**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview the facility failed to complete a baseline care plan within 48 hours for 10 of 24 (Resident #5, Resident #10, Resident #12, Resident #25, Resident #26, Resident #28, Resident #34, Resident #115, Resident #116, and Resident #166) sampled residents reviewed for baseline care plans. The findings include: 1. Review of the facility policy titled, Care Plans-Baseline, revised 3/2022, revealed .A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission . 2. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE], with diagnoses including Osteoporosis with Current Pathological Fracture, Chronic Kidney Disease, Osteoarthritis, and Spinal Stenosis. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated Resident #5 was cognitively intact. Review of the Baseline Care Plan revealed that it was not completed within 48 hours of admission. 3. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE], with diagnoses including Congestive Heart Failure, Cholecystitis, and Anxiety. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated that Resident #10 was cognitively intact. Review of the Baseline Care Plan revealed that it was not completed within 48 hours of admission. 4. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE]. with diagnoses including Pneumonia, Diabetes, Chronic Obstructive Pulmonary Disease, Depression, and Anxiety. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 14, which indicated Resident #12 was cognitively intact. Review of the Baseline Care Plan revealed that it was not completed within 48 hours of admission. 5. Review of the medical record revealed Resident #25 was admitted to the facility on [DATE], and readmitted [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Pulmonary Edema, End Stage Renal Disease, Dependance of Dialysis and Anxiety. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 13 which indicated Resident #25 was cognitively intact. 6. Review of medical record revealed Resident #26 was admitted on [DATE], with diagnoses including Paraplegia, Diabetes, and Acute Kidney Failure. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated Resident # 26 was cognitively intact. Review of the Baseline Care plan dated 4/8/2025, revealed that it was incomplete. There was no signature for the Resident or Responsible Party. 7. review of the medical record revealed Resident #28 was admitted to the facility on [DATE], with diagnoses including Traumatic Subdural Hemorrhage, Seizures, and End Stage Renal Disease. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 9 which indicated Resident #28 was moderately cognitively impaired. Review of the Baseline Care Plan revealed that it was not completed within 48 hours of admission. 8. Review of the medical record revealed that Resident #34 was admitted to the facility on [DATE], with diagnoses including Fracture of Right Femur, Diabetes, Hypertension, and Depression. Review of the admission MDS assessment dated [DATE] revealed a BIMS score of 11, which indicated that Resident #34 was moderately cognitively impaired. Review of the Baseline Care Plan revealed that it was not completed within 48 hours of admission. 9. Review of the medical record revealed Resident #115 was admitted to the facility on [DATE], and readmitted [DATE], with diagnoses including Pneumonia, Diabetes, Non-Pressure Chronic Ulcer of Left Foot, and Sepsis. Review of the BIMS TEMPORARY WORKSHEET . dated 4/29/2025, revealed Resident #115 had a BIMS score of 14 and was cognitively intact. Review of the Baseline Care Plan revealed that it was not completed within 48 hours of admission. 10. Review of the medical record revealed Resident #116 was admitted to the facility on [DATE], with diagnoses including Urinary Tract Infection, Transient Cerebral Ischemic Attack, Diabetes, Dementia and Anxiety. Review of the Baseline Care Plan revealed that it was not completed within 48 hours of admission. 11. Review of medical record revealed Resident #166 was admitted to the facility on [DATE], with diagnoses including Heart Failure, Chronic Obstructive Pulmonary Edema, and Diabetes. Review of the admission MDS assessment dated [DATE], revealed the assessment was still in progress. Review of the Baseline Care plan dated 5/1/2025, revealed that it was incomplete. There was no signature for the Resident or Responsible Party. During an interview on 5/7/2025 at 8:21 AM, the Director of Nursing (DON) was asked if the Baseline Care Plan was completed if it did not have the resident or responsible party's signature. The DON stated, We don't consider it complete until signed. During an interview on 5/7/2025 at 1:30 PM the DON confirmed that Baseline Care Plans should be completed within 48 hours of admission and should address all pertinent diagnoses and medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the facility protocols, medical record review, and interview, the facility failed to monitor bowel movements for 1 of 1 (Resident #115) sampled residents. The findings include: 1. Review of the Treat In Place Protocols/Advanced Nursing Protocols, signed by the Medical Director on 4/13/2025, revealed .The facility will provide assessment and early recognition of residents experiencing .change of condition .CONSTIPATION AND BOWEL PROTOCOL .check for bowel sounds .SET ONE: If No BM [Bowel Movement] for 3 days, give: Lactulose [used for constipation] .x1dose .STEP TWO: IF No BM, on the following day (4th day) Listen for bowel sounds: notify MD [Medical Doctor] if NO bowel sounds .Give Dulcolax [used for constipation] supp [suppository] .X1 AND Lactulose .every 6 hours for 24 hours or until .bowel movement .Bowel Protocol for Constipation For no BM in 3 days, Lactulose [used for constipation] . 2. Review of the medical record revealed Resident #115 was admitted to the facility on [DATE], and readmitted [DATE], with diagnoses including Pneumonia, Diabetes, Sepsis, Non-Pressure Chronic Ulcer of Left Foot, and Sepsis. Review of the care plan dated 4/22/2025, revealed .at risk for constipation r/t [related to] medication side effect, pain .will have a bowel movement at least every 3 days .Assess for any s/sx [signs of symptoms] of constipation QS [every shift] Date initiated: 04/22/2025 . Review of the BIMS TEMPORARY WORKSHEET . dated 4/29/2025, revealed Resident #115 had a Brief Interview for Mental Status (BIMS) score of 14 and was cognitively intact. Review of the untitled document revealed no bowel movements on 4/23/2025, 4/24/2025, 4/29/2025, 5/2/2025, 5/3/2025, and 5/4/2025. There was no documentation for 4/30/2025 and 5/1/2025. During an interview on 5/06/2025 at 1:43 PM, Resident #115's family member stated that she gave Resident #115 an enema last night (5/5/2025) since he was very uncomfortable. Resident #115 stated that he was uncomfortable in his abdomen. When asked if he made the staff aware that he had not had a bowel movement he stated .a nurse administered a thick yellowish liquid and said it should help. It didn't work so she gave it again the next day. The family member was asked if staff followed up and asked if he had a BM. Family member stated, No. Resident #115's family member stated, .I gave him an enema and let the nurse know I gave it .the nurse came in here with the Certified Nursing Assistant (CNA) and got him cleaned up . During an interview on 5/6/2025 at 2:54 PM, the Director of Nursing (DON) stated, The staffing coordinator runs a report of residents that have not had a BM and it's distributed to the nurses for them to follow up and provide an intervention. If a standing order is used, I expect it [the order] to be entered and activated and signed off as administered . The DON was asked, would you expect families to administer enemas to the residents, No, ma'am. The DON was asked should staff document a BM, Yes, and the interventions should be documented and initiated timely .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to follow Physician Orders for oxygen for 1 of 3 (Resident #25) sampled residents reviewed for respiratory care. The findings include: 1. Review of the facility policy titled, Oxygen Administration, dated October 2010, revealed .Verify there is a physician's order for this procedure .Review the resident's care plan . Review of the facility policy titled, .Medication and Treatment Orders, dated July 2016, revealed .Medications shall be administered upon the written order of a person .authorized to prescribe .following treat in place/standing orders . 2. Review of the medical record revealed Resident #25 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Pulmonary Edema, End Stage Renal Disease, Dependance of Dialysis, and Anxiety. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13 which indicated Resident #25 was cognitively intact. Special procedures included Hemodialysis. Review of the physician orders revealed no order for oxygen. Review of the Medication Administration Record (MAR) for May 2025, revealed oxygen was not listed. Review of the care plan dated 5/2/2025, revealed Resident was not care planned for oxygen. Observation in Resident #25's room on 5/5/2025 at 9:30 AM, 5/6/2025 at 8:16 AM and 8:50 AM, revealed Resident #25 was wearing Oxygen at 2l/min (liters/minute) binasal cannula (bnc). During an interview on 5/6/2025 at 4:49 PM Licensed Practical Nurse (LPN) D was asked if there was an order for the oxygen, LPN D stated, No, she was on it when I got here this morning. I took it off since she was fine without it . During an interview on 5/7/2025 at 8:32 AM, the Director of Nursing (DON) confirmed if a resident is wearing oxygen, they should have an order, and it should be care planned.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the Code of Federal Regulations, Title 42, Chapter IV, Subchapter G Part 483 review, medical record review, observation, and interview the facility failed to ensure 2 of 5 nurses (Registered Nurse (RN) G and Licensed Practical Nurse (LPN) E) administered medications with a medication error rate of less than 5 percent (%). A total of 3 errors were observed out of 27 opportunities, resulting in a medication error rate of 11.11%. The findings include: 1. Review of the Code of Federal Regulations Title 42, Chapter IV, Subchapter G, Part 483 dated 5/12/2025, revealed, . Standard: Drug administration. The facility must have an organized system for drug administration that identifies each drug up to the point of administration. The system must assure that . All drugs are administered in compliance with the physician's orders .All drugs, including those that are self-administered, are administered without error .Drug administration errors and adverse drug reactions are recorded and reported immediately to a physician . 2. Review of the medical record revealed Resident #24 was admitted to the facility on [DATE], with diagnoses of Diabetes Mellitus, Acute Kidney Failure, and Gastro-Esophageal Reflux Disease. Review of the Physician Order dated 4/4/2025, revealed, .Calcium Carbonate Antacid Oral Tablet .Chewable 1000 MG [milligram] .Give 1 tablet by mouth three times a day for indigestion. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #24 was cognitively intact. Observation during medication administration on 5/6/2025 at 1:11 PM, LPN E removed the following medication from the cart and administered to Resident #24. a. Calcium Carbonate Antacid 500 mg tablet 1 tablet (tab). LPN E failed to administer the physician ordered dose of 1000mg resulting in a medication error. During an interview on 5/7/2025 at 12:44 PM, the Director of Nursing (DON) confirmed that staff should follow physician orders regarding medication dosage. 2. Review of the medical record revealed Resident #318 was admitted to the facility on [DATE], with diagnoses including Chronic Kidney Disease, Diabetes Mellitus, Dry Eye Syndrome, Fracture of Right Acetabulum, and Fracture of Sacrum. Review of the Physician Order dated 5/5/2025, revealed . Methocarbamol [used as a muscle relaxant] Oral Tablet 750 MG .Give 1 tablet by mouth three times a day for muscle spasm . Review of the Physician Order dated 5/5/2025, revealed .Memantine [a medication to treat dementia related to Alzheimer's] HCl [hydrochloride] [a type of salt] Oral Tablet 5 MG .Give 1 tablet by mouth two times a day for memory . Review of the Physician Order dated 5/5/2025, revealed .Restasis Ophthalmic Emulsion 0.05% .Instill 1 drop in both eyes two times a day for dry eyes . Review of the Physician Order dated 5/5/2025, revealed .Diclofenac Sodium [used to treat arthritis] External Gel 1% . (Topical) [applied to skin] .Apply to affected area topically two times a day for pain for 30 Days . Review of the Physician Order dated 5/6/2025, revealed .Lidocaine External Patch 5 % .Apply to affected area topically one time a day for pain . Review of the Physician Order dated 5/6/2025, revealed .Cholecalciferol [vitamin d3] Oral Tablet 50 MCG [microgram] (2000 UT) [unit] .Give 1 tablet by mouth one time a day for supplement . Review of the Physician Order dated 5/6/2025, revealed .Losartan Potassium [used to treat high blood pressure] Tablet 50 MG Give 1 tablet by mouth one time a day for HTN [hypertension] HOLD FOR SBP [systolic blood pressure] < 100 OR HR [heart rate] < 60 . Review of the Physician Order dated 5/6/2025, revealed .Aspirin 81 Oral Tablet Chewable .Give 1 tablet by mouth in the morning for prophylaxis . Observation during medication administration on 5/7/2025 at 7:38 AM, RN G removed the following medications from the cart to administer to Resident #318. a. Losartan potassium 50mg 1 tab (blood pressure 156/104, pulse 80) med administered. b. Memantine hcl 5mg 1 tab c. Methocarbamol 750mg 1 tab d. ASA 81 ec [enteric coated] mg 1 tab e. Cholecalciferol 1000 iu [international units] 2 tabs f. Restasis ophthalmic 0.05% 1 drop both eyes g. Lidocaine patch 5% -apply to affected area topically for pain, remove in evening. RN G removed the medications from the cart and administered to Resident #318 resulting in a medication error for administering enteric coated aspirin instead of the correct form, chewable as physician ordered. Observation during medication administration on 5/7/2025 at 9:24 AM RN G applied the medication to Resident #318's bilateral knees and stated that the medication had already been signed out prior to administration resulting in a medication error related to signing medication out before administering. a. diclofenac sodium gel 1% apply to affected area topically During an interview on 5/7/2025 at 12:44 PM, the DON confirmed that staff should follow physician's orders related to medications and forms of those medications, and that medication should be signed out after administration, not before.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to ensure medications were properly stored when medications were found unsecured and unattended in 3 of 56 (Residents #26, #365, and #366) resident occupied rooms and when 1 of 4 (Cart B200) medication carts was found unlocked and unsecured. The findings include: 1. Review of the facility policy titled, Medication Labeling and Storage, dated 2/2023 revealed The facility stores all medications and biologicals in locked compartments .Only authorized personnel have access to keys . 2. Review of medical record revealed Resident #26 was admitted on [DATE], with diagnoses including Paraplegia, Pressure Ulcer of Left Hip, Diabetes, and Acute Kidney Failure. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #26 was cognitively intact. Review of the Physician's Orders dated 5/5/2025, revealed .Nystatin External Powder [for the treatment of yeast]100000 UNIT/GM [gram] .Apply to groin topically every shift for yeast . Observations in Resident #26 's room on 5/5/2025 at 9:00 AM, 9:37 AM, and 10:54 AM, revealed nystatin topical powder at bedside. During an interview on 5/5/2025 at 10:54 AM, Registered Nurse (RN) A confirmed that medications should not be left at bedside unattended. During an interview on 5/7/2025 at 8:21 AM, the Director of Nursing (DON) confirmed medications should not be left at bedside unattended. 3. Review of the medical record revealed Resident #365 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Diabetes, and Anxiety. Review of the BIMS Temporary Worksheet . assessment dated [DATE], revealed a BIMS score of 13, which indicated that Resident #365 was cognitively intact. admission MDS was not completed. Observations in the resident's room on 5/5/2025 at 9:25 AM and 11:00 AM, revealed an albuterol inhaler (used for asthma and other lung diseases) on bedside table. Review of the Physician Orders dated 5/7/2025, revealed there was no physician's order for the albuterol inhaler. Facility was unable to provide an assessment for Resident #365 to self-administer medications. 4. Review of the medical record revealed Resident #366 was admitted to the facility on [DATE], with diagnoses including Myocardial Infarction, Atrial Fibrillation, and Depression. Review of the BIMS Temporary Worksheet . assessment dated [DATE], revealed a BIMS score of 11, which indicated that Resident #366 was moderately cognitively impaired. admission MDS was not completed. Observations in the resident's room on 5/5/2025 at 9:15 AM and 11:00 AM, 5/6/2025 at 8:00 AM, and 5/7/2025 at 8:15 AM, revealed 3 vials of single use (Named) eye drops (for the temporary relief of eye dryness), (Named) nasal inhaler (provides temporary relief from nasal congestion), and a tube of (Named) saline nasal gel (used to treat dryness inside the nose) on the bedside table. Review of the Physician Orders dated 5/7/2025, revealed there were no physician orders for eye drops, nasal inhaler or saline nasal gel. Facility unable to provide an assessment for Resident #366 to self-administer medications. During an observation and interview in the Resident #366 room on 5/7/2025 at 1:34 PM, the DON confirmed that medications should not be at the bedside unattended. 5. Observation during medication administration on the B200 hall on 5/7/2025 at 7:38 AM, RN G walked away from the medication cart to administer medications. RN G entered the resident's room and closed the door. The medication cart was left unlocked with keys in the lock of the cart. The medication cart was out of sight and unattended. Upon return to the B200 hall medication cart, RN G stated, Oh, I left my keys . During an interview on 5/7/2025 at 1:00 PM, the DON confirmed that medication carts should never be left unlocked or have keys left in the lock when the cart is out of sight of the nurse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observations, and interviews, the facility failed to ensure practices to prevent the potential spread of infection were maintained when 1 of 5 nurses Registered Nurse ((RN) A) failed to wear eye protection while administering enteral medications in a Droplet isolation room, and 1 of 5 nurses (RN G) failed to perform hand hygiene and change gloves prior to administering eye drops to a resident. The findings include: 1. Review of the facility policy titled, Isolation Categories of Transmission Based Precautions, dated 9/2022, revealed, .Transmission-based precautions are initiated when a resident .is at risk of transmitting the infection to other residents .Droplet precautions are implemented for an individual documented or suspected to be infected with microorganisms transmitted by droplets .that can be generated by the individual coughing, sneezing, talking .Gloves, gown and goggles are worn if there is a risk of spraying respiratory secretions . Review of the facility policy titled, Infection Prevention and Control Program, dated 10/2028, revealed, .An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections .instituting measures to avoid complications or dissemination .educating staff and ensuring that they adhere to proper techniques and procedures . 2. Review of the medical record revealed Resident #165 was admitted to the facility on [DATE], with diagnoses including Methicillin Resistant Staphylococcus Aureus Infection (MRSA), Dysphagia, and Gastrostomy Status. Review of the Care Plan dated 4/29/2025, revealed a focus on .antibiotic therapy .Tube Feeding .isolation precautions [Droplet] [used for pathogens transmitted by respiratory droplets that are generated by a patient who is coughing, sneezing, or talking] R/T [related to] Infectious disease, (MRSA in sputum) [a mix of saliva and mucus coughed up from the respiratory tract] . Review of the Physician Order dated 4/30/2025, revealed .Place resident under isolation per CDC [Centers for Disease Control] guidelines and follow transmission based precautions. DROPLET ISOLATION - MRSA SPUTUM . every shift for MRSA Sputum . Observation during medication administration on 5/6/2025 at 3:19 PM, RN A failed to wear eye protection during the administration of PEG (percutaneous endoscopic gastrostomy) (a feeding tube placed in the stomach through the abdominal wall) medications to Resident #165 while in Droplet isolation. During an interview on 5/7/2025 at 12:44 PM, the Director of Nursing (DON) confirmed that staff should wear eye protection while providing medication administration to a resident in Droplet isolation. 3. Review of the medical record revealed Resident #318 was admitted to the facility on [DATE], with diagnoses including Chronic Kidney Disease, Diabetes Mellitus, Dry Eye Syndrome, Fracture of Right Acetabulum, and Fracture of Sacrum. Observation during medication administration on 5/7/2025 at 7:38 AM, in Resident #318's room RN G assessed resident's edema to right foot by pressing on foot with gloved hand, and administered eye drops to both eyes of resident, without performing hand hygiene or changing gloves. During an interview on 5/7/2025 at 12:44 PM, the DON confirmed staff should perform hand hygiene, wear clean gloves, and avoid touching items in the resident's room including other areas of the resident's body when administering eye drops.

Based on facility policy review, observations, and interviews the facility failed to ensure personal resident food items were labeled and dated for 2 of 2 nutrition rooms reviewed for proper food storage. The findings include: 1. Review of the facility policy titled, Foods Brought by Family/Visitors, dated 3/2022, revealed .Containers are labeled with the resident's name and date . 2. Observation in the 200-hall nutrition room on 5/7/2025 at 10:40 AM, revealed a sign on the refrigerator stating, .Please make sure all items in refrigerator and freezer Have the name, Room number, and date . The following items were found in the nutrition refrigerator unlabeled and undated: a. 1 opened 8 ounce (oz) bag of cheddar shredded cheese. b. 1 opened 24 oz bottle of chocolate syrup. c. 1 plastic zipper bag with 2 corndogs inside it. d. 1 reusable ice pack in the freezer. During an interview on 5/7/2025 at 10:43 AM, the DON confirmed that all items inside the refrigerator and freezer should be labeled and dated. 3. Observation in the 100-hall nutrition room on 5/7/2025 at 10:53 AM, revealed a sign on the refrigerator stating, .Please be sure to have name and date on all items . The following items were found in the nutrition refrigerator unlabeled and undated: a.1 bottle of dressing in the refrigerator. b. 1 frozen meal in the freezer . During an interview on 5/7/2025 at 10:55 AM, Certified Occupational Therapy Assistant (COTA) B confirmed the items was unlabeled and undated.

Based on policy review, observation, and interview, the facility failed to ensure medications were properly stored and secured when 1 of 6 staff members (Registered Nurse (RN A) left medications unattended at the resident's bedside, and when unused medications were taped and placed back into the medication cart, and when 1 of 6 medication carts was left unlocked and unattended during medication administration. The findings include: 1. Review of the facility's policy titled Medication Administration: Medication, Controlled and Biological Storage . dated 9/5/2023, revealed .It is the policy of this facility to ensure all medications housed on our premises shall be stored in the .medication rooms according .segregation and security .The medications shall be labeled in accordance with accepted professional principles to include .during a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area or cart .Unused medications: These medications are destroyed . 2. During an observation during medication administration on 6/20/2024 at 7:23 AM, RN A was observed preparing medications for Resident #211. RN A was observed removing 2 tablets out of a multi-dose package, leaving 1 tablet in the package. RN A applied tape and returned the medication package to the medication cart. RN A stated that the medication that was returned to the cart was the resident's Folic Acid that was not due at this time. RN A entered resident's room leaving the medication cart unlocked, unattended and out of sight outside the resident's room on the A Hall of the 1st floor. RN A placed the medications on the resident's bedside table and went into the resident's bathroom leaving the medications unattended and out of sight. 3. During an interview on 6/20/2024 at 5:06 PM, the Director of Nursing (DON) confirmed that the medication carts should not be left unlocked or unattended. The DON was asked should nursing staff leave medications at the resident's bedside unattended. The DON stated, No. The DON was asked what should staff do with unused medications. The DON confirmed that unused medications should be discarded and not taped.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when a Registered Nurse (RN A) failed to perform hand hygiene during medication administration and failed to wear Personal Protective Equipment (PPE) for 1 of 2 sampled residents (Resident #211) reviewed for enhanced barrier precautions. The findings include: 1. Review of the facility's policy titled, Medication Administration dated 8/4/2023, revealed .Medications administered via [by way of] feeding tube: Follow infection control precautions and related techniques to minimize the risks of contamination . Review of the facility's policy titled, Transmission Based Precautions, dated 4/1/2024, revealed .It is our policy to take appropriate precautions to prevent transmission of infectious agents. An order for enhanced barrier precautions shall be obtained for residents with any . feeding tubes .even if the resident is not known to be infected .Implementation of Enhanced Barrier Precautions .Make gowns and gloves available .High contact resident care activities include .device care or use, feeding tubes . 2. Review medical record revealed Resident #211 was admitted to the facility on [DATE], with diagnoses of Ataxia, Chronic Obstructive Pulmonary Disease, Anxiety, Quadriplegia, and Gastrostomy. Review of the Care Plan dated 6/13/2024 revealed .At risk for compromised nutritional status .receiving tube feedings .Check tube placement by aspiration before giving feeding .Monitor feeding tube site for redness or signs of infection . Review of the Physician's Order dated 6/12/2024, revealed Jevity 1.5 [tube feeding supplement] at 30cc/hr [cubic centimeters per hour] Observation during medication administration on 6/20/2024 at 7:23 AM, RN A prepared Resident #211's medications and donned and doffed gloves without performing hand hygiene prior to entering resident's room. RN A performed medication administration via peg tube without a gown PPE on. 3. During an interview on 6/20/2024 at 5:06 PM, the Director of Nursing (DON) confirmed that any residents with an artificial opening or an indwelling device should be in enhanced barrier precautions. The DON confirmed that a sign and supplies should be present on all residents' door in Enhanced Barrier Precautions. The DON was asked what PPE should be worn when administering medications via peg tube. The DON confirmed that gloves and a gown should be worn.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual v 1.17.1, October 2019, medical record review, and interview, the facility failed to accurately assess residents for Bowel Incontinence for 2 of 18 residents (Resident #7 and #59) reviewed for accuracy of MDS assessments. The findings include: 1. Review of the Minimum Data Set, 3.0 RAI Manual v 1.17.1, dated October 2019, page 1-7 revealed .Federal regulations at 42 CFR 483.20 (b)(1)(xviii ), (g), and (h) require that (1) the assessment accurately reflects the resident's status . 2. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses of Fracture of Left Femur, Hypertension, Ulcerative Colitis, Diabetes, and Osteoarthritis. Review of the Night Shift CNA [Certified Nursing Assistant] ASSIGNMENT SHEET, dated 4/21/2023 revealed Resident #7 had a bowel movement documented on that shift. Review of the admission minimum data (MDS) set dated 4/23/2023, revealed Resident #7 did not have a rating to address bowel movements. 3. Review of the medical record revealed Resident #59 was admitted to the facility on [DATE] with diagnoses of Left Hip Fracture, Acute Embolism/Thrombosis of Right Lower Extremity, Hypertension, and Pleural effusion. Review of the Day Shift CNA ASSIGNMENT SHEET, dated 6/17/2023, revealed Resident #59 had a bowel movement documented on that shift. Review of the Day Shift CNA ASSIGNMENT SHEET, dated 6/18/2023, revealed Resident #59 had a bowel movement documented on that shift. Review of the Day Shift CNA ASSIGNMENT SHEET, dated 6/20/2023, revealed Resident #59 had a bowel movement documented on that shift. Review of the MDS dated [DATE], revealed Resident #59 did not have a rating to address bowel movements. 4. During an interview on 7/13/2023 at 1:56 PM, the Director of Nursing (DON) confirmed Resident #7's MDS dated [DATE] and Resident #59's MDS dated [DATE] were coded incorrectly for bowel status.

Based on policy review, observation, and interview, the facility failed to ensure medications were labeled and stored appropriately when unsecured medications were observed in 1 of 58 resident rooms (Resident #59's room) and when 1 of 6 staff members (Licensed Practical Nurse (LPN) #1) left medications unattended in a resident's (Resident #60) room. There were no residents who wandered in the facility. The findings include: 1. Review of the facility policy titled, Medication Administration . Medication, Controlled and Biological Storage . dated 9/20/2022, revealed .It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms .All drugs and biologicals will be stored in locked compartments . 2. Observation in Resident #59's room on 7/10/2023 at 10:38 AM and 4:01 PM, revealed Resident #59 reclined in the bed, the over bed table was beside the bed on the left side and within reach of the resident. There was a 90 microgram albuterol sulfate inhaler (small handheld device that contains medication to relieve cough, wheezing and trouble breathing) on the over bed table. 3. Observations on the A100 Hall on 7/12/2023 at 4:04 PM, revealed LPN #1 crushed Resident #60's medications into 4 separate medication cups. LPN #1 entered Resident #60's room and sat the 4 medication cups with crushed medications on the overbed table. LPN #1 went into the bathroom with 2 plastic cups to obtain water. The medications were left out of sight and unattended. 4. During an interview on 7/13/2023 at 3:19 PM, the Director of Nursing (DON) confirmed the albuterol inhaler should not have been left in Resident #59's room. During an interview on 7/13/23 at 5:15 PM, Regional Nurse Consultant and the DON were asked should medications be left unattended and out of sight of a nurse. The DON stated, No, it should not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation and interview, the facility failed to ensure that 4 of 15 sampled residents (Resident #10, #35, #54, and #55) had alternative food and menu choices. The findings include: 1. Review of the facility policy titled, Resident Rights and Resident Responsibilities, dated 10/24/2022, revealed .The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences . Review of the facility policy titled, Dietary--Dining Services, dated 3/8/2023, revealed .Mealtimes and menus shall be posted for the resident and family . 2. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses of Gastroesophageal Reflux Disease, Diabetes Mellitus, and Malnutrition. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #10 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated she had moderate cognitive impairment. During an interview on 7/12/2023 at 11:23 AM, Resident #10 stated, .I don't know what we are eating until I get it . Resident #10 confirmed that she never received a menu to inform her of the daily menus and alternatives. 3. Review of the medical record revealed Resident #35 was admitted to the facility on [DATE] with diagnoses of Cancer, Diabetes Mellitus, and Hyperlipidemia. Review of the admission MDS dated [DATE] revealed Resident #35 had a BIMS score of 13, which indicated she was cognitively intact. During an interview on 7/10/2023 at 3:32 PM, Resident #35 was asked did facility staff ask her food preferences. Resident #35 shook her head no and stated, .I usually just manage, I eat what I can and what I can't I let it go . Resident #35 was asked if she knew what was on the daily menus. Resident #35 stated, I never know what we're going to have until I get it . Resident #35 was asked did she receive a menu every morning for the meals that day. Resident #35 stated, .no, we'll get what we get . 4. Review of the medical record revealed Resident #54 was admitted to the facility on [DATE] with diagnoses of Neoplasm of Anus, Sepsis, Human Immunodeficiency, Colostomy, and Pressure Ulcer of Sacrum. Review of the admission MDS dated [DATE] revealed Resident #54 had a BIMS score of 15, which indicated he was cognitively intact. During an interview on 7/11/2023 at 3:00 PM, Resident #54 was asked about the food in the facility. Resident #54 stated, .the food is not terrible, but I would like to have some choices. I don't get a menu to see any options. The food is just not my preferences . 5. Review of the medical record revealed Resident #55 was admitted to the facility on [DATE] with diagnoses of Fracture of Right Femur and Right Lower Leg, Fracture of Facial Bones, Motor Vehicle Accident, Traumatic Pneumothorax, and Malnutrition. Review of the admission MDS dated [DATE] revealed Resident #35 had a BIMS score of 15, which indicated he was cognitively intact. During an interview on 7/11/2023 at 9:07 AM, Resident #55 stated, .they never let me know what's for breakfast, lunch, dinner .not getting menus at all . Resident #55 was asked if he could hear the menu when it was announced over the intercom. Resident #55 stated, .not with the TV going . 6. Observation outside of the Dining Room on 7/12/2023 at 10:25 AM, revealed there was a sign posted at the dining room entrance with the daily menus listed. There were no menus noted in the building elsewhere. 7. During an interview on 7/12/2023 at 1:31 PM, Certified Nurse Aide (CNA) #1 was asked how do residents know what is on the menu for the day. CNA #1 stated, If they ask .sometimes the Activities Director will announce it on the intercom .we would call the kitchen . CNA #1 was asked if a resident's tv was on loud could it be heard in the resident's room. CNA #1 stated .might not be able to be heard. CNA #1 was asked were menus given to the residents. CNA #1 stated No, no menus. During an interview on 7/12/2023 at 2:44 PM, the Registered Dietician (RD) was asked how the residents know what menu is being served. The RD stated, The kitchen posts it out front of the dining room .and meals announced .read to the department heads .nurses or CNAs will also call down to the kitchen to find out if a resident asks. The RD was asked how do residents who do not go to the Dining Room learn what is on the menu. The RD stated, They can ask their CNA or nurse and they [CNA or nurse] can call down to the kitchen. The RD was asked should residents have to ask what is being served or should that be communicated to them. The RD stated, That's how we have managed that way residents can request alternate food items .mostly goes through nursing staff . The RD confirmed residents should be made aware of daily menus prior to being served so they have a food choice.

Based on policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions as evidenced by opened, unlabeled, and undated food in the kitchen on a metal shelf, in the walk-in refrigerator, in the walk-in freezer, and in the dry storage room and when 1 of 24 staff members (Certified Nurse Assistant (CNA) #1) failed to perform hand hygiene during dining. The facility had a census of 58, with 56 of those residents receiving a tray from the kitchen. The findings include: 1. Review of the facility's policy titled, .Dietary: Food Storage ., dated 8/25/2022, revealed .Food shall be stored in accordance with professional standards for food safety .Fresh fruits and vegetables are refrigerated . These items are sorted regularly, and damaged or spoiled pieces or discarded .Leftover foods are stored in appropriate containers .covered, labeled, and dated .Leftovers should be used within 3 days .All stored items should have an expiration date or a purchase/delivery date .Product shall be assessed for visible signs of spoilage: color, odor, and texture .Open Date .Refrigerated, ready-to-eat, potentially hazardous foods(time/temperature control for safety food) .shall be clearly marked at the time the original container is open . Review of the facility's policy titled, Dietary-Dining Services, dated 3/8/2023, revealed .Staff shall follow appropriate hand hygiene . 2. Observation in the kitchen on a metal shelf on 7/10/2023 at 9:18 AM, revealed the following: 6 opened, undated hamburger buns. 4 opened, undated slices of bread. 2 opened, undated hamburger buns. Observation in the walk-in refrigerator on 7/10/2023 at 9:24 AM, revealed the following: Beef tips in a clear, plastic container labeled use by 7/8/2023. Mushrooms in a clear, plastic container dated 7/5/2023. Bowl of chicken noodle soup with no date. A sandwich with no label and no date. An opened, undated bag of lettuce with brown leaves. Boiled eggs in a clear container with no date. 5 cabbages with black leaves in a container dated 6/6/2023. Container of Italian Pasta with a use by date of 7/8/2023. Observation in the walk-in freezer on 7/10/2023 at 9:36 AM revealed the following: Undated Sausage loin in a clear container. Opened, undated diced chicken in a clear container. Observation in the dry storage room on 7/10/2023 at 9:40 AM revealed Opened, unlabeled, and undated bag of a white powdery substance in a clear plastic bag. Opened, undated gravy mix. Opened, undated grits. During an observation and interview in the kitchen on 7/10/2023 between 9:18 AM and 9:40 AM, the Kitchen Manager was asked about the items in the walk-in refrigerator dated use by 7/5/2023 and use by 7/8/2023. The Kitchen Manager confirmed the food items should be thrown away. The Kitchen Manager confirmed the sandwich, chicken noodle soup, and boiled eggs should be labeled and dated. The Kitchen Manager was asked should the kitchen serve lettuce with brown leaves. The Kitchen Manager stated, No. The Kitchen Manager was asked about the cabbages with black leaves, dated 6/6/2023. The Kitchen Manager stated, They have been here too long, we need to throw them away. The Kitchen Manager was asked about the unlabeled, undated white, powdery substance in a clear plastic bag in the dry storage room. The Kitchen Manager stated, That is cake mix, I don't know why they left it on the shelf like that. The Kitchen Manager confirmed the opened gravy mix and the opened grits should have an open date. The Kitchen Manager was asked about the sausage loin and diced chicken in the freezer. The Kitchen Manager confirmed the diced chicken needed an open date and a use by date. The Kitchen Manager confirmed the sausage loin had no label to indicate when it was placed in the freezer or when it expired. Observation on the B 200 Hall on 7/10/2023 beginning at 12:35 PM, revealed CNA #1 obtained a meal tray from the meal cart, walked to the rolling steam table, obtained a plate of food from dietary staff, knocked on the door and entered Resident #220's room. CNA #1 placed the tray on Resident #220's over bed table and exited the room without performing hand hygiene. CNA #1 obtained a tray from the meal cart, walked to the rolling steam table, obtained a plate of food from dietary staff, knocked on the door and entered Resident #47's room. CNA #1 placed the tray on Resident #47's over bed table and exited the room without performing hand hygiene. CNA #1 obtained a tray from the meal cart, walked to the rolling steam table, obtained a plate of food from dietary staff, walked to Resident #216's room, donned a gown, mask, and gloves, knocked on the door and entered the room. CNA #1 placed the meal tray on the over bed table and set up the tray. CNA #1 doffed personal protective equipment in a biohazard trash barrel, and performed hand hygiene. CNA #1 obtained a meal tray from the meal cart, walked to the rolling steam table, obtained a plate of food from dietary staff, knocked on the door and entered Resident #42's room. CNA #1 placed the meal tray on Resident #42's over bed table and exited the room without performing hand hygiene. CNA #1 obtained a meal tray from the meal cart, walked to the rolling steam table, obtained a plate of food from dietary staff, knocked on the door and entered Resident #45's room. CNA #1 placed Resident #45's meal tray on the over bed table and exited the room without performing hand hygiene. CNA #1 did not perform hand hygiene before and after each meal tray was passed. During an interview on 7/12/2023 at 1:41 PM, the Registered Dietician (RD) confirmed opened food items should have an open date, food should be thrown away after the use by date, sandwiches and left overs should be labeled with a name and date, and used by the third day, lettuce with brown leaves and cabbage with black leaves should be thrown away. The RD confirmed all food items in the freezer should have labels with a use by or expiration date. During an interview on 7/13/2023 at 5:25 PM, the Regional Nurse Consultant and Director of Nursing confirmed that staff should perform hand hygiene before and after each meal tray is delivered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview the facility failed to ensure practices to prevent the potential spread of infection were maintained when 3 of 6 nurses (Licensed Practical Nurse (LPN#1) failed to clean reusable equipment before and after use and LPN #2 failed to maintain infection prevention and control procedures to prevent the spread of transmission of communicable diseases and infections when LPN #2 failed to ensure eye drops were not contaminated The findings include: 1. Review of the facility's policy's titled, Infection Prevention and Control Program, dated 10/24/2022 revealed .All reusable items and equipment requiring special cleaning or disinfection shall be cleaned .current procedures governing the cleaning and disinfection of soiled or contaminated equipment . Review of the facility's policy's titled, Medication Administration, dated 10/24/2022, revealed .Medication Administration .Perform hand hygiene . Medication administered via feeding tube .Follow infection control precautions and related techniques to minimize the risk of contamination . 2. Review of the medical record revealed Resident #214 was admitted to the facility on [DATE] with diagnoses of Metabolic Encephalopathy, Respiratory Failure, Neoplasm of Esophagus and Liver, and Congestive Heart Failure. Resident #214 had no comprehensive MDS completed at present. Observations on 7/12/2023 at 8:47 AM, revealed LPN #2 gathered an eye medication bottle that was in a plastic bag, from the drawer of the medication cart. LPN #2 placed the plastic bag containing eye drops under her arm on top of the isolation gown. Then removed the plastic bag into her hand while removing the isolation gown and placed the bag into her pocket of her scrub top so she could wash her hands. Then went to the medication cart placed the bag on top of cart unlocked the cart and placed the plastic bag in the drawer of the cart. 3. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses of Anxiety, Neoplasm of Bones of Skull and Face, Squamous Cell Carcinoma of Scalp and Neck, Diabetes, and Chronic Obstructive Pulmonary Disease. Review of the admission MDS dated [DATE] revealed Resident #10 had a Brief Interview for Mental Status (BIMS) of 12 which indicated cognitively intact. Observation on 7/12/2023 at 11:16 AM, revealed LPN #3 drawing up insulin (medication to lower blood sugar), LPN #3 opened a syringe from the plastic seal, removed the cap from the needle, and placed the cap on the top of the medication cart open side down. After drawing up the insulin into syringe LPN #3 picked up the cap and recapped the needle of the syringe. LPN #3 entered Resident #10's room and administered the insulin to the right upper arm and recapped the syringe prior to placing it in the sharps box for disposal. 4. Review of the medical record revealed Resident #60 was admitted to the facility on [DATE] with diagnoses of Aphasia, Cerebrovascular Accident, Dysphagia, Neoplasm of Brain, and Gastrostomy. Review of the admission MDS dated [DATE] revealed Resident #60 had a Brief Interview for Mental Status (BIMS) of 8, which indicates severe cognitive impairment. Observations on 7/12/2023 at 4:04 PM, revealed LPN #1 went to the First Floor Medication Room to obtain Resident #60's medication. LPN #1 punched each of four medications into her bare hand and then placed each medication into separate medication cups without performing hand hygiene. LPN #1 then went to the medication cart crushed the medications and placed a stethoscope around her neck. LPN #1 then entered Resident #60's room. Once in the room LPN #1 discontinued the resident's feeding tube and retrieved a cap from a candy container, disconnected the tubing and placed the cap on the end of the feeding tube. LPN #1 placed the bell of the stethoscope on Resident #60's abdomen to check placement and administered the medications per Percutaneous Endoscopic Gastrostomy (PEG) tube. Once medications administered per LPN #1 replaced the stethoscope around her neck and the tubing cap back into the candy container. LPN #1 failed to clean the stethoscope before or after use with Resident #60. Once back to medication cart LPN #1 placed the stethoscope on top of her clip board which was on top of the cart. 5. During an interview on 7/13/23 at 5:15 PM, Regional Nurse Consultant and the Director of Nursing (DON) were asked should a bag containing eye drops be placed under arm with isolation gown or placed into the pocket of scrubs, then back to top of medication cart and placed back into the drawer without being cleaned. The Regional Nurse Consultant stated No, that not appropriate. They were asked should staff pop out the medications into their bare hands. The DON stated, No they should be punched into a med [medication] cup. They were asked when should a stethoscope be cleaned. The Regional Nurse Consultant stated, It should be cleaned prior to using and after use on each resident. They were asked should the cap of a syringe be sat on top of cart then replaced on syringe or recapped after medication is administered. The DON stated No, it should not and should not recap syringe.