. For these residents, care plan goals may not be stated in terms of what the resident was able to achieve but in terms of the outcome of care and/or services provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review, the facility failed to ensure a justification for a midline (a type of peripheral intravenous catheter inserted into a large vein in the upper arm for longer therapy) was obtained and midline dressing changes were administered as ordered for 2 of 13 sampled residents (Residents 17 and 21). The deficient practice placed the residents at risk for midline complications such as occlusion and infection. Findings include: Resident 17 (R17) R17 was admitted on [DATE], with diagnoses including hemiplegia hemiparesis following cerebral infarction and sepsis. A hospital Discharge summary dated [DATE], revealed R17 was treated for sepsis and had completed intravenous (IV) antibiotic therapy on 02/13/2025. R17's discharge medications did not include any IV medications. An admission note dated 02/17/2025, documented R17 was admitted with a right upper arm midline. The medical record lacked documented evidence a clarification order was obtained from a physician on whether R17's midline was to be maintained or discontinued. On 03/18/2025 at 9:32 AM, R17 laid awake and alert in bed. A single lumen midline was observed on R17's right upper arm with dressing dated 03/10/2025 with ends coming loose. A Registered Nurse (RN) confirmed the observation and indicated midline dressing changes were done weekly on Sundays. The RN indicated R17's the midline had not been used in the facility. A physician's order dated 02/18/2025, documented to change midline dressing weekly. Clean with alcohol stick or chloraprep at insertion site, air dry, apply skin prep to peri-cath area and air dry. Apply bio-patch to insertion site. Cover with transparent dressing. The Medication Administration Record (MAR) for March 2025, documented a nurse had performed dressing change to R17's midline on 03/16/2025. On 03/18/2025 at 12:25 PM, the RN reviewed R17's medical record and indicated R17's midline was last used in the hospital, but there was no evidence a nurse-physician discussion had occurred regarding whether R17's midline was to be maintained or removed. The RN confirmed another nurse signed for R17's midline dressing change in the MAR on 03/16/2025 which did not align with actual observation of R17's midline dressing which was dated 03/10/2025. On 03/18/2025 at 12:29 PM, the Infection Preventionist (IP) confirmed R17 was admitted with a right upper arm midline with no evidence of a nurse-physician discussion on whether the line should be maintained or removed. The IP could not speak to why the nurse assigned to R17 on 03/16/2025 signed for the dressing change administration on the MAR when the actual dressing was labeled 03/10/2025. Resident 21 (R21) R21 was admitted on [DATE], with diagnoses including metabolic encephalopathy, dementia and history of craniotomy. On 03/18/25 at 10:12 AM, R21 laid in bed appearing weak and lethargic. R21 responded with singular words or nodding head. The Clinical Nurse Manager (CNM) extended R21's right arm which revealed a double lumen midline with dressing dated 03/09/2025, with ends coming loose. The CNM explained R21's midline was being used for IV banana bag (electrolytes) administration. On 03/18/2025 at 10:15 AM, the CNM reviewed R21's MAR and confirmed there was documented care for R21's midline on 03/16/2025, which did not align with the actual observation of the midline dressing dated 03/09/2025. The CNM described R21's midline dressing as not appearing new and edges were coming loose. The CNM corroborated the RN's explanation of the facility protocol where midline dressing changes were performed every Sunday and as needed. On 03/19/2025 at 3:01 PM, the Director of Nursing (DON) explained when a resident was admitted with a midline, the admission nurse or any nurse assigned to the resident should obtain clarification orders from the physician on whether the line would be maintained or discontinued. The DON explained IV dressing changes were performed weekly by Sunday night shift nurses or as needed. On 03/19/2025 at 3:04 PM, the DON indicated being made aware actual observations of R17's and R21's midline dressing dates did not align with documented care in the residents' MAR, which went against basic documentation guidelines and was unacceptable. The DON verbalized consequences to not performing midline care placed residents at risk for an infection. The DON indicated the facility did not have a policy specific for midlines, but the Peripherally Inserted Central Catheter (PICC) Dressing Change policy was applicable for midlines. In addition, the DON indicated the facility followed the [NAME] standard or practice. The PICC Dressing Change policy (undated), documented dressing must be labeled with date, time and initials of person performing the task. The Lippincott Nursing Procedure (ninth edition) documented; IV maintenance required transparent dressings were changed every five to seven days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure infection control measures were implemented according to the plan of care for a resident with indwelling urinary catheter and intravenous midline catheter (Resident 26). The deficient practice had the potential to increase the risk of healthcare-associated infections, compromise the resident's safety, and placed other residents and staff at risk by undermining the facility's overall infection prevention protocols. Findings include: Resident 26 (R26) R26 was admitted on [DATE] with diagnoses including septic shock, respiratory failure with hypoxia, pneumonia, and lung cancer. A physician's order dated 03/05/2025, documented to place R26 on enhanced barrier precautions due to the indwelling catheter and right arm intravenous midline catheter. On 03/18/25 at 10:07 AM, a therapist entered the room to transport R26 to the physical therapy department. The therapist assisted the resident for the transfer from the bed to a wheelchair. The therapist emptied the urinary bag connected to an indwelling catheter, then placed dignity cover over the urinary bag. The therapist used glove to perform the procedure but did not wear a gown. On 03/18/2025 at 10:10 AM, a registered Nurse confirmed the observation and indicated the therapist should have used the required personal protective equipment (PPE) when provided urinary care to R26. The RN explained gloves and gown should have been used to handle the urinary bag. On 03/20/2025 at 11:00 AM, the Infection Preventionist Nurse explained enhanced barrier precautions included the use of glove and gown and should have been adopted during the indwelling catheter care. Care plan dated 02/17/2025 documented, staff to don gloves and gown prior to beginning high-contact Patient care activities including assisting with toileting. The facility undated policy titled Enhanced Barrier Precautions version E1009, revealed the facility would adopt guidelines provided by the Centers for Disease Control and Prevention (CDC) regarding prevention of spread of multi-drug-resistant organism with the use of enhanced barrier precautions. The policy indicated these precautions would be applied for resident with certain conditions including indwelling medical devices such as urinary catheter and intravenous lines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews, and document review, the facility failed to ensure a physician order was obtained for the use of a splint, care orders on how to manage the resident's splint were transcribed and implemented, and a care plan was initiated for 1 of 16 sampled residents (Resident 7). The deficient practice could have the potential to result in improper healing, increased pain, or further injury. Findings include: Resident 7 (R7) R7 was admitted on [DATE], with diagnoses including falls and fracture of the lower and right radii (radial bone). The hospital Discharge summary dated [DATE], documented R7 was fully oriented, had an accident at home, sustained a broken wrist, and had findings of non-displaced intra-articular fracture distal radial metaphysis. The recommendation was to avoid surgical interventions and use a removable wrist brace to prevent weight bearing on the affected extremity. The facility's admission Skin assessment dated [DATE], documented a splint was in place on R7's right wrist. On 05/21/2024 at 12:08 PM, R7 was lying in bed, and a splint on the right wrist was in place. R7 ate lunch with the left hand. A Certified Nursing Assistant (CNA) indicated that R7 always had a right wrist splint in place. R7's medical records lacked documented evidence of a physician's order to use a splint, instructions for managing the splint, and a care plan. On 05/22/2024 at 9:09 AM, R7 was in bed, alert and verbally responsive, with a splint in place on the right wrist. R7 indicated a fall incident at home on [DATE], which resulted in a wrist fracture and required hospitalization. R7 explained the splint was provided in the hospital and had not been removed since admission to the facility. A Registered Nurse (RN) confirmed the splint was in place at all times, but no care orders had been obtained or transcribed, and no care plan had been initiated. The RN explained the admission nurse was responsible for ensuring the assessment was completed and the care orders and a care plan should have been in place. On 05/22/2024 at 10:26 AM, the Director of Nursing (DON) indicated the admission nurse was responsible for obtaining orders for the use of the splints, which should be followed by leadership upon chart review or by the wound nurses during a skin assessment. On 05/22/2024 at 1:58 PM, the Certified Occupational Therapy Assistant (COTA) indicated R7's evaluation was completed on 04/25/2024, and the splint was identified. The treatment plan did not include the splinting for R7's right wrist, which was for non-weight bearing. The COTA explained R7's gross motor control could not do anything except tap a balloon and provide range of motion; R7 could not grasp onto things and could not use the right hand for the activities of daily living. On 05/22/2024 at 2:03 PM, the Occupational Therapist (OT) indicated R7 was being evaluated for strengthening of the upper extremities. The therapy evaluation identified R7's right wrist splint, but did not include it in the therapy treatment plan. The OT indicated the nursing staff was responsible for obtaining the physician order, including the management of the splint. On 05/22/2024 at 2:07 PM, the Physical Therapy Assistant (PTA) indicated R7's splint order for evaluation and treatment should have been placed by the admission nurse based on the assessment upon R7's admission. On 05/23/2024 at 1:00 PM, the Director of Nursing (DON) explained had spoken to the admission nurse and confirmed the orders were missed and had not been obtained or transcribed. The DON indicated R7's splint required an order, and a care plan should have been formulated based on the assessment. The Splint Management Policy (undated), documented splints would be applied per physician orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews, and document review, the facility failed to ensure a physician's order for peripheral intravenous (IV) insertion and care orders were obtained, transcribed, and implemented for 1 of 16 sampled residents (Resident 138). The deficient practice could have led to potential complications such as infection, incorrect medication administration, or inadequate treatment. Findings include: Resident 138 (R138) R138 was admitted on [DATE], with diagnoses including urinary tract infection, sepsis, and dehydration. The Nursing Progress Note dated 05/18/2024, documented the initiation of IV fluids at 0.9 percent saline, to be administered at 75 milliliters (ml) per hour for a total of two liters. The Nursing Progress Note dated 05/18/2024, documented R138 was on the second bag of IV fluids at 75 ml/hour, infusing well. On 05/21/2024 at 8:16 AM, R138 was in bed with an IV heplock in place on the right wrist. The heplock appeared old and undated, with the dressing edges peeling off. The IV pole was at the bedside. R138 reported the facility had inserted the IV access four days ago and had asked the staff to remove the heplock as it was not in use. R138's medical records lacked documented evidence a physician's order was obtained for the insertion of an IV, including the care orders for flushing, monitoring the insertion site, or changing the dressing. On 05/21/2024 at 9:01 AM, a Registered Nurse (RN) confirmed there was no order for IV access insertion or related care. The RN noted the IV heplock was old, and the dressing was undated and peeling off. The RN stated that the IV heplock was good for three days, should be monitored, and should have been removed if not in use. The RN indicated the Resource Nurse was responsible for putting in the orders. On 05/23/2024 at 3:10 PM, the Resource Nurse indicated the admission nurse, the nurse who received the order, the resource nurse, or the leadership were responsible for ensuring a physician's order was obtained before the implementation of a task. On 05/23/2024 at 8:54 AM, the Director of Nursing (DON) indicated any IV access required an order for insertion and management, including flushing and monitoring of the insertion site. A facility policy titled Intravenous Access Device (undated), documented upon receipt of a physician's order for IV therapy and/or maintenance of the access device, the flushing protocol for a specific access site, and the type of catheter were reviewed. Clarify the physician's order to include the maintenance protocol, as per the facility policy, if it doesn't address these components. A facility policy titled Selection of IV Catheters (undated), documented a physician's order should be promptly obtained for the removal of any peripheral IV catheter that is no longer essential. A facility policy tiled IV Access Device Maintenance Protocol for peripheral access devices (undated), documented the frequency of saline flushes before and after each use with 3 cubic centimeters, as well as dressing changes with site changes every 3-7 days and as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews, and document review, the facility failed to ensure the Oxygen (O2) flow rate was followed as ordered or the titration rate and frequency of the administration were clarified for 1 of 16 sampled residents (Resident 137). The deficient practice could have led to potential respiratory distress, inadequate oxygenation, or exacerbation of the resident's underlying health conditions. Findings include: Resident 137 (R137) R137 was admitted on [DATE], with diagnoses including acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, and chronic pulmonary edema. The admission Observation Details List Report dated 05/16/2024, documented R137 had Oxygen via nasal cannula for shortness of breath with exertion or at rest. A Physician order dated 05/16/2024, documented O2 per nasal cannula (NC) at 2 liters per minute (LPM) to maintain SpO2 (peripheral capillary oxygen saturation) of more than 90% (percent). Document LPM. May titrate or discontinue O2 as tolerated while maintaining SpO2 greater than 90% for shortness of breath, dyspnea, or SpO2 less than 90%. The O2 order did not specify whether to administer the O2 continuously or as needed, nor did it specify the titration rate parameters. On 05/21/2024 at 8:43 AM, R137 was in bed with eyes closed, and O2 was flowing at 4 LPM connected to the wall via a nasal cannula. On 05/22/2024 at 8:20 AM, R137 was lying in bed in a supine position with the head of the bed elevated. R137's O2 was flowing at 4 LPM; there were no signs of respiratory distress. R137 indicated was dependent on O2 and the staff administered the O2 continuously. R137 was unsure how much O2 had been receiving. R137 indicated had no shortness of breath. The Medication Administration Record dated 05/22/2024, documented R137's O2 saturation was 98-99%. On 05/22/24 10:27 AM, R137's O2 was flowing at 4 LPM via nasal cannula. A Registered Nurse (RN) verified R137's O2 was flowing at 4 LPM, despite the prescribed 2 LPM. The RN confirmed the active order did not specify whether it should be continuous or if any titration parameters were required. The RN explained the physician order should have been followed because too much O2 may constitute toxicity and could potentially damage the lungs. The RN explained the Licensed Nurses were responsible for ensuring the residents received the correct O2 flow rate as ordered or clarifying orders for clarity. The RN indicated R137's O2 saturation was 94%. On 05/22/2024 at 1:19 PM, the Director of Nursing (DON) indicated the O2 required an order, and the staff was expected to verify and follow the O2 orders. The DON acknowledged the titration parameters, and the frequency should have been clarified. The Oxygen Administration policy (undated), documented to administer Oxygen in accordance with a physician order. Appropriate safety precautions were utilized to provide safe administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews, and document review, the facility failed to ensure the medication error rate was below five (5) percent (%) when two errors, and were identified with 32 opportunities observed, calculating an error rate of 6.25%. Failure to follow physician orders and timely administer medications posed a potential risk of injury or harm to the resident. Findings include: 1. On 05/22/2024 at 8:41 AM, Registered Nurse 2 (RN2) prepared 11 medications, including the standard iron tablet for R187, and administered the medication orally. A Physician order dated 05/10/2024, documented Ferrous Sulfate 325 milligrams (mg) oral tablet, delayed release as a supplement. The Medication Administration Record (MAR) dated 05/22/2024, documented the standard iron was successfully administered. On 05/22/2024 at 2:00 PM, RN2 was uncertain if there was a difference between the standard iron and the delayed release. On 05/22/2024 at 11:54 PM, the Pharmacist explained the standard iron medication and the delayed release had the same ingredients but a different release mechanism. The pharmacist confirmed the standard iron tablets have quicker absorption, whereas delayed-release forms release iron gradually. The Pharmacist further explained the delayed-release iron supplements were designed to bypass the stomach and release iron gradually in the intestines. On 05/22/2024 in the afternoon, the Director of Nursing (DON) acknowledged the standard iron tablet was different from the delayed release. The DON indicated the correct dosage form should have been verified to prevent medication errors. 2. A physician's order dated 05/21/2024, documented to administer Lidocaine 4% adhesive medicated patches at 7:00 AM-9:00 AM. The instructions were to apply two patches topically to painful sites for pain relief, with a schedule of 12 hours on in the morning and 12 hours off in the evening. On 05/22/2024 at 8:21 AM, Registered Nurse 1 (RN1) prepared 10 medications for the unsampled resident in room [ROOM NUMBER], including one (1) Lidocaine 4% patch, which was removed from the packaging. The RN asked the unsampled resident whether the Lidocaine patch would be administered at that time or later after therapy, and the unsampled resident preferred to receive the patch later after therapy. On 05/22/2024 at 3:30 PM, RN2 reoffered the Lidocaine patch, prepared 1 patch, and successfully applied it to the unsampled resident. RN2 confirmed only 1 patch was administered when 2 patches were ordered. On 05/22/2024 in the afternoon, the DON indicated the Licensed Nurses were expected to verify the order prior to administration, ensuring the correct dosage was administered to prevent medication errors. A facility policy titled Medication Error (undated), documented medication errors were to be minimized by following the six rights of medication administration, including the right patient, the right medication, the right dosage, the right dosage form, the right route, and the right time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure resident personal information was visible and not accessible to anyone passing by in the hallway, and the medication cart was locked and not left unattended for 2 of 2 medication carts. The deficient practice placed resident confidentiality at risk and could have facilitated unauthorized access to medications in the cart. Findings include: On 05/22/2024 at 2:10 PM, a medication cart located near resident room [ROOM NUMBER] was observed unattended. The computer screen on top of the medication cart was on and displayed resident pictures and names. The medication cart was unlocked. On 05/22/2024 at 2:12 PM, the Nurse acknowledged had walked away to obtain supplies and left the computer screen on and the cart unlocked. The nurse acknowledged the computer screen needed to be off and the medication cart locked to protect resident privacy and prevent anyone walking by from accessing the medication in the cart. The Medication Storage Policy and Procedure, undated, documented medication rooms, carts, and medication supplies were to be locked or attended by persons with authorized access.On 05/22/2024 at 8:21 AM, Registered Nurse 1 (RN1) prepared medications for an unsampled resident. RN1 had walked away to administer the medication in room [ROOM NUMBER]. The RN parked the medication cart facing the hallway, unlocked and unattended. The computer on top of the medication cart was open, displaying resident pictures and names. Visitors and staff members were walking down the hallway, and the screen was visible and accessible. On 05/22/2024 at 8:26 AM, RN1 acknowledged the medication cart and the computer screen were left unlocked and unattended. RN1 explained locking the medication cart was important to prevent unauthorized access and securing the computer screen to safeguard the resident's privacy. On 05/22/2024 in the afternoon, the Director of Nursing indicated that the medication carts should have been locked when unattended and the computer screens secured to prevent unauthorized access and protect the residents' privacy. The Administration of Medication policy (undated), indicated locking the medication cart whenever it was out of view. Before exiting the medication cart, log out of the electronic medication administration record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to: 1) discard five expired thickened orange juice containers stored in the nourishment room [ROOM NUMBER]) ensure a [NAME] was not eating next to the food tray line 3) ensure a Dietary Aide was not touching their face and nose with gloved hands while handling food during tray line and 4) ensure 1 of 4 soap dispensers in the kitchen was refilled timely. The deficient practices could have led to contamination of kitchen surfaces and food borne illness. Findings include: 1) Expired thickened orange juice containers. On 05/21/2024 at 7:45 AM, five thickened orange juice containers were observed in the nourishment room with an expiration date of October 2023. On 05/21/2024 at 7:45 AM, the Nutritional Services Director confirmed the expiration date for the thickened orange juice containers was October 2023. The Nutritional Services Director acknowledged expired food items needed to be discarded to prevent food borne illnesses. The Food Storage Policy, undated, documented all foods would be checked to assure that foods would be consumed by their safe use dates, frozen, or discarded. 2) [NAME] eating next to food tray line. On 05/22/2024 at 12:50 PM, a [NAME] was observed holding a plate of ribs with gloved hands, eating while standing next to the food tray line. On 05/22/2024 at 12:50 PM, the [NAME] acknowledged were not supposed to eat next to the food tray line. The [NAME] explained staff were to eat away from the kitchen, in the dining room or the back office to prevent contamination. On 05/23/2024 at 10:49 AM, the Nutritional Services Director reported based on policy, staff was not to eat food in the food preparation area of the kitchen and the [NAME] should have taken the plate of food into the dining room or the back office to eat. The Food Handling Policy and Procedure, dated 04/08/2021, documented personnel were not to eat or drink in the food preparation area. 3) Dietary Aide touched their face and nose with gloved hands, while handling food during tray line. On 05/22/2024 at 12:22 PM, a Dietary Aide was observed touching the cheek and nose with gloved hands while handling food during tray line. On 05/22/2024 at 1:18 PM, the Dietary Aide acknowledged should not have touched their face with gloved hands while working the food tray line. The Dietary Aide explained according to policy, after touching their face, should have washed hands, and changed gloves to prevent contamination. The Food Handling Policy and Procedure, dated 04/08/2021, documented food handlers must wash their hands after personal body functions and engaging in other activities that contaminated the hands. 4) Soap dispenser not refilled timely. On 05/21/2024 at 07:45 AM, a soap dispenser at the sink closest to the kitchen entrance was observed empty. On 05/22/2024 at 12:15 PM, the soap dispenser at the sink closest to the kitchen entrance was again observed empty. On 05/22/2024 at 12:15 PM, the Nutritional Services Director confirmed the soap dispenser was empty. The Nutritional Services Director reported housekeeping had been notified to provide soap to refill the dispenser and acknowledged it was the kitchen's staff responsibility to have the soap dispenser refilled to prevent contamination in the kitchen. On 05/23/24 at 02:39 PM, the Housekeeping Supervisor explained staff were to request refills of soap dispensers from Housekeeping. Housekeeping staff would then have the soap replaced immediately upon request. The Housekeeping Supervisor reported it was important to refill soap dispensers quickly to prevent any infection control issues. The Handwashing Policy, dated 04/08/2021, documented all employees' hands must be washed when visibly dirty or contaminated. Handwashing would occur including when coming on duty, before applying and removing gloves, after contact with any equipment or environmental surface that might have been soiled or contaminated, and before and after going on break and at the end of the shift before leaving the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) On 05/21/2024 at 8:38 AM, the hand sanitizer dispenser at the entrance of resident room [ROOM NUMBER] was observed empty. On 05/21/2024 at 8:42 AM, the hand sanitizer dispenser at the entrance of resident room [ROOM NUMBER] was observed empty. On 05/21/2024 at 9:23 AM, the hand sanitizer dispenser at the entrance of resident room [ROOM NUMBER], was observed empty. On 05/22/2024 at 4:28 PM, the hand sanitizer dispensers at the entrance of resident rooms number 120, 121, and 136 were again observed empty. On 05/22/2024 at 4:28 PM, a nurse confirmed the sanitizer dispensers were empty at the entrance of resident room numbers 120, 121 and 136. The nurse further acknowledged two of the resident rooms, numbers 121 and 136, had enhanced barrier precautions signs posted and acknowledged hand hygiene needed to be done by all staff and visitors prior to entering and exiting all resident rooms to prevent transmission of infection. On 05/23/24 at 02:39 PM, the Housekeeping Supervisor explained staff were to request refills of hand sanitizer from Housekeeping. Housekeeping staff would then have the hand sanitizer replaced immediately upon request. The Housekeeping Supervisor reported it was important to refill hand sanitizer dispensers quickly to prevent any infection control issues. The Alcohol Based Hand Sanitizer Policy dated 04/08/2021 documented, except for situations where hand washing was specifically required, antimicrobial agents such as alcohol-based hand sanitizers were also appropriate for cleaning hands. The purpose was to prevent transmission of infection from one patient to another via the health care worker, remove transient bacteria and prevent illness. Based on observations, interviews, record reviews, and document reviews, the facility failed to ensure: 1) transmission based precautions (TBP) was implemented during transportation and personal protective equipment (PPE) was donned as required before entering the TBP room for 1 of 16 sampled residents (Resident 28); and 2) hand sanitizer dispensers were refilled for resident rooms (rooms [ROOM NUMBER]). The deficient practices could have the potential to result in the spread of infection, an increased risk of cross-contamination, and compromised safety for other residents and staff members. Findings include: 1. R28 was admitted on [DATE], with diagnoses including stage 5 chronic kidney disease and dependence on dialysis. A Physician order dated 05/08/2024, documented R28 was on strict contact isolation for Extended Spectrum Beta-Lactamase (ESBL) for infection in the urine and Vancomycin-resistant Enterococcus (VRE). The History and Physical dated 05/09/2024, documented R28 was hospitalized and treated with antibiotics for ESBL in urine and VRE in blood. The recommended course of action was to administer antibiotics and monitor for infection control. On 05/21/2024 at 8:07 AM, R28 was not present in the room, contact precaution and enhanced barrier precaution signage were posted by R28's room door. The signage indicated to clean hands before entering and leaving the room, put on gloves and gown before room entry. Personal protective equipment (PPE) was readily available by R28's room entrance. A Certified Nursing Assistant (CNA) indicated R28 went out for dialysis early in the morning. On 05/21/2024 at 9:10 AM, R28 arrived in a wheelchair accompanied by the facility driver and proceeded to R28's room. Upon entering the room, the driver looked at the contact precaution signage by the door, then entered without cleaning hands, no PPE and assisted R28 inside. The driver expressed unawareness R28 was on contact precautions and lacked endorsement, but the driver acknowledged the signage was observed. The driver indicated had taken R28 to the dialysis center and picked R28 up post-dialysis treatment. The driver explained during transport, the TBP protocols were not observed, and upon arrival at the dialysis center, R28 was placed in the waiting area with other residents and individuals. On 05/21/2024 at 9:20 AM, a Registered Nurse (RN) indicated R28 was on contact isolation for bacteremia (infection in the blood) and ESBL urine. The RN confirmed staff members should have worn the required PPE upon entering R28's room. On 05/22/2024 at 3:01 PM, the Infection Preventionist (IP) indicated R28 was admitted with bacteremia and ESBL-urine and was placed in isolation with an enhanced barrier for the left AV shunt. The IP explained the staff members were expected to comply with TBP protocols during transportation and entering the TBP rooms, to prevent contamination or the spread of infection to individuals. The Infection Control facility policy (undated), indicated the facility maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment. The infection prevention and control program was designed to help prevent the development and transmission of communicable diseases and infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews, and document reviews, the facility failed to ensure: 1) dialysis intercommunication or post-dialysis treatment information was obtained or maintained for 2 of 2 sampled residents (Residents 28 and 27), 2) the resident's infection status was communicated to transportation staff or to the dialysis center for 1 of 2 sampled residents (Resident 28), and 3) the resident's arteriovenous fistula (AVF) was identified, care orders, and management were obtained, transcribed, and implemented for 1 of 2 sampled residents (Resident 27). The deficient practices could have led to potential cross-contamination among staff members and other residents, increased the risk of infection, and compromised the health and safety of the residents. Findings include: Resident 28 (R28) R28 was admitted on [DATE], with diagnoses including stage 5 chronic kidney disease and dependence on dialysis. A physician order dated 05/08/2024, documented to assess R28's vital signs pre- and post-dialysis. The medical records of R28 did not maintain documented evidence of the interchange of communication or collaboration of care between the facility and the dialysis center. On 05/21/2024 at 9:10 AM, R28 arrived in a wheelchair, accompanied by the facility driver from the dialysis center. The driver indicated did not have the dialysis communication paper post-dialysis treatment. The driver explained previously, a dialysis communication form was filled out by the facility and brought back to the facility with the resident's weight, vital signs, and instructions, but it was not implemented anymore. The driver indicated during dialysis days, the facility sent R28's information like the facesheet and the list of medications. On 05/21/2024 at 10:AM, a Registered Nurse (RN) indicated the dialysis center was responsible for obtaining the vital signs and the resident's weight post-dialysis treatment. The RN confirmed there was no information available about R28's vital signs and weights, nor were there any instructions for post-dialysis treatment. Resident 27 (R27) R27 was admitted on [DATE], with diagnoses including stage 5 chronic kidney disease or end-stage renal disease (ESRD) and dependence on dialysis. A physician order dated 04/30/2024, documented to assess R28's vital signs pre- and post-dialysis on Tuesday, Thursday, and Saturday. A Care plan dated 05/01/2024, documented R27 had a diagnosis of renal failure and was on hemodialysis. The interventions included monitoring weights and restricting fluid intake. Evaluate the record and assess for fluid excess (weight gain, increased blood pressure, edema , worsening of edema, and any change in condition). The goal was R27 would not exhibit signs of fluid volume excess. R27's medical records lacked documented evidence of the interchange of communication or collaboration of care between the facility and the dialysis center which was not maintained in the medical records. On 05/22/2024 at 3:01 PM, the Infection Preventionist (IP) verified and confirmed R28 and R27 were receiving dialysis treatment outside the facility, and there was no interchange of communication information in place. The IP acknowledged the importance of communication from the facility to the dialysis center and vice versa. The IP indicated at the moment, R28 and R27 were the only residents receiving hemodialysis. On 05/22/2024 in the afternoon, the Director of Nursing (DON) confirmed the facility had not utilized the communication form lately. The DON indicated upon leaving the facility for the dialysis center, the resident's information was sent through the driver, but post-dialysis treatment information was not obtained. The DON confirmed the pre- and post-dialysis communication form had not been utilized and was not maintained in the residents' charts. A facility policy titled Dialysis Services (undated), documented for the residents requiring hemodialysis, the facility would coordinate the appropriate care with an outside provider specializing in hemodialysis and renal care needs. The information exchange was beneficial or necessary for the resident's care. The Long Term Care Outpatient Dialysis Services Coordination Agreement: Mutual Obligations with the Collaboration of Care (undated), Both parties should ensure there is documented evidence of collaboration of care and communication between the LTC facility and ESRD dialysis unit. 2) Resident 28 (R28) R28 was admitted on [DATE], with diagnoses including stage 5 chronic kidney disease and dependence on dialysis. On 05/21/2024 at 8:07 AM, R28 was not present in the room, and contact precaution and enhanced barrier precaution signage were posted by R28's room door. Personal protective equipment (PPE) was readily available. A Certified Nursing Assistant (CNA) indicated R28 went out for dialysis early in the morning. A Physician order dated 05/08/2024, documented R28 was on strict contact isolation for Extended Spectrum Beta-Lactamase (ESBL) or infection in the urine and Vancomycin-resistant Enterococcus (VRE). The History and Physical dated 05/09/2024, documented R28 was hospitalized and treated with antibiotics for ESBL in urine and VRE in blood. R28 was on hemodialysis. The recommended course of action was to administer antibiotics and monitor for infection control. On 05/21/2024 at 9:10 AM, R28 arrived in a wheelchair, accompanied by the facility driver, and headed to R28's room. When entering the room, the driver looked at the contact precaution signage by the door, entered without PPE, and assisted R28 inside. The driver indicated had taken R28 to the dialysis center and picked R28 up post-dialysis treatment. The driver explained was unaware R28 was on contact isolation precautions and there had been no endorsement. The driver indicated during transport, the contact precautions were not observed, and upon arrival at the dialysis center, R28 was placed in the waiting area with other residents. The driver confirmed the dialysis center had not implemented isolation precautions. R28's medical records lacked documented evidence R28's infection status was communicated to the dialysis center. On 05/21/2024 at 9:20 AM, a Registered Nurse (RN) indicated R28 was on contact isolation for bacteremia (infection in the blood) and ESBL in the urine. The RN explained was uncertain if R28's infection status was communicated to the dialysis center. On 05/22/24 03:01 PM, the Infection Preventionist (IP) indicated R28 was admitted with multidrug-resistant organisms (MDRO) and ESBL in urine and was placed in contact isolation with enhanced barrier precautions for the AVF shunt. The IP indicated R28's active infections were not fully treated with intravenous (IV) antibiotic treatment due to the issue of R28's IV access. The IP acknowledged there was no documentation of R28's infection status being communicated to the dialysis center. The IP indicated when infection control was not appropriately communicated and implemented, there was a risk of transmission of infection affecting other individuals. The IP attempted to contact the dialysis center multiple times, but was unsuccessful. A facility policy titled Contact Precautions-Resident Transport (undated), documented to limit the movement and transport of the resident from the essential purposes only. If a resident was transported out of the room, ensure the precautions were maintained to minimize the risk of transmission of microorganisms to other residents and contamination of environmental surfaces or equipment. 3) A Physician order dated 05/10/2024, documented R28 had dialysis on Tuesday, Thursday, and Saturday at 5:00 AM. On 05/21/2024 at 9:30 AM, R28 was verbally alert and oriented, and the AV graft was in place on the left arm. R28 indicated the AV graft was the only access during dialysis treatment. R28's medical records lacked documented evidence a physician order was obtained and transcribed for AV graft monitoring for bleeding, infection, and drainage until 05/21/2024. On 05/22/2024, an RN confirmed care orders and management of R28's AV graft were not obtained or transcribed until 05/21/2024. The RN indicated the AV graft should have been monitored closely for signs of bleeding and infection. On 05/23/2024, the DON indicated the R28's dialysis access should have been monitored, and care orders and management should have been obtained, transcribed, and implemented. The Dialysis Services facility policy (undated), documented for the residents requiring hemodialysis, the facility would coordinate the appropriate care with an outside provider specializing in hemodialysis and renal care needs. The dialysis agreement would cover all aspects of managing the resident's care, including the creation and execution of a dialysis-related care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and document review, the facility failed to develop a baseline care plan for the care of a resident admitted with a gastrointestinal infection caused by the germ Clostridium difficile (a germ that causes vomiting, diarrhea, and bowel inflammation) for 1 of 12 sampled residents (Resident #22). The failure had the potential to delay implementation of appropriate resident care interventions to prevent and identify complications derived from the gastrointestinal infection such as vomiting, diarrhea, and dehydration. Resident #22 (R22) R22 was originally admitted on [DATE], and re-admitted on [DATE], with diagnoses including Clostridium difficile infection (CDI) and acute kidney failure. Hospital discharge summary documented R22 was admitted to the hospital complaining of diarrhea for about three months. The resident was found having a CDI. The resident was treated with antibiotics for 10 days, but the infection persisted. The resident was transferred to the facility to continue antibiotic therapy that included Flagyl (metronidazole), Vancomycin and Dificid (Fidaxomicin). An Infectious Disease Physician progress note dated 03/10/2023, revealed R22 complained of multiple episodes of diarrhea. The progress note documented R22 was recently treated at an acute care facility for diarrhea since November 2022. A review of the medical record revealed a baseline care plan was initiated on 03/06/2023. The baseline care plan did not document CDI and diarrhea as problems and did not list the respective approaches to prevent the spread of the infection, as well as complications derived from the gastrointestinal infection such as vomiting, diarrhea, and dehydration, and treatment goals. On 03/17/2023 at 9:00 AM, the Director of Nursing (DON) confirmed the baseline care plan lacked interventions to provide care for CDI, antibiotic, hydration, and transmission-based precautions. The DON explained the approaches for the care of a resident admitted with CDI should have been documented in the baseline care plan. The facility policy titled Clostridium difficile dated 08/06/2020, documented any patient with diarrhea should be assessed for dehydration regularly. The facility policy titled Interim and Temporary Care Plans dated 09/28/2022, indicated an interim care plan should be developed during the admission process and written to include the care the resident would receive, therapeutic goals to be accomplished, and the approaches necessary to attain the goals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review the facility failed to ensure proper infection control practices were implemented during intravenous (IV) medication administration for 1 of 12 sampled residents (Resident #1). This failure had the potential to introduce an infectious organism to a resident with compromised immune system. Resident #1 (R1) R1 was admitted on [DATE] with diagnosis including arthritis due to bacteria and cellulitis of upper limb. Findings include: On 03/16/2023 at 10:06 AM, during medication administration observation for R1 the Registered Nurse (RN) removed the end cap to flush one port on a double port central IV line and placed the end cap on the bedside table. After completing flush of the port, the RN placed the contaminated end cap from the bedside table on the port. 03/16/2023 at 3:39 PM, the RN verbalized a new end cap should have been placed on port not in use once cap was placed on bedside table. 03/17/2023 at 1:41 PM, the Director of Nursing (DON) and the Infection Preventionist (IP) verbalized when performing IV administration with central catheter line the expectation was to discard old end cap and replace with new end cap. The DON verbalized staff would be educated with information to reinforce infection control practices. The facility policy titled Medication Administration, Administering Medications by IV Push (Revised [DATE]) documented to discard used supplies in receptacle and to use proper infection control practices during intravenous medication administration. The facility policy titled Catheter Insertion and Care, Flushing Midline and Central Line IV Catheters (Revised [DATE]) documented to disinfect connection device when completed with flush or infusion.