**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the facility failed to provide respiratory care in accordance with professional standards. Specifically, the facility failed to ensure the nebulizer machines mask for Resident (R)69 and R389 were clean, labelled, and bagged when not in use. Findings include: Review of the policy titled Jet Nebulizer Treatment revised 09/07 reveals under procedure,10. When treatment is completed remove the nbulizer to the sink area, empty any remaining medication, rinse with water, and return setup to bag. Note change nebulizer setups weekly, date and initial equipment. Review of Review of Resident 69's face sheet revealed that resident was current admitted to the facility on [DATE] with the diagnoses listed but not limited to dementia, Alzheimer's disease, major depressive disorder, chronic obstructive pulmonary disease, hypertensive heart disease with heart failure, atherosclerotic heart disease, left bundle block, benign prostatic hyperplasia, and unqualified visual loss right eye. Review of Resident 389's face sheet revealed that resident was current admitted to the facility on [DATE] with the diagnoses listed but not limited to Alzheimer's Disease with late onset, chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, pulmonary hypertension, unspecified, hypertensive heart disease with heart failure, chronic diastolic (congestive) heart failure, atrial fibrillation, hypothyroidism, peripheral vascular disease, polyosteoarthritis and contracture. Review of R69's Physician Orders revealed orders for Budesonide Suspension for nebulization 0.5mg/2mL give twice a day. Review of R69's care plan revealed that R69 identified problem is Respiratory, at risk for complications related to Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, personal history of nicotine dependence, and shortness of breath. Approach administer nebulizer, inhaler as indicated. Review of R69's Minimum Data Set (MDS) quarterly review dated 09/03/2024 revealed a Brief Interview for Mental Status (BIMS) score is 10 out of 15, R 69 has moderate cognitive impairment. Section E revealed R63 has no rejection of care behavior exhibited. Section GG revealed R69 is independent in activities of daily life and feeding self. Review of R389's Physician Orders revealed orders for Albuterol Sulfate Solution for nebulization 2.5mg/3mL (0.083%) one nebulizer three times a day. Review of R389's care plan revealed that R389 is not care planned for breathing treatments scheduled or PRN. Last revised care plan with start date 09/16/2024 problem listed acute bronchitis with approaches medications and lab per orders, resident will complete antibiotics on 09/18/2024. Observe for increased signs and symptoms of infection, and vital signs as needed. Review of R389's annual MDS dated [DATE] revealed a BIMS score is 13 out of 15, R389 has intact cognition. Section E revealed R389 has no rejection of care behavior exhibited. Section GG revealed R389 is dependent to maximal assist of care. R389, with set up, is able to feed self, perform oral hygiene, and perform other personal hygiene task. During an observation and interview of R69 on 10/15/24 at 01:27 PM resident was fully dressed ambulatory in room. The face mask with connected tubing to the jet nebulizer machine was not dated, not in a bag, and located on the right side of the nightstand near floor. R69 revealed having a breathing treatment that morning. During an observation of R389's room on 10/15/24 at 12:15 PM, there was a face mask with connected tubing to the jet nebulizer machine not dated, not in a bag, located on the floor between the bed and nightstand. During an observation of R389's room on 10/16/24 at 10:29 AM, there was a face mask with connected tubing to the jet nebulizer machine not dated, not in a bag, located on the floor between the bed and nightstand. During an observation and interview on 10/16/24 at 10:39 AM, the Director of Nursing (DON) witnessed R389's jet nebulizer's face mask on the floor and revealed that the respiratory equipment is expected to be in a bag and dated. She stated, I am sure staff has had in-service on respiratory care and infection control. DON immediately discarded mask. DON revealed that respiratory therapy is in charge of weekly changes of respiratory equipment. The nurses are in charge of daily care. During an interview on 10/16/24 at 10:56 AM, Licensed Practical Nurse (LPN)2 revealed that she gave the jet nebulizer treatment and the inhaler that morning at 8:08 AM. She revealed that after treatment, she rinsed R69's face mask but, she left it across the bed. LPN2 was aware of the policy when it is not in use it is to be stored in a plastic bag to keep the dust and keep it clean. The bags are labeled treatments. During an interview on 10/16/24 at 03:52 PM, the DON revealed that staff are trained on respiratory equipment on hire and as needed for trends. The equipment or mask is expected to be rinsed after usage, set on a paper towel to dry and placed in a dated bag. The DON stated, It is expected to be changed weekly. It is my expectation that nurses are following policy as it pertains to medication administration and respiratory care. During an interview on 10/16/24 at 04:37 PM, the Assistant Director of Nursing revealed the policy for the nebulizer are expected to be followed. The nebulizer mask are to be rinsed out and bagged. The plan of correction we will reeducate staff on the proper storage of the respiratory equipment. During an interview on 10/17/24 at 11:50 AM the Administrator revealed an expectation is that the nebulizer is stored in a bag and labeled. It is expected to be rinsed, dried, dated, and packed in place. We must assure that it is being done by rounding and addressing that it is being done.

Based on the facility policy titled, Specific Medication Administration Procedures IIB1: Administration Procedures for All Medications, observations and interviews, the facility failed to ensure Resident (R)95 was free from significant medication errors. Specifically, ertapenem reconstituted solution 1 gram infused with 100mL of normal saline intravenous (IV) in a safe manner and in accordance with professional standards of medication administration via peripherally inserted central catheter (PICC or PICC line). The findings include: Review of the facility policy titled, Specific Medication Administration Procedures IIB1: Administration Procedures for All Medications, states under the Policy Statement, To administer medications in a safe and effective manner. An observation on 10/17/2024 at 1:08 PM revealed ertapenem intravenous administration for R95. Licensed Practical Nurse (LPN)1 failed to ensure R95 safely received antibiotic therapy via PICC line by improperly managing the IV line once primed to reduce the risk of contamination before going to the patient. The primed uncapped IV line was placed on a blue chux and then the outside of an alcohol packet, then administered to the R95. LPN1 when accessing PICC line failed to scrub/wipe top of access for a minimum of 15 seconds. Task completed less than 10sceonds and uncapped IV line was placed within access. LPN1 started infusion. During an interview on 10/17/24 at 01:46 PM the Director of Nursing revealed that skills training is done once a year. This training included PICC lines and IV infusions. The expectation is that staff follow protocol and follow infection control guidelines during medication administration. The last class was in November 2023 and that was the skill fair. Since this morning, we have started retaining the licensed practical nurses regarding the PICC and working with R95. We have another skills fair that is in November 2024. During an interview on 10/17/24 at 02:09 PM, LPN1 revealed that she does not remember her last PICC Training. LPN1 revealed that she was expected to use a clean technique when accessing a PICC line. She admitted to taking the uncapped primed IV line, placing on the blue pad, and once alerted placed the uncapped IV line on an alcohol pack. LPN1 revealed that she was expected to discard of the IV line and start over prior to administering to R95. Review of Competency Standard Skills Checklist for PICC lines with LPN name, signature, and not dated with DON name, signature, and date of 11/21/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, record review, observation and interview the facility failed to provide 1 of 4 residents (R95) and 1 of 34 medication opportunities given by 4 nurses, medication administration without possibility of cross contamination. Specifically, ertapenem reconstituted solution 1 gram infused with 100mL of normal saline intravenous in accordance with infection control and prevention standards of medication administration via peripherally inserted central catheter (PICC or PICC line). Findings include: Review of the facility policy titled, Specific Medication Administration Procedures IIB1: Administration Procedures for All Medications, states under the Policy Statement, To administer medications in a safe and effective manner. Review of the facility policy titled, PICC and Midline Catheter Flushing, states under general guideline, 3. Consult state Nurse Practice Act for RN/LPN scope of practice and function. Review of Competency standard skills checklist PICC lines with DON name, signature, and date of 11/ 21/23. LPN1 name and signature present without a date. Checklist revealed flushing the PICC line, administer infusion, changing the PICC line, and changing the PICC adapter instructions that have been checked off by LPN1 except for changing the PICC line. Under flushing the PICC line, Scrub the top of the adapter of the PICC with alcohol swab for minimum 15 seconds with a juicing action. Under Administer Infusion, 3. Thoroughly friction swab access site with alcohol for 15 seconds. Review of R95's face sheet revealed R95 was admitted to the facility on [DATE] with diagnoses including, but not limited to osteomyelitis of vertebra, sacral and sacrococcygeal region, Escherichia coli, extended spectrum beta lactamase, proteus, enterococcus as the cause of disease and presence of cardiac or vascular implant and graft, PICC line. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed R95 had a Brief Interview of Mental Status (BIMS) score of 2, suggesting R95 is severely cognitively impaired. It further revealed R95 does not exhibit behavior of rejection of care. Review of R95's physician orders revealed R95 has an ongoing ertapenem reconstituted solution 1 gram infused with 100mL of normal saline intravenous for one hour vis PICC line every 24 hours start date 09/18/2024 to end date 10/18/2024. An observation on 10/17/2024 at 1:08 PM revealed ertapenem intravenous administration for R95. Licensed Practical Nurse (LPN)1 failed to ensure R95 safely received antibiotic therapy via PICC line by improperly managing the intravenous (IV) line once primed to reduce the risk of contamination before going to the patient. The primed uncapped IV line was placed on a blue chux and then the outside of an alcohol packet, then administered to the R95. LPN1 when accessing PICC line failed to scrub/wipe top of access for a minimum of 15 seconds. Task completed less than 10sceonds and uncapped IV line was placed within access. LPN1 started infusion. During an interview on 10/17/24 at 1:46 PM, the Director of Nursing revealed that skills training is done once a year. She stated, this training included PICC lines and IV infusions. The expectation is that staff follow protocol and follow infection control guidelines during medication administration. The last class was in November 2023 and that was the skills fair. Since this morning, we have started retaining the licensed practical nurses regarding the PICC and working with R95. We have another skills fair that is in November 2024. During an interview on 10/17/24 at 1:51 PM, the Assistant Director of Nursing/Infection Preventionist revealed that the staff are expected to follow procedures for sterile and clean technique per policy when it is warranted. During an interview on 10/17/24 at 2:09 PM, LPN1 revealed that she does not remember her last PICC Training. She revealed that she was expected to use a clean technique with accessing a PICC line. LPN1 confirmed taking the uncapped primed IV line, placing on the blue pad, and once alerted placed the uncapped IV line on an alcohol pack. LPN1 revealed that she was expected to discard of IV line and start over prior to administering to R95.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility policies, the facility failed to ensure the environment remained free from potential accident hazards for 4 of 5 residents, related to medications at bedside. Specifically, the facility failed to ensure the environment for Resident (R)33, R389, R38, and R69, was free of medication that was required to be properly monitored and stored, to prevent accidental hazards. Findings include: Review of the facility policy, revised 01/01/2019, titled, Medication Storage in the Facility policy states, Medications and biologicals are stored safely, securely and properly manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Under Procedures, B. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medication are permitted to access medication. Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. Review of the facility policy, revised 01/01/2019, titled, Preparation and General Guidelines: Self-Administration of Medications policy revealed under procedures, A. If the resident desires to self-administer medications, an assessment is conducted by a member of the interdisciplinary team of the resident's cognitive (including orientation to time), physical, and visual ability to carry our responsibility. E. Beside medication storage is permitted only when it does not present a risk to confused residents who wander into the rooms of, or room with, resident who self-administer. Review of R33's Face Sheet revealed R33 was admitted to the facility on [DATE], with diagnoses including but not limited to: Dementia, Alzheimer's disease late onset, emphysema, left anterior fascicular block, right bundle-branch block, atherosclerosis of aorta, hypertension, Hypothyroidism, Alzheimer's disease, major depressive disorder, recurrent, mild, generalized anxiety disorder, and adult failure to thrive. Review of R33's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/25/24, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R33 has no cognitive impairment. Section E revealed R33 has no rejection of care behavior exhibited. Section GG revealed R33 requires no assistance with activities of daily life, notes that R33 is independent to feed self. Review of R33's medical record did not reveal evidence that an assessment was completed for self-administration of medication. Review of R33's Physician Orders revealed an active order for, 9AM administration of Cyanocobalamin (Vitamin B-12) 1000mcg, Quetiapine 25mg 1 tablet, Thera-M 19mg Iron 400mcg 1 tablet, Tylenol Extra Strength 500mg 1 po tablet, and Verapamil 180mg 1 tablet listed for nursing medication administration. Nurse signed off for administration on 10/15/24. No evidence of active orders for self-administration. Review of R33's Care Plan, last revised on 08/05/24, revealed R33's medication and treatment orders are considered part of the active care plan. Goal: R33 will not have any negative outcomes from medications and treatments. Approach administer medications and treatments as ordered. Cognition/Communication Deficits related to dementia with fluctuating cognition and inability to always stay on topic. BCRS (Brief Cognitive Rating Scale) score of 21/35 and GDS (Global Deterioration Scale) score of 4.2/7 indicating a moderate cognitive impairment per ST assessment on 09/08/23. Review of R389's Face Sheet revealed R389 was admitted to the facility on [DATE], with diagnoses including but not limited to: Alzheimer's Disease with late onset, chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, pulmonary hypertension, unspecified, hypertensive heart disease with heart failure, chronic diastolic (congestive) heart failure, atrial fibrillation, hypothyroidism, peripheral vascular disease, polyosteoarthritis and contracture. Review of R389's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/01/24, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating R389 has intact cognition. Further review of the MDS revealed R389 has no rejection of care behavior exhibited and is dependent to maximal assist of care. R389, with set up, is able to feed self, perform oral hygiene, and perform other personal hygiene task. Review of R389's medical record did not reveal evidence that an assessment was completed for self-administration of medication. Review of R389's Physician Orders did not reveal an order for topical medication Nystatin Powder. Review of R389's Care Plan, last revised on 08/08/24, reveals R389's medication and treatment orders are considered part of the active care plan. Goal: R389 will not have any negative outcomes from medications or treatments. Approach administer medication and treatments as ordered. Review of R38's Face Sheet revealed R38 was admitted to the facility on [DATE], with diagnoses including but not limited to: Bipolar Disorder, anxiety disorder, insomnia, hypothyroidism, radiculopathy cervical region, polyneuropathy, polyosteoarthritis, and atherosclerotic heart disease. Review of R38's Quarterly MDS with an ARD of 09/30/24, revealed a BIMS score of 14 out of 15, indicating R38 has intact cognition. Section E revealed R38 has no rejection of care behavior exhibited. Section GG revealed R38 is dependent to maximal assist of care. R38, with set up, is able to feed self, perform oral hygiene, and perform other personal hygiene task. Review of R38's medical record did not reveal evidence that an assessment was completed for self-administration of medication. Review of R38's Physician Order did not reveal an order for Nervive Roll on cream. Review of R38's Care Plan, with a revision date of 10/13/24, revealed R38's medication and treatment orders are considered part of the active care plan. Goal: R389 will not have any negative outcomes from medications or treatments. Approach: administer medication and treatments as ordered. Problem: Cognitive loss/dementia, goal is R38 will communicate simple needs for 90 days until next review and update. Approach is to offer cues and reminders as needed. Remind R38 of surroundings only if it calms patient and visit for conversation stimulation. R38's problem of behavioral symptoms by observed occasional declination of medications and care. Diagnosis of bipolar disorder, these behaviors fluctuate related to diagnosis extremely pleasant at times and just as quickly she is accusatory and yelling. Review of R69's Face Sheet revealed R69 was admitted to the facility on [DATE], with diagnoses including but not limited to: Dementia, Alzheimer's disease, major depressive disorder, chronic obstructive pulmonary disease, hypertensive heart disease with heart failure, atherosclerotic heart disease, left bundle block, benign prostatic hyperplasia, and unqualified visual loss right eye. Review of R69's medical record did not reveal evidence that an assessment was completed for self-administration of medication. Review of R69's Physician Orders revealed an active order for, Wixela Inhub (Fluticasone propion-salmeterol) blister with device 250-50 mcg/dose, amount one puff inhalation twice a day listed for nursing medication administration. Review of R69's Care Plan reveals R69's identified problem is cognitive loss/dementia. Cognition fluctuate, requires assistance with decision making. Requires cues and reminders for safety. Brief Cognitive Rating Scale, BCRS of 26/35 and GDS (Global Deterioration Scale) score of 5.2/7 indicating moderately severe cognitive impairment per speech therapy assessment on 12/13/23. Resident continues with liberal unassisted ambulation about facility; cognitive deficits with dx; risk harm from his peers related to occasional socially intrusive during his interactions as he strolls and some peer's inability to interpret his interactions; episodes of agitation and verbal aggression occur as well related to his deficits edited on 09/10/24. Review of R69's Quarterly MDS with an ARD of 09/03/24, revealed a BIMS score of 10 out of 15, indicating R69 has moderate cognitive impairment. Section E revealed R69 has no rejection of care behavior exhibited. Section GG revealed R69 is independent in activities of daily life and feeding self. During an observation and interview on 10/15/24 at 10:51 AM, of R33's room, a medication cup with several pills where on the bedside table in front of R33. There were no staff present and R33's roommate was in a wheelchair leaving the restroom. During introductions, R33 quickly took the medications in the cup without the nurse present. R33 stated, she does not know the medicine she takes but takes what the nurse places on the table in the cup for her to take. R33 revealed that staff occasionally leave her medicines in her room for her to take by herself because she is able. During an observation and interview on 10/15/24 at 10:54 AM, Licensed Practical Nurse (LPN)2 signed off administration of R33's 9:00 AM medications, which included: Cyanocobalamin (Vitamin B-12) 1000mcg, Quetiapine 25mg 1 tablet, Thera-M 19mg Iron 400mcg 1 tablet, Tylenol Extra Strength 500mg 1 po tablet, and Verapamil 180mb 1 tablet. LPN2 stated R33 can give herself the medication unattended because she is independent, and she knows her medications. LPN2 further stated, R33 is sometimes given her medications like this and has not had any issues in the past. LPN2 confirmed that R33 does not have an order to self-administer medications and acknowledged the facility policy for self-administration. During an observation on 10/15/24 at 12:41 PM, of R38's room, revealed a Nervive roll on 2.5oz 8/2025 Lot 4092Y5 and IcyHot Max Lidocaine lot 24B401 02/2026, was located on the bedside table in front of R38. Furthermore, there was one unopened box of Nervive 7/2025 Lot 4030Y5 box medication cream 3.0oz on the bookshelf. During an observation and interview on 10/16/24 at 10:36 AM, the Director of Nursing (DON) verified the Nystatin powder lot421209 3/31/2026, on R389's dresser. The DON stated that treatment medications should be secured on the cart unless it is peri care and lotion. If there is a prescription, there should be a bedside order. During an observation on 10/16/24 at 10:53 AM, of R69's room, revealed an inhalation medication on the tall dresser next to the television. The inhalar was left opened and unattended. Further review of the inhaler revealed, Fluticasone Propionate and Salmeterol 250mcg/50mcg 60 blisters with lot number AC2029A expiration date of MAR2026, 43 puffs left. No open date and no use by date on the medication. During an interview on 10/16/24 at 10:56 AM, Licensed Practical Nurse (LPN)2 verified the medication on the dresser in R69's room and stated that another LPN forgot it earlier after administration of medication due to cleaning R69's room. LPN2 further stated she watched R69 take medication and receive breathing treatment at 8:08 AM that morning. LPN2 than closed the medication and secured medication back in in cart. During an interview on 10/16/24 at 04:02 PM the (ADON) Assistant Director of Nursing/Infection Control revealed that she was not aware of the items being in the room and ADON was following up with R38 and seen the medication at bedside. ADON took the Nervive roll that was on the bedside table and three bottles of the Nervive R38 had in the bedside drawer. ADON reported that she educated the resident and left with the items. Expectations are for staff to follow policy and if items are coming from family educate the resident and let them know why they cannot have at bedside. We are to keep in the medication cart and regulate it for R38 and keep it locked up for patient safety. Expectation for self-administration is that we do have a protocol to follow to determine if they are competent to do to self-administer. During an interview on 10/16/24 at 04:15 PM the ADON revealed the expectation to follow policy that medication should be administered at bedside and watched. The ADON stated, we can assess their competency level to see if they can self-administer but there is a protocol. I do not know the specifics because i have not heard of it being done often and i have been here three years. R33 has not been assessed for self-administration. We train the nurses on medication administration and documentation annually and frequently at nurse's meetings probably 3 to 4 times a year. During an interview on 10/17/24 at 11:31 AM, the Administrator revealed that every patient is within eyesight of nurse and at bedside when taking medications. The Administrator stated, If the patient is able to self-administer the patient needs to be assessed and care planned appropriately. I am aware of two patients in this facility that is approved for self-administration. During an interview on 10/17/24 at 11:39 AM, the Administrator revealed that administration medications should be locked and if not the patient need to be cleared to self-administer. The barrier cream for peri-care is allowed but anything that is coming from the pharmacy should be properly assessed and screened for self-administration. Daily rounding by leadership is done to ensure there is not an incident or hazard and to assist staff. If there is an issue we are to address, educate. The way that we address family are at different intervals at admission and it states what they can and cannot provide. We explain to the family that we oversee care and if anything is needed, we can provide. We also address as it is an issue, we address it seasonally (especially Christmas), resident council, and at care plans. Based on observation, interview, record review, and review of facility policies, the facility failed to ensure the environment remained free from potential accident hazards for 4 of 5 residents, related to medications at bedside. Specifically, the facility failed to ensure the environment for Resident (R)33, R389, R38, and R69, was free of medication that was required to be properly monitored and stored, to prevent accidental hazards. Findings include: Review of the facility policy, revised 01/01/2019, titled, Medication Storage in the Facility policy states, Medications and biologicals are stored safely, securely and properly manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Under Procedures, B. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medication are permitted to access medication. Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. Review of the facility policy, revised 01/01/2019, titled, Preparation and General Guidelines: Self-Administration of Medications policy revealed under procedures, A. If the resident desires to self-administer medications, an assessment is conducted by a member of the interdisciplinary team of the resident's cognitive (including orientation to time), physical, and visual ability to carry our responsibility. E. Beside medication storage is permitted only when it does not present a risk to confused residents who wander into the rooms of, or room with, resident who self-administer. Review of R33's Face Sheet revealed R33 was admitted to the facility on [DATE], with diagnoses including but not limited to: Dementia, Alzheimer's disease late onset, emphysema, left anterior fascicular block, right bundle-branch block, atherosclerosis of aorta, hypertension, Hypothyroidism, Alzheimer's disease, major depressive disorder, recurrent, mild, generalized anxiety disorder, and adult failure to thrive. Review of R33's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/25/24, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R33 has no cognitive impairment. Section E revealed R33 has no rejection of care behavior exhibited. Section GG revealed R33 requires no assistance with activities of daily life, notes that R33 is independent to feed self. Review of R33's medical record did not reveal evidence that an assessment was completed for self-administration of medication. Review of R33's Physician Orders revealed an active order for, 9AM administration of Cyanocobalamin (Vitamin B-12) 1000mcg, Quetiapine 25mg 1 tablet, Thera-M 19mg Iron 400mcg 1 tablet, Tylenol Extra Strength 500mg 1 po tablet, and Verapamil 180mg 1 tablet listed for nursing medication administration. Nurse signed off for administration on 10/15/24. No evidence of active orders for self-administration. Review of R33's Care Plan, last revised on 08/05/24, revealed R33's medication and treatment orders are considered part of the active care plan. Goal: R33 will not have any negative outcomes from medications and treatments. Approach administer medications and treatments as ordered. Cognition/Communication Deficits related to dementia with fluctuating cognition and inability to always stay on topic. BCRS (Brief Cognitive Rating Scale) score of 21/35 and GDS (Global Deterioration Scale) score of 4.2/7 indicating a moderate cognitive impairment per ST assessment on 09/08/23. Review of R389's Face Sheet revealed R389 was admitted to the facility on [DATE], with diagnoses including but not limited to: Alzheimer's Disease with late onset, chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, pulmonary hypertension, unspecified, hypertensive heart disease with heart failure, chronic diastolic (congestive) heart failure, atrial fibrillation, hypothyroidism, peripheral vascular disease, polyosteoarthritis and contracture. Review of R389's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/01/24, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating R389 has intact cognition. Further review of the MDS revealed R389 has no rejection of care behavior exhibited and is dependent to maximal assist of care. R389, with set up, is able to feed self, perform oral hygiene, and perform other personal hygiene task. Review of R389's medical record did not reveal evidence that an assessment was completed for self-administration of medication. Review of R389's Physician Orders did not reveal an order for topical medication Nystatin Powder. Review of R389's Care Plan, last revised on 08/08/24, reveals R389's medication and treatment orders are considered part of the active care plan. Goal: R389 will not have any negative outcomes from medications or treatments. Approach administer medication and treatments as ordered. Review of R38's Face Sheet revealed R38 was admitted to the facility on [DATE], with diagnoses including but not limited to: Bipolar Disorder, anxiety disorder, insomnia, hypothyroidism, radiculopathy cervical region, polyneuropathy, polyosteoarthritis, and atherosclerotic heart disease. Review of R38's Quarterly MDS with an ARD of 09/30/24, revealed a BIMS score of 14 out of 15, indicating R38 has intact cognition. Section E revealed R38 has no rejection of care behavior exhibited. Section GG revealed R38 is dependent to maximal assist of care. R38, with set up, is able to feed self, perform oral hygiene, and perform other personal hygiene task. Review of R38's medical record did not reveal evidence that an assessment was completed for self-administration of medication. Review of R38's Physician Order did not reveal an order for Nervive Roll on cream. Review of R38's Care Plan, with a revision date of 10/13/24, revealed R38's medication and treatment orders are considered part of the active care plan. Goal: R389 will not have any negative outcomes from medications or treatments. Approach: administer medication and treatments as ordered. Problem: Cognitive loss/dementia, goal is R38 will communicate simple needs for 90 days until next review and update. Approach is to offer cues and reminders as needed. Remind R38 of surroundings only if it calms patient and visit for conversation stimulation. R38's problem of behavioral symptoms by observed occasional declination of medications and care. Diagnosis of bipolar disorder, these behaviors fluctuate related to diagnosis extremely pleasant at times and just as quickly she is accusatory and yelling. Review of R69's Face Sheet revealed R69 was admitted to the facility on [DATE], with diagnoses including but not limited to: Dementia, Alzheimer's disease, major depressive disorder, chronic obstructive pulmonary disease, hypertensive heart disease with heart failure, atherosclerotic heart disease, left bundle block, benign prostatic hyperplasia, and unqualified visual loss right eye. Review of R69's medical record did not reveal evidence that an assessment was completed for self-administration of medication. Review of R69's Physician Orders revealed an active order for, Wixela Inhub (Fluticasone propion-salmeterol) blister with device 250-50 mcg/dose, amount one puff inhalation twice a day listed for nursing medication administration. Review of R69's Care Plan reveals R69's identified problem is cognitive loss/dementia. Cognition fluctuate, requires assistance with decision making. Requires cues and reminders for safety. Brief Cognitive Rating Scale, BCRS of 26/35 and GDS (Global Deterioration Scale) score of 5.2/7 indicating moderately severe cognitive impairment per speech therapy assessment on 12/13/23. Resident continues with liberal unassisted ambulation about facility; cognitive deficits with dx; risk harm from his peers related to occasional socially intrusive during his interactions as he strolls and some peer's inability to interpret his interactions; episodes of agitation and verbal aggression occur as well related to his deficits edited on 09/10/24. Review of R69's Quarterly MDS with an ARD of 09/03/24, revealed a BIMS score of 10 out of 15, indicating R69 has moderate cognitive impairment. Section E revealed R69 has no rejection of care behavior exhibited. Section GG revealed R69 is independent in activities of daily life and feeding self. During an observation and interview on 10/15/24 at 10:51 AM, of R33's room, a medication cup with several pills where on the bedside table in front of R33. There were no staff present and R33's roommate was in a wheelchair leaving the restroom. During introductions, R33 quickly took the medications in the cup without the nurse present. R33 stated, she does not know the medicine she takes but takes what the nurse places on the table in the cup for her to take. R33 revealed that staff occasionally leave her medicines in her room for her to take by herself because she is able. During an observation and interview on 10/15/24 at 10:54 AM, Licensed Practical Nurse (LPN)2 signed off administration of R33's 9:00 AM medications, which included: Cyanocobalamin (Vitamin B-12) 1000mcg, Quetiapine 25mg 1 tablet, Thera-M 19mg Iron 400mcg 1 tablet, Tylenol Extra Strength 500mg 1 po tablet, and Verapamil 180mb 1 tablet. LPN2 stated R33 can give herself the medication unattended because she is independent, and she knows her medications. LPN2 further stated, R33 is sometimes given her medications like this and has not had any issues in the past. LPN2 confirmed that R33 does not have an order to self-administer medications and acknowledged the facility policy for self-administration. During an observation on 10/15/24 at 12:41 PM, of R38's room, revealed a Nervive roll on 2.5oz 8/2025 Lot 4092Y5 and IcyHot Max Lidocaine lot 24B401 02/2026, was located on the bedside table in front of R38. Furthermore, there was one unopened box of Nervive 7/2025 Lot 4030Y5 box medication cream 3.0oz on the bookshelf. During an observation and interview on 10/16/24 at 10:36 AM, the Director of Nursing (DON) verified the Nystatin powder lot421209 3/31/2026, on R389's dresser. The DON stated that treatment medications should be secured on the cart unless it is peri care and lotion. If there is a prescription, there should be a bedside order. During an observation on 10/16/24 at 10:53 AM, of R69's room, revealed an inhalation medication on the tall dresser next to the television. The inhalar was left opened and unattended. Further review of the inhaler revealed, Fluticasone Propionate and Salmeterol 250mcg/50mcg 60 blisters with lot number AC2029A expiration date of MAR2026, 43 puffs left. No open date and no use by date on the medication. During an interview on 10/16/24 at 10:56 AM, Licensed Practical Nurse (LPN)2 verified the medication on the dresser in R69's room and stated that another LPN forgot it earlier after administration of medication due to cleaning R69's room. LPN2 further stated she watched R69 take medication and receive breathing treatment at 8:08 AM that morning. LPN2 than closed the medication and secured medication back in in cart. During an interview on 10/16/24 at 04:02 PM the (ADON) Assistant Director of Nursing/Infection Control revealed that she was not aware of the items being in the room and ADON was following up with R38 and seen the medication at bedside. ADON took the Nervive roll that was on the bedside table and three bottles of the Nervive R38 had in the bedside drawer. ADON reported that she educated the resident and left with the items. Expectations are for staff to follow policy and if items are coming from family educate the resident and let them know why they cannot have at bedside. We are to keep in the medication cart and regulate it for R38 and keep it locked up for patient safety. Expectation for self-administration is that we do have a protocol to follow to determine if they are competent to do to self-administer. During an interview on 10/16/24 at 04:15 PM the ADON revealed the expectation to follow policy that medication should be administered at bedside and watched. The ADON stated, we can assess their competency level to see if they can self-administer but there is a protocol. I do not know the specifics because i have not heard of it being done often and i have been here three years. R33 has not been assessed for self-administration. We train the nurses on medication administration and documentation annually and frequently at nurse's meetings probably 3 to 4 times a year. During an interview on 10/17/24 at 11:31 AM, the Administrator revealed that every patient is within eyesight of nurse and at bedside when taking medications. The Administrator stated, If the patient is able to self-administer the patient needs to be assessed and care planned appropriately. I am aware of two patients in this facility that is approved for self-administration. During an interview on 10/17/24 at 11:39 AM, the Administrator revealed that administration medications should be locked and if not the patient need to be cleared to self-administer. The barrier cream for peri-care is allowed but anything that is coming from the pharmacy should be properly assessed and screened for self-administration. Daily rounding by leadership is done to ensure there is not an incident or hazard and to assist staff. If there is an issue we are to address, educate. The way that we address family are at different intervals at admission and it states what they can and cannot provide. We explain to the family that we oversee care and if anything is needed, we can provide. We also address as it is an issue, we address it seasonally (especially Christmas), resident council, and at care plans.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility policies, the facility failed to ensure the environment remained free from potential accident hazards for 4 of 5 residents, related to medications at bedside. Specifically, the facility failed to ensure the environment for Resident (R)33, R389, R38, and R69, was free of medication that was required to be properly monitored and stored, to prevent accidental hazards. Findings include: Review of the facility policy, revised 01/01/2019, titled, Medication Storage in the Facility policy states, Medications and biologicals are stored safely, securely and properly manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Under Procedures, B. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medication are permitted to access medication. Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. Review of the facility policy, revised 01/01/2019, titled, Preparation and General Guidelines: Self-Administration of Medications policy revealed under procedures, A. If the resident desires to self-administer medications, an assessment is conducted by a member of the interdisciplinary team of the resident's cognitive (including orientation to time), physical, and visual ability to carry our responsibility. E. Beside medication storage is permitted only when it does not present a risk to confused residents who wander into the rooms of, or room with, resident who self-administer. Review of R33's Face Sheet revealed R33 was admitted to the facility on [DATE], with diagnoses including but not limited to: Dementia, Alzheimer's disease late onset, emphysema, left anterior fascicular block, right bundle-branch block, atherosclerosis of aorta, hypertension, Hypothyroidism, Alzheimer's disease, major depressive disorder, recurrent, mild, generalized anxiety disorder, and adult failure to thrive. Review of R33's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/25/24, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R33 has no cognitive impairment. Section E revealed R33 has no rejection of care behavior exhibited. Section GG revealed R33 requires no assistance with activities of daily life, notes that R33 is independent to feed self. Review of R33's medical record did not reveal evidence that an assessment was completed for self-administration of medication. Review of R33's Physician Orders revealed an active order for, 9AM administration of Cyanocobalamin (Vitamin B-12) 1000mcg, Quetiapine 25mg 1 tablet, Thera-M 19mg Iron 400mcg 1 tablet, Tylenol Extra Strength 500mg 1 po tablet, and Verapamil 180mg 1 tablet listed for nursing medication administration. Nurse signed off for administration on 10/15/24. No evidence of active orders for self-administration. Review of R33's Care Plan, last revised on 08/05/24, revealed R33's medication and treatment orders are considered part of the active care plan. Goal: R33 will not have any negative outcomes from medications and treatments. Approach administer medications and treatments as ordered. Cognition/Communication Deficits related to dementia with fluctuating cognition and inability to always stay on topic. BCRS (Brief Cognitive Rating Scale) score of 21/35 and GDS (Global Deterioration Scale) score of 4.2/7 indicating a moderate cognitive impairment per ST assessment on 09/08/23. Review of R389's Face Sheet revealed R389 was admitted to the facility on [DATE], with diagnoses including but not limited to: Alzheimer's Disease with late onset, chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, pulmonary hypertension, unspecified, hypertensive heart disease with heart failure, chronic diastolic (congestive) heart failure, atrial fibrillation, hypothyroidism, peripheral vascular disease, polyosteoarthritis and contracture. Review of R389's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/01/24, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating R389 has intact cognition. Further review of the MDS revealed R389 has no rejection of care behavior exhibited and is dependent to maximal assist of care. R389, with set up, is able to feed self, perform oral hygiene, and perform other personal hygiene task. Review of R389's medical record did not reveal evidence that an assessment was completed for self-administration of medication. Review of R389's Physician Orders did not reveal an order for topical medication Nystatin Powder. Review of R389's Care Plan, last revised on 08/08/24, reveals R389's medication and treatment orders are considered part of the active care plan. Goal: R389 will not have any negative outcomes from medications or treatments. Approach administer medication and treatments as ordered. Review of R38's Face Sheet revealed R38 was admitted to the facility on [DATE], with diagnoses including but not limited to: Bipolar Disorder, anxiety disorder, insomnia, hypothyroidism, radiculopathy cervical region, polyneuropathy, polyosteoarthritis, and atherosclerotic heart disease. Review of R38's Quarterly MDS with an ARD of 09/30/24, revealed a BIMS score of 14 out of 15, indicating R38 has intact cognition. Section E revealed R38 has no rejection of care behavior exhibited. Section GG revealed R38 is dependent to maximal assist of care. R38, with set up, is able to feed self, perform oral hygiene, and perform other personal hygiene task. Review of R38's medical record did not reveal evidence that an assessment was completed for self-administration of medication. Review of R38's Physician Order did not reveal an order for Nervive Roll on cream. Review of R38's Care Plan, with a revision date of 10/13/24, revealed R38's medication and treatment orders are considered part of the active care plan. Goal: R389 will not have any negative outcomes from medications or treatments. Approach: administer medication and treatments as ordered. Problem: Cognitive loss/dementia, goal is R38 will communicate simple needs for 90 days until next review and update. Approach is to offer cues and reminders as needed. Remind R38 of surroundings only if it calms patient and visit for conversation stimulation. R38's problem of behavioral symptoms by observed occasional declination of medications and care. Diagnosis of bipolar disorder, these behaviors fluctuate related to diagnosis extremely pleasant at times and just as quickly she is accusatory and yelling. Review of R69's Face Sheet revealed R69 was admitted to the facility on [DATE], with diagnoses including but not limited to: Dementia, Alzheimer's disease, major depressive disorder, chronic obstructive pulmonary disease, hypertensive heart disease with heart failure, atherosclerotic heart disease, left bundle block, benign prostatic hyperplasia, and unqualified visual loss right eye. Review of R69's medical record did not reveal evidence that an assessment was completed for self-administration of medication. Review of R69's Physician Orders revealed an active order for, Wixela Inhub (Fluticasone propion-salmeterol) blister with device 250-50 mcg/dose, amount one puff inhalation twice a day listed for nursing medication administration. Review of R69's Care Plan reveals R69's identified problem is cognitive loss/dementia. Cognition fluctuate, requires assistance with decision making. Requires cues and reminders for safety. Brief Cognitive Rating Scale, BCRS of 26/35 and GDS (Global Deterioration Scale) score of 5.2/7 indicating moderately severe cognitive impairment per speech therapy assessment on 12/13/23. Resident continues with liberal unassisted ambulation about facility; cognitive deficits with dx; risk harm from his peers related to occasional socially intrusive during his interactions as he strolls and some peer's inability to interpret his interactions; episodes of agitation and verbal aggression occur as well related to his deficits edited on 09/10/24. Review of R69's Quarterly MDS with an ARD of 09/03/24, revealed a BIMS score of 10 out of 15, indicating R69 has moderate cognitive impairment. Section E revealed R69 has no rejection of care behavior exhibited. Section GG revealed R69 is independent in activities of daily life and feeding self. During an observation and interview on 10/15/24 at 10:51 AM, of R33's room, a medication cup with several pills where on the bedside table in front of R33. There were no staff present and R33's roommate was in a wheelchair leaving the restroom. During introductions, R33 quickly took the medications in the cup without the nurse present. R33 stated, she does not know the medicine she takes but takes what the nurse places on the table in the cup for her to take. R33 revealed that staff occasionally leave her medicines in her room for her to take by herself because she is able. During an observation and interview on 10/15/24 at 10:54 AM, Licensed Practical Nurse (LPN)2 signed off administration of R33's 9:00 AM medications, which included: Cyanocobalamin (Vitamin B-12) 1000mcg, Quetiapine 25mg 1 tablet, Thera-M 19mg Iron 400mcg 1 tablet, Tylenol Extra Strength 500mg 1 po tablet, and Verapamil 180mb 1 tablet. LPN2 stated R33 can give herself the medication unattended because she is independent, and she knows her medications. LPN2 further stated, R33 is sometimes given her medications like this and has not had any issues in the past. LPN2 confirmed that R33 does not have an order to self-administer medications and acknowledged the facility policy for self-administration. During an observation on 10/15/24 at 12:41 PM, of R38's room, revealed a Nervive roll on 2.5oz 8/2025 Lot 4092Y5 and IcyHot Max Lidocaine lot 24B401 02/2026, was located on the bedside table in front of R38. Furthermore, there was one unopened box of Nervive 7/2025 Lot 4030Y5 box medication cream 3.0oz on the bookshelf. During an observation and interview on 10/16/24 at 10:36 AM, the Director of Nursing (DON) verified the Nystatin powder lot421209 3/31/2026, on R389's dresser. The DON stated that treatment medications should be secured on the cart unless it is peri care and lotion. If there is a prescription, there should be a bedside order. During an observation on 10/16/24 at 10:53 AM, of R69's room, revealed an inhalation medication on the tall dresser next to the television. The inhalar was left opened and unattended. Further review of the inhaler revealed, Fluticasone Propionate and Salmeterol 250mcg/50mcg 60 blisters with lot number AC2029A expiration date of MAR2026, 43 puffs left. No open date and no use by date on the medication. During an interview on 10/16/24 at 10:56 AM, Licensed Practical Nurse (LPN)2 verified the medication on the dresser in R69's room and stated that another LPN forgot it earlier after administration of medication due to cleaning R69's room. LPN2 further stated she watched R69 take medication and receive breathing treatment at 8:08 AM that morning. LPN2 than closed the medication and secured medication back in in cart. During an interview on 10/16/24 at 04:02 PM the (ADON) Assistant Director of Nursing/Infection Control revealed that she was not aware of the items being in the room and ADON was following up with R38 and seen the medication at bedside. ADON took the Nervive roll that was on the bedside table and three bottles of the Nervive R38 had in the bedside drawer. ADON reported that she educated the resident and left with the items. Expectations are for staff to follow policy and if items are coming from family educate the resident and let them know why they cannot have at bedside. We are to keep in the medication cart and regulate it for R38 and keep it locked up for patient safety. Expectation for self-administration is that we do have a protocol to follow to determine if they are competent to do to self-administer. During an interview on 10/16/24 at 04:15 PM the ADON revealed the expectation to follow policy that medication should be administered at bedside and watched. The ADON stated, we can assess their competency level to see if they can self-administer but there is a protocol. I do not know the specifics because i have not heard of it being done often and i have been here three years. R33 has not been assessed for self-administration. We train the nurses on medication administration and documentation annually and frequently at nurse's meetings probably 3 to 4 times a year. During an interview on 10/17/24 at 11:31 AM, the Administrator revealed that every patient is within eyesight of nurse and at bedside when taking medications. The Administrator stated, If the patient is able to self-administer the patient needs to be assessed and care planned appropriately. I am aware of two patients in this facility that is approved for self-administration. During an interview on 10/17/24 at 11:39 AM, the Administrator revealed that administration medications should be locked and if not the patient need to be cleared to self-administer. The barrier cream for peri-care is allowed but anything that is coming from the pharmacy should be properly assessed and screened for self-administration. Daily rounding by leadership is done to ensure there is not an incident or hazard and to assist staff. If there is an issue we are to address, educate. The way that we address family are at different intervals at admission and it states what they can and cannot provide. We explain to the family that we oversee care and if anything is needed, we can provide. We also address as it is an issue, we address it seasonally (especially Christmas), resident council, and at care plans.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's policy, record review, observations, and staff interviews, the facility failed to check for placement of a gastrostomy (g)-tube prior to administering medications for 1 resident (Resident (R) 38) of 5 residents reviewed during medication administration. Findings include: Review of the facility's undated Feeding/Enteral Tube Medication Administration Procedure read, in pertinent part, Check tube placement by aspirating gastric contents (prior to water flush and medication administration). Review of R38's undated Resident Face Sheet, found in the electronic medical record (EMR) under the Face Sheet tab revealed R38 was admitted to the facility on [DATE] with diagnoses including schizophrenia, dementia with behaviors, dysphagia (difficulty swallowing), adult failure to thrive, and encounter for attention to gastrostomy tube (G-Tube-a tube surgically placed into the stomach through the abdomen used for hydration, nutrition, and medication administration). Review of R38'sPhysician Order Report, dated 08/30/22 and found in the EMR under the Orders tab, indicated orders for R38 to remain NPO (to have nothing by mouth) and for Midodrine tablet 10 MG (Milligrams) via gastric tube (G-tube) three times daily. Review of R38'sG-Tube Care Plan, most recently dated 06/27/22 and found in the EMR under the Care Plan tab, read, in pertinent part, Problem: Risk for aspiration pneumonia secondary to tube feeding, poor cognition, and inability to always manage her secretions. Approaches included: Check PEG (g-tube) for placement prior to use per policy. Licensed Practical Nurse (LPN)4 was observed administering R38's medication via her g-tube on 08/30/22 at 12:06 PM. LPN 4 did not check the placement of R38's g-tube prior to flushing the tube with water and administering the Midodrine. During an interview with LPN4 on 08/30/22 at 12:13 PM, she indicated R38's continuous feeding had been discontinued at 10:00 AM that morning and would be restarted at about 1:00 PM that day. LPN4 acknowledged she did not check R38's g-tube placement prior to administering the water flush or medication and stated her Unit Manager (Registered Nurse (RN)2 told her the facility policy had changed and g-tube placement no longer needed to be checked prior to administering anything through a g-tube. During an interview with RN2 on 08/30/22 at 12:18 PM, she verified her understanding was g-tube placement did not need to be checked prior to administering medication through the tube. RN2 stated, That policy changed more than two years ago. During an interview on 09/01/22 at 1:18 PM, the Director of Nursing (DON) verified her expectation was g-tube placement to be checked prior to the administration of fluid, medication, and nutrition and that the policy had not changed concerning checking placement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, record review, and staff interviews, the facility failed to ensure the appropriate use of side rails for 2 Residents (R), R7 and R38 of 4 residents reviewed for accidents. Findings include: The facility's side rail policies were requested on 09/01/22 at 10:34 AM and were not received prior to facility exit. In an interview conducted with the Director of Nursing (DON) at the time of the request, she indicated side rails were addressed for each resident specifically as part of each resident's individualized plan of care. 1. Review of R38's undated Resident Face Sheet, found in the electronic medical record (EMR) under the Face Sheet tab, revealed R38 was admitted to the facility on [DATE] with diagnoses including schizophrenia and dementia with behaviors. Review of R38's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/22/22 indicated R38 was dependent upon two or more staff for all mobility, including mobility within her bed and transfers in and out of her bed. Review of R38's Physician Order Report, dated 08/01/22 through 09/01/22 and found in the EMR under the Orders tab, indicated no orders for the use of side rails. R38's comprehensive care plan, most recently dated 06/27/22 and found in the EMR under the Care Plan tab, was reviewed and indicated no care plan had been developed for R38's use of side rails. Review of R38's Siderails Utilization Assessment, dated 09/01/22 and found in the EMR under the Observations tab, indicated R38 was not appropriate for the use of side rails. R38 was observed lying in her bed, awake and nonverbal, on 08/29/22 at 4:28 PM, 08/31/22 at 9:52 AM, 12:00 PM, and 2:47 PM, and on 09/01/22 at 8:44 AM. R38 was able to make nonsensical vocal noises at times during the observations, but did not appear to be able to move any part of her body on her own. Bilateral ¼ side rails were observed to be in the raised position on the resident's bed during each of the observations. During an interview with Certified Nursing Assistant (CNA)5 and CNA6 together on 09/01/22 at 8:49 AM, both staff members indicated they were familiar with R38, and both stated R38 required total care/assist with movement in her bed. Both staff members stated R38 was not able to use her side rails to assist with movement. CNA 6 stated, She [R38] is not able to use them [the side rails] at all. During an interview with Unit Manager Registered Nurse (RN)2 on 09/01/22 at 8:58 AM, she confirmed R38 required total assistance from staff to move in her bed. RN2 stated, She [R38] does not use any intentional movement to help reposition herself. During a follow-up interview with RN2 on 09/01/22 at 9:32 AM, she stated, She [R38] does not need the [side] rails. R38 was observed with RN2. RN2 acknowledged the bilateral side rails on R38's bed and RN2 stated she would contact maintenance to remove the rails from the bed. 2. Review of R7's undated Resident Face Sheet, found in the EMR under the Face Sheet tab revealed R38 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis (paralysis and weakness on one side) following a stroke. Review of R7's significant change MDS with an ARD of 08/22/22 indicated R7 was dependent upon two or more staff for all mobility, including mobility within her bed and transfers in and out of her bed. Review of R7's Physician Order Report, dated 08/01/22 through 09/01/22 and found in the EMR under the Orders tab, indicated no orders for the use of side rails. R7's Activities of Daily Living Care Plan, most recently dated 06/03/22 and found in the EMR under the Care Plan tab, was reviewed and read, in pertinent part, Problem: Continues with extensive to essentially total care per staff re [related to] her history of CVA [stroke]. Approaches included: 2 (¼) grab bars to assist with turning and positioning. Review of R7's Siderails Utilization Assessment, dated 08/11/22 and found in the EMR under the Observations tab, indicated R7 was unable to utilize the side rails as an enabler for mobility and indicated the use of the rails was not requested by the resident. The assessment, however, indicated the use of bilateral ¼ side rails on the upper right and upper left portion of the resident's bed. R7 was observed lying in her bed on 08/30/22 at 1:51 PM and 1:57 PM, and on 08/31/22 at 12:08 PM and 2:54 PM. Two ¼ rails were observed to be in the raised position during each of the observations. During an interview with Unit Manager (UM) Licensed Practical Nurse (LPN)3 on 08/30/22 at 1:57 PM, R7 was observed lying in her bed with both side rails in the raised position. LPN3 acknowledged the rails on R7's bed and stated, [R7] does not move at all independently. She is completely dependent [on staff to move in her bed.] During a follow-up interview with LPN3 on 09/01/22 at 9:11 AM, she confirmed R7 was totally dependent upon staff for movement from side to side. LPN3 stated, At one time she [R7] was able to hold on to the bar [side rail] to move from side to side. Now she's not able to use them [the side rails] due to a recent change in condition. LPN3 stated R7 no longer needed the rails on her bed. During an interview with the Director of Nursing (DON) on 09/01/22 at 9:36 AM, she stated side rails were typically used by residents for turning and repositioning in bed. The DON stated if a resident was not able to assist with repositioning in bed the side rails were not needed and should be removed from the resident's bed.

Based on policy review and interview, the facility failed to ensure that 2 of 8 staff (Certified Nursing Assistant (CNA)7 and CNA8) reviewed for COVID-19 vaccination status were fully vaccinated. This failure increases the risk of transmission of COVID-19 to residents and other staff members. Findings include: Review of the facility's policy titled Human Resources Policies and Procedures CMS Emergency Regulation- Mandatory COVID-19 Vaccine, revised 03/18/22, stated Our company requires all employees to receive the COVID-19 vaccine .If you are hired, the company will require you to prove that you have received the COVID-19 vaccine or have a valid medical or religious reason not to be vaccinated .New hires will be subject to the same requirements as current staff and must have received, at a minimum, the first dose of a two-dose COVID-19 vaccine or a one-dose COVID-19 vaccine prior to providing any care, treatment, or other services for the center/agency and/or its patients .The employer shall require and maintain documentation for each eligible individual (including new hires) proof of current vaccination against COVID-19 or the individual's completed COVID-19 Vaccination Declination Form (with vaccine exemption documentation with required exemption approval, as appropriate), and a system to track the vaccination status of all personnel (such as the CDC staff vaccination tracking tool available on the NHSN website). Review of facility document titled, Employee Listing, dated 08/31/22, provided by the facility indicated CNA7 was hired on 07/20/22 and CNA8 was hired on 06/29/22. Review of facility's untitled document provided by the Administrator on 09/01/22 included a line listing for staff including any/all doses of COVID-19 immunizations. CNA7 received an initial Moderna COVID-19 immunization on 01/25/22 with no additional doses documented. CNA8 received an initial Pfizer COVID-19 immunization on 06/10/22 with no additional doses documented. During an interview on 09/01/22 at 3:53 PM, the Infection Preventionist (IP) stated staff are considered fully vaccinated for COVID-19 if they have received the single-dose of Johnson & Johnson vaccine, or both doses of the two-dose Moderna or Pfizer vaccinations. The IP stated that if any staff are unvaccinated for COVID-19 they should have a medical or religious exemption in their employee file. The IP confirmed that CNA7 had received an initial dose of Moderna COVID-19 on 01/25/22 and had not received the second dose. Additionally, the IP stated the process for ensuring that staff are up to date on COVID-19 immunizations included notification of the nursing manager that specific staff members were due for the second dose of the immunization or boosters per CDC guidelines. During an interview on 09/01/22 at 4:31 PM, IP stated she spoke with CNA7 who told her that she was interested in getting an exemption for the remaining COVID-19 immunizations. During an interview on 09/01/22 at 4:32 PM, the IP confirmed CNA8 had received an initial dose of Pfizer COVID-19 on 06/10/22 and had not received the second dose.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of Center for Medicare and Medicaid Services (CMS) QSO-20-38-NH Revised, and policy review, interviews, and record reviews, the facility failed to perform COVID-19 testing immediately for all staff and residents regardless of vaccination status when an outbreak was identified and failed to retest every three to seven days until no additional cases were identified for 14 days. The facility failed to perform thorough contact tracing when staff tested positive for COVID-19 to determine residents and staff with higher exposure which added to the noncompliance with staff and resident testing in an outbreak. This noncompliance resulted in 17 residents (Resident (R) 18, R56, R69, R78, R83, R110, R120, R154, R155, R255, R258, R259, R260, R261, R262, R263, and R264) and 17 staff members contracting COVID-19 and increased likelihood for additional serious infections and potential hospitalizations and death due to transmission of COVID-19 between staff members and residents. Findings include: Review of the facility's policy titled Covid-19- Infection Control Manual Volume 1 Updated February 2022 .3. Determining the time period when the patient, visitor, or HCP (healthcare care personnel) with confirmed SARS-CoV-2 infection could have been infectious: a. For individuals with confirmed COVID-19 who developed symptoms, consider the exposure window to be 2 days before symptom onset through the time period when the individual meets criteria for discontinuation of Transmission-Based Precautions. b. For individuals with confirmed SARS-CoV-2 infection who never developed symptoms, determining the infectious period can be challenging. In these situations, collecting information about when the asymptomatic individual with SARS-CoV-2 infection may have been exposed could help inform the period when they were infectious. i. If the date of exposure cannot be determined, although the infectious period could be longer, it is reasonable to use a starting point of 2 days prior to the positive test through the time period when the individual meets criteria for discontinuation of Transmission-Based Precautions for contact tracing Review of QSO-20-38-NH, REVISED 03/10/2022, stated Newly identified COVID19 positive staff or resident in a facility that can identify close contacts: Test all staff, regardless of vaccination status, that had a higher-risk exposure with a COVID-19 positive individual. Test all residents, regardless of vaccination status, that had close contact with a COVID-19 positive individual. Newly identified COVID19 positive staff or resident in a facility that is unable to identify close contacts: test all staff, regardless of vaccination status, facility wide or at a group level if staff are assigned to a specific location where the new case occurred (e.g., unit, floor, or other specific area(s) of the facility). Test all residents, regardless of vaccination status, facility-wide or at a group level (e.g., unit, floor, or other specific area(s) of the facility). Testing of Staff and Residents During an Outbreak Investigation A new COVID-19 infection in any staff or any nursing home-onset COVID-19 infection in a resident triggers an outbreak investigation. In an outbreak investigation, rapid identification and isolation of new cases is critical in stopping further viral transmission. A resident who is admitted to the facility with COVID-19 does not constitute a facility outbreak. Upon identification of a single new case of COVID-19 infection in any staff or residents, testing should begin immediately. Facilities have the option to perform outbreak testing through two approaches, contact tracing or broad-based (e.g., facility-wide) testing. If the facility has the ability to identify close contacts of the individual with COVID-19, they could choose to conduct focused testing based on known close contacts. If a facility does not have the expertise, resources, or ability to identify all close contacts, they should instead investigate the outbreak at a facility-wide or group-level (e.g., unit, floor, or other specific area(s) of the facility). Broader approaches might also be required if the facility is directed to do so by the jurisdiction's public health authority, or in situations where all potential contacts are unable to be identified, are too numerous to manage, or when contact tracing fails to halt transmission. During an interview on 08/29/22 at 9:16 AM during the entrance conference, the Administrator stated there were no active COVID-19 cases in the building and that the facility was not in outbreak status. Review of the facility's COVID-19 testing logs provided by the Infection Preventionist (IP) revealed 17 residents tested positive for COVID-19 since July 1, 2022, which constituted an outbreak. The following residents tested positive for COVID-19: 1. Review of R18's Face Sheet located in the electronic medical record (EMR) under the Face Sheet tab revealed she was readmitted to the facility on [DATE] with a primary medical diagnosis of pressure ulcer of right heel, stage 3. Review of R18's COVID-19 testing log indicated the resident tested positive for COVID-19 on 07/13/22 with symptoms starting on 07/13/22. Symptoms included cough and congestion. Review of R18's Progress Notes located in the EMR under the Progress Notes tab indicated the resident tested positive for COVID-19 on 07/13/22 and was experiencing cough and congestion. 2. Review of R56's Face Sheet located in the EMR under the Face Sheet tab revealed she was admitted to the facility on [DATE] with a primary medical diagnosis of hypertensive chronic kidney disease. Review of R56's COVID-19 testing log indicated the resident tested positive for COVID-19 on 07/01/22 with a fever starting on 07/01/22. Review of R56's Progress Notes located in the EMR under the Progress Notes tab indicated the resident had an elevated temperature, along with positive COVID-19 test. 3. Review of R69's Face Sheet, located in the EMR under the Face Sheet tab revealed he was readmitted to the facility on [DATE] with a primary medical diagnosis of acute respiratory disease (COVID-19). Review of R69's COVID-19 testing log indicated the resident tested positive for COVID-19 on 07/11/22 with recent exposure and symptoms including cough and runny nose. Review of R69's Progress Notes located in the EMR under the Progress Notes tab indicated on 07/18/22 the resident was on isolation precautions related to positive COVID-19 test. On 07/13/22 the resident was noted to have difficulty breathing while lying flat. 4. Review of R78's Face Sheet, located in the EMR under the Face Sheet tab revealed she was readmitted to the facility on [DATE] with a primary medical diagnosis of chronic respiratory failure with hypoxia. Review of R78's COVID-19 testing log indicated the resident tested positive for COVID-19 on 07/31/22 and was symptomatic. Symptoms started on 07/29/22 which included cough and fatigue. The resident was sent to the hospital on [DATE] with a diagnosis of COVID-19 with Acute Respiratory Failure and acute hypoxia. Review of R78's Progress Notes located in the EMR under the Progress Notes tab indicated the resident complained of having a cough and not feeling well on 07/29/22. COVID-19 test was negative on 07/29/22. On 07/31/22 COVID-19 test repeated with positive results. The resident was experiencing loose stools and productive cough. 5. Review of R85's Face Sheet, located in the EMR under the Face Sheet tab, revealed she was readmitted to the facility on [DATE] with a primary medical diagnosis of enterocolitis due to Clostridium difficile. Review of R85's COVID-19 testing log indicated the resident tested positive for COVID-19 on 08/01/22 with no symptoms reported but had been recently exposed. Review of R85's Progress Notes located in the EMR under the Progress Notes tab indicated the resident tested positive for COVID-19 on 08/01/22 with no symptoms reported. 6. Review of R110's Face Sheet, located in the EMR under the Face Sheet tab, revealed she was admitted to the facility on [DATE] with a primary medical diagnosis of hemiplegia and hemiparesis (paralysis and weakness on one side) following cerebral infarction (stroke) affecting left non-dominant side. Review of R110's COVID-19 testing log indicated the resident tested positive for COVID-19 on 08/08/22 with no symptoms reported but had been recently exposed. Review of R110's Progress Notes located in the EMR under the Progress Notes tab indicated the resident tested positive for COVID-19 on 08/08/22, chest x-ray results indicated right lower lobe infiltrates, and was experiencing a dry, non-productive cough, and poor appetite. 7. Review of R120's Face Sheet, located in the EMR under the Face Sheet tab, revealed she was admitted to the facility on [DATE] with a primary medical diagnosis of acute respiratory disease (COVID-19). Review of R120's COVID-19 testing log indicated the resident tested positive for COVID-19 on 08/01/22 with no symptoms reported but had been recently exposed. Review of R120's Progress Notes located in the EMR under the Progress Notes tab indicated the resident tested positive for COVID-19 on 08/01/22 with symptoms including headache. 8. Review of R154's Face Sheet located in the EMR under the Face Sheet tab, revealed she was admitted to the facility on [DATE] with a primary medical diagnosis of acute respiratory disease (COVID-19). Review of R154's COVID-19 testing log indicated the resident tested positive for COVID-19 on 08/01/22, was symptomatic and had recently been exposed. Symptoms included cough and fatigue. Review of R154's Progress Notes located in the EMR under the Progress Notes tab indicated the resident tested positive for COVID-19 on 08/01/22 and was experiencing cough. 9. Review of R155's Face Sheet located in the EMR under the Face Sheet tab revealed she was admitted to the facility on [DATE] with a primary medical diagnosis of atrial fibrillation (irregular heartbeat). Review of R155's COVID-19 testing log indicated the resident tested positive for COVID-19 on 08/04/22 with no symptoms reported but had been recently exposed. Review of R155's Progress Notes located in the EMR under the Progress Notes tab indicated the resident tested positive for COVID-19 on 08/04/22 per dietician's notes. Nursing note dated 08/05/22 indicated orders were received to discharge the resident home with no diagnosis of COVID-19. No symptoms noted. 10. Review of R255's Face Sheet, located in the EMR under the Face Sheet tab, revealed she was readmitted to the facility on [DATE] with a primary medical diagnosis of displaced fracture of lateral malleolus of right fibula. Review of R255's COVID-19 testing log indicated the resident tested positive for COVID-19 on 07/08/22 with symptoms starting on 07/08/22. Symptoms included congestion and headache. Review of R255's Progress Notes located in the EMR under the Progress Notes tab indicated the resident had episodes of coughing on 07/10/22, then on 07/11/22 R255 noted to be on isolation precautions related to COVID-19. 11. Review of R258's Face Sheet, located in the EMR under the Face Sheet tab revealed he was admitted to the facility on [DATE] with a primary medical diagnosis of encounter for surgical aftercare following surgery on the circulatory system. Review of R258's COVID-19 testing log indicated the resident tested positive for COVID-19 on 07/04/22 with symptoms starting on 07/04/22. Symptoms included fever and cough. The resident went to the hospital on [DATE] and did not return. Review of R258's Progress Notes located in the EMR under the Progress Notes tab indicated the resident complained of difficulty breathing while lying flat on 07/02/22. On 07/04/22 the resident complained of coughing, had a fever, and that he felt like he had the flu. Rapid COVID-19 test was positive and the resident was placed on isolation precautions. The resident was transferred to the emergency department for evaluation and treatment. 12. Review of R259's Face Sheet, located in the EMR under the Face Sheet tab, revealed she was admitted to the facility on [DATE] with a primary medical diagnosis of acute respiratory disease (COVID-19). Review of R259's COVID-19 testing log indicated the resident tested positive for COVID-19 on 07/08/22 with symptoms starting on 07/08/22. Symptoms included congestion. Review of R259's Progress Notes located in the EMR under the Progress Notes tab did not document COVID-19 status until 07/13/22, stating resident resting no acute respiratory symptoms noted r/t [related to] COVID-19 . 13. Review of R260's Face Sheet, located in the EMR under the Face Sheet tab, revealed he was readmitted to the facility on [DATE] with a primary medical diagnosis of displaced intertrochanteric fracture of right femur (hip fracture). Review of R260's COVID-19 testing log indicated the resident tested positive for COVID-19 on 07/09/22 with symptoms starting on 07/08/22. Symptoms included fever. Review of R260's Progress Notes located in the EMR under the Progress Notes tab indicated the resident tested negative for COVID-19 on 07/08/22 but noted with 101.4 temperature. On 07/11/22 resident diagnosed with pneumonia. On 07/13/22 progress note indicated positive COVID-19 test results. 14. Review of R261's Face Sheet, located in the EMR under the Face Sheet tab revealed he was readmitted to the facility on [DATE] with a primary medical diagnosis of fracture of nasal bones. Review of R261's COVID-19 testing log indicated the resident tested positive for COVID-19 on 07/09/22 with symptoms starting on 07/08/22. Symptoms included cough. Review of R261's Progress Notes located in the EMR under the Progress Notes tab indicated the resident tested positive for COVID-19 on 07/09/22. Symptoms included intermittent coughing. 15. Review of R262's Face Sheet, located in the EMR under the Face Sheet tab revealed she was admitted to the facility on [DATE] with a primary medical diagnosis of acute respiratory disease (COVID-19). Review of R262's COVID-19 testing log indicated the resident tested positive for COVID-19 on 07/11/22 with recent exposure and symptoms including coughing and runny nose. Review of R262's Progress Notes located in the EMR under the Progress Notes tab indicated the resident tested positive for COVID-19 on 07/11/22 and had generalized pain. 16. Review of R263's Face Sheet, located in the EMR under the Face Sheet tab revealed he was admitted to the facility on [DATE] with a primary medical diagnosis of emphysema. Review of R263's COVID-19 testing log indicated the resident tested positive for COVID-19 on 07/14/22 with symptoms starting on 07/14/22. Symptoms included coughing. Review of R263's Progress Notes located in the EMR under the Progress Notes tab indicated the resident tested positive for COVID-19 on 07/14/22 and was experiencing loose stools on 07/18/22. 17. Review of R264's Face Sheet, located in the EMR under the Face Sheet tab, revealed he was readmitted to the facility on [DATE] with a primary medical diagnosis of hypertensive chronic kidney disease. Review of R264's COVID-19 testing log indicated the resident tested positive for COVID-19 on 07/15/22 with recent exposure and symptoms included not feeling well. Review of R264's Progress Notes located in the EMR under the Progress Notes tab indicated the resident tested positive for COVID-19 on 07/11/22, no symptoms noted. Review of the facility's COVID-19 testing logs provided by the Infection Preventionist (IP) revealed 17 staff tested positive for COVID-19 since July 1, 2022, which constituted an outbreak. The following staff members tested positive for COVID-19: 13.Review of Certified Nursing Assistant (CNA)s COVID-19 testing log indicated CNA13 tested positive for COVID-19 with an antigen covid test on 07/01/22. Symptoms started on 06/30/22 which included chills and body aches. The staff member had cared for a resident on 06/27/22 that later tested positive for COVID-19. 2. On 07/04/22, Registered Nurse (RN)1 tested positive for COVID-19 with an antigen covid test. Symptoms started on 07/03/22 which included chills and fatigue. 3. On 07/05/22, the Assistant Director of Nursing (ADON) tested positive for COVID-19 with an antigen covid test. Symptoms started on 07/04/22 which included sore throat. 4. On 07/07/22, Licensed Practical Nurse (LPN)2 tested positive for COVID-19 with an antigen covid test. Symptoms started on 07/06/22 which included chills and body aches. 5. On 07/08/22, CNA2 tested positive for COVID-19 with an antigen covid test. Symptoms included sinus drainage and sore throat. 6. On 07/08/22, LPN9 tested positive for COVID-19 with an antigen covid test. Symptoms included sore throat. 7. On 07/08/22, CNA3 tested positive for COVID-19 with PCR covid test. Unspecified symptoms started on 07/03/22. 8. On 07/11/22, the Assistant Administrator(AA) tested positive for COVID-19 with antigen covid test. Symptoms included cough, runny nose, and headaches. 9. On 07/14/22, Certified Occupational Therapy Assistant (COTA) 1 tested positive for COVID-19 with antigen covid test. Symptoms included sore throat, cough, and congestion. 10. On 07/18/22, Former MDS (Minimum Data Set) nurse tested positive for COVID-19 with an antigen covid test. Symptoms started on 07/17/22 included congestion. 11. On 07/26/22, Physical Therapist (PT)1 tested positive for COVID-19 with an antigen covid test. Symptoms started on 07/25/22 included sore throat. 12. On 07/28/22, Food Services Supervisor tested positive for COVID-19 with an antigen covid test. Symptoms started on 07/27/22 which included cough and sore throat. 13. On 08/11/22, LPN1 tested positive for COVID-19 with an antigen covid test. Symptoms started on 08/08/22 which included fever, chills, and sore throat. 14. On 08/11/22, the Receptionist/Cosmetologist tested positive for COVID-19 with PCR test. Staff member reported no symptoms. 15. On 08/11/22, Dietary Partner (DP1)tested positive for COVID-19 with an antigen covid test. Symptoms included headaches and body aches. 16. On 08/24/22, Housekeeper 1 (HSK1) tested positive for COVID-19 with an antigen covid test after working at the facility 7:00 AM-2:21 PM. Symptoms included runny nose and diarrhea. 17. On 08/26/22, Housekeeper 2 (HSK2) tested positive for COVID-19 with an antigen covid test. The last day worked was 08/23/22. Symptoms included congestion and cough. Review of the testing logs confirmed only routine testing for staff was completed for those staff members that were not vaccinated or were partially vaccinated despite the facility being in an outbreak. Further review of the testing logs confirmed staff and residents were tested when symptomatic but not as the result of outbreak testing. During an interview on 08/29/22 at 7:15 PM with the IP stated she performed Contact Tracing which only included interviewing of the two positive staff members, HSK1 and HSK2. During an interview with the IP, with the Administrator and survey team present on 08/29/22 at 7:18 PM, the IP stated she interviewed Housekeeper 1 on 08/24/22 and the staff member stated she was not in contact with any residents or staff longer than 15 minutes or within 6-foot distance. HSK1 had worked her shift on an unknown part of the facility and contact tracing was not done to determine which residents or staff were in contact with the positive staff member. During an interview on 08/29/22 at 7:18 PM with the IP and the Administrator present, the IP stated she interviewed Housekeeper 2 on 08/26/22 and the staff member told her they were not in contact with any residents or staff longer than 15 minutes or within 6-foot distance. Only the two staff members that tested positive (HSK1, HSK2) were tested due to her determining there was no high-risk exposure, so she didn't do full contact tracing. The IP stated she had not contacted the supervisor to determine exactly where the staff worked for their shifts. No additional staff members or residents were tested due to not being in proximity for more than 15 minutes per staff interviews with HSK1 and HSK2. During an interview on 08/30/22 at 3:20 PM, the IP stated on 08/11/22 she had an interview with the Cosmetologist/Receptionist who stated she was in contact with three residents and contact tracing was done. For Dietary Partner (DP)1 on 8/15/22 contact tracing was not done due to no exposure to residents or other staff for more than 15 minutes. During an interview on 08/30/22 at 3:41 PM, the Environmental Services Manager (ESM), stated HSK2 worked on 8/22/22 and 8/23/22 in the laundry room. On 8/24/22-8/25/22 HSK2 was off work. On 08/26/22 he called and said he was feeling funny, they tested him in the back parking lot, rapid test results were positive, and he has not returned back to work as of 08/30/22. Regarding HSK1 who tested positive on 8/24/22. HSK1 did the PCR test on 8/22/22 (worked Magnolia wing), test came back negative on 8/23/22 (worked Magnolia wing 100 hall, resident rooms, and administrative office), then she was still feeling bad on 8/24/22 midway through the shift, she was tested with a rapid COVID-19 test, and it came back positive. She returned to work 08/30/22 with negative results test. HSK1 always cleans resident rooms on the Magnolia Unit and cleans the administrative offices at entrance of the facility. During an interview on 08/31/22 at 8:51 AM the Administrator stated the facility was doing broad based COVID-19 testing that included certain units that they felt may have been exposed, but not all staff and residents were tested as per guidance from CMS QSO-20-38-NH Revised states for outbreak testing. The facility only performed COVID-19 testing on residents and staff that may have been potentially exposed to COVID-19.