Based on observation, medical record and staff interview the facility failed to ensure assessments were completed to determine if a device being utilized limited a resident's freedom of activity or movement indicating the use of a physical restraint. This affected one (Resident #89) of one residents reviewed for possible restraint use. The facility identified no residents currently utilizing restraint devices. The facility census was 39. Findings include: Review of Resident #89's medical record revealed an admission date of 02/20/25 with diagnoses that included vascular dementia, hypertension, hyperlipidemia and benign prostate hypertrophy. Review of the resident's progress notes dated 02/22/25 revealed the resident utilized a tilt-in-space wheelchair. Review of Resident #89's assessments revealed no evidence of any assessment completed to determine if the tilt-in-space wheelchair was a restraining device or an enabling device for resident comfort. Observation of Resident #89 on 03/03/25 at 9:30 A.M. revealed the resident was seated in a reclined tilt-in-space wheelchair (wheelchair which the seating surface and seat back can be reclined) in his room. Additional observation on 03/05/25 at 11:50 A.M. revealed the resident was seated in a reclined tilt-in-space wheelchair in his room. On 03/04/25 at 10:30 A.M. interview with the Director of Nursing verified the facility had not completed an assessment to determine if the tilt-in-space wheelchair was a restraint and prevented the resident's freedom of activity or movement or if the wheel chair was an enabling device.

Based on observation, interview, and medical record review the facility failed to ensure Resident #32's physician orders related to wrapping his bilateral legs and feet were followed. This affected one (Resident #32) of one residents reviewed for edema. The facility census was 39. Findings include: Review of the medical record for Resident #32 revealed an admission date of 11/09/24. Diagnoses include congestive heart failure (CHF), unspecified atrial fibrillation, and fluid overload. Review of Resident #32's Minimum Data Set Assessment revealed the resident had intact cognition. Review of Resident #32's care plan dated 02/19/25 revealed the resident has a fluid overload or potential fluid volume overload related to CHF and edema. Interventions included ace wraps to bilateral lover extremities to be put on in the morning and off at night. Review of the nursing progress note dated 02/18/25 Registered Nurse #150 documented the wound Certified Nurse Practitioner noted two plus edema to (the resident's) bilateral lower extremities. A new order for ace wraps to the bilateral lower extremities to be put on in the A.M. and off at night. Review of Resident #32's current physician orders revealed an order dated 02/18/25 to apply ace wraps to bilateral lower extremities on in the A.M., take off in the P.M., and wrap from toes to knees. The order had instructions to complete this every day shift. Observation on 03/03/25 at 10:51 A.M. revealed Resident #32 was seated in his wheelchair. His feet were resting on the floor and his legs and feet were noted to be moderately swollen. Observation on 03/04/25 at 2:11 P.M. revealed Resident #32 was seated in his wheelchair with his feet resting on the floor. His legs and feet were noted to be moderately swollen. Interview on 03/04/25 at 2:11 P.M. with Family Member #151 reported the facility frequently forgot to wrap the resident's legs and feet. Family Member #151 reported that at the resident's most recent care conference, the facility stated if he is not in bed, his legs and feet should be wrapped. She stated that lately the facility had not been following this order. Review of Resident #32's March 2025 Treat Administration Record revealed Registered Nurse (RN) #138 signed off that Resident #32's ace wraps were in place on 03/03/25 and 03/04/25. Interview on 03/04/25 at 2:13 P.M. RN #138 verified she signed off that Resident #138 ace wraps were applied to his bilateral lower extremities but confirmed they were not in place on 03/03/25 or 03/04/25. She stated she would have one of the Certified Nursing Assistants apply them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review and policy review the facility failed to ensure Resident #3 received adequate monitoring for side effects related to the use of anticoagulant medication. This affected one (Resident #3) of five residents reviewed for medication monitoring. The facility census was 39. Findings include: Review of the medical record for Resident #3 revealed an admission date of 10/06/2024. Diagnoses included combined systolic and diastolic heart failure, paroxysmal atrial fibrillation, hypertensive heart and chronic kidney disease with heart failure, and intracardiac thrombosis. Review of Resident #3's physician orders revealed orders for apixaban (anticoagulant or blood thinning medication) 5 milligrams (mg) by mouth two times a day for atrial fibrillation, Aspirin (blood thinning medication) 81 mg by mouth one time a day related to atrial fibrillation, and clopidogrel disulfate (antiplatelet) 75 mg by mouth one time a day for atrial fibrillation. Review of Resident #3's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 had intact cognition and received anticoagulant medication (a medication that slows down or prevents blood clotting). Review of Resident #3's 01/20/25 plan of care revealed the resident is on anticoagulant therapy related to atrial fibrillation. Interventions included to administer anticoagulant (medication) per physician order, daily skin inspection and report abnormalities to the nurse, and observe/assess/document/report as needed adverse reactions of anticoagulant therapy including blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising , blurred vision, shortness of breath. Observation on 03/03/25 at 9:11 A.M. revealed Resident #3 had notable bruising on her left hand spreading across three fingers. A moderate size bruise to her right hand spreading across two fingers and another bruise proximal to her thumb. An interview with Resident #3 at the time of the observation revealed the resident reported that she was on blood thinning medication which caused her to bruise easily. She stated that she probably hit her hands against something causing the bruising. Review of Resident #3's nursing progress notes from 02/15/25 through 03/05/25 revealed no evidence of bruising to Resident #3's bilateral hands or fingers was noted. Interview on 03/05/25 at 10:01 A.M. with the Director of Nursing (DON) revealed that if a resident's care plan stated to monitor a resident's skin daily and any issues, including bruising, should be documented in the nursing progress notes. Interview on 03/05/25 at 10:22 A.M. with the DON verified the facility did not complete daily anticoagulant monitoring or assess and monitor the bruising to Resident #3's bilateral hands and fingers. Review of the facility policy, Anticoagulant Policy and Procedure dated 10/2024 revealed residents on anticoagulant therapy will be monitored for signs and symptoms of bleeding and or new or excessive bruising. A physician or Certified Nurse Practitioner will be notified of any signs and symptoms of bleeding and or new excessive bruising.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, review of the facility's Self-Reported Incidents (SRI), and policy review the facility failed to investigate and report an injury of unknown origin to the state agency. This affected one resident (#5) out of one resident reviewed for abuse. The facility census was 39. Findings include: Observation on 06/20/23 at 11:53 A.M. revealed Resident #5 was noted to have a quarter size purple bruise with slight edema directly under her left eye. Interview at this time with Resident #5 revealed she was unsure of what happened to her eye. Review of the facility's SRIs revealed the last reported SRI was reported to the state agency on 03/27/18. Review of Resident #5's medical record revealed an admission date of 12/08/22. Diagnoses included dementia with behavioral disturbance, age related cognitive decline, hallucinations, anxiety disorder, and muscle weakness. A complete review of the medical record revealed a skin assessment of the residents bruising was never documented into the medical record. Review of Resident #5's Quarterly Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #5 was moderately cognitively impaired. Review of Resident #5's nursing progress note dated 06/06/23 at 5:50 P.M. Licensed Practical Nurse (LPN) #247 charted, Resident #5 was sitting at dining room table with another resident and was asked how she got the black eye. Resident #5 responded she poked herself with a pencil. Later LPN #247 asked the resident what happened, and she responded she poked her eye with a razor blade. The resident also had a bruise on the top of her shoulder which was yellow in color, and her left forearm black in color. Review of Resident #5's Nursing progress note, entered as a late entry, the note was created by the Director of Nursing (DON) on 06/20/23 at 11:28 A.M. and noted to be effective on 06/07/23 at 11:26 A.M. stated this was the investigation of bruise to the residents left eye. The note continued to state a nurse observed a bruise under Resident #5's left eye and a fading bruise on her shoulder. The resident was alert and oriented to person only and was unable to recall any incidents that resulted in the injuries. She was overheard by staff one day telling another staff member that she poked herself with a pencil, but then told the nurse that she poked herself with a razor. Staff were interviewed and all stated the only thing they can think of would be her recent falls. The resident does have confusion and hallucinations and has had a steady decline. She does sit in her room a lot per her choice. Spoke to the resident's son who agreed these injuries were more than likely a result of her recent falls. He also stated she may have gotten the bruise from her glasses as he noted that she is constantly messing with her glasses when he was visiting with her. The resident denied pain to the areas, and they appear to be healing. The Medical Director is aware and gave no new orders other than to notify if the area worsens. Interview on 06/21/23 at 9:35 A.M. the DON revealed on 06/07/23 she initiated an investigation into Resident #5's left eye bruising. She stated she interviewed two State Tested Nurses Assistants (STNAs) (STNA #207 and STNA #211) and one nurse (LPN #247) but did not document these interviews. After the three interviews it was assumed that the resident received the bruising during her recent falls. She also stated she spoke to the resident's son, and he stated it was hard to tell what could have happened and she was always fighting with her glasses. She stated a skin assessment was not completed on the bruising to the resident's eye or shoulder. She went on to say she did not interview any other staff or residents in the facility regarding the bruising. She stated the Abuse policy was not retrained due to the facility staff just receiving education in April 2023. She confirmed at this time a full investigation was not done into Resident #5's bruising and stated she did not report the bruising to the state agency because she did not believe it was a result of abuse. Interview on 06/21/23 at 2:15 P.M. the Administrator confirmed the facility did not complete a full and timely investigation into Resident #5's bruising. She stated she did not feel like the injury needed to be reported to the state injury because it was not in a suspicious location. Review of the facility policy, Resident Abuse Policy, dated 10/21/22, revealed injuries of unknown source is defined by when all the following criteria are met: The source of the injury was not observed by any person and the source of the injury could not be explained by the resident: And the injury is suspicious because of the extent of the injury or the location if the injury or the number of injuries observed at one particular point in time or the incidence of injuries over time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure Minimum Data Set (MDS) 3.0 assessments were accurate for Resident #22 and Resident #23. This affected two residents (#22 and #23) of 16 residents whose MDS assessments were reviewed. Findings include: 1. Record review revealed Resident #23 was admitted to the facility on [DATE] with diagnoses including impacted cerumen bilateral ears, atrial fibrillation, left hip artificial joint replacement, Parkinson's disease and dizziness. Review of Resident #23's optical visit summary, dated 03/16/21 revealed the resident had pseudophakia in both eyes, virtual in the right eye and refractive error. The resident was ordered new glasses. Review of Resident #23's quarterly MDS 3.0 assessment, dated 06/01/21 revealed the resident had adequate vision without glasses and adequate hearing without hearing aids. The MDS revealed the resident had received an anticoagulant medication for seven days during the assessment reference period. Review of Resident #23's medication orders and administration records, dated 05/01/21 to 06/01/21 revealed no evidence the resident received an anticoagulant during this time period. On 07/06/21 at 11:08 A.M. Resident #23 was observed wearing glasses. At the time of the observation, interview with the resident revealed he had double vision in his right eye. The resident revealed he had been waiting for five months for new glasses. During the interview the resident also reported he had hearing deficit and had hearing aids, but they were at home. The resident reported his ears were currently plugged. Review of Resident #23's plan of care revealed no evidence of a vision or hearing impairment/deficit plan of care. On 07/08/21 at 12:53 A.M. interview with MDS Coordinator, Registered Nurse (RN) #12 verified Resident #23's quarterly MDS 3.0 assessment, dated 06/01/21 was inaccurate related to vision and hearing. The MDS Coordinator reported she usually talks to the residents; however, she did not ask him if he had any hearing or vision impairments/deficits when this assessment had been completed. MDS Coordinator RN #12 revealed she relied on the staff to report issues/concerns. She stated she spoke to the resident today and he confirmed he had vision and hearing impairments which required assistive devices. On 07/13/21 at 3:40 P.M. interview with MDS Coordinator RN #12 verified the MDS 3.0 assessment was also inaccurate related to anticoagulant medication use as the resident had not received an anticoagulant during the seven day look back period. 2. Review of Resident #22's medical record revealed an admission date of 06/22/19 with diagnoses including dementia, congestive heart failure and urine retention. Review of the physician's orders, dated 06/22/20 revealed an order for an indwelling urinary catheter to aide in the healing of a pressure ulcer to the resident's sacrum (tailbone). The order indicated to change the catheter as needed. Review of the annual MDS 3.0 assessment, dated 05/30/21 revealed the resident had severe cognitive impairment. The resident required extensive assistance of two staff members with bed mobility, dressing and toilet use. The assessment revealed the resident had an indwelling catheter and was always incontinent of bladder. On 07/13/21 at 3:45 P.M. interview with MDS Coordinator RN #12 verified the MDS assessment was incorrect as the resident had an indwelling urinary catheter and was not incontinent of bladder.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and policy review the facility failed to ensure restorative services were provided per resident plan of care. This affected three residents (#19, #23 and #135) of four residents reviewed for restorative therapy. Findings include: 1. Medical record review revealed Resident #23 was admitted to the facility on [DATE] with the diagnoses included Parkinson diseases, aftercare following joint replacement, osteoarthritis, low back pain, muscle weakness, tremors, and dislocated internal left hip prosthesis. Review of Resident #23's plan of care dated 04/07/21 revealed the resident had limited physical mobility related to Parkinson's. Interventions included two nursing rehab/restorative programs. The first program was active range of motion six to seven times a week for at least 15 minutes a session. The second programs were a walking program six to seven times a week for at least 15 minutes a session. Review of Resident #23's restorative documentation dated 06/10/21 to 07/10/21 revealed the resident only received active range of motion 15 times and walking nine times in the past 30 days. Review of Resident #23's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 06/01/21 revealed the resident did not receive restorative during the seven day look back period. On 07/13/21 at 12:09 P.M. interview with the Director of Nursing (DON) and Administrator confirmed Resident #23 was not provided restorative therapy per the resident's plan of care. On 07/13/21 at 1:10 P.M. interview with Resident #23 confirmed he had not been receiving restorative therapy. The resident reported staff were not ambulating him and now he requires two staff to assist him with transfers. The resident's daughter was present during the interview and was unaware her father was receiving restorative therapy. On 07/13/21 at 3:40 P.M. interview with MDS Coordinator #12 revealed Resident #23's MDS was accurate and the resident did not receive restorative during the seven day look back period due to not having available staffing to provide the service. On 07/13/21 at 3:42 P.M. interview with the Administrator revealed restorative services were not completed for Resident #23 due to a staffing issue during the resident's MDS seven day look back period. The Administrator revealed the facility doesn't have a restorative aide. 2. Medical record review revealed Resident #135 was admitted to the facility on [DATE] with diagnoses including osteoarthritis, contusion of right knee, abnormalities of gait and mobility, unsteadiness of feet, muscle weakness and difficulty walking. Review of Resident #135's plan of care dated 06/14/21 revealed the resident had limited physical mobility related to osteoarthritis. The resident's interventions included two rehab/restorative programs. The first program was active range of motion six to seven times a week for at least 15 minutes a session. The second programs were a walking program six to seven times a week for at least 15 minutes a session. Review of Resident #135's restorative documentation dated 06/14/21 to 07/14/21 revealed the resident only received active range of motion nine times and walking seven times in the past 30 days. On 07/13/21 at 12:09 P.M. interview with the DON and Administrator confirmed Resident #135 was not provided restorative therapy per the resident's plan of care. The facility currently did not have a restorative aide due to the restorative aide resigning at the end of June or first of July 2021. The Administrator reported it was the floor staff responsibility to ensure the restorative programs were completed, however not all the floor staff had been provided education on the restorative programs. The floor staff had access to the programs under their task documentation and the plan of care in the electronic medical records. On 07/13/21 at 12:19 P.M. interview with Resident #135 revealed he was not receiving and had not received restorative therapy including active range of motion or walking. 3. Review of Resident #19's medical record revealed an admission date of 01/20/17 with diagnoses including depression, anxiety, chronic obstructive pulmonary disease and atherosclerotic heart disease (ASHD). Review of the physician's orders revealed an order, dated 08/09/19 for Hospice services for ASHD. Review of the quarterly MDS 3.0 assessment, dated 05/20/21 revealed the resident had moderate cognitive impairment for daily decision making and required extensive assistance of two staff members with dressing and toilet use. The resident was dependent of two staff members with transfers and required extensive assistance of one staff member with personal hygiene. Further review revealed the resident had impairment in mobility on one side of the lower extremities and received restorative services four out of seven days during the assessment period. Review of the current limited physical mobility related to weakness and dementia plan of care (implemented 01/23/17 and revised 10/14/20) revealed interventions including to offer active (resident performs activity) range of motion (ROM) six to seven times a week for at least 15 minutes a session with the goal of the resident to perform ten repetitions for at least 15 minutes for three sets to all extremities. Review of the ROM documentation from 06/20/21 through 07/10/21 revealed the program was provided four times during the week of 06/20/21 through 06/26/21 (06/21/21, 06/24/21, 06/25/21 and 06/26/21); the program was provided one time during the week of 06/27/21 through 07/03/21 (06/29/21) and the program was provided three times during the week of 07/04/21 through 07/10/21 (07/05/21, 07/06/21 and 07/10/21). On 07/08/21 interview with a staff member who requested to remain anonymous revealed the facility did not have any restorative aides and residents were not receiving restorative programs as written. The staff member revealed programs were to documented when they were provided, however the staff on the floor were unable to provide resident care and the restorative programs due to a lack of staff. On 07/13/21 at 12:09 P.M. interview with the Director of Nursing (DON) and Administrator confirmed Resident #19 was not provided restorative therapy per the resident's plan of care. The facility currently did not have a restorative aide due to the restorative aide resigning at the end of June or first of July 2021. The Administrator reported it was the floor staff responsibility to ensure the restorative programs were completed, however not all the floor staff had been provided education on the restorative programs. The floor staff had access to the programs under their task documentation and the plan of care in the electronic medical records. Review of Restorative Service policy dated 06/07/20 revealed the consulting physical therapist would evaluate the resident in areas which affect the individual's activity of daily living. Should training programs for skill development be indicated, the program would be instituted under the guidance of the physical therapist.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure timely identification of a condition change for Resident #87 following a hospitalization for heart failure and kidney disease. This affected one resident (#87) of one resident reviewed for edema. Findings include: Review of Resident #87's medical record revealed an admission date of 03/27/21 with diagnoses including diabetes, muscle weakness, dementia without behavioral disturbance, Alzheimer's disease and hypertension. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/07/21 revealed the resident was cognitively intact and required extensive assistance of two staff members with bed mobility, transfers and toilet use. The resident required extensive assistance of one staff member with locomotion, dressing and personal hygiene. The resident was also frequently incontinent of bladder and occasionally incontinent of bowel. The resident did not have a diagnosis of heart failure but had a diagnosis of renal (kidney) insufficiency/failure and hypertension. Further review of the medical record revealed the resident was hospitalized from [DATE] through 06/24/21 for heart failure and severe kidney disease. The resident returned to the facility with orders for Bumex (a diuretic medication) two milligrams twice a day for congestive heart failure. Review of the physician's orders revealed an order, dated 06/28/21 to monitor for signs and symptoms of swelling to the extremities and notify the physician if indicated, monitor for signs and symptoms of breathing difficulties (shortness of breath or jugular vein distention (measuring distended neck veins for increased pressure in the heart)) and notify the physician if indicated. An order, dated 06/29/21 was also noted for daily weights and to notify the physician of a weight gain greater than two pounds in one day or five pounds in a week. Review of the acute or chronic congestive heart failure plan of care, initiated 06/28/21 revealed interventions including check breath sounds and monitor/document for labored breathing; follow congestive heart failure (CHF) protocol; give cardiac medications as ordered; monitor/document/report as needed any signs or symptoms of CHF including dependent edema of legs and feet, shortness of breath upon exertion, distended neck veins, weight gain unrelated to intake; daily weight monitoring. Further review of the physician's orders revealed an order, dated 07/05/21 for oxygen two to four liters per minute via nasal cannula as needed for shortness of breath and to keep pulse ox (oxygen level) greater than 90%. Review of the resident weights revealed the following: On 07/05/21 the resident weighed 201.2 pounds and on 07/06/21 the resident weighed 207.6 pounds. The weight on 07/06/21 was documented by Registered Nurse (RN) #54 on 07/06/21 at 2:44 P.M. Review of the progress note, dated 07/05/21 at 10:28 P.M. revealed Licensed Practical Nurse (LPN) #77 entered Resident #87's room for bedtime medications. The resident was resting in bed with her eyes closed. The resident showed no signs or symptoms of distress however the pulse oximetry was placed on the resident's finger to obtain the resident's pulse reading for medications and her oxygen saturation was 80% on room air (normal is greater than 92%). The resident denied feeling short of breath at that time but oxygen was placed at two liters per minute via nasal cannula due to the resident's low oxygen level. The resident had generalized edema (swelling) and increased tremors were noted. The resident's blood pressure was 109/57 (normal 120/60) and the resident's heart rate was 67. After the resident was placed on oxygen, her oxygen saturation was 95% on the oxygen. On 07/06/21 at 11:15 A.M. Resident #87 was observed in her room, seated in a wheelchair with her legs elevated on a pillow on her wheelchair legs/pedals. The resident had oxygen at two liters per minute via nasal cannula in place. The resident's hands and feet/legs were observed to be edematous and the resident complained of her extremities feeling tight. The resident complained of not feeling well and when asked by the surveyor if her concerns were reported to the staff the resident stated yes but they aren't doing anything about it. The resident had her call pendant in reach and said she would ring for assistance if needed. Review of the progress notes revealed the next entry was dated 07/06/21 at 12:54 P.M. by RN #51 indicating transportation was arranged for a medical appointment dated 07/12/21. On 07/06/21 at 3:37 P.M. a follow up observation and interview with Resident #87 revealed the resident continued with her hands and legs feeling tight and the resident had shortness of breath requiring her to recently start using oxygen. The resident was observed to be touching her oxygen tubing, putting it in and out of her nose and the resident's cannula prong was currently out of her right nostril. The resident also complained of lower back pain and the surveyor asked the resident if she wanted her complaints of pain to be reported to the staff she replied yes. RN #49 was updated on the resident's complaint of pain upon completion of the resident's interview. Review of the progress note, dated 07/06/21 at 6:34 P.M. revealed the resident was reported to have a 6.4 pound weight gain overnight. The resident continued to wear her oxygen at two liters per minute via nasal cannula with increased shortness of breath on this date. The resident's lung sounds were diminished (which could be indicative of air or fluid in or around the lungs from pneumonia or heart failure) on auscultation. The resident was sitting in the dining room with her oxygen cannula out of her nose and her oxygen saturation/levels were 78-80%. The resident's oxygen was increased to four liter per minute via nasal cannula and her oxygen level increased to 90%. The resident's nail beds were cyanotic (blue, indicating poor blood circulation) and her hands were cool to touch. The resident had increased generalized edema. At this time, the nurse notified Certified Nurse Practitioner (CNP) #79 and orders were received to transfer the resident to the hospital due to weight gain and hypoxia (low oxygen level). Further review of the progress note, dated 07/06/21 at 10:27 P.M. revealed the resident was admitted to the hospital. No admitting diagnosis was listed. On 07/08/21 at 1:45 P.M. interview with State Tested Nursing Assistant (STNA) #63 revealed she was the bath aide on 07/06/21 and was responsible for weights that day. The STNA revealed Resident #87 was a daily weight and she weighed the resident either before breakfast or before lunch, noting the almost seven pound weight gain. The STNA revealed the nurses write the weights down on a piece of paper that were to be completed that day and once the weights were completed, the paper was placed at the nurse's station for the nurse to review. On 07/08/21 at 4:45 P.M. interview with Licensed Practical Nurse (LPN) #77 verified she notified the resident's nurse practitioner of the resident's weight gain on 07/06/21 when she noted the weights listed at the nurse's station. The LPN revealed the afternoon shift charge nurse does a daily physician update between 4:00 to 5:00 P.M. regarding any resident changes. The LPN verified the resident had a 6.4 pound weight gain and staff were to notify the physician of three pounds overnight and five pounds in a week. Further interview revealed in addition to the weight gain, Resident #87 had a low oxygen level and required oxygen. The resident's nail beds were cyanotic and her lung sounds were diminished. The resident was also edematous. On 07/08/21 at 5:32 P.M. interview with CNP #79 revealed he was not notified of the resident's weight gain until 6:30 P.M. on 07/06/21 and the notification should have been earlier in the day given the resident requiring oxygen, edema and weight gain which were all symptoms of CHF. On 07/08/21 at 5:42 P.M. interview with RN #51 revealed the resident did have a significant weight gain of almost seven pounds overnight and she was aware RN #54 entered the weights into the electronic health record. RN #51 verified she did not notify the resident's nurse practitioner or physician of the weight gain because there was no change in the resident's condition, however the nurse did not complete an assessment at the time the weight gain was identified. The RN stated she assessed the resident's pulse and oxygen saturation level earlier in the day, however this assessment was not documented. The nurse denied knowledge of the resident stating she was not feeling well this date. On 07/13/21 at 3:08 P.M. interview with the Director of Nursing (DON) verified the facility did not timely identify a change in Resident #87's condition at the time the resident's weight gain was identified. Further interview verified RN #51 should have completed an assessment of the resident once the weight gain was identified and the resident's physician or CNP should have been notified for further direction. The DON verified the resident was admitted to the hospital after an assessment was completed on 07/06/21.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure Resident #23 received eyeglasses timely. This affected one resident (#23) of two residents reviewed for vision. Findings include: Record review revealed Resident #23 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease and dizziness. Review of Resident #23's optical visit summary dated 03/16/21 revealed the resident had pseudophakia in both eyes, virtual in the right eye and refractive error. The resident was ordered new glasses. Review of Resident #23's current plan of care revealed no evidence of vision care plan. Review of Resident #23's quarterly Minimum Data Set (MDS) 3.0 assessment, 06/01/21 revealed the resident had adequate vision without glasses. On 07/06/21 at 11:08 A.M. Resident #23 was observed wearing glasses. At the time of the observation, interview with Resident #23 revealed the resident reported he had double vision in his right eye and had been waiting five months for new glasses but still had not received them. The resident reported he had seen the facility's eye doctor and the eye doctor had repaired the nose pieces on his old glasses, but recommended ordering new ones. On 07/08/21 at 11:48 A.M. interview with the Director of Nursing (DON) confirmed the resident was seen by the eye doctor on 03/16/21 and there was a recommendation for new glasses. The facility called the eye doctor's office and they reported they had sent a bill to the family for the new glasses; however, it was never returned so they did not order the glasses. The DON reported the facility was unaware the eye doctor had sent a bill and the glasses were not ordered and they would follow up today with the son. On 07/08/21 at 12:53 A.M. interview with MDS Coordinator #12 verified Resident #23's quarterly MDS dated [DATE] was inaccurate for vision. The MDS Coordinator reported she usually talks to the residents when doing the assessment, however, she did not ask him if he had any vision impairments/deficits. She reported she relied on the staff to report issues/concerns. She spoke to the resident today and he confirmed he had vision impairment that required assistive devices. On 07/13/21 at 1:25 P.M. telephone interview with Resident #23's daughter and son revealed they had only received one bill for $50 for the repair of glasses, which they paid. The resident and family confirmed they did not receive a $200 bill for new glasses, or they would have paid it. The daughter reported her father had been asking were his new glasses were.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Medical record review revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including pressure ulcer, heart disease, kidney disease, weakness, hypothyroidism and leukemia. Review of Resident #10's plan of care, dated 04/05/21 and revised 04/21/21 revealed the resident had a Stage II (partial-thickness skin loss with exposed dermis) pressure ulcer on the right buttocks. On 04/21/21 a new intervention included gel cushion to wheelchair and recliner. Review of Resident #10's pressure ulcer skin assessment, dated 07/06/21 revealed the resident had a Stage II facility acquired pressure ulcer measuring two centimeters (cm) in length by 1 cm width with 0.1 cm depth on the right buttocks. The area had a scant amount of serous drainage and there was 90% epithelia tissue and 10% granulation. Preventive measures included gel cushion and pressure relieving mattress. On 07/06/21 random observations throughout the day revealed no evidence Resident #10 had a gel cushion in his wheelchair. The resident was observed sitting in his wheelchair during dining observations made on this date. On 07/08/21 8:59 A.M. observation of Resident #10 with the DON verified Resident #10 did not have any type of gel cushion in his wheelchair. At the time of the observation, interview with Resident #10 revealed staff do not place a gel cushion in his wheelchair, but he had one for his recliner. The resident reported it would be nice to have one in his wheelchair so it would be more comfortable. The DON confirmed the findings during the observation. Review of the facility Skin Care Protocol, revised 02/26/20 revealed to utilize pressure relieving device(s) in the bed and chair as indicated and turn and reposition immobile residents every two to three hours and as needed. Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure pressure ulcer interventions were provided as ordered/care planned. This affected two residents resident (#10 and #22) of two residents reviewed for pressure ulcers. Findings include: 1. Review of Resident #22's medical record revealed an admission date of 06/22/19 with diagnoses including dementia with behavior disturbance, congestive heart failure and skin picking disorder. Resident #22 had an inpatient psychiatric stay from 04/17/20 through 05/13/20. Upon return to the facility, the resident was assessed to have a Stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle) to the sacrum (tailbone). Review of the current physician's orders revealed an order to cleanse the wound to the sacrum and apply a thin layer of A&D ointment to the periwound and lightly pack the wound with calcium alginate and cover with a small foam dressing daily. Further review revealed pressure relieving interventions including a gel cushion to the resident's wheelchair, pressure relieving mattress and the resident was to only be up (out of bed) for meals. Review of the Pressure Ulcer Risk assessment dated [DATE] revealed the resident was identified as moderate risk for pressure ulcer development. Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 05/30/21 revealed the resident had severe cognitive impairment and required extensive assistance of two staff members with bed mobility, dressing and toilet use. The resident was dependent of two staff members with transfers and had one Stage IV pressure ulcer. Resident #22 was not interviewable. On 07/06/21 at 1:00 P.M. the resident was observed up in his specialty wheelchair for lunch. On 07/06/21 at 2:00 P.M. the resident was observed up in his specialty wheel chair and not eating lunch. On 07/06/21 at 2:30 P.M. interview with STNA #58 verified the resident was to only be up for meals and had not been assisted to bed timely following the lunch meal on this date. On 07/06/21 interview with an anonymous staff member revealed Resident #22 was not assisted to bed after lunch due to a lack of staff. The staff member indicated that due to the facility being short staffed the resident, who required a mechanical lift for transfers was not assisted back to bed timely. The staff member voiced concerns the facility doesn't always have adequate staffing levels to provide care to the residents as required. On 07/06/21 at 3:30 P.M. interview with STNA #64 and #69 verified Resident #22 had remained up in his specialized wheelchair when they began their shift at 3:00 P.M. and would remain in his chair until after the dinner meal was finished, roughly around 7:30 P.M. to 8:00 P.M. when it was time for bed. On 07/07/21 at 3:12 P.M. interview with STNA #64 verified Resident #22 had remained in his wheelchair from before the lunch meal on 07/06/21 until after dinner between 7:30 to 8:00 P.M. On 07/08/21 at 5:00 P.M. interview with the Director of Nursing verified Resident #22 was to be up in his wheelchair for meals only due to the Stage IV pressure ulcer to his sacrum. On 07/08/21 at 5:00 P.M. interview with the Director of Nursing (DON) verified Resident #22 was to be up in his wheelchair for meals only due to the Stage IV pressure ulcer to his sacrum. The DON verified pressure relieving interventions were not implemented as ordered or per the resident's plan of care on 07/06/21 based on the above observations and staff interviews. Review of the facility Skin Care Protocol, revised 02/26/20 revealed to utilize pressure relieving device(s) in the bed and chair as indicated and turn and reposition immobile residents every two to three hours and as needed.

Based on record review and interview the facility failed to ensure an indwelling urinary catheter order contained all required components and failed to ensure physician notification occurred related to changes in the size of catheter usage for Resident #22. This affected one resident (#22) of two residents reviewed for pressure ulcers. Findings include: Review of Resident #22's medical record revealed an admission date of 06/22/19 with diagnoses including dementia with behavior disturbance, congestive heart failure and skin picking disorder. Record review revealed Resident #22 had an inpatient psychiatric stay from 04/17/20 through 05/13/20. Upon return to the facility the resident was assessed to have a Stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle) to the sacrum (tailbone). Review of the current physician's orders revealed an order dated to cleanse the wound to the sacrum and apply a thin layer of A&D ointment to the periwound and lightly pack the wound with calcium alginate and cover with a small foam dressing daily. An order, dated 06/22/20 revealed indwelling urinary catheter to aide in wound healing. The order did not indicate the catheter or balloon size to be inserted but the orders did reflect catheter care every shift and orders to change the drainage bag every Sunday. Review of the current resident has a catheter related to skin breakdown plan of care (initiated 12/14/20) revealed interventions including to change the catheter per order. Review of the progress notes revealed the following catheter documentation: On 06/21/20 at 10:00 P.M. a #14 French catheter with 10 cubic centimeter (cc) fluid balloon inserted On 06/25/20 at 11:35 A.M. a #14 French catheter with 20 cc fluid balloon inserted. 07/21/20 at 3:50 A.M. a #14 French with 25 cc fluid inserted into the balloon 08/05/20 at 2:36 P.M. a #14 French with 15 cc fluid inserted into the balloon 10/07/20 at 3:11 P.M. an #18 French with 15 cc fluid inserted into the balloon 11/05/20 at 4:45 A.M. no catheter size was indicated but 25 cc of fluid was inserted into the balloon 11/05/20 at 1:55 P.M. a #16 French with 30 cc fluid balloon; 01/04/21 at 11:01 A.M. a #16 French with with 12 cc fluid inserted into the balloon 03/12/21 at 4:30 P.M. no catheter size was indicated but a 20 cc fluid balloon was used On 07/15/21 at 9:40 A.M. interview with Certified Nurse Practitioner (CNP) #79 revealed catheter orders needed to include the catheter size as well as the balloon size. Further interview revealed nurses should be contacting the practitioner when the resident required a larger catheter size in order to receive an order for a larger catheter size. Further interview verified the CNP was unaware the resident was requiring a larger catheter size and his expectation would be to receive notification when a resident required changes to their catheter including catheter size changes. On 07/15/21 at 11:37 A.M. interview with the Director of Nursing verified the resident's catheter order was not complete and the order should have included the catheter and balloon size to be initially used and for subsequent catheter changes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy review and interview the facility failed to ensure respiratory equipment was properly maintained to prevent the spread of infection and to meet the respiratory care needs of Resident #10, #16 and #135. This affected three residents (#10, #16 and #135) of four residents reviewed for respiratory services. Findings include: 1. Medical record review revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure with hypoxia, pneumonia, congestive heart failure, bronchiectasis, wheezing, emphysema and shortness of breath. Review of Resident #10's current physician's orders for July 2021 revealed the resident was ordered oxygen 3.5 liters per minute via nasal cannula or mask continuously. Review of Resident #10's plan of care for shortness of breath related to bronchiectasis revealed continuous oxygen at night and 3.5 liters via mask or nasal cannula. On 07/06/21 at 3:28 P.M. observation of Resident #10's oxygen equipment revealed the oxygen tubing was dated 05/16/21 and there was no water in the humidification bottle. The nasal cannula was discolored. On 07/08/21 at 10:45 A.M. observation with the Director of Nursing (DON) verified Resident #10's oxygen tubing was dated 05/16/21 and the humidification bottle was empty. The DON reported the tubing was to changed weekly and staff should place a pink sticker on the tubing with the date the tubing was changed. On 07/08/21 at 10:45 A.M. interview with Registered Nurse (RN) #50 revealed oxygen tubing should be changed weekly. The RN reported there was no place the staff document when the tubing was changed in the medical record. Review of the facility policy titled Oxygen Use and Storage Policy, dated 07/25/20 revealed the policy did not contain the frequency of maintenance of oxygen equipment. 2. Medical record review revealed Resident #135 was admitted to the facility on [DATE] with diagnoses including congestive heart failure, chronic obstructive pulmonary disease and sleep apnea. Review of Resident #135's current physician's orders, for July 2021 revealed the resident was ordered three liters of oxygen continuous via nasal cannula. Review of Resident #135's respiratory plan of care revealed oxygen three liters via nasal cannula continuous. On 07/07/21 at 12:19 P.M. observation of Resident #135's oxygen equipment revealed there was no date on the oxygen tubing and the humidification bottle was empty. On 07/08/21 at 9:07 A.M. observation and interview with RN #50 verified Resident #135's oxygen tubing was not dated and the humidification bottle was empty. Review of the facility policy titled Oxygen Use and Storage Policy, dated 07/25/20 revealed the policy did not contain the frequency of maintenance of oxygen equipment. 3. Review of Resident #16's medical record revealed an admission date of 05/07/21 with diagnoses including hypoxia (low oxygen levels) and paralysis of the diaphragm. Review of the admission physician's orders revealed an order for oxygen four liters per minute via nasal cannula. Review of the altered respiratory status related to paralysis of the diaphragm and allergies plan of care, initiated on 05/12/21 revealed interventions including oxygen via nasal cannula at four liters per minute. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 05/14/21 revealed the resident had intact cognition and required extensive staff assistance with activities of daily living and wore oxygen during the assessment period. On 07/06/21 at 11:30 A.M. Resident #16 was observed sitting in a chair in his room with his oxygen intact. The tubing was not dated. On 07/07/21 at 9:55 A.M. the resident was observed seated in a chair in his room wearing his oxygen. The tubing was not dated. On 0/08/21 at 9:04 A.M. observation and interview with the DON verified Resident #16's oxygen tubing was not dated. The DON reported staff were to place a pink sticker on the tubing with the date it was changed. Review of the facility policy titled Oxygen Use and Storage Policy, dated 07/25/20 revealed the policy did not contain the frequency of maintenance of oxygen equipment.

Based on record review and interview the facility failed to ensure antipsychotic medication was administered to Resident #87 with appropriate diagnosis for medication use. This affected one resident (#87) of five residents reviewed for unnecessary medication use. Findings include: Review of Resident #87's medical record revealed an admission date of 03/27/21 with diagnoses including diabetes, muscle weakness, dementia without behavioral disturbance, Alzheimer's disease, and hypertension. Review of the physician's orders revealed an order for the antipsychotic medication, Zyprexa five milligrams daily for three weeks to treat itching. The medication was ordered from 03/26/21 through 04/16/21. Further review of the physician's orders dated 04/21/21 revealed to resume Zyprexa five milligrams daily for itching. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/07/21 revealed the resident was cognitively intact and required extensive assistance of two staff members with bed mobility, transfers and toilet use. The resident required extensive assistance of one staff member with locomotion, dressing and personal hygiene. The resident was also frequently incontinent of bladder and occasionally incontinent of bowel. The resident received antipsychotic medication seven days during the assessment period. On 07/13/21 at 3:30 P.M. interview with the Administrator revealed the resident was receiving the antipsychotic medication, Zyprexa for itching (pruritis). Further interview verified Zyprexa was not approved to treat pruritis and was only approved in the treatment of certain psychiatric disorders. Review of information from Medispan, the facility's electronic health record medication resource, revealed Zyprexa was approved for the treatment of schizophrenia, bipolar disorder and some depression. The provided information had a copyright date of 2009.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy and procedure review and interview the facility failed to provide adequate assistance to prevent falls, failed to ensure falls were thoroughly investigated and/or failed to ensure fall interventions were in place per plan of care. This affected four residents (#1, #13, #23, and #28) of six residents reviewed for falls. Findings include: 1. Record review revealed Resident #23 was admitted to the facility on [DATE] with diagnoses including Parkinson's, left hip joint replacement, osteoarthritis, anxiety, dizziness, muscle weakness, left hip and right knee pain, hallucination, depression, weakness and dislocation of left hip prosthesis. Review of Resident #23's fall plan of care revealed the resident was high risk for falls and had fallen seven times. Interventions included staff to check every hour while in his room, staff to apply gripper socks every evening with night care, ensure the resident's call light was within reach and encourage the resident to use it for assistance and as needed. On 07/06/21 at 11:04 A.M. Resident #23 was observed in his room without access to his call (light) pendant. Interview with the resident at the time of the observation revealed he did not know where his call pendent was. The resident shared he had fractured his hip twice since he had been admitted to the facility. The surveyor observed a call pendent in the bathroom hanging from the towel rack. The surveyor pushed the call pendant button and a State Tested Nursing Assistant (STNA) responded. The STNA confirmed the resident's call pendant was not accessible to him as he did not have it on. The STNA revealed the pendant in the bathroom should have been placed around the resident's neck. On 07/08/21 at 10:59 A.M. interview with STNA #47 revealed she did not have access to the resident's [NAME]/plan of care in the electronic medical record. The STNA reported she would receive new fall interventions during morning report. The STNA left the conference room and returned shortly and reported she was just told there was a board in the next room that had a list of all residents' fall intervention. Observation of the board with the STNA revealed the board did not include Resident #23's fall intervention for checks every hour while in the resident's room or to apply gripper socks during night care per the plan of care. The STNA confirmed findings during observation. 2. Medical record review Resident #28 was admitted to the facility on [DATE] with diagnoses of systemic involvement of connective tissue, abnormalities of gait and mobility, glaucoma, and fracture of upper and lower end of the left fibula a lower end of left tibia. Review of Resident #28's nursing progress note, dated 10/22/20 revealed the nurse was called to the resident's room where she found the resident laying on the bathroom floor with two STNAs present. Staff stated the resident slipped out of the sit to stand lift and was lowered to the floor by the STNA. No injuries resulted from the fall. The note revealed the STNA's failed to strap the resident's legs into the sit to stand lift and the resident had slipped out of it. Following the incident staff were educated on the proper sit to stand protocols. Review of Resident #28's nursing progress notes, dated 06/21/21 and 06/22/21 revealed the STNA was walking the resident to the bathroom and the resident got her foot tripped up and she fell at the foot of the bed. Upon assessment, it was noted the resident had a corn or callus to the right second toe that broke open during the fall, a small skin tear to right elbow, and a small abrasion on right knee. The resident was assisted by two staff into a wheelchair, taken into the bathroom but the resident would not stand at the bar. The STNA staff used the sit to stand lift to toilet the resident. The resident returned to bed and the right toe and right elbow were assessed. Upon further investigation it was noted the resident did not have her ankle foot orthotics (AFO's) in her shoes. Following the incident, staff were educated on the importance of the AFO's and assisting the resident with devices. Staff reported the resident had refused to put shoes on to ambulate to the bathroom at night and preferred slipper socks due to urgency. Staff and the resident were educated on the importance of the AFO's and shoes for transfer due to drop foot. Resident #28 complained of left lower leg pain after the fall and an x-ray was completed which indicated the resident had fractured her tibia/fibula. The resident went to emergency room, returned with a splint and was to follow up with orthopedic care. On 07/13/21 at 12:20 P.M. interview with the Director of Nursing (DON) verified Resident #28's falls were caused by staff not ensuring correct fall interventions were in-place and not utilizing transfer equipment safely. The DON reported staff had not previously notified nursing regarding the resident's refusal to wear AFO's at night. The DON verified staff should not have attempted to walk the resident without AFO's and utilized other methods of transferring the resident. 3. Medical record review revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including cerebrovascular disease, dysuria, and hemiplegia and hemiparesis following cerebrovascular disease. Review of Resident #13's nursing progress note, dated 04/27/21 revealed the resident had fallen on his way back from the bathroom. The resident placed himself back in bed and then called for staff. The resident was noted to be in his bare feet and confirmed with staff he had walked to the bathroom bare footed. A new intervention was to place gripper socks on bilateral feet every night. Review of Resident #13's nursing progress note, dated 06/28/21 at 2:50 A.M. revealed Resident #13 was found on the floor in his bathroom. The resident had no socks or shoes on his feet. The new intervention was to educate staff regarding encouraging and assisting the resident with slipper socks at bedtime and staff to help with toileting between 2:00 and 2:30 A.M. On 07/13/21 at 12:25 P.M. interview with the DON revealed the investigation of Resident #13's falls lacked evidence regarding why the resident did not have socks on since it was a prior intervention on 04/27/21 to place gripper socks on bilateral feet every night. The DON verified staff should have placed gripper socks on the resident during nighttime care. 4. Review of Resident #1's medical record revealed an admission date of 12/17/20 with diagnoses including Parkinson's Disease, disorientation, dementia without behavioral disturbance and lack of coordination. Review of the high risk for fall related to history of falls, mobility and cognition plan of care initiated 12/18/20 revealed interventions including ensure call light was within reach and ensure the resident was wearing appropriate footwear. Review of a Fall Risk Assessment, dated 01/19/21 identified the resident was at high fall risk. Review of the physician's orders revealed no physician ordered fall interventions were in place. Review of the fall investigation progress notes revealed: On 01/30/21 staff were interviewed regarding a fall. The resident was heard yelling out for her daughter. The STNA entered the room and found the resident sitting upright on her buttocks in front of her recliner chair. The recliner chair was all the way reclined. The resident stated she was trying to get up to go to the bathroom. The resident's call pendant was around her neck but was not used. The resident was in her bare feet, the floor was clean and dry. The resident was assisted to her feet and taken to the bathroom and brought to the common area before dinner. The intervention implemented was for gripper socks to be worn at all times and staff to toilet the resident daily between 2:00 and 3:00 P.M. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 06/22/21 revealed the resident had severe cognitive impairment and required extensive assistance of two staff members with bed mobility, dressing, toilet use and transfers. The resident required extensive assistance of one staff member with locomotion and personal hygiene and was frequently incontinent of bowel and bladder. Further review revealed one fall occurred since the last assessment. Review of the fall investigation progress notes for a fall that occurred on 06/24/21 at 6:44 A.M. revealed interviews were completed. The resident was sitting on her knees next to her bed on the floor mat next to her bed. The resident was wearing a soiled brief she had removed and was on her bed. The resident's call pendant was not in reach. The resident was not wearing pants, incontinence brief, shoes or socks at the time of the fall. The resident denied hitting her head. The floor was clean and dry. Upon assisting the resident off the floor she complained of pain to her left lower extremity. Upon assessment, her left ankle was noted to be red, edematous and warm to touch. Toes on her left foot noted to be smashed An x-ray was obtained and revealed a fracture of her left little toe. The resident was assisted back to bed with the left lower extremity elevated. The intervention implemented was to ensure the resident's call light was within reach when the resident was in bed and offer and assist to toilet the resident between 5:00 A.M. to 5:30 A.M. On 07/13/21 at 3:40 P.M. interview with the Director of Nursing verified call lights/pendants were to be within reach of all residents at all times. The DON also verified the fall investigations completed for Resident #1 were not comprehensive as the rationale for why the resident's recliner was reclined and why she was not wearing gripper socks or appropriate footwear during the falls was not addressed or identified and these were previously identified interventions required for the resident. Review of the Fall Management Policy, dated 09/01/19 revealed fall interventions would be posted on the [NAME]/plan of care. The rehab nurse would investigate the fall, review details of the fall and document in the resident's chart in the fall investigation note. Further review of policy revealed prevention/intervention included to review the [NAME]/plan of care, promote proper footwear, make sure resident had proper footwear on (shoes/gripper socks), notify rehab nurse if intervention were ineffective, encourage resident to use ambulatory devices if indicated and use proper transfer methods as indicated for each resident.

Based on observation, facility policy and procedure review and interview the facility failed to ensure food was stored and served in a manner to prevent contamination. This had the potential to affect 24 residents (#1, #2, #3, #5, #6, #8, #9, #10, #11, #13, #15, #17, #18, #19, #21, #23, #24, #27, #29, #30, #31, #32, #33 and #87) of 24 residents eating in the dining room. The facility census was 36. Findings include: 1. On 07/06/21 at 12:06 P.M. observation of the dinette lunch tray line revealed Dietary Aide (DA) #23 reached into the cooler and a four ounce carton of chocolate milk fell onto the dinette floor. DA #23's left foot touched the carton of chocolate milk. DA #23 picked up the carton of chocolate milk and placed it back on the tray in the reach in cooler. On 07/06/21 at 12:10 P.M. interview with Director of Dietary (DOD) #11 verified once an item touched the floor, the item was to be disposed in the trash. On 07/06/21 at 12:30 P.M. interview with DA #23 verified the chocolate milk container fell on the floor and she placed it back into the reach in cooler but had since removed the chocolate milk from the cooler when she was instructed to do so by DOD #11. 2. On 07/06/21 at 12:24 P.M. DA #23 and [NAME] #35 were observed to plate the lunch meal which included pineapple teriyaki chicken, lo mein noodles and edemame. A two ounce and four ounce ladle with holes were observed in the lo mein noodles. During the observation, the entire two ounce ladle was observed to slide into the lo mein noodles. DA #23 used a pair of tongs to retrieve the two ounce ladle from the lo mein noodles and placed the ladle to her left side, off of the steam table. DA # 13 was then observed to plate the lunch meal for Resident #13 and placed it in the service window. State Tested Nursing Assistant (STNA) #58 was observed to obtain the plate and place it in front of Resident #13. Interview with DA #23 and [NAME] #35 immediately following the observation verified the ladle slid entirely into the lo mein noodles but they were unsure if they needed to get a new pan of low mein noodles from the kitchen. DOD #11 then intervened and informed the staff a new pan of low mein noodles would need to be obtained. Resident #13 had not started to eat his meal and STNA #58 removed the plate from the resident and explained he would get a new plate of food. The facility identified 24 residents, Resident #1, #2, #3, #5, #6, #8, #9, #10, #11, #13, #15, #17, #18, #19, #21, #23, #24, #27, #29, #30, #31, #32, #33 and #87 who ate in the dining room who could have been affected. Review of the Dietary Procedures for Infection Control Policy and Procedure, updated 06/19/19 revealed food stored was to be protected from contamination and growth of any pathogenic organisms. Perishable ingredients were refrigerated when they were not being used. During serving time food was to be protected from contamination and growth of any pathogenic organism.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Medical record review revealed Resident #23 was admitted to the facility on [DATE] with the diagnoses included Parkinson diseases, aftercare following joint replacement, osteoarthritis, low back pain, muscle weakness, tremors, and dislocated internal left hip prosthesis. Review of Resident #23's plan of care dated 04/07/21 revealed the resident had limited physical mobility related to Parkinson's. Interventions included two nursing rehab/restorative programs. The first program was active range of motion six to seven times a week for at least 15 minutes a session. The second programs were a walking program six to seven times a week for at least 15 minutes a session. Review of Resident #23's restorative documentation dated 06/10/21 to 07/10/21 revealed the resident only received active range of motion 15 times and walking nine times in the past 30 days. Review of Resident #23's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident did not receive restorative during the seven day look back period. On 07/13/21 at 12:09 P.M. interview with the Director of Nursing (DON) and Administrator confirmed Resident #23 was not provided restorative therapy per the resident's plan of care. On 07/13/21 at 1:10 P.M. interview with Resident #23 confirmed he had not been receiving restorative therapy. The resident reported staff were not ambulating him and now he requires two staff to assist him with transfers. The resident's daughter was present during the interview and was unaware her father was receiving restorative therapy. On 07/13/21 at 3:40 P.M. interview with MDS Coordinator #12 revealed Resident #23's MDS was accurate and the resident did not receive restorative during the seven day look back period due to not having available staffing to provide the service. On 07/13/21 at 3:42 P.M. interview with the Administrator revealed restorative services were not completed for Resident #23 due to a staffing issue during the resident's MDS seven day look back period. The Administrator revealed the facility doesn't have a restorative aide. 6. Medical record review revealed Resident #135 was admitted to the facility on [DATE] with diagnoses including osteoarthritis, contusion of right knee, abnormalities of gait and mobility, unsteadiness of feet, muscle weakness and difficulty walking. Review of Resident #135's plan of care dated 06/14/21 revealed the resident had limited physical mobility related to osteoarthritis. The resident's interventions included two rehab/restorative programs. The first program was active range of motion six to seven times a week for at least 15 minutes a session. The second programs were a walking program six to seven times a week for at least 15 minutes a session. Review of Resident #135's restorative documentation dated 06/14/21 to 07/14/21 revealed the resident only received active range of motion nine times and walking seven times in the past 30 days. On 07/13/21 at 12:09 P.M. interview with the DON and Administrator confirmed Resident #135 was not provided restorative therapy per the resident's plan of care. The facility currently did not have a restorative aide due to the restorative aide resigning at the end of June or first of July 2021. The Administrator reported it was the floor staff responsibility to ensure the restorative programs were completed, however not all the floor staff had been provided education on the restorative programs. The floor staff had access to the programs under their task documentation and the plan of care in the electronic medical records. On 07/13/21 at 12:19 P.M. interview with Resident #135 revealed he was not receiving and had not received restorative therapy including active range of motion or walking. The facility did not have a staffing policy to review during the annual recertification survey. Review of the Facility Assessment, dated 02/05/21 revealed staffing and resource needs reflect a mix of 12 and eight hour shifts, a higher staff presence in the morning hours for morning care and two meal services. A 9:30 A.M. to 5:30 P.M. restorative aide to assist with restorative programs and specialized dining programs. Three to five nurses a day to provide direct care services and eight to eleven STNAs a day. On 07/13/21 at 4:00 P.M. interview with the DON verified the facility had staffing concerns as noted based on the above identified concerns, but felt this had more to do with time management than a lack of staff. The DON revealed the facility recently had some new hires. The DON verified all residents were to receive care per their plans regardless of staff time management issues. Based on observation, record review and interview the facility failed to maintain sufficient levels of nursing staff to ensure fresh ice/water was provided timely to all residents, to ensure restorative nursing programs were provided as planned and to ensure residents were assisted to bed timely. This affected Resident #3, #7, #16, #17, #19, #21, #22, #23, #27, #28 and #135 and had the potential to affect all 36 residents residing in the facility. Findings include: 1. Review of a 07/31/20 Resident Council Questionnaire (summary) form, completed by Director of Activities #9 revealed resident concerns/suggestions including a concern from Resident #17 who indicated she does not receive ice on a regular basis if the restorative aides were not working. Review of the resident council follow-up, dated 08/21/20 revealed the State Tested Nursing Assistant (STNA) assigned to baths on day and afternoon shift would pass ice and the charge nurse would monitor. This was to be addressed by the Director of Nursing (DON). On 07/07/21 8:45 A.M. interview with Resident #7 revealed she never gets fresh ice or water. Observation at the time of the interview revealed no ice was noted in the resident's pitcher. The resident attributed the lack of fresh ice water to a lack of facility staff to complete the task timely. On 07/07/21 at 10:35 A.M. Resident #7's water pitcher remained without ice or condensation on the pitcher. The pitcher was noted to be half full at this time. On 07/07/21 at 2:00 P.M. a Resident Group Meeting was held with Resident #3, #17, #21 and #28 present. During the meeting, Resident #17 revealed she does not receive fresh water or ice unless she requested it. She stated she activated her call light daily around 3:45 P.M. to 4:00 PM. for ice. If staff don't respond or tell her they will return, she goes to the kitchen herself for fresh ice. The resident stated it was not an issue for her to have to go to the kitchen to get her own fresh ice/water but worried about the residents who were unable to get their own water and ice. The three other residents present at the meeting verified getting fresh ice and water was a problem. The residents attributed the issue to a lack of staffing. On 07/07/21 at 3:11 P.M. Resident #19's water pitcher was half full and no ice or condensation was noted on the pitcher. On 07/07/21 at 3:12 P.M. interview with Resident #16 revealed he does not get fresh ice and water often and cannot recall the last time he received fresh ice and water. Observation at the time of the interview revealed the resident did not have fresh ice/water at this time. The resident attributed the lack of fresh ice water to a lack of facility staff to complete the task timely. On 07/08/21 at 10:30 A.M. Resident #16's water pitcher was observed to be a quarter full with no ice or condensation on the pitcher. Interview with Resident #16 at this time verified he had not received fresh ice/water. On 07/07/21 at 3:15 P.M. Resident #27's water pitcher was observed to be a quarter full and did not have ice or condensation on the outside of the water pitcher. On 07/08/21 at 10:45 A.M. Resident #17's water pitcher was observed to be empty. Interview with the resident revealed she had not received ice or water since she asked yesterday at 4:00 P.M. The resident revealed she worries about the residents who are unable to go to the kitchen and get ice and water when they want it. On 07/08/21 interview with a staff member who requested to remain anonymous revealed residents do not get ice and fresh water on their shift. The staff member revealed the restorative aide used to pass ice and water but since they don't currently have a restorative aide, whoever has time passes ice and water. The staff member verified residents reporting they are not routinely getting ice and fresh water would be accurate. On 07/08/21 interview with a staff member who requested to remain anonymous revealed the staff member was unsure when staff were to pass ice on the shifts but indicated it wasn't always completed. Further interview revealed it was difficult to provide residents with the care they needed when the facility didn't have enough staff. Further interview revealed the facility tried to have four aides on days and afternoons but the residents had a high level of needs and it wasn't always enough. On 07/08/21 interview with a staff member who requested to remain anonymous revealed ice and water were not passed on day shift due to the staff not having enough time to provide the ice and water. On 07/08/21 at 4:30 P.M. interview with the Director of Nursing (DON) revealed ice water was to be refreshed twice a day, once on day shift and once on afternoon shift. On 07/13/21 interview with a staff member who requested to remain anonymous revealed residents don't always receive fresh water and ice especially during the day. Further interview verified ice and water were to be passed two to three times a day and it is not provided to the residents consistently. The facility did not have a policy and procedure for providing fresh ice/water. 2. On 07/06/21 at 3:30 P.M. interview with STNA #64 revealed Resident #16 doesn't always get his baths on his preferred days but he does receive his baths at some point during the week. On 07/07/21 at 9:48 A.M. interview with Resident #16 revealed staff on afternoon shift often tell him they do not have adequate staffing levels for him to get his whirlpool on Wednesdays. The resident stated he does eventually receive the care at some point during the week but doesn't feel the facility has enough staff to provide care to the residents. 3. Review of Resident #22's medical record revealed an admission date of 06/22/19 with diagnoses including dementia with behavior disturbance, congestive heart failure and skin picking disorder. Further review of the medical record revealed the resident had an inpatient psychiatric stay from 04/17/20 through 05/13/20. Upon return to the facility, the resident had a Stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle) to the sacrum (tailbone). Review of the Pressure Ulcer Risk assessment dated [DATE] revealed the resident was identified as moderate risk for pressure ulcer development. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severe cognitive impairment and required extensive assistance of two staff members with bed mobility, dressing and toilet use. The resident was dependent of two staff members with transfers and had one Stage IV pressure ulcer. Resident #22 was not interviewable. Review of the current physician orders revealed an order, dated 06/21/21 the resident was to only be up (out of bed) for meals. On 07/06/21 at 1:00 P.M. the resident was observed up in his specialty wheelchair for lunch. On 07/06/21 at 2:00 P.M. the resident was observed up in his specialty wheel chair and not eating lunch. On 07/06/21 at 2:30 P.M. interview with STNA #58 verified the resident was to only be up for meals and had not been assisted to bed timely following the lunch meal on this date. On 07/06/21 interview with an anonymous staff member revealed Resident #22 was not assisted to bed after lunch due to a lack of staff. The staff member indicated that due to the facility being short staffed the resident, who required a mechanical lift for transfers was not assisted back to bed timely. The staff member voiced concerns the facility doesn't always have adequate staffing levels to provide care to the residents as required. On 07/06/21 at 3:30 P.M. interview with STNA #64 and #69 verified Resident #22 had remained up in his specialized wheelchair when they began their shift at 3:00 P.M. and would remain in his chair until after the dinner meal was finished, roughly around 7:30 P.M. to 8:00 P.M. when it was time for bed. On 07/07/21 at 3:12 P.M. interview with STNA #64 verified Resident #22 had remained in his wheelchair from before the lunch meal on 07/06/21 until after dinner between 7:30 to 8:00 P.M. On 07/08/21 at 5:00 P.M. interview with the Director of Nursing verified Resident #22 was to be up in his wheelchair for meals only due to the Stage IV pressure ulcer to his sacrum. 4. Review of Resident #19's medical record revealed an admission date of 01/20/17 with diagnoses including depression, anxiety, chronic obstructive pulmonary disease and atherosclerotic heart disease (ASHD). Review of the physician's orders revealed an order, dated 08/09/19 for Hospice services for ASHD. Review of the quarterly MDS 3.0 assessment, dated 05/20/21 revealed the resident had moderate cognitive impairment for daily decision making and required extensive assistance of two staff members with dressing and toilet use. The resident was dependent of two staff members with transfers and required extensive assistance of one staff member with personal hygiene. Further review revealed the resident had impairment in mobility on one side of the lower extremities and received restorative services four out of seven days during the assessment period. Review of the current limited physical mobility related to weakness and dementia plan of care (implemented 01/23/17 and revised 10/14/20) revealed interventions including to offer active (resident performs activity) range of motion (ROM) six to seven times a week for at least 15 minutes a session with the goal of the resident to perform ten repetitions for at least 15 minutes for three sets to all extremities. Review of the ROM documentation from 06/20/21 through 07/10/21 revealed the program was provided four times during the week of 06/20/21 through 06/26/21 (06/21/21, 06/24/21, 06/25/21 and 06/26/21); the program was provided one time during the week of 06/27/21 through 07/03/21 (06/29/21) and the program was provided three times during the week of 07/04/21 through 07/10/21 (07/05/21, 07/06/21 and 07/10/21). On 07/06/21 interview with a staff member who requested to remain anonymous revealed the facility did not have any restorative aides and residents were not receiving restorative programs as written. The staff member revealed programs were to documented when they were provided, however the staff on the floor were unable to provide resident care and the restorative programs due to a lack of staff. On 07/13/21 at 12:09 P.M. interview with the Director of Nursing (DON) and Administrator confirmed Resident #19 was not provided restorative therapy per the resident's plan of care. The facility currently did not have a restorative aide due to the restorative aide resigning at the end of June or first of July 2021. The Administrator reported it was the floor staff responsibility to ensure the restorative programs were completed, however not all the floor staff had been provided education on the restorative programs. The floor staff had access to the programs under their task documentation and the plan of care in the electronic medical records.

Based on observation, record review, facility policy review and interview the facility failed to ensure resident medication orders matched the medication administered and failed to ensure prescription and controlled medications were stored properly. This affected four residents (#7, #9, #19 and #29) and had the potential to affect all 36 residents residing in the facility. Findings include: 1. On 07/07/21 at 8:41 A.M. Registered Nurse (RN) #51 was observed administering medication to Resident #29. Record review revealed the resident was ordered Folic Acid 400 milligrams (mg) two tablets daily and Trazadone 25 mg one tablet. Observation revealed RN #51 administered one 800 mg tablet of Folic Acid and one 1/2 tablet of Trazadone 50 mg. Interview with RN #51 at the time of the observation verified the medication orders for Resident #29 did not match the actual medications she was observed to administer. On 07/07/21 at 11:00 A.M. interview with the Director of Nursing (DON) revealed she had the nurse call the pharmacy regarding the discrepancy in Resident #29's orders and medication being administered to ensure the medication orders matched what was given on the label. 2. On 07/07/21 at 8:45 A.M. RN #51 was observed administering medications to Resident #7. Upon entering the resident's room, there was a medication cup observed sitting on the resident's bedside table. There was one small pill and two larger pills in the cup. The RN confirmed the finding and reported the resident only received one scheduled medication (Meclizine for hypotension) three times daily by mouth, which was the smaller pill. The nurse reported the resident had an as needed order for Tylenol, however it had not been documented as being administered since 06/28/21. Review of Resident #7's physician orders and medication administration record, dated 07/2021 revealed the resident was ordered Meclizine 12.5 mg three times daily for hypotension and Tylenol 325 mg two tablets every four hours as needed for pain or fever. The Meclizine was signed off as being administered at 6:00 A.M. on 07/07/21. There was no evidence the resident received Tylenol the entire month. Further review of Resident #7's medical record revealed no evidence the resident had been assessed to self-administer medications. On 07/07/21 at 11:00 A.M. interview with the DON verified Resident #7 had not been assessed to self-administer medication and she removed the pills from the resident's room since the nurse could not verify what all the pills were. The DON confirmed the resident's Meclizine medication was supposed to be administered at 6:00 A.M. and it was 8:45 A.M., the resident still had not taken the 6:00 A.M. dose of Meclizine and her next dose was due at noon. On 07/07/21 at 11:26 A.M. and 07/12/21 at 12:04 A.M. interview with the Administrator confirmed prescription medication should not be left out unsecured on a resident's bedside table even if the resident had an order to self-medicate. The facility did not a policy regarding resident self-administration of medication. Review of the facility policy titled Nursing Services Policy, dated 07/25/20 revealed the nurse must remain with the resident while the medicine was being taken unless there was a physician order for the medication to be self-administered. Drugs were to be administered in accordance with the physician orders. 3. On 07/08/21 at 9:30 A.M. observation of medication storage room with the DON revealed there was two small clear plastic unfixed narcotic lock boxes in the unlocked refrigerator. The one box had a Lorazepam 2 mg/milliliter (ml) 30 ml bottle for Resident #19. The second box had two stock bottles of Ativan injectable 2 mg/ml 1 ml vials, Marinol 2.5 mg six caps, Ativan 2 mg/ml 30 ml vial and Ativan 2 mg/ml 30 ml vial for Resident #9. The DON confirmed the medications were not locked in a fixed compartment since the boxes were not permanently affixed in the refrigerator. Review of the facility policy titled Nursing Services Policy, dated 07/25/20 revealed all controlled substances requiring refrigeration were to be secured in a lock box in the refrigerator within the locked medication room and counted at the beginning and end of each shift.

Based on observation, record review and interview the facility failed to ensure residents had access to and were routinely provided fresh drinking water and ice. This affected 31 of 31 residents residing in the facility who could have drinking water/ice at their bedside for consumption. The facility identified four residents (#18, #22, #24, and #32) who required thickened liquids and one resident (#135) who was on a physician ordered fluid restriction. The facility census was 36. Findings include: Review of a 07/31/20 Resident Council Questionnaire (summary) form, completed by Director of Activities #9 revealed resident concerns/suggestions including a concern from Resident #17 who indicated she does not receive ice on a regular basis if the restorative aides were not working. Review of the resident council follow-up, dated 08/21/20 revealed the State Tested Nursing Assistant (STNA) assigned to baths on day and afternoon shift would pass ice and the charge nurse would monitor. This was to be addressed by the Director of Nursing (DON). On 07/07/21 8:45 A.M. interview with Resident #7 revealed she never gets fresh ice or water. Observation at the time of the interview revealed no ice was noted in the resident's pitcher. The resident attributed the lack of fresh ice water to a lack of facility staff to complete the task timely. On 07/07/21 at 10:35 A.M. Resident #7's water pitcher remained without ice or condensation on the pitcher. The pitcher was noted to be half full at this time. On 07/07/21 at 2:00 P.M. a Resident Group Meeting was held with Resident #3, #17, #21 and #28 present. During the meeting, Resident #17 revealed she does not receive fresh water or ice unless she requested it. She stated she activated her call light daily around 3:45 P.M. to 4:00 PM. for ice. If staff don't respond or tell her they will return, she goes to the kitchen herself for fresh ice. The resident stated it was not an issue for her to have to go to the kitchen to get her own fresh ice/water but worried about the residents who were unable to get their own water and ice. The three other residents present at the meeting verified getting fresh ice and water was a problem. The residents attributed the issue to a lack of staffing. On 07/07/21 at 3:11 P.M. Resident #19's water pitcher was half full and no ice or condensation was noted on the pitcher. On 07/07/21 at 3:12 P.M. interview with Resident #16 revealed he does not get fresh ice and water often and cannot recall the last time he received fresh ice and water. Observation at the time of the interview revealed the resident did not have fresh ice/water at this time. The resident attributed the lack of fresh ice water to a lack of facility staff to complete the task timely. On 07/08/21 at 10:30 A.M. Resident #16's water pitcher was observed to be a quarter full with no ice or condensation on the pitcher. Interview with Resident #16 at this time verified he had not received fresh ice/water. On 07/07/21 at 3:15 P.M. Resident #27's water pitcher was observed to be a quarter full and did not have ice or condensation on the outside of the water pitcher. On 07/08/21 at 10:45 A.M. Resident #17's water pitcher was observed to be empty. Interview with the resident revealed she had not received ice or water since she asked yesterday at 4:00 P.M. The resident revealed she worries about the residents who are unable to go to the kitchen and get ice and water when they want it. On 07/08/21 interview with a staff member who requested to remain anonymous revealed residents do not get ice and fresh water on their shift. The staff member revealed the restorative aide used to pass ice and water but since they don't currently have a restorative aide, whoever has time passes ice and water. The staff member verified residents reporting they are not routinely getting ice and fresh water would be accurate. On 07/08/21 interview with a staff member who requested to remain anonymous revealed the staff member was unsure when staff were to pass ice on the shifts but indicated it wasn't always completed. Further interview revealed it was difficult to provide residents with the care they needed when the facility didn't have enough staff. Further interview revealed the facility tried to have four aides on days and afternoons but the residents had a high level of needs and it wasn't always enough. On 07/08/21 interview with a staff member who requested to remain anonymous revealed ice and water were not passed on day shift due to the staff not having enough time to provide the ice and water. On 07/08/21 at 4:30 P.M. interview with the Director of Nursing (DON) revealed ice water was to be refreshed twice a day, once on day shift and once on afternoon shift. On 07/13/21 interview with a staff member who requested to remain anonymous revealed residents don't always receive fresh water and ice especially during the day. Further interview verified ice and water were to be passed two to three times a day and it is not provided to the residents consistently. The facility did not have a policy and procedure for providing fresh ice/water.

Based on observation, record review, facility policy and procedure review and interview the facility failed to develop and implement a comprehensive infection control program to properly track and trend infections in the facility. The facility failed to maintain adequate infection control practices during incontinence care, meal delivery and related to COVID-19 precautions to prevent the spread of infection including COVID-19. This had the potential to affect all 36 residents residing in the facility. Findings include: 1. On 07/06/21 at 1:38 P.M. State Tested Nursing Assistant (STNA) #58 was observed entering Resident #86's room to deliver the resident's lunch meal tray. Resident #86 was identified to be in quarantine for COVID-19. The STNA applied a clear plastic gown. However, the arms of the gown were ripped from the shoulder down to the STNA's elbow exposing the STNA's upper arms. The gown also did not cover the STNA's back. The STNA then applied a clean surgical mask over the surgical mask she already had on. There was no N95 mask in the supply box sitting outside of the resident's room and the STNA did not apply an N95 mask before entering the room. On 07/06/21 at 2:19 P.M. interview with STNA #58 confirmed the supply box outside Resident #86 room did not have any N95 masks available for staff use. STNA #58 reported she was fitted for an N95 mask and she had them stored in her locker. She stated she would wear one for five applications per day and would keep the mask and reuse it again in 72 hours. The STNA reported she needed a special N95 mask because she had a smaller face and she was limited with the amount of N95 masks she had. The STNA revealed she also worked in the attached assisting living (AL), used the same N95 mask in both the nursing home and the assisted living and there was a current COVID-19 outbreak in the assisted living. On 07/07/21 at 10:35 A.M. interview with the Administrator revealed STNA #58 should be wearing an N95 mask when entering Resident #86's room and should not be wearing the same N95 mask between the AL and nursing home. The STNA should have separate N95 masks for each entity. Review of the facility undated procedure for Use Personal Protective Equipment (PPE) When Caring for Patients with Confirmed or Suspected COVID-19 revealed to apply (don) N95 mask prior to entering the resident room and remove (doff) and dispose the N95 mask when leaving the room. 2. On 07/07/21 at 8:45 A.M. Registered Nurse (RN) #51 was observed providing to care to residents on C hall in the nursing home along with residents on the first floor of the facility attached assisted living. Interview with the RN at the time of the observation revealed she utilized the same N95 mask when caring for residents in both the nursing home and the assisted living. RN #51 revealed there was currently a COVID-19 outbreak in the assisted living. On 07/07/21 at 10:35 A.M. interview with the Administrator revealed RN #51 should not be wearing the same N95 mask caring for residents in the nursing home and the assisted living. The Administrator revealed the RN should remove the N95 mask before leaving the AL and going to the nursing home to provide care and vice versa. Review of the facility undated procedure for Use Personal Protective Equipment (PPE) When Caring for Patients with Confirmed or Suspected COVID-19 revealed to apply (don) N95 mask prior to entering the resident room and remove (doff) and dispose the N95 mask when leaving the room. 3. On 07/12/21 at 1:37 P.M. STNA #67 was observed providing incontinence care to Resident #18. During the observation, STNA #67 did not change her gloves or complete hand hygiene at all throughout the entire procedure. STNA #67 assisted the resident to the bathroom. She then applied gloves, turned the water on in the sink, placed a water basin in the sink, removed the resident's incontinent brief, used wet wipes to clean the majority of bowel movement off the resident's buttocks, removed a new pair of pants from the closet, removed the resident's shoes and soiled pants, applied a new brief and pants and put the resident's shoes back on. STNA #67 then proceeded to cleanse the resident's buttocks with a wash cloth and soap and water and then threw the wash cloth with bowel movement (BM) into the sink. The STNA used a second wash cloth to cleanse the resident's scrotum and then the tip of his penis. The STNA did not cleanse the shaft or base of the resident's penis. The STNA dried the resident's entire peri area using one towel. Next, she pulled up the resident's brief and pants with the same gloved hands, assisted him out of the bathroom to his recliner, touching him with her gloved hands and arranged his pad in the chair. The STNA then removed her original gloves and used hand sanitizer. Following the observation, interview with the STNA verified the above observation. STNA #67 verified she did not change her gloves during the entire procedure and did not properly cleanse the resident's entire perineal area. Review of the facility procedure for Changing an Adult Brief, Provide Perineal Care for a Make with Hand Washing, dated 11/20/20 revealed to perform hand hygiene and gather supplies and position resident. Apply (don) new gloves and remove the soiled brief and discard in the designated container. Use water and a soapy washcloth and cleanse the top of the penis and move down the shaft of the penis using a clean portion of the washcloth. Next cleanse the scrotum with a clean portion of the washcloth. Rinse and dry with a new washcloth in the same manner. With a new, soapy wash cloth to clean the rectal area. Remove gloves and perform hand hygiene with soap and water. 4. Review of the facility infection control logs dated 12/16/20 to 07/13/21 revealed no evidence the facility was comprehensively trending infections during this time period. On 07/06/21 at 12:52 P.M. interview with the Administrator and RN #15 revealed they had both been working on the infection control log. RN #15 and Administrator confirmed the facility did not have evidence they were trending infections. In addition to the lack of trending of infections on an infection control log, the following resident specific concerns were identified related to infection control log documentation: a. Review of Resident #3's medical record revealed the resident was ordered Bacitracin (typical antibiotic) ointment to be applied to the lower lip every day and evening shift for skin healing for seven days on 06/30/21. Review of Resident #3's medication administration record (MAR) dated 07/2021 revealed the resident was administered Bacitracin twice daily from 07/01/21 to 07/07/21. Review of the facility infection control log, dated 06/16/21 to 07/13/21 revealed no evidence the resident was included on the log related to the infection the Bacitracin was used to treat. On 07/07/21 at 1:03 P.M. interview with RN #15 and the Administrator confirmed Resident #3 had a skin alteration on his lower lip and was treated with antibiotic ointment. However, the resident had not been included on the infection control log. RN #15 reported she fills out the log from a report the computer generates and it must have not pulled over. b. Review of Resident #135's medical record revealed on 06/21/21 the resident was ordered Ofloxacin (antibiotic eye drop) one drop in left eye every two hours while awake until 06/23/21. Review of Resident #135's MAR dated 06/2021 revealed the resident was administered Ofloxacin in the left eye every two hours on 06/21/21 and 06/22/21. Review of the infection control log dated 06/16/21 to 07/16/21 revealed no evidence Resident #135 was included on the infection control log related to this infection. On 07/07/21 at 1:03 P.M. interview with RN #15 and the Administrator revealed Resident #135 had surgery on his eye and received antibiotics post-surgery. However, the resident had not been included on the infection control log. RN #15 reported she fills out the log from a report the computer generates and it must have not pulled over as well. On 07/13/21 at 12:09 P.M. interview with the Administrator revealed she had completed the infection control log for a few months in the last six months but she had not completed an infection preventionist training. The Administrator revealed she had started the training. Review of the Infection Prevention and Control Program, dated 10/2019 revealed the danger of infections of various types were a great concern to the facility. The facility goals were to prevent, identify, report, investigate and control infection and communicable diseases. The facility would track the most common infections and monitor for patterns and organism as indicated.

Based on record review, review of McGeer criteria, facility policy and procedure review and interview the facility failed to develop and implement a comprehensive and effective antibiotic stewardship program to ensure the proper use of antibiotics. This affected five residents (#3, #4, #19, #85 and #135) and had the potential to affect all 36 residents residing in the facility. Finding include: 1. Review of the infection control log dated 05/15/21 to 06/16/21 revealed documentation Resident #4 had pneumonia with on onset date of 05/25/21. An x-ray was ordered on 05/25/21 and the resident was started on the antibiotic, Doxycycline . The infection was documented as resolved on 06/02/21. Record review revealed there was no evidence the resident met the McGeer criteria. Review of Resident #4's medical record revealed no evidence a McGeer criteria form was completed. Review of Resident #4's chest x-ray completed on 05/25/21 revealed the x-ray indicted the resident had a viral respiratory infection. There was no evidence the resident had pneumonia. Review of Resident #4's physician orders and medication administration records for 05/2021 revealed the resident received Doxycycline 100 milligrams (mg) twice daily for seven days. Review of the McGeer's criteria for pneumonia revealed the resident must have a chest x-ray demonstrating pneumonia, probably pneumonia, or new infiltrate. On 07/13/21 at 4:31 P.M. interview with the Administrator verified Resident #4 did not meet criteria for antibiotic treatment. The Administrator reported a McGeer form should have been completed and documented in the electronic medical record under assessment, however there was no evidence one completed for Resident #4. 2. Review of the infection control log dated 05/15/21 to 06/16/21 revealed documentation Resident #19 had an upper respiratory infection with on onset date of 05/30/21. The resident did not have a chest x-ray and was ordered the antibiotic, Z-pack for five days. The infection was documented as resolved on 06/06/21. Review of Resident #19's physician orders and MAR dated 05/2021 and 06/2021 revealed the resident received a Z-pack for five days. There was no evidence the resident met the McGeer criteria. Review of Resident #19's medical record revealed no evidence a McGeer criteria form was completed or the resident met criteria for antibiotic treatment. On 07/13/21 at 4:31 P.M. interview with the Administrator verified there was no evidence the resident met criteria for antibiotic treatment and the facility did not complete the McGeer criteria form to ensure the resident met criteria. 3. Review of Resident #3's medical record revealed the resident was ordered Bacitracin (topical antibiotic) Ointment to be applied to the lower lip every day and evening shift for skin healing for seven days on 06/30/21. Review of Resident #3's medication administration record (MAR) dated 07/2021 revealed the resident was administered Bacitracin twice daily form 07/01/21 to 07/07/21. Review of the infection control log dated 06/16/21 to 07/13/21 revealed no evidence Resident #3 was included on the log or met criteria of antibiotic treatment. Review of McGeer's soft tissue criteria revealed a resident must have pus present and at least four of the following heat, redness, swelling, tenderness, and serous drainage to the affected area for antibiotic use. On 07/07/21 at 1:03 P.M. interview with Registered Nurse (RN) #15 and the Administrator revealed Resident #3 had a skin alteration on his lower lip and was treated with antibiotic ointment. However, the infection was not included on the infection control log. The Administrator confirmed there was no evidence the resident met the McGeer criteria for treatment and a McGeer form was not completed. 4. Review of Resident #135's medical record revealed on 06/21/21 the resident was ordered Ofloxacin (antibiotic eye drop) one drop in left eye every two hours while awake until 06/23/21. Review of Resident #135's MAR dated 06/2021 revealed the resident was administered Ofloxacin in the left eye every two hours on 06/21/21 and 06/22/21. Review of the infection control log dated 06/16/21 to 07/16/21 revealed no evidence Resident #135 was included on the log or evidence the resident met McGeer criteria for antibiotic treatment. On 07/07/21 at 1:03 P.M. interview with RN #15 and the Administrator revealed Resident #3 had surgery on his eye and received antibiotics post-surgery. However, the resident was not included on the facility infection control log. The Administrator confirmed there was no evidence the resident met McGeer criteria for antibiotic treatment and no McGeer form was completed. On 07/13/21 at 12:09 P.M. interview with the Administrator revealed she had completed the infection control log for a few months in the last six months. The Administrator revealed she had started training but had not completed the infection preventionist training. On 07/13/21 at 4:45 P.M. interview with the Administrator confirmed the facility infection control and antibiotic stewardship programs were not comprehensive. The facility was not completing the criteria forms to ensure resident met the McGeer criteria and the log did not include all infections and antibiotics. The facility was also not ensuring new admission residents were meeting criteria for antibiotic treatment. The Administrator revealed when the previous infection preventionist employee left the facility she had taken all the criteria information with her resulting in staff just administering antibiotics without ensuring the criteria was met. 5. Review of Resident #85's medical record revealed an admission date of 04/20/21 with diagnoses including end stage renal disease and diabetes. Review of the medical record revealed the resident had a hospital stay from 06/15/21 through 06/23/21 to remove her left hip hardware and a spacer was placed. Review of a left hip capsule culture obtained on 06/18/21 revealed Enterococcus faecalis was identified and medications such as cephalosporins, Clindamycin and Bactrim DS were not effective in treating enterococcal infections. This culture was not part of the facility record as of 07/07/21. Review of the physician's order, dated 06/26/21 revealed the resident was to receive Vancomycin (antibiotic) 750 milligrams (mg) intravenous on Tuesday, Thursday and Saturday after dialysis related to infection and inflammatory reaction due to internal left hip prosthesis until 07/30/21. Review of the medical record revealed no evidence the facility antibiotic stewardship identified the use of IV vancomycin or the absence of the left hip culture completed during the resident's surgical procedure to determine if antibiotic use was appropriate. Review of the five day Minimum Data Set (MDS) 3.0 assessment, dated 06/27/21 revealed the resident was cognitively intact and required extensive assistance of two staff members with bed mobility, transfers and toilet use. Further review revealed the resident required extensive assistance of one staff member with locomotion, dressing and personal hygiene and the resident received dialysis during the assessment period. Also the resident was receiving surgical aftercare and intravenous therapy. On 07/08/21 at 1:00 P.M. interview with RN #15 revealed the facility used McGeer's Criteria for antibiotic stewardship to determine if physician ordered antibiotics were appropriate to treat identified infections. Further interview verified the facility did not have a copy of the resident's wound and hip culture obtained during her hospital stay and surgical procedure to remove infected left hip hardware. Further interview verified the facility administered antibiotics to Resident #85 before ensuring the antibiotic was appropriate to treat the organism identified in her left hip. The RN verified the facility failed to utilize the antibiotic stewardship program appropriately. In addition, review of the physician's order, dated 06/26/21 revealed Macrobid (antibiotic) 100 mg daily for prophylaxis. The order did not specify what was being treated prophylactically. Review of the June 2021 Infection Control Log revealed Resident #85 was prescribed prophylactic Macrobid for recurrent urinary tract infections (UTI). Review of the UTI without a catheter- McGeer's Criteria dated 07/02/21 revealed the resident had increased urgency and frequency. The criteria directed the facility to contact the physician for a urinalysis and culture. Review of the urine culture dated 07/05/21 revealed the urine culture showed less than 10,000 colony forming units of bacteria per milliliter of urine. And was not a significant urine culture. Further review of the McGeer's Criteria revealed no evidence the physician was notified the resident did not meet criteria for the use of Macrobid and did not currently have a UTI. On 07/08/21 at 1:00 P.M. interview with RN #15 verified the treatment with Macrobid did not meet McGeer's criteria and the physician was not updated regarding not meeting criteria for a UTI. Review of the facility Antibiotic Stewardship policy, dated 10/2019 revealed the facility would develop antibiotic use protocols and systems to monitor antibiotic use.