**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, medical record review, observation and interview the facility failed to complete assessments before or during use of a specialized harness (a chest harness connected to his wheelchair that pulled over his shoulders on both sides and snaped on both sides above his waste) for 1 of 1 (Resident #24) sampled residents reviewed for physical restraints. The findings include: 1. Review of the undated facility policy titled SIDERAILS POLICY, revealed, .PHYSICAL RESTRAINT .[Named Facility #1] is a restraint-free facility .ACKNOWLEDGEMENT OF RESTRAINT POLICIES .restraint use in our facility will only be considered to treat a medical symptom/condition that endangers the physical safety of the resident or other residents and under the following conditions .a last resort measure after a trial period where less restrictive measures have been undertaken and proven unsuccessful .with a physician order .with the consent of the resident or legal representative .If restraint use is deemed necessary, the goal will be to use the least restrictive type of restraint for the shortest period of time possible . Review of the undated facility policy titled, Assistive and Positioning Devices Policy, revealed, Purpose To support resident mobility, comfort, and well-being through the safe use of assistive and positioning devices in a compassionate setting .Assessment: Qualified staff will evaluate residents to determine device needs .Safety: Devices will be checked regularly for functionality and cleanliness, with issues addressed promptly by maintenance staff .Compliance: Follows Tennessee Department of Health and federal regulations for long-term care . 2. Review of the medical record revealed Resident #24 admitted on [DATE], with diagnoses which included Spastic Diplegic Cerebral Palsy, Epilepsy, Conversion Disorder with Seizures, Scoliosis, Postural Kyphosis, and Reduced Mobility. Review of Resident #24's Seating and Mobility Evaluation dated 3/17/2022, revealed .Mobility Skills .standing gait .unable to complete .Postural Assessment .Shoulders .right left .Comments: fluctuations due to MS [Muscle] tone and involuntary MS spasms .Trunk .Kyphosis .Lateral Lean/Scoliosis .Convex Right .Lean Left .Supports Required Harness/Vest .Justification: Patient requires supports listed to ensure safety due to fluctuations in MS tone and involuntary MS Spasms .Due to patient's Cerebral Palsy diagnosis, patient has decreased postural control, limited trunk control, involuntary MS spasms, increased risk for compromised skin integrity, and compromised safety awareness. Patient would benefit from ultra-light weight manual WC [Wheelchair] to aid in listed deficits . Review of the Care Plan with revision date 1/8/2025, revealed .Problem .Increased Risk for Impaired Skin Integrity AEB [as evidenced by] .I have a safety harness in my chair .Approach/Intervention .Staff Education on proper placement .staff to assess circulation q [every] shift . Review of the Quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #24 had poor short term and long-term memory. Continued review revealed Resident #24 was dependent for upper and lower body dressing and a trunk restraint was not used in the last 7 days. Review of Order Summary Report dated 4/8/2025 revealed Resident #24 had an order for Specialized Harness to aid mobility. Review of the Treatment Administration Record (TAR) and Medication Administration Record (MAR) dated 3/1/2025 - 3/31/2025 revealed no check of the specialized harness which was used as an assistive and positioning device. Review of the TAR and MAR dated 4/1/2025-4/8/2025 for Resident #24 revealed no check of the specialized harness which was used as an assistive and positioning device. During an observation and interview in Resident #24's room on 4/9/2025 at 3:30 PM, Resident #24 was crawling on the floor next to a mattress lying adjacent of his low bed to floor. Certified Nursing Assistant (CNA) I and Housekeeping/Laundry Supervisor assisted Resident #24 to his feet. Resident #24 was very unsteady and unable to stand upright due to foot drop to both feet. Resident #24 was able to take a few steps to his bed with assistance of 2 staff members where incontinence care could be provided. After care was completed CNA I unlocked the bathroom door and obtained his wheelchair. CNA I stated, .we have to keep his closet and bathroom locked for his safety . CNA I and Housekeeping/Laundry Supervisor pivoted Resident #24 from his bed to his wheelchair. CNA I pulled the harness over his shoulders and snaped the harness into place. The chest harness has 4 point of connections, two connections to the back of the wheelchair and two above his waist on both sides. During an interview on 4/9/2025 at 5:11 PM, the MDS Coordinator was asked to explain a physical restraint. The MDS Coordinator stated, .something restricting the resident in any way . The MDS Coordinator was asked if the harness for Resident #24 restricted his movement, bending over, or touching his leg if the resident wanted to perform that activity. The MDS Coordinator stated, .I wouldn't think it was a restraint for him. I guess he couldn't touch his leg .he mainly has it for his safety .he jerks forward in his chair .I don't know of any assessments we are doing. [referring to the specialized harness used for assistance and positioning) I don't know of a signed consent from the family . During an interview on 4/9/2025 at 5:20 PM, the DON stated, .I don't think it restrains him [referring to the harness for Resident #24] .it's used for his safety .his sister was the one that ordered the chair for him. The harness came with the wheelchair .splints are put on the TAR [Treatment Administration Record] to monitor for signs and symptoms of restriction and making sure it is not rubbing the skin which could cause breakdown .I don't see the harness on the TAR or MAR [Medication Administration Record] .he would come out of the chair if he had a seat belt .the sister has ordered another chair for him with more head support but it hasn't came [come] in yet . The DON was unable to provide any assessments, skin checks for the harness, or a consent signed by responsible party for the use of Resident #24's harness for mobility since 2022.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview the facility failed to develop a person-centered comprehensive care plans for 4 of 15 residents (#9, #34, #38, #42) sampled residents. The findings include: 1. Review of the facility's policy titled, MDS & CARE PLAN POLICY AND PROCEDURE dated 7/26/2021, revealed .The facility must develop and implement a comprehensive person-centered care plan for each resident .with measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment .care plans will be completed within 13 days of admission, and quarterly thereafter . 2. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE], with diagnoses including Schizophrenia, Viral Hepatitis, Delusional Disorders, Bipolar, Psychosis, Dementia, Auditory Hallucinations. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 0, which indicated severe cognitive impairment. Resident #9 was dependent on staff for care, occasionally incontinent of bowel and bladder, and coded for Viral Hepatitis (spread through bodily fluids, contaminated food or drink). Review of the Care Plan dated 12/4/2024, revealed there were no interventions related to the diagnosis of Viral Hepatitis. During an interview on 4/9/2025 at 6:13 PM, the Director of Nursing (DON) confirmed that Viral Hepatitis should have been included on the Care Plan. 3. Review of the medical record revealed Resident #34 was admitted to the facility on [DATE], with diagnoses including PTSD (Post Traumatic Stress Disorder-anxiety and flashbacks triggered by a traumatic event) Major Depressive Disorder, Anxiety Disorder, and Vascular Dementia. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 5, which indicated Resident #34 had severely impaired cognition and had PTSD. Review of the Care Plan with revision date of 3/26/2025, revealed there were no interventions related to the diagnosis of PTSD. During an interview on 4/9/2025 at 2:42 PM, the MDS Coordinator stated that Resident #34 had PTSD from his military experience, and it should have been addressed on the Care Plan. During an interview on 4/9/2025 at 6:13 PM, the DON confirmed that a diagnosis of PTSD should have been on the Care Plan. 4. Review of the medical record revealed Resident #38 was admitted to the facility on [DATE], with diagnoses including Diabetes, Anxiety, Malignant Neoplasm of Prostate and Bladder. Review of the annual MDS dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 9, which indicated moderate cognitive impairment, and received hospice services. Review of the Physician Orders dated 11/12/2024 revealed an order to admit to Hospice services. Review of the Care Plan revealed there were no interventions related to hospice care. During an interview on 4/9/2025 at 6:13 PM, the DON confirmed that Hospice should have been on the Care Plan. 5. Review of the medical record revealed Resident #42, was admitted to the facility on [DATE], with diagnoses including Neuropathy, Anxiety, and Dementia. Review of the Physician Order dated 2/21/2025, revealed an order to place a wander guard at this time. Review of the Progress Note dated 2/22/2025, revealed LPN A charted .observed resident packing bags while stating, My son's going to come pick me up. I have to be ready . Review of the Elopement Evaluation dated 2/24/2025, revealed .Resident #42 has history of elopement at home . verbally expressed the desire to go home .packed belongings to go home or stayed near an exit door . Review of admission MDS assessment dated [DATE], revealed a BIMS score of 6, which indicated Resident #42 had severe cognitive impairment, and documented no Wander/elopement alarms were in use. Review of the admission Care Plan dated 2/27/2025, revealed there were no interventions related to the potential for elopement or wander guard use. During an interview on 4/7/2025 at 2:25 PM, LPN E was asked if Resident #42 should have on a wander guard bracelet, since it was not viewable on Resident #42's body. LPN E stated .it's in her purse, the edema in Resident# 42's ankles has went down, and Resident #42 was able to get the wander guard off . Observation on 4/7/2025, at 2:30 PM in Resident #42's room LPN E and Social Services Director, applied wander guard to Resident #42's ankle. During an interview on 4/9/2025 at 5:12 PM, the MDS Coordinator confirmed that residents who are wander/elopement risks should have a care plan to address the risk, and the MDS should be coded for the alarm bracelet. During an interview on 4/9/2025 at 6:35 PM, the DON confirmed that residents at risk for wandering/elopement should be care planned for wandering and elopement risk, and it should be documented on their MDS.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, Pharmacy Services Agreement review, medical record review, and interview the facility failed to provide pharmaceutical services that assure a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate account of medication destruction for 5 of 5 (Resident #3, #6, #15, #29, and #36) sampled residents reviewed for drug destruction. The findings include: 1. Review of the undated facility policy titled, Drug Destruction Policy and Procedure, revealed .It is the policy of [Named Facility #1] to ensure the destruction of unused or expired medications .The purpose of this policy is to ensure compliance with federal regulations .Label/Store Drugs and Biologicals .It is the responsibility of nursing staff, administrative staff, and the contracted pharmacist .Outdated or unused medications will be returned to [Named Pharmacy] where [Named Pharmacist] will destroy the medication . 2. Review of the Pharmacy Services Agreement revealed, .[Named Pharmacy] is willing and able to provide such Services to qualified residents of Nursing Facility .[Named Pharmacy] agrees to comply with federal and state laws and regulations .Nursing Facility agrees, that [Named Pharmacy] will be the sole provider of pharmacy services to resident of nursing facility . 3. Review of the medical record revealed Resident #3 admitted to the facility on [DATE], and discharged on 4/5/2025, with diagnosis which included Secondary Osteoarthritis, Anxiety Disorder, Malignant Neoplasm of Vulva, and Carcinoma in skin of left upper limb, including shoulder. Review of the Order Summary Report revealed an order dated 4/13/2022, for Alprazolam (schedule IV-controlled drug given for anxiety) 0.25 mg (milligram) tablet give 0.25 mg by mouth two times a day. Continued review revealed an order dated 12/11/2024, for Hydrocodone-Acetaminophen (schedule II controlled Opioid medication given for moderate to severe pain) tablet 10-325 mg give 1 tablet by mouth as needed for breakthrough pain. Further review revealed an order dated 1/20/2025 for Morphine Sulfate (schedule II controlled Opioid medication given for severe pain) Solution 20 mg/ml (milliliter) give 0.25 ml by mouth every 3 hours as needed for pain. Review of the Nursing Home Medication Destruction Log revealed Resident #3 had 23 Alprazolam 0.25 mg tablets, 111 Hydrocodone-Acetaminophen tablets, and 27 milliliters of Morphine Sulfate noted for destruction by Pharmacist and the Director of Nursing (DON). Further review revealed All destroyed at [Named Police Department]. 4. Review of the medical record revealed Resident #6 admitted to the facility on [DATE], with diagnosis which included Pathological Fracture of Hip. Review of the Order Summary report revealed an order dated 2/21/2025, for Hydrocodone-Acetaminophen 5-325 mg give 1 tablet by mouth every 24 hours as needed for pain. Review of the Nursing Home Medication Destruction Log revealed Resident #6 had 26 Hydrocodone-Acetaminophen tablets noted for destruction by Pharmacist and the DON. Further review revealed All destroyed at [Named Police Department]. 5. Review of the medical record revealed Resident #15 admitted on [DATE], with diagnosis which included Spinal Stenosis, Lumbar Region without Neurogenic Claudication, Low Back Pain, and Osteoarthritis. Review of the Order Summary report revealed an order dated 2/25/2025 for Alprazolam 1 mg give 1 mg by mouth three times a day and Tramadol Hydrochloride (HCL) (Opioid schedule IV-controlled drug given for moderate to severe pain) 50 mg give 1 tablet by mouth as needed for pain. Review of the Nursing Home Medication Destruction Log revealed Resident #15 had 4 Alprazolam 1 mg tablets and 89 Tramadol HCL tablets noted for destruction by Pharmacist and the DON. Further review revealed All destroyed at [Named Police Department]. 6. Review of the medical record revealed Resident #29 admitted to the facility on [DATE], and expired on 4/4/2025 with diagnosis which included Anxiety Disorder and complete Traumatic Amputation at Knee Level, Right Lower Leg. Review of the Control Drug Check Sheet revealed .DRUG: Morphine 100mg/5 ml 0.25 ml po [by mouth] q [every] 3 h [hours] PRN [as needed] for pain .4/7/25 [4/7/2025] .return to pharmacy 29.25 ml . Continued review revealed .DRUG: Lorazepam [schedule IV controlled drug given for anxiety] 0.5 mg 1 tab po q 4 hrs [hours] PRN for restlessness or anxiety .4/7/25 .return to pharmacy 30 . Review of the Nursing Home Medication Destruction Log revealed Resident #29 had 30 Lorazepam tablets and 27 mls of Morphine Sulfate 100 mg/ml noted for destruction by Pharmacist and the DON. Further review revealed All destroyed at [Named Police Department]. 7. Review of the medical record revealed Resident #36 admitted to the facility on [DATE], with diagnosis which included Cerebral Palsy, Schizoaffective Disorder, and Scoliosis. Review of the Control Drug Check Sheet revealed .DRUG: Tramadol 50 mg BID [twice per day] . Review of the Nursing Home Medication Destruction Log revealed Resident #36 had 31 Tramadol tablets noted for destruction by Pharmacist and the DON. 7. During a telephone interview on 4/9/2025 at 1:20 PM, the Pharmacist stated, .the facility does use my pharmacy, and I am the Pharmacist for the building .I come up once a month or as needed .Narcotics are in the locked cart. The nurses will give me the meds to destroy. I sign them off on the resident record, bring it back to the pharmacy make sure it is logged correctly, then the narcotics go immediately to the police destruction at the [Named Police Department] .I drop it off .No one at the police department signs that it has been dropped off .it is a sealed box in the lobby of the police department .if I need to do something different I will . During an interview on 4/9/2025 at 2:09 PM the Administrator was asked how the facility keeps record of controlled drug destruction. The Administrator stated, .from my understanding we entrust that over to the pharmacist to destroy those . The Administrator was asked if the facility should have a receipt that the narcotics were destroyed. The Administrator stated, .I think that we can certainly go above and beyond on us doing this the proper way .we will be making adjustments to the process right now .the Pharmacist does take the medications out in a locked suitcase . During an interview on 4/09/25 at 2:28 PM, the DON stated, .we have a locked suitcase for the narcotic transport . The DON was asked how the facility was showing a receipt of destruction for controlled drugs. The DON stated .we sent them back to the pharmacist and he destroys them .we returned to the pharmacy then it is on his side .It shows we sent it back to the pharmacist .that is our policy and procedure . The DON was asked how the facility can prove the controlled drugs were destroyed. The DON stated, .I will get with my Administrator for a fail proof plan to transport and know that they will be destroyed .I probably should have known more about the destruction of the medications . The DON was asked if a nurse needed to destroy a narcotic during a medication pass how are they completed this task. The DON stated, .the nurse with a witness of another nurse will dispose of it in a sharps container .no one would try to get in a sharps box to get a narcotic . During a telephone interview on 4/9/2025 at 3:03 PM, Chief Assistant Police Officer for (Named Police Department) was asked if he had records of the Pharmacist dropping of narcotic medications from Facility for destruction. Chief Assistant Police Officer stated, .I don't know we have a lock box in the lobby .its possible .we don't know who drops it off. No logs are kept related to the medicines .we just bag it up, keep it in the vault then .dangerous drug task force picks it up .the box we put it in is a sealed barrel .we don't touch it at all .we schedule a pickup when it is full, and they bring us a new barrel to put out .

Based on review of federal regulations, Quarterly Payroll Based Journal (PBJ), and interview, the facility failed to report PBJ for Quarter 2 in 2024 (January 1-March 31). The findings include: 1. Review of the federal regulation 483.70(p) revealed, .The facility must electronically submit to CMS (Centers for Medicaid and Medicare Services) complete and accurate direct care staffing information . 2. Review of Quarterly Payroll Based Journal (PBJ) dated January 1, 2024-March 31, 2025, revealed, .No RN (Registered Nurse) Hours .Four or More Days within the Quarter with no RN Hours . During an interview on 4/9/2025 at 4:10 PM, the Administrator confirmed the facility failed to submit the required PBJ data for the second quarter of 2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review and interview, the facility failed to implement appropriate infection prevention and control practices for 1 of 1 sampled resident (Resident #22) who required enhanced barrier precautions (EBP an infection control strategy that uses gloves and gowns to reduce the spread of multidrug resistant organisms (MDRO microorganisms that are resistant to at least one class of antimicrobial (substance that kills bacteria) agents) in nursing homes during medication administration. The findings include: 1. Review of undated Policy titled Enhanced Barrier Policy .to safe guard residents from multidrug-resistant organisms (MDROs) during high-contact resident care activities while preserving their quality of life through focused infection control practices .This policy applies to all staff members .The policy applies to residents .with .PEG (Percutaneous Endoscopic tube is a feeding tube inserted through the skin and into the stomach, used for long-term nutritional support when someone cannot eat or drink )tubes .Infection control team will designate residents requiring EBP (Enhanced Barrier Precautions) in their care plans .Discrete signage indicating EBP will be placed at resident's room entrance .Staff must wear gloves and gowns during high-contact care activities with EBP-designated residents, including tasks involving PEG tube or other devices .PPE is donned immediately prior to activity and removed immediately after, followed by hand hygiene . Review of undated policy titled Medication Pass Policy .Follow infection control practices . 2. Review of the medical record revealed Resident #22, was admitted to the facility on [DATE], with diagnoses including Dementia, Anxiety, Dysphagia, and Convulsions. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 1, which indicated Resident #22 has severe cognitive impairment. Review of Resident #22's Comprehensive care plan dated 1/30/2025, revealed the facility failed to include EBP in the care plan. Observation of administration of medication through Peg tube for Resident #22 on 4/8/2025 at 4:20 PM, with LPN (Licensed Practical Nurse) E revealed there was no sign for EBP precautions on Resident #22's door. LPN E failed to place a protective gown on and then pushed the medication cart into Resident #22's room. LPN E accessed the peg tube and administered her medications without following EBP while providing care for Resident #22. During an interview on 4/9/2025 at 9:30 AM, LPN A was asked to explain EBP precautions. LPN A stated, .let me find out the correct information and I will get back with you . LPN A left the surveyor and went to speak to the Director of Nursing (DON). During an interview on 4/9/2025 at 9:35 AM, LPN B was asked to explain EBP. LPN B stated, .it's about keeping a clean surface . LPN B was asked when you would use EBP. LPN B stated, .if you were doing a glucose monitor check, eye drops, involving body fluids you would want to wear gloves and gowns anything necessary to provide a barrier maybe a face shield . LPN B was asked why you would practice EBP and she stated, .it is for your protection and the patients protection . LPN B was asked if any resident at the facility was under EBP. LPN B stated, .not that I know of . During an interview on 4/9/2025 at 9:47 AM, Certified Nursing Assistant (CNA) C was asked if she cared for [Named Resident #22] and if any precautions should be taken when providing incontinence care. CNA C stated, .I use gloves .always washing my hands .I like to have someone with me to help me watch the feeding tube to make sure it isn't pulled out . CNA C was asked what would be reasons she would need to wear a gown when providing resident care. CNA C stated, .if a resident had covid or maybe when emptying a catheter . CNA C stated, .I don't know of a resident that would require a gown all the time during care . Observation on 4/9/2025 at 9:55 AM, Resident #22 had no sign for EBPs. During an interview on 4/9/2025 at 10:13 AM, the Administrator stated, .I believe last year Centers for Medicare and Medicaid Services [CMS] made it mandatory for gowns with EBP. We didn't have a policy for that we have created one right now . The Administrator was asked why EBP precautions should be used. The Administrator stated, .to reduce MDROs bacterial organisms . During an interview on 4/09/25 at 10:20 AM, the DON was asked if she was the infection control preventionist. The DON stated, . I am the infection control nurse my training was in 2022 and 2023 just on the computer training . The DON was asked about EBP. The DON stated, .I do not recall seeing any of that in my training, just heard recently about it . The DON was asked what type of residents would need to be on EBP. The DON stated, .anybody with multidrug-resistant [MDR] bacteria, open wounds, infections, patients with peg tube, or colostomy. The DON was asked if the resident's door should denote whether a resident is on enhanced barrier precautions. The DON stated, .the door should note the need for this type of care .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to implement Comprehensive Care Plans for 2 of 13 (Resident #13 and #34) sampled residents reviewed for care planning. The findings include: 1. Review of the facility's policy titled, Care Plan Policy and Procedure, dated 7/23/2021 revealed, .implement a comprehensive person-centered care plan .meet a resident's medical .mental and psychosocial needs . 2. Review of the medical record revealed Resident #34 was admitted on [DATE], with diagnoses of Anxiety Disorder and Cognitive Deficit. Review of the annual MDS dated [DATE], revealed Resident #34 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment, and had diagnoses of Anxiety, Depression, and Psychotic Disorder. Review of the Care Plan dated 9/13/2023, revealed Resident #34 was not care planned for psychotic features, hallucinations, or harm to self. During an interview on 10/11/2023 at 5:43 PM, the Director of Nursing (DON) confirmed that Resident #34 should have been care planned for psychotic features, hallucinations, and harm to self. 3. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE], with diagnosis of Atrial Fibrillation, Diabetes, Dementia, Major Depressive Disorder. Review of the annual MDS dated [DATE], revealed Resident #39 had a BIMS score of 5, which indicated she was cognitively impaired. Review of the Care Plan dated 8/16/2023, revealed Resident #13 had an increased risk for bleeding related to receiving Xarelto (a blood thinner) daily. Further review of the Car Plan revealed to administer Xarelto as ordered and monitor for signs and symptoms of unexplained bleeding. Review of the medical record revealed the facility failed to provide documentation that monitoring was conducted for the Xarelto as car planned. During an interview on 10/11/2023 at 5:23 PM, the DON confirmed if the resident is care planned to be monitored for sign symptoms of bleeding, bruising, blood in urine, or blood in stool, that it should be documented in the Treatment Administration Record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to perform complete neurological (neuro) checks, revise the Care Plan, implement appropriate fall interventions, and notify the provider for 3 of 3 (Resident #15, #22, and #28) sampled residents reviewed for accidents. The findings include: 1. Review of the facility's undated policy titled, .FALLS AND RESIDENT INCIDENTS, revealed .A fall is defined when a resident accidently touches the floor .Identified residents with the potential for a fall or have fallen will have 1 falling star, visual aide placed beside their door to alert the nursing staff .The nursing home staff using the fall-risk assessment sheet will identify these residents. New admissions will be evaluated upon admission and pre-existing residents that have fallen will be evaluated using this form . Review of the facility's undated policy titled, FALL PROTOCOL: RESIDENTS AT RISK FOR FALLS, revealed .THREE FALLS .(within 90 days) .Request attending physician to complete an evaluation and document findings-review medications and reduce as necessary. Interdisciplinary Team to reassess appropriateness/effectiveness of any restraints in use . Review of the facility's policy titled, .CARE PLAN POLICY AND PROCEDURE, dated 7/26/2021, revealed .To ensure compliance .Comprehensive Care Plans .The facility must develop and implement a comprehensive person-centered care plan for each resident .The comprehensive care plan must describe the following .The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .The resident's goals for admission and desired outcomes .Care Plans will be completed after resident is admitted to this facility within 13 days, quarterly .then upon any significant changes, in resident status . Review of the facility's undated policy titled, NEURO CHECKS, revealed, .q[every]15min[minute]x[times]1hr[hour] .q 30minx2hr . q4hrsx24hrs . qshift x 48hr . Initial Neuro assessment & [and] follow-up VS [vital signs], level of consciousness .orientation .speech, facial symmetry, motor (Grips & strengths) and sensory (Pupils) function . 2. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE], with diagnoses of Hypothyroidism, Dementia, Repeated Falls, Delusions, and Hallucinations. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #15 had a Brief Interview for Mental Status (BIMS) score of 00, which indicated severe cognitive impairment, and was not coded for falls. Review of the FALL RISK ASSESSMENT, dated 3/5/2023, revealed Resident #15 had a score of 18, which indicated she was a high risk for falls. Review of progress note dated 3/20/2023 at 8:00 PM, revealed I [Resident #15] just slid off the bed .Observed .1cm [centimeters] x 1cm abrasions to L [left] knee .2.5 cm .light blue ecchymosis to R [right] outer forearm by elbow, 3.5 cm x 2 cm .pink area to L arm .2.5 cm .L side middle back .820 [8:20] pm [PM] While sitting on toilet resident states my head hurts Upon palpation observed an .3.5 cm x 3.5 cm .0.7 cm tall dark purple hematoma to L upper forehead in hairline .MD [Medical Doctor] Notified .EMS [Emergency Medical Services] notified .907pm [9:07 PM] .Leaving facility .3-21-23 [3/21/2023] .515am [5:15 AM] return to facility .Alert .confused .3/21/23 .Alert .responsive, confused per usual .5/1/23 .CNA [Certified Nursing Assistant] called nurse to room, Resident slid out of recliner to floor .[symbol for no] injuries . Review of the ED [Emergency Department] Note dated 3/20/2023 revealed, XXX[AGE] year-old female who fell off the bed and has left forehead hematoma. Fall happened just prior to arrival. Fall was unwitnessed. Patient with baseline altered mental status but appears at her baseline according to EMS and nursing home . Review of the Care Plan revealed, .Problem .Increased risk for falls .Interventions .3/20/23 .Encourage to call for assist .Encourage to use walker .5/1/23 .Encourage to call for assist . Review of the INCIDENT REPORT, dated 5/1/2023 revealed, .CNA called nurse to room. Res [Resident] had slid out of recliner to floor on buttocks . Observations in the Dining Room on 10/9/2023 at 11:57 AM, revealed Resident #15 was dressed and sitting in the recliner in the dining room. The facility was unable to provide documentation that neuro checks were performed every 4 hours for 24 hours after the fall on 3/30/2023. During an interview on 10/11/2023 at 4:54 PM, the Director of Nursing (DON) confirmed neuro checks were not completed for Resident #15's fall on 3/20/2023. The DON was asked if a resident has a BIMS of 00 and was severely cognitively impaired would the intervention to call for assistance be appropriate for a fall. The DON stated, .no . 3. Review of the medical record revealed Resident #22 was admitted to the facility on [DATE], with diagnoses of Paraplegia, Transverse Myelitis in Demyelinating Disease of the Central Nervous System, Lupus, Pressure Ulcers, and Osteoporosis. Review of the quarterly MDS dated [DATE], revealed Resident #22 had a BIMS of 11, which indicated moderate cognitive impairment, and required extensive staff assistance with activities of daily living (ADLs). Review of the Nurse's Note dated 9/22/2023, revealed Resident #22's right lower leg had two plus edema, bruising, and was warm to the touch. The physician was notified, and the resident was transported to the emergency room. The resident returned to the facility the same day. Review of the [Named Facility] Radiology Report dated 9/22/2023, reveled .Nondisplaced medial tibial plateau fracture and right fibular head fracture . Review of the Care Plan with a revision date of 9/22/2023, revealed Resident #22 was at an increased risk for impaired skin integrity and her right lower leg had two plus edema, bruising, and warmth. Resident #22's Care Plan was not updated to include the diagnosis of closed fracture of right tibial plateau and closed fracture of head of right fibula. Observation in the resident's room on 10/9/2023 at 3:02 PM, revealed Resident #22 lay in bed on her back, a brace was applied to her right leg from the upper thigh to lower calf. During an interview on 10/9/2023 at 3:13 PM, Resident #22 stated, .my leg hit the rail [side rail] .got a brace . Resident #22 was asked were any bones broken. Resident #44 stated, Yeah .couple of weeks ago .my legs like jerk and kick back .involuntary movement .it wasn't nobody's fault . Resident #22 confirmed she went out the emergency room for treatment and returned the same day. During an interview on 10/11/2023 at 6:00 PM, the DON was asked should Resident #22's Care Plan have been revised to reflect her medial tibial plateau and right fibular head fracture. The DON stated, Yeah .I just haven't got it updated yet .this one just kind of . [slipped by] yes. 4. Review of the medical record revealed Resident #28 was admitted to facility on 3/11/2021, with diagnoses of Alzheimer's Disease, Dementia, Psychotic Disorder, Major Depressive Disorder, Chronic Obstructive Pulmonary Disorder, and Anxiety Disorder. Review of the INCIDENT REPORT, dated 7/3/2023, revealed .resident slid self to side of recliner .fell to floor .denies pain . Review of the Care Plan with a revision date of 7/3/2023, revealed the only intervention implemented for Resident #28's fall on 7/3/2023, was to encourage her to ask for assistance. Review of the quarterly MDS dated [DATE], revealed Resident #28 had a BIMS of 00, which indicated severe cognitive impairment, and required limited to extensive assistance of 1 to 2 staff members with all ADLs. Review of the INCIDENT REPORT, dated 7/17/2023, revealed .[Resident #28] was seated at dining room table and stood up and walked around the table .seen sitting herself down in the floor .stated she was ok .neurocheck and vitals done as precaution . Review of the Nurse's Notes dated 7/17/2023, revealed neurochecks were not initiated. The facility was unable to provide documentation that neuro checks were completed. Review of the Care Plan with a revision date of 7/17/2023, revealed the only intervention implemented for Resident #28's fall on 7/17/2023 was to encourage her to ask for assistance. Review of the INCIDENT REPORT, dated 7/22/2023, revealed .observed resident on side in floor beside recliner .denies pain or discomfort . Review of the Care Plan with a revision date of 7/22/2023, revealed the only intervention for Resident #28's fall on 7/22/2023 was to encourage her to ask for assistance. Review of the INCIDENT REPORT dated 9/24/2023, revealed .resident sitting on buttocks beside of recliner in floor .denies hitting head . Review of the Care Plan with a revision date of 9/24/2023, revealed the only intervention for Resident #28's fall on 9/24/2023 was to encourage her to ask for assistance. Review of the medical record revealed there was no documentation the physician was notified of Resident #28's fall on 7/3/2023, 7/17/2023, and 9/24/2023. Observation on 10/9/2023 at 10:53 AM, revealed Resident #28 was not in her room. Observation in the Dining Room on 10/9/2023 at 11:12 AM, revealed Resident #28 reclined in a trendelenburg position [reclined flat on back with the feet elevated above the head] in a recliner, covered with a blanket, her eyes were closed, and she appeared to be asleep. During an interview on 10/10/2023 at 5:43 PM, Certified Nursing Assistant (CNA) #1 was asked if there was a sign to inform employees which residents are at high risk for fall. CNA #1, stated, No. No one ever told me about a sign. During an interview on 10/11/2023 at 9:06 AM, the DON was asked what the process is when a resident falls. The DON stated, If it's witnessed or not witnessed let the nurse know, she does an assessment, she calls the physician, the on call nurse, and we call the family. The DON was asked how staff knew which residents were a fall risk. The DON stated, All of our residents are fall risk .we have the falling stars on the doors and then in report if there's been any falls, we say .need to pay closer attention. The DON was asked how staff were in-serviced to know what the falling star means. The DON stated, We in-service twice a month when we get paid and we go over all of the safety issues safety rules, safety measures go over the falling stars and have a question and answer . The DON was asked how the facility determined which residents were interviewable. The DON stated, By their cognitive status . The DON was asked how the facility determined which residents were educatable. The DON stated, We educate every resident, whether they retain the information, we educate every patient when they are put in bed here's your call light this is the button you push, and we put it right there. The DON was asked was a resident with a BIMS of 00 considered to be educatable. The DON stated, On paper it would be no, but in reality, we still educate them. The DON confirmed Resident #28 had severe cognitive impairment. The DON was shown Resident #28's Care Plan and asked should the only fall intervention for the last 4 falls be to remind the resident to ask for assistance. The DON stated, I should've put on there to sit up front and to have a partner when she's trying to get up .or getting restless . The DON confirmed the facility should do neurochecks on each resident who fell and hit their head. The DON was asked if the resident was non-interviewable, and the fall was unwitnessed how they knew if the resident hit their head. The DON stated, When we assess we look to see if [there's] any red places, markings, any signs that they hit their head. The DON was unable to answer if neurochecks were completed on each unwitnessed fall. During an interview on 10/11/23 at 10:10 AM, Licensed Practical Nurse (LPN) #2 was asked if there were any visual indicators of a fall risk in residents' rooms. LPN #2 stated, No.

Based on interview, and observations, the facility failed to ensure narcotics were not expired on the medication cart, the drug destruction sheets were accurately documented and signed by the pharmacist and Director of Nursing (DON) and failed double lock and secure accurate inventories of controlled substances on 2 of 2 medication carts (Medication Cart #1 and Medication cart #2). The findings include: 1. Review of the facility undated policy's titled, Policy on Disposal of Medicines, revealed .Medication that are expired are to be placed in the basket located behind the door in the med [medication] room .These medications will be properly disposed of monthly by the pharmacist . Review of the policy's titled, Drug Destruction Policy and Procedure, dated 10/5/2021, revealed .It is the policy of [Named Nursing Home] to ensure the destruction of unused or expired medications .It is the responsibility of nursing staff, administrative staff, and the contracted pharmacist .Outdated or unused medications will be returned to the Name Pharmacist where pharmacist [Named Pharmacist] will destroy the medication . Review of the undated WORKING CONTRACT ., revealed .Destroy all continued or outdated medication .Come to the facility once a month for pharmacy documentation, to do the drug review .Inspect department regularly for compliance with established policies and procedures, and federal and state standards .review of the EXPIRED MEDICINE CHECKLIST, dated 2/14/2023 through 10/10/2023, revealed the medication room and the medication cart were check. Review of the Nursing Home Medication Destruction Log, dated 3/24/32023 through 8/4/2023, 8/8/2023 through 10/10/2023, and 10/10/2023 revealed there was only the Pharmacist signature on the form reconciling the medications. 2. The pharmacist failed to document the expired Diazepam (a sedative and controlled substance) elixir found on Medication Cart #1 on 10/10/2023 at 10:35 AM, make sure the narcotic count was correctly and the total amount was accurate. The Pharmacist failed to review the correct amount documented on the narcotic sheet and the bottle reconciled. Review of the NARCOTIC COUNT SHEETS, dated 9/27/2023 through 10/10/2023, revealed Named Resident #17's Valium (Diazepam) documented amount left 50 ml. On 10/10/2023 an addendum was made with the amount of 37.5 left. 3. Observation in medication Cart #1 on 10/10/2023 at 10:35 AM, with Licensed Practical Nurse #5 revealed one bottle of Diazepam elixir with approximately 30 milliliters (ml) and the narcotic sheet documented 50 ml remaining. 4. Observation on Medication Carts Cart #1 on 10/10/2023 at 6:08 PM, revealed the following controlled substances were not secure under double lock and key: a. Resident #8's Ativan (sedative and controlled substance) and Gabapentin (medication to treat seizures and pain, and is a controlled substance). b. Resident #12's Gabapentin. c. Resident #13's Gabapentin. d. Resident #26's Gabapentin. e. Resident #33's Ativan and Gabapentin. 5. During an interview and observation on 10/10/2023 at 6:14 the Director of Nursing (DON) confirmed on Medication Cart #2 the following controlled substances were not under double lock: a. Resident #1's Ativan. b. Resident #20's Ativan. c. Resident #24's was Ativan. d. Resident #31's was dispensed 2 Ativan. e. Resident #38's Gabapentin and Ativan. During an interview on 10/10/2023 at 5:58 PM and 10/11/2023 at 3:07 PM, the Pharmacist was asked if he could tell me about the process for when he comes to the facility. The Pharmacist stated, .So we come out to the facility .go through the medication room .I check the medication carts for out of date medications .I go through the medication carts and check for expired medication .In the medication room .look for expired medication .I check the temperatures .to monitor to make sure the medication is stored in proper temperature .such as the insulin .I go through the charts and monitoring for changes .for the month document and improve them and drug interaction with the chart complete medication reviews . The Pharmacist was asked when the last time was the Diazepam elixir was filled. The Pharmacist stated, .It was last time filled as a prn order on 8/6/2022 for a quantity of 300 ml . The Pharmacist was asked how the Diazepam was missed on the monthly checks for expired medications. The Pharmacist stated, .I don't know how that was missed [Diazepam] . The Pharmacist was asked if he measured the remaining Diazepam elixir during the drug destruction on yesterday. The Pharmacist stated, .No I did not .I trusted [Named LPN #1] .she told me there was 37.5 ml . The Pharmacist was asked how the narcotics are reconciled. The Pharmacist stated .we do have a running list of the drugs to destroy .there is a list in the pharmacy review book .I come out each month .the medications that or discontinued or expired .I take with me and destroyed them . The Pharmacist was asked where the medication destruction sheet are for the past 4 months. The Pharmacist stated, I have not completed them I will have them by 6:30 pm today. The Pharmacist was asked should all control substance (Ativan and Gabapentin) be place in the narcotic draw and accounted for. The Pharmacist stated, Yes . During an interview on 10/11/2023 at 3:30 PM, LPN #1 was asked how much of the Diazepam elixir was left in the bottle. LPN #1 confirmed she counted the elixir with LPN #4 and there were 37.5 milliliters left in the bottle. The Pharmacist failed to ensure all control substances (Ativan and gabapentin) were under double lock and document on a narcotic sheet. The Pharmacist failed to accurately check the medication carts for expired drugs and ensure the narcotic count was correct.

**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 a medication administration rate of less than 5 percent (%) when 1 of 3 nurses (Licensed Practical Nurse (LPN) #1) failed to properly administer medications for 1 of 7 (Resident #23) sampled residents observed during medication administration. This resulted in a medication administration error rate of 7.41%. The findings include: 1. Review of the facility's undated policy titled, Medication Pass Policy, revealed .Medications will be administered as ordered .refer to the MAR [Medication Administration Record] . 2. Review of the medical record revealed Resident #23 was admitted to the facility on [DATE] with diagnoses of Dysphagia, Anxiety Disorder, Gastrostomy Status, Major Depression, and Dementia. Review of the Physician's Orders dated 9/13/2023, revealed .Decrease Abilify to 1 mg via PEG . Review of the Medication Administration Record, dated October 2023 revealed, .Abilify [antipsychotic] 1 mg [milligram] via [by way of] PEG [percutaneous endoscopic gastrostomy] .Dilantin [medication for seizures] 200mg . CRUSH MEDS . Observation in the resident's room on 10/10/2023 at 4:42 PM, revealed LPN #1 split the Abilify 2 milligram tablet using a pill splitter. LPN #1 placed half of the Abilify in a plastic medication cup along with the Dilantin, crushed the two medications with the pill crusher, and placed them into the same plastic medication cup. LPN #1 poured a small amount of water into the plastic cup and mixed the medications. LPN #1 then flushed the PEG Tube with 30 milliliters of water, administered the medications per PEG Tube, and flushed with 30 millimeters of water after the medications were administered. There were no Physician's Orders to mix the 2 medications before administering through the PEG Tube, resulting in 2 medication errors. During an interview on 10/11/2023 at 10:57 AM, the Director of Nursing (DON) was asked if nurses should cocktail medications for a PEG Tube. The DON stated, .No . only if there was a physician's order to cocktail .otherwise they should be given one at a time .

Based on policy review, observation, and interview, the facility failed to ensure medications were properly stored in 2 of 4 medication storage areas (Medication Storage Room, Medication Cart #1, and Medication Cart #2) when the facility had opened, undated, and expired medications, and controlled substances that were not secured behind two locks on the medication cart. The findings include: 1. Review of the facility's undated policy titled, Policy on Disposal of Medication, revealed .Medications that are expired are to be placed in the basket located behind the door in the med [medication] room. These medications will be properly disposed of monthly by the pharmacist . 2. Observation and interview on 10/10/2023 at 10:35 AM, revealed Medication Cart #1 had one open and undated bottle of Diazepam (sedative and controlled substance) with an expiration date of 2/2023. Licensed Practical Nurse (LPN) #2 was asked should the medication carts have open, undated, and expired medication. LPN #2 stated, .No . Observations in the Medication Storage Room on 10/9/2023 at 10:46 AM, revealed the following: a. One open and undated Basaglar (Long acting insulin, works to lower blood glucose) Flex insulin pen. b. 2 open and undated Victoza (Help control blood sugar) Flex insulin pens. During an observation on 10/10/2023 at 4:56 PM, with LPN #1 during medication administration revealed, LPN #1 pulled Resident # 26's Gabapentin (sedative and pain medication, and controlled substance) from the regular section in the medication cart and was not under double lock and key in the narcotic section of the medication cart. Observation on Medication Carts Cart #1 on 10/10/2023 at 6:08 PM, revealed the following control substances were not secure under double lock and key: a. Resident #8's Ativan (sedative and controlled substance) and Gabapentin. b. Resident #12's Gabapentin. c. Resident #13's Gabapentin. d. Resident #26's Gabapentin. e. Resident #33's Ativan and Gabapentin. During an interview and observation on 10/10/2023 at 6:14 the Director of Nursing (DON) confirmed on Medication Cart #2 the following resident's controlled substances were not under double lock: a. Resident #1's Ativan. b. Resident #20's Ativan. c. Resident #24's was Ativan. d. Resident #31's was dispensed 2 Ativan. e. Resident #38's Gabapentin and Ativan. During a telephone interview on 10/10/2023 at 5:58 PM, the Pharmacist was asked should the medication storage areas have open and undated medication and expired medication. The Pharmacist confirmed the medication storage areas should not have expired and open and undated medication. The Pharmacist was asked if the control substances be stored under double lock and key. The Pharmacist stated, .Yes . During an interview on 10/10/2023 at 11:11 AM, the DON confirmed the medication storage areas should not have expired, and open and undated medication. The DON confirmed that the narcotic count should be correct, and the control substances (Ativan and Gabapentin) should be under double lock and key in the medication carts.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the policy review, medical record review, and interview, the facility failed to resubmit a PASRR [Preadmission Screening and Resident Review] after the resident had the addition of a new antipsychotic medication and a new mental health diagnosis for 4 of 5 sampled residents (Resident #5, #13, #18, and #34) reviewed for PASRR. The findings include: 1. Review of the facility's policy titled, CARE PLAN POLICY AND PROCEDURE, dated 7/26/2021, revealed .Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR [Preadmission Screening and Resident Review], it must indicate its rationale in the resident's medical record . 2. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses of Diabetes, Psychosis, Anxiety, and Depression. Resident #5 had a PASRR completed on admission in 2004 with diagnosis of mild mental retardation. The physician ordered a new antipsychotic medication, Abilify, in 2022. Review of the Physician's Orders dated 1/24/2022, revealed .Abilify 2.5mg po [by mouth] at HS [bedtime] . Review of the quarterly MDS dated [DATE], revealed Resident #5 had a BIMS score of 3, which indicated severe cognitive impairment. Medications received were Antipsychotic, Antidepressant, and Antianxiety. During an interview on 10/11/2023 at 5:15 PM, the DON confirmed Resident #5's last PASRR was done August 2004, and a new PASRR was not done when the new antipsychotic medication Abilify was added. 3. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] with diagnoses of Dementia, Diabetes, Atrial Fibrillation, and Major Depressive Disorder. Resident #13 had a PASRR completed on 2/26/2015, on admission to the facility, and review of the care plan dated 4/3/2019 and revised on 8/16/2023 showed a new psychological diagnosis of Schizophrenia. Review of the Physician's Orders dated 1/10/2021, revealed .Bipolar disorder .Zyprexa 5mg [5 milligrams] .daily . Review of the annual MDS dated [DATE], revealed Resident #13 had a BIMS score of 8, which indicated moderate cognitive impairment. Medications received were Antipsychotic and Antidepressant. During an interview on 10/12/2023 at 5:23 PM, the DON was asked, what is the process for updating the PASRR's. The DON stated, .When they get a new diagnosis of bipolar or schizophrenia or a new drug for bipolar or schizophrenia. The DON was asked should Resident #13 have an update PASRR with his new diagnosis of Bipolar and Schizophrenia. The DON stated Yes. 4. Review of the medical record revealed Resident #18 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease, Schizoaffective Disorder, Anxiety, Depression, Hypothyroidism, and Bipolar Disorder. Resident #18 had a PASRR Level I and ll completed in 2018 on admission to the facility, with diagnoses of Schizoaffective Disorder and Bipolar Disorder. Psychotropic Medications included Klonopin, Wellbutrin SR, Zyprexa, Depakene and Aricept. Review of the Physician's Orders dated 2/14/2022 revealed, .Cogentin 2 mg po QD [every day] . Review of the quarterly MDS dated [DATE] revealed Resident #18 had a BIMS score of 00, which indicated severe cognitive impairment. Medications received were Antipsychotic, Antianxiety and Antidepressant. During an interview on 10/11/2023 at 5:10 PM, the DON was asked should there have been a new PASRR done for Resident #18 when she had a new order for Cogentin. The DON stated, .I don't know anything about PASRR .I didn't know that . 5. Review of the medical record revealed Resident #34 was admitted to the facility on [DATE] with diagnoses of Dementia, Anxiety, and Depression. Resident #34 had a PASRR completed 9/8/2022, on admission to the facility and had a new psychological diagnoses on 4/29/2023 of Dementia with Psychotic Features. Review of Physician's Orders dated 4/29/2023, revealed .add dx of dementia c [symbol for with] psychotic features . Review of the annual MDS dated [DATE] revealed Resident #34 had a BIMS score of 3, which indicated severe cognitive impairment. Medications received were Antipsychotic, Antidepressant, and Antibiotic. During an interview on 10/11/2023 at 5:43 PM, the DON was asked to explain the new diagnosis of dementia with psychotic features. The DON stated, She [Named Resident #34] was lashing out with hallucinations and harming herself .she was saying she has mosquitos flying in her vagina . The DON was asked if Resident #34 should have a new screening for a PASRR. The DON stated, .Yes .

Based on policy review, observation, and interview the facility failed to ensure infection control practices to prevent the spread of infection when 3 of 3 nurses (Licensed Practical Nurses (LPN) #1, LPN #3, and LPN #4) failed to perform hand hygiene and to clean equipment during medication administration. The findings include: 1. Review of the facility undated policy titled, Handwashing Policy, revealed .all employees are required to wash hands before and after any direct resident care as follows .Washes all surfaces of hands and wrist with liquid soap for at least 20 seconds .Dries hands on clean paper towel .Turn off faucet with a second .clean dry paper towel . Review of the PROTOCOL FOR ADMINISTRATION OF MEDICINES & [and] WATER FLUSHES PER PEG TUBE [percutaneous endoscopic gastrostomy], revealed .Check for placement .flush with 30 cc [cubic centimeters] of water .Mix approximately 20-30 cc of water .crush or liquid medicines .give per peg, flush with 30 cc of water .reconnect tube feeding .Rinse syringe with warm water and return to bag .wash hands . 2. Observation in the resident's room on 10/10/2023 at 4:42 PM, revealed LPN #1 entered Resident #23's room with the medication cart, prepared the medication for Peg Tube administration, and exposed the resident's Peg Tube. LPN #1 used a syringe and stethoscope, checked placement, and placed the stethoscope back around her neck after use. LPN #1 failed to clean the stethoscope before or after use. LPN #1 administered Resident #23's medication and placed the syringe back into the plastic bag. LPN #1 failed to clean the syringe before she placed it back into the plastic bag. LPN #1 removed her gloves, washed her hands for 8 seconds, removed the stethoscope from around her neck, placed the stethoscope on top of the medication cart, and exited the room with the medication cart. LPN #1 failed to clean the medication cart after she left Resident #23's room and failed to wash her hands for 20 seconds per the facility's policy. Observation in the resident's room on 10/10/2023 at 4:56 PM, revealed LPN #1 rolled the medication cart into Resident #26's room to perform a glucose check and administer medications. LPN #1 donned her gloves, administered the medication, removed her gloves, and washed her hands for only 8 seconds. LPN #1 donned a new pair of gloves, administered insulin, removed her gloves, and washed her hands for only 9 seconds. LPN #1 exited the room with the medication cart and failed to clean the medication cart. LPN #1 failed to wash her hands for 20 seconds per the facility's policy. 3. Observation in the resident's room on 10/10/2023 at 5:21 PM, revealed LPN #3 entered Resident #27's room to perform a glucose check, donned her gloves, checked the resident's glucose, removed her gloves, washed her hands for only 9 seconds, and turned off the faucet with the same wet towel with which she dried her hands. LPN #3 failed to wash her hands for 20 seconds and use a clean dry paper towel t turn off faucet the facility's policy. 4. Observation in the resident's room on 10/11/2023 at 10:28 AM, revealed LPN #1 entered Resident #28's room with the medication cart and washed her hands for only 13 seconds. LPN #1 donned her gloves, administered an eye drop in the left eye, removed her gloves, and washed her hands for only 10 seconds. LPN #1 donned a new pair of gloves, administered an eye drop in Resident #28's right eye, touched the tip of the dropper to her upper eyelid. LPN #1 removed her gloves, washed her hands for only 5 seconds, and exited the room with the medication cart. LPN #1 failed to clean the medication cart after she exited Resident #28's room, failed to ensure the tip of the dropper was not contaminated and failed to wash hands for 20 seconds per the facility's policy. 5. Observation in the resident's room on 10/11/2023 at 12:17 PM, revealed LPN #4 entered Resident #26's room with the medication cart to perform a glucose check and medication administration. LPN #4 exited Resident #26's room with the medication cart, rolled the medication cart back to the nursing station, and failed to clean the medication cart after she exited Resident #26's room. During an interview on 10/11/2023 at 10:58 AM, the Director of Nursing (DON) was asked should staff members place the dirty syringe back into the plastic bag after giving medications through a PEG Tube. The DON stated, .clean the syringe with water and dry the outside and air dry .after cleaning, then place it back in plastic bag . The DON was asked if the staff member should take the entire medication cart in the residents' rooms. The DON stated, .No . The DON confirmed staff members should clean their stethoscope before and after use. The DON was asked how long should staff members wash their hands. The DON stated, .20 seconds . The DON was asked how should staff members turn off the faucet after they wash their hands. The DON stated, .wash hands, rinse hands, dry [hands] and get a clean paper towel to turn off faucet with . The DON was asked should staff members touch the tip of the resident's eye with the eye dropper. The DON stated, No .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to report an allegation of abuse to the State Survey Agency for 1 of 1 sampled resident (Resident #25) reviewed for an allegation of abuse. The findings include: Review of the facility's policy titled, .Abuse, Neglect, Misappropriation Protocol ., revised 2/2017, revealed .Reporting procedures should be followed as outlined in this policy .If the events that cause the reasonable suspicion do not result in serious bodily injury to a resident, the facility shall report the suspicion not later than 24 hours after forming the suspicion . Review of the medical record, revealed Resident #25 was admitted to the facility on [DATE] with diagnoses of Vascular Dementia, Cerebral Atherosclerosis, Osteoporosis, and Osteoarthritis. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #25 had a Brief Interview for Mental Status Score (BIMS) of 8, which indicated moderate cognitive impairment. Review of a Nurses' Note dated 7/20/2021, revealed .Resident called, on call system repeatedly stating .Can you send somebody down here to wash my face .she was down here and washed by butt then washed my face . Review of a Nurse's note dated 7/25/2021, revealed, .Resident reported to N/P [Nurse Practitioner] [with] this nurse .accusations that staff member 'grabbed my cheeks .said ugly words to me' .when asked who did this states 'I dont [don't] know her name .That same person wipes me too rough' .Reported to [Named Interim DON] . Observation in the resident's room on 7/27/2021 at 11:55 AM, revealed Resident #25 was sitting up in a recliner. Resident #25 asked the surveyor to come in her room. During an interview on 7/27/2021 at 11:58 AM, Resident #25 told the surveyor a staff member, (Named Certified Nursing Assistant (CNA) #1) had grabbed her cheeks and shook her face. During an interview on 7/27/2021 at 12:10 PM, the surveyor reported the allegation of abuse to the Interim Director of Nursing (DON). The Interim DON stated they had already looked at it and confirmed the facility did not report the allegation of abuse to the State Survey Agency. During an interview on 7/28/2021 at 5:15 PM, the Interim DON confirmed she had not reported Resident #25's allegations of abuse that occurred on 7/20/2021 or 7/25/2021. During an interview on 7/28/2021 at 6:26 PM, the Administrator confirmed the facility should have reported Resident #25's allegations of abuse to the State Survey Agency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, facility investigation review, medical record review, and interview, the facility failed to ensure a thorough investigation was completed for 1 of 1 sampled resident (Resident #25) reviewed for an allegation of abuse. The findings include: Review of the facility's policy titled, .Abuse, Neglect, Misappropriation Protocol ., revised 2/2017, revealed .Investigations Process .The individual conducting the investigation will, as a minimum .Review the completed 'Resident Abuse Report' .Review the resident's medical record to determine events leading up to the incident .Interview the person(s) reporting the incident .Interview any witnesses to the incident .Interview the resident .Interview the resident's Attending Physician as needed to determine the resident's current level of cognitive function and medical condition .Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident .Interview other residents to whom the accused employee provides care or services .Review all events leading up to the alleged incident . Review of the medical record, revealed Resident #25 was admitted to the facility on [DATE] with diagnoses of Vascular Dementia, Cerebral Atherosclerosis, Osteoporosis, and Osteoarthritis. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #25 had a Brief Interview for Mental Status Score (BIMs) of 8, which indicated moderate cognitive impairment. Review of a Nurse's note dated 7/20/2021, revealed .Resident called, on call system repeatedly stating .Can you send somebody down here to wash my face .she was down here and washed by butt then washed my face . Review of the facility's investigation revealed only 2 staff members were interviewed, the incident was only recorded in the nurses' notes, no other residents were interviewed, no witness written statements were obtained, and the Abuse Investigation report was not completed. During an interview on 7/28/2021 at 3:48 PM, Certified Nursing Assistant (CNA) #3 confirmed she worked the hall the night Resident #25 alleged someone washed her bottom and used the same cloth to wash her face. She was asked if she was interviewed or wrote a statement about the incident. She stated, .the nurse asked me about it. I didn't write a statement . During an interview on 7/28/2021 at 4:35 PM, CNA #1 confirmed she had worked with Resident #24 on 7/20/2021. She stated, .She told me on the call light that someone had been in her room and wiped her bottom with a cloth and then used it to wash her face . She was asked if she had been asked to write a statement. She confirmed she had not been asked to write a statement. During an interview on 7/28/2021 at 3:17 PM, Licensed Practical Nurse (LPN) #1 confirmed she worked on 7/20/2021, and Resident #25 was on the call light. She stated, .she told us someone had come in there and washed her bottom and then used the same cloth to wash her face . She was asked if she had them write statements. She stated, .no .I just notified [Named Interim Director of Nursing (DON)] . During an interview on 7/28/2021 at 5:25 PM, Interim DON was asked if she had completed the Resident Abuse Report after she was notified about an allegation of abuse by Resident #25. She stated, .I'm not sure what you are referring to . The Interim DON was asked if she reviewed the resident's medical record and documented in the investigation. She confirmed she had not. She was asked if she had interviewed witnesses to the alleged allegation. She stated the nurse had interviewed CNA #1 and CNA #3 and documented it in the nurse's notes. The Interim DON was asked if she had interviewed all staff members on all shifts who had contact with the resident during the period of the alleged incident. The Interim DON stated, .I don't know that she did .some of the documentation wasn't fully completed . The Interim DON was asked if other residents to whom the accused employee provided care were interviewed. She stated, .if there is, I don't have it . She was asked if she obtained witness statements in writing. The Interim DON stated, .No . The Interim DON was asked if the results of the investigation were on the Resident Abuse Investigation report. The Interim DON stated, .We didn't think it classified as abuse . During an interview on 7/28/2021 at 6:28 PM, the Administrator confirmed the facility should have done a more thorough investigation.

**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 a comprehensive Care Plan was developed for a side rail/enabler for 2 of 6 sampled residents (Resident #34 and #44) reviewed for accidents. The findings include: Review of the facility's undated policy titled, MDS [Minimum Data Set] & CARE PLAN POLICY AND PROCEDURE, revealed .It is the policy and procedure .that .Care Plans are completed .upon any significant changes, in-resident status, discharges from facility, and readmission .Care Plans are reviewed and updated at least quarterly and reviewed at quarterly care plan meeting . Review of the facility's undated policy titled, SIDERAILS POLICY, revealed .Siderails are used for two reasons: a physical restraint or an enabler .Enabler .A side rail is an enabler when it allows the resident to function at a higher level. Residents that request the side rail for positioning and bed mobility is also considered an enabler . Review of the medical record, revealed Resident #34 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, Diabetes Mellitus, Heart Failure, and Neuropathy. Review of Physician Orders dated 7/12/2021, revealed .may have SR [side rail] up x [times] 1 [on one side] per request to aide with repositioning and mobility . Review of the medical record, revealed that there was no comprehensive Care Plan for side rails to aide in repositioning and mobility for Resident #34. Observation in the resident's room on 7/26/2021 at 9:29 AM, 12:53 PM, and 2:40 PM, 7/27/2021 at 9:30 AM, 7/27/2021 at 4:23 PM, and on 7/29/2021 at 11:09 AM, revealed Resident #34 was lying in his bed with a 3/4 length side rail up on one side of his bed. Review of the medical record, review revealed Resident #44 was admitted to the facility on [DATE] with diagnoses of Paranoid Schizophrenia, Bipolar Disorder, Diabetes Mellitus, and Osteoarthritis. Review of Physician Orders dated 5/4/2021, revealed .may have side rails up x 2 [both side rails] per request to aide with bed mobility . Review of the medical record, revealed that there was no comprehensive Care Plan for side rails to aide in mobility for Resident #44. Observation in the resident's room on 7/26/2021 at 8:55 AM, and 2:45 PM, 7/27/2021 at 2:47 PM, and on 7/28/2021 at 8:55 AM and 10:34 AM, revealed Resident #44 was lying in her bed with 3/4 length side rails up on both sides of her bed. During an interview conducted 7/29/2021 at 6:48 PM, the Interim Director of Nursing (DON) confirmed the side rail/enabler should have been on the comprehensive Care Plan for Resident #34 and Resident #44.

Based on policy review, observation and interview, the facility failed to ensure food was distributed and served in a sanitary manner when 4 of 15 staff members (Nursing Assistant (NA) #1, (NA) #2, Certified Nursing Assistant (CNA) #2, and the Activity Director) did not perform hand hygiene between serving residents and after touching contaminated surfaces and touched residents' food with their bare hands. The findings include: Review of the facility's undated policy titled, INFECTION CONTROL PRACTICES DURING RESIDENT DINING, revealed .employees must wash hands with soap and water before touching a resident's tray. An employee can use alcohol-based hand rub (ABHR) if hands are not visibly soiled .Employees must wash hands: Before serving .After direct resident contact .After self-contact .If resident's request assistance with food preparation such as cutting-up food or applying condiments, employees must wear gloves. Observation in the Dining Room on 7/26/2021 beginning at 12:31 PM, revealed NA #2 set up a meal tray for Resident #9 and placed a clothing protector over the resident. NA #2 did not perform hand hygiene, touched her hair, and then placed a clothing protector over Resident #38. She touched the chair, opened the milk, and used the utensils to cut up the food on the plate. NA #2 did not perform hand hygiene in between residents or in between touching potentially contaminated objects and touching the resident's tray items and utensils. Observation in the Dining Room on 7/26/2021 at 12:42 PM, revealed the Activity Director set up a meal tray for Resident #26. The Activity Director touched the table, touched the resident's wheelchair, and then touched the top of the sandwich with her bare hand to hold it down while she cut the sandwich in half. The Activity Director did not perform hand hygiene in between touching potentially contaminated objects and touching Resident #26's sandwich. Observation in the Long Hall on 7/26/2021 beginning at 12:50 PM, showed CNA #2 served a tray to Resident #1. She set up the tray, did not perform hand hygiene, went back to the cart and touched the condiments and obtained mayonnaise and mustard. She returned to Resident #1's room, did not perform hand hygiene, removed the top of the sandwich with her bare hand, applied the mayonnaise and mustard, and put it back on top of the sandwich with her bare hand. Observation in the resident's room on 7/26/2021 at 12:53 PM, revealed NA #1 placed a lunch meal tray on the overbed table, touched the curtain to move it, raised the head of the bed, moved the overbed table, turned on the light, touched Resident #34's pillow, then took the resident's urinal that was full of yellow urine to the bathroom, emptied the urinal, flushed the toilet, and returned to the resident's bedside. NA #1 proceeded to open food containers, took tops off of the food containers of dessert, opened tea, opened milk, and opened the eating utensils while handing the utensils to the resident, without performing hand hygiene. During an interview on 7/29/2021 at 5:55 PM, the Interim Director of Nursing (DON)confirmed that staff should perform hand hygiene between every resident encounter, after they have touched contaminated objects, and before they assist a resident with a meal or set up a meal. The Interim DON stated, .staff should not touch residents food with their bare hands .

Based on the Centers for Disease Control and Prevention (CDC) guidelines, policy review, COVID-19 Daily Employees Screening Logs, staffing schedules, and interview, the facility failed to follow CDC Infection Control guidelines to ensure all staff who enter the facility completed the screening process for the prevention or spread COVID-19 when 5 of 107 staff members (Certified Nursing Assistant (CNA) #4 and #5, Dietary Staff #1 and #2, and Laundry Staff #1) failed to complete screenings for COVID 19 prior to working for 8 of 14 days (7/11/2021, 7/12/2021, 7/16/2021, 7/17/2021, 7/18/2021, 7/19/2021, 7/21/2021, and 7/23/2021) reviewed. This had the potential to affect the 44 residents residing in the facility. The findings include: Review of the Centers for Disease Control and Prevention (CDC) website document titled, .Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 [Coronavirus Disease] Spread in Nursing Homes, updated 3/29/2021, revealed .Establish a process to ensure HCP [Healthcare Personnel], (including .ancillary staff environmental services and dietary services) entering the facility are assessed for symptoms of COVID-19 .individual screening on arrival at the facility . Review of the facility's undated policy titled, .Covid-19 Precautions Check - In Procedures, revealed, .Go to Testing Trailer for Screening prior to entering -Temperature, Oxygen Saturation Level checks and/or Covid-19 Rapid Test . Review of the Staff Schedules and COVID-19 Daily Employee Screening Logs from 7/10/2021-7/23/2021 revealed the following employees worked on the following days and failed to screen for signs and symptoms of COVID-19: a. CNA #4 - 7/19/2021 b. CNA #5 - 7/19/2021 and 7/21/2021 c. Dietary Staff #1 - 7/11/2021 and 7/12/2021 d. Dietary Staff #2 - 7/23/2021 e. Laundry Staff #1 - 7/16/2021, 7/17/2021, and 7/18/2021 During an interview on 7/29/2021 at 8:28 PM, the Interim Director of Nursing (DON) confirmed all staff should be screened for COVID-19 upon entering the facility and stated, .they said they forgot to write it down .