**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, interview, and document review, the facility failed to ensure a resident with intellectual disabilities (Resident #20) was provided the necessary care and services to address the resident's scratching and picking at their arms and legs. This deficient practice had the potential to cause the resident preventable discomfort and placed the resident at risk of skin infections from scratching and picking at skin. Findings include:Resident #20 was admitted to the facility on [DATE], with diagnoses including traumatic subarachnoid hemorrhage with loss of consciousness status unknown, subsequent encounter, mild intellectual disabilities, and unspecified dementia, unspecified severity, with agitation.Resident #20's Comprehensive Care Plan documented a care plan related to communication. The care plan documented an alteration in communication related to intellectual disability, dementia. The interventions included determining the resident's communication methods and comprehension level and adapt communication techniques based on the resident's responses.Resident #20's Comprehensive Care Plan documented a care plan for the use of the medication hydroxyzine. The care plan documented the resident was prone scratching and picking at the resident's skin and causing bleeding. The care plan included interventions related to the adverse side effects of the medication.A physician's order documented to wash arms and apply lotion to both arms. Apply geri sleeves to both arms related to the resident picking and scratching. If geri sleeves were not available, may use tubi grip.A physician's order documented Hydroxyzine 25 milligram (mg) tabs, give 25 mg by mouth every eight hours as needed for itching, scratching causing bleeding, and picking at skin. The medication had a start date of 07/15/2025.Resident #20's Medication Administration Record for July 2025, documented the medication was given one time on 07/17 and 07/18/2025, and twice on 07/19/2025.A Communication with physician note dated 06/28/2025, documented Resident #20 had open areas and scratch marks to the left shin. Blood was noted on the resident's fingers from scratching and active bleeding was observed. There were multiple small, scattered broken spots.An Orders Administration Note dated 06/28/2025, documented Resident #20's right shin had scattered open spots.A Communication with Family note dated 07/15/25, documented Resident #20 documented Resident #20 was being given hydroxyzine for scratching and picking at both arms and both legs.On 07/21/2025 at 11:23 AM, Resident #20 had geri sleeves to both arms what appeared to be scratch marks could be seen on the resident's wrists.On 07/24/2025 at 8:38 AM, a Licensed Practical Nurse (LPN) verbalized Resident #20 wore geri sleeves to help prevent scratching and picking at the resident's skin.On 07/24/2025 at 8:42 AM, the LPN verbalized Resident #20 did not have the cognitive ability to ask for PRN medications and was not sure why the medication was ordered as a PRN medication. The LPN explained nurses would give the resident hydroxyzine if they noticed the resident scratching The LPN confirmed the resident was not capable of telling anyone when the resident was feeling itchy.On 07/24/2025 at 11:30 AM, the Chief Executive Officer (CEO) and the interim Director of Nursing (DON) verbalized they would like to defer resident questions to Registered Nurse (RN1) due to RN1 spent more time with the residents. The CEO and DON confirmed the preference to have questions deferred to RN1.On 07/24/2025 at 12:50 PM, RN1 verbalized RN1 was not sure why the Resident #20 had an order for PRN hydroxyzine rather than scheduled. RN1 explained nurses knew when Resident #20 needed a dose of Hydroxyzine when nurses observed the resident itching and scratching. The RN confirmed Resident #20 did not have the ability to ask for medications when needed.A facility policy titled Care of Residents with Intellectual and Developmental Disabilities dated 08/2022, documented Intellectual Disability (ID) was a disability characterized by significant limitations in intellectual functioning and adaptive behavior. The facility ensured the provision of appropriate and individualized care to residents with intellectual and developmental and intellectual disabilities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review, the facility failed to ensure 1 of 13 sampled residents (Resident #1) was provided medication for pain relief per the physician's order and failed to ensure medications prescribed for pain as needed (PRN) included the severity of pain the medication was prescribed for. This deficient practice had the potential to result in discomfort, prolonged or unmanaged pain and/or an adverse drug event.Findings include:Resident #1 was admitted to the facility on [DATE], with diagnoses including alcoholic cirrhosis of the liver without ascites, pain, unspecified, low back pain, unspecified, and age-related osteoporosis without current pathological fracture.A Physician's order dated 10/30/2024, documented to give Tylenol (acetaminophen) give 650 milligrams (mg) by mouth every four hours as needed for general discomfort for a pain level 1-4.The order did not specify the pain scale to used, such as 0-10, and did not include instructions regarding how much acetaminophen not to exceed (NTE) during a 24 time frame. (3,250 milligrams, (mg) of acetaminophen should not be exceeded during a 24 hour time frame)A Physician's order dated 06/28/2025, documented to give Percocet oral tablet 5-325 mg (oxycodone/acetaminophen), give one tablet by mouth every eight hours as needed for pain, unspecified. The order did not include instructions regarding the pain level (mild, moderate, severe) to administer the medication for and did not include a method for assessing the pain such as a numeric pain scale of 0-10. The order did not include NTE instructions for acetaminophen.Resident #1's Medication Administration Record (MAR) dated June 2025, documented from 06/01/2025 - 06/30/2025, Resident #1 was not administered Tylenol including when the resident reported a pain level of four.Resident #1's MAR dated June 2025, documented from 06/28/2025 - 6/30/2025, the resident was administered Percocet two times per day on 06/28/2025, and three times per day 06/29 and 06/30/2025. Percocet was administered for a pain level of four one time on 06/30/2025.Resident #1's MAR dated July 2025, documented the resident was not given Tylenol during July 2025, including for pain rated at 4.Resident #1's MAR dated July 2025, documented the resident was administered Percocet as follows:-07/01/2025 - 07/21/2025, Resident #1 was given Percocet two times per day for seven in 21 days. The resident was given Percocet three times per day for 14 times in 21 days.The MAR documented Resident #1 reported pain levels at four or less and was administered Percocet and not Tylenol as follows:-A pain level of zero was documented one time on 07/06/2025.-A pain level of one was documented one time on 07/02/2025.-A pain level of four was documented four times on 07/01, 07/20, 07/21, and 07/22/2025.Resident #1's Comprehensive Care Plan included a care plan initiated on 01/13/2025 for increased back pain related to chronic compression fractures. The care plan documented the resident had Computed Topography (CT). The CT found the resident had acute/sub-acute and chronic compression fractures, retropulsion of bone fragments causing stenosis of the spinal cord, and bilateral neural foramina.The resident reported chronic pain in the resident's left leg related to an old fracture with hardware. The resident had arthritis and plate in the right leg.The care plan documented to administer pain medications as ordered and keep the physician updated on effectiveness/ineffectiveness.On 07/21/2025 at 2:24 PM, Resident #1 verbalized the resident had chronic pain and the resident's pain was worse when it was cold. The resident verbalized the resident's room was always cold, especially at night. The resident explained the resident had back pain from compression fractures of the spine and the pain was often pretty bad.On 07/24/2025 at 8:11 AM, a Licensed Practical Nurse (LPN) verbalized pain was what ever the resident said it was. A numerical scale of 0-10 was used to assess residents pain.On 07/24/2025 at 8:14 AM, the LPN confirmed Resident #1's order for Tylenol included a pain rating of 1-4, and confirmed the resident's Percocet did not include parameters, such as a numerical scale.On 07/24/2025 at 12:26 PM, a Registered Nurse (RN) verbalized Resident #1 watched the clock and did not have the signs of pain you would expect to see. The RN acknowledged the resident had back surgery for compression fractures and had been on a lot of pain medications during this time.On 07/24/2025 at 12:38 PM, the RN confirmed Resident #1's order for Percocet was written for generalized pain and did not include a pain scale. The RN explained physician orders for PRN medications at the facility were sometimes entered for mild, moderate, or severe pain but did not include a pain scale to define what mild, moderate, and severe pain were on a pain scale. The RN verbalized not being familiar with setting parameters for PRN pain medications when there was more than one medication ordered for pain.On 07/24/2025 at 2:40 PM, the Interim Director of Nursing (DON) confirmed Resident #1's order for Percocet should have included parameters, and when the resident reported a pain of 4 or less, the resident should have been administered Tylenol per Physician's orders.On 07/24/2025 at 2:44 PM, the DON confirmed the expectation was orders containing acetaminophen would include instructions NTE acetaminophen as instructed by the physician.On 07/24/2025 at 2:46 PM, the DON explained the concern with not monitoring the amount of acetaminophen the resident was administered had the potential to lead to the resident receiving too much acetaminophen which could lead to liver issues and verbalized especially for Resident #1 due to the resident having a diagnosis of alcohol related cirrhosis of the liver.The Manufacturer's instructions/warning label for Tylenol/acetaminophen, documented NTE 3,250 mg of acetaminophen during a 24 hour period.The facility policy titled PRN Medication Administration dated 05/2023, documented PRN medications must have a complete physician order including specific indications (e.g., pain rated 5/10, anxiety, nausea) and the maximum daily dose or number of doses per 24 hours. PRN medications were administered per the prescriber's order and the nurse must verify absence of contraindication or duplicate therapies. The Interdisciplinary Team regularly reviewed PRN medication use during care plan meetings and pharmacy reviews. The DON or designee audited PRN usage patterns monthly for trends or potential overuse/misuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interview, and document review, the facility failed to ensure coordination of care between the facility and the dialysis center, a written contract and/or agreement with the dialysis provider, and a dialysis policy was developed for the care of a resident on dialysis for 1 of 13 sampled residents (Resident #2). This deficient practice had the potential to result in unmonitored and uncoordinated care for all residents on dialysis in the facility, and a preventable adverse event.Findings include: Resident #2 Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including end stage renal disease and dependence on renal dialysis. A Comprehensive Care Plan included care plan initiated 07/22/2025, documenting Resident #2 required hemodialysis related to a diagnosis of end stage renal disease. A physician's order dated 04/25/2025, documented to take vital signs upon return from Dialysis on Mondays, Wednesdays, and Fridays one time a day. Resident #2's clinical record lacked documentation of an order for hemodialysis. The Dialysis and Nursing Home Handoff Communication Tool forms from May 2025 through July 2025, lacked documentation in the to be completed by dialysis section on the following dates:-05/02/2025.-05/23/2025.-05/31/2025.-06/02/2025.-06/06/2025.-06/11/2025.-06/16/2025. On 07/24/2025 at 9:14 AM, a Licensed Practical Nurse (LPN) verbalized Resident #2 was on dialysis and the [NAME] coordinated treatment with the dialysis center. The LPN explained the dialysis center provided all of Resident #2's care related to dialysis, including care of the fistula. The LPN verbalized the facility did measure vitals prior to dialysis appointments, however the dialysis center took responsibility for weighing the resident. The LPN verbalized if the LPN wanted to know the policy and procedures related to caring for a resident on dialysis, the LPN would reach out to the Interrem Director of Nursing (DON). On 07/24/2025 at 10:02 AM, the DON verbalized the facility did not have a contract with the dialysis center outlining roles and responsibilities of the dialysis center and the facility. The DON also verbalized the facility did not have a dialysis policy. The DON was unsure how staff would know how to care for residents on dialysis without a dialysis policy. On 07/24/2025 at 10:41 AM, the Chief Executive Officer (CEO) explained Resident #2 was the first and only resident on dialysis to be admitted to the facility. Resident #2's admission was discussed in depth at the monthly utilization review committee and was determined Resident #2 could be retained at the facility if the [NAME] took responsibility for the resident's transportation to and from the dialysis center. The CEO explained the facility was not responsible for any of the resident's care related to dialysis because the facility was not a dialysis center. The dialysis center took responsibility for the safety of the resident. The CEO explained confirmed there were no orders in Resident #2's clinical record for hemodialysis because the situation was treated the same as if the resident went home after a dialysis treatment. The facility was only responsible for taking pre and post treatment vitals. If there was a concern with the fistula site, the facility would refer the resident to the nephrologist at the Dialysis center. The CEO verbalized being unsure whether staff monitored the fistula site. On 07/24/2025 at 1:06 PM, the CEO explained the facility did not have a contract with the dialysis center because the facility would need to have a contract for everything, and the facility was not prepared to have a commitment over the resident's life. The CEO explained the facility was not involved with the dialysis center. The dialysis center took responsibility for the dialysis and the facility took responsibility of everything else while the resident was in the facility. The CEO verbalized being unsure what was expected of nursing staff for the care of residents on dialysis, what staff would monitor residents on dialysis for, and what information the facility received from the dialysis center. The CEO confirmed the incomplete Dialysis and Nursing Home Handoff Communication Tool form and verbalized being unsure whether staff reviewed the forms upon return to the facility. The CEO confirmed a contract with the dialysis center could assist in outlining responsibilities of the facility and the dialysis center to ensure coordination of care was implemented.

Based on interview and document review, the facility failed to ensure the facility had a full time Director of Nursing (DON). This deficient practice could have allowed all 27 residents residing in the facility on the affected date to go without proper assessments or certain cares Registered Nurses (RN), Licensed Practical Nurses (LPN), and Certified Nursing Assistants (CNA) perform and compromise the supervision of proper assessments and proper care due to lack of oversight. Findings include: On 07/21/2025, during entrance conference, the Chief Executive Officer (CEO) explained the current Chief Nursing Officer (CNO) was acting as the Interim Director of Nursing (DON) until the position was filled. The Facility Assessment, last reviewed 03/2025, documented the Skilled Nursing Facility required a DON and hours would be based off of the facility needs. The Staffing Schedule for the week of 07/13/2025 through 07/26/2025, documented the DON was working in the facility for 32 hours each week. On 07/24/2025 at 8:51 AM, the DON explained working for the facility a total of 40 hours each week and the time worked was split working for the hospital 80 percent (%) of the time and working for the Long Term Care 20% of the total time. The DON verbalized working eight hours per week for the facility and confirmed the facility did not have a full time DON.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and document review, the facility failed to ensure a resident's Oxygen flow was administered per physician orders for a resident with chronic obstructive pulmonary disease for 1 of 13 sampled residents (Resident #9). This deficient practice had the potential to result in low Oxygen saturations and harm to the resident.Findings include: Resident #9 Resident #9 was admitted to the facility on [DATE], with diagnoses including chronic respiratory failure with hypoxia and chronic obstructive pulmonary disease, unspecified. A physician's order dated 09/26/2023, documented Oxygen (O2) via nasal canula (NC) at three liters per minute (LPM) as needed for shortness of breath. May remove as desired if breathing is comfortable. An Oxygen Saturations Summary Report documented an Oxygen flow of two LPM on the following dates:-On 07/06/2025 at 10:39 PM.-On 06/10/2025 at 8:22 PM.-On 06/09/2025 at 9:08 PM.-On 06/08/2025 at 8:03 PM.-On 05/01/2025 at 10:10 PM.-On 04/29/2025 at 8:13 PM. On 07/21/2025 at 9:53 AM, Resident #9 wore Oxygen via NC. Resident #9's oxygen concentrator was set to a flow of two LPM. On 07/21/2025 at 9:53 AM, Resident #9 verbalized Resident #9 wore Oxygen all the time and often needed to gasp for air. Resident #9 verbalized Resident #9's Oxygen was supposed to be set at four LPM. 07/23/2025 at 9:56 AM, a Licensed Practical Nurse (LPN) verbalized Resident #9's clinical record included a physician's order for Oxygen at three LPM as needed to address difficulty breathing. The LPN explained Resident #9 wore the Oxygen continuously because the resident's Oxygen levels desaturated when not in use. The LPN verbalized the resident did not have a known behavior of changing the Oxygen flow on the resident's oxygen concentrator. The LPN verbalized the LPN measured Resident #9's Oxygen saturations once a day and ensured the oxygen concentrator was at the dose prescribed per physician's orders. On 07/23/2025 at 10:10 AM, Resident #9 wore Oxygen via NC. Resident #9's Oxygen concentrator was set to a flow of two LPM. On 07/23/2025 at 10:10 AM, Resident #9 verbalized the resident was struggling to breathe and requested an as needed breathing treatment. On 07/23/2025 at 10:10 AM, the LPN observed Resident #9's oxygen concentrator and verbalized the flow was set to right below two LPM. The LPN verbalized Resident #9's clinical record did not include a physician order for Oxygen titration. The LPN explained it was important for Resident #9 to have Oxygen at the prescribed level to prevent shortness of breath and hyperventilation. On 07/23/2025 at 10:21 AM, the Interim Director of Nursing (DON) verbalized the DON expected medications to be administered at the correct dose as outlined in the physician order. The DON confirmed Oxygen was considered a medication. The DON verbalized Resident #9 did not wear the Oxygen continuously, however did use Oxygen fairly often. The DON reviewed Resident #9's clinical record and confirmed the resident had a physician order to administer Oxygen at three LPM. The DON confirmed Resident #9's Oxygen Saturations Summary Report documented Resident #9 received Oxygen at two LPM, against the physician's order of three LPM. 07/23/2025 at 11:26 AM, Resident #9 verbalized the resident did not touch the oxygen concentrator. All Oxygen was administered by the facility. The resident explained even if the resident wanted to change the resident's oxygen flow, Resident #9 would not know where to look or what to do. On 07/23/2025 at 11:28 AM, the DON verbalized the DON would consider a medication administered at an incorrect dose to be a medication error. The facility policy titled, Administration of Medications, revised 01/2021, documented prior to administering any medications, the administering nurse was to consider the ten rights: right resident, right drug, right dose, right route, right time, right documentation, right client education, right to refuse, right assessment, and right evaluation. Cross reference with F842.

Based on observation, interview, clinical record review, and document review, the facility failed to ensure the Facility Assessment (FA) was accurate and included nicotine dependence and addiction with the facility's common diagnoses and conditions. This deficient practice had the potential to result in facility staff not receiving adequate training on the care of residents with nicotine dependence and addiction diagnoses and the needs of those residents not being met. Findings include: During the entrance conference with the facility on 07/21/2025, a list of cigarette smokers (smokers) residing in the facility and the FA was provided by the facility. The list of smokers in the facility included five residents. The smoking location was designated off the outside patio accessed through the facility dining room. The Facility Assessment last reviewed March 2025, did not include nicotine abuse or addiction nor a list of the number of active or current substance abuse disorders. On 07/24/2025 at 8:37 AM, the Interim Director of Nursing (DON) verbalized the DON assisted with reviewing and completing the FA. The DON confirmed nicotine addiction was not identified on the FA as a diagnosis in the facility and the FA lacked documented evidence of the number of residents with active or current substance use disorders. The DON confirmed five residents in the facility were current cigarette smokers. The Centers for Disease Control and Prevention article titled Treatment of Substance Use Disorders, dated 04/25/2024, documented a substance use disorder was a treatable, chronic disease and could range in severity from moderate to severe. A substance use disorder could be applied to many types of drugs including tobacco (nicotine). The facility policy titled Facility Assessment Plan, undated, documented the FA would include the care required by the resident population considering the types of diseases and other pertinent facts present within the population.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and document review, the facility failed to ensure a resident's Oxygen administration was documented in the resident's medication administration record (MAR) for 1 of 13 sampled residents (Resident #9). This deficient practice had the potential to result in unmanaged Oxygen saturation levels.Findings include: Resident #9 Resident #9 was admitted to the facility on [DATE], with diagnoses including chronic respiratory failure with hypoxia and chronic obstructive pulmonary disease, unspecified. A physician's order dated 09/26/2023, documented to administer Oxygen (O2) via nasal canula (NC) at three liters per minute (LPM) as needed for shortness of breath. May remove as desired if breathing is comfortable. An Oxygen Saturations Summary Report documented an Oxygen flow of two LPM on the following dates:-On 07/06/2025 at 10:39 PM.-On 06/10/2025 at 8:22 PM.-On 06/09/2025 at 9:08 PM.-On 06/08/2025 at 8:03 PM.-On 05/01/2025 at 10:10 PM.-On 04/29/2025 at 8:13 PM. Resident #9's May, June, and July 2025 MARs lacked documentation Oxygen was administered on any day within the three-month time span. On 07/21/2025 at 9:53 AM, Resident #9 wore Oxygen via NC. Resident #9's oxygen concentrator was set to a flow of two LPM. On 07/21/2025 at 9:53 AM, Resident #9 verbalized the resident wore Oxygen all the time and often needed to gasp for air. Resident #9 verbalized believing Resident #9's Oxygen was supposed to be set at four LPM. On 07/21/2025 at 11:58 AM, Resident #9 wore Oxygen via NC. 07/23/2025 at 9:56 AM, a Licensed Practical Nurse (LPN) verbalized Resident #9's clinical record included a physician order for Oxygen at three LPM as needed to address difficulty breathing. The LPN explained Resident #9 wore the Oxygen continuously because the resident's Oxygen levels desaturated when not in use. The LPN verbalized the LPN did not document Resident #9's Oxygen administration anywhere in the electronic health record (EHR). On 07/23/2025 at 10:10 AM, Resident #9 wore Oxygen via NC. Resident #9's oxygen concentrator was set to a flow of two LPM. On 07/23/2025 at 10:10 AM, the LPN observed Resident #9's oxygen concentrator and verbalized the flow was set to right below two LPM. On 07/23/2025 at 10:21 AM, the Interim Director of Nursing (DON) verbalized the DON expected medication administration to be documented on the MAR at the time of administration. The DON confirmed Oxygen was considered a medication. The DON explained it was important to document as needed Oxygen administration to determine how often Oxygen was used and to assess whether the resident would benefit from alterations in the resident's medication regimen. The DON verbalized Resident #9 did not wear the Oxygen continuously, however did use Oxygen fairly often and had periodically observed the resident wearing the Oxygen. The DON confirmed Resident #9's May, June and July 2025 MARs lacked documented evidence of Oxygen administration on any day within the three-month time span. The DON verbalized the Oxygen administration should have been documented in the resident's MAR. 07/23/2025 at 11:26 AM, Resident #9 verbalized the resident did not touch the oxygen concentrator. All Oxygen was administered by the facility. The resident explained even if the resident wanted to change the resident's oxygen flow, Resident #9 would not know where to look or what to do. The facility policy titled, Administration of Medications, revised 01/2021, documented prior to administering any medications, the administering nurse was to consider the ten rights: right resident, right drug, right dose, right route, right time, right documentation, right client education, right to refuse, right assessment, and right evaluation. Chart all administered medication and treatments in the EHR within appropriate timeframes, and include all required information needed for the medication or treatment. Cross reference with F760.

Based on interview and document review, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to identify a concern and ensure corrective action was implemented related to the lack of tracking and trending of infections and antibiotic use within the Antibiotic Stewardship Program (ASP). This deficient practice had the potential to result in unnecessary antibiotic use and the development of antibiotic-resistant organisms.Findings include: On 07/24/2025 at 3:11 PM, during the QAPI review with the Chief Executive Officer (CEO), the CEO verbalized the facility ceased tracking of infection prevention and control from August 2024 through May 2025, due to not having an Infection Preventionist on staff at the facility. The CEO explained as a result, the QAPI committee did not identify a concern related to the lack of antibiotic stewardship tracking for resident antibiotics. The facility policy titled, Quality Management Program, revised 06/2025, documented the performance improvement plan would address all systems of care and management practice. Performance measures known to jeopardize the safety of residents would be monitored. At a minimum, performance measures related to medication management and infection prevention and control would be monitored by the performance improvement committee. Cross reference with F881 and F882.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and document review, the facility failed to ensure Transmission-Based Precautions (TBP) were implemented according to facility policy and Centers for Disease Control and Prevention (CDC) recommendations for 1 of 13 sampled residents (Resident #6). This deficient practice had the potential to increase risk of spreading infectious organisms throughout the facility.Findings include: Resident #6 Resident #6 was admitted to the facility on [DATE], with a diagnosis of methicillin resistant staphylococcus aureus (MRSA) infection, unspecified site. An aerobic bacterial culture report dated 03/27/2025, documented light growth of MRSA to the resident's left leg. A hospital Discharge summary dated [DATE], documented an order for contact precautions related to MRSA. A Comprehensive Care Plan included a care plan initiated 06/18/2025, documenting Resident #6 had a chronic fistula to the left inner knee related to chronic MRSA. An intervention initiated 04/06/2025, documented to instruct family, visitors, and caregivers to wear a disposable gown and gloves during physical contact with the resident. An intervention initiated 07/18/2025, documented contact precautions would be followed when providing treatment to the resident's wound. Resident #6's clinical record lacked documentation of an active order for contact precautions. On 07/21/2025 at 1:45 PM, the entrance of Resident #6's room lacked TBP signage and a Personal Protective Equipment (PPE) cart. On 07/21/2025 at 1:45 PM, Resident #6 verbalized Resident #6 had a staph (staphylococcus) infection in the resident's left inner thigh. On 07/23/2025 at 2:43 PM, Resident #6 verbalized staff wore gloves when providing wound care, transfer and dressing assistance, and food service. However, staff did not wear gowns or wear face masks at any point. On 07/23/2025 at 3:08 PM, a Certified Nursing Assistant (CNA) entered Resident #6's room, did not don PPE, provided snack service and pulled the blanket up to the resident's chest. The CNA washed their hands prior to exiting the resident's room. On 07/23/2025 at 3:11 PM, the CNA verbalized staff would don a gown and gloves prior to touching a resident or their environment for residents with MRSA. The CNA verbalized expecting a sign and PPE cart outside the room of a resident on TBP. The CNA verbalized being unaware Resident #6 had an active MRSA diagnosis and confirmed the CNA did not don PPE prior to entering Resident #6's room and touching the resident's environment. On 07/23/2025 at 3:15 PM, a Registered Nurse (RN) verbalized contact precautions were required for residents with confirmed or suspected contagious infections in order to prevent spread to residents and staff. Residents on contact precautions were to be given private rooms if available. The RN explained the Infection Preventionist (IP) was responsible for determining who would require TBP as well as ensuring signage and carts were present at room entrances. The RN confirmed Resident #6 was admitted to the facility with an active diagnosis of MRSA and described MRSA to be a highly transmissible infection. The RN confirmed a care plan indicating the use of contact precautions was included in Resident #6's clinical record. The RN verbalized the resident was not on contact precautions. On 07/24/2025 at 11:16 AM, the IP verbalized contact precautions were a type of TBP appropriate for residents with known or suspected infections of multidrug-resistant organisms (MDROs). Contact precautions required the use of gloves and gowns when caring for residents to protect both residents and staff. The IP would expect to see signage and carts available outside the rooms of residents on contact precautions. The IP verbalized the IP would expect residents with an active diagnosis of MRSA to be on contact precautions. The IP explained Resident #6 had an ongoing fistula with drainage and an active diagnosis of MRSA. The IP confirmed Resident #6 should have been on contact precautions. The facility policy titled Transmission Based Precautions, revised 08/2024, documented TBP was used for residents with a documented or suspected infection or colonization with highly transmissible pathogens. Contact precautions would be used for residents with known or suspected infections or evidence of syndromes that represent an increased risk for contact transmission. The facility followed CDC pathogen-specific recommendations. The CDC document titled 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, updated 09/2024, documented MDROs were generally defined as microorganisms which were resistant to one or more classes of antimicrobial agents. MDROs of concern included MRSA. Documented outbreaks in long-term care facilities were caused by various viruses and bacteria and could lead to substantial morbidity and mortality and increased medical costs. Prompt detection and implementation of effective control measures were required. Placement of a resident in a single room was preferred when there was concern about transmission of an infectious agent, including residents on contact and droplet precautions. Recommendations for residents infected or colonized with an MDRO judged as clinically important by the infection control program included contact in addition to standard precautions.

Based on document review and interview, the facility failed to ensure the facility maintained an Antibiotic Stewardship Program (ASP) including tracking and trending of infections and antibiotic use from 08/2024 through 05/30/2025. This deficient practice had the potential to result in residents not receiving the correct or best antibiotic for infections resulting in prolonged or exacerbated infections and the spread of infections throughout the facility.Findings include:On 07/24/2025 at 2:46 PM, the facility was not able to provide documented evidence of an ASP, including tracking and trending of infections and antibiotic use between 08/2024 and 05/30/2025. On 07/24/2025 at 2:47 PM, the Infection Preventionist (IP) confirmed the IP had not been documenting data related to tracking and trending of infections and antibiotic use. The IP explained how the IP tracked infections and antibiotic use and monitored for trends but did not document the findings. The IP began working at the facility on 05/12/2025 and began to perform tracking and trending of infections and antibiotic use on 05/30/2025.On 07/24/2025 at 3:12 PM, the interim Director of Nursing (DON) confirmed the facility was not able provide documented evidence of an ASP, including tracking and trending between 08/2024 and 05/30/2025. The DON explained the concern with not having an ASP, including tracking and trending was the risk of increased infections throughout the facility.The facility policy titled Antimicrobial Stewardship Program last revised 12/2024, documented the ASP proactively monitored for the use of antimicrobial prescriptions. The IP summarized and kept records of the antibiotic use from electronic health records and laboratory data. The data included the culture site and organism, infection start date, antibiotic name, strength, date, duration, how the medication was administered, antibiotic sensitivity, and if the infection was a healthcare associated infection or a community acquired infection. The IP used the Long Term Care Infection Map to document all infections each month. The IP monitored and kept track of the communication from the clinical staff regarding infections and prescribed antibiotics, the Four Moments document including the antibiotic time out information, and resident/guardian education, signatures and dates.Cross reference with F865 and F882

Based on document review and interview, the facility failed to ensure an Infection Preventionist (IP) was employed by the facility at least part time each month from 12/27/2024 to 05/12/2025. This deficient practice had the potential to result in lapses in infection control and the Antibiotic Stewardship (ASP) program with potential for infections to spread throughout the facility and residents to be treated with ineffective antibiotics.Findings include: A facility document titled Payroll Status Form documented IP-1's last day of work at the facility was 12/26/2024. A facility document titled Payroll Status Form documented IP-2's first date of work at the facility was 05/12/2025. On 07/23/2025 at 8:42 AM, the Human Resource Manager (HRM) confirmed IP-1's last day of work at the facility was 12/26/2024, and IP-2's first day of work at the facility was 05/12/2025. The HRM verbalized to the best of the HRM's knowledge, there was not another individual who worked as an IP at the facility between 12/26/2024 and 05/12/2025. 07/23/2025 at 3:12 PM, the Chief Executive Officer (CEO) verbalized there were two additional employees at the facility with IP certification. The CEO confirmed the two additional employees had not worked in the role of the facility's IP including the antibiotic stewardship program, immunization, education of staff and residents, and surveillance of infection control practices throughout the facility. On 07/23/2025 at 3:13 PM, the interim Director of Nursing (DON) confirmed an IP had not worked at the facility from 12/27/2024 through 05/11/2025. The DON verbalized not having an IP working at the facility during this time span and the lack of oversight of the facility's Infection Prevention and Control Program and Antibiotic Stewardship Program could lead to increased infections throughout the facility.Cross reference with F881

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure an allegation of neglect and abuse was reported to the State Agency (SA) within the required time frame for 1 of 22 sampled residents (Resident #18). This deficient practice could result in allegations of abuse not being investigated timely. Findings include: Resident #18 Resident #18 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including type two diabetes mellitus with diabetic polyneuropathy and chronic obstructive pulmonary disease, unspecified. A Facility Reported Incident (FRI) was submitted to the SA on 11/27/2024, documenting an allegation of resident neglect and abuse by a Certified Nursing Assistant (CNA). The FRI documented the alleged incident occurred on 11/22/2024, and the Chief Nursing Officer (CNO) was notified of the allegations on 11/25/2024 by the long-term care unit secretary. On 01/29/2025 at 1:41 PM, the Director of Nursing Secretary (DON Secretary) verbalized the facility's abuse coordinator was the DON and all allegations of abuse were to be reported to the DON. The DON Secretary recalled an Observation Aide (OA) notified the DON Secretary of an allegation of resident neglect and abuse by a CNA. The DON Secretary verbalized the DON Secretary reported the allegation to the CNO as the facility did not have a DON at the time. The CNO was notified the same day the DON Secretary received the allegations from the OA. On 01/29/2025 at 2:25 PM, an Observation Aide (OA) recalled the OA was working in the evening on 11/22/2024. The OA recalled Resident #18 called out for help and verbalized the resident needed to be changed. Later in the shift, the OA observed from the hallway, Resident #18 had no brief on and was uncovered from the waist down. Resident #18 reported to the OA the CNA had come to change Resident #18's brief and had left without putting a brief on the resident or covering the resident. On 11/25/2024, the OA spoke to the DON Secretary about the incident and asked the DON Secretary how to contact the CNO to report it. The facility policy titled Freedom From Abuse (Residents, Patients), revised May 2021, documented abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish or the deprivation of goods or services necessary to attain or maintain physical, mental, and psychosocial well-being. Neglect was defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Any person identifying signs of resident abuse or neglect were to immediately report to the charge nurse and the charge nurse would notify the DON and the Chief Risk Officer. The DON or the Chief Risk Officer would report suspected abuse to the SA within 24 hours. FRI #NV00072852

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, document review, and interview the facility failed to demonstrate effective administration by not ensuring the Chief Executive Officer (CEO) and the Chief Nursing Officer (CNO) adequately interpreted and implemented effective infection control protocols per the Centers for Disease Control and Prevention (CDC) guidance to effectively prevent the spread of COVID-19 (COVID) resulting in a wide spread outbreak of COVID amongst facility staff and residents. Findings include: A facility COVID tracking sheet documented between [DATE] and [DATE], 16 employees and 16 of 22 residents residing in the facility tested positive for COVID. (See Tag F880 for details). On [DATE] at 3:04 PM, the Chief Nursing Officer (CNO) confirmed the facility had a COVID outbreak in the facility around October or November. The CNO explained the rooms at the far end of the hallway had been used in the past to isolate residents with COVID. The residents would have been able to ambulate in the hallways without coming in contact with COVID negative residents due. The CNO explained the rooms were able to be separated from the rest of the facility by closing the firewall doors. However, the CNO explained an interim (travel) Director of Nursing (DON) verbalized to the CNO, the facility could not require residents to stay in their rooms. On [DATE] at 3:06 PM, the CNO confirmed the facility had not used the isolated pods due to the travel DON flat out saying they were the DON and they (the DON) had said no. The CNO verbalized unfortunately, they allowed the COVID positive residents to go to the dining room and this was how a lot of the residents became sick. On [DATE] at 3:08 PM, the CNO confirmed the DON was the CNO's subordinate. The CNO confirmed the CNO had the authority to instruct the DON regarding resident care and the functioning of the facility including the use of the rooms on the other side of the fire doors. The CNO confirmed the CNO should have instructed the DON to ensure COVID positive residents were isolated and did not intermingle with other residents and had failed to do so. On [DATE] at 3:10 PM, the CNO verbalized during the COVID outbreak staff attempted to get residents and visitors to wear mask. The CNO explained during the COVID outbreak staff wore surgical mask but as more employees and residents became infected with COVID, staff began to wear N95 respiratory mask. The rationale for the selection of source control was as the outbreak got larger, the facility decided it would behoove them all to wear N95 respirator mask to help prevent further spread. The CNO explained surgical mask were effective in the prevention of spreading COVID as long as the mask were not worn for too long of a period. On [DATE] at 3:12 PM, the CNO verbalized the Infection Preventionist (IP) working at the facility during the outbreak agreed with the use of surgical mask, but after speaking with the DON it was decided the facility should switch to N95 respirator mask. On [DATE] at 1:19 PM, the acting Long Term Care (LTC) Medical Director verbalized the facility had hired a physician to take over as the Medical Director for LTC. However, the physician's state licensure was taking longer than expected and around the first week of October, the Medical Director became involved with the facility's COVID outbreak and explained at this time there were approximately five COVID positive residents. The Medical Director verbalized during this time the facility had an interim (travel) Director of Nursing (DON) and the DON reviewed the facility's policies regarding COVID testing and quarantine. The Medical Director explained the facility's COVID policies were unclear regarding when to stop testing and there was confusions and debate amongst facility leadership. The Medical Director recalled reviewing CDC guidance with another physician and argued against 48 hour testing. The Medical Director confirmed testing was completed on residents and staff every 48 hours and believed this practice continued for a week or two. The Medical Director explained during past COVID outbreaks the facility was able to separate and isolate residents. Due to the amount of exposure which had already occurred, it was decided not to move residents around. The Medical Director confirmed Resident #12 was sent to an acute care hospital outside of the facility's hospital system and confirmed Resident #12 expired during the hospitalization. On [DATE] at 2:11 PM, the CNO confirmed the facility followed the Centers for Medicare and Medicaid (CDC) guidance. Cross reference with F880

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, document review, and interview, the facility failed to ensure the Centers for Disease Control and Prevention (CDC) guidance and the facility's Infection Prevention and Control Plan (IPCP) were followed regarding the management of COVID-19 (COVID). This failure resulted in an outbreak of COVID within the facility resulting in 16 employees and 16 of 22 residents (Resident #14, #18, #4, #19, #9, #10, #3, #11, #16, #21, #15, #2, #5, #6, #17, and #12) becoming infected with COVID during September and [DATE]. Resident #12 was transferred to an acute care hospital for treatment of COVID symptoms the facility was not able to manage. Resident #12 expired during this hospitalization. Findings include: Employees An untitled and undated facility spread sheet utilized for tracking employee COVID status, documented during the months of September and [DATE], facility employees were tested for COVID as follows. -On [DATE], a consulting physician with a hire date of [DATE], tested positive for COVID and tested negative for COVID on [DATE]. The physician complained of a cough, stuffy/runny nose, and pain beginning on [DATE] and worked on [DATE]. The documentation indicated the physician was tested on day two and day five following the onset of symptoms. The spread sheet lacked documented evidence of additional testing and did not indicate when the employee could or did return to work. -On [DATE], a Dietary Aide with a hire date of [DATE], tested positive for COVID. The Dietary Aide tested negative on [DATE]. The Dietary Aide complained of sore throat and congestion starting on [DATE] and had worked all week while wearing a mask. The documentation indicated the Dietary Aide was tested on day four and day 10 following the onset of symptom. The spread sheet lacked documented evidence of additional testing and did not indicate when the employee could or did return to work. -On 09/30, 10/02, and [DATE], a Physical Therapist (PT) with a hire date of [DATE] tested positive for COVID. The PT tested negative on [DATE]. The PT called in sick on [DATE], and complained of a sore throat, runny nose, cough, and fever. The documentation indicated the PT was tested on day zero, day two, and day four, and day seven. The spread sheet lacked documented evidence of additional testing and did not indicate when the employee could or did return to work. -On 10/02 and [DATE], a Minimum Data Set (MDS) Coordinator with a hire date of [DATE], tested positive for COVID. The MDS Coordinator tested negative on [DATE]. The MDS Coordinator had complained of body aches and fever starting on [DATE]. The documentation indicated the MDS Coordinator was tested on day two, day four, and day seven. The spread sheet lacked documented evidence of additional testing and did not indicate when the employee could or did return to work. -On 10/02 and [DATE], Certified Nursing Assistant (CNA) with a hire date of [DATE], tested positive for COVID. The CNA tested negative on [DATE]. The CNA had complained of fever, sore throat, cough, body aches and gastrointestinal symptoms starting on [DATE]. The documentation indicated the CNA was tested on day two, day four, and day seven. The spread sheet lacked documented evidence of additional testing and did not indicate when the employee could or did return to work. -On 10/03, 10/04, and [DATE], an Aide with the hire date of [DATE] tested positive for COVID. The Aide tested negative on [DATE]. The Aide had complained of a runny nose, cough and sore throat starting on [DATE]. The CNA worked on 09/30 and [DATE]. The Aide was sent home on [DATE]. The documentation indicated the aide was tested on day two, day three, and day six. The spread sheet lacked documented evidence of additional testing and did not indicate when the employee could or did return to work. -On 10/05, 10/07, 10/09, and [DATE] an Assistant Housekeeping Supervisor with a hire date of [DATE] tested positive for COVID. The Housekeeping Supervisor tested negative on [DATE]. The housekeeper complained of having a hoarse voice on [DATE]. The documentation indicated the Housekeeping Supervisor was tested on day two, day four, day six, day eight, and day 11. The spread sheet lacked documented evidence of additional testing and did not indicate when the employee could or did return to work. -On 10/07 and [DATE] a Housekeeping Supervisor with a hire date of [DATE]. tested positive for COVID. The Housekeeping Supervisor tested negative on [DATE]. The Housekeeping Supervisor complained of a fever, headache, sore throat, cough, and a stuffy nose on [DATE]. The documentation indicated the Housekeeping Supervisor was tested on day two, day four, and day six. The spread sheet lacked documented evidence of additional testing and did not indicate when the employee could or did return to work. -On [DATE], a CNA with a hire date of [DATE] tested positive for COVID. The CNA tested negative for COVID on [DATE]. The CNA complained of fever, chills, body aches, runny nose, and headache starting on [DATE]. The documentation indicated the CNA was tested on day two and day four. The spread sheet lacked documented evidence of additional testing and did not indicate when the employee could or did return to work. -On 10/08 and [DATE] a CNA with a hire date of [DATE], tested positive for COVID. The CNA tested negative on [DATE]. The CNA complained of symptoms starting on [DATE]. The documentation indicated the CNA was tested for COVID on day three, day five, and day seven. The spread sheet lacked documented evidence of additional testing and did not indicate when the employee could or did return to work. -On 10/08 and [DATE], a Dietary [NAME] with a hire date of [DATE], tested positive for COVID. The Dietary [NAME] tested negative on [DATE]. The CNA complained of chills, aches, congestion, and a sore throat starting on [DATE]. The documentation indicated the Dietary [NAME] was tested on day two, day four, and day six. The spread sheet lacked documented evidence of additional testing and did not indicate when the employee could or did return to work. -On [DATE], a Housekeeper with a hire date of [DATE], tested positive for COVID. The Housekeeper tested negative on [DATE]. The Housekeeper complained of headache, sore throat, and runny nose starting on [DATE]. The documentation indicated the Housekeeper was tested on day two and day four. The spread sheet lacked documented evidence of additional testing and did not indicate when the employee could or did return to work. -On [DATE], a CNA with a hire date of [DATE], tested positive for COVID. The CNA tested negative on [DATE]. The CNA complained of a cough, headache, and runny nose starting on [DATE]. The documentation indicated the CNA was tested on day three and day five. The spread sheet lacked documented evidence of additional testing and did not indicate when the employee could or did return to work. -On 10/10 and [DATE] a CNA with a hire date of [DATE] tested positive for COVID. The CNA tested negative on [DATE]. The CNA complained of symptoms starting on [DATE]. The documentation indicated the CNA was tested for COVID on day two, day four, and day six. The spread sheet lacked documented evidence of additional testing and did not indicate when the employee could or did return to work. -On 10/14 and [DATE] a Licensed Practical Nurse (LPN) with a hire date of [DATE] tested positive for COVID. The LPN tested negative on [DATE]. The LPN complained of a sore throat and stuffy nose starting on [DATE]. The documentation indicated the LPN was tested on day two, day four, and day six. The spread sheet lacked documented evidence of additional testing and did not indicate when the employee could or did return to work. Additionally, an untitled and undated flow sheet documented on 09/282024 and [DATE], a Registered Nurse (RN) with a hire date of [DATE], tested positive for COVID. The RN tested negative on [DATE]. The RN complained of a cough and sore throat starting on [DATE] and was not scheduled to work until [DATE]. The documentation indicated the RN was tested on day three, day six, and day eight. The flow sheet lacked documented evidence of additional testing and did not indicate when the employee could or did return to work. The RN was not included on the facility's COVID testing spread sheet and was not included on the facility's employee list. On [DATE] at 3:24 PM, the Chief Nursing Officer (CNO) verbalized in the beginning of the COVID outbreak, staff wore surgical mask. The CNO confirmed surgical mask were worn, and explained the surgical mask were worn for no more than two weeks. The CNO verbalized during the beginning of the outbreak the Centers for Medicare and Medicaid Services (CMS) and the Infection Preventionist's (IP) instructions were followed. The CNO explained when an employee tested positive for COVID, the employee was not allowed to return to work until symptoms resolved and the employee tested negative for COVID. On [DATE] at 2:11 PM, the CNO confirmed the facility followed CDC guidance. On [DATE] at 2:44 PM, during a telephone interview, the Chief Executive Officer (CEO) confirmed the facility followed CDC guidance as much as possible and added the facility was stricter than CDC guidance. The CNO explained we can be stricter, and we have so much data we can show. The CEO confirmed employees and residents were tested every other day. A CDC memo titled Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 (COVID) Infection or Exposure to COVID, dated [DATE], documented health care workers with mild to moderate illness who were not moderately or severely immunocompromised could return to work after the following criteria was met: -At least seven days had passed since symptoms first appeared if a negative viral test was obtained within 48 hours prior to returning to work (or after 10 days if testing was not performed or if a positive test was obtained at days 5-7), AND -At least 24 hours had passed since the last fever without the use of fever reducing medications, AND -Symptoms such as cough and shortness of breath had improved. The return-to-work criteria for healthcare workers who were exposed to individuals with confirmed SARS CoV-2 infection included: -A series of three viral tests for COVID infection. Testing was recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. -All recommended infection prevention and control practices were to be followed, including wearing well-fitting source control, monitoring for fever or symptoms consistent with COVID, and health care workers were not to report to work when ill or if testing positive for COVID. Health care workers who have entered the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a National Institute for Occupational Safety and Health (NIOSH) approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). The facility policy titled Healthcare Personnel (HCP) with a COVID-19 Diagnosis or Exposure and their Return to Work revised on 04/2023, documented HCP with mild to moderate illness who were not moderately or severely immunocompromised could return to work after the following criteria was met: -At least seven days had passed since symptoms first appeared if a negative viral test was obtained within 48 hours prior to returning to work (or after 10 days if testing was not performed or if a positive test was obtained at days 5-7), AND -At least 24 hours had passed since the last fever without the use of fever reducing medications, AND -Symptoms such as cough and shortness of breath had improved. The return to work criteria for healthcare workers who were exposed to individuals with confirmed SARS CoV-2 infection included: -A series of three viral tests for COVID infection. Testing was recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. -All recommended infection prevention and control practices were to be followed, including wearing well-fitting source control, monitoring for fever or symptoms consistent with COVID, and health care workers were not to report to work when ill or if testing positive for COVID. The facility policy titled COVID-19: Source Control, revised 06/2024, documented source control options for HCP's included a NIOSH approved particulate respirator with N95 filters or higher, a respirator approved in other countries could be used if a NIOSH approved N95 was not available. A barrier face covering that met ASTM F3502-21 requirements including Workplace Performance and Workplace Performance Plus mask, OR a well-fitting facemask. A NIOSH approved particulate respirators with N95 filters or higher was recommended during the care of a patient with SARS-CoV-2 infection. Residents Resident #14 Resident #14 was admitted to the hospital on [DATE], with diagnoses including dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, unspecified severe protein-calorie malnutrition, and chronic obstructive pulmonary disease (COPD). A laboratory (lab) report documented Resident #14 tested positive for COVID on 10/012024. The report did not document any additional COVID testing. An untitled and undated facility COVID tracking spread sheet documented Resident #14 tested positive for COVID on 10/01, 10/03, 10/07, 10/09, and [DATE]. The resident tested negative on [DATE]. Resident #18 Resident #18 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including type II diabetes mellitus with diabetic polyneuropathy, COPD, and unspecified dementia, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A lab report documented Resident #18 tested positive for COVID on 10/02, 10/04, 10/06, and [DATE]. The resident tested negative on [DATE]. An untitled and undated facility COVID tracking spread sheet documented Resident #18 tested positive for COVID on 10/02, 10/04, 10/06, and [DATE]. The resident tested negative on [DATE]. Resident #4 Resident #4 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including unspecified dementia, unspecified severity, with other behavioral disturbance, and deficiency of other specified B group vitamins, and nutritional anemia, unspecified. A lab report documented Resident #4 tested positive for COVID on 10/04, 10/07, 10/09, and [DATE]. An untitled and undated facility COVID tracking spread sheet documented Resident #4 tested positive for COVID on 10/02, 10/07, 10/09, and [DATE]. The resident tested negative on [DATE]. Resident #19 Resident #19 was admitted to the facility on [DATE], with hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, essential (primary) hypertension, unspecified disorder of circulatory system, and adult failure to thrive. A lab report documented Resident #19 tested positive for COVID on 10/02, 10/04, 10/07, and 10/09. The resident tested negative on [DATE]. An untitled and undated facility COVID tracking spread sheet documented Resident #19 tested positive for COVID on 10/02, 10/04, 10/07, and 10/09. The resident tested negative on [DATE]. Resident #9 Resident #9 was admitted to the facility on [DATE], with diagnoses including multiple sclerosis, essential (primary) hypertension, and vitamin D deficiency, unspecified. A lab report documented Resident #9 tested positive for COVID on 10/02, 10/04, and [DATE]. The resident tested negative on [DATE]. An untitled and undated facility COVID tracking spread sheet documented Resident #9 tested positive for COVID on 10/02, 10/04, and [DATE]. The resident tested negative on [DATE]. Resident #10 Resident #10 was admitted to the facility on [DATE], with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right non-dominant side. A lab report documented Resident #10 tested positive for COVID on 10/03, 10/07, and [DATE]. The resident tested negative for COVID on 10/02 and [DATE]. An untitled and undated facility COVID tracking spread sheet documented Resident #10 tested positive for COVID on 10/03, 10/07, and [DATE]. The resident tested negative for COVID on 10/02 and [DATE]. Resident #3 Resident #3 was admitted to the facility on [DATE], with diagnoses including alcoholic hepatic failure without coma, alcoholic cirrhosis of liver with ascites, essential (primary) hypertension, and unspecified protein-calorie malnutrition. A lab report documented Resident #3 tested positive for COVID on 10/04, 10/07, 10/09, and [DATE]. The resident tested negative for COVID on [DATE]. An untitled and undated facility COVID tracking spread sheet documented Resident #3 tested positive for COVID on 10/04, 10/07, 10/09, and [DATE]. The resident tested negative for COVID on 10/02 and [DATE]. Resident #11 Resident #11 was admitted to the facility on [DATE], and last readmitted on [DATE], with diagnoses including Alzheimer's disease, unspecified, essential (primary) hypertension, presence of cardiac pacemaker, and shortness of breath. A lab report documented Resident #11 tested positive for COVID on 10/04, 10/07, and [DATE]. The resident tested negative for COVID on 10/02 and [DATE]. An untitled and undated facility COVID tracking spread sheet documented #11 tested positive for COVID on 10/04, 10/07, and [DATE]. The resident tested negative for COVID on 10/02 and [DATE]. Resident # 16 Resident #16 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including COPD, type II diabetes mellitus without complications, polyneuropathy, unspecified. A lab report documented Resident #16 tested positive for COVID on 10/04, 10/07, 10/09, 10/11, 10/14, 10/16 and [DATE]. The lab report did not document a negative COVID test result. An untitled and undated facility COVID tracking spread sheet documented Resident #16 tested positive for COVID on 10/04, 10/07, 10/09, 10/11, 10/14, 10/15 and [DATE]. The resident tested negative for COVID on [DATE], prior to testing positive. The tracking spread sheet did not document any additional COVID test. Resident #21 Resident #21 was admitted to the facility on [DATE], with diagnoses including cerebral infarction due to unspecified occlusion or stenosis of left middle cerebral artery, essential (primary) hypertension, acute respiratory failure with hypoxia, unspecified asthma, and dependence on long term (current) use of antibiotics. A lab report documented Resident #21 tested positive for COVID on 10/04 and [DATE]. The resident tested negative for COVID on 10/02 and [DATE]. An untitled and undated facility COVID tracking spread sheet documented Resident #21 tested positive for COVID on 10/04 and [DATE]. The resident tested negative for COVID on 09/23, 10/02 and [DATE]. Resident #15 Resident #15 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including hemiplegia, unspecified affecting right dominant side, essential (primary) hypertension, and vascular dementia, unspecified severity, with other behavioral disturbance. A lab report documented Resident #15 tested positive for COVID on 10/04, 10/07, 10/09, 10/11, 10/14, 10/16, and [DATE]. The lab report did not document a COVID negative test. An untitled and undated facility COVID tracking spread sheet documented Resident #15 tested positive for COVID on 10/04, 10/07, 10/09, 10/11, 10/14, 10/15, and [DATE]. The resident tested negative for COVID on [DATE], prior to testing positive. The tracking spread sheet did not document any additional COVID test. Resident #2 Resident #2 was admitted to the facility on [DATE], with diagnoses including vascular dementia, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, disease of pancreas, unspecified, and essential (primary) hypertension. A lab report documented Resident #2 tested positive for COVID on [DATE]. The resident tested negative for COVID on 10/03 and [DATE]. An untitled and undated facility COVID tracking spread sheet documented Resident #2 tested positive for COVID on [DATE]. The resident tested negative for COVID on 10/03 and [DATE]. Resident #5 Resident #5 was admitted to the facility on [DATE], with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non dominant side, hypertensive heart disease with heart failure, and occlusion and stenosis of unspecified carotid artery. A lab report documented Resident #5 was tested negative for COVID on 10/02 and [DATE]. The lab report did not document any additional COVID test. An untitled and undated facility COVID tracking spread sheet documented Resident #5 tested positive for COVID on 10/07, 10/09, 10/11, and [DATE]. The resident tested negative for COVID on 10/02, 10/03, and [DATE]. Resident #6 Resident #6 was admitted to the facility on [DATE], with diagnoses including pleural effusion, not elsewhere classified, adult failure to thrive, and chronic atrial fibrillation, unspecified. A lab report documented Resident #6 tested positive for COVID on 10/07 and [DATE]. The resident tested negative for COVID on 10/04, 10/11, and [DATE]. An untitled and undated facility COVID tracking spread sheet documented Resident #6 tested positive for COVID on 10/07 and [DATE]. The resident tested negative for COVID on 09/13, 09/18, 10/02, 10/04, 10/11, and [DATE]. Resident #17 Resident #17 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including acute respiratory failure with hypoxia, hypertensive heart disease with heart failure, acute on chronic diastolic (congestive) heart failure, type II diabetes mellitus with hyperglycemia, obstructive sleep apnea, and morbid (severe) obesity due to excess calories. A lab report documented Resident #17 tested positive for COVID on 10/11 and [DATE]. The resident tested negative on 10/02, 10/03, 10/09, and [DATE]. An untitled and undated facility COVID tracking spread sheet documented Resident #17 tested positive for COVID on 10/11 and [DATE]. The resident tested negative on 10/02, 10/03, 10/09, and [DATE]. Resident #12 Resident #12 was admitted to the facility on [DATE], and was last re-admitted to the facility on [DATE], with diagnoses including quadriplegia, unspecified, hydrocephalus, unspecified, hypotension, unspecified, respiratory failure, unspecified, unspecified whether with hypoxia or hypercapnia, unspecified severe protein-calorie malnutrition, and adult failure to thrive. A diagnosis of COVID was added on [DATE], and a diagnosis of pneumonia due to corona virus disease 2019 was added on [DATE]. A lab report documented Resident #12 tested positive for COVID on 10/06 and [DATE]. The resident tested negative for COVID on 10/02 and [DATE]. An untitled and undated facility COVID tracking spread sheet documented Resident #12 tested positive for COVID on 10/06 and [DATE]. The resident tested negative for COVID on 10/02 and [DATE]. A Health Alert note dated [DATE], documented Resident #12's oxygen saturating had begun to deteriorate to 88 percent (%). The resident's oxygen was increased to three liters per minute (LPM) with little effect and a physician was notified of the resident's condition. A Change of Condition note entered by a physician and dated [DATE] documented Resident #12 had a fever of 101.5 degrees Fahrenheit (F) on [DATE]. On [DATE], the resident had more of a cough and was tired. The resident's oxygen saturation had decreased to 88% on one LPM of oxygen. The oxygen was increased to three LPM and the resident's oxygen saturation remained at 88%. Resident #12 had received two nebulizer treatments while in the resident's regular room. Resident #12 was tested for COVID, and results were pending. The physician documented the physician believed the resident was COVID positive and planned to move the resident to a negative pressure room. The continued to document Resident #12's COVID test results had just come back positive, and the resident would be moved to a negative pressure room. A Health Status Note dated [DATE], documented Resident #12 was COVID positive and receiving antibiotics for pneumonia. A Health Status Note dated [DATE], documented Resident #12 was receiving oxygen at five LPM via nasal cannula and the resident's oxygen saturations were in the 60's. The resident did not want to go to the emergency room (ER) and requested to try a face mask for oxygen delivery. A face mask was applied and the resident's oxygen saturations increased to 75%. The resident agreed to be transferred to the ER. A Health Status Note dated [DATE], documented Resident #12's oxygen saturations remained in the 70's with oxygen being delivered at five LPM via face mask. The resident's heart rate was tachycardia in the 140's and the resident was transferred to the ER. On [DATE] at 3:04 PM, The Chief Nursing Officer (CNO) confirmed the facility had a COVID outbreak in the facility around October or November. The CNO explained the rooms at the far end of the hallway had been used in the past to isolate residents with COVID. The CNO explained the rooms were able to be separated from the rest of the facility by closing the firewall doors and residents would have been able to ambulate in the hallways without coming in contact with COVID negative residents. However, the CNO explained an interim (travel) Director of Nursing (DON) verbalized to the CNO, the facility could not require residents to stay in their rooms. On [DATE] at 3:06 PM, the CNO confirmed the facility had not used the isolated pods due to the travel DON flat out saying they were the DON, and they (the DON) had said no. The CNO verbalized unfortunately, they allowed the COVID positive residents to go to the dining room and this was how a lot of the residents became sick. On [DATE] at 3:08 PM, the CNO confirmed the DON was the CNO's subordinate. The CNO confirmed the CNO had the authority to instruct the DON regarding resident care and the functioning of the facility including the use of the rooms on the other side of the fire doors. The CNO confirmed the CNO should have instructed the DON to ensure COVID positive residents were isolated and did not intermingle with other residents and had failed to do so. On [DATE] at 3:10 PM, the CNO verbalized during the COVID outbreak staff attempted to get residents and visitors to wear mask. The CNO explained during the COVID outbreak staff wore surgical mask but as more employees and residents became infected with COVID, staff began to wear N95 respiratory mask. The rationale for the selection of source control was as the outbreak got larger, the facility decided it would behoove them all to wear N95 respirator mask to help prevent further spread. The CNO explained surgical mask were effective in the prevention of spreading COVID as long as the mask were not worn for too long of a period. On [DATE] at 3:12 PM, the CNO verbalized the Infection Preventionist (IP) working at the facility during the outbreak agreed with the use of surgical mask, but after speaking with the DON it was decided the facility should switch to N95 respirator mask. On [DATE] at 1:19 PM, the acting Long-Term Care (LTC) Medical Director verbalized the facility had hired a physician to take over as the Medical Director for LTC. However, the physician's state licensure was taking longer than expected and around the first week of October, the Medical Director became involved with the facility's COVID outbreak and explained at this time there were approximately five COVID positive residents. The Medical Director verbalized during this time the facility had an interim (travel) Director of Nursing (DON), and the DON reviewed the facility's policies regarding COVID testing and quarantine. The Medical Director explained the facility's COVID policies were unclear regarding when to stop testing and there was confusions and debate amongst facility leadership. The Medical Director recalled reviewing CDC guidance with another physician and argued against 48-hour testing. The Medical Director confirmed testing was completed on residents and staff every 48 hours and believed this practice continued for a week or two. The Medical Director explained during past COVID outbreaks the facility was able to separate and isolate residents. Due to the amount of exposure which had already occurred, it was decided not to move residents around. The Medical Director confirmed Resident #12 was sent to an acute care hospital outside of the facility's hospital system and confirmed Resident #12 expired during this hospitalization. On [DATE] at 2:11 PM, the CNO confirmed the facility followed CDC guidance. The CDC document titled Infection Control Guidance: SARS-CoV-s dated [DATE], documented during an outbreak of COVID, the approach to an outbreak investigation involved either contact tracing or a broad-based approach; however, a broad-based (e.g., unit, floor, or other specific area(s) of the facility) approach was preferred if all potential contacts could not be identified or managed with contact tracing or if contact tracing failed to halt transmission Testing was completed for all residents and HCP identified as close contacts or on the affected unit(s) if using a broad-based approach, regardless of vaccination status. Testing was recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This was typically at day 1 (where day of exposure is day 0), day 3, and day 5. If additional cases were identified, strong consideration was given to shifting to the broad-based approach if not already being performed and implementing quarantine for residents in affected areas of the facility. As part of the broad-based approach, testing continued on affected unit(s) or facility-wide every 3-7 days until there are no new cases for 14 days. Cross Reference with F835

Based on interview and document review, the facility failed to ensure pertinent State agencies and advocacy groups contact information posted in the facility were in a language understandable to residents. Findings include: On 07/16/2024 between 10:30 AM and 11:00 AM, during the Resident Council Interview, one of seven residents verbalized through a translator device, they were not aware of where the State agencies and advocacy groups contact information was located. This resident only read and spoke Spanish. On 07/16/2024 at 2:45 PM, the Director of Nursing verbalized none of the postings were understandable for the resident who read and spoke only Spanish. The DON confirmed the postings should be in a language understandable to the resident. The facility policy titled Resident Communication Rights, revised 07/2015, documented residents had the right to receive communication orally and in writing, including Braille or in a format and language the resident understands.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and document review, the facility failed to ensure a resident was protected from resident-to-resident verbal abuse and harassment for 1 of 12 sampled residents (Resident #16). Findings include: Resident #16 Resident #16 was admitted to the facility on [DATE], with diagnoses including adjustment disorder with anxiety and chronic obstructive pulmonary disease. Resident #15 Resident #15 was admitted to the facility on [DATE], with diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and nutritional anemia, unspecified. On 07/16/2024 at 10:43 AM, Resident #16 verbalized a resident had been harassing them and calling them names. On 07/16/2024 at 11:04 AM, Resident #15 verbalized they believed Resident #16 had stolen a picture out of their room. The resident explained they believed Resident #16 must be gay because they took the picture. Resident #15 verbalized they called Resident #16 gay because they knew Resident #16 did not like it. Resident #15 laughed and verbalized they knew Resident #16 was having sex with male members of the surrounding community. On 07/16/2024 at 11:26 AM, Resident #16 verbalized Resident #15 had been harassing them. Resident #16 explained Resident #15 had started accusing Resident #16 of stealing a picture out of their room. Resident #16 had never seen the picture and did not think it existed. Resident #16 verbalized Resident #15 called Resident #16 slurs such as a whore, slut, thief. Resident#16 verbalized whenever they entered a room with Resident #15 present, Resident #15 would remark Oh, there Resident #16 is. The resident recalled Resident #15 would say it in an unwelcoming tone. Resident #16 recalled they informed the Director of Nursing (DON) of Resident #15's harassment. The DON told Resident #16 to try to get along with Resident #15 and to be the bigger person because of Resident #15's mental state and decline. Resident #16 verbalized they felt embarrassed when Resident #15 called them a thief and slut. Resident #15 often called Resident #16 names in front of other residents. Resident #16 felt it was very offensive when Resident #15 accused them of stealing. The resident did not want Resident #15 hounding them. Resident #15 would go 'on and on and Resident #16 just wanted it to stop. Resident #16 recalled Resident #15 would go into Resident #16's room to search for the picture and accuse Resident#16 of stealing. Resident #16 verbalized they felt tormented by Resident #15. Resident #16 explained they tried to avoid areas where Resident #15 frequented, however it was hard because they lived in a small area. On 07/16/2024 at 3:19 PM, an Observation Aide verbalized a few months ago they witnessed Resident #15 accuse Resident #16 of stealing a picture. The Observation Aide attempted to redirect Resident #15, but Resident #15 did not want to redirect. Resident #15 continued to insist Resident #16 had the picture, and then began to call Resident #16 a faggot and said they were gay. The Observation Aide told Resident #15 it was not nice to call Resident #16 names. Resident #15 continued to call Resident #16 gay slurs in the presence of the Observation Aide. The Observation Aide informed the nurse of Resident #15's verbal outbursts. The Observation Aide considered the name calling to be verbal abuse. On 07/16/2024 at 3:30 PM, an Activity Aide (AA1) verbalized Resident #15 did not get along with Resident #16. The AA1 witnessed a verbal altercation in the hallway a couple of months ago between Resident #15 and Resident #16. Resident #15 was accusing Resident #16 of stealing a picture. Resident #15 called Resident #16 a dyke. On 07/16/2024 at 3:36 PM, an AA2 verbalized when Resident #16 walked into a room where Resident #15 was present, Resident #15 would remark oh no, here they come. Resident #15 would often barge into whatever room Resident #16 was in to call them names. The AA2 explained they felt it was harassment because it happened often and Resident #15 was always instigating. One time, the AA2 heard Resident #15 saying leave me alone, I don't have your picture. The AA2 had to physically redirect Resident #15 away from Resident #16. On 07/16/2024 at 4:08 PM, an AA3 verbalized Resident #15 would go into Resident #16's room and instigate. The AA3 explained Resident #15 was sneaky and would wait for the opportunity to go into Resident #16's room. On 07/16/2024 at 4:24 PM, a Registered Nurse (RN) verbalized Resident #15 accused residents of taking items daily. The RN explained Resident #15 could be rude and nasty to other staff and residents. The RN had heard Resident #15 call Resident #16 the b-word. On 07/18/2024 at 10:44 AM, the DON defined abuse as any willingly harmful emotional, physical, or sexual abuse. The DON explained verbal abuse was abuse and all abuse needed to be reported to charge nurse or DON. The DON verbalized they were made aware of the interactions and name calling between Resident #15 and Resident #16. The DON explained Resident #15 had made accusations of theft against Resident #16. The DON spoke with Resident #15 and Resident #15 told the DON Resident #16 had stolen their picture because Resident #16 was in love with them. The DON explained Resident #15 was hard to redirect and was stuck on the topic. The DON spoke with Resident #16 and listened to their concerns. The DON did not initially think the harassment and verbal abuse was abuse because Resident #15 had dementia. A Communication Note for Resident #16, dated 06/15/2024, documented Resident #16 came out of their room to complain about another resident going into their room, threatened Resident #16 and made accusations the resident was sleeping with men over the weekend of Christmas. The other resident then accused Resident #16 of stealing a picture and refused to leave the room. The Certified Nursing Assistant (CNA) had to remove the resident from Resident #16's room. As the resident left Resident #16's room, the resident continued to call Resident #16 nasty names and insisted Resident #16 was sleeping with everyone in the facility. A Patient Grievance Form for Resident #16, dated 06/15/2024, documented Resident #15 went into Resident #16's room and made accusations the resident was sleeping with men over the weekend of Christmas. The resident then accused Resident #16 of stealing a picture and refused to leave the room. The CNA had to remove the resident from Resident #16's room. As the resident left Resident #16's room, the resident continued to call Resident #16 nasty names and insisted Resident #16 was sleeping with everyone in the facility. A Communication Note for Resident #16, dated 06/17/2024, documented the DON spoke with Resident #16 regarding their concerns and informed them the DON had spoken with Resident #15 and told Resident #15 they were not allowed to enter Resident #16's room. On 07/18/24 at 1:15 PM, the DON verbalized the DON became aware of the issues between Resident #15 and Resident #16 on 06/17/2024. The facility policy titled Abuse Prevention, revised 05/2023, documented residents would be free from abuse from other residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review, and document review, the facility failed to report and investigate an allegation of resident-to-resident verbal abuse and harassment for 1 of 12 sampled residents (Resident #16). This deficient practice could allow allegations of abuse to occur and not be reported for investigation. Findings include: Resident #16 Resident #16 was admitted to the facility on [DATE], with diagnoses including adjustment disorder with anxiety and chronic obstructive pulmonary disease. Resident #15 Resident #15 was admitted to the facility on [DATE], with diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and nutritional anemia, unspecified. On 07/16/2024 at 10:43 AM, Resident #16 verbalized a resident had been harassing them and calling them names. On 07/16/2024 at 11:04 AM, Resident #15 verbalized they believed Resident #16 had stolen a picture out of their room. The resident explained they believed Resident #16 must be gay because they took the picture. Resident #15 verbalized they call resident #16 gay because they knew Resident #15 did not like it. Resident #15 laughed and verbalized they knew Resident #16 was having sex with male members of the surrounding community. On 07/18/2024 at 10:44 AM, the DON defined abuse as any willingly harmful emotional, physical, or sexual abuse. The DON explained verbal abuse was abuse and all abuse needed to be reported to charge nurse or DON and all suspected abuse needed to be reported to the State Agency (SA) immediately or within two hours of the incident. The DON explained Resident #15 had made accusations of theft against Resident #16. The DON spoke with Resident #15 and Resident #15 told the DON Resident #16 had stolen their picture because Resident #16 was in love with them. The DON explained Resident #15 was hard to redirect and was stuck on the topic. The DON spoke with Resident #16 and listened to their concerns. The DON did not report the verbal abuse and harassment to the State Agency (SA) because Resident #15 had dementia. The DON confirmed the accusations and name calling were verbal abuse and harassment and should have been reported to the SA. A Communication Note for Resident #16, dated 06/15/2024 documented Resident#16 came out of their room to complain about another resident going into their room, threatened Resident #16 and made accusations the resident was sleeping with men over the weekend of Christmas. The resident then accused Resident #16 of stealing a picture and refused to leave the room. The Certified Nursing Assistant (CNA) had to remove the resident from Resident #16's room. As the resident left Resident #16's room, the resident continued to call Resident #16 nasty names and insisted Resident #16 was sleeping with everyone in the facility. A Patient Grievance Form for Resident #16, dated 06/15/2024, documented Resident #15 went into their room and made accusations the resident was sleeping with men over the weekend of Christmas. The resident then accused Resident #16 of stealing a picture and refused to leave the room. The Certified Nursing Assistant (CNA) had to remove the resident from Resident #16's room. As the resident left Resident #16's room, the resident continued to call Resident #16 nasty names and insisted Resident #16 was sleeping with everyone in the facility. A Communication Note for Resident #16, dated 06/17/2024, documented the DON spoke with Resident #16 regarding their concerns and informed them the DON had spoken with Resident #15 and told Resident #15 they were not allowed to enter Resident #16's room. On 07/18/2024 at 1:15 PM, the DON verbalized the DON became aware of the issues between Resident #15 and Resident #16 on 06/17/2024. The facility policy titled Abuse Prevention, revised 05/2023, documented residents would be free from abuse from other residents. Alleged, suspected or observed abuse would reported immediately and an investigation begun.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review, and document review, the facility failed to ensure physician visits were completed timely for 3 of 12 sampled residents (Resident #26, #19, and #7). Findings include: Resident #26 Resident #26 was admitted to the facility on [DATE], with diagnoses including traumatic subarachnoid hemorrhage with loss of consciousness, fall on same level, and unspecified dementia with other behavioral disturbances. The clinical record for Resident #26 included documentation of the physician visits during the first 90 days were dated 05/11/2024, and 07/01/2024. The record lacked documented physician visits in June of 2024 by either a physician or a nurse practitioner. On 07/23/2024 at 10:24 AM, the Director of Nursing (DON) confirmed Resident #26 lacked a physician's visit in June of 2024. The DON explained a physician visit should had been completed as the resident was to be seen every 30 days for the first 90 days. Resident #7 Resident #7 was admitted to the facility on [DATE], with diagnoses including chronic obstructive pulmonary disease, unspecified, type II diabetes mellitus without complications, and other specified hypothyroidism. The clinical record for Resident #7 included documentation of physician visits dated 01/17/2024 and 05/06/2024. The record lacked a documented evidence of a physician visit dated in March of 2024. On 07/23/2024 at 10:26 AM, the DON confirmed Resident #7's clinical record lacked a physician's visit in March of 2024. The DON verbalized the expectation was a physician's visit would be conducted every 60 days after the first 90 days of admission. Resident #19 Resident #19 was admitted to the facility on [DATE], with diagnoses including type two diabetes mellitus with diabetic chronic kidney disease, acquired absence of left leg below the knee, and retinal edema. The clinical record for Resident #19 included documentation of the physician visits dated 2/14/2024 and 3/6/2024. The record lacked a physician visit in April 2024. On 07/23/2024 at 10:25 AM, the DON confirmed Resident #19's clinical record lacked a physician's visit in April 2024.

Based on interview and personnel record review, the facility failed to ensure a Certified Nursing Assistant (CNA) had an annual performance evaluation completed timely for 1 of 2 CNAs employed greater than one year, sampled for personnel record review (Employee #7). Findings include: On 07/17/2024 at 11:04 AM, the Human Resources Supervisor participated in an interview to confirm the accuracy of the Personnel Records Checklist completed by the facility for 20 employees. Employee #7 Employee #7 was hired as a CNA with a start date of 04/01/2023. The CNA's personnel record lacked documented evidence of the completion of an annual performance evaluation. On 07/17/2024 at 1:53 PM, the Human Resources Supervisor confirmed the CNA's personnel record lacked documented evidence of the completion of an annual performance evaluation. The facility policy titled Performance Evaluation, revised 06/2019, documented employees would be evaluated by their supervisor annually in the month of their hire date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, interview, and document review the facility failed to ensure the label on a bottle of Morphine oral suspension (a liquid medication) included a measuring guide for 1 of 27 sampled residents (Resident #2). Due to this failure the facility was not able to determine if the medication was correctly reconciled in the facility's Narcotics Reconciliation log and/or if the medication had been diverted. Findings include: Resident #2 Resident #2 was admitted to the facility on [DATE], with diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, heart failure, unspecified, and unspecified atrial fibrillation. A physician's order dated 06/20/2024, documented Morphine Sulfate (concentrate) oral solution 20 milligrams/milliliters (mg/ml), give 0.1 ml by mouth every two hours as needed for pain related to chronic pain syndrome. A Controlled Drug Record for Resident #2 documented Morphine Sulfate 20 mg/5 ml. The starting quantity on 06/20/2024, was documented as 30 ml, an entry documented on 07/16/2024 at 1:30 PM, documented 25 of 30 ml remained in the bottle. On 07/17/2024 at 7:44 AM, during an inspection of a medication cart with the Director of Nursing (DON), a 30 ml bottle of Morphine oral suspension, 20 mg/ml was found. The bottle did not contain a measurement guide to be used by nurses when reconciling controlled substances at the end of each shift. The DON confirmed the bottle of Morphine oral suspension did not include a label with a measurement guide routinely used by nurses to determine the amount of the medication remaining in the bottle at the end of each shift. The DON confirmed the bottle was a 30 ml bottle and per the count in the Narcotics Reconciliation Log (NARC log) there should be 25 ml remaining. The DON confirmed the amount remaining in the bottle appeared to be a less than 25 ml and verbalized the bottle may have leaked. The DON confirmed the DON would expect to see approximately 5/6 of the morphine remaining in the bottle and there was approximately only 3/6 of the bottle remaining. On 07/18/2024 at 11:21 AM, the Pharmacist confirmed bottles of Morphine oral suspension should include a label with a measurement guide. The Pharmacist verbalized the DON sent a photograph of the bottle to the Pharmacist and the Pharmacist confirmed the bottle did not have a measuring guide. The Pharmacist declined to comment further or answer additional questions. The manufacturer's guide/instructions, titled Morphine Sulfate - Morphine Sulfate Solution, undated, documented Morphine Sulfate solution contained morphine, a schedule II controlled substance. Morphine Sulfate oral solution, like other opioidss, could be diverted for non-medical use into illicit channels of distribution. Careful record-keeping, including quantity, as required by state and federal laws was strongly advised.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review, and document review, the facility failed to ensure a psychotropic medication was prescribed to a resident with a diagnosed indication for use for 1 of 12 sampled residents (Resident #9). Findings include: Resident #9 Resident #9 was admitted to the facility on [DATE], with diagnoses including vascular dementia, unspecified severity, with other behavioral disturbance and depression, unspecified. On 07/17/2024 at 3:17 PM, a Registered Nurse (RN) verbalized Resident #9 was administered Buspirone three times a day for behaviors such as yelling out, banging their fists, and throwing items. A physician's order dated 10/19/2023, documented Buspirone Hydrochloride (HCI) 15 milligram (mg) tablets. Give one tablet by mouth three times a day for anxiety as evidenced by outbursts and inconsolable crying. A physician's order dated 10/19/2023, documented antianxiety medication Buspar (Buspirone) - monitor for clinical side effects associated with the medication: appetite changes, memory impairment, muscle weakness, pronunciation difficulties, rash, respiratory depression, sedation, urinary retention, and weight loss/gain. Resident #9's July Medication Administration Record (MAR) documented Buspirone HCI 15 mg tablets was administered three times daily from 07/01/2024-07/16/2024. On 07/18/2024 at 9:16 AM, the Director of Nursing (DON) verbalized Resident #9 received Buspirone for anxiety three times daily. The DON confirmed Resident #9 did not have a diagnosis for anxiety and should have an indication for use prior to the administration of Buspirone. The facility policy titled Psychotropic Medication Use, revised 08/2018, documented psychotropic drugs were any drug which affected the brain activities associated with mental processes and behavior. The drugs included drugs such as anti-anxiety drugs. Psychotropic drugs may be ordered by a physician when medically necessary. Attending physicians must certify a psychotropic medication was necessary to treat a specific condition/behavior.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, interview, and document review the facility failed to ensure medications were not repackaged for 1 of 27 sampled residents (Resident #3) Findings include: Resident #3 Resident #3 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including nondisplaced oblique fracture of shaft of right tibia, subsequent encounter for closed fracture with routine healing, age related osteoporosis with current pathological fracture, unspecified site, subsequent encounter for fracture with routine healing, other muscle spasm, and localized edema. A physician's order date 05/10/2024, documented hydrocodone-acetaminophen (Norco) oral tablet 5-325 milligram (mg). Give one tablet by mouth every six hours for chronic arthritic pain. A Controlled Drug Record belonging to Resident #3, documented on 07/17/2024, the remaining count of Norco was 105. On 07/17/24 at 7:52 AM, during an inspection of the section one medication cart, conducted with the Director of Nursing (DON), a bottle of Norco belonging to Resident #3 was located. The bottle contained five tablets of Norco. The remaining 100 tablets had been separated into 10 packages of 10 each. The packages were created by using a plastic see through envelope used for crushing medications. The resident's last name and Norco 5/325 was written on the packets with a black marker and the packet was stapled with one staple. No additional information was written on the packets. The DON confirmed the medication was separated into the plastic packets by nursing staff and labeled with only the resident's last name, name and strength of the medication. No additional information was included on the labels. The facility policy titled Administration of Medications, dated 01/2021 documented medications should never be transferred from one container to another. The policy lacked guidance regarding what to include on a medication label including prescribed dose, strength, resident's name, route of administration, precautions such as take with meals or do not crush.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure a vegetable substitute of equal nutritive value was offered to 1 of 27 residents' trays observed during tray line (Resident #27). Findings include: Resident #27 Resident #27 was admitted to the facility on [DATE], with diagnoses including heart failure, chronic obstructive pulmonary disease and gastro-esophageal reflux disease without esophagitis. The lunch menu for 07/16/2024, documented roast turkey, Brussels sprouts, and corn pudding. Resident #27's Food Likes and Dislikes on the tray card, documented dislikes Brussels sprouts. On 07/16/2024 at 12:07 PM, during tray line observation, Resident #27's tray was plated with turkey, corn pudding and mashed potatoes were substituted for Brussels sprouts. On 07/16/2024 at 3:34 PM, the Registered Dietician (RD) verbalized when a resident had dislikes being served for the meal, the resident should be offered a substitute comparable in nutritional value. The RD confirmed mashed potatoes were not comparable in nutritional value for Brussels sprouts.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, clinical record review, and document review, the facility failed to provide meals based on resident's preferences for 1 of 12 sampled residents (Resident #27). Findings include: Resident #27 Resident #27 was admitted to the facility on [DATE], with diagnoses including heart failure, chronic obstructive pulmonary disease and gastro-esophageal reflux disease without esophagitis. Resident #27's Food Likes and Dislikes on the tray card, documented dislikes carrots. On 07/16/2024 at 11:32 AM, the Dietary Manager verbalized if a resident disliked what was being served, those items were to be marked on the tray card for the [NAME] to be aware of what was and was not to be on the resident's plate. The Dietary Aide was responsible for checking the tray card to make sure the plate did not contain resident dislikes. On 07/16/2024 at 3:34 PM, the Registered Dietician (RD) verbalized when a resident had dislikes being served for the main entree, the resident should not be served items the resident disliked. On 07/16/2024 a Dietician Note, documented the resident had requested no carrots or Brussels sprouts. The lunch menu for 07/17/2024 documented the vegetable served was broccoli and carrots. On 07/17/2024 at 12:33 PM, Resident #27 was eating lunch in their room. The plate contained carrots. On 07/17/2024 at 12:35 PM, Resident #27 verbalized not liking carrots and was not going to eat them. The facility policy titled Nutritional Assessment Program, undated, documented residents were screened at admission about their likes, dislikes and allergies to food or drinks.

Based on interview and document review the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to identify 1) the facility lacked screening and implementation for pneumococcal (PNA) and influenza vaccinations and education was not provided for declinations and consents were not obtained for vaccinations given 2) the Infection Preventionist (IP) had not completed a specialized IP training course 3) the Infection Control and Prevention Plan (IPCP) policy was reviewed annually and contained outdated information, and 4) the facility's Antibiotic Stewardship Program (ASP) policy was reviewed annually and contained outdated information. Findings include: Screening and Implementation for Pneumococcal (PNA) and Influenza vaccinations On 07/18/2024 at 8:29 AM, the Director of Nursing (DON) confirmed the facility did not have a process in place for screening residents for eligibility to receive a flu vaccine and did not provide education related to flu vaccines to the residents. The DON confirmed consents were signed at admit and new consents were not signed prior to each new flu vaccine administered. On 07/18/2024 at 8:36 AM, the DON confirmed the facility did not have a screening tool or an algorithm to assist in determining eligibility and/or the recommended PNA vaccine for a resident. The DON confirmed the facility was not using the Vaccine Information Sheet (VIS) educational documents to provide education related to flu and PNA vaccines to residents or the resident's representative/guardian. On 07/16/2024 at 4:22 PM, the DON confirmed the facility did not have a screening process in place related to PNA vaccines and did not provide education related to PNA vaccines to residents or the resident's representative. The DON confirmed none of the facility's 27 residents had been screened for vaccination with a PNA vaccine and education related to PNA vaccines was not provided to the residents. On 07/23/2024 at 3:20 PM, the Administrator verbalized the QAPI Committee was not aware of the lack of screening and implementation for PNA and influenza vaccinations. The Administrator explained the QAPI Committee would not have become aware of the lack of screening and implementation until the State Agency brought it to the attention of the facility. The Administrator verbalized the QAPI Committee was not aware education was not provided for declinations and consents were not obtained for vaccinations given. Cross reference with F883 Specialized Training On 07/16/2024 at 11:45 AM, the IP verbalized the IP had completed the Centers for Disease Control and Prevention (CDC) training course and had completed and passed the courses final comprehensive test. The IP was not able to provide a certificate documenting the course was completed and provided a transcript which documented Modules 1-15 had been completed, an expiration date for each module was 10/01/2025. The end of training plan verification and continuing education (CE) information section was marked as completed but had an expiration date of 06/30/2024. The Completion for Nursing Home Infection Preventionist Training Course was marked as not started. On 07/16/2024 at 3:11 PM, the DON confirmed the Infection Preventionist Training Course Transcript provided by the IP lacked documented evidence the IP had completed the IP training course and confirmed the course needed to be completed in its entirety prior to being the facillity's IP. The DON confirmed the form did not include the IP's name. On 07/23/2024 at 3:33 PM, the Administrator verbalized the QAPI Committee was not aware the IP had not completed the Nursing Home Infection Preventionist Training Course. Cross reference with F882 Infection Control and Prevention Plan Policy The facility's IPCP policy documented the policy was last reviewed by the facility on 10/2022. The facility was not able to provide evidence the policy had been reviewed and/or revised after 10/2022. The policy referred to IPCP as the hospital's IPCP and the referenced duties for hospital staff did not include language indicating the policy included the Long-Term Care facility. The IPCP lacked the following elements: -a list of reportable communicable diseases and a process for reporting to the appropriate state agencies. -prohibition of employees with communicable diseases or infected skin lesions from direct contact with residents or their food if direct contact could transmit disease. -a process for communicating at time of a transfer to another care provider, to include diagnoses, infections, multi-drug resistant organisms (MDRO)status, special instructions or precautions including transmission-based precautions (TBP), medications, lab work, other diagnostics, test results, treatments, and discharge summary if applicable. -a process to ensure receipt of pertinent notes when transferred back from an acute care hospital or other facility type. The IPCP policy referenced an additional policy titled List of Nationally Notifiable Diseases, last revised 06/2020. The policy did not list the reportable diseases but provided two links to the most current nationally notifiable diseases. The links were dated 2020 and neither of the links were active. At the bottom of the policy, under references, an active link was provided. The policy did not include guidance for prohibition of employees with communicable diseases or a process for reporting to the appropriate agencies. On 07/18/24 at 8:45 AM, the Director of Nursing (DON) confirmed the IPCP provided was the policy used by the facility. On 07/18/24 at 8:00 AM, the DON confirmed the IPCP lacked the following elements: -a list of reportable communicable diseases and a process for reporting to the appropriate state agencies. -prohibition of employees with communicable diseases or infected skin lesions from direct contact with residents or their food if direct contact could transmit disease. -a process for communicating at time of a transfer to another care provider, to include diagnoses, infections, MDRO status, special instructions or precautions including TBPs, medications, lab work, other diagnostics, test results, treatments, and discharge summary if applicable. -a process to ensure receipt of pertinent notes when transferred back from an acute care hospital or other facility type. Cross reference with Tag F880 Antibiotic Stewardship Policy A facility policy titled Antimicrobial Stewardship Program, revised on 10/2023, lacked the following components: -Antibiotic use protocols related to prescribing antibiotics, including documentation of the indication, dosage, and duration of use of antibiotics -a process for periodic review of antibiotic use by prescribing practitioners. (such as review of labs and med orders, progress notes and medication administration records to determine if an infection or communicable disease was documented and whether an appropriate antibiotic was used for the recommended length of time). -a process for reviewing antibiotic use when a resident is newly admitted , returns, or is transferred from another facility/hospital -protocols to ensure the proper antibiotics are prescribed. -a system for the provision of feedback reports on antibiotic use, resistance patterns based on labs, and the prescribing practices of prescribing practitioners. The policy documented the ASP program included the following components, but failed to document how each element was accomplished and/or the guidelines used. -Formal programs for tracking, auditing, and reporting antimicrobial use. -Clinician and patient education on antimicrobial use. -Use of nationally recognized antimicrobial use guidelines. -A standardized process for outcome measurement. On 07/18/24 at 8:00 AM, the DON confirmed the facility's ASP policy lacked the following components: -Antibiotic use protocols related to prescribing antibiotics, including documentation of the indication, dosage, and duration of use of antibiotics -a process for periodic review of antibiotic use by prescribing practitioners. (such as review of labs and med orders, progress notes and medication administration records to determine if an infection or communicable disease was documented and whether an appropriate antibiotic was used for the recommended length of time). -a process for reviewing antibiotic use when a resident is newly admitted , returns, or is transferred from another facility/hospital -protocols to ensure the proper antibiotics are prescribed. -a system for the provision of feedback reports on antibiotic use, resistance patterns based on labs, and the prescribing practices of prescribing practitioners. On 07/23/2024 at 3:27 PM, the Administrator verbalized the Infection Control and Prevention Plan policy and the facility's Antibiotic Stewardship Program policy had been reviewed annually. The Administrator explained the IP was responsible to keep the policies updated. The Administrator confirmed the QAPI Committee was not aware the policies were not updated with the most current information. Cross reference with Tag F880 The facility policy titled Quality Management Program, last revised 11/2017, documented the QAPI committee, with the support and approval of the Governing Body, had the responsibility for monitoring every aspect of resident care and service from the time the resident entered the facility, through diagnosis, treatment, recovery, and discharge in order to identify and resolve any breakdowns with the potential to result in sub-optimal resident care and safety, while striving to continuously improve and facilitate positive resident outcomes.

Based on observation, clinical record review, interview, and document review the facility failed to ensure a Certified Nursing Assistant (CNA) was screened for eligibility to receive a COVID-19 (COVID) booster vaccine, education regarding the vaccine was provided and the CNA had an opportunity to make an informed decision to receive or decline the vaccination, and 2) 1 of 6 residents reviewed for immunization with a COVID booster vaccine were screened for eligibility to receive the vaccine, education regarding the vaccine was provided to the resident or the resident's representative, and the resident or the resident representative had the opportunity to make an informed decision to receive or decline the vaccine. Findings include: CNA The facility lacked documented evidence a CNA with the hire date of 10/25/2020, was screened for eligibility to receive a COVID booster vaccine, education regarding the vaccine was provided and the CNA had an opportunity to make an informed decision to receive or decline the vaccination. The CNAs state immunization record documented the CNA recieved a dose of a COVID vaccine on 10/13/2021 and 02/03/2021. On 07/16/2024 at 12:13 PM, the Director of Nursing (DON) confirmed the facility did not have documented evidence the CNA had been provided education regarding updated COVID vaccines, was screened for eligibility and had either been provided the vaccine or completed a declination for the vaccine. The facility was not able to provide documented evidence the vaccine was provided by a third party provider. The DON confirmed the facility was no longer tracking COVID vaccination status for staff. On 07/18/2024 at 9:10 AM, the DON verbalized education related to COVID vaccines was only provided when new vaccines were available or when a vaccination clinic was held. The DON confirmed education related to COVID vaccines was not being provided to residents or staff.

Based on personnel record review, interview and document review, the facility failed to ensure communications training was completed by staff for 1 of 20 sampled employees (Employee #4). Findings include: Employee #4 Employee #4 was hired as the Registered Dietician on 09/11/2003. Employee #4's personnel record lacked documented evidence of communication training. On 07/23/2024 at 9:42 AM, the Human Resources Supervisor verbalized all staff were required to complete Communication training within 30 days of hire and annually thereafter. The Human Resources Supervisor confirmed Employee #4 did not have Communication training. The facility policy titled Communication Training, effective 04/2022, documented employees were to complete Communication training at a minimum of annually.

Based on personnel record review, interview and document review, the facility failed to ensure resident rights training was completed by staff for 1 of 20 sampled employees (Employee #4). Findings include: Employee #4 Employee #4 was hired as the Registered Dietician on 09/11/2003. Employee #4's personnel record lacked documented evidence of resident rights training. On 07/23/2024 at 9:42 AM, the Human Resources Supervisor verbalized all staff were required to complete Resident Rights training within 30 days of hire and annually thereafter. The Human Resources Supervisor confirmed Employee #4 did not have Resident Rights training. The facility policy titled Resident Rights Training, effective 08/2022, documented employees were to complete Resident Rights education at a minimum of annually.

Based on personnel record review, interview and document review, the facility failed to ensure elder abuse training was completed timely for 7 of 20 sampled employees (Employee #4, #7, #10, #11, #17, #19, and #20). Findings include: Employee #4 Employee #4 was hired as the Registered Dietician on 09/11/2003. Employee #4's personnel record documented elder abuse training completed 10/06/2022, however lacked documented evidence elder abuse training was completed in 2023. Employee #7 Employee #7 was hired as a Certified Nursing Assistant (CNA) on 04/01/2023. Employee #7's personnel record documented elder abuse training completed 10/29/2023, however was completed more then 30 days after hire. Employee #10 Employee #10 was hired as a Licensed Practical Nurse on 06/06/2024. Employee #10's personnel record lacked initial elder abuse training completed prior to starting work on the floor. Employee #11 Employee #11 was hired as a Registered Nurse (RN) on 01/22/2024. Employee #11's personnel record documented elder abuse training completed 06/12/2024,however was completed more then 30 days after hire. Employee #17 Employee #17 was hired as a CNA on 11/13/2023. Employee #17s personnel record lacked initial elder abuse training completed prior to starting work on the floor. Employee #19 Employee #19 was hired as a Hospitality Aide on 04/19/2024. Employee #19's personnel record lacked initial elder abuse training completed prior to starting work on the floor. Employee #20 Employee #20 was hired as a Housekeeper on 11/09/2023. Employee #20's personnel record documented elder abuse training completed 12/27/2023, however was completed more then 30 days after hire. On 07/17/2024 at 11:04 AM, the Human Resources Supervisor verbalized all staff were required to complete elder abuse training within 30 days of hire and annually thereafter. The Human Resources Supervisor confirmed Employees #4, #7, #10, #11, #17, #19, and #20 lacked timely elder abuse training. The facility policy titled Abuse Prevention, revised 05/2023, documented all staff would be in serviced annually on the facility abuse prohibition policy. The facility abuse policy lacked the requirement to complete abuse training upon orientation.

Based on interview and document review, the facility failed to ensure Quality Assurance Performance Improvement (QAPI) training had been completed to include objectives of resident care needs for 1 of 20 sampled employees (Employee #4). Findings include: Employee #4 Employee #4 was hired as the Registered Dietician on 09/11/2003. Employee #4's personnel record lacked documented evidence of QAPI training. On 07/23/2024 at 9:42 AM, the Human Resources Supervisor verbalized all staff were required to complete QAPI training within 30 days of hire and annually thereafter. The Human Resources Supervisor confirmed Employee #4 did not have QAPI training. The facility policy titled Quality Management Program, revised 11/2017, documented all staff shall receive annual training on the facility's QAPI program.

Based on interview and document review, the facility failed to provide timely infection control training to all staff to ensure proper procedures and standards of the program for 1 of 20 sampled employees (#4). Findings include: Employee #4 Employee #4 was hired as the Registered Dietician on 09/11/2003. Employee #4's personnel record lacked documented evidence infection control training had been completed. On 07/23/2024 at 9:42 AM, the Human Resources Supervisor verbalized all staff were required to complete infection control training within 30 days of hire and annually thereafter. The Human Resources Supervisor confirmed Employee #4 did not have infection control training. The facility policy titled Infection Control Training, effective 01/2021, documented education and training would be provided to all healthcare personnel annually.

Based on interview and document review, the facility failed to ensure compliance and ethics training was completed timely for 1 of 20 sampled employees (#4). Findings include: Employee #4 Employee #4 was hired as the Registered Dietician on 09/11/2003. Employee #4's personnel record lacked documented evidence of compliance and ethics training. On 07/23/2024 at 9:42 AM, the Human Resources Supervisor verbalized all staff were required to complete Compliance and Ethics training within 30 days of hire and annually thereafter. The Human Resources Supervisor confirmed Employee #4 did not have compliance and ethics training. The facility policy titled Compliance and Ethics Training, Effective 10/2022, documented all employees complete Compliance and Ethics continuing education. Education and training shall be provided to all staff annually.

Based on interview and document review, the facility failed to ensure behavioral health training was completed timely for 1 of 20 sampled employees (Employee #4). Findings include: Employee #4 Employee #4 was hired as the Registered Dietician on 09/11/2003. Employee #4's personnel record lacked documented evidence of behavioral health training. On 07/23/2024 at 9:42 AM, the Human Resources Supervisor verbalized all staff were required to complete Behavioral Health training within 30 days of hire and annually thereafter. The Human Resources Supervisor confirmed Employee #4 did not have Behavioral Health training. The facility policy titled Behavioral Health Care Training, effective 07/2022, documented employees were to complete Behavioral Health Care training at a minimum of annually.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, interview, and document review the facility failed to ensure 1) the Infection Control and Prevention Plan (IPCP) policy was reviewed annually, and 2) enhance barrier precautions (EBP) were being implemented for 2 of 2 residents with indwelling medical devices (Resident #1 and #4). Findings include: Infection Control and Prevention Plan The facility's IPCP policy documented the policy was last reviewed by the facility on 10/2022. The facility was not able to provide evidence the policy had been reviewed and/or revised after 10/2022. The policy referred to IPCP as the hospital's IPCP, referenced duties for hospital staff, and did not include language indicating the policy included the Long Term Care facility. The IPCP lacked the following elements: -a list of reportable communicable diseases and a process for reporting to the appropriate state agencies. -prohibition of employees with communicable diseases or infected skin lesions from direct contact with residents or their food if direct contact could transmit disease. -a process for communicating at time of a transfer to another care provider, to include diagnoses, infections, multi-drug resistant organisms (MDRO)status, special instructions or precautions including transmission based precautions (TBP), medications, lab work, other diagnostics, test results, treatments, and discharge summary if applicable. -a process to ensure receipt of pertinent notes when transferred back from an acute care hospital or other facility type. The IPCP policy referenced an additional policy titled List of Nationally Notifiable Diseases, last revised 06/2020. The policy did not list the reportable diseases but provided two links to the most current nationally notifiable diseases. The links were dated 2020 and neither of the links were active. At the bottom of the policy, under references, an active link was provided. The policy did not include guidance for prohibition of employees with communicable diseases or a process for reporting to the appropriate agencies. On 07/18/24 at 8:00 AM, the DON confirmed the IPCP lacked the following elements: -a list of reportable communicable diseases and a process for reporting to the appropriate state agencies. -prohibition of employees with communicable diseases or infected skin lesions from direct contact with residents or their food if direct contact could transmit disease. -a process for communicating at time of a transfer to another care provider, to include diagnoses, infections, MDRO status, special instructions or precautions including TBPs, medications, lab work, other diagnostics, test results, treatments, and discharge summary if applicable. -a process to ensure receipt of pertinent notes when transferred back from an acute care hospital or other facility type. On 07/18/2024 at 8:45 AM, the Director of Nursing (DON) confirmed the IPCP provided was the policy used by the facility. The facility policy titled Infection Prevention and Control Program, revised 10/2022, documented the IPCP was conducted in accordance with all applicable federal and state rules and regulations. The IPCP was evaluated annually and whenever risk had significantly changed. Revisions were made as appropriate. Enhanced Barrier Precautions Resident #1 Resident #1 was admitted to the facility on [DATE], and last re-admitted to the facility on [DATE], with diagnoses including quadriplegia, unspecified, calculus of kidney, and other artificial openings of urinary tract status. Resident #1's Comprehensive Care Plan documented Resident #1 had a urostomy related to complications of quadriplegia. Resident #4 Resident #4 was admitted to the facility on [DATE], with a diagnosis of multiple sclerosis, neuromuscular dysfunction of bladder, retention of urine, unspecified, benign prostatic hyperplasia with lower urinary tract symptoms. Resident #4's Comprehensive Care Plan documented Resident #4 had a suprapubic catheter related to urinary retention, possibly related to the inhibition of the reflex arc, secondary to multiple sclerosis. On 07/15/2024 at 8:03 AM, the DON confirmed Resident #1 and #4 both had indwelling medical devices and should have had Enhanced Barrier Precautions (EBP) in place. The DON confirmed EBP had not been initiated and/or implemented for Resident #1 and #4. On 07/15/2024 at 9:48 AM, during an inspection of the facility, TBP including EBP, were not in place for any of the resident rooms, including Resident #1 and #4. On 07/18/2024 at 8:18 AM, the DON verbalized diagnostic testing and symptoms were used to determine if a resident needed to be placed in TBP. A facility policy titled Enhanced Barrier Precautions, last revised 07/2024, with an effective date of 01/2024, documented the facility ensured staff used EBPs while caring for residents with wounds and indwelling medical devices. Effective implementation of EBP included staff training on the proper use of personal protective equipment (PPE) and the availability of PPE and hand hygiene products at the point of care. Clear signage was to be posted outside of the resident room indicating the type of PPE required and to define the high risk patient care activities. Gowns, gloves and alcohol-based hand rub were available outside of the residents room. A trash can was made available for the disposal of PPE for each room. EBPs were continued for the duration of the resident's stay.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, document review, and interview the facility failed to demonstrate effective administration by not ensuring the facility's influenza (flu) and pneumonia (PNA) vaccination program included 1) screening residents for eligibility to receive the vaccines, 2) the provision of education related to the risk and benefits of the vaccines to residents and/or the resident's representative preventing the resident or the resident's representative from making an informed decision regarding the vaccines, 3) a process for determining/selecting the correct PNA vaccine for each resident per the Centers for Disease Control and Prevention (CDC) guidance. This failure resulted in substandard quality of care. Findings include: Influenza Vaccine The facility lacked documented evidence 23 of 26 residents eligible or potentially eligible to receive a flu vaccine were screened for eligibility to receive a flu vaccine and lacked documented evidence education related to the 2023/2024 flu vaccines was provided to the resident or the resident's representative (Resident #4, #16, #10, #24, #11, #15, #19, #6, #13, #5, #23, #1, #3, #22, #21, #9, #7, #20, #18, #12, #26, #17 and #8). The facility administered Flu vaccines to the residents as follows: -8 of 26 residents eligible to receive a flu vaccine declined vaccination (Resident #11, #19, #13, #23, #3, #9, #18, and #12. The residents' clinical records lacked documented evidence the residents were screened for eligibility to receive a flu vaccine and the residents and/or residents' representatives were provided education regarding the 2023/2024 flu vaccines prior to declining vaccination resulting in the resident not having the opportunity to make an informed decision. -5 of 26 residents (Resident #24, #22, #7, #17 and #8) clinical records lacked documented evidence the residents were screened to determine eligibility to receive a flu vaccine and were provided education regarding the 2023/2024 flu vaccines prior to signing consents and prior to the administration of a 2023/2024 flu vaccine. This failure resulted in the residents not having the opportunity to make an informed decision prior to being administered a 2023/2024 flu vaccine and put residents at risk of having adverse reactions to the flu vaccine related to risk factors identified during the screening process. -3 of 26 residents (Resident #16, #20 and #26) clinical records lacked documented evidence the residents were screened for eligibility to receive a flu vaccine, education regarding the 2023/2024 flu vaccine was provided, and consent was given by the resident or the residents representative prior to administering a flu vaccine to the residents. This failure resulted in the residents not having the opportunity to make an informed decision and either consent to receive or decline to receive a flu vaccine prior to being administered a 2023/2024 flu vaccine. The lack of screening for eligibility put the residents at risk of having adverse reactions to the flu vaccine related to risk factors identified during the screening process. 6 of 26 residents (Resident #10, #15, #6, #5, #1 and #21) clinical records documented consents were signed to receive a flu vaccine during the 2022/2023 flu season. The residents' clinical records lacked documented evidence the residents were screened for eligibility to receive vaccination with a 2023/2024 flu vaccine, the resident or the resident's representative were provided education regarding the 2023/2024 flu vaccines, and consent for vaccination with the 2023/2024 flu vaccine was obtained prior to administering a 2023/2024 flu vaccine to the residents. This failure resulted in the residents not having the opportunity to make an informed decision and either consent to receive or decline to receive a flu vaccine prior to being administered a 2023/2024 flu vaccine. The lack of screening for eligibility put the residents at risk of having adverse reactions to the flu vaccine related to risk factors identified during the screening process. 1 of 26 residents (Resident #4) was screened for eligibility to receive a flu vaccine with a hospital consent form. The screening/consent form included a section with an acknowledgement of receipt of a Vaccination Information Sheet (VIS) and an acknowledgement the resident reviewed the information on the back of the form. The form documented the VIS provided to the resident was dated 08/06/2021. The form documented the vaccine administered to Resident #4, Fluad manufactured by Seqirus, was to be given to individuals 65 and older only !!!! and Resident #4 was 61 YOA. A Food and Drug Administration package insert titled Fluad Quadrivalent - Seqirus Incorporated, dated March 2023, documented the Fluad vaccine was approved for use in individuals [AGE] years of age or older and was not approved by the FDA for people under the age of 65. The facility policy titled Influenza Vaccination, revised 12/2023, documented influenza vaccination was the primary method for preventing influenza and it's severe complications. Therefore, vaccination against influenza was offered to residents. Upon admission residents were assessed for recent and past flu vaccination, and flu vaccines were administered to residents annually thereafter. The healthcare professional administering the vaccine obtained a signed consent from the resident or resident representative at the time of admission or prior to the next flu season. Residents were routinely vaccinated, unless contraindicated, at one time, annually, before the influenza season. Residents and/or the resident representatives were provided a copy of the most current VIS regarding the flu vaccine the resident was to be given. Residents were screened for history of Guillain-Barre Syndrome, and for severe allergic reaction to a previous dose, vaccine component, and egg protein. A flu vaccine was not to be administered to residents exhibiting signs and symptoms of moderate or severe acute illness, with or without fever. The facility referred to current Advisory Committee on Immunization Practices (ACIP) recommendations for special circumstances such as immunosuppression, immunodeficiencies, corticosteroid therapy and organ transplantation. Pneumonia Vaccine The facility lacked documented evidence 26 of 26 residents eligible or potentially eligible to receive a PNA vaccine were screened for eligibility to receive a PNA vaccine and lacked documented evidence education regarding the PNA vaccine the resident was eligible to receive was provided to the resident or the resident's representative (Resident #4, #27, #16, #10, #24, #11, #15, #14, #19, #6, #13, #5, #23, #2, #1, #3, #22, #21, #9, #7, #20, #18, #12, #26, #17, and #8). The facility administered PNA vaccines to the residents as follows: -13 of 26 residents (Resident #4, #16, #10, #24, #11, #15, #19, #6, #13, #5, #23, #1, #3, #22, #21, #9, #7, #20, #18, #12, #26, #17 and #8) eligible or potentially eligible to receive a PNA vaccine declined vaccination The residents' clinical records lacked documented evidence the residents were screened for eligibility to receive a PNA vaccine and the residents and/or residents' representatives were provided education regarding the PNA vaccines prior to declining vaccination resulting in the resident not having the opportunity to make an informed decision. -7 of 26 residents' clinical record included a signed consent requesting to receive vaccination with a PNA vaccine (Resident #2, #21, #8, #7, #22, #24, and #10). The residents' clinical record lacked documented evidence the resident was screened for eligibility to receive a PNA vaccine, education was provided related to the PNA vaccine the resident was eligible to receive, and the PNA vaccine was administered to the resident. The facility policy titled Pneumococcal Polysaccharide Vaccination, last revised 10/2017, documented because pneumococcal disease was known to lead to serious infections in the resident population and was proving to be resistant to antibiotics, the facility provided vaccination against pneumococcal disease to prevent the spread of infection. PPSV protected against multiple types of pneumococcal bacteria and was offered to the resident population. Residents were screened for severe allergic reactions after a previous dose of PPSV and consent was obtained from the resident or the resident's representative/guardian. Residents or the resident's representative/guardian were provided with information regarding potential reactions and a copy of the most current VIS. Copies of the VIS were obtained from the CDC website. Documentation in the residents clinical record included the date of administration, amount and dosage given, reactions to the vaccine. The policy was last revised in 2017, and documented the sole reference was titled CDC, Morbidity and Mortality Weekly Report (MMWR), Prevention of Pneumococcal Disease: Recommendations of the Advisory Committee on Immunization Practices (ACIP), volume 46/No. RR-8, dated 04/04/1997. The reference included a weblink, but the link indicated the page could no longer be found. The guidance in the policy was outdated and did not include the CDC's most recent guidance regarding the selection and administration of pneumococcal vaccines.

Based on observation, clinical record review, interview, and document review the facility failed to ensure 1) the facility's Antibiotic Stewardship Program (ASP) policy was reviewed annually, 2) education regarding the ASP/antibiotic use was provided to staff and residents, #3) a process was in place to ensure the Infection Preventionist (IP) was made aware when a resident had a new infection and an antimicrobial medication was prescribed, 4) an antibiotic time out was performed to ensure the best treatment was being provided to residents, and 5) the IP had a process in place related to communicating infection, treatment, and prescribing concerns to prescribing providers. Findings include: Antibiotic Stewardship Policy A facility policy titled Antimicrobial Stewardship Program, revised on 10/2023, lacked the following components: -Antibiotic use protocols related to prescribing antibiotics, including documentation of the indication, dosage, and duration of use of antibiotics -A process for periodic review of antibiotic use by prescribing practitioners such as: review of labs and med orders, progress notes and medication administration records to determine if an infection or communicable disease was documented and whether an appropriate antibiotic was used for the recommended length of time. -A process for reviewing antibiotic use when a resident is newly admitted , returns, or is transferred from another facility/hospital. -Protocols to ensure the proper antibiotics are prescribed. -A system for the provision of feedback reports on antibiotic use, resistance patterns based on labs, and the prescribing practices of prescribing practitioners. The policy documented the ASP program included the following components, but failed to document how each element was accomplished and/or the guidelines used. -Formal programs for tracking, auditing, and reporting antimicrobial use. -Clinician and patient education on antimicrobial use. -Use of nationally recognized antimicrobial use guidelines. -A standardized process for outcome measurement. On 07/18/2024 at 8:00 AM, the Director of Nursing (DON) confirmed the facility's ASP policy lacked the following components: -Antibiotic use protocols related to prescribing antibiotics, including documentation of the indication, dosage, and duration of use of antibiotics -A process for periodic review of antibiotic use by prescribing practitioners such as: review of labs and med orders, progress notes and medication administration records to determine if an infection or communicable disease was documented and whether an appropriate antibiotic was used for the recommended length of time. -A process for reviewing antibiotic use when a resident is newly admitted , returns, or is transferred from another facility/hospital. -Protocols to ensure the proper antibiotics are prescribed. -A system for the provision of feedback reports on antibiotic use, resistance patterns based on labs, and the prescribing practices of prescribing practitioners. Antibiotic Stewardship Education On 07/18/2024 at 9:20 AM, the facility was not able to provide documented evidence education related to the ASP was provided to staff and residents. On 07/18/2024 at 9:22 AM, the IP confirmed the facility had not provided education related to the ASP to staff or residents. On 07/18/24 at 10:17 AM, the IP confirmed the IP did not provide education related to the ASP to staff or residents because the IP was not clinical. A facility policy titled Antimicrobial Stewardship Program, revised on 10/2023, documented staff and residents were provided education related to antimicrobial medications. Antibiotic Stewardship Process On 07/18/2024 at 9:25 AM, the IP verbalized the IP did not review resident's antibiotic use upon admit and explained the review was completed by the pharmacist. The IP confirmed the pharmacist only came to the facility one time per month. On 07/18/2024 at 9:30 AM, the IP explained a form titled The Four Moments of Antibiotic Decision Making as completed by nurses when a new onset of infection was suspected. The form was used to guide antibiotic selection, antibiotic duration, ensure cultures were completed, and ensure follow up after 24 hours. The IP verbalized the IP did not use the form and the form was not forwarded to the IP after it was completed by nursing. The IP verbalized when lab results were returned for a resident, the resident's nurse contacted the provider to confirm the resident was receiving the correct antibiotic. The IP explained when a resident had an infection, the IP was notified the resident had an infection when the resident's lab work result came back. After receiving the lab results, the IP looked to see if the correct antibiotic was being administered. Next the IP notified the pharmacist and documented the data onto a spreadsheet. A facility policy titled Antimicrobial Stewardship Program, revised on 10/2023, documented the ASP proactively monitored the use of antimicrobial prescriptions with real time feedback and advised clinicians regarding the appropriate antimicrobial use in patients. The facility followed the Four Moments of Antibiotic Decision Making for every antibiotic order. Antibiotic Time Out On 07/18/2024 at 10:12 AM, the IP explained when nurses sent a culture to the lab, the nurse did not always tell the IP and most of the time the IP was not aware a culture had been sent until the results came back. The IP confirmed an antibiotic time out was not completed at any time during a resident's course of antibiotics. A Centers for Disease Control and Prevention document titled The Core Elements of Antibiotic Stewardship for Nursing Homes, dated 03/18/2024, documented broad interventions to improve antibiotic use and standardize the practices which should be applied during the care of any resident suspected of an infection. The practices included improving the evaluation and communication of clinical signs and symptoms when a resident was first suspected of having an infection. The use of diagnostic testing was optimized when an antibiotic review process known as an antibiotic time out was implemented for all antibiotics prescribed in the facility. Antibiotic reviews provided clinicians with an opportunity to reassess the ongoing need for and choice of an antibiotic when the clinical picture was clearer, and more information was available. A facility policy titled Antimicrobial Stewardship Program, revised on 10/2023, documented the resource for the policy was the Centers for Disease Control and Prvention (CDC) Core Elements of Antibiotic Stewardship Program. Communication with Prescribing Providers On 07/18/2024 at 10:17 AM, the IP verbalized the IP did not communicate with the physician regarding antibiotics including prescribing habits and antibiotic usage because the IP was not clinical. The IP confirmed the IP was not involved with the decision process for selecting the type of transmission based precautions (TBP) a resident may need and explained the decision was made and implemented by nursing staff. The IP confirmed the IP never communicated with the physician regarding any of the concerns of the ASP. A facility policy titled Antimicrobial Stewardship Program, revised on 10/2023, lacked guidance related to a system for the provision of feedback reports on antibiotic use, resistance patterns based on labs, and the prescribing practices of prescribing practitioners.

Based on observation, clinical record review, interview, and document review the facility failed to ensure the Infection Preventionist ( IP) 1) completed a specialized IP training course, 2) provided education related to the Antibiotic Stewardship Program (ASP) to staff 3) understood and conducted an antibiotic time out (an active reassessment conducted of an antimicrobial prescription 48-72 hours after the first administration), 4) had a process in place to ensure residents and staff were offered vaccines (see tag F883 and F887), and 5) the IP communicated with providers regarding prescribing trends, needs, and outcomes, with the potential to effect the facility's entire census of 27 residents. Findings include: Specialized Training A facility document titled Payroll Status Form, dated 10/13/2022, documented the facility's IP had a hire and status (role) date of 10/13/2022. The role was documented as Infection Preventionist. On 07/16/2024 at 7:39 AM, the IP verbalized the IP had completed the Centers for Disease Control and Prevention (CDC) Infection Preventionist Training Course and provided a certificate documenting the IP had participated in an educational activity and was awarded two Continuing Education Units (CEUs). The certificate did not document the 19.75 CEU hours required for course completion. The IP provided a copy of the IP's Nursing Home Infection Preventionist Training Course transcript. The transcript documented the IP had completed 15 of the IP training course modules and one course was still required. The section of the transcript titled Completion for Nursing Home Infection Preventionist Training Course, was marked as not started. The IP confirmed the IP did not have any further documented evidence of course completion. On 07/16/2024 at 3:11 PM, the Director of Nursing (DON) confirmed the Infection Preventionist Training Course Transcript provided by the IP lacked documented evidence the IP had completed the IP training course. The DON verbalized the IP training course needed to be completed prior to an individual assuming the role of IP and confirmed the IP had been working in the role of IP without having completed an approved IP specialized training course. A facility document titled Infection Control Preventionist - Job Description, signed and dated by the IP on 04/04/2022, documented the IP was required to have knowledge of state and federal regulations regarding infection control. The Job Description failed to address the requirements related to the completion of specialized training in infection control. Antibiotic Stewardship Education On 07/18/2024 at 9:12 AM, the facility was not able to provide documented evidence the facility provided education related to the ASP to the facility's staff. The DON confirmed the facility did not have documented evidence education related to the ASP was provided to staff and confirmed the education was not provided. A facility policy titled Antimicrobial Stewardship Program, revised on 10/2023, documented staff and residents were provided education related to antimicrobial medications. A facility policy titled Infection Prevention and Control Program, last revised 10/2022, documented the Infection Control Professional (IP) was responsible for providing education to residents, visitors, and staff. A facility document titled Infection Control Preventionist - Job Description, signed and dated by the IP on 04/04/2022, documented the IP was responsible for teaching principles and practical application on infection prevention and control to all levels of healthcare staff. The IP promoted the ASP. Cross reference with F881 Antibiotic Time Out A facility form titled Four Moments of Antibiotic Decision Making Form (Four Moments), undated, documented to review a residents length of time on antibiotics and determine if antibiotics could be stopped, therapy narrowed, or intravenous antibiotics changed to oral. On 07/18/2024 at 9:25 AM, the IP verbalized the IP did not review resident records for antibiotic use upon admit and explained the review was completed by the pharmacist. The IP confirmed the pharmacist only worked at the facility one time per month and was only available remotely if needed. On 07/18/2024 at 9:30 AM, the IP explained the Four Moments form was utilized by nurses when a new onset of infection was identified. Nurses communicated laboratory (lab) results to providers and confirmed if residents were being administered the correct antibiotics based on the lab results. The IP verbalized when a resident had an infection, the IP became aware when notified by the lab of lab results. The IP entered the information provided by the lab onto a spread sheet and notified the pharmacist. On 07/18/2024 at 9:34 AM, the IP verbalized the IP did not track isolation needs, timing of infections, and change in medications if indicated. The IP was not able to explain or describe a process related to an antibiotic time out and confirmed the IP did not use the Four Moments form at any time during a resident's course of treatment and was not aware of any other form used by the facility for the purpose of conducting and documenting an antibiotic time out. 07/18/2024 9:48 AM, the IP confirmed the IP did not use Four Moments Form and explained the form was filled out by nurses and confirmed the IP did not receive a copy of the form or utilize the form in any way. 07/18/2024 10:12 AM, the IP confirmed when nurses sent a culture to the lab, the IP was not always notified and confirmed most of the time the IP was not aware of an infection until culture results came back from the lab. The IP confirmed an antibiotic time out was not conducted. Nurses collected urine samples and sent them in and communicated with the doctor. The IP never communicated with the doctor. The nurses would tell the IP when they sent out a sample some of the time. The IP would ask nurses if there were any changes or anyone on anything new. If they had something new, the IP initiated on the flow sheet. A facility policy titled Antimicrobial Stewardship Program, revised on 10/2023, documented the resource for the policy was the CDC's Core Elements of Antibiotic Stewardship Program. A Centers for Disease Control and Prevention document titled The Core Elements of Antibiotic Stewardship for Nursing Homes, dated 03/18/2024, documented broad interventions to improve antibiotic use and standardize the practices which should be applied during the care of any resident suspected of an infection. The practices included improving the evaluation and communication of clinical signs and symptoms when a resident was first suspected of having an infection. The use of diagnostic testing was optimized when an antibiotic review process known as an antibiotic time out was implemented for all antibiotics prescribed in the facility. Antibiotic reviews provided clinicians with an opportunity to reassess the ongoing need for and choice of an antibiotic when the clinical picture was clearer, and more information was available. A facility policy titled Antimicrobial Stewardship Program, revised on 10/2023, documented the resource for the policy was the CDC's Core Elements of Antibiotic Stewardship Program. Cross reference with F881 Resident Vaccines On 07/18/2024 at 8:29 AM, the DON confirmed the facility did not have a process in place for screening and providing education to residents and/or the residents' representatives regarding influenza (flu) vaccines and did not have residents sign new consents each year prior to administration of the vaccine. On 07/16/2024 at 4:22 PM, the DON confirmed the facility did not have a process in place for screening and providing education to residents and/or the residents' representatives regarding pneumonia (PNA) vaccines. The DON confirmed due to the lack of a process for screening residents for eligibility to receive a flu or PNA vaccine and the lack of provision of education related to the risk and benefits of receiving the vaccines to the resident and/or resident representative, none of the residents in the facility had been screened for eligibility to receive the vaccines and would not have been provided education related to the risk and benefits of the vaccines. On 07/18/2024 at 9:34 AM, the IP verbalized the IP only followed TB for vaccine type stuff and was not involved with the facility's flu and PNA vaccination process. The IP explained another staff member would provide the information regarding immunizations and the IP entered the data into the required data base, but was not otherwise involved. On 07/18/2024 at 9:48 AM, the IP verbalized the IP did not track immunizations because the IP was not clinical and immunizations were to be tracked by another staff member. Cross Reference with F883 Communication with Prescribing Providers On 07/18/2024 at 10:12 AM, the IP never communicated with physicians/providers and explained the IP was not clinical. A facility policy titled Infection Prevention and Control Program, last revised 10/2022, documented the Infection Control Professional (IP), collaborated with all staff regarding infection prevention and control processes. The IP communicated to staff, including medical staff, concerns related to infection control processes. Cross reference with F881

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, interview, and document review the facility failed to ensure 26 of 27 residents residing at the facility were screened for eligibility to receive immunization with an influenza (flu) vaccine and/or a pneumonia (PNA) vaccine and failed to ensure education related to the vaccines was provided resulting in substandard quality of care (Resident #4, #27, #16, #10, #24, #11, #15, #14, #19, #6, #13, #5, #23, #2, #1, #3, #22, #21, #9, #7, #20, #18, #12, #26, #17, and #8). Findings include: Resident #4 Resident #4 was admitted to the facility on [DATE], with a diagnosis of multiple sclerosis. The resident was [AGE] years of age (YOA). Resident #27 Resident #27 was admitted to the facility on [DATE], with diagnoses including heart failure, unspecified, chronic obstructive pulmonary disease (COPD), unspecified, and unspecified asthma, uncomplicated. The resident was 95 YOA. Resident #16 Resident #16 was admitted to the facility on [DATE], with diagnoses including COPD, chronic respiratory failure with hypoxia, fibromyalgia, and adult failure to thrive. The resident was 78 YOA. Resident #10 Resident #10 was admitted to the facility on [DATE], with diagnoses including vascular dementia, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, and disease of pancreas, unspecified. The resident was 86 YOA. Resident #24 Resident #24 was admitted to the facility on [DATE], with diagnoses including alcoholic hepatic failure without coma, alcoholic cirrhosis of liver with ascites, and unspecified protein calorie malnutrition. The resident was 63 YOA. Resident #11 Resident #11 was admitted to the facility on [DATE], with diagnoses including Parkinson's disease without dyskinesia, without mention of fluctuations, adult failure to thrive, heart failure, unspecified, and hypothyroidism. The resident was 76 YOA. Resident #15 Resident #15 was admitted to the facility on [DATE], with diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and nutritional anemia, unspecified. The resident was 81 YOA. Resident #14 Resident #14 was admitted to the facility on [DATE], with diagnoses including cerebral infarction, unspecified, and hypertensive heart disease with heart failure. The resident was 79 YOA. Resident #19 Resident #19 was admitted to the facility on [DATE], with diagnoses including type II diabetes mellitus with diabetic chronic kidney disease and diabetic polyneuropathy, hypertensive chronic kidney disease with stage I through stage IV chronic kidney disease, or unspecified chronic kidney disease, and anemia in chronic kidney disease. The resident was 56 YOA. Resident #6 Resident #6 was admitted to the facility on [DATE], with diagnoses including cerebral infarction, unspecified, vascular dementia, moderate with agitation, and post COVID-19 condition, unspecified. The resident was 74 YOA. Resident #13 Resident #13 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease, unspecified, post COVID-19 condition, unspecified, and acute kidney failure, unspecified. The resident was 88 YOA. Resident #5 Resident #5 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease, unspecified, disease of pancreas, unspecified, and other nonspecific abnormal finding of lung field. The resident was 93 YOA. Resident #23 Resident #23 was admitted to the facility on [DATE], with diagnoses including COPD, adult failure to thrive, pulmonary hypertension, unspecified, and unspecified dementia, unspecified severity, with mood disturbance. The resident was 84 YOA. Resident #2 Resident #2 was admitted to the facility on [DATE], with diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance mood disturbance, and anxiety, heart failure, unspecified, and unspecified atrial fibrillation. The resident was 93 YOA. Resident #1 Resident #1 was admitted to the facility on [DATE], and last re-admitted to the facility on [DATE], with diagnoses including quadriplegia, unspecified, hydrocephalus, epilepsy, unspecified, not intractable, without status epilepticus, unspecified asthma, uncomplicated, respiratory failure, unspecified, unspecified whether with hypoxia or hypercapnia, unspecified severe protein calorie malnutrition, calculus of kidney, other artificial openings of urinary tract status, other postprocedural cardiac functional disturbances following cardiac surgery, and adult failure to thrive. The resident was 41 YOA. Resident #3 Resident #3 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including type II diabetes mellitus with diabetic chronic kidney disease, hypertensive chronic kidney disease with stage I through stage IV chronic kidney disease, or unspecified chronic kidney disease, nonrheumatic aortic (valve) stenosis with insufficiency, chronic atrial fibrillation, unspecified, anemia in chronic kidney disease, coagulation defect, unspecified, and Guillain-Barre syndrome. The resident was 81 YOA. Resident #22 Resident #22 was admitted to the facility on [DATE], with diagnoses including Parkinson's disease without dyskinesia, without mention of fluctuations, unspecified severe protein-calorie malnutrition, and COPD. The resident was 84 YOA. Resident #21 Resident #21 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease with late onset, atherosclerotic heart disease of native coronary artery without angina pectoris, and personal history of pulmonary embolism. The resident was 73 YOA. Resident #9 Resident #9 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including hemiplegia, unspecified affecting right dominant side, and vascular dementia, unspecified severity, with other behavioral disturbance. The resident was 86 YOA. Resident #7 Resident #7 was admitted to the facility on [DATE], with diagnoses including COPD, unspecified, type II diabetes mellitus without complications, and other specified hypothyroidism. The resident was 76 YOA. Resident #20 Resident #20 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with diagnosed including endocarditis, valve unspecified, primary pulmonary hypertension, nonrheumatic tricuspid (valve) insufficiency, hypothyroidism, and obstructive sleep apnea (adult) (pediatric). The resident was 86 YOA. Resident #18 Resident #18 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including type II diabetes mellitus with diabetic polyneuropathy, long term (current) use of insulin, COPD, unspecified, and unspecified dementia, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The resident was 80 YOA. Resident #12 Resident #12 was admitted to the hospital on [DATE], with diagnoses including unspecified disorder of circulatory system, encephalopathy, unspecified, adult failure to thrive, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, unspecified convulsions. The resident was 64 YOA. Resident #26 Resident #26 was admitted to the facility on [DATE], with diagnoses including traumatic subarachnoid hemorrhage with loss of consciousness, status unknown, subsequent encounter, and unspecified dementia, unspecified severity, with other behavioral disturbance. The resident was 79 YOA. Resident #17 Resident #17 was admitted to the facility on [DATE], with diagnoses including transient cerebral ischemic attack, unspecified, unspecified atrial fibrillation, and myasthenia gravis without (acute) exacerbation. The resident was 89 YOA. Resident #8 Resident #8 was admitted to the facility on [DATE], with diagnoses including COPD, unspecified, other forms of dyspnea, hypoxemia, and hypothyroidism, unspecified. The resident was 95 YOA. Influenza Vaccine The facility lacked documented evidence 23 of 26 residents eligible or potentially eligible to receive a flu vaccine were screened for eligibility to receive a flu vaccine and lacked documented evidence education related to the 2023/2024 flu vaccines was provided to the resident or the resident's representative (Resident #4, #16, #10, #24, #11, #15, #19, #6, #13, #5, #23, #1, #3, #22, #21, #9, #7, #20, #18, #12, #26, #17 and #8). The facility administered flu vaccines to the residents as follows: -8 of 26 residents eligible to receive a flu vaccine declined vaccination (Resident #11, #19, #13, #23, #3, #9, #18, and #12). The residents' clinical records lacked documented evidence the residents were screened for eligibility to receive a flu vaccine and the residents and/or residents' representatives were provided education regarding the 2023/2024 flu vaccines prior to declining vaccination resulting in the resident not having the opportunity to make an informed decision. -5 of 26 residents' (Resident #24, #22, #7, #17 and #8) clinical records lacked documented evidence the residents were screened to determine eligibility to receive a flu vaccine and were provided education regarding the 2023/2024 flu vaccines prior to signing consents and prior to the administration of a 2023/2024 flu vaccine. This failure resulted in the residents not having the opportunity to make an informed decision prior to being administered a 2023/2024 flu vaccine and put residents at risk of having adverse reactions to the flu vaccine related to risk factors identified during the screening process. -3 of 26 residents' (Resident #16, #20 and #26) clinical records lacked documented evidence the residents were screened for eligibility to receive a flu vaccine, education regarding the 2023/2024 flu vaccine was provided, and consent was given by the resident or the residents representative prior to administering a flu vaccine to the residents. This failure resulted in the residents not having the opportunity to make an informed decision and either consent to receive or decline to receive a flu vaccine prior to being administered a 2023/2024 flu vaccine. The lack of screening for eligibility put the residents at risk of having adverse reactions to the flu vaccine related to risk factors identified during the screening process. -6 of 26 residents' (Resident #10, #15, #6, #5, #1 and #21) clinical records documented consents were signed to receive a flu vaccine during the 2022/2023 flu season. The residents' clinical records lacked documented evidence the residents were screened for eligibility to receive vaccination with a 2023/2024 flu vaccine, the resident or the resident's representative were provided education regarding the 2023/2024 flu vaccines, and consent for vaccination with the 2023/2024 flu vaccine was obtained prior to administering a 2023/2024 flu vaccine to the residents. This failure resulted in the residents not having the opportunity to make an informed decision and either consent to receive or decline to receive a flu vaccine prior to being administered a 2023/2024 flu vaccine. The lack of screening for eligibility put the residents at risk of having adverse reactions to the flu vaccine related to risk factors identified during the screening process. -1 of 26 residents (Resident #4) was screened for eligibility to receive a flu vaccine with a hospital consent form. The screening/consent form included a section with an acknowledgement of receipt of a Vaccination Information Sheet (VIS) and an acknowledgement the resident reviewed the information on the back of the form. The form documented the VIS provided to the resident was dated 08/06/2021. The form documented the vaccine administered to Resident #4, Fluad manufactured by Seqirus, was to be given to individuals 65 and older only !!!! and Resident #4 was 61 YOA. The hospital consent form instructed to initial on the line next to each acknowledgement and to sign the line below the acknowledgement to give consent for vaccination. A check mark was entered into the provided line in front of each acknowledgement and were not initialed by the resident or a resident representative. The signature line for consent documented verbal consent and did not document who gave the consent. This failure resulted in Resident #4 not having the opportunity to make an informed decision prior to being administered a 2023/2024 flu vaccine and put residents at risk of having adverse reactions to the flu vaccine related to risk factors identified during the screening process. On 07/18/24 at 8:29 AM, the Director of Nursing (DON) confirmed the facility did not have a process in place for screening residents for eligibility to receive a flu vaccine and did not provide education related to flu vaccines to the residents. The DON confirmed consents were signed at admit and new consents were not signed prior to each new flu vaccine administered. On 07/18/2024 at 8:36 AM, the DON confirmed the facility did not have a screening tool or an algorithm to assist in determining eligibility and/or the recommended PNA vaccine for a resident. The DON confirmed the facility was not using the VIS educational documents to provide education related to flu and PNA vaccines to residents or the resident's representative/guardian. A Food and Drug Administration (FDA) package insert titled Fluad Quadrivalent - Seqirus Incorporated, dated March 2023, documented the Fluad vaccine was approved for use in individuals [AGE] years of age or older and was not approved by the FDA for people under the age of 65. The facility policy titled Influenza Vaccination, revised 12/2023, documented influenza vaccination was the primary method for preventing influenza and it's severe complications. Therefore, vaccination against influenza was offered to residents. Upon admission residents were assessed for recent and past flu vaccination, and flu vaccines were administered to residents annually thereafter. The healthcare professional administering the vaccine obtained a signed consent from the resident or resident representative at the time of admission or prior to the next flu season. Residents were routinely vaccinated, unless contraindicated, at one time, annually, before the influenza season. Residents and/or the resident representatives were provided a copy of the most current VIS regarding the flu vaccine the resident was to be given. Residents were screened for history of Guillain-Barre Syndrome, and for severe allergic reaction to a previous dose, vaccine component, and egg protein. A flu vaccine was not to be administered to residents exhibiting signs and symptoms of moderate or severe acute illness, with or without fever. The facility referred to current Advisory Committee on Immunization Practices (ACIP) recommendations for special circumstances such as immunosuppression, immunodeficiencies, corticosteroid therapy and organ transplantation. The licensed nurse administered flu vaccines according to the manufacturer's instructions and followed the Six Rights of Drug Administration. Pneumonia Vaccine The facility lacked documented evidence 26 of 26 residents eligible or potentially eligible to receive a PNA vaccine were screened for eligibility to receive a PNA vaccine and lacked documented evidence education regarding the PNA vaccine the resident was eligible to receive was provided to the resident or the resident's representative (Resident #4, #27, #16, #10, #24, #11, #15, #14, #19, #6, #13, #5, #23, #2, #1, #3, #22, #21, #9, #7, #20, #18, #12, #26, #17, and #8). The facility administered PNA vaccines to the residents as follows: -13 of 26 residents (Resident #4, #16, #10, #24, #11, #15, #19, #6, #13, #5, #23, #1, #3, #22, #21, #9, #7, #20, #18, #12, #26, #17 and #8) eligible or potentially eligible to receive a PNA vaccine declined vaccination. The residents' clinical records lacked documented evidence the residents were screened for eligibility to receive a PNA vaccine and the residents and/or residents' representatives were provided education regarding the PNA vaccines prior to declining vaccination resulting in the resident not having the opportunity to make an informed decision. -7 of 26 residents' clinical record included a signed consent requesting to receive vaccination with a PNA vaccine (Resident #2, #21, #8, #7, #22, #24, and #10). The residents' clinical record lacked documented evidence the resident was screened for eligibility to receive a PNA vaccine, education was provided related to the PNA vaccine the resident was eligible to receive, and the PNA vaccine was administered to the resident. Resident #14's clinical record lacked documented evidence the resident was screened for eligibility to received a PNA vaccine, education regarding PNA vaccines was provided, a consent or declination to receive a PNA vaccine was obtained, and the resident was provided with a PNA vaccine based on eligibility for the vaccine and the resident's desire to be vaccinated. The Centers for Disease Control and Prevention (CDC) app PneumoRecs VaxAdvisor (VaxAdvisor) recommendation for Resident #14 was to receive one dose of Pneumococcal conjugate vaccine (PCV)15 or PCV20. If PCV20 was administered, the resident's vaccinations were considered complete. If PCV15 was administered the recommendation was for Resident #14 to receive one dose of pneumococcal polysaccharide vaccine (PPSV) 23 after one year. Resident #4's clinical record included a consent signed by the resident on 10/11/2014, requesting to receive a PNA vaccine. Resident #4's clinical record documented the resident received one dose of PPSV23 on 11/07/2017, approximately three years after consenting/requesting to receive a PNA vaccine. Resident #4's clinical record lacked documented evidence the resident was screened for eligibility to receive a PNA vaccine and to determine the recommended dose to give the resident, and lacked documented evidence education regarding PNA vaccines was provided. The resident's clinical record lacked documented evidence the resident was screened for eligibility to receive any additional doses of a PNA vaccine. Resident #15's clinical record included a consent to receive a PNA vaccine signed by the resident's guardian on 02/10/2023. One dose of PPSV23 was administered to the resident on 02/13/2023. Resident #15's clinical record lacked documented evidence the resident was screened for eligibility to receive a PNA vaccine and to determine the recommended PNA vaccine to administer prior to administering a PNA vaccine. Resident #15's clinical record lacked documented evidence the resident and/or the resident's guardian were provided education related to the vaccine administered to Resident #15. Resident #6's clinical record included a consent to receive a PNA vaccine, the consent was verbal consent from the resident dated 09/09/2022. Resident #6's clinical record documented the resident received one dose of PPSV23 on 11/09/2022. Resident #6's clinical record lacked documented evidence the resident was screened for eligibility to receive a PNA vaccine and to determine the CDC recommended PNA vaccine to administer. The residents clinical record lacked documented evidence the resident was provided education related to PPSV23. Resident #6's clinical record lacked documented evidence the resident was screened for eligibility to receive any additional subsequent doses of a PNA vaccine. Resident #5's clinical record included a consent to receive a PNA vaccine signed by the residents guardian on 08/31/2011. Resident #5's clinical record documented the resident received one dose of PPSV23 on 12/04/2017, approximately six years after consenting/requesting to receive a PNA vaccine. Resident #4's clinical record lacked documented evidence the resident was screened for eligibility to receive a PNA vaccine and to determine the recommended dose to give the resident, and lacked documented evidence education regarding PNA vaccines was provided to the resident or the resident's guardian. The resident's clinical record lacked documented evidence the resident was screened for eligibility to receive any additional doses of a PNA vaccine. Resident #20's clinical record documented the resident was administered one dose of PPSV23 on 11/08/2022. Resident #20's clinical record did not include a signed consent to receive the vaccine, evidence the resident was screened for eligibility to receive a PNA vaccine and to determine which PNA vaccine to administer. Resident #20's clinical record lacked documented evidence the resident or the resident's representative were provided education regarding PNA vaccines. The CDC's VaxAdvisor recommended to administer one dose of PCV15 or PCV20 at least one year after the last dose of PPSV23 in order for the resident's PNA vaccinations to be complete. The failure to screen residents for eligibility to receive a PNA vaccine and determine the correct PNA vaccine to administer to each resident, placed residents at risk of being vaccinated with the wrong PNA vaccine for the resident, or not receiving additional needed doses of a PNA vaccine. The lack of education related to the PNA vaccine a resident was eligible to receive resulted in the residents not having the opportunity to make an informed decision and consent prior to being administered the vaccine. The failure to administer a PNA vaccine to eligible residents put the residents at risk of developing PNA with the potential to result in complications associated with PNA. On 07/16/24 at 4:22 PM, the DON confirmed the facility did not have a screening process in place related to PNA vaccines and did not provide education related to PNA vaccines to residents or the resident's representative. The DON confirmed none of the facility's 27 residents had been screened for vaccination with a PNA vaccine and education related to PNA vaccines was not provided to the residents. The facility policy titled Pneumococcal Polysaccharide Vaccination, last revised 10/2017, documented because pneumococcal disease was known to lead to serious infections in the resident population and was proving to be resistant to antibiotics, the facility provided vaccination against pneumococcal disease to prevent the spread of infection. PPSV protected against multiple types of pneumococcal bacteria and was offered to the resident population. Residents were screened for severe allergic reactions after a previous dose of PPSV and consent was obtained from the resident or the resident's representative/guardian. Residents or the resident's representative/guardian were provided with information regarding potential reactions and a copy of the most current VIS. Copies of the VIS were obtained from the CDC website. Documentation in the residents clinical record included the date of administration, amount and dosage given, reactions to the vaccine. The policy was last revised in 2017, and documented the sole reference was titled CDC, Morbidity and Mortality Weekly Report (MMWR), Prevention of Pneumococcal Disease: Recommendations of the Advisory Committee on Immunization Practices (ACIP), volume 46/No. RR-8, dated 04/04/1997. The reference included a weblink, but the link indicated the page could no longer be found. The guidance in the policy was outdated and did not include the CDC's most recent guidance regarding the selection and administration of pneumococcal vaccines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on dining observation, interview, and document review the facility failed to ensure a resident was served at the same time as two other residents at the same table in the dining room for 1 of 3 residents at a table (Resident #8). Findings include: Resident #8 Resident #8 was admitted to the facility on [DATE], with a diagnosis of chronic obstructive pulmonary disease, unspecified. On 09/25/23 at 11:55 PM, Resident #8 was sitting in a wheelchair at a table in the dining room with two other residents. Resident #8's table mates were served lunch trays and Resident #8 was not served a lunch tray. On 09/25/23 at 12:08 PM, a Certified Nursing Assistant (CNA) delivered Resident #8's lunch tray. On 09/25/23 at 12:18 PM, the CNA verbalized lunch was always delivered in two separate tray carts. The CNA explained the tray carts usually came out together but were sent out one at a time on 09/25/23, during the lunch service. The expectation was all residents sitting at a table would be served at the same time. The CNA confirmed Resident #8's lunch tray was not on the first cart out and the resident was not served lunch at the same time as the resident's table mates. The facility policy titled Resident Rights, undated, documented residents had the right to be treated with consideration, respect, and full recognition of dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and document review the facility failed to ensure the accuracy of a Minimum Data Set 3.0 (MDS) assessment for 1 of 14 sampled residents (Resident #18). Findings include: Resident #18 Resident #18 was admitted to the facility on [DATE], with diagnoses including Alzheimer's with late onset, vascular dementia, unspecified severity, with psychotic disturbance and dementia in other diseases classified elsewhere, moderate, with psychotic disturbance. Behavioral Progress Notes for June 2023, documented Resident #18 had five instances of verbal aggression. Behavior Progress Notes for the seven day look back period included the following: -On 06/28/23 the resident was being assisted with removing shoes and got agitated. The resident told the nurse Get out of here! The staff member left the resident's room for five minutes and returned to the room. The resident was pleasant. -On 06/29/23 the resident was entering other resident rooms. Staff attempted to stop the resident from entering other resident rooms. The resident verbalized to staff the resident was going to go into the room and to move or I'll get you with this. The resident lifted his walking cane high up in the air and shook the cane at staff. -On 07/02/23 the resident would not give staff the resident's top dentures. Two staff attempted and were not successful. Resident #18's MDS quarterly assessment dated [DATE], section E, documented the resident did not exhibit any verbal behavioral symptoms directed towards others to include threatening others, screaming at others, and cursing at others during the seven day look back period. On 09/26/23 at 12:35 PM, the MDS Coordinator confirmed Resident #18's MDS assessment lacked documented evidence the resident had any behavioral symptom concerns during the MDS assessments seven day look back period. The MDS Coordinator confirmed Section E should have documented the resident had verbal aggressive and physical aggressive behaviors during the look back period, however did not. On 09/26/23 at 1:21 PM, the Director of Nursing (DON) explained Resident #18 had mostly verbal behaviors were aggressive and sometimes the behaviors were physical in nature. The resident would yell at staff, threaten staff and once threw a shoe at a staff member. The DON confirmed the MDS assessment should have documented the behaviors for Resident #18 and lacked documented evidence of the behaviors. The facility policy titled Significant Errors in Minimum Data Set (MDS) Assessments, last revised July 2015, documented the facility was to have an accurate MDS assessment as a part of the medical record and if there was an error on the MDS, the error would be changed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and document review, the facility failed to ensure a baseline care plan was created timely for the treatment and care needs for 1 of 14 sampled residents (Resident #475). Findings include: Resident #475 Resident #475 was admitted to the facility on [DATE], with diagnoses including chronic obstructive pulmonary disease with exacerbation, chronic respiratory failure with hypoxia and dependence on supplemental oxygen. Resident #475's clinical record lacked documented evidence a baseline care plan was completed for oxygen use. On 09/26/23 at 10:33 AM, a Registered Nurse (RN) verbalized Resident #475 was on 3 liters per minute of supplemental oxygen. The RN confirmed the resident was admitted to the facility with oxygen and there was no baseline care plan. On 09/26/23 at 10:48 AM, the Director of Nursing (DON) explained baseline care plans were required to be completed within 48 hours of a resident's admission to the facility and explained baseline care plans were important to explain resident care needs to staff. The DON confirmed Resident #475 lacked a baseline care plan for oxygen use. The facility policy titled, Patient Care Plans, last revised on 06/2023, documented initial care plans would begin on the day of admission and based on the individual needs of each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #475 Resident #475 was admitted to the facility on [DATE], with diagnoses including chronic obstructive pulmonary disease with exacerbation, chronic respiratory failure with hypoxia and dependence on supplemental oxygen. Resident #475's clinical record lacked documented evidence a care plan had been initiated for oxygen use. The Minimum Data Set 3.0 (MDS) assessment dated [DATE], documented Resident #475 was on oxygen. On 09/26/23 at 10:33 AM, a Registered Nurse (RN) verbalized Resident #475 was on 3 liters per minute of supplemental oxygen. The RN confirmed the resident was admitted to the facility with oxygen and there was no Comprehensive Care Plan for oxygen use. On 09/26/23 at 10:48 AM, the DON explained Comprehensive Care Plans were required to be completed and were important to explain resident care needs to staff. The DON confirmed Resident #475's Comprehensive Care Plan lacked a care plan related to the administration of oxygen. On 09/26/23 at 12:35 PM, a Licensed Practical Nurse (LPN)/MDS Coordinator verbalized the information on the MDS assessment was transferred to the care plans. Resident #5 Resident #5 was admitted to the facility on [DATE], with diagnoses including adjustment disorder with depressed mood, cerebral infarction, unspecified, and vascular dementia with moderate agitation. Resident #5's clinical record lacked documented evidence a care plan had been initiated for behaviors related weight loss. On 09/26/23 at 11:48 AM, an RN verbalized when a resident had weight loss it was reported to the dietician and interventions to implement would be documented on the care plan. The RN confirmed Resident #5 had a nine-and-a-half-pound weight loss between 06/07/23 and 06/27/23 and there was not a care plan documenting the interventions and behaviors related to Resident #5's weight loss. On 09/26/23 at 1:10 PM, the DON explained a Comprehensive Care Plan would include a care plan for weight loss if a resident had identified weight loss. The DON verbalized interventions for a care plan related to weight loss may include health shakes, queuing at meals and behaviors related to weight loss. The DON explained Resident #5 had the behavior to stop eating when the resident was unhappy. The DON confirmed the resident had weight loss between 06/07/23 and 06/27/23, and a care plan related to the resident's behaviors and weight loss was not initiated. The facility policy titled Patient Care Plans, revised 06/2023, documented care plans for the residents were a working tool to reflect the resident's status and plan of care. The licensed nurse, who either receives or notes the order, was responsible for adding it to the comprehensive care plan. Based on clinical record review, interview, and document review, the facility failed to ensure Comprehensive Care Plans included a care plan related to 1) chronic pain for 1 of 14 sampled residents (Resident #3), F2) the administration of oxygen for 2 of 14 sampled residents (Resident #4 and #475), and 3) behaviors related to weight loss for 1 of 14 sample residents (Resident #5). Findings include: Resident #3 Resident #3 was admitted to the facility on [DATE], with diagnoses including personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits, and other chronic pain. Resident #3's Minimum Data Set 3.0 (MDS) assessment, dated 07/19/23, Section N0410H, documented the resident received opioid medications seven of seven days. A physician's order note dated 09/06/23, documented orders for Resident #3 as follows: -Morphine sulfate (concentrated) oral solution 100 milligrams (mg) 5 milliliters (ml) (morphine sulfate), give 0.25 ml by mouth three times a day for pain. -Gabapentin 400 mg tablets, give 400 mg by mouth in the evening for moderate nerve pain. Resident #3's Comprehensive Care Plan included a care plan related to the potential need for narcotic medication but did not include a care plan related to the resident's diagnosis of chronic pain. On 09/26/23 at 12:29 PM, the Director of Nursing (DON)confirmed Resident #3's Comprehensive Care Plan did not include a care plan related to chronic pain. The DON explained the expectation was a care plan related to chronic pain would include instructions for the administration of prescribed pain medications, the name of the medication, the signs and symptoms of adverse effects to monitor for, and any necessary instructions such as holding the medication based on the resident's parameters for respiration rate. Resident #4 Resident #4 was admitted to the facility on [DATE], with a diagnosis of emphysema, unspecified. On 09/26/23 at 10:47 AM, Resident #4 was resting in bed while wearing a nasal cannula. The resident's oxygen concentrator was set at 2.5 liters per minute (LPM). A physician's order dated 09/24/23, documented oxygen via concentrator at 2.0 LPM via nasal cannula every hour for low oxygen saturation. On 09/26/23 at 10:50 AM, the Director of Nursing (DON) verbalized Resident #4 had an order for oxygen administration and was currently receiving oxygen administration via the nasal cannula from an oxygen concentrator. On 09/26/23 at 12:07 PM, the Registered Nurse (RN) confirmed Resident #4 was receiving oxygen administration and oxygen administration should be care planned. The RN confirmed Resident #4's Comprehensive Care Plan had not been updated to include oxygen administration. On 09/26/23 at 1:34 PM, the DON verbalized oxygen administration should be care planned since oxygen was a medication and an intervention and confirmed Resident #4's care plan had not been updated to include oxygen administration. The DON verbalized any nurse had access to the care plan and the nurse should have updated Resident #4's care plan when the oxygen administration order was received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, interview, and document review the facility failed to ensure 1) an order for comfort care included the indication for comfort care, 2) the facility had a policy and process to help direct care and concerns related to comfort care, and 3) a resident was reassessed for continued need to remain on comfort care for 1 of 14 sampled residents (Resident #3). Findings include: Resident #3 Resident #3 was admitted to the facility on [DATE], with diagnoses including personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits, type II diabetes mellitus, and other chronic pain. Diagnoses including dementia in other diseases classified elsewhere, unspecified severity, with agitation, Parkinson's disease, violent behavior, disease of pancreas, unspecified, other nonspecific abnormal findings of lung field, and elevation of levels of liver transaminase levels were entered into the resident's clinical record during the resident stay at the facility. A physician's order dated 07/07/22, documented Comfort Care. The order lacked an indication for Comfort Care and did not include any further instructions. Resident #3's Comprehensive Care Plan included a care plan related to an anticipated decline and documented the resident was on comfort care protocols. A physician's progress note dated 08/17/23, documented the resident woke easily but did not answer questions and only verbalized don't do that when an exam was attempted. The plan included no new orders or changes, supportive care only. A dietary note dated 08/31/23, documented the resident remained on comfort care with weights deferred and oral intake averaged 69%. The current diet order was continued and the was resident was assisted with meals as needed. A physician's progress note dated 09/06/23, documented Resident #3 would not allow an exam and did not like to be touched, the resident was stable and on comfort care. On 09/25/23 at 3:40 PM, the Director of Nursing (DON) explained comfort care was handled on a case by case basis and confirmed the facility did not have a protocol for comfort care. Staff assessed residents on comfort care to ensure the resident was not in pain and obtained orders from the physician as needed. On 09/26/23 at 10:40 AM, a Registered Nurse (RN) verbalized comfort care meant something different for each resident. The RN knew what a resident's comfort care needs were by reviewing the resident's Physician Orders for Life Sustaining Treatment (POLST), asking the resident's family/guardian, and talking with the resident's provider. The RN verbalized Resident #3 had been on comfort care for approximately two years and had scheduled morphine and Ativan. The RN verbalized Resident #3 was doing pretty good and explained the resident was still eating and drinking adequately and was able to verbally express needs. The RN did not know why Resident #3 was on comfort care and explained the reason for comfort care was not on the physician orders, and the resident did not have a diagnosis commonly associated with comfort care. On 09/26/23 at 10:49 AM, the RN confirmed Resident #3's care plan related to comfort care instructed the nurse to follow the facility's protocol for comfort care. The RN confirmed the RN was not able to locate comfort care protocols in the facility's computer system, in any of the binders at the Nurse's Station, or in the resident's clinical record, including the resident's paper chart. The RN acknowledged the POLST was intended for emergent and end of life instructions and was not intended to be used to direct comfort care. On 09/26/23 at 11:39 AM, the DON explained comfort care was initiated when a resident decline was noticed and the resident had signs and symptoms of impending death and/or when a resident had a terminal diagnosis where intervention was necessary but the resident or the family did not want to pursue treatment. Comfort was the focus of comfort care. Comfort care could mean something different for each resident based on the resident's needs and wishes. Different physicians could also have different ideas of what comfort care was and the facility followed whatever the physician ordered. On 09/26/23 at 11:44 AM, the DON explained the criteria for initiating comfort care included not eating or drinking, and diagnoses such as end stage Parkinson's disease, end stage dementia, kidney failure, strokes, and multiple sclerosis. On 09/26/23 at 11:55 AM, the DON verbalized nurses reported changes, including improvements and decline to the DON, the Assistant DON, and the physician. If the resident improved or had a turn around, the resident no longer needed to be on comfort care. On 09/26/23 at 12:00 PM, the DON verbalized the criteria to take a resident off of comfort care could include an improvement in oral intake, an improvement in function and activities of daily living, becoming more alert and verbal, and generally an overall sense of improvement. The DON verbalized when a resident was on comfort care for a lengthy time the resident's physician would document in a physician's note to continue or discontinue comfort care. On 09/26/23 at 12:09 PM, the DON confirmed when a resident was on comfort care, palliative and supportive care was provided and an improvement in the resident status was not expected. On 09/26/23 at 12:12 PM, the DON confirmed Resident #3 previously had a decline and was not eating, not alert and was kind of out of it, but was now stable and had not worsened. The DON verbalized during February of 2020 Resident #3 was no longer independently eating and recalled at sometime in 2022 Resident #3 had decreased energy, weight loss and poor appetite related to long COVID but was now able to eat independently when finger foods were offered and cueing was provided. The DON had difficulty locating documentation of when and why the resident was placed on comfort care. On 09/26/23 at 12:22 PM, the DON confirmed after being placed on comfort care, Resident #3 had not continued to decline and a resident on comfort care would not receive the care necessary to promote the resident's highest practicable level of well being. On 09/26/23 at 12:29 PM, the DON confirmed Resident #3 should have been assessed for the need to discontinue comfort care but was not assessed. The facility policy titled Comfort Care, undated, documented comfort care was discussed on a case by case basis with the Medical Director and Nursing staff/resident/responsible party. Respecting their advanced directives and POLST. The policy did not include any additional text, a policy number, a revision date, or an indication the policy had been approved. Cross reference with F656, F835, and F865

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review and document review, the facility failed to ensure a resident was supervised during eating while allowing resident to eat in a reclined position for a resident with chewing difficulty and medication administration for 2 of 14 sampled residents (Resident #16 and #18). Findings include: Resident #16 Resident #16 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnosis of unspecified dementia, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and type 2 diabetes mellitus with diabetic polyneuropathy. On 09/25/23 at 11:26 AM, Resident #16 explained the resident did not like the resident's bed because it did not go up enough to sit the resident comfortably during eating. The resident verbalized the resident had a fear of choking due to the reclined back. Resident #16's physician ordered diet dated 04/13/23, documented No Concentrated Sweets diet Mechanical Soft texture, regular consistency. Resident #16's Comprehensive Care Plans documented the following: -Potential for chewing difficulty, pain and weight loss related to resident stating the resident had difficulty chewing. The resident had upper dentures the resident did not wear, and a few lower front teeth worn down to the gumline. Date Initiated: 07/17/23 Revised: 07/17/23 -Resident #16 had an Activities of Daily Living (ADL) self-care performance deficit related to dementia and impaired balance. Date Initiated: 04/17/23 Revised: 06/03/23 EATING: set up and supervision Date Initiated: 04/22/23 Revised: 04/22/23 Resident #16's Care Conference Progress Note, dated 07/20/23, documented the resident needed set up and staff supervision to enjoy meals. On 09/26/23 at 10:52 AM, a Certified Nursing Assistant#1 (CNA) explained Resident #16 ate meals in both the dining room or the resident's room. The CNA#1 explained when the resident ate in the resident's room, the CNA#1 would unload the resident's tray, offer to cut the resident's meat, and bring the resident coffee. The CNA#1 verbalized the resident usually remained in bed when eating in the resident's room. On 09/26/23 at 12:29 PM, Resident #16 was in bed, eating lunch. The resident had been moved to a new room today, but the bed remained the same with the same ability to raise the back of the bed. The resident had two pillows behind the resident's head to adjust position to be more upright while eating. The resident verbalized the resident placed the pillows behind the resident's head. There were no staff present in the resident's room or outside the resident's doorway as the resident completed eating lunch. The resident's back of bed was reclined and not at a full seated position. On 09/26/23 at 12:35 PM, CNA#2 explained the CNA's training had defined supervision to include someone must be with a resident at all times while eating if supervision was required. CNA#2 confirmed being familiar with care needs of Resident #16 and verbalized the resident required supervision while eating. The resident would need a CNA present if the resident chose to eat in the resident's room. On 09/26/23 at 12:41 PM, the Director of Nursing (DON) explained supervision for eating was determined by observing the resident upon admit. The care plan would reflect supervision. The DON defined supervision to include staff must be in the same room to supervise a resident while eating. On 09/26/23 at 12:43 PM, the DON confirmed Resident #16 had been identified as set up and supervision for eating. The resident sometimes chose to eat in the resident's room and staff should be present. On 09/26/23 at 12:46 PM, the DON verbalized Resident #16's difficulty chewing would not be a reason for supervision. The DON reviewed the resident's electronic medical record and was unable to explain how the facility determined Resident #16 needed supervision for eating. Resident #16's back of bed should be elevated all the way up to seated position when eating in bed and if it was, the DON assumed it to be ok for the resident. The DON confirmed eating without supervision in the resident's room at lunch today would not have been safe. The facility policy titled Assisting Residents with Meals, last revised 05/2022, documented to position resident in a comfortable sitting position, with head slightly forward, not leaning backwards. Reclining interferes with chewing. The Resident Assessment Instrument (RAI) manual defined Supervision for eating as oversight, encouragement or cuing. Resident #18 Resident #18 was admitted to the facility on [DATE], with diagnoses including Alzheimer's with late onset, vascular dementia, unspecified severity, with psychotic disturbance and dementia in other diseases classified elsewhere, moderate, with psychotic disturbance. A Behavior Incident Progress Note dated 09/19/23, documented during the evening shift, the resident complained of a headache and was getting loud with a Licensed Practical Nurse (LPN). The LPN handed Resident #18 a Tylenol tablet and decided to leave the resident alone, without observation of the resident swallowing the medication, because the resident was upset. The LPN documented not knowing if the resident had taken the Tylenol tablet. On 09/26/23 at 12:35 PM, an LPN explained when administering medications, the nurse must observe the resident until the medication was swallowed. The LPN verbalized when a resident was left alone with a medication, it would not be known if the resident swallowed the medication or if another resident took and swallowed the medication. On 09/26/23 at 12:35 PM, the Assistant Director of Nursing (ADON) verbalized when administering medications, it was important to observe the resident swallow the medications and confirm the medication was administered properly. If a resident was left unsupervised with a medication, the resident could choke, provide the medication to another resident and it could cause health issues for the resident and other residents. The ADON confirmed on 09/19/23, Resident #18 was left unsupervised with a Tylenol tablet and it was unknown if the resident took the medication. On 09/26/23 at 1:21 PM, the Director of Nursing (DON) explained the expectation for medication administration was to have a licensed nurse administer medications to the resident. It was not appropriate for staff to walk away without a medication administration observation because the resident could throw the medication away, give the medication to another resident and it could cause harm to the resident or other residents. The DON confirmed on 09/19/23, an LPN walked away from Resident #18 after handing the resident a Tylenol tablet. The facility policy titled Administration of Medications, last revised January 2021, documented all medications should never be left unattended. Cross Reference with Tag F761

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, document review and interview, the facility failed to 1) obtain a physician's order for oxygen therapy for 1 of 14 sampled residents (Resident #475), and 2) administer oxygen therapy per a physician's order for 1 of 14 sampled residents (Resident #4). Findings include: Resident #475 Resident #475 was admitted to the facility on [DATE], with diagnoses including chronic obstructive pulmonary disease with exacerbation, chronic respiratory failure with hypoxia and dependence on supplemental oxygen. Resident #475's clinical record lacked documented evidence of a physician's order for the use of oxygen. On 09/25/23 at 4:03 PM, Resident #475 was in the dining room on oxygen administered via a nasal cannula. The resident's oxygen administration was set at three liters per minute (LPM). On 09/26/23 at 10:30 AM, a Certified Nursing Assistant (CNA) confirmed Resident #475 was receiving oxygen at three LPM. Resident #475's Medication Administration Record (MAR) and Treatment Administration Record (TAR) lacked documented evidence of oxygen administration for July, August, and September 2023. The Nursing History and Observation dated 07/28/23, documented Resident #475 was on three LPM of oxygen. On 09/26/23 at 10:33 AM, a Registered Nurse (RN) verbalized Resident #475 was receiving oxygen at three LPM. The RN verbalized Resident #475 did not have a physician's order for the administration of oxygen. The RN confirmed the resident had been receiving oxygen since 07/28/23, and oxygen was considered to be a medication. On 09/26/23 at 10:48 AM, the Director of Nursing (DON) verbalized residents who were receiving oxygen should have a physician's order. Resident #475's clinical record lacked a physician's order for the administration of oxygen, and the resident had been receiving oxygen since admission on [DATE]. Resident #4 Resident #4 was admitted to the facility on [DATE], with a diagnosis of emphysema, unspecified. On 09/26/23 at 10:47 AM, Resident #4 was resting in bed with a nasal cannula placed under the resident's nose and the resident's oxygen concentrator was set at 2.5 LPM. A physician's order dated 09/24/23, documented oxygen via concentrator at 2.0 LPM via nasal cannula every hour for low oxygen saturation. On 09/26/23 at 10:50 AM, the DON verbalized the resident's nasal cannula was disconnected from the resident's humidifier/oxygen concentrator and was unsure how long it had been disconnected. The DON confirmed the oxygen concentrator flow rate was set at 2.5 LPM. The DON confirmed the physician's order was for 2.0 LPM via nasal cannula. The DON verbalized Resident #4's TAR prompted staff in the electronic health record to check the oxygen administration for Resident #4 hourly and sign off it the nasal cannula was correctly placed and the oxygen was flowing at 2.0 LPM. The DON verbalized the TAR had been signed off on 09/26/23 on the day shift at 7:00 AM, 8:00 AM, 9:00 AM, and 10:00 AM. On 09/26/23 at 12:07 PM, the RN verbalized not being aware Resident #4's nasal cannula tube was not connected to the humidifier/concentrator. The RN verbalized the TAR was set up to check Resident #4's oxygen administration every hour to verify the nasal cannula was properly placed and the flow meter was set at the prescribed flow rate. The RN verbalized Resident #4's oxygen saturation levels had fallen below 90% so the resident was placed on supplemental oxygen. The facility policy titled Oxygen revised 04/2023, documented oxygen was considered a medication and should be administered only as prescribed. Connect the nasal cannula to the bubble humidifier and adjust the flow meter to the flow rate ordered by the physician. The facility policy titled Administration of Medication, revised 01/2021, documented a physician's order was required before a nurse administered any medication. The facility policy titled Respiratory Therapies Provided by Nursing, revised 07/2015, documented a written order will be in the patient's record that designates the type of treatment, duration, frequent, dosages, and mixing of any medications to be used during the treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interview, and document review, the facility failed to ensure medications were stored correctly and were not left unsupervised with a resident who could not self-administer medications for 1 of 14 sampled residents (Resident #18). Findings include: Resident #18 Resident #18 was admitted to the facility on [DATE], with diagnoses including Alzheimer's with late onset, vascular dementia, unspecified severity, with psychotic disturbance and dementia in other diseases classified elsewhere, moderate, with psychotic disturbance. A Behavior Incident Progress Note dated 09/19/23, documented during the evening shift, the resident complained of a headache and was getting loud with a Licensed Practical Nurse (LPN). The LPN handed Resident #18 a Tylenol tablet and decided to leave the resident alone, without observation of the resident swallowing the medication, because the resident was upset. The LPN documented not knowing if the resident had taken the Tylenol tablet. On 09/26/23 at 12:35 PM, an LPN explained when administering medications, the nurse must observe the resident until the medication was swallowed by the resident. On 09/26/23 at 12:35 PM, the Assistant Director of Nursing (ADON) confirmed on 09/19/23, Resident #18 was left unsupervised with a Tylenol tablet and it was unknown if the resident took the medication. On 09/26/23 at 1:21 PM, the Director of Nursing (DON) explained the expectation for medication administration was to have a licensed nurse administer medications to the resident.The DON confirmed on 09/19/23, an LPN walked away from Resident #18 after handing the resident a Tylenol tablet. The facility policy titled Administration of Medications, last revised January 2021, documented medications would never be left unattended. Cross Reference with Tag F689

Based on document review and interview, the facility failed to demonstrate effective administration by not ensuring the facility's policy regarding comfort care included a procedure to direct the care and assessment needs of residents placed on comfort care. Findings include: The facility's policy related to comfort care did not include a process directing the care, assessment, and monitoring of residents on comfort care, including criteria to initiate or discontinue comfort care. On 09/26/23 at 2:56 PM, the Administrator confirmed the facility's policy related to comfort care lacked a procedure/process to guide the care of residents requiring comfort care. The Administrator confirmed the facility should have a policy related to the process for initiating comfort care, monitoring the resident for declines and improvements, and needed care and concerns. The facility policy titled Comfort Care, undated, documented in total comfort care was discussed on a case by case basis with the Medical Director and Nursing staff/resident/responsible party. Respecting their advanced directives and the Physician Orders for Life Sustaining Treatment (POLST). The policy did not include any additional text, a policy number, a revision date, or an indication the policy had been approved. Cross reference with F656, F684, and F865.

Based on interview and document review the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to identify 1) the facility's Antibiotic Stewardship (ASP) policy and processes included the criteria the facility used to define infections and the use of data collection and monitoring tools, including an antibiotic time out, 2) the lack of a process to ensure COVID-19 (COVID) vaccines were ordered and administered timely to residents wishing to receive the vaccine, and 3) a policy and process was in place to guide appropriate care of residents placed on comfort care. Findings include: Antibiotic Stewardship Program On 09/26/23 at 2:48 PM, the Administrator confirmed the QAPI committee did not identify concerns related to the ASP/policy's failure to include criteria to be used for the identification of infections, such as McGeer's criteria, and the lack of data collection and monitoring tools used to ensure appropriate antibiotic use, such as an antibiotic time out. The Administrator could not explain how the QAPI committee could have identified a concern with the policy as the QAPI committee did not review policies. Cross reference with F881 COVID Vaccines On 09/26/23 at 2:53 PM, the Administrator confirmed the QAPI committee did not identify concerns related to obtaining COVID vaccines for residents who wanted to receive the vaccine. The Administrator explained concerns related to ordering COVID vaccines were not discussed during QAPI meetings and the vaccine could have been ordered by entering a note into the facility's system requesting the vaccine anytime a vaccine was needed. Cross reference with F887 Comfort Care On 09/26/23 at 2:56 PM, the Administrator confirmed the QAPI committee did not identify concerns related to the lack of a policy/procedure to guide the care of residents requiring comfort care. The Administrator confirmed the facility should have a policy related to the process for initiating comfort care, monitoring the resident for declines and improvements, and needed care and concerns. Cross reference with F684 and F835. The facility policy titled Quality Management Program, last revised 11/2017, documented the QAPI committee, with the support and approval of the Governing Body, had the responsibility for monitoring every aspect of resident care and service from the time the resident entered the facility, through diagnosis, treatment, recovery, and discharge in order to identify and resolve any breakdowns with the potential to result in sub-optimal resident care and safety, while striving to continuously improve and facilitate positive resident outcomes.

Based on clinical record review, document review, and interview the facility failed to ensure the facility's Antibiotic Stewardship Program (ASP) included a process for conducting antibiotic timeouts with the potential to affect any resident prescribed antibiotics in the facility. Findings include: On 09/26/23 at 12:09 PM, the Chief Nursing Officer (CNO) verbalized the Pharmacist only reviewed antibiotics prescribed during the Pharmacist's on-site visits twice a month. The CNO confirmed a resident could complete a course of antibiotics prior to the Pharmacist reviewing to ensure the correct antibiotic was prescribed and the nursing staff did not perform an antibiotic time out or contact the Pharmacist for review of the antibiotic prior to administering the medication. On 09/26/23 at 12:28 PM, the Administrator verbalized the feedback to the prescriber did not happen in real time and the facility did not use any criteria or a formal documented process to determine appropriate antibiotic use prior to administration of antibiotics. The facility policy titled Antimicrobial Stewardship Program, revised 10/2022, documented the Antimicrobial Stewardship Program (ASP) would proactively monitor the use of antimicrobial prescriptions with real time feedback and advice to clinicians regarding appropriate antimicrobial use in residents. The ASP program would include formal programs for tracking, auditing, and reporting antimicrobial use and the use of nationally recognized antimicrobial use guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interview, and document review, the facility failed to ensure residents requesting a COVID-19 (Covid) vaccination received the vaccine in a timely manner to protect the residents from potential exposure from Covid positive staff for five of five residents who requested the vaccine (Residents #7, #8, #19, #475, and #476). Findings include: Resident #7 Resident #7 was admitted to the facility on [DATE], with diagnoses including chronic obstructive pulmonary disease, unspecified and type two diabetes mellitus without complications. Resident #8 Resident #8 was admitted to the facility on [DATE], with diagnoses including chronic obstructive pulmonary disease, unspecified and other forms of dyspnea. Resident #19 Resident #19 was admitted to the facility on [DATE], with diagnoses of Parkinson's disease and chronic obstructive pulmonary disease, unspecified. Resident #475 Resident #475 was admitted to the facility on [DATE], with diagnoses of chronic obstructive pulmonary disease with (acute) exacerbation and chronic respiratory failure with hypoxia. Resident #476 Resident #476 was admitted to the facility on [DATE], with diagnoses of sepsis, unspecified organism and type two diabetes mellitus with diabetic polyneuropathy. On 09/26/23 at 10:34 AM, the Director of Nursing (DON) verbalized the facility was waiting for five residents to request the Covid vaccine prior to ordering a vial from the pharmacy to administer. The DON explained the pharmacy could send one dose at a time as the vaccine was requested by residents but a vial with enough vaccine for five residents would be the same cost. The DON verbalized the choice to wait until five residents requested the vaccine before ordering was more cost effective. The DON explained the DON tracked the residents requesting a vaccine by keeping copies of the order for the resident, a progress note, or would make a handwritten note and stored the documentation in a binder. The DON verbalized the vaccine had been ordered for Residents #7, #8, #19, #475, and #476 and the vaccines would be administered by the end of the week. A Progress Note for Resident #7, dated 08/02/23, documented the resident would like the Covid booster. An Orders - Administration Note for Resident #8, dated 08/01/23, documented the resident stated the resident would like the Covid booster and to offer the vaccine/booster to the resident. A Communication Note for Resident #19, dated 08/14/23, documented the resident's Power of Attorney agreed to the resident receiving a Covid booster. A Progress Note for Resident #475, dated 08/02/23, documented the resident would like the Covid booster. A Physician Order for Resident #476, dated 08/01/23, documented to offer the vaccine/booster to the resident. A note on the order documented the resident would like to get the booster. On 09/26/23 at 12:43 PM, the Chief Nursing Officer (CNO) verbalized the CNO and Administrator had offered to order the vaccine for the residents who had requested the vaccine. The CNO explained the purpose of the vaccine/booster was to provide extra protection from severe illness after exposure to Covid and cost savings was not a valid reason to not vaccinate. On 09/26/23 at 12:52 PM, the Administrator verbalized two staff members, an Activity Aide and a Registered Nurse (RN), had tested positive since the residents had requested the Covid vaccine. A tracking form provided by the Administrator documented the following: - An RN experienced nasal congestion on 09/10/23, and worked 09/11/23, while wearing a mask. The RN tested Covid positive on 09/12/23. - An Activity Aide was sent home on [DATE], after experiencing gastrointestinal symptoms and a headache. The Activity Aide tested Covid positive on 09/12/23. On 09/26/23 at 2:03 PM, the Administrator verbalized the Covid vaccine/booster had not yet been ordered for the residents and should have been ordered as needed or requested by the residents. The facility policy titled COVID-19 Vaccination in Long Term Care, revised 05/2022, documented to protect long term care residents from COVID-19 the facility would provide vaccines to all residents who elect them.

Based on observation, interview, and document review, the facility failed to ensure food was stored properly and residents received the portion sizes indicated on the facility's menu with the potential to affect the entire facility census of 27 residents. Findings include: Food Storage On 09/25/23 at 10:11 AM, in a reach-in refrigerator, there were two sealed packages of hard boiled eggs, each containing a dozen. The packages were labeled with a use-by date of 08/29/23. A third package was open and unsealed, containing six hardboiled eggs with the same use-by date of 08/29/23. The Dietary Supervisor verbalized the hardboiled eggs should have been used or thrown away by 08/29/23 because they could have made residents sick if consumed after the use-by date. The Dietary Supervisor explained the opened package of six hard boiled eggs should have been transferred to a different container for storage and labeled. On 09/25/23 at 10:24 AM, in the dry food storage room there was a bag of Cheetos, opened and spilling from the bag. On 09/25/23 at 10:29 AM, the Dietary Supervisor confirmed the bag of opened Cheetos should have been thrown away and the loose Cheetos could have brought in rodents. The facility policy titled Food Labeling and Dating, last revised 12/2017, documented the date on the label was the date it should be discarded. The facility policy titled Food Storage, last revised 12/2017, documented all leaking and broken containers of food were to be destroyed. Portion Sizes On 09/26/23 at 11:40 AM, during lunch tray line observation, the following serving utensils were used: -black slotted for spoon green beans -black spoon for roasted potatoes -blue scoop for mechanical soft pork loin -blue scoop for pureed pork loin -green scoop for whipped potatoes On 09/26/23 at 11:57 AM, the signage on the wall indicated the scoop sizes for the colored scoops as follows: -blue scoop two ounces or a quarter cup -green scoop 2 2/3 ounces or one third cup The signage did not indicate serving sizes of the black spoon and black slotted spoon. On 09/26/23 at 11:58 AM, the [NAME] explained the facility was using the Week One Menu. The [NAME] confirmed the menu indicated the following serving sizes: -whipped potatoes half a cup -pureed pork loin three ounces -mechanical soft pork loin three ounces The [NAME] confirmed the following: -Whipped potatoes were served with one third cup serving scoop and not served the full portion of half a cup. -Pureed pork loin was served with a two ounce scoop and not served the full portion of three ounces. -Mechanical soft pork loin was served with a two ounce scoop and not served the full portion of three ounces. On 09/26/23 at 12:14 PM, the [NAME] zeroed the scale and measured the weight capacity of the slotted spoon and regular spoon. Each spoon's capacity weighed three ounces. The [NAME] confirmed the residents were shorted one ounce of roasted potatoes and one ounce of green beans during lunch. Week One Menu documented the following serving sizes: -green beans: half a cup (four ounces) -roasted potatoes: half a cup (four ounces) -pork loin for all textures: three ounces -whipped potatoes: half a cup (four ounces)