**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure that services provided by the facility, as outlined by the comprehensive care plan, met professional standards of quality. Specifically, for 2 out of 49 sampled residents, medications were left unattended at a resident's bedside and a resident's tube feed was not labeled with the date and time. Resident identifiers: 5 and 128. Findings include:1. Resident 128 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, and cognitive communication deficit. On 8/4/25 at 9:03 AM, an interview was conducted with resident 128. The medication Fluticasone-Salmeterol Inhalation Aerosol Powder Breath Activated was observed on resident 128’s bedside table. When resident 128 was asked how often she took the medication, resident 128 stated that she thought she took the medication twice a day. When resident 128 was asked if the staff allowed her to keep the medication at bedside, resident 128 stated “no” the staff would usually take the medication away after use but sometimes they would forget the medication. Resident 128’s medical record was reviewed on 8/5/25. A physician's order dated 7/28/25, documented Fluticasone-Salmeterol Inhalation Aerosol Powder Breath Activated 250-50 MCG/ACT [micrograms per actuation] (FluticasoneSalmeterol) 1 puff inhale orally two times a day for COPD [chronic obstructive pulmonary disease.]” It was documented on the August 2025 Medication Administration Record that the medication had been administered on the morning of 8/4/25. On 8/6/25 at 7:53 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that if a resident was self administering medication there had to be a physician’s order to leave the medications at bedside. LPN 1 stated medications like ear drops, eye drops, and albuterol inhalers were examples of medications she would consider leaving at the bedside or medications that the resident took often. LPN 1 stated there was one resident on the other side of the building that administered their own medications. On 8/6/25 at 8:14 AM, an interview was conducted with LPN 6. LPN 6 stated that medication should not be left at the residents bedside unless there was a physician’s order to do so. On 8/6/25 at 12:10 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that generally staff should not leave medications at the residents bedside unless the resident had it care planned and a self administration assessment had been completed. 2. Resident 5 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included nontraumatic intracranial hemorrhage, aphasia, quadriplegia, and hydrocephalus. On 8/4/25 at 8:22 AM, an observation was made of resident 5. Resident 5 was observed to have a feeding tube. The tube feed bag was observed to be unlabeled and undated. Resident 5’s medical record was reviewed on 8/4/25 through 8/7/25. A review of resident 5’s physician orders revealed, “Enteral feed order every shift CONTINUOUS FEEDING OF: [NAME] Farms 1.4 50cc/hr [cubic centimeter/hour] + [plus] FWF [free water flush] 75 cc/hr from 15:00 [3:00 PM] to 11:00 am daily. …” On 8/5/25 at 2:10 PM an interview was conducted with LPN 2. LPN 2 stated that resident 5 had a continuous tube feed. LPN 2 stated that resident 5 was disconnected from the tube feed from 11:00 AM to 3:00 PM daily. On 8/6/25 at 9:47 AM, an interview was conducted with LPN 3. LPN 3 stated that all tube feeds should be labeled with the date, time the tube feed was started, and initialed by the nurse. On 8/7/25 at 8:24 AM, an interview was conducted with the DON. The DON stated that for tube feeds every 24 hours a new bottle or bag and tubing should be replaced. The DON stated that there should be a date and time labeled on the tube feed bottle or bag.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure that the resident received treatment and care in accordance with professional standards of practice. Specifically, for 1 out of 49 sampled residents, a resident reported constipation with no bowel movement for five days and no effective treatment was provided. Resident identifier: 119.Findings included: Resident 119 was admitted to the facility on [DATE] with diagnoses which included, psoas muscle abscess, cognitive communication deficit, and neuromuscular dysfunction of bladder.Resident 119's medical record was reviewed on 8/4/25 through 8/7/25.On 8/4/25 at 9:07 AM, an interview was conducted with resident 119. Resident 119 stated that he had been really constipated and had not had a bowel movement for a while. Resident 119 stated that his stomach hurt. An observation was made of resident 119's abdomen and it appeared distended.A review of resident 119's physician orders revealed:a. Bisacodyl Rectal Suppository 10 milligram (mg). Insert one suppository rectally every 24 hours as needed for no results from Senna Plus-Bowel Care. Notify Provider if no results. Start date: 7/28/25.b. Lactulose Oral Solution 10 gram (gm)/15 milliliters (ml). Give 15 ml by mouth one time a day for constipation. Hold for loose stools. Start date 7/29/25.c. MiraLax Oral Powder 17 gm/scoop. Give 17 gm by mouth every 24 hours as needed for bowel care. Mix in six toeight8 ounces of liquid. Start date 7/28/25.d. Naloxegol Oxalate Oral Tablet 25 mg. Give one tablet by mouth in the morning for opioid-induced constipation. Hold for loose stools. Start date: 7/29/25.e. Senna-Plus Oral Tablet 8.6-50 mg. Give one tablet by mouth every 12 hours as needed for Miralax ineffective - Bowel Care. Start date 7/28/25.A review of resident 119's bowel log revealed bowel movements on 7/30/25 at 2:01 PM and 7/30/25 at 9:05 PM.A review of resident 119's Medication Administration Record revealed:a. Lactulose was not given to resident 119 on 7/31/25, as the medication was pending delivery from the pharmacy. It should be noted that resident 119 refused the medication on 7/29/25.b. Naloxegol was not given to the resident on 8/3/25 and 8/4/25, as the medication was on order. c. Bisacodyl Rectal Suppository had not been given to resident 119.d. MiraLax had been given to resident 119 on 7/31/25, 8/3/25, and 8/4/25.e. Senna had been given to resident 119 on 8/4/25.A review of resident 119's progress notes revealed:a. On 7/29/25 at 3:35 PM, a Nurse Practitioner / Physician Assistant progress note documented, . his last BM [bowel movement] was a couple of days ago and he does feel like he is getting constipated.b. On 7/31/25 at 9:26 AM, an electronic Medication Administration Record (eMAR) medication administration note documented, Lactulose Oral Solution 10 GM/15ML Give 15 ml by mouth one time a day for constipation. Hold for loose stools. pending delivery from pharmacy.c. On 7/31/25 at 4:54 PM, an eMAR medication administration note documented, MiraLax Oral Powder 17 GM/SCOOP Give 17 gram by mouth every 24 hours as needed for Bowel Care *Mix in 6 to 8 ounces of liquid PRN [as needed] Administration was: Unknown pt [patient] able to sit on commode and pass gas, which did relieve some discomfort, but no BM as of yetafter [sic] miralax given.d. On 8/3/25 at 8:35 AM, an eMAR medication administration note documented, Naloxegol Oxalate Oral Tablet 25 MG Give 1 tablet by mouth in the morning for opioid-induced constipation. Hold for loose stools. drug on order., miralax given.e. On 8/4/25 at 8:47 AM, an eMAR medication administration note documented, Naloxegol Oxalate Oral Tablet 25 MG Give 1 tablet by mouth in the morning for opioid-induced constipation. Hold for loose stools. drug on order.f. On 8/4/25 at 10:31 AM, an eMAR medication administration note documented, MiraLax Oral Powder 17GM/SCOOP Give 17 gram by mouth every 24 hours as needed for Bowel Care Mix in 6 to 8 ounces of liquid per patient request.g. On 8/4/25 at 2:47 PM, an eMAR medication administration note documented, MiraLax Oral Powder 17GM/SCOOP.PRN Administration was: Ineffective not effective.h. On 8/4/25 at 2:47 PM, an eMAR medication administration note documented, Senna Plus Oral Tablet 8.6-50 MG Give 1 tablet by mouth every 12 hours as needed for Miralax ineffective - Bowel Care per patient request.A review of resident 119's care plan did not reveal any focus, goals, or interventions regarding constipation.On 8/6/25 at 8:17 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that residents were checked every two hours to see if they had a bowel movement. CNA 1 stated that they informed nurses if a resident complained of constipation. CNA 1 stated that CNAs documented in the resident's chart when residents had bowel movements. CNA 1 stated that CNAs do not monitor how often residents had bowel movements as that was something nurses did.On 8/6/25 at 8:22 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that nurses monitored resident's bowel movements by what CNAs document in the chart. LPN 1 stated that residents should not go more than three days without having a bowel movement. LPN 1 stated that there was a bowel program at the facility and that nurses start by giving residents Senna and then Miralax. LPN 1 stated that if those were ineffective then a suppository or enema was given. LPN 1 stated that resident 119 had complained of constipation since he arrived at the facility. LPN 1 stated the last charted bowel movement for resident 119 was 7/30/25. On 8/7/25 at 8:41 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that an alert populated on the resident's medical record if a resident had not had a bowel movement for three days. The DON stated that she expected nurses to notice the alert and to intervene accordingly. The DON stated that she expected nurses to use interventions which included Miralax or Senna. The DON stated that she expected staff to contact the provider if these interventions were ineffective and to get new orders from the provider. The DON stated that she expected staff to notify the provider if constipation medications were unavailable and to see what other interventions the provider would like for the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility did not ensure that drugs and biologicals used in the facility were labeled in accordance with accepted professional principles, and the drugs were stored under proper temperature controls. Specifically, for 2 out of 49 sampled residents, the medication cart contained an opened insulin vial that had expired and there were three unopened insulin auto injector pens that were stored in the medication cart instead of the refrigerator. Resident identifiers: 29 and 111.Findings included:On [DATE] at 7:53 AM, an observation was conducted of the E hall medication cart with Licensed Practical Nurse (LPN) 1. A vial of insulin lispro that belonged to resident 29 was labeled with an open date of [DATE]. LPN 1 verified the open date on the vial and stated that resident 29's insulin came from a different facility with resident 29. LPN 1 stated as long as the insulin was not open the insulin was good by the expiration date on the bottle. LPN 1 stated that once the insulin was opened it was good for 30 days. LPN 1 stated that there were still a few days left before resident 29's insulin vial needed to be discarded. Three insulin auto injector pens were observed in the medication cart unopened. LPN 1 stated that the insulin auto injector pens had not been opened as of yet. The Humalog kwikpen that belonged to resident 111 was in a bag labeled refrigerate. LPN 1 stated resident 111 had an insulin pump and resident 111's blood glucose was checked every four hours. LPN 1 stated that resident 111 was a type 1 diabetic and the insulin pump would malfunction. There were two lispro insulin kwikpens that belonged to resident 29 unopened and stored in the medication cart. LPN 1 stated the unopened insulin was stored in the medication cart and the extras would be stored in the medication fridge. On [DATE] at 8:14 AM, an interview was conducted with LPN 6. LPN 6 stated that insulin was good for 28 days once it was opened. LPN 6 stated that she dated everything when it was opened.On [DATE] at 10:49 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that insulin should be dated with an open date and was good for 28 days. The DON stated if the insulin was not open and in use it should be stored in the refrigerator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not file in the resident's clinical record the laboratory reports that were dated and contained the name and address of the testing laboratory. Specifically, for 2 out of 49 sampled resident's, laboratory results were not located in the medical record. Resident identifiers: 3 and 10. Findings included:1. Resident 3 was admitted to the facility on [DATE] with diagnoses which included acute respiratory failure with hypoxia, Crohn's disease, and hemiplegia affecting the left nondominant side.Review of resident 3's medical record was completed on 8/4/25 through 8/7/25.On 5/19/25, a completed Physician's Order documented a Complete Blood Count (CBC) and Comprehensive Metabolic Panel (CMP), one time only for follow up labs. It should be noted that no laboratory results could be located in the medical record.On 7/5/25 at 9:44 AM, a Nursing progress note revealed the provider gave orders for immediately (STAT) CBC and CMP related to the patient complaining of burning with urination.On 7/5/25, a completed Physician's Order documented a STAT CBC and CMP one time only.It should be noted that no laboratory results could be located in the medical record.On 7/16/25 at 2:44 PM, a Nursing progress note revealed new orders per the physician's assistant, Clostridioides difficile (C-diff) sample due to diarrhea greater than five days.On 7/16/25, a completed Physician's Order documented C-diff one time only for diarrhea.It should be noted that no laboratory results could be located in the medical record.2. Resident 10 was admitted to the facility on [DATE] with diagnoses which included schizoaffective disorder, bipolar type, diabetes mellitus with kidney complication, and chronic kidney disease.Review of resident 10's medical record was completed on 8/4/25 through 8/7/25. On 7/6/25, an active physician's order for Glycated Hemoglobin (HgbA1C) to be drawn every six months on the 7th for diabetes.It should be noted that no laboratory results could be located in the medical record.On 8/7/25 at 9:39 AM, an interview was conducted with Licensed Practical Nurse (LPN) 4. LPN 4 stated that if a STAT lab was requested, the results were usually faxed to the facility then reviewed by the medical provider. For routine labs, those results were located on the online portal, medical records would then upload the results to the resident's medical record.On 8/7/25 at 11:20 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated they were having issues with the online lab portal that was providing their lab results. The facility had reached out and recently made changes to their online portal. The ADON stated that she had been tracking ordered labs and lab results with a spreadsheet and binder, so she was aware of which labs need to be attached to the resident's medical record. The ADON stated that Medical Records oversaw that lab results were attached to the resident's medical record, that was done by going to the online portal, downloading the lab results, and uploading them to the resident's medical record.On 8/7/25 at 11:20 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the lab results for resident 3 and resident 10 were not in their medical record, they were found on the website the facility used to retrieve results and were downloaded when requested to view results. The DON stated that STAT labs were located on a different online portal than the routine lab results. The DON stated that she was the one that accepted the labs to be reviewed by the provider, and this was done within 24 hours, sooner if there was an urgency regarding the results.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that each resident was offered the pneumococcal vaccine. In addition, the resident's medical record did not include documentation that indicated the resident either received, refused, or the vaccine was medically contraindicated. Specifically, for 1 out of 5 sampled residents, a resident did not have documentation in the medical record stating either the pneumococcal immunization was offered, received, or refused. Resident identifier: 93.Findings included:Resident 93 was admitted to the facility on [DATE] with diagnoses which included chronic diastolic heart failure, emphysema, and unspecified dementia. Review of resident 93's medical record was completed on 8/4/25 through 8/7/25.A form titled admission Immunization Record and Consent Form was reviewed. Under Pneumococcal Vaccine: lists four different options; I have been screened and found to be eligible to receive the Pneumococcal vaccine, I have received verbal and written patient education concerning the risks vs benefits of receiving this, I understand the risks and benefits and desire to RECEIVE the pneumococcal vaccine, I understand the risks and benefits and wish to REFUSE the pneumococcal vaccine, or I have already received two (2) pneumococcal immunizations. It was noted there were no marked options for pneumococcal vaccine. No documentation was located indicating that resident 93 had a history of previously receiving the pneumococcal vaccine or had been offered the pneumococcal vaccine.The Center of Disease Control (CDC) recommends adults 50 years or older to be administered the pneumococcal vaccine, if they have never received one or whose previous vaccination history is unknown.On 8/7/25 at 9:39 AM, an interview was conducted with Licensed Practical Nurse (LPN) 4. LPN 4 stated when a resident was admitted to the facility the admitting nurse would briefly go over vaccines and ask if any were needed. LPN 4 stated the vaccines which were offered were Coronavirus disease 2019 (COVID 19), influenza, and pneumococcal. LPN 4 stated that the immunization history was per resident's recall or listed in the admitting paperwork. If a resident was wanting any of the offered vaccines, the nurse was able to administer those vaccines. LPN 4 stated he would document resident's vaccine refusals in the medical record.On 8/7/25 at 10:41 AM, an interview was conducted with LPN 1. LPN 1 stated the facility had a sheet that listed three vaccines; COVID-19, influenza, and pneumococcal. When a resident was admitted to the facility the nurse would review and offer the three vaccines. LPN 1 stated that if it was not flu season at the time of admission the influenza vaccine would not be offered at that time. The nurse would ask the resident about the resident's pneumococcal vaccine status to see if they have had any. LPN 1 stated the sheet was then forwarded to the Infection Preventionist (IP). The IP would then follow up and provide education with the resident regarding any refusals or pneumococcal vaccine status. LPN 1 stated that when a resident wanted or needed the pneumococcal vaccine, an order would be placed to the pharmacy and once it arrived it would then be administered to the resident.On 8/7/25 at 11:05 AM, an interview was conducted with the IP. The IP stated that she tracks a new resident's immunization status with a vaccine question form that was filled out by the admitting nurse. The IP stated that she would review, follow-up, and track the resident, regarding the vaccines that were due and offered pneumococcal and COVID-19. Every year during the flu season, influenza vaccines were offered to all the residents. The IP stated that all residents should be offered the vaccines and this needed to be documented in the resident's chart if the vaccine was administered or refused.On 8/7/25 at 11:43 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that vaccines should be offered to all residents upon admission to the facility. If a resident was requesting or in need of the pneumococcal vaccine, they would check the CDC guidelines to confirm if the resident was able to receive it. It should be documented in the resident's medical record if any vaccine was administered or refused. For the pneumococcal vaccine it should be documented in the resident's record regarding the CDC guidelines, if the resident was unable to receive one. https://www.cdc.gov/pneumococcal/hcp/vaccine-recommendations/index.html

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, for 4 out of 49 sampled residents, Enhanced Barrier Precautions (EBP) were not implemented for a resident with a peripherally inserted central catheter (PICC) line and the glucose monitor was not disinfected between resident usage. Resident identifiers: 6, 29, 119, and 121.Findings included:1. On 8/6/25 at 7:25 AM, Licensed Practical Nurse (LPN) 1 was observed to return to the medication cart after obtaining resident 29’s blood sugar. LPN 1 was observed to gather supplies for the next resident. LPN 1 did not clean or disinfect the glucose monitor. On 8/6/25 at 7:26 AM, LPN 1 was observed to donn gloves, collect an alcohol wipe, lancet, glucose monitor, and enter resident 121’s room. LPN 1 was observed to obtain resident 121’s blood sugar, doffed the gloves, and used the alcohol based hand rub (ABHR) in the hallway. LPN 1 went back to the medication cart and gathered supplies for the next resident. LPN 1 did not clean or disinfect the glucose monitor. On 8/6/25 at 7:29 AM, LPN 1 was observed to donn gloves, collect an alcohol wipe, lancet, glucose monitor, and enter resident 6’s room. LPN 1 was observed to obtain resident 6’s blood sugar, doffed the gloved, and used the ABHR in the hallway. LPN 1 went back to the medication cart and was observed to wipe down the glucose monitor with an alcohol wipe and immediately put the glucose monitor in its case and in the medication cart. On 8/6/25 at 7:33 AM, an interview was conducted with LPN 1. LPN 1 stated that she cleaned the glucose monitor every time she did a resident blood sugar. LPN 1 stated she wiped down the glucose monitor with the alcohol wipe before she left the resident room. LPN 1 stated she would wipe the glucose monitor down again with an alcohol wipe when she was finished with all of the resident blood sugars and would put the glucose monitor away. LPN 1 stated the glucose monitor brand was a One Care Pro. The medication cart on the E hall was observed with purple top wipes. On 8/6/25 at 10:49 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the glucose meter should be cleaned in between resident usage preferably with a bleach wipe. The DON stated there were purple or blue top wipes, germicidal disposable wipes, on the medication carts. On 8/6/25 at 1:08 PM, an interview was conducted with LPN 3. LPN 3 stated that she would use the purple top wipes on the glucose monitor between residents. LPN 3 stated she would wipe down the glucose monitor and would wait the two minute dry time. LPN 3 stated she would check the crevices of the glucose monitor to make sure there was no blood. The medication cart on the F hall was observed with purple top wipes. On 8/6/25 at 1:46 PM, an interview was conducted with LPN 7. LPN 7 stated that she would clean the glucose monitor between residents with the saniwipes and she would let the glucose monitor dry before using it again. The medication cart on the A hall was observed with blue top wipes. The facility Infection Control Policy and Procedure for Glucometer, Cleaning and Disinfection of was reviewed. “POLICY: It is the policy of this facility to follow recommendation from the CDC [Centers for Disease Control and Prevention]. The CDC states that HBV [hepatitis B Virus] can survive for at least one week in dried blood on environmental surfaces or on contaminated instruments. The following recommendations provide the guidance for cleaning and decontamination of glucometers that may be contaminated with blood and body fluids. PROCEDURES: 1. Clean glucometer surface when visible blood or bloody fluids are present by wiping with a cloth dampened with soap and water to remove any visible organic material. 2. If no visible organic material is present, disinfect after each use the exterior surfaces following the manufacturer’s directions using a cloth/wipe with either an EPA [Environmental Protection Agency]-registered detergent/germicide with a tuberculocidal or HBV/HIV [human immunodeficiency virus] label claim, or a dilute bleach solution of 1:10 (one part bleach to 9 parts water) to 1:100 concentration. Additional Information: • Directions for glucometer disinfection vary between manufacturers and models within brands. • Many manufacturers do not recommend the use of quaternary ammonium compounds because of the corroding effects on metal parts. This includes products that combine bleach with detergents or disinfectants. • All manufacturers caution that having the cloth too saturated could allow liquid to get inside the glucometer and cause damage. Screens and ports currently are not sealed on these devices. Therefore, using a bleach-only disinfecting wipe is less likely to cause Damage. …” The policy was issued and revised on 12/2009. Resident 119 was admitted to the facility on [DATE] with diagnoses which included, psoas muscle abscess, cognitive communication deficit, and neuromuscular dysfunction of bladder. 2. On 8/4/25 at 8:50 AM, an observation was made of resident 119’s room. There was no EBP signage or Personal Protective Equipment (PPE) on the resident’s door or inside the resident’s room. On 8/4/25 at 8:55 AM, an observation was made of LPN 5 access resident 119’s PICC line without wearing a gown. On 8/4/25 at 8:59 AM, an interview was conducted with resident 119. Resident 119 stated that he had been receiving intravenous (IV) antibiotics while at the facility. Resident 119’s medical record was reviewed on 8/4/25 through 8/7/25. A review of resident 119’s physician orders revealed that on 7/28/25 at 10:31 PM, Enhanced Barrier Precautions were ordered. A review of resident 119’s care plan dated 7/29/25, revealed a focus of “[Resident 119] has infection of Psoas Muscle: 7/29/25: IV Cefepime and Daptomycin until 09/02/2025.” Interventions included, “Use Enhanced Barrier Precautions.” On 8/5/25 at 2:10 PM, an interview was conducted with LPN 2. LPN 2 stated that residents that have tube feeds, urinary catheters, and central or midlines all required the use of EBP. On 8/5/25 at 2:28 PM, an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated that residents should have EBP precautions if they have PICC lines, catheters, or for a resident that may get an infection easily. CNA 2 stated that she wore PPE if she was bathing a resident or performing any personal hygiene on a resident with EBP. CNA 2 stated that she knew which residents were on EBP because there was a sign on the door stating that the resident required EBP. CNA 2 stated that if there was no sign then the resident did not require any precautions or special PPE. On 8/7/25 at 8:28 AM, an interview was conducted with the DON. The DON stated that residents who have dialysis and urinary catheters should have EBP. The DON stated that any direct care with these residents required a gown and gloves. The DON stated that residents that have EBP have a sign on their door and bin full of gowns and gloves outside the room. The DON stated that there was a collaboration between nursing staff and the Infection Preventionist about who puts the precaution signs up on resident’s doors. The DON stated that if a resident had a PICC line then they would require EBP.

Based on observation and interview, the facility failed to maintain a safe, clean, comfortable and homelike environment. Specifically, walls with large white patches and missing paint were observed. Findings included: On 11/13/23 at 12:05 PM, an observation was made of resident room A19. The wall opposite from the A bed had white patches across the dark colored wall. The resident stated it had been there since she moved in, and it looked terrible. On 11/13/23 at 1:40 PM, an observation was made of resident room A13. The wall just inside the entrance to the room was observed to be scuffed and had areas with white patches near the bottom of the wall and behind a wheelchair that was parked there. On 11/14/23 at 8:30 AM, an observation was made of resident room B18. The corner wall of the room had been spackled and partially repaired, but had not been repainted. On 11/14/23 at 10:10 AM, an observation was made of resident room B17. One wall was observed to have white paint patches and had not been repainted, and the wall behind the side of the resident's bed had a very large square area that had been partially repaired, but not finished and painted. The resident stated the white patches on the wall had been there for a long time. On 11/16/23 at 9:39 AM, an interview was conducted with the Maintenance Manager (MM). The MM stated he had been at the facility since September. The MM stated there was a system for prioritizing repairs that needed to be done. The MM stated repairing walls was more of a medium priority. The MM stated a TELLS application through the facility direct supplier was used to put in order requests. The MM stated anyone could submit a maintenance request. The MM stated if there was an emergent concern, staff would call him directly. The MM stated he used to spend a couple of hours sanding and painting walls and a couple of days later it is banged up again. The MM stated the Administrator (ADM) was also taking care of some of the wall repairs. The MM stated Administrators in training were helping with lower priority projects. On 11/16/23 at 10:44 AM, an interview was conducted with the ADM. The ADM stated that the MM was hired in September. The ADM stated the previous MM was not getting things done and was taking forever to respond to problems. The ADM stated since hiring the current MM, he and the MM had been going hall by hall to take inventory of the environmental problems, such as patching walls, and getting them completed. The ADM stated some of the repairs just required another coat of mud and then they would be painted. He stated when a resident moved out, they were trying to get repairs in that room finished before another resident moved in.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined, the facility failed to ensure all residents received treatment and care in accordance with professional standards of practice. Specifically, for 1 out of 34 sampled residents, the facility did not administer medication to provide for the physical, mental, and psychosocial needs of a terminally ill resident on hospice services. Resident identifier: 38. Findings include: Resident 38 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus, chronic obstructive pulmonary disease, encephalopathy, dysphagia, congestive heart failure, atrial fibrillation, bipolar disorder, and opioid dependence. On 11/16/23, resident 38's medical record was reviewed. A physician's order dated 10/31/23, indicated a medication order of haloperidol lactate oral concentrate 2 milligrams (mg)/milliliter (ml), 1 mL every four hours for bipolar disorder. A medication administration note dated 11/1/23 at 10:42 AM, indicated haloperidol 2 mg every four hours for bipolar disorder was, Out. Hospice will bring. A medication administration note dated 11/1/23 at 7:57 PM, indicated haloperidol 2 mg every four hours for bipolar disorder was, Hospice will bring according to previous nurse. A medication administration note dated 11/1/23 at 11:23 PM, indicated haloperidol 2 mg every four hours for bipolar disorder was, Not yet arrived from hospice. A medication administration note dated 11/2/23 at 10:19 AM, indicated haloperidol 2 mg every four hours for bipolar disorder was, Out. Hospice aware & will send. A medication administration note dated 11/2/23 at 9:00 PM, indicated haloperidol 2 mg every four hours for bipolar disorder was, Medication has been requested by hospice nurse, stated it would be sent. Has not arrived yet. A medication administration note dated 11/3/23 at 7:21 AM, indicated haloperidol 2 mg every four hours for bipolar disorder was, Hospice will deliver. A medication administration note dated 11/3/23 at 1:51 PM, indicated haloperidol 2 mg every four hours for bipolar disorder was, Medication not available, contacted [name redacted] for more medication. NP [Nurse Practitioner] and MD [Medical Doctor] notified. A medication administration note dated 11/3/23 at 7:08 PM, indicated haloperidol 2 mg every four hours for bipolar disorder was, Medication not available. [Name redacted] and DON [Director of Nursing] have been notified, hospice stated it will be sent tonight. A medication administration note dated 11/11/23 at 10:40 AM, indicated haloperidol 2 mg every four hours for bipolar disorder was, Patients medication has not been delivered from hospice yet. A Nursing note dated 11/12/23 at 8:41 PM, indicated, called [redacted], they did not answer, left voice mail that medications need refill. A Nursing note dated 11/13/23 at 5:29 AM, indicated, called [redacted] and was sent directly to voice mail. Left message regarding medication Haldol (haloperidol) that has been out and needs refill. A medication administration note dated 11/13/23 at 9:24 AM, indicated haloperidol 2 mg every four hours for bipolar disorder was, On order from hospice which have been called 4 times. The Medication Administration Record (MAR) for November 2023, indicated resident 38 missed a total of 23 doses of haloperidol lactate oral concentrate 2 mg every four hours for bipolar disorder between the dates of 11/1/23 through 11/13/23. An interview was conducted on 11/14/23 at 12:15 PM, with Licensed Practical Nurse (LPN) 1. LPN 1 stated it was hard to get Haldol for resident 38, but that did not happen very often. LPN 1 stated for residents on hospice, hospice provided the facility with medications, and they were administered by the facility. An interview was conducted on 11/16/23 at 9:51 AM, with Registered Nurse (RN) 1. RN 1 stated resident 38 was to receive Haldol multiple times a day and but she could not get a hold of hospice. RN 1 stated when she was not able to contact hospice, she notified the Assistant Director of Nursing (ADON). RN 1 stated the ADON was able to get hold of hospice, and the medication was delivered that night. RN 1 stated she would try to contact hospice if one dose of medication was missed and then escalate up the chain of command if she did not receive the medication. RN 1 stated that was the only time she was unable to get medication from hospice and Haldol had been fully stocked since that occurred. RN 1 stated the facility did not usually keep Haldol in stock. An interview was conducted on 11/16/23 at 10:28 AM, with the DON. The DON stated resident 38 missed doses of Haldol because hospice did not send it and the facility did not carry Haldol. The DON stated hospice was contacted once she had heard the doses had been missed. A concurrent interview was conducted on 11/16/23 at 10:28 AM, with the Corporate Resource Nurse (CRN). The CRN stated the pharmacy and MD should have been contacted when 15 doses were missed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined, that the facility did not provide routine and emergency drugs and biological's to its residents. Specifically, for 3 out of 34 sampled residents, medications were not administered as ordered by the physician due to the medications not being available by the pharmacy. Resident identifiers: 8, 43, and 58. Findings included: 1. Resident 8 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, acute respiratory failure with hypoxia, gastrointestinal hemorrhage, dysphagia, mild cognitive impairment, moderate protein-calorie malnutrition, diabetes mellitus, chronic diastolic congestive heart failure, anxiety disorder, acute kidney failure, opioid dependence, chronic pain, and major depressive disorder. Resident 8's medical record was reviewed on 11/15/23. On 9/16/23 at 9:05 AM, an electronic Medication Administration Record (eMAR)-Medication Administration Note documented Note Text: Colesevelam HCl [hydrochloride] Oral Packet 3.75 GM [grams] Give 1 packet by mouth one time a day for Hyperlipidemia Not available from pharmacy. Provider notified. Should be delivered later today. On 10/19/23 at 10:51 AM, an eMAR-Medication Administration Note documented Note Text: Sucralfate Oral Suspension 1 GM/10ML [milliliter] Give 1 tablet via G [gastrostomy]-Tube four times a day for upper GI [gastrointestinal] bleed dissolve 1 tablet in 10ml liquid Not available from pharmacy. Will be delivered later today. On 10/22/23 at 2:30 PM, an eMAR-Medication Administration Note documented Note Text: FLUoxetine HCl Oral Solution 20 MG [milligrams]/5ML Give 7.5 ml via NG [nasogastric]-Tube one time a day for depression ordered from pharmacy. On 11/13/23 at 10:12 AM, an eMAR-Medication Administration Note documented Note Text: FLUoxetine HCl Oral Solution 20 MG/5ML Give 7.5 ml via NG-Tube one time a day for depression unavailable. ordered from pharmacy. 2. Resident 43 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, metabolic encephalopathy, cognitive communication deficit, dysphagia, pneumonia, and major depressive disorder. Resident 43's medical record was reviewed on 11/15/23. On 10/27/23 at 5:43 PM, an eMAR-Medication Administration Note documented Note Text: Lansoprazole Oral Suspension 3 MG/ML Give 10 ml via NJ [nasojejunal]-Tube two times a day for GERD [gastroesophageal reflux disease] waiting for supplies for pharmacy. provider aware. On 10/27/23 at 6:42 PM, an eMAR-Medication Administration Note documented Note Text: Enteral Feed Order every 4 hours Flush feeding tube with 175 ml water every 4 hours waiting for supplies from pharmacy. provider aware. On 10/29/23 at 4:10 PM, an eMAR-Medication Administration Note documented Note Text: Lansoprazole Oral Suspension 3 MG/ML Give 10 ml via NJ-Tube two times a day for GERD Med [medication] to [NAME] [delivery] per pharmacy. On 10/31/23 at 5:04 PM, an eMAR-Medication Administration Note documented Note Text: Lansoprazole Oral Suspension 3 MG/ML Give 10 ml via NJ-Tube two times a day for GERD Medication unavailable. Rx [prescription] sent to pharmacy. On 11/2/23 at 10:44 AM, an eMAR-Medication Administration Note documented Note Text: Ascorbic Acid Oral Tablet 500 MG Give 1 tablet by mouth one time a day for supplement for 14 Days med not in pharmacy notified and will deliver today. On 11/2/23 at 10:45 AM, an eMAR-Medication Administration Note documented Note Text : Zinc Sulfate Oral Tablet 220 . MG Give 1 tablet by mouth one time a day for supplement for 14 Days med not in pharm [pharmacy] notified. On 11/3/23 at 6:01 PM, an eMAR-Medication Administration Note documented Note Text: Lansoprazole Oral Suspension 3 MG/ML Give 10 ml via NJ-Tube two times a day for GERD pharmacy to deliver. On 11/7/23 at 4:35 PM, an eMAR-Medication Administration Note documented Note Text: Lansoprazole Oral Suspension 3 MG/ML Give 10 ml by mouth two times a day for GERD Medication not available, MD [Medical Director] and pharmacy notified. 3. Resident 58 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, nontraumatic intracerebral hemorrhage, hypotension, cramp and spasm, altered mental status, epilepsy, autonomic dysreflexia, essential hypertension, presence of cerebrospinal fluid drainage device, and hydrocephalus. Resident 58's medical record was reviewed on 11/16/23. On 9/24/23 at 4:33 AM, an eMAR-Medication Administration Note documented Note Text: Omeprazole Oral Suspension 2 MG/ML Give 20 ml via G-Tube two times a day for GERD Waiting to get from pharmacy. On 10/7/23 at 9:57 AM, an eMAR-Medication Administration Note documented Note Text: Sennosides Oral Syrup 8.8 MG/5ML Give 10 ml via G-Tube two times a day for Constipation Medication out of stock. Pharmacy order has been placed. On 10/30/23 at 8:07 AM, an eMAR-Medication Administration Note documented Note Text: Modafinil Oral Tablet 200 MG Give 1 tablet via J [jejunostomy]-Tube two times a day for wakefulness Medication out of stock, pharmacy order sent. On 10/30/23 at 1:11 PM, an eMAR-Medication Administration Note documented Note Text: Modafinil Oral Tablet 200 MG Give 1 tablet via J-Tube two times a day for wakefulness Medication unavailable. Order sent to pharmacy. On 11/14/23 at 7:37 AM, an eMAR-Medication Administration Note documented Note Text: Adderall XR [extended release] Oral Capsule Extended Release 24 Hour 10 MG Give 10 mg via J-Tube in the morning for attention DON [Director of Nursing] contacting pharmacy to deliver. On 11/15/23 at 11:06 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated when the medication card got low, typically the last row on the medication card, she would pull the sticker tab on the medication card and fax it to the pharmacy to refill. LPN 1 stated for a new admission, whomever was putting the medication orders in would get the medication list and fax it to the pharmacy. LPN 1 stated there had been times she had not received a medication timely from the pharmacy. LPN 1 stated the pharmacy may have to order the medication or the medication would need a prior authorization. LPN 1 stated if the medication needed a prior authorization she would then see about changing the medication to something comparable. LPN 1 stated the facility had an emergency medication system that was stocked. LPN 1 stated she had never ran into a medication that she could not get out of the emergency medication system unless she was taking the last one. On 11/15/23 at 12:24 PM, an interview was conducted with the DON. The DON stated the staff were to pull the sticker on the medication card and send to the pharmacy for refill. The DON stated for new admissions as soon as they got the orders the receptionist would fax the orders to the pharmacy. The DON stated if their were any changes to the new admission orders the nurses would call the pharmacy. The DON stated she was not aware of any concerns with the pharmacy. The DON stated the facility had an emergency medication system and all the nurses had access.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined, the facility did not ensure safe and secure storage of drugs and biological's in accordance with accepted professional principles; or include the appropriate accessory and cautionary instructions, and the expiration date on the medication. Specifically, opened multi-dose vials of medications were not labeled with open dates, medications were found expired and still available for use in two of the medication carts, and one medication refrigerator was found to have low temperatures not compatible with medication storage. Findings included: 1. On [DATE] at 8:05 AM, the C-Hall medication cart was inspected. It was observed that there were three open multi-dose vials of insulin which were not labeled with the open or expiration dates. An interview was immediately conducted with Registered Nurse (RN) 2. RN 2 stated the open vials of insulin should have been labeled when they were opened and discarded 30 days after the open date. On [DATE] at 8:20 AM, the E-Hall medication cart was inspected. It was observed that there was one open multi-dose vial of insulin which was not labeled with the open or expiration date. An interview was immediately conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated the insulin needed to be labeled because they only last for approximately 30 days once opened. An interview was conducted on [DATE] at 8:14 AM, with LPN 2. LPN 2 stated open insulin needed to be labeled with an open date. 2. The North Station medication refrigerators were inspected on [DATE] at 8:25 AM. The refrigerators contained medications which included an influenza vaccine, antibiotics, liquid omeprazole, and a tuberculin Purified Protein Derivative (PPD). The [DATE] temperature log on the refrigerators had nine recorded temperatures of 32 degrees Fahrenheit, three documented temperatures of 30 degrees Fahrenheit, and one documented temperature of 29 degrees Fahrenheit. An interview was immediately conducted with LPN 3. LPN 3 stated he did not know how low the temperature of the medication refrigerators could go. An email correspondence was received on [DATE] at 1:23 PM, from the Director of Nursing (DON). The email indicated the DON called and spoke to the pharmacist on [DATE] around 9:25 AM, regarding the refrigerator temperatures. The email further indicated the DON read the pharmacist all the medications that were in the refrigerators. The email indicated the pharmacist advised that if the temperature was below 32 degrees Fahrenheit for 14 days or more, the medications should be discarded. It further indicated that the only medications that needed to be discarded were the Tubersol tuberculin PPD and Afluria (Influenza Vaccine). The email further indicated that the DON put a sign on each of the refrigerators that read, Refrigerator temps [temperatures will be maintained between 34-45. Any problem will be reported to nursing management. The facility policy for Storing and Controlling Medication, indicated, Medications requiring storage in the refrigerator will be kept by the staff in the medication room refrigerator. Refrigerated temps will be maintained between 34-45 degrees Fahrenheit.

9. On 11/15/23 at 8:07 AM, an observation was made of a staff member assisting a resident in the main dining area. The staff member brought the resident a covered dish. When the cover was taken off, a cinnamon roll was stuck to the lid that was taken off the plate. The staff member pulled the cinnamon roll from the lid with their bare hand and put the cinnamon roll on the resident's plate. On 11/15/23 at 8:19 AM, an observation was made in the dining room of Certified Nursing Assistant (CNA) 1 who was assisting two residents with their meals. CNA 1 was observed to be holding a piece of toast with their bare hand, for the first resident, and was trying to get the resident to take a bite. CNA 1 was then observed to pick up a pancake for the second resident with their bare hand and give it to the resident. CNA 1 did not sanitize their hands after handling either of the residents' food. CNA 1 was observed to get up from the table to get one of the residents more milk. When opening the milk, the cap fell onto the floor. CNA 1 was observed to pick up the cap, and placed it back on the cart next to the milk container without wiping it off. CNA 1 then went back to the table to deliver the milk and was observed to adjust the first resident's clothing protector and touch the resident's hair. CNA 1 then sat down and picked up the utensil from the second resident's plate and fed the resident some fruit. CNA 1 was not observed to sanitize their hands throughout the entire meal. On 11/15/23 at 1:02 PM, an interview was conducted with CNA 1. CNA 1 stated that he normally helped more than one resident at a time. CNA 1 stated he had been a CNA for about 22 years. CNA 1 stated they did not remember receiving any education about feeding residents with regards to infection control. CNA 1 stated he did his yearly training required by the facility. Based on observation and interview, it was determined, that the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, meal tray items were uncovered when delivered by staff throughout resident hallways and a staff member that was assisting residents with eating was cross contaminating. Findings Included: 1. On 11/13/23, lunch meal trays, which included, uncovered meal items were transported through resident hallway F. The meal cart was stationed near resident room F13. At 12:06 PM, a staff member was observed to carry a meal tray to resident room F17. The apple sauce and pudding were not covered. At 12:09 PM, a staff member was observed to carry a meal tray to resident room F15. The pudding and an additional food item was uncovered. At 12:11 PM, a staff member was observed to carry a meal tray to resident room F10. The fruit and an additional food item was uncovered. 2. On 11/13/23, lunch meal trays, which included, uncovered meal items were transported through resident hallway E. The meal cart was stationed near resident room E11. At 12:19 PM, a staff member was observed to carry a meal tray to resident room E16. The pudding and an additional food item was uncovered. At 12:19 PM, a staff member was observed to carry a meal tray to resident room E17. The pudding and an additional food item was uncovered. At 12:19 PM, a staff member was observed to carry a meal tray to resident room E18. The pudding and an additional food item was uncovered. At 12:21 PM, a staff member was observed to carry a meal tray to the nurses station where the resident was sitting. The pudding and an additional food item was uncovered. 3. On 11/13/23 at 12:40 PM, observations were made of staff passing lunch trays in the resident hallway B. The meal cart was located near the entrance to the B hallway. Staff were observed taking meal trays from the cart and walking them down the hallway to resident rooms. The fruit cup and the pudding cup were both uncovered on each tray. 4. On 11/15/23, breakfast meal trays, which included, uncovered meal items were transported through resident hallway D. The meal cart was located near resident room D13. At 7:55 AM, a staff member was observed to carry a meal tray to resident room D15. The pears were not covered. At 7:57 AM, a staff member was observed to carry a meal tray to resident room D10. The peaches were not covered. At 8:00 AM, a staff member was observed to carry a meal tray to resident room D18. The pears were not covered. At 8:02 AM, a staff member was observed to carry a meal tray to resident room D16. The pears were not covered. 5. On 11/15/23, breakfast meal trays, which included, uncovered fruit items were transported through resident hallway F. The meal cart was stationed near resident room F17. At 7:56 AM, a staff member was observed to carry a meal tray to resident room F11. At 7:58 AM, a staff member was observed to carry a meal tray to resident room F21. At 8:00 AM, a staff member was observed to carry a meal tray to resident room F20. At 8:00 AM, a staff member was observed to carry a meal tray to resident room F12. At 8:02 AM, a staff member was observed to carry a meal tray to resident room F13. At 8:02 AM, a staff member was observed to carry a meal tray to resident room F18. 6. On 11/15/23, breakfast meal trays, which included, uncovered fruit items were transported through resident hallway E. The meal cart was stationed near resident room F11. At 8:06 AM, a staff member was observed to carry a meal tray to resident room E14. At 8:06 AM, a staff member was observed to carry a meal tray to resident room E12 and then walked the meal try to the nurses station where the resident was sitting. At 8:07 AM, a staff member was observed to carry a meal tray to resident room E16. At 8:08 AM, a staff member was observed to carry a meal tray to resident room E10. The cleaning cart was stationed outside of the resident room. At 8:09 AM, a staff member was observed to carry a meal tray to resident room E18. At 8:10 AM, a staff member was observed to carry a meal tray to resident room E13. 7. On 11/15/23 at 8:14 AM, an observation was made of breakfast meal trays being delivered on the C hallway. A fruit cup was observed to be uncovered on trays delivered to resident rooms C14, C16, C17, and C18. The meal trays were being walked down the hall to the resident rooms. 8 On 11/15/23 at 8:17 AM, an observation was made of breakfast meal trays being delivered on the B hallway. The fruit cups on each meal tray were uncovered, and the meal trays were being walked down the hall from the meal cart that was located near the entrance to the B hallway. On 11/15/23 at 8:15 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated the meal trays should have all the food covered when they were taken to the residents to keep the food from being contaminated. On 11/16/23 at 9:19 AM, an interview was conducted with the Dietary Manager (DM). The DM stated that all food on meal trays should be covered, including the fruit cups and desserts. The DM stated she would educate the kitchen staff about ensuring food items were covered when leaving the kitchen. On 11/16/23 at 12:29 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that all food items on the meal tray should be covered prior to carrying the meal tray through the hallway.

Based on observation and interview, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, food items in the walk-in refrigerator and the walk-in freezer were open to air. Additionally, the dish machine was not reaching appropriate temperatures for sanitizing and staff were not using alternate methods of sanitizing dishware. Findings included: On 11/13/23 at 9:38 AM, an initial walk-through of the kitchen was conducted. Inside the walk-in freezer a box containing beef patties was open to air, a box containing turkey franks was open to air, a box containing chicken tenders was open to air, and a box containing turkey burgers was open to air. An observation of the high temperature dish machine revealed the wash temperature was 126 degrees Fahrenheit (F) and 128 degrees F during two consecutive observations. The rinse temperature was 176 degrees F and 175 degrees F during two consecutive observations. [Note: High temperature dish machines should reach 150 degrees F and 180 degrees F, respectively, during the wash and rinse cycles.] The November 2023 dish machine temperature logs were reviewed. For the breakfast meal the temperatures documented for 11/1/23 through 11/13/23, were all 150 and 180 degrees F, respectively, for the wash and rinse cycles. For the lunch meal the temperatures documented for 11/1/23 through 11/12/23, were all 150 and 190 degrees F, respectively, for the wash and rinse cycles. For the dinner meal the temperatures documented for 11/1/23 through 11/12/23, were all 150 and 190 degrees F, respectively, for the wash and rinse cycles. On 11/13/23 at 9:55 AM, an interview was conducted with the Dietary Manager (DM). The DM stated that recently a part on the water heater had broken and was in the process of being fixed. The DM stated that when the temperature on the dish machine was low the staff would wash the dishes multiple times. The DM stated a company representative came every other week to ensure the dish machine was functioning properly. The DM stated she would speak with the Maintenance Manager (MM) about the low water temperature. On 11/13/23 at 10:05 AM, an interview was conducted with the MM. The MM stated the company representative had been out about one and a half weeks ago to address the low water temperatures and a part had been ordered to fix the water heater. The MM stated he did not know when the part would be delivered and installed. The MM stated the problem with the water heater was added to the facility Quality and Performance Improvement plan to ensure it was fixed. On 11/16/23 at 9:10 AM, an observation was made of the dish machine temperatures. The first two cycles observed revealed the water temperature for the wash cycle at 138 degrees F, and at 190 degrees F for the rinse cycles. The third observation revealed a wash temperature of 122 degrees F and a rinse temperature of 175 degrees F. The fourth observation revealed a wash temperature of 122 degrees F and a rinse temperature of 175 degrees F. On 11/16/23 at 8:41 AM, a second walk-through of the kitchen was conducted. Inside the walk-in refrigerator a box containing raw chicken was open to air. Inside the walk-in freezer a box containing pre-cooked meatballs was open to air, a box containing beef patties was open to air, a box containing turkey franks was open to air, a box containing Salisbury steak was open to air, and a box of chicken tenders was open to air. On 11/16/23 at 8:58 AM, an interview was conducted with the Day shift [NAME] (DC). The DC stated one of the dietary aides checked the food orders when they were delivered. The DC stated when food was removed from the refrigerator or freezer to prepare a meal, the staff did not have to close the food items back up that remained in the refrigerator or freezer. The DC stated that after ten days the food items in the freezer would be thrown away, and after three days the food items in the refrigerator would be thrown away. The DC stated the consultant dietitian came on a monthly basis to inspect the kitchen. The DC stated the dietary team discussed the dietitian's findings after the last audit so they could improve. The DC stated kitchen audits were given to the Administrator after the staff review. On 11/16/23 at 9:10 AM, an interview was conducted with the Dietary Aide (DA). The DA confirmed that the water temperature was too low at 132 degrees F. The DA told the staff member putting dishes in the dish machine to slow down. The DA began filling the three sink compartment with sanitizer. Once the sink was filled, the DA began putting the dishes that most recently were put through the dish machine into the sanitizer. The DA stated that she would hold the dishes in the sanitizer for a few minutes and then let them air dry. On 11/16/23 at 9:19 AM, an interview was conducted with the DM. The DM stated after the observation of low water temperatures on 11/13/23, the temperatures were fine. The DM stated she checked with the laundry staff and they were not doing laundry at the time of the observation. The DM stated she had called the dishmachine company to report the problem. The DM stated she was told a representative would come out, but no one had come yet. The DM stated the staff were telling her about the low dish washer temperatures. The DM stated when staff needed something from the refrigerator or freezer they grab what they need from the box. The DM stated she was unaware that food items were being left open to air in the refrigerator and freezer. The DM stated the consultant dietitian came to audit the kitchen once monthly and she was not sure if the dietitian checked inside the boxes to ensure the food items were sealed. The DM stated she would start checking that. On 11/16/23 at 9:39 AM, an interview was conducted with the MM. The MM stated the low water temperature problem started on 10/27/23. The MM stated a plumbing company was called and came on 10/30/23. The MM stated a pipe was replaced and an exhaust motor. The MM stated a part was ordered and had not yet arrived. The MM stated he last spoke with the plumbing company on 11/8/23, and was told the part had shipped. The MM stated the water heater continued to read that there was blocked exhaust. The MM stated he was keeping track of water temperatures, but was checking the temperature in the sinks within the kitchen and he was not monitoring the dish machine in the kitchen. The MM stated the kitchen staff were supposed to be using the sink sanitizer to sanitize all dishes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined that the facility did not treat residents with respect and dignity. Specifically, for 1 out of 30 sampled residents, a resident was without a urinal and was instructed by staff to urinate in his brief. Resident identifier: 47. Findings included: Resident 47 was admitted to the facility on [DATE] with diagnoses which included but not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, heart failure, chronic atrial fibrillation, chronic respiratory failure with hypoxia, morbid (severe) obesity due to excess calories, asthma, muscle weakness, difficulty in walking, stage 3 chronic kidney disease, major depressive disorder, and essential (primary) hypertension. On 4/4/22 at 9:28 AM, an interview was conducted with resident 47's family member. The family member stated that resident 47 had been sharing a urinal with his roommate. The family member stated that she had brought a urinal from home for resident 47 to use. The family member stated that supplies were low at the facility and it had been four days since resident 47 had a urinal. On 4/4/22 at 1:42 PM, an interview was conducted with resident 47's. Resident 47 stated the staff had borrowed his urinal for his roommate to use. Resident 47 stated he did not have a urinal to use since the staff took his urinal. Resident 47 stated he had been told by staff to go in his brief. Resident 47 stated that he did go in his brief because he did not have a choice. Resident 47's medical record was reviewed on 4/5/22. An admission Minimum Data Set (MDS) assessment dated [DATE], documented that resident 47 had a Brief Interview for Mental Status (BIMS) score of 14. A BIMS score of 13 to 15 would indicate intact cognition. Resident 47 was documented as occasionally incontinent of bladder and required extensive assistance of one person for toilet use. A care plan Focus initiated on 3/16/22, documented [Name of resident 47 removed] Has bowel/bladder incontinence r/t (related to) Disease Process, Impaired Mobility, Medication Side Effects. A care plan Goal documented Will decrease frequency of urinary incontinence through the next review date. A care plan Intervention documented Ensure there is an unobstructed path to the bathroom. A 30 day look back review of the Task section of the medical record for Bladder Incontinence documented the following entries: a. On 3/8/22 at 1:28 PM, incontinent. b. On 3/8/22 at 7:06 PM, continent. c. On 3/9/22 at 9:31 PM, incontinent. d. On 3/10/22 at 5:56 PM, continent. e. On 3/11/22 at 5:33 AM, incontinent. f. On 3/11/22 at 12:35 PM, incontinent. g. On 3/12/22 at 2:16 PM, incontinent. h. On 3/15/22 at 1:02 AM, continent. i. On 3/15/22 at 10:33 AM, continent. j. On 3/16/22 at 11:12 PM, incontinent. k. On 3/17/22 at 5:59 PM, continent. l. On 3/18/22 at 2:21 PM, incontinent. m. On 3/18/22 at 9:49 PM, continent. n. On 3/19/22 at 3:05 PM, incontinent. o. On 3/19/22 at 7:25 PM, incontinent. p. On 3/20/22 at 7:17 PM, incontinent. q. On 3/21/22 at 12:25 PM, continent. r. On 3/21/22 at 9:05 PM, incontinent. s. On 3/22/22 at 12:33 PM, continent. t. On 3/22/22 at 10:22 PM, incontinent. u. On 3/23/22 at 10:42 PM, incontinent. v. On 3/24/22 at 11:30 AM, continent. w. On 3/25/22 at 1:46 PM, incontinent. x. On 3/26/22 at 12:49 AM, incontinent. y. On 3/26/22 at 1:37 PM, incontinent. z. On 3/26/22 at 9:48 PM, incontinent. aa. On 3/27/22 at 10:04 AM, incontinent. bb. On 3/28/22 at 11:29 AM, incontinent. cc. On 3/29/22 at 11:11 AM, incontinent. dd. On 3/30/22 at 1:44 PM, incontinent. ee. On 3/30/22 at 9:36 PM, incontinent. ff. On 4/1/22 at 2:51 PM, incontinent. gg. On 4/3/22 at 3:27 AM, incontinent. hh. On 4/4/22 at 11:33 AM, incontinent. On 4/5/22 at 2:18 PM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated on occasion the glucometer strips have been out. CNA 1 stated the glucometer strips were a supplier issue. CNA 1 stated the supply room had run short on 3X sized briefs but there were only three residents that used the 3X sized briefs. CNA 1 stated if the supply room was out of the 3X sized briefs he would use the 2X sized briefs and he would make sure they were applied loose on the resident. CNA 1 stated the supply room was out of urinals and he was unsure where to find urinals other than the supply room. CNA 1 stated that supplies like urinals were a facility ordering issue. CNA 1 stated he had heard of a resident sharing a urinal and CNA 1 took care of the situation and found a urinal for resident 47. CNA 1 stated the situation happened three days ago. On 4/5/22 at 2:24 PM, an interview was conducted with Assistant Director of Nursing (ADON) 1. ADON 1 stated that he started ordering supplies for the facility in December 2021. ADON 1 stated that he would run a resident census and order one and a half packages of wipes for each resident. ADON 1 stated that the Restorative Nurse Assistants (RNAs) would rotate the urinals and oxygen tubing out weekly and the RNAs would let ADON 1 know if supplies needed to be ordered. ADON 1 stated one brief every four hours was ordered for each resident that wore briefs. ADON 1 stated that he would watch the medical glove consumption and ordered as needed. ADON 1 stated there was no problem with ordering and receiving supplies unless it was not a regular item that the facility purchased. ADON 1 stated the facility had received one of two cases of urinals today. ADON 1 stated the delivery was two days behind schedule. On 4/5/22 at 2:46 PM, an interview was conducted with the MDS Coordinator. The MDS Coordinator stated the resident urinals were switched out on Fridays. The MDS Coordinator stated that she had not heard from the RNA that the facility was out of supplies. On 4/5/22 at 3:00 PM, a follow up interview was conducted with CNA 1. CNA 1 stated that resident 47's family member told him on April 1st or April 2nd about the sharing of the urinal. CNA 1 stated that when a resident received a new urinal the urinal was dated and initialed. CNA 1 stated that resident 47's family member wanted to bring in a urinal for resident 47 and CNA 1 told the family member that he would get a urinal for resident 47. On 4/5/22 at 3:06 PM, a follow up interview was conducted with resident 47. Resident 47 stated that he could not remember when his urinal was taken and gave to his roommate. Resident 47 stated that his family member brought him his own personal urinal. Resident 47 stated that the facility never did provide him with a urinal. An observation was conducted of resident 47's urinal in the shower. Resident 47's urinal was labeled and documented [Name of resident 47 removed] personal do not share. Resident 47 stated that his family member brought him the urinal the day before yesterday, Sunday. An observation was conducted of the urinal that belonged to resident 47's roommate. The urinal was hanging on the bedside rail of the roommates bed and was observed to be labeled with the roommates name and dated 3/26/22. On 4/6/22 at 10:39 AM, an interview was conducted with CNA 3. CNA 3 stated that he would bring resident 47 to the toilet and he would go. CNA 3 stated that resident 47 would sit on the toilet for awhile. CNA 3 stated that resident 47 was not always incontinent of bladder. CNA 3 stated that resident 47 would call for assistance and he would hold the urinal for resident 47. CNA 3 stated that resident 47's urinal was next to his bed. CNA 3 stated that resident 47 wore pull up briefs and in the mornings resident 47 would be wet. On 4/6/22 at 10:55 AM, an interview was conducted with resident 47's family member and resident 47. The family member stated that last Wednesday, 3/30/22, she knew for sure that resident 47 was without a urinal. The family member stated on 3/28/22, she could not find resident 47's urinal and on 3/30/22, the staff provided resident 47 with a graduated measuring cup to urinate in. An observation was conducted of a graduated measuring cup on resident 47's bed side dresser. The family member stated she had observed CNAs enter resident 47's room to assist resident 47 with the urinal. The family member stated when the CNAs could not find resident 47's urinal they would tell resident 47 to use the roommates. Resident 47 stated that he felt like he was in a second class institution. On 4/6/22 at 11:50 AM, an interview was conducted with ADON 2. ADON 2 stated that weird things would be on back order and yes supplies were a struggle. ADON 2 stated that being out of urinals was not usually a thing. ADON 2 stated the RNAs would change out the urinals every week so you just order a bunch. ADON 2 stated the urinals were kept in the two supply rooms. ADON 2 further stated the urinals would be changed out if they looked grungy and a new admission would receive a urinal. On 4/6/22 at 12:45 PM, an interview was conducted with the Nurse Practitioner (NP). The NP stated that resident 47's roommate was completely incontinent of bowel and bladder. The NP stated that resident 47's roommate was unable to use a urinal and she was not sure why there was a urinal at the bedside. The NP stated that resident 47 had left sided weakness, he was a reliable resource, and would not share a urinal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 56 was admitted to the facility on [DATE] with medical diagnoses that included, but were not limited to, acute respiratory with hypoxia, limitations of activities due to disability, muscle weakness, pneumonia due to Coronavirus Disease-2019, dysphagia, dependence of supplemental oxygen, type 2 diabetes mellitus, hyperlipidemia, and cognitive communication deficit. On 4/4/22 at 3:17 PM, the facility's matrix was reviewed, and indicated resident 56 had a fall since their admission on [DATE]. On 4/6/22 at 10:44 AM, resident 56 was interviewed. Resident 56 stated they had fallen recently when they tried to get out of bed on their own. During this interview resident 56 was seated in their bed. Resident 56's bed was situated against one of the walls and was in the low position, there was no floor mat located beside resident 56's bed. Resident 56 stated, they would have liked to have a floor mat placed next to their bed, and this would have made her feel safer in bed. Resident 56 stated the facility had not placed a fall mat next to her bed following her past fall. On 4/6/22 at 12:24 PM, a follow-up observation was made of resident 56's room. Resident 56 was resting in bed. Resident 56's bed was observed lowered to the floor; the bed was placed against one of the room's walls; and there was no fall mat next to resident 56's bed. On 4/7/22 at 8:08 AM, a follow-up observation was made of resident 56's room. Resident 56's bed was lowered to the floor, arranged next to one wall, and there was no fall mat placed next to resident 56's bed. Resident 56 was then observed near the nurses' station having breakfast with a family member. Resident 56 and their family member stated they would have liked to have a fall mat placed next to resident 56's bed to prevent injuries from any falls out of bed. On 4/7/22, a review of resident 56's medical record was completed. The following were noted; A fall incident report dated 3/23/22, read,Heard patient yelling for help. RN (Registered Nurse) entered and found patient on floor wedged between bed and wheelchair. RN called for help and staff were able to get patient out from position and back into bed. Patient denies hitting her head or having any pain. Patient NG (nasogastric) tube when fell was dislodged. NG tube had come out almost completely. Pump was turned off and NG tube was assessed. Tube removed. Neuros (neurologicals) started. Vitals (vital signs) taken. Full body assessment did not show any wounds or sores . Preventative measures: Meds (medications) and treatments per orders, labs per orders, assist with ADL's (Activities of Daily Living), anticipate pt needs, pain control, 1-person assist with transfers . Response (interventions): fall mat at bedside when patient is in bed. A Nursing Note dated 3/24/22, read Patient found on floor between bed and wheelchair. Patient stated she was reaching for something and fell. Patient denies pain or hitting her head. Patient given full body assessment, neuro checks started, vitals taken. Patient returned to bed. Bed in lowest position, adequate lighting in room and personal items placed next to bed within reach of patent. MD (Medical Doctor), DON (Director of Nursing) and family member . notified. Resident 56 had a Care Plan, initiated on 3/24/22, with a Focus that read, [Name of resident 56 removed] has had an actual fall. Interventions for this Care Plan read; a. bed against wall, low bed at all times when in bed, floor mat to bedside r/t family request for fall. b. Continue interventions on the at-risk plan. c. Floor mat at all times when in bed r/t fall 3/23/22. On 4/6/22 at 10:32 AM, RN 1 was interviewed. RN 1 stated if they had found out a resident had fallen they would go to the resident's location and assess the resident to see what needed to be done. RN 1 stated they would ensure the resident was safe to transfer and if they could RN 1 would either transfer the resident with help from staff or RN 1 would call Emergency Medical Service. RN 1 stated they would notify the resident's family member or Power of Attorney, the doctor, and the DON. RN 1 stated if a fall was unwitnessed or a resident was witnessed to hit their head during a fall the facility staff would initiate neuro checks and gather vitals regularly for the next 72 hours. RN 1 stated these sheets were kept on the unit until they were completed and the completed vitals sheets were then provided to Medical Records to be uploaded into the resident's medical record. RN 1 stated the fall would be charted in the Risk Management assessments and this would develop the fall incident report and a progress note. RN 1 also stated any adjustments to the resident's Care Plans would be done by the leadership team, like the ADONs or the DON. On 4/6/22 at 10:46 AM, CNA 2 was interviewed. CNA 2 stated resident 56 required extensive assistance with most ADLs. CNA 2 stated resident 56 was moderate assistance with standing if resident 56 was having a good day. CNA 2 stated they were unaware if resident 56 had any recent falls. CNA 2 stated resident 56 had become more alert since their admission and was now able to communicate better and had less confusion. CNA 2 stated resident 56 had a fall when they were first admitted to the facility and the resident had fallen out of bed, so staff were to keep resident 56's bed lowered to the ground, ensure it was against one of the walls, and would check on resident 56 every 2 hours if the resident was in her room. CNA 2 stated when a resident was found to have a fall it was the facility's protocol for the CNA to not move the resident and have the nurse come assess the resident before the resident could be transferred. CNA 2 stated the CNA would help the nurse to obtain vitals and would also ensure the neuro check vitals sheet was completed accurately. CNA 2 stated when that sheet was completed the nurse would provide the neuro sheet to Medical Records. CNA 2 stated any interventions a resident had in place to prevent a fall would be communicated to CNA staff through the Plan of Care or the CNA Brain, which told the CNA's all about their resident's care needs. CNA 2 stated the facility staff were also good about reviewing recent falls during their beginning of shift report, and CNA 2 learned about recent falls and interventions through the verbal report. [Note: CNA 2 did not state resident 56 should have a fall mat near their bed due to recent falls.] On 4/6/22 at 10:52 AM, RN 2 was interviewed. RN 2 stated resident 56 did have interventions in place to prevent injury from falls. The interventions in place included keeping resident 56's bed lower to the ground, ensuring the bed was up against the wall, using a bed alarm when she was in her room without visitors or staff and having the CNA staff check on resident 56 at least every two hours. [Note: RN 2 did not state resident 56 should have a fall mat near their bed due to recent falls.] On 4/6/22 at 10:55 AM, the Medical Records staff member was interviewed. Medical Records stated when a resident had a neuro vitals sheet completed this was provided to Medical Records, and the vitals sheet would then be uploaded into the resident's medical record. Medical Records stated resident 56's neuros vital sheet from her fall on 3/23/22, was not within resident 56's chart and Medical Records did not have a copy of the completed neuros vital sheet. On 4/6/22 at 12:26 PM, the CNA coordinator was interviewed. The CNA coordinator stated CNAs were educated on any interventions in place regarding fall prevention through referring to the CNA Brain. The CNA coordinator stated the CNA brain was updated once a shift, and would be passed onto the next shift. On 4/7/22 at 8:47 AM, ADON 2 was interviewed. ADON 2 stated following resident 56's fall a fall mat was placed next to the bed to prevent injury from any falls. ADON 2 stated they had not gone into resident 56's room in several days and was unaware that there was no longer a fall mat next to resident 56's bed. ADON 2 stated resident 56 should have still had a fall mat next to their bed and it was still a Care Plan intervention that should be in place. Based on observation, interview, and record review it was determined that the facility did not develop and implement a comprehensive, person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and time frames to meet a resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment. Specifically, for 2 out of 30 sampled residents, the facility did not demonstrate implementation of care plan interventions related to a resident falls. Resident identifiers: 30 and 56. Findings included: 1. Resident 30 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included Parkinson's disease, type 2 diabetes mellitus with neuropathy, bipolar disorder, orthostatic hypotension, anxiety disorder, and severe protein-calorie malnutrition. On 4/4/22 at 12:58 PM, an interview was conducted with resident 30. Resident 30 was observed laying in his bed watching television. The bed was centered in the room and at a level resident 30 could be spoken to without bending over or sitting down. Resident 30 stated he had slipped out of bed and staff helped him get back in bed. Resident 30 was unable to remember when this occurred, or who helped him get back into bed. On 4/6/22, resident 30's medical record was reviewed. Resident 30 sustained a fall on 3/25/22, with no injury. A fall risk evaluation dated 3/25/22 at 6:30 AM, with a description of Change of Condition, revealed resident 30 was at a medium fall risk with a score of 7. Resident 30's care plan was updated on 3/25/22, that included new interventions to place bed with one side against the wall per pt (patient) request Low bed when in bed, floor mat next to bedside r/t (related to) fall 3/25/22. A Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed that Resident 30 required extensive one person physical assistance with bed mobility and dressing. Substantial maximal assistance was required for toileting hygiene and bathing. Partial moderate assistance to roll from left to right in bed, to sit on the side of the bed from a lying position, and to lay down from a sitting position. On 4/6/22 at 10:12 AM, an interview was conducted with Assistant Director of Nursing (ADON) 2. ADON 2 stated if there were any occurrences with residents, they would be addressed by the facility Interdisciplinary Team (IDT) the following morning. ADON 2 stated the MDS staff member would update the care plan as the interventions were decided upon at the meeting. ADON 2 stated if the change was something that the resident needed to know about or do, a staff member would talk with the resident. ADON 2 stated it was important to get the right information to the right people in order to implement interventions. ADON 2 stated when Certified Nursing Assistants (CNAs) received information regarding a change in the care plan, they would go to the nurse who was caring for the resident and have an update put on the nursing screen. ADON 2 also stated that in-services and impromptu meetings could be called if there were questions about changes to a resident's care plan. ADON 2 stated that herself or ADON 1 would watch to ensure staff were implementing new interventions. ADON 2 stated the CNAs should be charting what they were doing with resident cares daily. ADON 2 stated sometimes things are not getting charted because the facility had a lot of agency staff. ADON 2 stated she was not sure if agency staff were doing what was required. On 4/6/22 at 2:47 PM, an observation was made of resident 30. Resident 30 was observed to be sleeping and was not able to be aroused. Resident 30's bed was in the center of the room, was not low to the floor, and there was no mat at the side of the bed. On 4/6/22 at 3:17 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that he was not caring for resident 30 at the time of the fall. LPN 1 stated that he was told that resident 30 rolled off the left side of the bed. LPN 1 stated that the CNA found resident 30 early in the morning, around 5:00 AM. LPN 1 stated after a resident sustained a fall the staff would check on the resident more frequently. LPN 1 also stated resident 30's bed would be lowered in the evening. On 4/6/22 at 3:20 PM, an interview was conducted with ADON 1. ADON 1 stated that resident 30's bed should be on the floor at all times and the bed should be against the wall. ADON 1 stated the process to implement changes to the resident's care plan, once the staff determined appropriate interventions, was that he would notify the CNAs and the CNAs implemented the necessary changes. ADON 1 stated one of the staff members on the IDT would contact the resident's family or representative and request that a consent be signed for the changes that were to be made. On 4/7/22 at 9:21 AM, an observation was made of resident 30's room. Resident 30 was siting up in his bed with his breakfast tray in front of him. Resident 30's bed was in the middle of his room, in a raised position. There was no mat observed at the side of the bed. On 4/7/22 at 10:03 AM, an interview was conducted with ADON 1. ADON 1 stated that resident 30's family was good with him having his bed low, but that resident 30 did not like it low. ADON 1 stated there was no documentation in place that resident 30 or his representative had reviewed the risks versus benefits of having the resident's bed at the regular height to prevent falls, and there was no documentation that the issue was addressed with the resident's hospice agency. ADON 1 stated the facility should do that. On 4/7/22 at 11:48 AM, an interview was conducted with CNA 1. CNA 1 stated he was aware of the fall that resident 30 had but was not at the facility at the time. CNA 1 stated he was not aware of what was in resident 30's care plan for fall prevention. CNA 1 stated when a change was made to a resident's care plan it could be texted out or put on the CNA brain, or the nurses on the unit would inform CNAs during the shift change. CNA 1 stated both nursing and CNAs were responsible for implementing changes to the care plan, and CNAs were kept accountable for the changes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 56 was admitted to the facility on [DATE] with medical diagnoses that included, but were not limited to, acute respiratory with hypoxia, limitations of activities due to disability, muscle weakness, pneumonia due to Coronavirus Disease-2019, dysphagia, dependence of supplemental oxygen, type 2 diabetes mellitus, hyperlipidemia, and cognitive communication deficit. On 4/4/22 at 3:17 PM, the facility's matrix was reviewed, and indicated resident 56 had a fall since their admission on [DATE]. On 4/6/22 at 10:44 AM, resident 56 was interviewed. Resident 56 stated they had fallen recently when they tried to get out of bed on her own. During this interview resident 56 was seated in their bed. Resident 56's bed was situated against one of the walls and was in the low position, there was no floor mat located beside resident 56's bed. Resident 56 stated, they would have liked to have a floor mat placed next to their bed, and this would have made her feel safer in bed. Resident 56 stated the facility had not placed a fall mat next to her bed following her past fall. On 4/6/22 at 12:24 PM, a follow-up observation was made of resident 56's room. Resident 56 was resting in bed. Resident 56's bed was observed lowered to the floor, and there was no fall mat next to resident 56's bed. On 4/7/22 8:08 AM, a follow-up observation was made of resident 56's room. At this time, resident 56 was observed near the nurses' station having breakfast with a family member. Resident 56 and their family member stated they would have liked to have a fall mat placed next to resident 56's bed to prevent injuries from any falls, and no fall mat had been placed next to resident 56's bed following their previous fall. Resident 56's room was observed to have the bed lowered to the floor and there was no fall mat placed next to resident 56's bed. On 4/7/22, a review of resident 56's medical record was completed. The following were noted; A fall incident report was dated 3/23/22, and read, Heard patient yelling for help. RN (Registered Nurse) entered and found patient on floor wedged between bed and wheelchair. RN called for help and staff were able to get patient out from position and back into bed. Patient denies hitting her head or having any pain. Patient NG (nasogastric) tube when fell was dislodged. NG tube had come out almost completely. Pump was turned off and NG tube was assessed. Tube removed. Neuros (neurologicals) started. Vitals (vital signs) taken. Full body assessment did not show any wounds or sores . Preventative measures: Meds (medications) and treatments per orders, labs per orders, assist with ADL's (Activities of Daily Living), anticipate pt (patient) needs, pain control, 1-person assist with transfers . Response (interventions): fall mat at bedside when patient is in bed. Resident 56 had a Care Plan, initiated on 3/24/22, with a Focus that read, [Name of resident 56 removed] has had an actual fall. Interventions for this Care Plan read; a. bed against wall, low bed at all times when in bed, floor mat to bedside r/t family request for fall. b. Continue interventions on the at-risk plan. c. Floor mat at all times when in bed r/t fall 3/23/22. On 4/6/22 at 10:32 AM, RN 1 was interviewed. RN 1 stated if they had found out a resident had fallen they would go to the resident's location and assess the resident to see what needed to be done. RN 1 stated they would ensure the resident was safe to transfer, and then RN 1 would either transfer the resident with help from staff or RN 1 would call Emergency Medical Service. RN 1 stated they would notify the resident's family member or Power of Attorney, the doctor and the Director of Nursing. RN 1 stated if a fall was unwitnessed or a resident was witnessed to hit their head during a fall the facility staff would initiate neuro checks and gather vitals regularly for the next 72 hours. RN 1 stated these sheets were kept on the unit until they were completed and the completed vitals sheets were then provided to Medical Records to be uploaded into the resident's medical record. RN 1 stated the fall would be charted in the Risk Management assessments and this would develop the fall incident report and a progress note. On 4/6/22 at 10:46 AM, CNA 2 was interviewed. CNA 2 stated resident 56 required extensive assistance with most ADLs. CNA 2 stated resident 56 was moderate assistance with standing if resident 56 was having a good day. CNA 2 stated they were unaware if resident 56 had any recent falls. CNA 2 stated resident 56 had become more alert since their admission and was now able to communicate better and had less confusion. CNA 2 stated resident 56 had a fall when they were first admitted to the facility and the resident had fallen out of bed, so staff were to keep resident 56's bed lowered to the ground, ensure it was against one of the walls and would check on resident 56 every two hours if the resident was in her room. CNA 2 stated when a resident was found to have a fall it was the facility's protocol for the CNA to not move the resident and have the nurse come assess the resident before the resident could be transferred. CNA 2 stated the CNA would help the nurse to obtain vitals and would also ensure the neuro check vitals sheet was completed accurately. CNA 2 stated when the sheet was completed the nurse would provide the neuro sheet to Medical Records. CNA 2 stated any interventions a resident had in place to prevent a fall would be communicated to CNA staff through the Plan of Care or the CNA Brain. CNA 2 stated the CNA Brain told the CNA's all about their resident's care needs. CNA 2 stated the facility staff were also good about reviewing recent falls during their beginning of shift report, and CNA 2 learned about recent falls and interventions through the verbal report. [Note: CNA 2 did not state resident 56 should have a fall mat near their bed due to recent falls.] On 4/6/22 at 10:52 AM, RN 2 was interviewed. RN 2 stated resident 56 did have interventions in place to prevent injury from falls. The interventions in place included keeping resident 56's bed lower to the ground, ensuring the bed was up against the wall, using a bed alarm when she was in her room without visitors or staff and having the CNA staff check on resident 56 at least every two hours. [Note: RN 2 did not state resident 56 should have a fall mat near their bed due to recent falls.] On 4/6/22 at 10:55 AM, the Medical Records staff member was interviewed. Medical Records stated when a resident had a neuro vitals sheet completed this was provided to Medical Records, and the vitals sheet would then be uploaded into the resident's medical record. Medical Records stated resident 56's neuros vital sheet from her fall on 3/23/22, was not within resident 56's chart and Medical Records did not have a copy of the completed neuros vital sheet. On 4/6/22 at 12:26 PM, the CNA coordinator was interviewed. The CNA coordinator stated CNAs were educated on any interventions in place regarding fall prevention through referring to the CNA Brain. The CNA coordinator stated the CNA brain was updated once a shift, and would be passed onto the next shift. On 4/7/22 at 8:47 AM, ADON 2 was interviewed. ADON 2 stated following resident 56's fall a fall mat was placed next to the bed to prevent injury from any falls. ADON 2 stated they had not gone into resident 65's room in several days and was unaware that there was no longer a fall mat next to resident 65's bed. ADON 2 stated resident 56 should have still had a fall mat next to their bed and it was still a Care Plan intervention that should be in place. Based on observation, interview, and record review it was determined that the facility did not ensure that the resident's environment remained as free of accident hazards as possible, and that each resident received adequate supervision and assistive devices to prevent accidents. Specifically, for 2 out of 30 sampled residents, the facility did not provide adequate supervision to prevent falls from occurring, and care plan interventions were not implemented. Resident identifiers: 30 and 56. Findings included: 1. Resident 30 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included Parkinson's disease, type 2 diabetes mellitus with neuropathy, bipolar disorder, orthostatic hypotension, anxiety disorder, and severe protein-calorie malnutrition. On 4/4/22 at 12:58 PM, an interview was conducted with resident 30. Resident 30 was observed laying in his bed watching television. The bed was centered in the room and at a level resident 30 could be spoken to without bending over or sitting down. Resident 30 stated he had slipped out of bed and staff helped him get back in bed. He was unable to remember when this occurred, or who helped him get back into bed. On 4/6/22 at 2:34 PM, resident 30's medical record was reviewed. On 3/25/22 at 6:30 AM, a fall risk evaluation was completed. The evaluation revealed that resident 30 was a moderate fall risk, with a score of 7. The progress note associated with the fall risk evaluation documented that resident 30 was found on the floor of his room by a Certified Nursing Assistant (CNA). The CNA alerted the nurse on duty who then assessed resident 30 an found him to have no injuries. Resident 30's care plan initiated on 4/21/21, included a focus area of falls related to Parkinson's disease. Interventions included anticipate and meet needs, Ensure the call light is within reach and encourage to use it and call for assistance as needed, keep needed items, water, etc. within reach, occupational, physical, speech-language therapy evaluation and treatment per physician orders. On 3/25/22, resident 30's care plan was updated stating has had an actual fall 3/25/22 no injury. New interventions put in place included continue interventions on the at-risk plan, place bed with one side against wall per patient request, low bed when in bed, floor mat next to bed r/t (related to) fall 3/25/22. The Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed that resident 30 required extensive one person physical assistance with bed mobility and dressing, substantial maximal assistance for toileting hygiene and bathing, and partial moderate assistance to roll from left to right in bed, sit on the side of the bed from a lying position, and lay down from a sitting position. On 4/6/22 at 2:47 PM, an observation was made of resident 30 in his room. Resident 30 was sleeping and was not able to be aroused. Resident 30's bed was in the center of the room, was not low to the floor, and there was no mat at the side of the bed. On 4/7/22 at 9:21 AM, an observation was made of resident 30. Resident 30 was lying in bed with his bedside table and breakfast in front of him. Resident 30's bed was in the same position as the two prior observations, in the middle of the room. There was no mat observed next to the bed for safety. The far side of the bed had a side table with a photo frame on it, and an armchair sitting next to the bed. [Note: Resident 30's room was at the end of the B hallway and the door was closed each time the surveyor arrived for an observation.] On 4/6/22 at 10:12 AM, an interview was conducted with Assistant Director of Nursing (ADON) 2. ADON 2 stated if there were any occurrences with residents, they would be addressed by the facility Interdisciplinary Team (IDT) the following morning. ADON 2 stated the MDS staff member would update the care plan as the interventions were decided upon at the meeting. ADON 2 stated it was important to get the right information to the right people in order to implement interventions. ADON 2 stated when CNA's received information regarding a change in the care plan, they would go to the nurse who was caring for the resident and have an update put on the nursing screen. ADON 2 stated that she or ADON 1 would watch to ensure staff were implementing new interventions. On 4/6/22 at 3:17 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that he was not caring for resident 30 at the time of the fall. LPN 1 stated that he was told that resident 30 rolled off the left side of the bed. LPN 1 stated after a resident sustained a fall the staff would check on the resident more frequently. LPN 1 also stated resident 30's bed would be lowered in the evening. On 4/6/22 at 3:20 PM, an interview was conducted with ADON 1. ADON 1 stated that resident 30's bed should be on the floor at all times and the bed should be against the wall. On 4/7/22 at 10:03 AM, an interview was conducted with ADON 1. ADON 1 stated that resident 30's family was good with him having his bed low, but that resident 30 did not like it low. ADON 1 stated there was no documentation in place that resident 30 or his representative had been educated about the risks/benefits of having the resident's bed at the regular height versus low position. ADON 1 stated the facility should do that. On 4/7/22 at 11:48 AM, an interview was conducted with CNA 1. CNA 1 stated he was aware of the fall that resident 30 had but was not at the facility at the time. CNA 1 stated he was not aware of what was in resident 30's care plan for fall prevention. CNA 1 stated both nursing and CNAs were responsible for implementing changes to the care plan, and CNAs were kept accountable for the changes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined that the facility did not ensure that a resident maintained acceptable parameters of nutritional status, such as usual body weight, unless the resident's clinical condition demonstrated that this was not possible or resident preferences indicate otherwise. Specifically, for 1 out of 30 sampled residents, the facility did not implement a diet recommendation made by the Registered Dietician (RD) for 8 days after a resident had a significant weight change. Resident identifier: 265 Findings included: Resident 265 was admitted to the facility on [DATE] with diagnoses which included Alzheimer Disease, Chronic Obstructive Pulmonary Disease, Cerebral infarction (CVA), and dysphagia following cerebral infarction. Resident 265's medical record was reviewed on 4/7/22. Resident 265's hospital admission form dated 3/22/22, documented that it was recommended for the resident to continue on an all-liquid consistencies and soft bite sized food diet. On admission to the facility, resident 265 was put on a regular diet, soft and bite sized Level 6 texture, and thin liquids consistency. A Speech Therapy (ST) Evaluation and Plan of treatment note dated 3/23/22, documented The patient is at risk for compromised general health. Patient present with dysphagia following CVA indicated by high risk of choking or aspirating due to poor cognitive function and impulsivity, which necessitates skilled Speech Language Pathologist services for dysphagia to design and implement strategies, reduce signs and symptoms of aspiration and instruct in compensatory strategies in order to improve ability to use facilitative techniques that increase safety. Recommendations included, soft bite sized diet with thin liquids. Resident 265 had a care plan in place regarding their nutritional status which read, The resident has nutritional problem or potential nutritional problem r/t (related to) new admit, swallow concern. Recent hospital stay, medication use. Date initiated: 3/22/2022. Interventions in place regarding this Care Plan focus included; a. Provide, serve diet as ordered. Monitor intake and record q (every) meal. b. Registered Dietician to evaluate and make diet change recommendations PRN (as needed). A facility report titled Weight Summary revealed the following weights for resident 265 [Note: All weights were in pounds (Lbs).] a. On 3/23/22, was 218.4 b. On 3/29/22, was 195.4 c. On 4/5/22, was 203.2 d. On 4/7/22, was 199.8 The Task section of the medical record for the Amount Eaten documented the following entries: a. March 2022, resident 265 had a meal consumption percentage documented. For 3 out of 12 possible meals, resident 265 had a meal consumption of 0-50% of total meal eaten; for 6 out of 12 meals, resident 265 had a meal consumption of 51-75% of total meals eaten; and for 3 out of 12 meals resident 265 had a meal consumption of 76-100% of total meal eaten. b. April 1 through April 6 2022, Resident 265 had a meal consumption percentage documented. For 7 out of 12 possible meals, Resident 265 had a meal consumption of 51-75% of total meal. Resident 265's nutrition progress notes documented the following: a. A RD progress note dated 3/27/22 at 9:56 PM, documented Pt (patient) reports he is getting enough to eat and satisfied with meals but intake puts Pt at risk for unintended weight loss. Suggest:1. DC (discontinue) Current diet 2. Start SNP (Specialized Nutrition Program) IDDSI (International Dysphagia Diet Standardization Initiative) 6 (soft and bite sized level 6). b. A RD progress noted dated 4/4/22 at 11:58 AM, documented resident 265 had a weight loss of 23 lbs. Resident 265 lost 10.5 % of body weight from weight taken on 3/29/22 at 1:41 PM. The RD documented, Admit weight is reported to have been obtained with WC (wheelchair) in place. However, intake with some variance with 51-76% of meals taken. SNP diet suggested. RD recommended Med Pass to be given three times a day between meals and to notify the doctor. c. A Nurse Note dated 4/4/22 at 6:16 PM, documented that the RD recommended drink supplement (Med Pass). Doctor notified of weight change and recommendations made by RD. Orders were entered to reflect suggestions made by RD. The April 2022 Medication Administration Record documented the following physician's orders: a. On 4/4/22 at 6:01 PM, MED PASS 2.0 three times a day. Offer 60 milliliters three times a day between meals. b. On 4/4/22, SNP diet, SOFT and BITE SIZED - Level 6 texture, THIN LIQUIDS consistency. [Note: Resident 265's nutrition orders were implemented on 4/4/22, eight days after the RD's initial recommendations and after a 15 lb weight loss.] On 4/5/22 at 12:51 PM, an interview was conducted with the RD. The RD stated recommendations were made on 3/27/22, due to periods of decreased intake. The RD stated that Resident 265 popped up on her screening on 4/4/22, due to weight loss. The RD stated recommendations were made on diet modifications and supplements were added. The RD was unsure if there was an actual weight loss but she put things in place and resident 265 would be reweighed this week. On 4/6/22 at 12:08 PM, an observation was made of resident 265. Resident 265 was observed to eat his lunch at the bedside table in his room. Resident 265 was observed to feed himself while the ST sat across from him. The ST was observed to watch resident 265 while he took bites of the food. The ST was observed to be in resident 265's room for approximately 20 minutes. On 4/6/22 at 12:10 PM, an interview was conducted with the ST. The ST stated they had been working with resident 265 since admission to the facility on 3/22/22. The ST stated they had observed resident 265 while he ate to reduce impulsivity to avoid aspiration or choking on the food. The ST stated they did not come in resident 265's room for every meal. On 4/6/22 approximately 1:00 PM, an interview was conducted with Assistant Director of Nursing (ADON) 1. ADON 1 stated they did not have a reliable weight on resident 265 and believed it was an abnormal high admission weight. ADON 1 stated they may have forgotten to subtract the wheelchair weight but he was unsure of the weight variable for resident 265. On 4/7/22 at 8:40 AM, an interview was conducted with Certified Nursing Assistant (CNA) 3. CNA 3 stated that resident 265 usually ate pretty good by himself and the only help needed was supervision. CNA 3 stated that resident 265 usually ate about 75-100 % of his meal. On 4/7/22 at 08:50 AM, an interview was conducted with Registered Nurse (RN) 3. RN 3 stated that resident 265 was on the list to be weighed. RN 3 was notified by ADON 1 about all the residents that needed to be weighed for the day. RN 3 stated that sometimes there was a big difference between the admission weight and the weight taken one to two days later. RN 3 stated that weights were very inconsistent but when there was a big weight difference, interventions were put into place for the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined that the facility did not provide routine and emergency drugs and biologicals to its residents. Specifically, for 1 out of 30 sampled residents, a residents medications were not administered as ordered by the physician due to not being available by the pharmacy. Resident identifiers: 47. Findings included: Resident 47 was admitted to the facility on [DATE] with diagnoses which included but not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, heart failure, chronic atrial fibrillation, chronic respiratory failure with hypoxia, morbid (severe) obesity due to excess calories, asthma, muscle weakness, difficulty in walking, stage 3 chronic kidney disease, major depressive disorder, and essential (primary) hypertension. Resident 47's medical record was reviewed on 4/5/22. On 3/17/22 at 10:03 PM, an electronic Medication Administration Record (eMAR)-Medication Administration Note documented Eliquis tablet 5 milligrams (mg) by mouth two times a day for atrial fibrillation. Out of medication, Waiting for medication to be delivered to facility. On 3/21/22 at 9:25 AM, an eMAR-Medication Administration Note documented metoprolol tartrate tablet 25 mg by mouth two times a day for hypertension. unavailable. ordered from pharmacy. On 3/21/22 at 9:25 AM, an eMAR-Medication Administration Note documented calcium citrate with vitamin D tablet 250-200 mg-unit by mouth one time a day for supplement. unavailable. ordered from pharmacy. On 3/28/22 at 10:55 AM, an eMAR-Medication Administration Note documented Miralax packet 17 grams (gm) by mouth two times a day for constipation. waiting for med (medication). On 3/29/22 at 7:12 AM, an eMAR-Medication Administration Note documented Miralax Packet 17 gm by mouth two times a day for constipation. Medication not available. [Note: A review of the March 2022 Medication Administration Record documented that resident 47 had not received Eliquis, metoprolol tartrate, calcium citrate with vitamin D, and Miralax as ordered by the physician.] On 4/6/22 at 11:58 AM, an interview was conducted with Assistant Director of Nursing (ADON) 2. ADON 2 stated ordering medications for a new admission would consist of sending the medication list to the contracted pharmacy and the pharmacy would fill the medications. ADON 2 stated if there was a medication change the providers would clarify the medication prior to ordering from the contracted pharmacy. ADON 2 stated that regular medication orders were on a cycle fill. ADON 2 stated that every 30 days the contracted pharmacy would send the new months worth of medications for the residents. ADON 2 stated if a resident was on the skilled side of the facility medications were ordered when low due to the resident not being in the facility long term. ADON 2 stated a resident on skilled days only received a 14 day supply of medications at a time. ADON 2 stated that narcotics required a signed physician's order. ADON 2 stated that more medications were being stored in the emergency medication system in the facility and were available to nursing staff for use. ADON 2 further stated that the cycle fill program was put into place possibly around August 2021. ADON 2 stated if a residents medications ran out before the cycle fill the contracted pharmacy would fill the gap until the next cycle fill.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility provided residents with therapeutic diets as prescribed by the attending physician. Specifically, for 2 out of 30 sampled residents, the facility did not provide residents' with the cardiac diet as prescribed by their physician. Resident identifiers: 29 and 219. Findings included: 1. Resident 29 was admitted to the facility on [DATE] with medical diagnoses which included, but were not limited to, fracture of the right femur, atrial fibrillation (Afib), atherosclerotic heart disease, ischemic cardiomyopathy, muscle weakness, difficulty walking, hypertension (HTN), hyperlipidemia (HLD), presence of a cardiac pacemaker. On 4/4/22 at 12:50 PM, resident 29 stated the facility's kitchen was a nightmare. Resident 29 stated he was supposed to be on a very low salt, heart healthy diet, and he did not receive that at his meals. Resident 29 stated he needed this diet because too much salt would cause him to hold onto fluid, which made it harder for him to breathe, and created more fluid accumulation in his legs. Resident 29 stated his wife had begun to bring meals into the facility regularly because he was not receiving the diet he should have been getting from the facility. On 4/7/22, a review of resident 29's medical record was completed. The following were noted; Resident 29's hospital discharge paperwork with discharge instructions dated 3/24/22, read, Discharge Diet Instruction: Discharge Diet: Cardiac Diet, 2 g (gram) sodium. A Nursing Note, dated 3/23/22, read Pt [patient] is able to communicate and make needs known. Pleasant and cooperative per the nurse. On Cardiac diet/2 g sodium/ regular texture/ thin liquids. On 2000 ml (milliliter)/day fluid restriction. Able to feed self. A Registered Dietitian (RD) Note dated 3/31/22, read Pt re-admitted for rehab and medical care for recent fall while at gym with FX (fracture) to R (right) hip. Other DX (diagnoses) of concern: CAD (coronary artery disease), HTN, CHF (congestive heart failure) s/p (status post) ICD (Implantable cardioverter defibrillator), paroxysmal Afib, HTN (sic), OSA (obstructive sleep apnea), ankylosing spondylitis. Nutritional risk factor: 1. Need of mechanical altered diet r/t (related to) DX of CHF aeb (as evidence by) H&P (history and physical) 2. Overweight class I obesity r/t dietary and lifestyle choice aeb BMI (body mass index) of 30.6 . At this time current POC (plan of care) appears adequate to sustain weight and nutritional status. Continue with set POC and provide support as indicated. A Nutrition Risk Review assessment, completed by the RD on 3/31/22, read Diet/ consistency: Cardiac/ NAS (no added salt), regular. Resident 29's April 2022 Medication Administration Record (MAR) indicated on 4/5/22, that resident 29's diet was, CARDIAC DIET diet REGULAR texture, THIN LIQUIDS consistency, 2 gram sodium. Resident 29's meal ticket printed on 4/5/22, read Regular- NAS. 2. Resident 219 was admitted to the facility on [DATE] with medical diagnoses that included, but not limited to, cardiomyopathy, atherosclerotic heart disease, HTN, HLD, hypothyroidism, dependence on supplemental oxygen, congestive heart failure, Afib, acute respiratory failure, cardiac arrest, ST Elevated myocardial infarction, muscle weakness, and limitation of activities due to disability. On 4/4/22 at 10:58 AM, resident 219 was interviewed. Resident 219 stated they were supposed to be receiving a cardiac diet from the kitchen, and resident 219 stated some of the foods they received did not fit within a cardiac diet. Resident 219 stated they had brought up their concern to several staff members, and resident 219 stated they would like to ensure they were being provided a cardiac diet. On 4/7/22, a review of resident 219's medical record was completed. The following were noted; A Nursing Note dated 3/28/22, read 75 F (female) arrived at facility .following dx of dysrhythmia. pt was fitted with a life vest.pt is on a 1500ml/day fluid restriction. CCHO (consistent carbohydrate)/cardiac diet. An RD-Nutrition Risk Review, completed by the RD on 3/31/22, read Diet/consistency: Cardiac regular. An RD Note, written by the RD, and completed on 3/31/22, read Pt admitted for rehab and medical cares after CHF exacerbation. Other DX of concern: Morbid obesity. Nutritional risk factor- low malnutrition risk. 1. Need of therapeutic diet r/t DX of CHF aeb H&P; 2. Overweight class V obesity r/t dietary and lifestyle choices aeb BMI 51; Daily weights in place with desired and anticipated weight loss. Resident 219's April 2022 MAR indicated on 4/5/22, that resident 219's diet was, Diet CARDIAC DIET diet REGULAR texture, THIN LIQUIDS consistency. Resident 219's meal ticket dated 4/5/22, read Regular- NAS. An Orders Note written on 4/5/22 at 7:56 PM, by the Minimum Data Set (MDS) staff member read, Order clarification per Dietary: Please clarify cardiac diet to be written as NAS diet Per facility preference. 1500 ML fluid restriction. Start Date: 4/5/2022. A review of the facility, Daily Spreadsheet for meal portions indicated resident's on a Heart Healthy diet would have had a lunch meal on 4/5/22 of oven fried chicken, a baked sweet potato, mixed vegetables, and a bread or a roll. [Note: Residents 29 and 219 were provided with an NAS diet, not a cardiac diet. The NAS diet on the Daily Spreadsheet indicated there were differences between the NAS meal and the Heart Healthy meal. Residents on a Heart Healthy meal would have received low sodium gravy and a baked sweet potato.] On 4/5/22 at 12:13 PM, Dietary [NAME] 1 was interviewed about residents on a Cardiac, 2 gram sodium or heart healthy diet. Dietary [NAME] 1 stated there were no residents who were to receive those diets that they were aware of. Dietary [NAME] 1 stated they knew this because residents who needed to be provided a heart healthy diet would have displayed on his meal preparation spreadsheet, and he would need to prepare a special meal for those residents. Dietary [NAME] 1 stated if there was a resident on a Cardiac, 2 gram sodium or heart healthy diet he would have provided the resident with a different meal that included less sodium. The meal provided was oven fried chicken, twice baked sweet potatoes, gravy, mixed vegetables, and bread or a roll. On 4/5/22 at 1:01 PM, the RD was interviewed. The RD stated they came into the facility at least once a week on Thursdays, and she would talk with the residents about their food allergies and food preferences while they complete the resident's admission assessment. The RD stated residents who come into the facility on a Cardiac or 2 gram sodium diet were transitioned to a NAS diet unless the resident asked for a more restrictive diet during their interview. The RD stated they would talk with the resident and educate the resident on what the cardiac diet would look like to ensure that was what the resident would like to receive. On 4/6/22 at 8:42 AM, the Dietary Manager (DM) was interviewed. The DM stated they planned to initiate regular audits of the residents' electronic medical records and meal tickets to ensure the resident's were being provided with the diet as prescribed by the physician. The DM stated they were just made aware that resident 29 and 219 had diet orders within their electronic medical record that did not match what the kitchen staff were providing. The DM stated when residents were admitted to the facility, the DM would talk with the nursing staff about cardiac diets. The DM stated they would have the nursing staff talk with the doctor about having the diet adjusted to an NAS diet. The DM stated for residents 29 and 216 the changes in their diet orders were never made to NAS. On 4/6/22 at 9:38 AM, Registered Nurse (RN) 1 was interviewed. RN 1 stated when a resident was admitted to the facility the nurse on duty would fill out a Diet Communication Slip which would be sent to the kitchen. RN 1 stated there was one copy sent to the kitchen and a second copy was provided to medical records to be uploaded into the resident's medical record. RN 1 stated a nursing staff member would then deliver the Diet Communication Slip to the kitchen. On 4/6/22 at 2:22 PM, the MDS coordinator was interviewed. The MDS coordinator stated they did place a note into resident 219's chart about a diet order change. The MDS coordinator stated they made the change in the order because the RD told her to and indicated that the facility had followed what was on the resident's hospital discharge on admission when both residents 29 and 219 were placed on cardiac diets.

Based on observation, interview, and record review it was determined that the facility did not ensure safe and secure storage of drugs and biologicals in accordance with accepted professional principles; or include the appropriate accessory and cautionary instructions, and the expiration date on the medication. Specifically, for 3 out of 30 sampled residents, opened multi-dose vials of insulin were not labeled with open dates or expiration dates and were available for use. Resident Identifiers: 5, 44, and 60. Findings included: 1. On 4/6/22 at 8:59 AM, the medication cart on the A hall was inspected and the following items were expired and available for use. [Note: Multi-dose vials of insulin should be discarded within 28 days after opened or accessed.] a. Resident 60's multi-dose vial of Ademelog (insulin lispro) was not labeled with an open date or an expiration date. The medication was dispensed from the pharmacy on 3/10/22. b. Resident 60's multi-dose vial of Insulin glargine was not labeled with an open date or an expiration date. The medication was dispensed from the pharmacy on 3/27/22. An interview was immediately with Registered Nurse (RN) 4. RN 4 stated the expiration of insulin once accessed would depend on the type of insulin. RN 4 stated that the insulin would be good for 28 days after accessed. RN 4 stated that the insulin was still okay to use because it was within the pharmacy dispense date. 2. On 4/6/22 at 9:07 AM, the medication cart on the F hall was inspected and the following items were expired and available for use. a. Resident 44's multi-dose vial of Ademelog (insulin lispro) was not labeled with an open date or an expiration date. The medication was dispensed from the pharmacy on 3/20/22. b. Resident 5's multi-dose pen of Insulin glargine was not labeled with an open date or an expiration date. An interview was immediately conducted with RN 2. RN 2 stated that the insulin would be good for 28 days. On 4/6/22 at 9:10 AM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated that the nurses were responsible to check their medication carts for expired medications and the pharmacy would come and retrieve the expired medications. On 4/6/22 at 11:46 AM, an interview was conducted with Assistant Director of Nursing (ADON) 2. ADON 2 stated the second the nurses open the box of insulin; it should be labeled so they know when the medications expire. ADON 2 stated multi-dose vials of insulin expire within 30 days of access.

Based on observation and interview, it was determined the facility did not ensure to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the resident communal nourishment refrigerators included unlabeled, undated and expired items. Findings included: On 4/6/22 at 8:42 AM, the Dietary Manager (DM) was interviewed. The DM stated the kitchen was in charge of monitoring the facility's communal nourishment refrigerators that were located at the north side and south side nurses' stations. The DM stated they planned to talk with leadership because the DM had found the communal nourishment refrigerators were far from the kitchen area, and this made it hard for kitchen staff to monitor what went into the communal nourishment refrigerators. The DM stated it may be more effective to have nursing staff monitor those refrigerators because the nursing staff were typically the staff that would place food items into the communal nourishment refrigerators for residents. On 4/6/22 at 8:50 AM, observations were made of the communal nourishment refrigerator located at the south side nurses' station. These observations were made accompanied by the DM. The DM stated any item that entered the refrigerator should be labeled with the resident's name or room number and a date that it entered the refrigerator. The DM stated if a food item was opened or was a homemade item it should be used within three days, and for grocery items with a use by date the facility would allow the item to remain in the refrigerator as long as it was not expired. The following observations were made of the communal nourishment refrigerator located at the south side nurses' station; a. Within the refrigerator was a small bowl, with a plastic cover, that was labeled with a resident's name, but no date. The DM stated that cup contained the beets from last evening's dinner, and a resident must have enjoyed the beets and wanted more for later. The DM stated the food item should have been labeled with a date prior to entering the communal nourishment refrigerator. b. A larger bowl with a plastic cover was located in the refrigerator. The DM stated the bowl contained jam from the facility's kitchen. The jam was labeled, 3/30. The DM stated they were unsure why that was located in the communal nourishment refrigerator. c. A container of a brown soup looking substance was labeled with a room number, but was not labeled with the date it entered the refrigerator. The DM stated that should have been labeled with a date. d. A plastic grocery bag was located in the communal nourishment refrigerator. Within the bag was a container of soup, fruit and a salad. All items were not labeled with a date they entered the refrigerator or a resident name or room number. e. Several mighty shakes were observed located in the communal nourishment refrigerator. The mighty shakes were not labeled with a date they were thawed. The mighty shake product label read, Keep frozen. Thaw at or below 40 degrees. Use thawed product within 14 days. f. A food product labeled with a resident's name had a use by date of 3/17/22. The DM stated they were unsure if this item should remain in the communal nourishment refrigerator. g. Observations were made of the attached freezer of the communal nourishment refrigerator. The DM stated ice cream would be allowed to stay in the communal nourishment freezer for up to six months, and items should be labeled with a date and a resident name or room number. Three pints of ice cream were located in the freezer and were labeled with a resident name, but not a date. One carton of red, white and blue ice cream was located in the freezer and was not labeled with a resident name or room number or a date. Also, within the communal nourishment freezer was an ice pack that had product labeling which read, Medline, and, Hot and Cold Compress. The ice pack was stored next to the residents' food items. The DM stated they were unsure if the hot and cold compress, ice pack could be stored near resident food items. On 4/6/22 9:02 AM, observations were made of the communal nourishment refrigerator located at the north side nurses' station. These observations were made accompanied by the DM. The following observations were made; a. A plastic grocery bag labeled with no name, room number or date was located in the communal nourishment refrigerator. Within the bag was small containers of guacamole, fresh snap peas, and a protein shake. On the snap peas package labeling was a best by date of 3/21/22. b. A cheese snack pack was located in the refrigerator, and was not labeled with a resident name or room number. c. A container of Orange Fig Spread was located in the resident communal nourishment refrigerator. The spread was not labeled with a resident name, room number, or a date it entered the refrigerator. d. A mighty shake was stored in the resident communal nourishment refrigerator. The mighty shake was not labeled with the date it was thawed. The mighty shake product labeling read, Keep frozen. Thaw at or below 40 degrees. Use thawed product within 14 days. The DM stated the mighty shakes did need to be used within a certain timeframe once they were thawed. The DM stated the facility would adjust how they store the mighty shakes at the nursing stations, and the mighty shakes would remain frozen until a nurse took the mighty shake out of the freezer to thaw. e. A container of whipped cream was located in the communal nourishment refrigerator, and was not labeled with a resident name or room number. The product labeling had a use by date of 3/27/22. f. Observations were made of the freezer attached to the north side communal nourishment refrigerator. Within the communal nourishment freezer, was a chicken pastry product which was not labeled with a resident name, room number or a date it entered the freezer. On 4/6/22 at 9:10 AM, the DM stated they were typically the person who would go through the items in the communal nourishment refrigerators and freezers, and they would look into the refrigerators and freezers every Monday, Wednesday, and Friday.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined that the facility did not ensure that each resident's medical record included documentation that indicated that the resident or resident's representative was provided education regarding the benefits and potential side effects of the influenza and pneumococcal immunizations; and that the resident either received the influenza and pneumococcal immunizations or did not receive the influenza and pneumococcal immunizations due to medical contraindications or refusal. Specifically, for 5 out of 30 sampled residents, the facility did not keep documentation within the residents' medical record regarding the residents' influenza and pneumococcal consent status or education of the benefits and potential risks associated with the immunizations. Resident identifiers: 3, 24, 38, 41, and 216. Findings included: 1. Resident 24 was admitted to the facility on [DATE] with diagnoses which included but not limited to dementia without behavioral disturbance, dysphagia, repeated falls, severe protein-calorie malnutrition, aphasia, major depressive disorder, anxiety disorder, essential (primary) hypertension, and bradycardia. Resident 24's medical record was reviewed on 4/7/22. A review of the Immunization section of the medical record documented that resident 24 was administered the Influenza immunization on 10/12/21, and the consent status was complete. An Influenza and Pneumococcal Vaccines Consent Form dated 10/12/21, was provided and not included within resident 24's medical record. 2. Resident 38 was admitted to the facility on [DATE] with diagnoses which included but not limited to cerebral palsy, dysphagia, stage 3 chronic kidney disease, muscle weakness, and scoliosis. Resident 38's medical record was reviewed on 4/7/22. A review of the Immunization section of the medical record documented that resident 38's Influenza and Pneumococcal immunization consent status was refused. An Influenza and Pneumococcal Vaccines Consent Form dated 10/12/21, was provided and not included within resident 38's medical record. 3. Resident 3 was admitted to the facility on [DATE] with diagnoses which included but not limited to paraplegia, muscle weakness, severe protein-calorie malnutrition, hypoxemia, chronic pain syndrome, and dependence on wheelchair. Resident 3's medical record was reviewed on 4/7/22. A review of the Immunization section of the medical record documented that resident 3's Influenza immunization consent status was refused. The Pneumococcal immunization consent status was documented as not eligible. An Influenza and Pneumococcal Vaccines Consent Form dated 9/28/21, was provided and not included within resident 3's medical record. 4. Resident 41 was admitted to the facility on [DATE] with diagnoses which included but not limited to cerebral aneurysm, muscle weakness, cognitive communication deficit, dysphagia, essential (primary) hypertension, and atrial fibrillation. Resident 41's medical record was reviewed on 4/7/22. A review of the Immunization section of the medical record documented that resident 41's Influenza immunization consent status was refused. An Influenza and Pneumococcal Vaccines Consent Form dated 10/12/21, was provided and not included within resident 41's medical record. 5. Resident 216 was admitted to the facility on [DATE] with diagnoses which included but not limited to aphasia following cerebral infarction, malignant neoplasm of connective and soft tissue, aftercare following surgery for neoplasm, cognitive communication deficit, essential (primary) hypertension, and localization-related idiopathic epilepsy. Resident 216's medical record was reviewed on 4/7/22. A review of the Immunization section of the medical record revealed no documentation regarding resident 216's Influenza immunization status. An admission Immunization Record and Consent Form dated 3/30/22, was provided and not included within resident 216's medical record. On 4/7/22 at 11:22 AM, an interview was conducted with the Corporate Resource Nurse (CRN). The CRN stated the local pharmacy would come to the facility and administer the Coronavirus Disease-2019 (COVID-19) vaccination to the residents. The CRN stated that before the COVID-19 vaccine was administered the pharmacy would have the resident fill out the consent form and if the resent had dementia the family would complete the consent form. The CRN stated the COVID-19 booster vaccine for the residents was completed by the contracted pharmacy. The CRN stated that the vaccinations were charted under the Immunization tab in the medical record and a nurses note would be completed if the resident refused any of the vaccines. The CRN stated the admission Immunization Record and Consent Form was completed for the new admission residents. The CRN stated that the Infection Preventionist had a binder that she would keep all the resident immunization consent forms in.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined, the facility did not ensure the resident's medical record included documentation that indicates, at a minimum, the following: that the resident or resident representative was provided education regarding the benefits and potential risks associated with Coronavirus Disease-2019 (COVID-19) vaccine; each dose of COVID-19 vaccine administered to the resident; or if the resident did not receive the COVID-19 vaccine due to medical contraindications or refusal. Specifically, for 3 out of 30 sampled residents, the facility did not keep documentation within the residents' medical record regarding the residents' COVID-19 vaccination refusal or education of the benefits and potential risks associated with the COVID-19 vaccination. Resident identifiers: 24, 38, and 216. Findings included: 1. Resident 24 was admitted to the facility on [DATE] with diagnoses which included but not limited to dementia without behavioral disturbance, dysphagia, repeated falls, severe protein-calorie malnutrition, aphasia, major depressive disorder, anxiety disorder, essential (primary) hypertension, and bradycardia. Resident 24's medical record was reviewed on 4/7/22. A review of the Immunization section of the medical record documented that resident 24's COVID-19 consent status was refused. No documentation was located indicating that resident 24 or the resident representative was provided education regarding the benefits and potential risks associated with the COVID-19 vaccination. 2. Resident 38 was admitted to the facility on [DATE] with diagnoses which included but not limited to cerebral palsy, dysphagia, stage 3 chronic kidney disease, muscle weakness, and scoliosis. Resident 38's medical record was reviewed on 4/7/22. A review of the Immunization section of the medical record documented that resident 38's COVID-19 consent status was refused. No documentation was located indicating that resident 38 or the resident representative was provided education regarding the benefits and potential risks associated with the COVID-19 vaccination. 3. Resident 216 was admitted to the facility on [DATE] with diagnoses which included but not limited to aphasia following cerebral infarction, malignant neoplasm of connective and soft tissue, aftercare following surgery for neoplasm, cognitive communication deficit, essential (primary) hypertension, and localization-related idiopathic epilepsy. Resident 216's medical record was reviewed on 4/7/22. A review of the Immunization section of the medical record revealed no documentation regarding resident 216's COVID-19 immunization status. No documentation was located indicating that resident 216 or the resident representative was provided education regarding the benefits and potential risks associated with the COVID-19 vaccination. On 4/7/22 at 11:22 AM, an interview was conducted with the Corporate Resource Nurse (CRN). The CRN stated the local pharmacy would come to the facility and administer the COVID-19 vaccination to the residents. The CRN stated that before the COVID-19 vaccine was administered the pharmacy would have the resident fill out the consent form and if the resent had dementia the family would complete the consent form. The CRN stated the COVID-19 booster vaccine for the residents was completed by the contracted pharmacy. The CRN stated that the vaccinations were charted under the Immunization tab in the medical record and a nurses note would be completed if the resident refused any of the vaccines. The CRN stated the admission Immunization Record and Consent Form was completed for the new admission residents. The CRN stated that the Infection Preventionist had a binder that she would keep all the resident immunization consent forms in.