**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, and policy review, the facility failed to ensure that an allegation of verbal abuse by a certified nursing assistant (CNA) A to a resident (1) was reported with the required time frame by CNA B. Findings include: 1. Review of the provider's 7/7/25 FRI revealed:*On 6/30/25, CNA B heard CNA A call a resident (1) a (profanity), while providing care to that resident.*CNA B asked CNA A to repeat what she said, CNA A said, Not you, [resident 1], then CNA A walked out of the room.*CNA B had not reported the incident to the provider until 7/7/25 at 10:00 a.m.-Resident 1 was assessed at that time and was unable to explain or report the occurrence.*CNA A was suspended pending investigation. 2. Review of resident 1's electronic medical record revealed:*She was admitted on [DATE].*Her 6/3/25 Minimum Data Set (MDS) assessment indicated she was rarely understood or able to understand others and was severely cognitively impaired.*Her diagnoses included: Alzheimer's Disease, cerebral infarction (stroke), and dementia with other behavioral disturbances. 3. Interview on 7/9/25 at 10:11 a.m. with administrator C regarding reporting of allegations of abuse revealed:*He expected allegations of abuse or neglect to be immediately reported to a supervisor so that an investigation could be initiated.*He was not aware of the alleged verbal abuse until 7/7/25 when director of nursing D reported it to him.4. Interview on 7/9/25 at 11:24 a.m. with licensed practical nurse E regarding the above incident revealed CNA B had reported the alleged verbal abuse toward resident 1 by CNA A to her on 7/6/25, and she had reported it to director of nursing D on 7/6/25.The provider implemented changes to ensure the deficient practice does not recur was confirmed after record review revealed the facility had followed their quality assurance process, including initiating a performance improvement project, education was provided to all staff regarding reporting of potential abuse incidents, and after staff interviews confirmed knowledge of the reporting of incidents policies and process.Based on the above information, non-compliance at F609 was determined on 6/30/25, and based on the provider's 7/7/25 implemented corrective actions for the deficient practice confirmed on 7/9/25, the non-compliance is considered past non-compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and policy review the provider failed to ensure the care plans were reviewed and revised to reflect the current care needs for two of fourteen sampled residents (2 and 35). Findings include: 1. Observation on 1/28/25 at 10:40 a.m. of resident 2 revealed: *She was sitting in the hallway on a bench. *She had a four-wheel walker in front of her. *She loudly requested staff to remove another resident that was talking to her, stating, She is bothering me. *She got up from the bench and walked to an exit door. *She pushed on the door but did not exit. Observation on 1/28/25 at 3:38 p.m. of resident 2 revealed she had a Wander guard (wearable door alarming device) on her left ankle. Interview on 1/29/25 at 4:34 p.m. with certified nursing assistant (CNA) T regarding resident 2 revealed: *Interventions for behaviors and falls were included in her care plan. *When she exhibited behaviors staff were to offer her picture books, assist her to call her daughter, and turn on old country music. *Interventions in place for her falls included a pressure call light under hip to alert staff when she was getting up. *She recently was on a one-to-one staff monitoring because when she was left alone, she tried to get up and she was unsteady. *She had been working with physical therapy. Review of resident 2's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her 11/13/24 Brief Interview of Mental Status (BIMS) assessment score was 5, which indicated she had severe cognitive impairment. *Her diagnoses included Alzheimer's disease and other specified depressive episodes. *A 1/15/25 physician's order for lorazepam injection solution 2 mg(milligrams)/ml(milliliters) with instructions to inject 2 mg intramuscularly every 24 hours as needed for anxiety, aggressive behavior. Review of resident 2's 1/29/25 care plan revealed: *An intervention, initiated on 11/18/24, within the cognitive function focus area indicated, Wander Guard applied to walker due to wandering and difficulty with direction. *A focus area initiated on 11/1/24 of at risk for altered mood/psychosocial well-being r/t [related to] SNF [skilled nursing facility] placement, change in environment, loss of independence, depression and anxiety. *On 12/10/24 it was revised to include Deer Oaks [a psychological service utilized by the provider] for psychological services in place. *A focus area of The resident has potential for elopement R/T [related to] Hx. [history] leaving building during night hours R/T [related to] Alzheimer's, Dementia *Interventions for this focus included: -Attempt non-pharmacological interventions. -Wander guard used to alert staff to resident's movements. -Minimize potential of resident behavior problems by modifying environmental factors and daily routine. --The modifications were not specified. *A focus area for falls r/t [related to] Alzheimer's Disease, Dementia, Wandering behavior's, E/B [evidence by] Confusion, Wander Guard in place, Exit seeking, hx [history] of falls prior to admission. *The interventions for falls did not include a pressure call light under hip to alert staff when she was getting up. *Interventions that staff identified were not addressed in the care plan. 2. Observation on 1/28/25 at 9:39 a.m. of resident 35 in her room revealed: *The door on her room was closed. *After being invited to enter, resident 35 was crouched behind her lift chair. *Her walker was not near her. *She was pulling cords out of the back of the partially lifted lift chair. *She walked to the bathroom without her walker. *There was a sign on the wall above her bed that said, CALL DON'T FALL. *Resident 35 then stood beside the lift chair, lowered the chair to a reclined position and turned on the heat and massage function of the chair. *Her call light was attached to the lift chair. *She returned to the back of the lift chair and pulled on the cords. *When she was asked if she could turn her call light on for assistance, she moved from behind the lift chair and pressed the call light to turn it on. *She then walked to her room door, without her walker. *Multiple unidentified staff walked past resident 35 standing at the door of her room without her walker. *When CNA U answered the call light she removed the remote for the heat/massage from the lift chair. *Resident 35 continued to walk in her room without the use of her walker. CNA U did not give the walker to resident 35 or encourage her to use it. Observation on 1/28/25 at 3:38 p.m. of resident 35 in her room revealed: *The door to her room was open. *She was walking in her room without her walker. *There was a gold gait belt hanging on the bathroom door. Observation on 1/29/25 at 10:49 a.m. of resident 35 revealed: *She was walking in the hall with her walker. *Staff were not assisting. *She was not wearing a gait belt. Interview on 1/29/25 at 4:36 p.m. with CNA T regarding intervention for resident 35's falls revealed: *Staff visualized her frequently. *Staff were to ensure she had her walker when she was ambulating, and she used it correctly. *Staff were to ensure her call light was near her when she is in her room. *A gait belt was not used because she walked independently with her walker. Review of resident 35's EMR revealed: *She was admitted on [DATE]. *Her 1/6/25 BIMS assessment score was 8, which indicated she had moderate cognitive impairment. *Her diagnoses included dementia, depressive episodes, and anxiety. *There was no assessment completed for resident 35's safe use of the lift chair. Review of resident 35's 1/29/25 care plan revealed: *Her care plan did not address the use of a lift-chair with heat and massage features. *Within the activities of daily living focus area the ambulation intervention indicated, Resident 1 assist to ambulate with walker or at least supervised with ambulation, gait belt on if resident allows, as safety measure. Resident will not remember to use call light or wait for assist [assistance] to walk. Respect residents right to self ambulate. *The focus falls area indicated, The resident is at risk for falls R/T [related to] reported by resident and [family member] that [resident 35] has fallen frequently in the past few months E/B [evidence by] Bruises present to buttocks and right elbow/forearm when admitted . *One of her fall interventions indicated, Obtain gold gait belt for increased compliance and use. *The interventions for frequent visualizations and ensuring resident 35 had her walker and was using it properly were not included in her care plan. Interview on 1/30/25 at 9:19 a.m. with Minimum Data Set (MDS) registered nurse (RN) K revealed: *Care plans gave direction for staff to care for the residents and should be person-centered. *Each morning there was a stand up meeting, where the falls were reviewed, and interventions were determined. *After the meeting the interventions were to be entered in the resident's care plan. *The updates were to be in the care plan, at the nurse's station, and in the breakroom. *CNAs could also refer to the resident's [NAME] (a report of residents' care needs and interventions) to view the interventions. *New residents had a baseline care plan for falls, pressure ulcers, and pain. *Sometimes specific falls were put included in the care plan. *She stated if she was not aware of a specific fall it would not be entered into the care plan. *She indicated multiple staff would enter information into the residents' care plans. *MDS RN K indicated the injuries identified in resident 35's care plan were no longer present. *When asked to clarify if resident 35 was to use a gait belt with the assistance of one staff or was to walk independently she replied, the staff should know if someone was walking independently and a gait belt did not need to be used. *When asked about the gold gait belt for resident 35, MDS RN K indicated she was not aware of that intervention. *She stated staff should know how to care for the residents and their interventions, because the facility is small. *She agreed that resident 35's improper use of her walker and the interventions should be included under her risk for falls in her care plan. Review of the provider's 12/2/24 Care Plan policy revealed: *Each resident will have an individualized, person-centered, comprehensive plan of care that will include measurable goals and timetables directed toward achieving and maintaining the resident's optimal medical, nursing, physical, functional, spiritual, emotional, psychosocial and educational needs. *The plan of care will be modified to reflect the care currently required/provided for the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to adhere to professional standards of practice for: *Following a physician-ordered pain assessment scale prior to the administration of narcotic pain medication for one of one sampled resident (88). *Obtaining physician clarification regarding the type of pain scale assessment ordered by that provider for use with one of one sampled resident (88). *Completing a safety smoking assessment for one of one sampled resident (11) who smoked. Findings include: 1. Observation on 1/28/25 at 10:00 a.m. of resident 88 in her room revealed: *The resident was transferred from her wheelchair to her bed by two caregivers. -She wore a sling on her left arm and verbalized Ow when that arm was touched or moved by the caregivers during the transfer process. Review of resident 88's electronic medical record (EMR) revealed: *She was admitted on [DATE] and her diagnoses included a left humerus (the long bone in the upper arm extending from the shoulder joint to the elbow) fracture and vascular dementia. *Her 1/16/25 Brief Interview for Mental Status (BIMS) assessment score was 1. That indicated her cognition was severely impaired. Review of resident 88's January 2025 medication administration record (MAR) revealed: *Her physician-ordered pain medications included oxycodone HCI (5 mg) which to be given every four hours as needed (PRN). Give 1 capsule by mouth every 4 hours as needed for pain 8-10/10 scale [a numerical rating of pain based on a scale of zero (no pain) through 10 (severe pain) as reported by the resident]. *Oxycodone was administered 12 times between 1/16/25 and 1/29/25. -Seven of those times it was administered for a pain level less than 8: once for a pain level of zero, twice for a pain level of 1, and once each for pain levels of 2, 4, 6, and 7. -Four different licensed nursing staff had been responsible for those same oxycodone administrations. Interview on 1/29/25 at 2:50 p.m. and review of resident 88's above MAR with licensed practical nurse (LPN) F revealed: *The resident was not able to have rated her pain based on a numeric scale because of the level of her cognitive impairment. -LPN F used a faces pain assessment scale. That included a series of face pictures with different expressions that provided her with a way to understand what level of pain the resident may have been experiencing. *She agreed the PRN oxycodone order was not administered according to the physician's order. for 7 of 12 administrations. Interview on 1/29/25 at 3:05 p.m. and review of resident 88's above MAR with director of nursing (DON) B revealed: *PRN oxycodone was not administered per the physician's order for 7 of 12 administrations. -Those administrations were considered to have been medication errors. *Nursing staff failed to notify the physician the resident was unable to verbally rate her pain and a pain scale appropriate for someone with a severe cognitive impairment was needed instead. Review of the provider's 2/2/24 Pain Management policy revealed: *The licensed nurse will assess current pain levels and develop with the physician and interdisciplinary team interventions that may be non-pharmacological [without medication], as well as pharmacological [medication]. The licensed nurse will review response to medication intervention and work closely with the physician to assist in the individualized pain management plan. Review of the provider's revised 4/1/24 Physician/Practitioner Orders policy revealed: *Physician/Practitioner Orders Content: 1. Clarification orders are needed when reviewing any type of physician/practitioner orders that are incomplete or raise questions. If any question arises, nursing services are responsible for obtaining clarification. 2. Interview during the entrance conference on 1/28/25 at 8:30 a.m. with DON B revealed the facility was a non-smoking facility. Observation and interview on 1/28/25 at 9:02 a.m. with resident 11 revealed: *She entered her room. *Her daughter was already in the room. *Resident 11 stated she was going to go out of the facility with her daughter. Review of resident 11's EMR revealed: *Her admission date was 3/28/24. *Her 12/23/24 BIMS assessment score was a 14, which indicated her cognition was intact. *Her diagnoses included: diabetes, chronic kidney disease, COPD, Hypertension, Major Depressive Order, Alzheimer's Disease, Post Traumatic Stress Disorder, Chronic pain, fibromyalgia, heart disease, and anxiety. *A 9/26/24 physician order's indicated Resident may go out on pass with family. She may not smoke on the facility grounds. She may not go out to smoke unless a responsible party is with her. Daughter must sign resident out at the Nurses Station before she can leave [the] facility to visit. May not go out overnight. *Her nurse progress notes included: *On 9/26/24 resident 11 stated she was going outside to smoke. -The nurse read the new order pertaining to leaving facility to resident. -Resident 11 became upset and stated that she has two friends who were coming over to check her out. -The nurse explained the MD [medical doctor] order specified daughter is who the resident could leave with. Review of resident 11's 1/28/25 care plan included: *A 7/12/24 focus area that indicated, resident 11: - Is a smoker and expresses the desire to smoke despite ongoing education from facility staff and provider regarding the risks of continued smoking with her current health status. -Will demonstrate compliance with the facility nonsmoking policy e/b [evidenced by] not smoking in facility, on facility grounds or off property (unless taken out on pass by family). -Has been offered a referral for smoking cessation and staff will continue to counsel her on the detrimental effects of continued smoking. -Per provider: [Resident 11] lacks the safety awareness to sign herself out to go off [the] property to smoke, [resident 11] has an active order that she can only go out on pass/off facility grounds with a family member. -And her family are aware of the tobacco free facility policy and their responsibility to abide by those rules. Interview and review of EMRs on 1/29/25 at 1:49 p.m. with DON B regarding resident smoking assessments revealed: *The admission/re-admission assessment included a question about whether a resident smoked or not. -If this question was marked 'positive' it would trigger a smoking assessment to be completed. *Resident 11's 11/4/24 return from the hospital readmission assessment revealed: -Her current use of tobacco was marked positive which indicated she smoked. -There was no documented safe smoking assessment completed. Continued interview on 1/29/25 at 2:00 p.m. with DON B revealed a safe smoking assessment should have been completed for resident 11 after she was re-admitted from the hospital. Review of the provider's 4/27/22 Tobacco Free policy revealed: *Residents who smoke must not pose a safety hazard to themselves or others.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and policy review, the provider failed to: *Implement and document physician-ordered bowel management interventions for one of one sampled resident (88). *Follow a physician-ordered therapeutic diet for one of one sampled resident (88). Findings include: 1. Observation on 1/28/25 at 10:00 a.m. of resident 88 in her room revealed: *The resident was transferred from her wheelchair to her bed by two caregivers. -She wore a sling on her left arm and verbalized Ow when that arm was touched or moved by the caregivers during the transfer process. Review of resident 88's electronic medical record (EMR) revealed: *She was admitted on [DATE] and her diagnoses included a left humerus (the long bone in the upper arm extending from the shoulder joint to the elbow) fracture and vascular dementia. *Her 1/16/25 Brief Interview for Mental Status (BIMS) assessment score was 1. That indicated her cognition was severely impaired. Review of resident 88's 1/16/25 through 1/27/25 medication administration record (MAR) revealed: *Her pain medication included physician orders for: -Extra-strength acetaminophen (500 milligram [mg]), acetaminophen (650 mg), and oxycodone HCI (5 mg). *A side effect of those pain medications was constipation. Her ordered medications to mitigate the risk for constipation included: -Docusate Sodium (stool softener) which was to be administered twice daily. -A fiber powder (makes stools bulkier/softer) mixed in liquid which was to be administered daily. *Her ordered PRN (as needed) constipation medications included: -Dulcolax suppository. Insert 1 application rectally as needed for constipation. Give daily as needed. Contact provider/practitioner if there are three days without a significant BM [bowel movement]. -Fleet enema. Insert 1 application rectally as needed for constipation. One time daily as needed. Contact provider/practitioner if there are three days without a significant BM. -Milk of Magnesia. Give 30 ml [milliliters] by mouth as needed for constipation. Give daily as needed. Contact provider/practitioner if there are three days without a significant BM. *None of those PRN constipation medications had been administered to her in January 2025. Continued review of resident 88's EMR revealed: *The resident's bowel continence, amount, and consistency from 1/16/25 through 1/27/25 was documented on a user-defined assessment (UDA). -That UDA documentation indicated there had been two instances when resident 88 had gone without having a BM for at least three days. Those dates were 1/18/25 through 1/21/25 and from 1/25/25 through 1/27/25. *Review of resident 88's interdisciplinary progress notes revealed no mention of her having had constipation symptoms, requiring any constipation-related interventions, or that her physician was notified she had not had a BM for three days. Interview on 1/29/25 at 2:50 p.m. with licensed practical nurse F regarding resident 88's bowel management program revealed she: *Confirmed the UDA documentation above was completed throughout the day by certified nurse aides to document a resident's bowel activity. Nursing staff were to review and implement bowel management interventions based on that documentation. *Thought resident 88 had received non physician-ordered constipation interventions such as prune juice when she had not had a BM in three days. She confirmed there was no documentation to support that had occurred. There was no documentation to support the physician's order to have been contacted if the resident had no significant BM in three days was followed. Interview on 1/29/25 at 3:05 p.m. with director of nursing B regarding resident 88 revealed: *The interdisciplinary team met on weekday mornings to discuss resident-related information including residents identified through UDA documentation who had no BM after three days. That same documentation also prompted an alert on the EMR dashboard that notified the nursing staff of the same information. -It was expected nursing staff had documented a response and/or nursing intervention in response to that alert before they cleared it from the dashboard. That had not occurred. *There was no documentation to support acknowledgement of resident 88 having had no BM in three days or that physician-ordered bowel management interventions had been implemented for her. Review of the provider's revised 5/21/24 Bowel & Bladder policy revealed: *Purpose: To assess bowel and bladder function appropriately. To identify appropriate bowel or bladder management programs. Policy: Based on the resident's comprehensive assessment, the location will ensure that each resident with bowel or bladder incontinence will receive appropriate treatment and services to restore as much normal bowel or bladder functioning as possible.

Based on observation, interview, record review, and policy review, the provider failed to ensure a registered dietician's (RD) recommendations had been implemented for one of one sampled resident (6) at nutritional risk related to her weight loss. Findings include: 1. Observations on 1/28/25 at 10:09 a.m. and 12:15 p.m. of resident 6 in her room revealed: *She had been asleep in her bed. *There was an opened bottle of Boost + (a nutritional supplement) with a straw inside of it, a lidded plastic mug with eight ounces of water and a straw inside of it, and an unopened container of Medtrition Gelatein (a jello-type protein supplement) on her nightstand beside her bed. Interview on 1/28/25 at 10:15 a.m. with director of nursing (DON) B regarding resident 6 revealed: *She was hospitalized mid-January 2025 with an upper respiratory infection. During her hospital stay, she developed a COVID-19 infection. -The resident had a physical decline and a decline in behaviors (slapping, kicking, biting, and pinching) since her return from the hospital. Review of resident 6's electronic medical record (EMR) revealed: *Her Brief Interview for Mental Status assessment score was 2. That indicated her cognition was severely impaired. *A 1/12/25 Nutritional Status progress note completed by registered dietician (RD) V: -Resident weights: 125 lbs. (8/6/24), 118.5 lbs. (11/6/24), and 113.4 lbs. (12/31/24). That weight loss was considered to have been unavoidable related to her poor oral intake. Her nutritional goal was to avoid further weight loss and improve her oral intake. -Her diet order was for a regular diet with minced and moist texture food textures. *Nutritional plan recommendations staff were to provide the resident included: -Continue Boost + three times a day at meals. -Continue eight ounces of whole milk three times per day at meals and offer chocolate milk or hot chocolate made with milk to assist with intake if the resident accepted that. -Offer puddings, yogurt, ice cream, hot cereal, or other smooth foods at each meal for extra calories if she accepted that. *RD V's 1/24/25 post-hospitalization Nutritional Status progress note indicated: -The resident's weight on 1/23/25 was 104.4 lbs. and the resident's diet order was changed to a regular diet with pureed texture. -Discussed resident with dietary manager this morning and to consider re-starting the Mighty Shakes [liquid nutritional supplement] tid [three times a day] at meals, along with the Boost +. *Nutritional Plan recommendations for staff were to: -Offer Gelatein trial and, if accepted, obtain an order and continue it. -Continue eight ounces of whole milk tid at meals. -Continue offering puddings, yogurt, ice cream, hot cereal, or other smooth foods at each meal for extra calories if she accepts. Observations on 1/27/25 between 5:30 p.m. and 5:35 p.m. in resident 6's room and of resident 6 in the dining room revealed: *The above observed water and supplements remained untouched on resident 6's nightstand. *The resident was seated in the dining room for the evening meal at a table where staff were available to encourage her to eat. -She was served a four-ounce cup of water and an eight-ounce cup of lemonade. *She independently drank the lemonade. *There were no nutritional supplements, whole milk, or other food items such as pudding or yogurt served to the resident with that meal as recommended by RD V. *Her menu card identified her diet texture but had not indicated any nutritional supplements, whole milk, or any of the above smooth foods recommended by RD V that she was expected to have been either served or offered with her meals. Observations on 1/28/25 at 10:10 a.m. and 12:30 p.m. of resident 6 and at 6:00 p.m. in resident 6's room revealed: *She was in the hallway, awake, and in her wheelchair near the nurses' station. *She ate her noon-time meal in the dining room. -With her meal she was served a four-ounce cup of water and an eight-ounce cup of fruit juice. *There were no nutritional supplements, whole milk, or other food items such as those recommended by RD V served to the resident with that meal. *The above observed water and supplements remained untouched on resident 6's nightstand. Observation on 1/30/25 at 8:15 a.m. in resident 6's room revealed: *The above observed water and Gelatein cup remained on the resident's nightstand but the Boost + was gone. *The resident reached out for and held the surveyor's hand in silence. Interview on 1/30/25 at 8:30 a.m. with unlicensed medication aide W regarding resident 6 revealed she: *Provided the resident Boost + at each meal when she had worked. -Offered the resident four ounces of the supplement at a time. The resident likes Boost +. -Boost + intake or refusal was to be documented daily on the resident's medication administration record. Interview on 1/30/25 at 8:50 a.m. with RD V regarding resident 6 revealed: *After she had completed her resident assessments she would meet with dietary manager (DM) D to discuss her findings and her recommended dietary interventions (Mighty Shakes, Gelatein cups, whole milk, yogurt, pudding etc.) the food and nutritional services (FNS) department was responsible for implementing. -She would communicate with DON B her recommended dietary interventions (physician-ordered supplements such as Boost +) the nursing department was responsible for implementing. Interview on 1/30/25 at 9:00 a.m. with DM D regarding RD V's 1/24/25 FNS-related recommendations for resident 6 revealed: *Each resident's menu card was expected to list individualized dietary interventions including those recommended by RD V. It was his responsibility to ensure the FNS staff had been educated on those recommendations. *He had not updated resident 6's menu card to reflect RD V's recommendations for: -Serving her whole milk at all meals, restarting Mighty Shakes at all meals, or adding Gelatein cups with the noon-time meal. *He agreed the nutritional and caloric value of the mealtime fluid recommendations made by RD V (Mighty Shakes and whole milk) surpassed the mealtime fluids (water and juice) resident had been served by the FNS staff. Interview on 1/30/25 at 9:50 a.m. with FSA (food service assistant) H revealed: *There was a list she reviewed to know which residents received nutritional interventions provided by FNS staff. -Resident 6's name was not listed under the Mighty Shake section of that list so she would not have been served that supplement. -Her name was listed in the Gelatein Cup section. The cup was to be served with her noon-time meal. FSA H had not known why the resident had not received that cup at either of her 1/28/25 or 1/29/25 noon-time meals. -Resident 6's name was not listed under the Milk Served with Meals section of that list so she would not have been served whole milk. *A side-by-side refrigerator outside of the kitchen was stocked with Mighty Shakes, Gelatein cups, milk, and food items such as puddings, and yogurt that were accessible to the FNS staff to have been served to any resident. Observation on 1/30/25 at 12:40 p.m. of resident 6 in the dining room during the noon-time meal revealed: *She was served a four-ounce cup of water, an eight-ounce cup of pink juice, and a container of Gelatein. -There were no nutritional supplements, whole milk, or other food items such as those recommended by RD V served to the resident with that meal. Interview on 1/30/25 at 1:30 p.m. with DON B regarding resident 6 revealed: *She would not have been able to access and consume the water, Boost +, or Gelatein cup left on her bedside stand without assistance from staff. -The palatability and safety of consuming those items after they had been left out at room temperature for the above amount of time was compromised. A Weight Loss policy was requested from DON B on 1/30/25 at 2:30 p.m. She stated the facility had no Weight Loss policy. A 10/15/24 revised Weight and Height policy was provided instead. It only had described the procedures for weighing and measuring residents and not a procedure staff were expected to follow regarding residents at nutritional risk related to having weight loss.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review, the provider failed to ensure an in-room call light system was accessible for three of three sampled residents (10, 28, and 32) who needed staff assistance for their care needs. Findings include: 1. Observation on 1/28/25 at 5:14 p.m. of resident 28 revealed: *She was sitting in her wheelchair beside her bed. *A staff member was present in the room. *The call light was clipped to the call light cord at the receptacle on the wall. *The staff member exited the room and closed the door without moving the call light to be accessible to resident 28. Review of resident 28's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her 1/10/25 Brief Interview of Mental Status (BIMS) assessment score was 2, which indicated she had severe cognitive impairment. *Her diagnoses include Alzheimer's disease, left wrist fracture, and pubic rami (pelvic) and sacral (lower spine) fractures from falls. Review of resident 28's 1/29/25 care plan revealed: *She was at risk for falls. *She required assistance from one staff member for transfers for safety. 2. Observation on 1/29/25 at 2:10 p.m. of resident 32 revealed: *He was sitting in his wheelchair in the middle of the room, looking out the window. *His call light was on the floor beside his bed. Observation on 1/29/25 at 3:12 p.m. of resident 32 revealed: *He was reclined in his wheelchair in the middle of his room, looking out the window. *His call light was in the top drawer of his bedside stand. *The bedside stand was on his left side and not within reach. Review of resident 32's EMR revealed: *He was admitted on [DATE] *His 10/29/24 BIMS assessment score was 6, which indicated he had severe cognitive impairment. *His diagnoses include cerebral infarct (stroke) and hemiplegia (weakness or partial paralysis on one side of the body) affecting left non-dominant side. Review of resident 32's 1/29/25 care plan revealed: *He required the assistance of one to two staff members for activities of daily living. *He was at risk for falls. *His interventions for falls included: -Ensure call light is within reach at all times. -Place call light near [resident's] Right Hand due to LUE [left upper extremity] paralysis. 3. Interview and observation on 01/28/25 at 5:47 p.m. with resident 10 revealed: *She spent a large portion of her time in her bed due to her medical condition. *Staff members often forget to place her call light within her reach. -When she was not able to reach her call light, she would use her cell phone to call the facility and ask for someone to come and assist her. -She felt this was a working solution for her. *She was lying in bed. *Her call light was clipped to the divider curtain in her room, that was not within her reach. Review of resident 10's EMR revealed: *Her admission date was 12/5/23. *Her 12/9/24 BIMS assessment score was a 14, which indicated her cognition was intact. *Her diagnoses included: multiple sclerosis, adult failure to thrive, unspecified severe protein calorie malnutrition, adjustment disorder with depressed mood, chronic kidney disease, and major depressive disorder. Interview on 1/30/25 at 11:17 a.m. with director of nursing (DON) B revealed: *It was her expectation call light would be placed within the reach of residents. *Audits were being completed on call light placement and response times. Review of provider's 7/29/24 Call Light policy revealed: *The purpose of the call light was To ensure resident always has a method of calling for assistance. *When leaving the room, place call light within easy reach of resident.

Based on record review, interview, and policy review, the provider failed to follow their policy for: *Maintaining a physical inventory count of controlled substances at each shift change by two qualified staff for two of two medication carts. *Maintaining a system of receipt for controlled medications (medications that risk abuse or addiction)received from the pharmacy to ensure accurate medication reconciliation of those medications for four of four (2, 6, 17, and 25) residents. Findings include: 1. Review on 1/29/25 of the January 2025 Narcotic Control Sheet (sheet used to document the count of controlled medications between shifts) and the Controlled Drug Records located in the 100-hall medication cart revealed: *The form indicated: -When signed at each change of shift by off-going and on-coming nurse of medication aide, verifies the correct number of schedule 2 narcotics in lock box. -Both nurses and/or medication aides must sign. -Sign-off times on the form were 0630 (6:30 a.m.), 1430 (2:30 p.m.), and 1830/2230 (6:30 p.m./10:30 p.m.). *There were areas where signatures were not present, which included: -One signature on 1/7/25 at 1430 and one at 1830/2230. -One signature on 1/18/25 at 0630 and two at 1430. -Two signatures on 1/21/25 at 1430 and one at 1830/2230. -One signature on 1/22/25 at 0630 and one at 1430. -One signature on 1/23/25 at 1430 and one at 1830/2230. *One Controlled Drug Record did not contain the quantity, date, or nurses signature to verify the receipt of 60 Tramadol, for resident 25. 2. Review on 1/29/25 of the January 2025 Narcotic Control Sheet and Controlled Drug Records located in the 200-hall medication cart revealed: *There were areas where signatures were not present, which included: -Two signatures on 1/4/25 at 1430. -One signature on 1/5/25 at 1430. -One signature on 1/8/25 at 1830/2230. -Two signatures on 1/11/25 at 1430. *Resident 2's controlled drug record did not contain the quantity, date, or nurse's signature to verify the receipt of 10 tablets of lorazepam (anxiety medication). *Resident 17's controlled drug record did not contain the quantity, date, or nurse's signature to verify the receipt of 30 tablets of oxycodone (pain medication). *Resident 6's controlled drug record did not contain the quantity, date, or nurse's signature to verify the receipt of 60 tablets of Tramadol. Resident 6's controlled drug record did not contain the quantity, date, or nurse's signature to verify the receipt of 30 half tablets of Tramadol. Interview on 1/29/25 at 11:08 a.m. with licensed practical nurse (LPN) F revealed: *When controlled medications would arrive from the pharmacy the licensed nurse on duty was to count the medications and compare that count to the amount documented on the controlled drug record. *If the controlled medication count matched the amount documented on the controlled drug form the licensed nurse would document the quantity, the date, and sign the form to verify that the information on the form was accurate. *There were missing nurse signatures on the controlled drug records. *The controlled drug form was then placed in the binder with the Narcotic Control Sheet to be used for the medication reconciliation counts between each shift. *Controlled medication counts were to be done on both carts between each shift. *The nurses'/ UMA's signatures indicated that the narcotic count had been completed. *There were missing signatures on the Narcotic Control Sheets. Interview on 1/30/25 at 10:59 a.m. with director of nursing (DON) B revealed: *It was her expectation that the narcotics were to be counted anytime there was an exchange of medication cart keys. *She expected the nurse who received the controlled medications from the pharmacy to verify the medication count being received, document the quantity and date received and then sign the controlled drug record. Review of the providers 6/27/24 Medications: Controlled policy revealed: *The provider along with the consultant pharmacist will establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation that determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. *Each time the keys that secure controlled medications change from one nurse/medication aide to another, the oncoming and off-going nurse/medication aide will work together to reconcile controlled medications, including all discontinued controlled medications and document the same. *When a new controlled medication is delivered, the nurse in the skilled nursing facility will be responsible for counting the medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the provider failed to ensure: *Two of two sampled residents' (12 and 2) PRN (as needed) psychotropic medications had been discontinued after fourteen days. *An appropriate diagnosis for the use of a psychotropic medication administered to two of two sampled residents (2 and 28). Findings include: 1. Review of resident 12's electronic medical record (EMR) revealed: *A 12/20/24 physician's order for .25 milligrams lorazepam (anti-anxiety/psychotropic medication) to have been administered every 24 hours PRN for combativeness with personal cares. -The physician's order note regarding that same medication indicated: If PRN, order stop date=14 days. Review of resident 12's December 2024 and January 2025 medication administration records (MAR) revealed. *She was administered PRN lorazepam on 12/23/24 and 1/7/25. -The PRN lorazepam order had not been discontinued after 14 days. Interview on 1/30/25 at 12:15 p.m. with director of nursing (DON) B regarding resident 12's PRN lorazepam order revealed it was the responsibility of a licensed nurse to have entered a stop date for that medication for it to have been discontinued according to the physician's order notes. That had not occurred. 2. Review of resident 2's EMR revealed: *She was admitted on [DATE]. *Her 11/13/24 Brief Interview of Mental Status (BIMS) assessment score was 5, which indicated she had severe cognitive impairment. *Her diagnoses included Alzheimer's disease and other specified depressive episodes. *A 1/15/25 physician's order for lorazepam injection solution 2 mg/ml(milliliters) with instructions to inject 2 mg intramuscularly every 24 hours as needed. -The order did not have an end date. -The targeted behavior was indicated to be anxiety aggressive behavior. -There was no diagnosis associated with the lorazepam order. *She did not have a diagnosis of anxiety or behavioral disturbances. 3. Review of resident 28's EMR revealed: *She was admitted on [DATE]. *Her 1/10/25 BIMS assessment score was 3, which indicated she had severe cognitive impairment. *Her diagnoses included dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. *A 11/11/24 physician's order for Ativan (lorazepam) every two hours as needed. *The targeted behavior for the Ativan was anxiety. *There was not a diagnosis associated with the Ativan order. *She did not have an anxiety diagnosis. Interview on 1/30/25 at 11:26 a.m. with DON B regarding the Ativan (lorazepam) orders revealed: *She agreed there was no end date on the Ativan order for resident 2. *It was her expectation that the nurse that received the order would enter and date at 14 days unless there was another date specified by the provider. *She verified there was not a diagnosis associated with the Ativan orders for resident 2 and 28, only an indication for use. *Neither resident had a diagnosis of anxiety in their EMR. Review of the provider's 12/30/24 Psychotropic Medications policy revealed: *Residents do not receive psychotropic drugs pursuant to a PRN [as needed] order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. *The order must contain an appropriate medication, in an appropriate dose and corresponding diagnosis, as well as medical symptoms from the physician. *PRN orders for psychotropic drugs are limited to 14 days. If the attending physician or prescribing practitioner believes that it is appropriate for the prn order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the prn order.

Based on observation, interview, and policy review, the provider failed to ensure: *Kitchenware was stored in a clean and sanitary manner. *Food items in one of one refrigerator designated for resident use and one of one side-by-side refrigerator in the dining room were properly labeled and dated. *One of one refrigerator designated for resident use and one of one side-by-side refrigerator were maintained in a clean manner. *Kitchenware was handled in a manner to mitigate the risk of cross-contamination by one of one lead cook (G) during two of two observed meal services. Findings include: 1. Observation on 1/28/25 at 10:40 a.m. during the initial kitchen tour revealed: *Multiple plastic water pitchers and pitcher lids were stored inside one of the slide-out drawers of the six-drawer kitchenware storage unit. -The pitchers sat upside down inside of that drawer. Two pitchers and one of the lids sat on top of an area that was damp with water. *A four-drawer Tool Shop cabinet held kitchen utensils. -A piece of black foam sat on the bottom of the inside of those drawers. Food crumbs were scattered on top of that foam where the kitchen utensils sat on top of. -Some of the drawers had plastic organizers inside of them that held kitchen utensils. Food crumbs were scattered on the bottom of those organizers that the kitchen utensils sat on top of. *The wall-mounted plastic knife holder had scattered food crumbs on the bottom of it. *There was a [NAME] Cleaning List taped onto a wall. One of the weekly tasks included Clean utensil drawers inside and out. and was initialed as having been completed on 1/24/25. 2. Observation on 1/28/25 at 11:25 a.m. of the refrigerator designated for resident use revealed: *A white carton of peach and vanilla ice cream. It had no open or expiration date on it. *A jar of Buffalo Berry jam without an open date. *About 75% of the refrigerator's back wall was covered in a layer of thin, lumpy white ice build-up. 3. Continued observation of the side-by-side refrigerator next to the resident refrigerator revealed the bottom of the inside of that refrigerator had a dried red-colored substance on it. That same substance had run down one side of the inside of that refrigerator. Interview on 1/29/25 at 1:30 p.m. with food service assistant (FSA) H regarding the above refrigerators revealed: *All staff were responsible for cleaning both refrigerators on a regular and an as needed basis. *Residents' families or kitchen staff were expected to have labeled and dated all food placed inside the resident designated refrigerator. -All staff were responsible for ensuring the refrigerator's contents were regularly checked for outdated or unlabeled food and to have removed those food items. 4. Observations on 1/28/25 from 11:35 a.m. through 12:10 p.m. and on 1/29/25 at 5:00 p.m. of lead cook G preparing food in the kitchen and serving food at the steam table revealed he: *Removed a metal container of pureed vegetable from the steam oven using his bare thumb to hold the inside rim of that container as he removed it. -Shook then wiped off his thumb after it had touched the contents of the pureed food mixture when it was removed. *Used the countertop blender to puree a mixture of boneless pork chop, gravy, and vegetable stock. -Took the blender lid off then placed his bare thumb on the inside rim of the blender cup, removed it from its base, and poured the contents into a metal container for serving. *Removed mashed potatoes from the steam oven and inserted a digital food thermometer far enough into the potatoes to cover both the temperature probe and the bottom surface of the plastic base attached to the probe. *Used his bare thumb to hold the inner lip of each plated dish that was served to a resident. -Handled paper menus, touched the metal top of the steam table and other items in and around that food service area in between touching each plate and without having performed any hand hygiene. *Placed two re-usable squeeze bottles of salad dressing inside the same container of lettuce salad mix causing those bottles to touch the salad mix. -Removed and returned the squeeze bottles from that container throughout the meal service to dispense salad dressing. At the end of the meal service the bottles were placed back into a refrigerator. Interview on 1/30/25 at 11:30 a.m. with dietary manager D regarding the above observations revealed: *Since November 2024 he had been splitting his time as dietary manager between this facility and a sister facility until a full-time dietary manager was hired for this facility. *He had educated kitchen staff about safe kitchenware storage practices. He knew kitchenware that was stored on moist surfaces had the potential to attract bacteria. *He had assigned a FSA to examine the contents of both the above refrigerators to ensure all food items had been properly labeled/dated or discarded if that was appropriate. Examining the refrigerators would have also included ensuring they had been clean. He had not checked to ensure the assigned FSA had completed the task as he requested. *He expected hot food vessels to be handled using hot pads preventing the need for contact with the inside of that vessel. Bare fingers should not have been used to handle the inside of a blender cup or to hold the inner rim of serving plates. Only the probe of the digital food thermometer was expected to have touched food including the potatoes. Re-usable plastic squeeze bottles should not have been placed in the same container with a consumable food item. -Failure to perform the practices above in an appropriate manner had increased the risk of cross-contamination. Review of the provider's revised 5/12/23 Safe Handling of Personal Food, Outside Food-Food and Nutrition policy revealed: *Procedure: 6.b. Food and beverages without manufacturer expiration date should be dated upon arrival in the facility and discarded 7 days after date marked. *Personal Food Stored in Common Areas: -3. The resident/family: a. Labels, dates and covers all opened foods that are brought in for the resident. All food must have the resident name and room number clearly visible on the container/package. lb. Removes personal food when no longer considered safe for consumption. 4. Employees monitor common food storage areas, clean the equipment and remove unsafe foods without replacing the items. Review of the provider's revised 6/13/24 Dining Service Standards-Food and Nutrition Services policy revealed employees will follow procedures for prevention of foodborne illness when serving meals.

Based on interview and record review, the provider failed to ensure bathing was provided to 13 of 16 sampled residents (2, 7, 10, 11, 12, 17, 23, 27, 29, 30, 32, 34, and 35), in a census of 36 residents while certified nursing aide (CNA)/bath aide N was not at the facility. Findings include: 1. Interview on 1/29/25 at 1:40 p.m. with CNA L revealed: *Residents were to be bathed at least once per week. Some residents preferred two baths. *CNA/bath aide N was in charge of bathing residents and making the bathing schedule. *He stated that all CNAs were trained and capable of bathing residents. *He was able to show this surveyor the bathing schedule and the completed bath sheet. Interview on 1/29/25 at 2:30 p.m. with licensed practical nurse (LPN) F revealed: *Residents were to be bathed at least once per week. *CNA/bath aide N was in charge of bathing residents. *If CNA/bath aide N was ill or unable to work, another CNA would be given the task of bathing residents that day if staffing permitted. *If staffing did not permit, the resident would be offered their bath on a different day that week. Interview on 1/30/25 at 1010 a.m. with CNA/bath aide N revealed: *She is scheduled to work every week from Sunday through Thursday, 8 hours per day. *She recently missed two weeks period work due to a scheduled hand surgery. *It was her expectation residents would still have received their baths during her absence. *She reported that she had trouble keeping up with the bathing schedule by herself. *The other CNAs help as much as they can. *She had asked management for help but has not received it. Interview on 1/30/25 at 10:30 a.m. with director of nursing (DON) B revealed: *She was aware CNA/bath aide N was recently on leave from work. *She expected residents to be bathed at least once per week. *She reported that registered nurse (RN) E made the CNA schedule. *She had assumed RN E would have scheduled other staff to complete the bathing task in CNA/bath aide N's absence, but she did not. Interview on 1/30/25 at 12:35 p.m. with resident 10 revealed: *She preferred to have two baths per week. *She recalled when CNA/bath aide N was not working recently, she was not receiving her baths as scheduled. Interview on 1/30/25 at 12:45 p.m. with resident 29 revealed: *She preferred to have two baths per week. *She recalled she recently was not getting her baths as scheduled. It's because [CNA/bath aide N] was gone. *We really missed her. Review of the provider's Suggestion or Concern form completed by resident 17's daughter on 1/22/25 revealed she had concerns about resident 17 missing his scheduled baths. Review of documentation in Point Click Care (PCC) (documentation system used by the provider) regarding resident baths revealed: *Resident 2 received a bath on 1/15/25, then did not receive a bath until 1/29/25, 13 days in between baths. *Resident 7 received a bath on 1/15/25, then did not receive a bath until 1/28/25, 12 days in between baths. *Resident 10 received a bath on 1/9/25, then did not receive a bath until 1/27/25, 17 days in between baths. *Resident 11 received a bath on 1/8/25, then did not receive a bath until 1/29/25, 20 days in between baths. *Resident 12 received a bath on 1/7/25, then did not receive a bath until 1/23/25, 15 days in between baths. *Resident 17 received a bath on 1/9/25, then did not receive a bath until 1/23/25, 13 days in between baths. *Resident 23 received a bath on 1/9/25, then had not receive a bath through the time of the survey on 1/29/25. *Resident 27 received a bath on 1/7/25, then did not receive a bath until 1/20/25, 12 days in between baths. *Resident 29 received a bath on 1/9/25, then did not receive a bath until 1/26/25, 16 days in between baths. *Resident 20 received a bath on 1/13/25, then did not receive a bath until 1/23/25, 9 days in between baths. *Resident 32 received a bath on 1/13/25, then did not receive a bath until 1/27/25, 13 days in between baths. *Resident 34 received a bath on 1/13/25, then did not receive a bath until 1/27/25, 13 days in between baths. *Resident 35 received a bath on 1/7/25, then had not received a bath through the end of the survey on 1/29/25.

Based on observation, interview, and policy review the provider failed to ensure: *Medications for three of three residents (30, 32, and 35) were properly labeled. *An insulin pen for one of one resident (89) was dated when opened. *Two of two medication carts were locked when left unattended. *An outdated medication for one of one resident (22) was properly disposed of. Findings include: 1. Observation on 1/30/25 at 7:36 a.m. of the medication cart in the 200-hallway revealed: *The medication cart was unlocked. *No staff were present at the medication cart. *Registered nurse (RN) J exited a resident room, returned to the medication cart, and charted medication administration. Observation on 1/30/25 at 11:16 a.m. revealed the medication cart in the 100-hallway was not locked and there was no staff at or within eyesight of the medication cart. 2. Observation on 1/29/25 at 10:58 a.m. of the medication cart in the 100-hallway revealed a Lantus (long-acting) insulin pen that belonged to resident 89 without a date on the pen that would have indicated when the pen was removed from the refrigerator and was opened. Interview on 1/29/25 at 11:08 a.m. with licensed practical nurse (LPN) F regarding resident 89's insulin pen revealed she: *Verified the insulin pen was not dated. *Indicated it should have been dated when it was opened. *Disposed of the insulin pen. *Stated the pen needed to be disposed of because the date it was opened could not be verified. 3. Observation and interview on 1/29/25 at 11:28 a.m. of the medication cart in the 200-hallway revealed: *Two open packages of 4 x 4 Hydrogel Impregnated [for wound healing] Gauze Dressing. -There was a portion removed from each of the gauze dressings. -The dressings did not include an opened date or a resident identification. *A medication card that of hydrocodone-acetaminophen (pain medication) 5/325 milligrams (mg) indicated it had been dispensed on 11/1/23 for resident 22. -The back of that medication card indicated the medication expired on 10/24. *Certified Nursing Assistant (CNA)/unlicensed medication aide (UMA) L indicated that licensed nursing staff completed all dressing changes. *He verified the expiration date of that medication and stated he would alert the charge nurse. 4. Observation and interview on 1/30/25 at 8:25 a.m. with RN J during medication pass on the 200-hallway revealed: *There was no dose indicated on resident 35's Calcium Citrate with vitamin D medication card. *Resident 35's Preservision (eye health supplement) order read 1 unit and the label on the bottle reflected tablets. *Resident 32's had an order for Senna S 8.6/50 mg one tablet daily. *That medication card did not indicate a dose and the name of the medication on the medication card was Stimulant Laxative Plus, which did not match the medication name on the order. *Resident 30's ordered dose of Calcium + Vit D liquid did not match the dose on the label of the medication bottle. *RN J verified all of the above, collected those medications, and brought them to the charge nurse. *The charge nurse then gave the collected medications to the director of nursing (DON). Interview on 1/30/25 at 11:05 a.m. with DON B revealed: *She was notified of and verified the above medication and label issues with the medications and had notified the pharmacy. *It was her expectation that insulin pens be dated when opened. *She would expect that a new dressing be opened with each dressing change and any dressing that was left over was to be disposed. *She witnessed the unlocked medication cart in the 100-hallway and locked it. Review of the provider's 9/5/24 Medication: Insulin Administration policy revealed during the procedure indicated, Verify provider order, the expiration date and the number of days the pen has been open. Review of the provider's 3/29/24 Medications: Acquisition Receiving Dispensing and Storage policy revealed: *Licensed nursing employees are responsible for ordering from the pharmacy and checking all new orders of medications from the physician's orders. *The order will include the date of change, the location name, resident's name, medication name, dosage, route, quantity, or duration and strength, diagnosis or indication for use and the physician's name. *Medications will be stored in a locked medication cart, drawer or cupboard. *The location will routinely check for expired medications and necessary disposal will be done in accordance with state/pharmacy regulations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to ensure: *Contact precautions were appropriately implemented and utilized for one of one sampled resident (10) with a feeding tube and a history of MRSA Bacteria [Methicillin-resistant Staphylococcus aureus], VRE [Vancomycin-resistant Enterococci], and MDR [multidrug-resistant organism] infections. *Enhanced barrier precautions (EBP) were appropriately implemented and utilized for one of one sampled resident (23) with an indwelling urinary catheter and daily dressing changes. *One of one resident (27) was separated from other residents while awaiting further tests following a positive QuantiFERON (blood test for tuberculosis) result. Findings include: 1. Observation on 1/28/25 at 5:47 p.m. of resident 10's room and tube feeding placement revealed: *There was a sign on her door that stated to use contact precautions. -Directions on the sign included to put on gloves and a gown before entering the room and to remove the gown and gloves before leaving the room. -There was no available gloves and gown available outside of resident 10's room. *Registered nurse (RN) J entered resident 10's room and washed her hands. -She then placed clean one-time-use gloves on her clean hands. -She did not have on a gown. *RN J then completed the tube feeding. Observation 1/29/25 at 9:55 a.m. of resident 10's room and hallway. *The door to her room was closed. *The contact precaution sign remained posted on her door. *There was a personal protective equipment (PPE) cart located in hallway, next to her room, with gowns and gloves in it. *There was a trashcan with lid located next to PPE cart. Review of resident 10's electronic medical record (EMR) revealed: *Her admission date was 12/5/23. *Her 12/9/24 Brief Interview of Mental Status assessment score was a 14, indicating her cognition was intact. *Her diagnoses included: multiple sclerosis, adult failure to thrive, unspecified severe protein calorie malnutrition, adjustment disorder w/depressed mood, chronic kidney disease, major depressive disorder. *There was a 12/6/23 physician order that indicated to use contact precautions when performing cares or in close contact as per facility policy. -This order included No swab for VRE Clearance at this time. *Her 1/27/25 care plan included a 12/6/23 focus of a history of MRSA Bacteria, VRE and MDR infections requiring Contact Precautions during cares. -The goal for this focus included, The resident's infection will resolve with minimal complications as evidenced by negative culture, vital signs WNL [within normal limits] and no s/s [signs and symptoms] of acute infection through the review date. -The interventions for this focus and goal included, CONTACT PRECAUTIONS: Wear gowns and masks when changing contaminated linens. Place soiled linens in bags marked biohazard. Bag linens and close bag tightly before taking to laundry. Interview on 1/29/25 at 1:25 p.m. with licensed practical nurse (LPN) S regarding resident 10's care revealed: *She had been placed on contact precautions since enhanced barrier precautions [EBP] were initiated for the facility. -She was not certain of that date. *When she provided care to resident 10, she wore a gown, gloves, and a mask just because. Interview on 1/29/25 at 2:40 p.m. with infection preventionist (IP)/registered nurse (RN) E regarding contact precautions for resident 10 revealed: *Contact precautions included a staff member wearing a gown and gloves when providing care. *Resident 10 was admitted on [DATE] with a physician's order to use contact precautions. -When staff members went into resident 10's room they were to complete hand hygiene before entering the room and when exiting the room. -They were to wear a gown and glove when providing her close contact cares. *Her expectation was for a nurse to wear a gown and gloves when assisting resident 10 with her tube feeding. *She was not aware PPE was not outside of resident 10's room on 1/28/25. -She stated the trashcan should be in the resident's room and not in the hallway. *Regarding contact precautions due to no swab for VRE clearance, she thought resident 10 had a couple of drug-resistant organisms in her urine. *Review of resident 10's care plan confirmed contact precautions were to be used. -Those contact precautions listed did not include gloves. -She stated gloves should be a big part of that [contact precautions]. *Her expectations for contact precautions included the use of a gown and gloves and a trashcan should be placed in the resident's room for disposal of PPE before leaving the room. Review of the provider's 4/2/24 Standard and Transmission Based Precautions revealed: *Standard precautions are meant to reduce the risk of transmission of bloodborne and other pathogens from both recognized and unrecognized sources. They are the basic level of infection control precautions which are to be used in the care of all residents. These precautions are designed to reduce the risk of microorganisms regardless of diagnosis. They are designed to protect employees and residents from both recognized and unrecognized sources of infection. *Contact precautions will be used in addition to standard precautions for residents/patients with known or suspected infections or evidence of syndromes that represent an increased risk for contact precautions. *Post clear signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE. -Gloves and Gowns. 2. Review of resident 27's electronic medical record (EMR) revealed: *A progress note from 1/10/25 at 10:19 a.m. written by RN I stated lab returns showing + quantiferon, order received per physician assistant (PA) X to send resident to urgent care for CXR [chest x-ray] today. *Progress note on 1/10/25 at 12:43 p.m. noted that resident's sister was informed of the positive TB blood test. *Progress note on 1/10/25 at 1:26 p.m. stated resident returned with note to call Radiology for report, per PA X, she will watch for report. *Progress note on 1/11/25 at 5:43 a.m. stated 24 hr [24 hour] check-still awaiting dictation. Interview on 1/29/25 at 2:40 p.m. with resident 27 revealed he was not able to recall if he had ever been exposed to tuberculosis or the events that occurred on 1/10/25. Interview on 1/29/25 at 3:05 p.m. with licensed practical nurse (LPN) F revealed: *She had never cared for a resident who was positive for tuberculosis. *Her expectation was if there were a resident positive for tuberculosis, she would notify the director of nursing (DON) immediately and the resident would be separated from other residents to prevent spreading it. Interview with DON B on 1/30/25 at 10:30 a.m. revealed: *She was not immediately made aware of resident 27's positive tuberculosis test on 1/10/25. *She was surprised RN I did not notify her of the positive tuberculosis result. *RN I did immediately call the physician, but did not separate resident 27 from other residents and staff. *She reported resident 27's roommate was not moved to a different room after the RN I knew of the positive tuberculosis blood test. *It was the DON's expectation to be notified immediately of a positive tuberculosis test and to separate that resident from any other residents or staff. Interview on 1/30/25 at 1:05 p.m. with administrator A regarding tuberculosis revealed: *It was his expectation that RN I would have notified the DON and administrator immediately. *It was his expectation resident 27 would have been isolated from other residents and staff until the results of his chest x-ray were available. *It was his opinion that a positive tuberculosis blood test should have been considered active tuberculosis until determined otherwise by the chest x-ray. Review of the provider's 5/2023 Tuberculosis Control Plan for Residents, R/S, LTC, Home Health policy revealed: *PURPOSE: To provide early identification of residents infected with Mycobacterium tuberculosis (TB) to prevent the spread of TB through appropriate screening, placement, and treatment of residents with exposure to TB. *Residents with Suspected or Confirmed Tuberculosis (SNF and Home Health) -Isolate the resident on Airborne Precautions. The resident may be isolated in their own room if roommates are removed. -Place a warning sign outside the isolation room. The wording must say STOP, HALT, or NO ADMITTANCE and refer persons to the nurses' station or to other staff members for instructions. -Restrict contact with the resident until transfer to an appropriate center. -Notify the transportation company that the resident being transported has suspected or confirmed TB. Respiratory protection is required for the transporting team when the resident is in a closed vehicle. 3. Observation on 1/28/25 at 9:19 a.m. revealed EBP signage was posted outside resident 23's room. Interview and observation on 1/28/25 at 9:20 a.m. with resident 23 revealed she had an indwelling urinary catheter and received daily dressing changes for a pressure ulcer on her buttocks. -She agreed to the observation of her wound care and stated that dressing changes are usually done in the morning. Observation of wound care on 1/29/25 at 10:03 a.m. revealed: *Certified nursing aide (CNA) M had already performed personal hygiene for resident 23 and was holding her on her left side. -CNA M was wearing gloves but no gown. *Licensed practical nurse (LPN) F provided wound care to resident 23's pressure ulcer. -LPN F was wearing gloves but no gown. Interview on 1/29/25 at 2:40 p.m. with infection preventionist/wound care registered nurse (RN) E regarding EBP revealed she expected staff to wear a gown and gloves during close contact care and to perform hand hygiene before and after resident contact. Review of resident 23's medical record revealed: *She was admitted on [DATE] *She had a brief interview for mental status (BIMS) assessment score of 13, which indicated she was cognitively intact. *Her diagnoses included hemiplegia (paralysis that affects one side of the body) and hemiparesis (weakness that affects one side of the body) following cerebral infarct (a stroke) affecting the left non-dominant side, neuromuscular dysfunction of the bladder (nerves controlling the bladder are damaged, leading to disrupted communication between the brain and bladder), and polyneuropathy (multiple peripheral nerves are damaged, leading to problems with sensation and coordination). *A care plan focus area initiated on 6/28/24 indicated: -The resident requires Enhanced Barrier Precautions (EBP) R/T [related to] indwelling medical device- Foley catheter. *Her care plan included a 6/28/24 initiated intervention: - Don [put on] gown and gloves when performing high contact care activities including: dressing, bathing, transferring, providing hygiene such as shaving or brushing teeth, changing linens, repositioning, checking and changing [related to incontinence needs], device care and/or use, and wound care. Review of the provider's 4/2/24 Standard and Transmission-Based Precautions, All Service Lines policy revealed: *Enhanced Barrier Precautions - Enhanced barrier precautions expand the use of PPE beyond situations in which exposure to blood and body fluids is anticipated and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. - Enhanced barrier Precautions are needed for residents with chronic wounds (Pressure Ulcers, Diabetic Foot Ulcers, Unhealed surgical wounds, and venous stasis ulcers) and Residents with Indwelling Medical devices (central line, hemodialysis catheters, indwelling urinary catheters, feeding tubes, and tracheostomies). - High-contact Resident Care Activities include: Transfers, dressing, assisting during bathing, providing hygiene, changing briefs or assisting with toileting, working with resident in therapy gym, specifically when anticipating close physical contact while assisting with transfers and mobility, changing linens, device care or use (central line, urinary catheter, feeding tube, tracheostomy), Wound care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review the provider failed to ensure physician orders for pressure ulcer interventions had been implemented in an appropriate amount of time for one of one sampled resident (86). 1. Observation on 11/16/23 at 9:18 a.m. of resident 86 in his room revealed: *He was seated in his recliner with the foot rest in the elevated position. *The heels of his feet were resting on the outer edge of the footrest. -On his feet were red felt booties. *There was a square foam pad positioned between his thighs which caused his legs to spread outward. *His eyes were closed. Review of resident 86's electronic medical record revealed: *He was admitted on [DATE]. *His diagnoses included: heart failure, urinary tract infection, chronic kidney disease, morbid obesity, malignant neoplasm of the prostate. *His 11/3/23 admission skin observation documentation revealed the following wounds: -A pressure ulcer on his right heel that measured 2.2 centimeters (cm) by (x) 1.5 cm by 0.2 cm. -A pressure ulcer on his left heel that measured 1.0 cm x 1.5 cm x with no depth. -An open area on his right buttock that measured 3.0 cm x 2.3 cm. -A dry reddened area with excoriation on his left buttock that measured 3.0 cm x 3.0 cm. *His 11/13/23 wound data collection form revealed the following wounds: -A stage III pressure ulcer (a wound that extends into deeper tissue and fat but does not reach the muscle, tendon, or bone) on his right heel with no measurements. -A pressure ulcer on his left heel that measured 0.5 cm x 0.8 cm with no depth. -Shearing on his right buttock that was improved. -Shearing on his left buttock that was improved. *His 11/2/23 NEW Nursing Home Physician Orders noted on 11/15/23 included: -Daily weights and to call his provider if he had a weight increase of 3 pounds (lbs) overnight or 5 lbs in a week. -Heel protectors. -Low air loss chair/recliner cushion/mattress. *His electronic medical record physician orders revealed the following start dates for the above orders were: -On 11/7/23 the heel protectors. -On 11/15/23 the: --Daily weights and to call his provider if he had a weight increase of 3 pounds (lbs) over night or 5 lbs in a week. --Low air loss chair/recliner cushion/mattress. Interview on 11/16/23 at 9:24 a.m. with licensed practical nurse D regarding resident 86's pressure ulcers revealed she thought the stage III right heel pressure ulcer was improving based on the information provided to her during change of shift. Interview on 11/16/23 at 10:15 a.m. with certified nursing assistant F regarding resident 86 revealed: *He always slept in his recliner. *She tried to prop his legs up so his heels would not touch the footrest. -She stated it Is hit or miss due to his non compliance. *His red slippers were to take the place of grippy socks to prevent falls. *His feet were wrapped with ace wraps due to the wounds. Interview on 11/16/23 at 10:52 a.m. and again at 12:32 p.m. with director of nursing B revealed: *The low loss air mattress that had been physician ordered on 11/2/23 was not ordered from the vendor until 11/7/23. *There was not a low air loss chair or recliner available. *Not all of resident 86's physician orders from 11/2/23 had been recorded in his electronic medical record. -A temporary agency nurse had entered part of the orders. --She had not been aware that all of the orders needed to be entered. Interview on 11/16/23 at 11:15 a.m. with administrator A regardin resident 86's physician ordered interventions revealed the provider did not have a low air loss chair or recliner. Review of the provider's Pressure Ulcers Policy revealed: *Policy -A resident who has a pressure ulcer will receive the necessary treatment and services to promote healing, prevent infection and prevent new pressure ulcers from developing. -Residents will receive appropriate assessments and services to promote and maintain skin integrity.

Based on observation, interview, and policy review the provider failed to ensure two of two cooks (G and L) on two of two observed opportunities had prepared pureed food for residents with adequate nutritional value. Findings include: 1. Observation and interview on 11/14/23 at 9:00 a.m. with cook G revealed: *Two stainless containers with pureed looking food on the counter. -He stated it was pureed food for residents and they mixed water with it instead of milk/cream due to the amount of phlegm the milk products produced for residents. Observation and interview on 11/14/23 at 11:15 a.m. with cook G regarding pureed food revealed: *He used water to puree the chicken and mix vegetables. *He had been instructed by dietary supervisor O to use water, due to residents coughing and having congestion. -He was not aware water would deplete the nutritional value of the pureed food. 2. Observation and interview on 11/16/23 at 7:31 a.m. with cook L revealed: *She pureed two servings of eggs with one-half cup of water. -The eggs were too runny so she added two squirts of thickener. *She pureed two servings of apple pie filling with one cup of water. -The apples were very runny so she added two squirts of thickener. -Stated some people serve apple sauce instead of pureed apples. *She had been trained by dietary supervisor O to use water. *One of the residents requiring pureed food was allergic to diary products. *Agreed using something with nutritional value would have been a better choice than water. Interview on 11/16/23 at 7:51 a.m. with administrator A regarding the process for resident's pureed food revealed he: *Was not aware that water was being used to puree the food. *Stated dairy products would provide better nutrition and would make the consistency more appealing than water. *Review of the provider's Texture-Modified Diets Policy revealed: *Purpose -To ensure safe consumption of food/fluids for those residents who have difficulty chewing/swallowing (dysphagia). *Policy -Food and nutrition services provide texture-modified diets that are prescribed by the resident's attending physician. Texture-modified diets are served .and prepared by methods that conserve nutritive value, flavor, and appearance. Policy review and interview on 11/16/23 at 8:25 a.m. with administrator A revealed that he agreed the policy had not been followed. Dietary Manager O not available for an interview throughout the survey.

Based on observation, interview, and policy review, the provider failed to ensure one of one observed counter ice machine was maintained in sanitary condition. Findings include: 1. Observation on 11/14/23 at 12:05 p.m. of the counter ice machine located in the dining room had: *Three cracks extending from the bottom plastic cup holder upwards about three inches high. *Two cracks directly underneath of the ice dispenser. *There was a clear plastic funnel for the dispensing ice to flow through. -That funnel was not in place on the ice dispenser. --It was sitting on the counter next to the ice dispenser. Random observations throughout the survey on 11/14/23 from 11:15 a.m. to 4:00 p.m. and again on 11/16/23 from 7:32 a.m. through 11:00 a.m. revealed the plastic funnel was not in place on the ice dispenser. Interview on 11/16/23 at 8:48 a.m. with administrator A regarding the ice machine revealed: *He was not aware of the unsanitary condition of the ice machine prior to the surveyor bringing it to his attention. *He stated he would order a new full front for the ice machine. Review of the provider's Ice Machines Use and Maintenance-Food and Nutrition Policy revealed: *Purpose: -To provide procedures to limit contamination of ice. -To provide procedures for proper maintenance of ice machines. *Maintaining the Ice Machine -1. Clean, descale and change filters according to manufacturer recommendations. Adjust the frequency based upon the use and conditions related to the ice machine (location, quality of water, etc.). 2. Use an EPA [Environmental Protection Agency] registered disinfectant suitable for use on ice machines according to manufacturers' instructions.

Based on Payroll Based Journal (PBJ) record review, employee timecard review, staffing schedules, and electronic medical record review, the provider failed to submit PBJ data accurately for three of three federal fiscal quarters (Quarter 1, 2023; Quarter 2, 2023; and Quarter 3, 2023). Findings include: 1. Review of PBJ records submitted to the Center for Medicaid and Medicare (CMS) services revealed the provider submitted the following for no licensed nursing coverage 24 hours per day for: -Quarter 1, 2023 for seven days: 10/8/22, 10/9/22, 10/16/22, 10/23/22, 10/30/22, 11/20/22, and 12/04/22. -Quarter 2, 2023 for six days: 1/8/23, 1/14/23, 1/15/23, 1/21/23, 2/12/23, and 3/5/23. -Quarter 3, 2023 for four days: 5/20/23, 6/3/23, 6/24/23, and 6/25/23. Review of the provider's employee timecards, staffing schedules and resident's electronic medical records documentation revealed the provider had licensed nursing coverage 24 hours per day for the period referenced above. Interview with director of nursing (DON) B on 11/16/23 at 10:50 a.m. regarding PBJ online reporting revealed: *The information was automatically obtained from individual staff timecards by their electronic payroll system. *They would receive a notification if something appeared to have been incorrect. --Incorrect information was usually related to not having hours worked in the correct code. -The administrator was able to sign into the electronic payroll system and update any incorrect information. *At one point in time agency staff hours were not able to be recorded in the provider's electronic payroll system. -Those hours worked would not have been automatically sent to CMS. *When the DON worked as the charge nurse, her hours codes would have needed to be adjusted. -The administrator or the DON would have had to adjust the payroll code information to reflect actual hours worked. Interview on 11/16/23 at 11:15 a.m. with administrator A regarding PBJ online reporting revealed: *The information was automatically obtained from individual staff timecards by their electronic payroll system. *He was aware that incorrect information had been submitted to CMS on occasion. *He was unsure as to why certain employee's time worked was not being electronically transferred correctly. -He had been, trying to figure out why. *The administrator and the DON should have had access to the electronic reporting system to correct the submission information before sending the information electronically. -They both had started in the facility recently, and did not have the, working knowledge how to fix it.

Based on observation, interview, record review, policy review the provider failed to ensure: *Hand hygiene was completed per facility policy during two of two observed water passes to all residents. *Oxygen tubing and nasal cannulas had been replaced for two of two sampled residents (1 and 9) on a routine basis. *An insulin pen was stored in a sanitary manner after use for one of one sampled resident (10). *Oxygen tubing was stored in a sanitary manner for one of one sampled resident (9) when not in use. 1. Observation on 11/14/23 at 11:04 a.m. of certified nursing assistant (CNA) E during the water pass to residents in the north hall revealed she had: *A push-cart with clean water cups with straws, that had contained ice water, on the top shelf of the cart. -There had been enough cups on the top shelf for every resident in the facility. *Brought clean water cups into a resident's room without performing hand hygiene. *Removed the used water cups from the same room and placed them on the second shelf of the cart. *Not performed hand hygiene before picking up two clean cups from the top of the cart and bring those clean cups into a different resident room. *Continued to pass the remaining resident's water without performing hand hygiene. Observation and interview on 11/16/23 at 10:23 a.m. of CNA E and CNA F during the water pass to residents in the north hall revealed: *They had prepared the water cups in the dining room without first performing hand hygiene. *The ice water cups had been passed in the same matter as the above observation two days before. *CNA E agreed that hand hygiene should have been performed after grabbing the used water cups and before grabbing a new clean water cup for a different resident. Interview on 11/16/23 at 11:35 a.m. with director of nursing (DON) B regarding the above observations revealed: *She was unable to recall what the facility's procedure for passing water to the residents was. *She had agreed that the staff should have been sanitizing their hands after touching anything in a resident's room and before touching anything that would have been going into another resident's room. Review of the provider's August 2023 Water Pitcher policy revealed that water pitchers would be collected daily, and hands would be washed before distributing clean water pitchers. Review of the provider's March 2022 Hand Hygiene policy revealed: *POLICY: *All employees in patient care areas (unless otherwise noted in their policy) will adhere to the 4 Moments of Hand Hygiene and 2 Zones of hand hygiene. *1. Entering Room *2. Before Clean Task *3. After Bodily Fluid/Glove Removal *4. Exiting Room *5. Zones: Patient zone and Health-care zone 2. Observation on 11/14/23 at 2:40 p.m. of resident 1's room revealed: *She had been receiving oxygen through nasal cannula tubing. *There was no label on the oxygen tubing that indicated when that tubing had been placed, when it was to have been changed or any staff initials of whom had placed the oxygen tubing. Interview on 11/15/23 at 1:40 p.m. with DON B regarding the above observation revealed that the bath aide had taken it upon herself to change the tubing weekly. Interview on 11/16/23 at 7:50 a.m. with CNA N regarding changing oxygen tubing revealed she: *Had been the CNA who completed resident baths weekly from Sunday through Thursday. *Had explained that she did not change the oxygen tubing and it had been the previous bath aide that had changed the oxygen tubing. *Would have changed the oxygen tubing of any resident she was bathing if the label had been outdated or if the tubing around the face looks old and brittle. Interview on 11/16/23 at 8:12 a.m. with CNA K revealed the night shift staff was to have changed the oxygen tubing but was not aware of the day of the week that it was to have been changed. Interview on 11/16/23 at 8:17 a.m. with DON B regarding the process for changing oxygen tubing revealed: *The previous bath aide had been in charge of changing the oxygen tubing, but she was no longer employed at the facility. *She had explained that the task of changing resident oxygen tubing had been a new task for the night shift staff. *She had been told by the night staff that the residents' oxygen tubing had been getting changed. *The facility had no way to document and track that the tubing had been changed but she had been working on a task list for the overnight staff that would include changing the oxygen tubing weekly. *She was unaware that the resident's oxygen tubing was not getting labeled with the date and staff initials. *Her expectation would have been that when the oxygen tubing was changed, the date the tubing needed to have been changed and the staff initial of who had changed the tubing would have been written on a label placed on the oxygen tubing. Review of the provider's June 2023 Oxygen Administration, Safety, Mask Types policy revealed that disposable equipment should be changed weekly or according to manufacturer's instruction and marked with date and initials. 3. Observation and interview on 11/15/23 from 7:30 a.m. to 8:05 a.m. with licensed practical nurse (LPN) H while performing resident's medication administration revealed: *She had been employed with the facility for about a month. *She had prepared resident 10's oral medications and removed the resident's insulin pen from the medication cart. *She placed resident 10's insulin pen in her scrub shirt pocket, picked up the medication cup containing the resident's medications and brought them to the resident who was eating breakfast in the dining room. *After she had given the resident her oral pills she told the resident that she would give her insulin after she was done eating breakfast. *She had then prepared another resident's medications and administered them to the resident in the resident's room. -She still had resident 10's insulin pen in her scrub pocket. *She performed another resident's medication administration in a third resident's room while resident 10's insulin pen was still in her scrub pocket. *She was not aware that the insulin pen was still in her pocket, and she agreed that the insulin pen should have been returned to the medication cart after she realized that resident 10 was in the dining room eating breakfast. Interview on 11/16/23 at 11:35 a.m. with DON B regarding the above observation revealed: *Her expectation would be that the nursing staff not put resident insulin pens into their scrub shirt pockets. *She had explained that the facility had trays that the nursing staff could use during medication administration if their hands were full. *She would not expect a nurse to keep the insulin pen in her pocket while going into other resident's rooms. Review of the provider's infection control policies did not account for the above situation. Review of the provider's March 2023 Medication Administration policy revealed: *PROCEDURE *4. Follow the Six Rights: Right mediation, right dose, right resident, right route, right time and right documentation. 4. Observation and interview on 11/15/23 at 3:29 p.m. with resident 9 regarding oxygen (02) usage revealed: *He was sitting in his recliner. *He had an O2 nasal cannula placed in his nostrils and was attached to his O2 concentrator. -The O2 concentrator had been set to administer 3 liters of O2 per minute. *He used O2 at all times. -A portable O2 tank was used when in his w/c. -An O2 concentrator was used when in his room. *He was not sure when the O2 tubing and nasal cannula were replaced. *He would place the cannula from the O2 concentrator on the bed when using the portable 02 tank. *The cannula to the portable O2 tank was laying on his wheelchair seat which had crumbs on it. *There was nothing attached to O2 concentrator or the portable O2 tank to store the cannula when it was not in use. Interview on 11/16/23 at 9:24 a.m. with licensed practical nurse D regarding resident 9's O2 cannula storage revealed: *The nasal cannula was to have been stored in a plastic bag that was attached to the O2 concentrators and the portable 02 tanks. *When the nasal cannula was placed on an unclean surface it should have been replaced. Interview on 11/16/23 at 10:15 a.m. with certified nursing assistant F regarding resident 9's O2 cannula storage revealed: *The cannula was to have been stored in a plastic bag that was attached to the O2 concentrators and the portable O2 tanks. *She confirmed resident 9 had no plastic bag attached to his O2 concentrator or his portable O2 tank. *When an O2 cannula was found on an unclean surface she would have wiped it down with an alcohol wipe and continued to use it. Interview on 11/16/23 at 10:52 a.m. with DON B regarding O2 nasal cannula infection control process revealed: *The cannula was to have been stored in a plastic bag that was attached to each resident's O2 concentrator or portable O2 tank. *If a nasal cannula was dropped on the floor, it should have been replaced with a new one. *She was not aware the concentrator and portable O2 tank that resident 9 had used had no plastic bag attached do it. *She was not aware the nasal cannula was being placed on the bed or chair when not in use. *She confirmed that when a nasal cannula was placed on an unclean surface it should have been replaced. Review of the provider's Oxygen Administration, Safety, Mask Types Policy revealed: *Procedure -Guidelines --11. When oxygen is not in use, store cannula face mask or face tent and tubing in a zip-lock bag/plastic bag secured to oxygen cylinder or concentrator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review the provider failed to ensure: *Alternatives to side rails had been attempted and documented for 6 of 6 sampled residents (4, 8, 18, 12, 29, and 34) prior to the implementation of side rails. *The providers' policy for side rails had been followed. Findings include: 1. Observation on 11/28/22 at 1:58 p.m. of resident 8 revealed: *She was laying in her bed, with her eyes closed. *There had been bilateral side rails attached to the upper part of the bed in the up position. Review of resident 8's medical record revealed: *Her 11/23/22 BIMS score was a 99, meaning she had been unable to complete the interview. *There was a care plan intervention that included she required assistance of one staff person and cueing to use her grab bars. *There were side rail risk education versus benefit education, informed consent, and an assessment for side rail use completed. 2. Observation on 11/28/22 at 1:59 p.m. of resident 29 revealed: *He was in his recliner, with his feet up and eyes closed. *There had been bilateral side rails attached to the upper portion of the bed in the up position. Review of resident 29's medical record revealed: *His 11/7/22 BIMS score was a 3, meaning he had severe cognitive impairment. *His care plan included: -A focus that he had the potential for pressure ulcer development due to poor safety awareness and required assistance of one person for bed mobility. -A focus that he had an activity of daily living deficit related to a traumatic brain injury, Type II diabetes, and Alzheimer's disease. --The intervention for this focus included he was independent in using his assist bar. *There were side rail risk education versus benefit education, informed consent, and an assessment for side rail use completed. 3. Observation and interview on 11/28/22 at 2:14 p.m. with resident 18 revealed: *She was laying in her bed, awake. *There had been bilateral side rails attached to the upper part of the bed in the up position. *She said she used the side rails. *They had been attached to the bed when she was admitted on [DATE]. Review of resident 18's medical record revealed: *Her 9/20/22 brief interview of mental status (BIMS) score was a 15, meaning she was cognitively intact. *There was a care plan intervention that included she required two staff and extensive support with cueing to use her grab bars. *There were side rail risk education versus benefit education, informed consent, and an assessment for side rail use completed. 4. Observation on 11/29/22 at 10:25 a.m. with resident 4 revealed: *She was up in her wheelchair. *There had been bilateral side rails attached to the upper portion of the bed. *She had not been able to tell me what the side rails where, or if she used them. Review of resident 4's medical record revealed: *Her BIMS score was 4, meaning she had severe cognitive impairment. *There was a care plan intervention that included she required assistance of one staff person and cueing to use her side rail. *There were side rail risk education versus benefit education, informed consent, and an assessment for side rail use completed. 5. Observation on 11/29/22 at 10:33 a.m. of resident 34 revealed: *He was in bed with blanket over his head. *There had been bilateral side rails attached to the upper portion of the bed. Review of resident 34's medical record revealed: *He was admitted on [DATE] to facility and had a BIMS of 99, meaning he had been unable to complete the interview. *There had been a care plan intervention that included he required assistance of one staff person cueing to use side rail and guiding hands to the rail. *There were side rail risk education versus benefit education, informed consent, and an assessment for side rail use completed. 6. Observation and interview on 11/30/22 at 11:20 a.m. with resident 12 revealed: *She was awake in her recliner. *There had been bilateral side rails attached to the upper portion of the bed. *She had not been able to tell me what the side rails where, or if she used them. *There were side rail risk education versus benefit education, informed consent, and an assessment for side rail use completed. Review of resident 12's medical record revealed: *Her BIMS score was 7, meaning she had severe cognitive impairment. *There had been a care plan intervention that included she required assistance of one staff person cueing to use side rail and guiding hands to side rail. 7. Interview on 12/1/22 at 1:43 p.m. with director of nursing B regarding side rails revealed: *All new residents have side rails when they are admitted . *When a resident was admitted there were no interventions attempted prior to installation of side rails on their bed. *If it is determined a resident does not need side rails, then they are removed. *She had no concerns of residents continuing use to a side rail when they had a decline in their overall condition. 8. Interview on 12/1/22 at 2:27 p.m. with administrator A revealed: *The side rails on the beds had not been hindering residents getting out of bed and were not a restraint. *The bed controller for some of the beds was attached to the side rail, making it necessary to have a side rail on the bed for residents to move the bed up and down. *There were no interventions attempted prior to residents using side rails. *Assessments had been completed for residents using side rails, but no other interventions had been attempted prior to the installation of side rails on the beds. 9. Review of the provider's 9/6/22 bed safety including bed rails, side rails, assist bars policy revealed: *Purpose: -To promote appropriate use of bed rails for resident safety when being used for a medical provider-identified medical necessity. *Policy: -Bed rail/side rail/assist bar usage will occur only when: --a. Medical necessity is supported by resident assessment and data collection documentation allowing resident to assist or be independent with bed mobility and/or transfer. *Procedure: -*8. Documentation of this informed consent may done . and should include the following --Alternatives attempted that failed to meet the resident's needs and alternatives considered but not attempted because they were considered to be inappropriate. *The provider had no documententation for use of alternatives attempted in order to meet the residents needs before implementing side rail use.