**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident 5 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, depression and insomnia disorder. Resident 5's medical record was reviewed. A physician's order dated 1/29/19, documented sertraline (Zoloft) 25 mg. Administer 12.5 mg daily for a diagnosis of depression. A physician's order dated 1/29/19, documented zolpidem (Ambien) 5 mg daily at bedtime for a diagnosis of insomnia. A physician's order dated 2/14/20, documented diphenhydramine (Banophen) 25 mg daily at bedtime for a diagnosis of allergies and insomnia. A physician documented clinical contraindication was unable to be located and the medications had not received the appropriate GDR. 4. Resident 14 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, anxiety. Resident 14's medical record was reviewed. A physician's order dated 3/22/23, documented quetiapine (Seroquel) 25 mg daily for a diagnosis of agitation. A physician's order dated 3/22/23, documented quetiapine 50 mg daily at bedtime for a diagnosis of agitation. A physician's order dated 3/22/23, documented mirtazapine (Remeron) 30 mg daily at bedtime for a diagnosis of insomnia. A physician's order dated 11/17/23, documented lorazepam 1 mg twice daily (BID) for a diagnosis of anxiety. A physician's order dated 7/16/24, documented lorazepam 0.5 mg BID for a diagnosis of anxiety. It should be noted the dosage was initially prescribed on 11/17/23. On 6/17/25 at 11:00 AM, a LTC Psychotropic Medication Review note documented no GDR on medications and stable on all medications. It should be noted that all of resident 14's LTC Psychotropic Medication Review notes documented no GDR on medications and stable on all medications. A physician documented clinical contraindication was unable to be located and the medications had not received the appropriate GDR. The antipsychotic medication Seroquel did not have the appropriate indication for use. On 6/24/25 at 10:35 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident behaviors were addressed in the Interdisciplinary Team meeting. The DON stated If staff were doing rounds they could add a note for agitation. The DON stated that under caregiver rounding the staff would document behaviors. The DON stated she did not know how GDRs were done because she was not involved with them at all. The DON stated the pharmacist was involved in the psychotropic meetings. On 6/24/25 at 10:56 AM, an interview was conducted with the Nurse Administrator. The Nurse Administrator stated that when the physicians did their resident rounds they would put the GDR in their summary and the pharmacist would address the medications monthly. On 6/24/25 at 11:36 AM, a follow up interview was conducted with the Nurse Administrator. The Nurse Administrator verified the staff would use a progress note and what ever the physician documented on their rounds to determine GDRs. Based on interview and record review, the facility did not ensure that residents who use psychotropic drugs received a gradual dose reduction (GDR), and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. Specifically, for 4 out of 12 sampled residents, residents did not have an attempted GDR for psychotropic medications. Additionally, residents were given an antipsychotic medication without an appropriate diagnosis. Resident identifiers: 5, 7,14, and 15. Findings included: 1. Resident 7 was admitted to the facility on [DATE] with diagnoses which included depression. Resident 7's medical record was reviewed on 6/22/25 through 6/25/25. A physician's order dated 4/17/24, documented fluoxetine 20 milligram (mg) daily for depression. A physician documented clinical contraindication was unable to be located and the medication had not received a GDR. 2. Resident 15 was admitted to the facility on [DATE] with diagnoses which included dementia and insomnia. Resident 15's medical record was reviewed on 6/22/25 through 6/25/25. A physician's order dated 7/29/24, documented Seroquel 25 mg at bedtime for insomnia/agitation. On 6/5/25 at 8:23 AM, a Long Term Care (LTC) Psychotropic Medication Review note documented no GDR on Seroquel and that the resident was stable on the medication. It should be noted that all of resident 15's LTC Psychotropic Medication Review notes documented no GDR on medication and stable on medication. A physician documented clinical contraindication was unable to be located and the medication had not received the appropriate GDR. The antipsychotic medication Seroquel was administered without the appropriate indication for use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure an assessment accurately reflected the resident's status. Specifically, for 3 out of 12 sampled residents, residents were coded as taking antipsychotic medications when they were not taking them. Resident identifiers: 1, 8, and 12. Findings included: 1. Resident 1 was admitted to the facility on [DATE] with diagnoses which included, traumatic brain injury and depression. Resident 1's medical record was reviewed on 6/22/25 through 6/25/25. On 5/16/25, a quarterly Minimum Data Set (MDS) assessment documented that resident 1 was taking an antipsychotic medication. On 5/14/25 at 9:24 AM, a Long Term Care (LTC) Psychotropic Medication Review documented resident 1 was taking: a. nortriptyline 30 milligrams (mg) at bedtime with a diagnosis of depression. b. Effexor 37.5 mg twice daily with a diagnosis of depression. It should be noted that these medications were not classified as antipsychotic medications. 2. Resident 8 was admitted to the facility on [DATE] with diagnoses which included, dementia and depression. Resident 8's medical record was reviewed on 6/22/25 through 6/25/25. On 5/1/25, an annual MDS assessment documented that resident 8 was taking an antipsychotic medication. On 4/22/25 at 9:49 AM, a LTC Psychotropic Medication Review documented resident 8 was taking Zoloft 50 mg daily with a diagnosis of depression. It should be noted that this medication was not classified as an antipsychotic medication. 3. Resident 12 was admitted to the facility on [DATE] with diagnoses which included, depression and anxiety. Resident 12's medical record was reviewed on 6/22/25 through 6/25/25. On 4/16/25, a quarterly MDS assessment documented that resident 12 was taking an antipsychotic medication. On 4/2/25 at 10:09 AM, a LTC Psychotropic Medication Review documented resident 12 was taking: a. Welbutrin 150 mg once daily for anxiety and depression. b. Celexa 20 mg once daily for anxiety and depression. c. clonazepam 0.25 mg three times daily for anxiety. d. Remeron 15 mg at bedtime for insomnia. It should be noted that these medications were not classified as antipsychotic medications. On 6/24/25 at 9:21 AM, an interview was conducted with the MDS Coordinator. The MDS Coordinator stated that the pharmacist performed the psychotropic medication reviews for the residents. The MDS Coordinator stated that residents 1, 8, and 12 were not taking an actual antipsychotic medication. The MDS Coordinator stated that she reviewed this with the pharmacist and was informed that she should mark on the MDS assessment that the residents were taking antipsychotic's. On 6/24/25 at 10:47 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that she believed that the medications that residents 1, 8, and 12 were taking were antipsychotic's. The DON stated that she did not know why the MDS assessment was marked that the residents were taking an antipsychotic when they were not.

**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 3 out of 12 sampled residents, Enhanced Barrier Precautions (EBP) were not implemented for residents with wounds and indwelling urinary catheters. Resident identifiers: 2, 9, and 10.Findings included:1. Resident 2 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, urinary tract infection.On 6/22/25 at 1:29 PM, an interview was conducted with resident 2. Resident 2 was observed to have a down drain urinary catheter bag. Resident 2 stated the staff would wear gloves when they emptied or changed the catheter bag but the staff have never worn gowns.Resident 2's medical record was reviewed.A care plan problem initiated on 4/10/25, documented Long Term Care Urinary Incontinence Indwelling Catheter.On 4/1/25 at 12:42 PM, a History and Physical Note documented . suprapubic catheter Catheter protocols will be in place. Change once monthly.Resident 2's room was observed without EBP signage.On 6/24/25 at 10:29 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 2 was admitted with the supra pubic catheter and resident 2 has had the catheter for awhile.2. Resident 10 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, cerebral palsy.Resident 10's medical record was reviewed.On 6/17/25 at 10:26 AM, a Wound Clinic Office Note documented Patient presenting for reevaluation of stage III coccyx ulceration. Patient was last seen in the wound clinic on 4/22/25, where the wound appeared epithelialized. Wound has reopened with drainage. Facility staff report continued offloading and repositioning. Wound has been covered with an Allevyn to help manage moisture and drainage. Skin: Exposed skin normal with no rashes, stage 3 ulceration of the coccyx with slough and serous drainage. Slight maceration to periwound. Blanchable erythema to bilateral buttocks. Measurements 0.7 x 0.4 cm [centimeters].Resident 10's room was observed without EBP signage. 3. Resident 9 was admitted to the facility on [DATE] with diagnoses of recurrent urinary tract infection (UTI), and cognitive deficits.On 2/14/25 at 5:17 PM, a nursing narrative note documented, .Pt. [patient] has a super [sic] pubic catheter present on admission.On 6/22/25 at 1:10 PM, an observation was made of resident's 9 room. There was no signage indicating that resident 9 required EBP.On 6/23/25 at 7:42 AM, an interview was conducted with resident 9. Resident 9 stated that she had a suprapubic urinary catheter. On 6/25/25 at 9:35 AM, an interview was conducted with the Minimum Data Set (MDS) Coordinator. The MDS Coordinator stated that resident 9 came to the facility with a supra pubic catheter in place. The MDS Coordinator stated that resident 9 had a UTI on 4/14/25. On 6/24/25 at 9:41 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that she would wear a gown when emptying resident 9's catheter. CNA 1 stated that if she was getting resident 9 dressed or changing her brief that she would just wear gloves. On 6/24/25 at 11:55 AM, an interview was conducted with the Infection Preventionist (IP). The IP stated that EBP was for any resident that had a urinary catheter or open wounds. The IP stated that staff should know which residents were on EBP even if EBP signage was not on the door. The IP stated that signage should be up for those residents that required EBP.

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, there was undated food in the refrigerator and freezer, kitchen staff were observed to not be wearing hairnets and beard coverings, and the sanitizer bucket was not testing at the required sanitation levels.Findings included:On 6/22/25 at 12:07 PM, an initial tour of the kitchen was conducted. The following observations were made:a. An open energy drink was out on the food prep table.b. Three bags of bread slices were unlabeled and undated in the refrigerator.c. Two slices of cheese and ham were in a bag that was undated and unlabeled in the refrigerator.d. Turkey breast was in a bag and was not dated in there refrigerator.e. Hotdog's were opened in a bag and were not labeled or dated in the refrigerator.f. A plastic bag that was undated and unlabeled with turkey and swiss cheese in the refrigerator.g. An opened bag of sausage patties and links were undated in the refrigerator.h. A bag of roast beef and cheese were undated and had a strong smell to them in the refrigerator.i. Five bags of frozen soup were unlabeled and undated in the refrigerator.j. Cheesecake bites with a use by date of 6/19/25, were in the freezer.k. Three boxes of cheesecake were undated and opened in the freezer.l. Four loaves of bread were unlabeled and undated in the freezer.m. Three pie crusts were open to air, unlabeled, and undated in the freezer.n. A package of omelets were undated in the freezer.o. A bin was filled with roasted pan sauce with a date of 11/22/24, in the freezer.On 6/22/25 at 12:37 PM, an interview was conducted with the Dietary Manager (DM). The DM stated that the sanitary buckets were changed every two hours or as needed. It was observed that the DM was not wearing a hairnet. On 6/22/25 at 12:40 PM, an observation was made of the cook cleaning the counter top prep area and placing a rag in the sanitary bucket.On 6/22/25 at 12:43 PM, an observation was made of the cook testing the sanitary bucket. The sanitary bucket strip turned orange. The cook stated that the level was 100 parts per million (PPM) and should be between 200-400 PPM. On 6/22/25 at 2:08 PM, a concurrent observation and interview were conducted with the cook. The cook was observed to have a beard and was not wearing a beard covering. The cook stated that all things in the fridge should have dates on them. The cook stated that he was unsure of the opened date of the cheesecake in the freezer. The cook stated that items in the freezer are good for six months to one year. The cook stated that the bread in the freezer should have been dated. The cook stated that there should at least be a received on date for items in the freezer. The cook stated that staff should be wearing hair nets even if they have a shaved head. The cook stated that he was not sure at what length a beard needed to be to have it covered. The cook stated that the food in the plastic bag inside the refrigerator was food that the dietary manager was going to give to his dog. The cook stated that opened drinks should not be in the prep area and he was in a rush and forgot and left it there. On 6/24/25 at 7:36 AM, a follow up tour of the kitchen was conducted. The following was observed:a. An opened half loaf of bread was undated in the freezer.b. Three coconut cream pies were undated in the freezer.c. Two cheesecakes were undated in the freezer.d. Three pie shells were open to air and undated in the freezer.e. Omelets were undated in the freezer.On 6/24/25 at 7:53 AM, a concurrent observation and interview were conducted with the DM. It was observed that the DM was not wearing a hairnet or head cover. The DM stated that foods were okay to be stored on the freezer for six months. The DM stated that frozen foods should be dated when they were received and that the items in the freezer should be dated. The DM stated that he took the outdated items in the refrigerator to his dog. The DM stated that staff should be wearing a hairnet or hat while they were in the kitchen and beard nets need to be worn. The DM stated that he did not require a hairnet because he was almost bald.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 3 sampled residents, that the facility in response to an allegation of neglect did not have evidence that the allegation was thoroughly investigated and did not prevent further abuse while the investigation was in progress. Specifically, the facility did not have evidence of a thorough investigation and allowed the alleged perpetrator to continue to provide resident care while the investigation was being conducted. Resident identifier: 1. Findings included: Resident 1 was admitted to the facility on [DATE] with diagnoses which included anxiety, arthritis, chest pain, decubitus ulcer of coccyx, degenerative joint disease, dementia, depression, history of malignant neoplasm of cervix, hypertension, morbid obesity, osteoporosis, pain, and Schizophrenia. On 5/1/24 resident 1's medical record was reviewed. On 7/21/23, resident 1's Quarterly Minimum Data Set (MDS) Assessment documented that resident 1 was always incontinent of urine with no episodes of continent voiding. The assessment further documented that resident 1 was dependent on staff for all of her toileting hygiene. On 9/25/23 at 9:46 PM, the progress note documented that resident 1 was alert and oriented to self only and was disoriented to time, situation, and place. The note documented that resident 1 only gets up to the toilet for bowel movements. The note documented that resident 1 had redness noted to her coccyx. On 9/25/23, resident 1's intake and output documented that the resident was incontinent of bladder and was changed at midnight, 4:00 AM and 7:00 AM. On 9/25/23, the facility reported to the State Survey Agency (SSA) on form 358 an allegation of resident neglect. The report documented that Licensed Practical Nurse (LPN) 1 documented, All night I had a feeling that [Certified Nurse Assistant (CNA) 1] wasn't actually checking briefs and peri-pads when she said she was because she would come out of rooms way quicker than me and the trashes were never filled up or taken out. I couldn't prove she was lying until our 0400 rounds, where we change most of the resident's briefs before day shift. I knew that a specific resident [resident 1] would be incontinent, as she is every night at midnight and at 0400. So, when me and [CNA 1] went into rooms at the same time and when I came out after changing a brief and she had already 'changed' 2 people in the time that I changed one, I grew more suspicious. I asked her, '[CNA1], did you change [resident 1] and reposition her?' [CNA 1] replied, 'No, I didn't reposition her and yes, she was wet.' I volunteered to rotate her. When I went to rotate her, I instead checked her brief and sure enough, she was soaked. Her pads were so heavy with urine it most definitely did not happen in the two minutes or so since [CNA 1] said she had checked her brief. The form documented that resident 1 had redness, macerated peri area, and coccyx redness. Review of the facility form 359 final facility investigation documented that resident 1 was not able to provide much information due to dementia. Resident 1 was unable to recall who had provided her incontinence care. The summary of interview(s) with witness(es) documented that the facility was in the process of scheduling an interview with LPN 1. The summary of interview(s) with the alleged perpetrator(s) documented, Caregiver only works PRN [as needed] and nights. I have not had the opportunity to catch her. She is not willing to come in and sign verbal warnings in the past. The form documented that interviews with other residents were not conducted. The form documented, resident only had redness in the perineal areas from sitting in urine for a long period of time. No other signs of abuse/neglect. The corrective actions taken documented, The caregiver may be suspended for a period of time or not able to care for this resident. The facility conclusion of the investigation documented that the allegation was verified and documented, The interview with the resident did not provide sufficient evidence that she was not cared for. The resident had some skin redness and breakdown in her private areas from sitting in her urine for a long period of time. Review of the facility abuse investigation revealed no other documentation other than what was submitted in form 358 and form 359 to the SSA. CNA 1's September and October 2023 timecard revealed the following: a. On 9/24/23, CNA 1 punched in at 5:26 PM, and punched out at 5:57 AM. b. On 9/27/23, CNA 1 punched in at 5:49 PM, and punched out at 4:31 AM. c. On 9/28/23, CNA 1 punched in at 5:57 PM, and punched out at 8:22 PM. d. On 9/30/23, CNA 1 punched in at 5:55 PM, and punched out at 8:45 PM. e. On 10/1/23, CNA 1 punched in at 5:53 PM, and punched out at 8:38 PM. f. On 10/2/23, CNA 1 punched in at 5:54 PM, and punched out at 10:01 PM. g. On 10/12/23, CNA 1 punched in at 3:47 PM, and punched out at 11:44 PM. h. On 10/14/23, CNA 1 punched in at 5:47 PM, and punched out at 9:05 PM. i. On 10/16/23, CNA 1 punched in at 5:51 PM, and punched out at 8:16 PM. j. On 10/17/23, CNA 1 punched in at 5:39 PM, and punched out at 8:42 PM. k. On 10/18/23, CNA 1 punched in at 5:44 PM, and punched out at 8:51 PM. l. On 10/27/23, CNA 1 punched in at 3:40 PM, and punched out at 4:34 AM. m. On 10/29/23, CNA 1 punched in at 5:54 PM, and punched out at 8:41 PM. n. On 10/31/23, CNA 1 punched in at 5:23 AM, and punched out at 6:03 PM. It should be noted that CNA 1's timecard documented her last day worked at the facility was 12/9/23. The facility Abuse Long Term Care Policy documented that in response to allegations of abuse and neglect the facility would protect the resident from further potential abuse while the investigation was in progress. The policy further documented that if the alleged violation was verified that appropriate corrective action was taken, and that the facility would have evidence that all alleged violations were thoroughly investigated. On 5/1/24 at 1:04 PM, an interview was conducted with resident 1. Resident 1 stated that she was not able to ambulate to the toilet by herself and required staff assistance for toileting. Resident 1 stated that staff assisted her to the bathroom so that she could change her soiled brief. Resident 1 stated that she did not have too much experience with staff helping her to the bathroom at night, and that staff did not come to see if her brief was wet during the night. Resident 1 stated that staff had never left her in a wet brief for a long period of time and she reported no issues with skin breakdown in the buttock or groin area. On 5/1/24 at 4:03 PM, an interview was conducted with the Nurse Manager (NM). The NM stated that she was in the process of working with Human Resources (HR) to terminate CNA 1 because she did not meet the performance requirements. The NM stated that CNA 1 worked as needed at the facility and was suspended after the incident in September 2023. The NM stated she was not aware that CNA 1 was allowed to continue to work at the facility. On 5/1/24 a 4:24 PM, a follow-up interview was conducted with the NM. The NM stated that she received a report from LPN 1 that CNA 1 was not performing incontinence care. The NM stated that she interviewed LPN 1 about the incident but did not have any documentation of that interview. The NM stated that it was the same information that was submitted in the event report which was documented on form 358. The NM stated that she then went through the process with the Nursing Administrator (NADM) on what to fill out with regards to the SSA notification. The NM stated that she made the report to the SSA and APS. The NM stated that she was informed by HR that they had to go through the proper channel of warnings and that she could not just terminate CNA 1. The NM stated that she does not recall if she interviewed CNA 1 after the incident and stated that she did not have any documentation of an interview. The NM stated that they would ensure the safety of the residents by not allowing CNA 1 to be in the facility. The NM stated that CNA 1 came into the facility to sign a written warning, and she was not sure how long she was suspended for. On 5/1/24 at 4:38 PM, an interview was conducted with the Clinical Operations Manager (COM). The COM stated that CNA 1 should have been suspended during the incident investigation. The COM stated that none of the incidents came through the safety net and therefore she was not aware of them. The COM verified that CNA 1 worked 2 shifts after the incident occurred and that CNA 1 worked up until December 2023. The COM stated that CNA 1 was still not terminated, and they were working with HR with that process. On 5/1/24 at 4:53 PM, an interview was conducted with the NADM. The NADM stated that the COM and NM would conduct any abuse investigations with the support of the risk management team. The NADM stated that the NM was responsible for the abuse investigation primarily with support from the social worker and the management team. The NADM stated that the social worker would ensure that the resident was emotionally supported during the investigation. The NADM stated that she was aware that the NM was working with HR on education. The NADM stated that she knew that there were concerns with CNA 1 related to attendance, sleeping on the job, and concerns about care that was being addressed with HR, but the specifics she was not aware of. The NADM stated that the investigation process was collaborative effort of the management team. On 5/1/24 at approximately 5:00 PM, an interview was conducted with the Licensed Clinical Social Worker (LCSW). The LCSW stated that when there was an allegation of abuse whoever was notified first would do the investigation and they would bring people in as needed. The LCSW stated that the NM was ultimately responsible for the investigation. The LCSW stated that he was made aware of the incident with CNA 1 today. The LCSW stated that the NM completed the form 359 and did not conduct any other resident interviews. The LCSW stated that he would assess the resident for any psychological or emotional damage during the investigation. The LCSW stated that when he was notified of any incident(s) he would open a care management note and document throughout the day the time notifications were made to outside agencies. On 5/2/24 at 9:07 AM, an interview was conducted with the NM, the NADM, the Administrator (ADM), and the LCSW. The NADM stated that when they had an allegation of abuse or neglect it was reported to any one of the shared leaders and they could initiate a report to Adult Protective Services (APS) and the SSA. The NADM stated that the abuse coordinator was the NM, but the allegations were reviewed by risk management of the nursing home and the attached hospital. The NADM stated that an event report was then generated and that was how they tracked and documented any allegations. The NADM stated that the facility investigation would take place and then they would close the loop with the actions taken for the investigation. The NADM stated that any of the administrative staff could handle this. The NADM stated that they get HR involved to protect the resident and HR would suspend the caregiver if needed. The NADM stated that they conducted coaching sessions with the caregiver and they worked with HR to do what was needed. The NADM stated that they felt that the licensed nurses were providing the care that the resident needed and that they were working with a performance issue with CNA 1. The NADM stated that education and coaching occurred prior to CNA 1 returning to work. It should be noted that no documentation could be found of the education, coaching or performance plan that was implemented after the incident on 9/25/23 and prior to CNA 1 returning to work on 9/27/23. The NADM stated that they needed to look at the coaching and education a little bit closer. The NADM stated that CNA 1 was off the schedule but picked up the extra shifts and returned to work. The NADM stated. I don't know that we knew she picked up that shift after the fact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 14 sampled residents, that the facility did not consult with the resident's physician and notify when there was an accident involving the resident that resulted in injury; a significant change in the resident's physical, mental, or psychosocial status; or a need to alter treatment or commence a new form of treatment. Specifically, the staff injured a resident while providing nail care which resulted in the need for wound care and the physician was not notified. Resident identifier 15. Findings included: Resident 15 was admitted on [DATE] with diagnoses which consisted of right pontine stroke, hemiparesis left side, dysarthria, left leg injury, occlusion right vertebral artery, atrial fibrillation, hypertension, diabetes mellitus type II, anemia, hypokalemia, benign prostatic hyperplasia, cardiac pacemaker, cellulitis, congestive heart failure, communication impairment, diabetic peripheral neuropathy, gout, hyperlipidemia, male breast cancer, multiple falls, and syncope. On 7/31/23 at 2:41 PM, an interview was conducted with resident 15. Resident 15's right pinky finger was observed with a bandage over it. Resident 15 stated that a Certified Nurse Assistant (CNA) clipped his nails and cut the tip of his right pinky finger during the process. Resident 15 stated the nurses or physician usually cut his nails. Resident 15 stated this happened last Friday. On 8/1/23 resident 15's medical records were reviewed. Review of resident 15's progress notes revealed no documentation of the injury to the resident's finger nor notification to the physician of the incident. No documentation could be found of a Incident Report or Safety Event Report for the injury to resident 15's finger. On 8/01/23 at 12:12 PM, an observation was made of resident 15's finger with RN 1. Resident 15 reported to RN 1 that the aide was cutting his fingernails and cut his finger, and resident 15 stated it hurt. RN 1 removed the band aide from resident 15's right pinky finger and the tip of the finger directly under the end of the nail was observed cut with a flap of skin removed. Resident 15 stated that his finger was sore. Resident 15 stated that the CNA had felt bad about the cut but had told him that he moved during the clipping and that was what caused the injury. Resident 15 stated that he did not think he moved. Resident 15 stated that he could not recall the female CNA's name, but that it was an accident. RN 1 cleaned the wound with a 4 x 4 sterile gauze soaked in wound cleaner, and two overlapping band aides were applied to the fingertip. RN 1 stated that the nail looked like it was recently clipped, and the skin was completely removed, definitely went way too deep. RN 1 stated it was cut down to the quick. Resident 15 stated that it bled quite a bit. RN 1 stated that it should have been passed off to the nurse, I'm guessing it got missed. RN 1 stated that they had a spot on the report board for wounds and she would put it there for the next shift. RN 1 stated that this was something that should have been reported to the physician. On 8/01/23 at 2:06 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that they did not have a policy for nail care so they were in the process of adopted a policy that they used for skills testing. The DON stated that the policy was to not clip diabetic resident's foot or finger nails. The DON stated that the CNAs should not be clipping resident's nails. The DON stated that the licensed nurse could clip nails, but not the diabetics either. The DON stated that they had a podiatrist that came one time per month for care and they would clip resident's nails. The DON stated that the CNA should not have clipped resident 15's nails because he was a diabetic. The DON stated that there should have been an event report for the injury or any incident that needed to be reported up the chain further. The DON stated that at the time of the incident the physician should have been notified if there was an injury to the patient, such as the tip of finger being clipped off. [Cross-refer F684]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined for 2 of 14 sampled residents, that the facility did not provide the necessary assistance to ensure each resident maintained or improved their ability to perform activities of daily living, including eating. Specifically, residents with swallowing issues were not provided supervision while eating when it was identified as a need based on the comprehensive assessment. Resident identifiers: 1 and 12. Findings included: An observation of the dining room was conducted on 7/31/23 at 12:12 PM. Resident 1 was in the dining room sitting at a table alone and facing a window with her back to the dining room. Resident 1 was in a slouched position with her head slightly hunched over her lap. Certified Nursing Assistant (CNA) 3, was sitting at another table with resident 8. Resident 12 was sitting in a wheelchair at a different table alone. At 12:15 PM, CNA 3 got up and walked over to resident 1 and spoke with her. An observation of the dining room was conducted on 8/1/23 at 9:00 AM. Residents 1, 8, and 12 were in the dining room. Each resident was sitting at their own table. No facility staff were present in the dining area. Resident 1 was sitting in her wheelchair at a table by herself and facing a window with her back to the dining room. Resident 1 was observed to be using her right hand to eat. The Therapeutic Recreation Technician (TRT) was observed to be sitting in the activity coordinators office with no line of sight to residents 1 or 12. The TRT then came out of the office into the dining room. An observation of the dining room was conducted on 8/01/23 at 12:45 PM. Resident 1 was sitting in the dining room in her wheelchair at a table by herself and facing a window with her back to the dining room. Resident 1 was eating and reading a paper while music played on her iPad. Resident 12 was sitting in a recliner chair eating lunch. It was observed that there were no facility staff present in the dining room. At 12:55 PM one staff member was observed to enter the dining room. An observation of the dining room was conducted on 8/2/23 at 9:16 AM. Residents 1 and 12 were eating in the dining room at separate tables. No facility staff were observed in the dining room. At 9:20 AM, the TRT came into the dining room and went into the activity coordinator's office and then went back into the dining room and sat down with resident 12. 1. Resident 1 was admitted on [DATE] with diagnoses which included traumatic brain injury resulting in significant brain damage, left-sided paralyzation, and compromised motor skills; gastroesophageal reflux disease; depression; osteopenia; and dental prophylaxis. On 8/02/23, resident 1's medical records were reviewed. The MDS Section G Functional Status dated 5/11/23 under ADL [Activities of Daily Living] Self-Performance and Eating indicated that resident 1 required, supervision-oversight, encouragement or cueing. A Nursing Narrative Note dated 12/20/22 at 10:58 AM indicated resident 1 had progressively declined in her swallowing abilities. A comprehensive assessment summary dated 3/23/23 at 3:02 PM indicated, Eating LTC [long term care]: Supervision/Cueing was indicated under ADL abilities. It further indicated that the section of Services Recommendation/Review listed, Speech Therapy Area of Skilled Services: Swallowing . A Nursing Narrative Note dated 6/10/23 at 9:43 PM indicated, Pt eats in day room with staff supervision. A Nursing Narrative Note dated 6/13/23 at 9:52 PM documented that, I administered Pt [patient] her evening pills with a spoonful of yogurt as per her usual routine. I waited until I thought she had swallowed all of them and returned to the med room. The PCT [patient care technician] in the dayroom promptly came and got me around 19:00 [7:00 PM] because the Pt had begun coughing and explaining that a pill had gotten stuck. Pt was assessed and monitored, she was coughing quite a bit but was able to swallow and drink as normal .the coughing cleared up after about 45 minutes. I did offer to take the Pt to be seen at the ER [emergency room] .By 20:00 [8:00 PM] her coughing had stopped completely and Pt was comfortable and stable. A Nursing Narrative Note dated 6/17/23 at 10:03 PM indicated resident eats in day room with staff supervision. A Nutrition Note dated 7/10/23 at 6:05 AM indicated that resident was on a soft and bite-sized diet. A Weekly Evaluation note dated 7/29/23 indicated resident eats soft, bite-sized foods and eats with supervision. No additional documentation of a speech therapy evaluation was provided. On 8/1/23 at 9:06 AM, an interview was conducted with the Therapeutic Recreation Technician (TRT). The TRT stated resident 1 eats on her own but needs supervision. The TRT stated resident 1 cannot use her left arm and she has trouble shutting her jaw so food will fall out of her mouth. The TRT stated resident 1 will catch the food falling out of her mouth and push it back into her mouth with her right hand. On 8/1/23 at 12:55 PM, an interview was conducted with CNA 2. CNA 2 stated she had supervised the dining area previously. CNA 2 stated resident 1 needed to be supervised and a staff member needed to be in the dining room at all times when she was eating. On 8/1/23 at 1:32 PM, an interview was conducted with CNA 4. CNA 4 stated resident 1 needed supervision because she will choke. CNA 4 stated supervision meant being attentive and being in the room when a resident was eating. On 8/1/23 at 2:12 PM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that she had previously supervised the dining room. RN 2 stated resident 1 was a choking hazard and needed to be supervised while eating. RN 2 stated when resident 1 was eating, staff had to be in the dining room with direct vision of resident 1. On 8/1/23 at 2:37 PM, an interview was conducted with the Director of Nursing (DON). The DON stated resident 1 was on a minced diet and was a choking hazard. The DON stated that staff was supposed to be in the dining area all the time. On 8/2/23 at 2:29 PM, an interview was conducted with the Minimum Data Set (MDS) Coordinator. The MDS Coordinator stated resident 1's MDS Section G Functional Status dated 5/11/23 under ADL [Activities of Daily Living] Self-Performance and Eating indicated resident 1 required supervision, oversight, encouragement, and set up and that meant there was a need for staff to be in the dining room at all times to watch resident 1 eat. The MDS coordinator further stated how she determined the MDS documentation: (a) Reviewed the residents daily charting, (b) Reviewed the nursing notes, and (c) Reviewed any other documentation of how well the resident eats which included if the resident had any choking episodes, eating level, and support needed. The MDS Coordinator stated she also observed the resident eating and interviewed staff about the residents eating before she made the determination of her MDS documentation. 2. Resident 12 was admitted on [DATE] with diagnoses which included Alzheimer's dementia, chronic kidney disease, depression with anxiety, diabetes mellitus type 2, diabetic retinopathy, hypertension, and hypercholesteremia. On 8/2/23, resident 12's medical records were reviewed. The MDS Section G Functional Status dated 5/27/23 under ADL [Activities of Daily Living] Self-Performance and Eating indicated that resident 12 required, supervision-oversight, encouragement or cueing. A Nursing Narrative Note dated 10/9/22 at 9:12 AM indicated, Pt has a good appetite and eats meals in day room under staff supervision. Pt has frequent coughing during meals which has been addressed with speech therapist. A Nursing Narrative Note dated 11/30/22 at 8:38 PM indicated, Pt eats meals in the day room under staff supervision and has a good appetite. Pt has frequent coughing during meals which has been addressed with speech therapist. A Nursing Narrative Note dated 11/23/22 at 10:25 PM indicated, Pt eats meals in the day room under staff supervision and has a good appetite. Pt has frequent coughing during meals which has been addressed with speech therapist. A Nutrition Note dated 12/1/22 indicated resident 12 was on soft and bite-sized regular diet and Receives chopped up meats and no rice to help with chewing. Res [resident] does have noted coughing during meals . A Nursing Narrative note dated 12/7/22 at 11:32 PM indicated, Pt has frequent coughing during meals. A Nursing Narrative Note dated 1/18/23 at 10:08 PM indicated Pt [patient] eats in day room with good appetite and staff supervision. A Nutrition Note dated 5/11/23 at 9:41 AM indicated resident 12 had a Regular diet IDDSI [International Dysphasia Diet Standardization Initiative] level 5 mince & moist. Diet downgraded from IDDSI level 6 in April due to missing dentures, worsening issues with chewing. No additional documentation of a speech therapy evaluation was provided. On 8/1/23 at 12:55 PM, an interview was conducted with CNA 2. CNA 2 stated she had supervised the dining area previously. CNA 2 stated resident 12 needed to be supervised and a staff member needed to be in the dining room at all times when she was eating. On 8/1/23 at 2:37 PM, an interview was conducted with the Director of Nursing (DON). The DON stated resident 12 was supervised for choking because she took big bites of her diced food. The DON stated that staff was supposed to be in the dining area all the time. On 8/2/23 at 2:29 PM, an interview was conducted with the Minimum Data Set (MDS) Coordinator. The MDS Coordinator stated resident 12's MDS Section G Functional Status dated 5/11/23 under ADL [Activities of Daily Living] Self-Performance and Eating indicated resident 12 required supervision, oversight, encouragement, and set up and that meant there is a need for staff to be in the dining room at all times to watch resident 12 eat. The MDS coordinator further stated how she determined the MDS documentation: (a) Reviewed the residents daily charting, (b) Reviewed the nursing notes, and (3) Reviewed any other documentation of how well the resident eats which included if the resident had any choking episodes, eating level, and support needed. The MDS Coordinator stated she also observed the resident eating and interviewed staff about the residents eating before she made the determination of her MDS documentation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 2 or 14 sampled residents, that the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, a resident was receiving wound care without a physician order for the care and a resident sustained an injury from staff improperly clipping the residents' fingernails. Resident identifiers: 9 and 15. Findings included: 1. Resident 9 was admitted to the facility on [DATE] with diagnoses which consisted of cerebral palsy, depression, mental retardation, hypertension, and aphasia. On 7/31/23 at 1:46 PM, an observation was made of resident 9. Resident 9 was lying supine in bed. Resident 9 had decorticate posturing and the bilateral wrists were contracted. A sheet was covering resident 9's lower extremities. Resident 9's progress notes revealed the following: a. On 7/7/23 at 9:39 PM, the nursing progress note documented that resident 9's skin was intact with no wounds. b. On 7/13/23 at 9:26 PM, the nursing progress note documented that resident 9 required full staff assistance with all Activities of Daily Living (ADLs). The note documented that resident 9 had an open coccyx wound with dressing changes as needed (PRN). c. On 7/20/23 at 10:24 PM, the nursing progress note documented that resident 9 had an open coccyx wound, the dressing was changed PRN, and resident 19 was rotated to keep pressure off the coccyx every two hours. d. On 8/1/23, the provider note documented, has a new coccyx wound and is having is (sic) rotated q [every] 2 hours and dressing changed prn [as needed]. Review of resident 9's physician orders revealed no documentation for wound orders. On 6/15/23, resident 9's Quarterly Minimum Data Set (MDS) Assessment documented that resident 9 did not have a Brief Interview for Mental Status (BIMS) assessment due to the resident was rarely or never understood. The assessment documented that resident 9 was a 2 person assist with full dependence for bed mobility, transfers, locomotion on and off the unit, dressing, eating, toilet use and personal hygiene. The assessment did not document any unhealed pressure ulcers for resident 9. Resident 9's care plan for Altered Skin Status Prevention/Management was initiated on 5/16/22. Interventions identified included maintain skin integrity, assess the Braden Score, implement adult skin bundle, utilize the altered skin integrity protocol, conduct a skin evaluation as care was provided, collaborate with wound care specialist, collaborate with dietician, collaborate with clinical support services as appropriate, and turn every 2 hours to prevent and maintain skin integrity. On 8/02/23 at 9:04 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that she completed resident 9's dressing change last evening with the physician. RN 1 stated that the wound was located on the coccyx, was barely open, and was a stage 2 pressure ulcer. RN 1 stated that resident 9's wound was facility acquired. RN 1 stated that the physician did not obtain any measurements of the wound during the dressing change. On 8/02/23 at 2:39 PM, an interview was conducted with Certified Nurse Assistant (CNA) 1. CNA 1 stated that resident 9 use to have a carrot in his palm or he wore a glove because he chewed on his fingers. CNA 1 stated that the family preference was for resident 9 not to wear the glove any longer. CNA 1 stated that resident 9 did not have an alternating pressure air mattress. Resident 9 was observed positioned supine, with the head of the bed elevated to a 30 degree angle. The resident was observed with his right and left leg positioned on a pillow. CNA 1 stated that they turned and repositioned resident 9 every two hours. On 8/02/23 at 3:07 PM, a follow-up interview was conducted with RN 1. RN 1 stated that they did not have wound orders for resident 9's coccyx wound. RN 1 stated that the physician put a PUP (Pressure Ulcer Prevention) dressing on resident 9's coccyx wound, and stated keep doing what you are doing. RN 1 stated that they provided basic wound care which was cleaning with wound with wound cleaner or normal saline, applying Cavilon skin prep to the periwound, and then applying a basic dressing such as a PUP or a Allevyn gentle border adhesive dressing. RN 1 stated that anytime the dressing was soiled it was to be replaced. RN 1 stated that if the licensed nurse felt the wound was worsening then they obtained more specific wound orders. RN 1 stated that resident 9's wound started out as Moisture Associated Skin Damage and was not a Pressure Ulcer. RN 1 stated that resident 9 was not on an alternating air mattress for wound prevention, but was turned and repositioned every two hours. On 8/02/23 at 3:17 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 9 was bed bound, but the CNAs do turn and reposition him every 2 hours. The DON stated that if the licensed nurses were doing wound care they should have orders for that treatment. 2. Resident 15 was admitted on [DATE] with diagnoses which consisted of right pontine stroke, hemiparesis left side, dysarthria, left leg injury, occlusion right vertebral artery, atrial fibrillation, hypertension, diabetes mellitus type II, anemia, hypokalemia, benign prostatic hyperplasia, cardiac pacemaker, cellulitis, congestive heart failure, communication impairment, diabetic peripheral neuropathy, gout, hyperlipidemia, male breast cancer, multiple falls, and syncope. On 7/31/23 at 2:41 PM, an interview was conducted with resident 15. Resident 15's finger was observed with a bandage over it. Resident 15 stated that a Certified Nurse Assistant (CNA) clipped his nails and cut the tip of his right pinky finger during the process. Resident 15 stated the nurses or physician usually cut his nails. Resident 15 stated it happened last Friday. On 8/1/23 resident 15's medical records were reviewed. Review of resident 15's progress notes revealed no documentation of the injury to resident 15's finger nor notification to the physician of the incident. No documentation could be found of a Incident Report or Safety Event Report for the injury to resident 15's finger. On 8/01/23 at 11:53 AM, an interview was conducted with CNA 2 and RN 1. CNA 2 stated that when they provided the residents with bathing or shower care they also performed nail care. CNA 2 stated that the nail care included cleaning underneath the nails and and clipping the nails unless the resident was a diabetic. CNA 2 stated that the RN would inform the aides which residents were diabetic and which ones they could not clip the nails. CNA 2 stated that resident 15 was a diabetic. CNA 2 stated that the podiatrist would cut the resident's toenails. CNA 2 stated that did not cut resident 15's fingernails but they did file them. RN 1 stated that resident 15 had a fungus on his fingers, but that she was not aware of any cut on the finger. RN 1 stated that resident 15 was alert and oriented times 4 to person, place, time and situation. RN 1 stated that resident 15 did have some occasional confusion with short term memory deficits. RN 1 stated that resident 15 had some confusion with timeframes, and he might combine multiple events into one. RN 1 stated that the aides should have notified her about any cuts. RN 1 stated that the aides provided fingernail care with each bath but any major nail trimming would be a nursing task. RN 1 stated that typically if the resident was having their nails filed 2-3 times a week then they did not need to be cut. RN 1 stated that some of the aides did cut resident fingernails, and it may have been done by a CNA. RN 1 stated, at times I think they forget he's diabetic and may have forgotten that, and they should be filing them. RN 1 stated that the aide may have forgotten to report the cut finger to the nurse. On 8/01/23 at 12:12 PM, an observation was made of resident 15's finger with RN 1. Resident 15 stated that the cut happened on Friday. Resident 15 reported to RN 1 that the aide was cutting his fingernails and cut his finger, and resident 15 stated it hurt. RN 1 removed the band aide from resident 15's right pinky finger and the tip of the finger directly under the end of the nail was observed cut with a flap of skin removed. Resident 15 stated that his finger was sore. Resident 15 stated that the CNA had felt bad about the cut but had told him that he moved during the clipping and that was what caused the injury. Resident 15 stated that he did not think he moved. Resident 15 stated that he could not recall the female CNA's name, but that it was an accident. RN 1 cleaned the wound with a 4 x 4 sterile gauze soaked in wound cleaner, and two overlapping band aides were applied to the fingertip. RN 1 stated that the nail looked like it was recently clipped, and the skin was completely removed, definitely went way too deep. RN 1 stated it was cut down to the quick. Resident 15 stated that it bled quite a bit. RN 1 stated that it should have been passed off to the nurse, I'm guessing it got missed. RN 1 stated that they had a spot on the report board for wounds and she would put it there for the next shift. RN 1 stated that this was something that should have been reported to the physician. On 8/01/23 at 2:06 PM, an interview was conducted with the DON. The DON stated that they did not have a policy for nail care so they were in the process of adopted a policy that they used for skills testing. The DON stated that the policy was to not clip diabetic resident's foot or finger nails. The DON stated that the CNAs should not be clipping resident's nails. The DON stated that the licensed nurse could clip nails, but not the diabetics either. The DON stated that they had a podiatrist that came one time per month for care and they would clip the resident's nails. The DON stated that the CNA should not have clipped resident 15's nails because he was a diabetic. The DON stated that there should have been an event report for the injury or any incident that needed to be reported up the chain further. The DON stated that at the time of the incident the physician should have been notified if there was injury to the patient, such as the tip of finger being clipped off.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 14 sampled residents, that the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug was any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indication for its use; or in the presence of adverse consequences. Specifically, a resident's narcotic pain medication was not administered per the physician ordered parameters. Resident identifier 4. Findings included: Resident 4 was admitted on [DATE] with diagnoses which included Multiple Sclerosis, complex partial seizures, depression, urinary incontinence, chronic pain, history of urinary tract infection, inability to walk, hypoxia, diabetes mellitus type 2, and weight loss. On 8/02/23, resident 4's medical records were reviewed. On 1/13/23, resident 4's physician ordered Oxycodone/Acetaminophen 5-325 milligrams (mg), give 1 tablet by mouth every 4 hours as needed for pain. Review of resident 4's Medication Administration Record for July 2023 revealed the following: a. On 7/2/23 at 9:59 AM, the Oxycodone was administered. On 7/2/23 at 1:20 PM, the Oxycodone was administered again. This was 3 hours and 21 minutes after the last dose was administered. B. On 7/2/23 at 1:20 PM, the Oxycodone was administered. On 7/2/23 at 4:58 PM. the Oxycodone was administered again. This was 3 hours and 38 minutes after the last dose was administered. c. On 7/3/23 at 5:02 PM, the Oxycodone was administered. On 7/3/23 at 8:39 PM, the Oxycodone was administered again. This was 3 hours and 36 minutes after the last dose was administered. d. On 7/6/23 at 8:53 AM, the Oxycodone was administered. On 7/6/23 at 12:26 PM, the Oxycodone was administered again. This was 3 hours and 27 minutes after the last dose was administered. e. On 7/6/23 at 5:31 PM, the Oxycodone was administered. On 7/6/23 at 8:57 PM, the Oxycodone was administered again. This was 3 hours and 26 minutes after the last dose was administered. f. On 7/7/23 at 12:45 PM, the Oxycodone was administered. On 7/7/23 at 4:24 PM, the Oxycodone was administered again. This was 3 hours and 39 minutes after the last dose was administered. g. On 7/8/23 at 4:55 AM, the Oxycodone was administered. On 7/8/23 at 8:11 AM, the Oxycodone was administered again. This was 3 hours and 16 minutes after the last dose was administered. h. On 7/9/23 at 4:54 AM, the Oxycodone was administered. On 7/9/23 at 8:17 AM, the Oxycodone was administered again. This was 3 hours and 23 minutes after the last dose was administered. i. On 7/10/23 at 5:06 AM, the Oxycodone was administered. On 7/10/23 at 8:40 AM, the Oxycodone was administered again. This was 3 hours and 34 minutes after the last dose was administered. On 2/11/19, a care plan for Pain Management was initiated for resident 4. Interventions identified were to utilize the pain protocol; identify individualized pain control program; collaborate with clinical support services as appropriate; encourage resident to voice when pain was above tolerable level; and encourage resident to voice when chronic pain needed to be addressed by nursing staff. On 8/02/23 at 1:34 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that for narcotic pain medications that were ordered every 4 hours she would feel safe giving the medication 10-15 minutes early. RN 1 stated that giving the medication even 30 minutes early was pushing it and 40 minutes early was not safe. On 8/02/23 at 1:39 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the Oxycodone medication should be administered as it was written by the physician every 4 hours. The DON stated that the pharmacy should put limits on the medication and not allow early access until the 4 hours had passed. The DON stated that the narcotic pain medication should not be administered earlier than the parameters set forth by the physician in the order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 out of 14 residents sampled, that the facility did not ensure that residents who used psychotropic drugs received a gradual dose reduction (GDR) unless clinically contraindicated, in an effort to discontinue these drugs. Specifically, a resident's Quetiapine order did not have any GDR's in the first year of use and no documentation could be found for a clinical contraindication to the GDR. Resident identifier 5. Findings included: Resident 5 was admitted on [DATE] with diagnoses which consisted of generalized weakness, chronic kidney disease, depression, diabetes mellitus type 2, congestive heart failure, hypertension, gout, lower extremity edema, atrial fibrillation, infection of prosthetic right knee joint, morbid obesity, obstructive sleep apnea, cellulitis of the leg, and venous stasis ulcers of bilateral lower extremities. On 8/01/23, resident 5's medical records were reviewed. On 8/16/22, resident 5's physician ordered Quetiapine (Seroquel) 25 milligram (mg) tablet, give 25 mg by mouth daily at bedtime. Resident 5's monthly Psychotropic Medication Review revealed that a GDR was not attempted from September 2022 through July 2023. No documentation could be found that the physician deemed the Quetiapine to be clinically contraindicated for a GDR. On 1/11/22, resident 5's Comprehensive Care Plan had a focus area for Psychotropic Medication Use. The interventions identified were to collaborate with the pharmacist regarding dose adjustments; consult physician regarding medication response and side effects; and evaluate activities of daily living (ADL) decline with psychotropic medication use. On 8/01/23 at 2:37 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that resident 5 was seen by an outside therapist with a Mental Health Service and the resident was also seen by the facility Social Service Worker (SSW). RN 1 stated that resident 5 took Wellbutrin, Cymbalta, and Seroquel and the physician ordered to monitor for adverse side effects (ASE) of these medications. RN 1 stated that the pharmacist monitored the medications monthly and made sure from the resident's charting that he was not having any ASE. RN 1 stated that the psychotropic medications were automatically reviewed and the physician had to address them for a GDR every 45 to 60 days. RN 1 stated that the pharmacist and the physician would review the GDR. RN 1 stated that on 6/30/23 the provider note documented no indication for dose reduction or stoppage of medication. RN 1 stated that the provider note did not specify which psychotropic medications were not indicated for a GDR. RN 1 stated that the Seroquel indication of use was for an atypical antipsychotic for bipolar disorder, depression, and schizophrenia and resident 5 used it for a mood stabilizer for his depression. On 8/02/23 at 10:34 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the contraindications for a GDR were located in the psychotropic meeting progress notes and if a GDR was done for the Seroquel it would be documented there also.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined, for 1 of 14 sampled residents, 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, during wound care multiple observation were made of cross contamination and no hand hygiene was performed. Resident identifier 4. Findings included: Resident 4 was admitted on [DATE] with diagnoses which included Multiple Sclerosis, complex partial seizures, depression, urinary incontinence, chronic pain, history of urinary tract infection, inability to walk, hypoxia, diabetes mellitus type 2, and weight loss. On 7/31/23 12:50 PM, an interview was conducted with resident 4. Resident 4 stated she had a pressure ulcer on her behind, and she was not sure how often the dressing was changed. On 8/02/23, resident 4's medical records were reviewed. On 7/26/23, the Nurse Practitioner (NP) ordered wound care to the coccyx and right ischial tuberosity as follows: remove old dressing (making sure all pieces of sponge were accounted for); irrigate with Normal Saline; apply no sting barrier film to periwound; apply hydrocolloid to periwound as needed; apply vac drape to periwound (use as little drape as possible); apply black sponge to both wound bed making sure all sponge was touching wound bed (label how many pieces of sponge used); secure with more vac drape, apply [NAME] pad to black sponge; set suction to 150 millimeters of Mercury (mmHg) continuous suction; and change the dressing on Monday/Wednesday/Friday and as needed if the bandage became soiled or dislodged. On 6/5/23, resident 4's Quarterly Minimum Data Set (MDS) Assessment documented that resident 4 had a Brief Interview for Mental Status (BIMS) score of 12/15, which would indicate a moderate cognitive impairment. The assessment documented that resident 4 was a 2 person physical assist with total dependence for bed mobility, transfers, dressing, and toilet use. The assessment documented that resident 4 had one or more unhealed pressure ulcers and two Stage 4 pressure ulcers. On 2/11/19, a care plan for Altered Skin Status Prevention/Management was initiated for resident 4. Interventions identified were to provide a skin evaluation as care was provided; collaborate with dietician; collaborate with clinical support services as appropriate; assist to change position frequently; and ensure pressure reducing devices were being used. On 8/02/23 at 10:57 AM, an observation was made of Registered Nurse (RN) 1 providing wound care to resident 4. RN 1 was assisted by Certified Nurse Assistant (CNA) 1. The resident was repositioned from a supine position to the right lateral side. CNA 1 was positioned on resident 4's right side and held resident 4 in the right lateral position for the wound care. RN 1 donned a pair of gloves. Resident 4 had a large formed bowel movement when the incontinence brief was undone by RN 1. RN 1 wiped the stool away with an incontinence wipe and disposed of the brief in the garbage can. RN 1 doffed her gloves and new gloves were donned, no hand hygiene was performed. RN 1 placed a new chucks pad under resident 4 and two towels were placed under resident 4's buttocks. RN 1 removed resident 4's old wound vac dressing from the coccyx and right ischial tuberosity wounds. The wound vac tubing was observed anchored to the left buttocks with a cushion underneath. The old dressing was labeled with 2 pieces of foam in each wound bed and was dated 7/31/23. RN 1 stated that this identified the number of foam pieces that needed to be removed. RN 1 doffed her gloves and donned new gloves, no hand hygiene was performed. RN 1 sprayed normal saline (NS) into each wound bed to moisten the foam for removal. RN 1 obtained a pair of tweezers from the bedside table and cleaned them with an alcohol prep pad. RN 1 used the tweezers to remove the foam pieces from inside the coccyx wound bed. RN 1 stated that the white areas inside the coccyx wound bed was granulation tissue. RN 1 obtained a sterile cotton tipped applicator from the bedside table and inserted it into the coccyx wound bed to measure undermining and tunneling. RN 1 stated that the coccyx wound had undermining from 12 o'clock to 3 o'clock and at 5 o'clock, and minor undermining at 11 o'clock and at 9 o'clock. RN 1 stated the entire wound use to have undermining around the entire circumference. RN 1 placed a green sticker on the skin next to the wound. RN 1 obtained an iphone from the bedside table and a picture was taken to upload into the electronic medical records. RN 1 obtained a second sterile cotton tipped applicator and measurements were obtained from the coccyx wound. RN 1 stated that at 12 o'clock to 3 o'clock the undermining measured 1 centimeter (cm), at 5 o'clock the undermining measured 0.5 cm, and at 9 o'clock the undermining measured 0.5 cm. RN 1 obtained these measurements using a paper measuring tape from the bedside table. RN 1 touched the sterile cotton tip of the applicator with her fingertips and then placed the applicator back inside the coccyx wound bed to confirm the measurements. RN 1 then obtained the NS bottle from the bedside table and sprayed the inside the right ischial tuberosity wound. RN 1 obtained the tweezers from the bedside table and removed the foam pieces from the wound bed. The tweezers were not cleaned between use of the coccyx wound and the right ischial tuberosity wound. RN 1 obtained the used cotton tipped applicator from the bedside table and measurements were obtained from the ischial wound. It should be noted that the right ischial wound was measured using the same cotton tipped applicator that was used on the coccyx wound. RN 1 stated that the right ischial tuberosity undermining measured 1.8 cm at 2 o'clock, and the undermining measured 1 cm at 1 o'clock. RN 1 placed a green sticker on the skin next to the wound and a picture was taken using the iphone. RN 1 obtained a 2 x 2 skin prep pad and applied it to the periwound of the coccyx extending down to the right buttock and right ischial tuberosity. RN 1 used 4 skin prep pads in total. RN 1 removed the towels and chucks pad from under resident 4. RN 1 doffed the gloves and new gloves were donned, no hand hygiene was performed. RN 1 placed a new chuck pad under resident 4. RN 1 removed the foam pads from the sterile package and placed on top of the bedside table. RN 1 cleaned a pair of scissors with a alcohol prep pad. RN 1 cut the adhesive dressing cover with scissors. The clear adhesive dressing was placed over the coccyx wound and a circle was drawn to indicate the location of the wound bed. RN 1 traced the wound bed of the right ischial tuberosity wound on a second adhesive dressing. RN 1 obtained the scissors from the bedside table and holes were cut into the center of the adhesive dressings. RN 1 applied the adhesive dressing over the surrounding peri area of the coccyx wound. RN 1 obtained the scissors from the bedside table and cut a hole out of the right ischial tuberosity adhesive dressing, and the dressing was placed over the peri area of the wound. RN 1 then took the circular cut out adhesive dressing and placed them on top of the foam dressing and traced the circumference with a sharpie pen. RN 1 obtained the scissors from the bedside table and cut the foam piece to the size of the coccyx wound, and the foam was placed inside the coccyx wound bed. RN 1 cut two rectangular foam pieces and one was placed inside the coccyx wound undermining on the 12-3 o'clock location, and then the circular foam piece was placed over top. RN 1 placed the second rectangular foam piece in the right ischial tuberosity wound at 12 o'clock, and a the circular foam piece was placed over the top. RN 1 doffed her gloves and donned new gloves, no hand hygiene was performed. RN 1 obtained the adhesive dressing cover from the bedside table supply box and cut the piece in two with the scissors obtained from the bedside table. RN 1 doffed her gloves and donned new gloves, no hand hygiene was performed. RN 1 placed a long foam piece in between the two wound beds to connect the wound beds together for suction and an adhesive dressing was placed over the top. RN 1 placed the [NAME] pad on top of the coccyx wound and covered with an adhesive dressing. The [NAME] pad and tubing contained foam cushion built in and extended over the left buttocks. RN 1 labeled and dated the dressing and the pressure was set to 150 mmHg continuous. RN 1 stated that she applied an extra adhesive pad over the coccyx wound so it would not lift and would seal properly. RN 1 stated that the dressing was acting like it had a leak. RN 1 and CNA 1 positioned resident 4 supine with a pillow under the right side and pillows were placed under the bilateral lower extremities. An immediate interview was conducted with RN 1 upon completion of the dressing change and wound care. RN 1 stated that she cleaned the bedside table with a purple top wipe prior to the beginning of the dressing change. RN 1 stated that hand hygiene should be performed before and after the dressing change. RN 1 stated technically you were supposed to perform hand hygiene after each glove change. RN 1 stated that a new cotton tipped applicator should be used for each wound. RN 1 stated that resident 4 had the pressure ulcers for a very long time, at least a year, and that they were a chronic wound. RN 1 stated that the wounds were acquired in the facility and that they were shrinking in size and improving. On 8/03/23 at 10:21 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that staff should perform hand hygiene between doffing and donning new gloves, especially if they are removing an old dressing. The DON stated that staff should use separate applicators when touching the wound bed of multiple wounds to prevent cross contamination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 2 of 5 sampled residents, that the facility failed to ensure each resident received the pneumococcal immunization when the resident consented to the immunization and when it was not contraindicated. Specifically, the facility failed to administer the pneumococcal immunization when the offer was accepted by the resident. Resident identifiers: 7 and 8. Findings included: 1. Resident 7 was admitted on [DATE] with diagnoses which consisted of general weakness, congestive heart failure, hypertension, asthma, and obstructive sleep apnea. On 8/2/23 resident 7's medical records were reviewed. Review of resident 7's Immunization Screening dated 6/14/23 at 12:19 PM indicated, Patient agrees to a pneumococcal vaccine and A pneumococcal vaccine is indicated. Review of resident 8's Immunization history indicated the most recent pneumococcal vaccine was administered on 4/20/15. Review of resident 7's physician orders revealed an order for pneumococcal 20-valent conjugate vaccine (Prevnar 20) on 6/14/23 at 4:23 PM. Review of resident 7's medical record revealed no documentation of the administration or refusal of the pneumococcal immunization. An interview was conducted on 8/2/23 at 4:28 PM with the Director of Nursing (DON). The DON stated resident 7 was a recent admit and there was no documentation of the administration of the pneumococcal immunization. The DON stated that an immunization review was completed on admission and that resident 7's was missed. An interview was conducted on 8/03/23 at 9:54 AM with the Infection Preventionist (IP). The IP stated the immunization consent and review was part of the admission packet. The IP stated resident 7 consented to receive the pneumonia immunization and that she was not sure why resident 7 never received it. 2. Resident 8 was admitted on [DATE] with diagnoses which consisted of vascular dementia, right sided carpal tunnel syndrome, hypertension, hypothyroidism, and osteoporosis. On 8/2/23 resident 8's medical records were reviewed. Review of resident 8's Immunization Screening dated 10/25/22 at 11:30 AM indicated, Patient agrees to a pneumococcal vaccine and A pneumococcal vaccine is indicated. Review of resident 8's Immunization history indicated the most recent pneumococcal vaccine was administered on 2/17/16. Review of resident 8's medical record revealed no documentation of the administraton or refusal of the pneumococcal immunization. An interview was conducted on 8/03/23 at 9:54 AM with the Infection Preventionist (IP). The IP stated the immunization consent and review was part of the admission packet. The IP stated resident 8 consented to receive the pneumonia immunization on 10/25/22 and that resident 8 never received it.

**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 individual financial record was available to the resident through quarterly statements and upon request. Specifically, for 1 out of 12 sampled residents, the quarterly financial statements were not being issued. Resident identifier: 6. Resident 6 was admitted to the facility on [DATE] with diagnoses which included but not limited to anxiety, weakness, pain management, communication impairment, and hypothyroidism. On 9/13/21 at 2:21 PM, an interview was conducted with resident 6. Resident 6 stated she did not receive quarterly statements for the funds the facility managed for her. On 9/14/21 at 11:29 AM, an interview was conducted with the Recreational Therapy Aid (RTA). The RTA stated there was a safe under the desk in her office. The RTA stated she kept a ledger of funds that included how much each resident started with and how much money each resident currently had. The RTA stated the facility did not allow the residents to keep more than $50 in their account or the funds had to go into an interest bearing account. The RTA stated if a resident requested some of their money, two staff members were present to take the money out of the safe. If a resident brought back money from shopping, staff would put the funds back into the resident account and document the balance. The RTA stated she would initial the transactions when she took money out, but other staff members typically did not. The RTA stated the funds were always available to the residents including weekends. The RTA stated residents would usually tell a nurse and the nurse would relay the information to her if a resident requested money. The RTA also stated residents knew they could come to her for their money. The RTA stated if she was not in the facility there was an extra key to the safe kept in the medication cart and the Director of Nursing (DON) also had a key. The RTA stated facility staff had been educated about how to obtain the money for residents. The RTA stated she lived locally and the staff could call her if they had questions on the weekend or they need someone to withdraw money for a resident. On 9/14/21 at 1:10 PM, an interview was conducted with the DON. The DON stated she did not want all the staff to have a key to the safe. The DON stated the RTA and the assistant RTA had a key to the safe and the residents had access to their money Monday through Saturday from 8:00 AM until 7:00 PM. The DON stated the facility had a patient account services manager, but recently the responsibility was transferred to the activities staff. The DON stated she was unsure if quarterly statements were being sent out in another way to the residents. On 9/15/21, a copy of the facility policy for managing resident funds was obtained. In the policy, section 2-2.3 documented The individual financial record is available to the resident through quarterly statements and upon request. On 9/15/21 at 8:50 AM, a follow up interview was conducted with the RTA. The RTA verified that she managed funds for resident 6 and that she did not provide quarterly statements. On 9/15/21 at 10:26 AM, a follow up interview was conducted with the DON. The DON stated since hospital staff turned resident funds over to the RTA, quarterly statements had not been provided to the residents. The DON stated she had looked at the previously responsible staff members procedures and they did not include providing quarterly statement to the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility did not ensure that each resident's medical record included documentation that indicated the resident or resident's representative was provided education regarding the benefits and potential side effects of the influenza immunization. Specifically, for 4 out of 12 sampled residents, the medical record did not include the influenza informed consent that included information on influenza risks, benefits, and potential side effects. Resident identifier: 2, 7, 9, and 11. Findings include: 1. Resident 2 was admitted to the facility on [DATE] with diagnoses which included but not limited to heart failure and depression. Resident 2's medical record was reviewed on 9/14/21. A Progress Note dated 11/10/20, documented that resident 2 received the influenza vaccination on 11/10/20. Resident 2 gave written consent to receive the flu vaccination. Risk and benefits discussed. No documentation could be located or provided indicating that resident 2 had completed the immunization informed consent that included information on influenza risks, benefits, and potential side effects. 2. Resident 7 was admitted to the facility on [DATE] with diagnoses which included but not limited to hypertension, orthostatic hypotension, renal insufficiency, dementia, and cerebrovascular accident. Resident 7's medical record was reviewed on 9/14/21. A Progress Note dated 11/10/20, documented that resident 7 received the influenza vaccination on 11/10/20. Resident 2's Power of Attorney was called previously and consent was given to vaccinate with the vaccinations needed. Resident 2 gave consent and education given. No documentation could be located or provided indicating that resident 7 had completed the immunization informed consent that included information on influenza risks, benefits, and potential side effects. 3. Resident 9 was admitted to the facility on [DATE] with diagnoses which included but not limited to anemia, coronary artery disease, heart failure, hypertension, renal insufficiency, and anxiety disorder. Resident 9's medical record was reviewed on 9/14/21. A Progress Note dated 11/10/20, documented that resident 9 received the influenza vaccination on 11/10/20. Resident 9 gave consent for the vaccinations needed. Risk and benefits discussed. No documentation could be located or provided indicating that resident 9 had completed the immunization informed consent that included information on influenza risks, benefits, and potential side effects. 4. Resident 11 was admitted to the facility on [DATE] with diagnoses which included but not limited to anemia, hypertension, hyponatremia, and dementia. Resident 11's medical record was reviewed on 9/14/21. A Progress Note dated 11/10/20, documented that resident 11 received the influenza vaccination on 11/10/20. Resident 11's son was called previously and consent was given to vaccinate with the vaccinations needed. Resident 11 gave consent and risk and benefits discussed. No documentation could be located or provided indicating that resident 11 had completed the immunization informed consent that included information on influenza risks, benefits, and potential side effects. On 9/15/21 at 10:40 AM, an interview was conducted with the Director of Nursing (DON). The DON stated residents were registered through the clinic as an outpatient to receive the influenza vaccine. The DON stated a Medical Assistant (MA) from the clinic would administer the vaccines at the facility to the residents. On 9/15/21 at 11:28 AM, an interview was conducted with the Shared Leader (SL). The SL stated the doctors that work at the clinic also see the residents at the facility. The SL stated the MA at the clinic would track the residents immunizations. The SL stated she would talk with the residents about what immunizations were due for the year. The SL stated the resident would sign the vaccination consent if they want the influenza vaccine. The SL stated the resident consents were stored at the clinic and entered into the Utah Statewide Immunization Information System. The SL stated the staff would click a box located within the medication administration record that indicated education was provided but the consent form was not in the resident medical record.

Based on observation and interview, it was determined the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, items within the facility's walk-in fridge were observed stored uncovered and unlabelled, and the sanitizer level within the dish machine and sanitizer buckets was not maintained at manufacturer recommended levels. Findings included: 1. On 9/13/21 at 12:32 PM, the facility's walk-in and reach-in refrigerators were examined. a. A sheet pan containing a quinoa, corn, and rice mixture was observed in the walk-in fridge uncovered and unlabelled. b. A plastic bag containing a section of ham was observed in the walk-in refrigerator left open to air. c. Within the walk-in freezer, doughs of flatbread were observed left open to air. d. Ciabatta bread and buns stored in the walk-in refrigerator had been opened and were found unlabelled with an opened on or used by date. A follow-up examination of the walk-in fridge took place on 9/14/21 at 1:21 PM. A container with baked beans was observed stored in the walk-in fridge without a cover and left unlabelled and undated. 2. On 9/14/21 at 1:16 PM, the Dietary [NAME] tested the sanitizer level of the dish washing machine utilizing a Quick Response Quaternary Ammonium Compounds (QAC) test strip. The test strip was observed to read the sanitizer concentration at a level of 50 ppm (parts per million) or lower. The Dietary [NAME] stated the sanitizer level should read at 100 to 200 ppm. The Dietary [NAME] stated, at this time the facility was not testing and recording the sanitizer levels on a consistent basis. Following testing of the sanitizer concentration in the dish machine, the sanitizer bucket was tested. The sanitizer bucket also tested at a level of 50 ppm or lower. On 9/14/21 at 1:21 PM, the Dietary [NAME] was interviewed. The Dietary [NAME] stated he had checked the sanitizer in the dish machine again and the level remained low. On 9/15/21 at 9:09 AM, the Dietary Manager (DM) was interviewed. The DM stated he had now called the company in charge of managing the sanitizer, and the company would be coming into the facility to look at the system. The DM stated the kitchen staff would now start testing the sanitizer level of the dish machine and sanitizer buckets four times a day to monitor for issues with the sanitizer levels.