**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and policy review, the facility did not maintain confidentiality of resident medical record information for 3 of 5 sampled and supplemental residents (R45, R19, R16) reviewed. This is evidenced by: Facility policy titled, Confidentiality, Security, and Access to Protected Health Information, with an effective date of 08/19/03, states in part: Protected health information .written, verbal, or stored in paper, photographic, video, or electronic format .will remain confidential. 2. Protected Health Information (PHI) - Health information (medical record) that is identifiable to a specific individual and that is maintained or transmitted by a covered entity in any form, whether in oral, paper, or electronic form. Confidentiality and Security of PHI: 2. Care needs to be taken .in an area and manner that ensures client privacy. Surveyor reviewed facility's training for new hire employees included in the employee handbook titled, Privacy/HIPAA, with no date, states in part: .employees are exposed to confidential information about residents .it is important that all such information be kept strictly confidential. On 04/09/25 at 7:32 AM, Surveyor observed medication administration performed by Licensed Practical Nurse (LPN) H. LPN H prepared R19's medications and entered R19's room leaving medication cart locked in hallway with the computer screen open with R19's medical record displayed unattended. On 04/09/25 at 7:35 AM, Surveyor observed LPN H exit R19's room and return to medication cart. LPN H retrieved a stethoscope from the medication cart and returned to R19's room. LPN H left R19's medical health record displayed on the computer screen unattended. Surveyor observed a staff member walk down the hallway past the open computer screen. On 04/09/25 at 7:40 AM, Surveyor observed LPN H prepare R45's medications and enter R45's room leaving medication cart locked in hallway with the computer screen open with R45's medical record displayed unattended. On 04/09/25 at 8:10 AM, Surveyor observed LPN H enter R16's room with medications leaving the medication cart outside of room in hallway with R16's medical record displayed unattended. Surveyor observed two certified nursing assistants walk past open computer screen looking for LPN H. On 04/09/25 at 8:32 AM, Surveyor was standing in the 100 unit and observed LPN H outside of rooms [ROOM NUMBERS] at the medication cart. Surveyor observed LPN H leave medication cart and enter a resident's room with the computer screen open and resident information displayed on the screen. Surveyor was unable to see which resident was displayed on the screen. Surveyor stopped Nursing Home Administrator (NHA) A in the hallway and asked if she could see the medication cart with the open computer screen unattended down the hallway. NHA A pointed to cart and stated, Ok. I see what you are seeing, and walked down to the medication cart as LPN H exited the resident's room. Surveyor heard NHA A ask LPN H why the computer screen was left open unattended. Surveyor heard LPN H respond that she forgot to close the screen. On 04/10/25 at 10:24 AM, Surveyor interviewed NHA A regarding observation. NHA A stated that employees are expected to safeguard PHI and close/lock the computer screen when left unattended to protect resident's privacy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Example 2 R3 was admitted to the facility on [DATE]. R3's current diagnoses include Alzheimer's disease, dementia, constipation, hypertension, neuralgia, osteoarthritis of knee, muscle weakness, spinal stenosis, pain, transient ischemic attack, anxiety, dysphagia, hemiplegia and hemiparesis, dysphagia, atrial fibrillation, cognitive communication deficit. On 03/12/25, R3 was started with hospice services. R3's Minimum Data Set (MDS), dated [DATE], documented R3's Brief Interview for Mental Status (BIMS) score as having severely impaired cognition. R3 is dependent on staff for all activities of daily living (ADL) and receives hospice services. R3's care plans did not have a hospice or end of life plan of care developed. On 04/08/25 at 3:30 PM, Surveyor asked Nursing Home Administrator (NHA) A if a hospice care plan was developed for R3. NHA A indicated there is no hospice care plan. Based on observation, interview and record review, the facility did not develop and implement a comprehensive person-centered care plan addressing medical and nursing needs. This occurred for 2 of 15 residents (R), (R1, R3) reviewed. R1 did not have a care plan developed to monitor for adverse reactions when R1 was prescribed a diuretic medication. R3's care plans were not developed for hospice and end of life care. This is evidenced by: Facility policy titled, Care Plans, Comprehensive Person-Centered, with a revised date of 03/2022, states in part, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .reflects currently recognized standards of practice for problem areas and conditions .interventions are chosen only after data gathering, proper consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. R1 was admitted to the facility on [DATE] with pertinent diagnoses of type 2 diabetes mellitus, chronic kidney disease stage 3b and edema. R1's quarterly Minimum Data Set (MDS) assessment dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of 11/15 indicating moderate cognitive impairment, makes self understood and able to understand others. Medications being administered include diuretics. Surveyor reviewed R1's care plan after observation and record review and did not observe a plan of care in place for monitoring and assessing R1 while being administered diuretic medications. Review of R1's medication noted: Furosemide 20 mg once daily with a start date of 12/29/23; Furosemide 40 mg twice a day with a start date of 04/05/25. On 04/08/25 at 9:04 AM, Surveyor observed R1 wheeling self in wheelchair from dining. R1's left arm and both lower legs were significantly edematous. Surveyor observed a urinary catheter hanging below the wheelchair in a dignity bag. Surveyor observed R1 having difficulty wheeling self and having to stop numerous times. On 04/10/25 at 10:45 AM, Surveyor interviewed Director of Nursing (DON) B regarding R1's care plan. DON B stated recognition that R1 should have had a care plan in place to monitor for adverse events and efficacy with the use of diuretics. DON B stated that she is currently working with the pharmacist to identify high-risk medications requiring close monitoring, such as diuretics, to ensure resident safety.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure care plans were revised to reflect residents' current needs and to provide the needed direction to staff in providing necessary care and services. The facility practice affected 1 of 15 residents' care plans reviewed (R55). R55 had recent increase in behaviors resulting in resident-to-resident altercations on 3/03/2025 and again on 4/1/2025. R55's care plan was not updated to reflect changes identified and the care the resident received. Findings include: Surveyor reviewed the facility's policy titled Care Planning -Interdisciplinary Team revised March 2022. The policy reads in part: Policy Statement The interdisciplinary team is responsible for the development of the resident care plans. Policy Interpretation an Implementation . 11. Assessments of the residents are ongoing, and care plans revised as information about the residents and residents' conditions change. According to the Resident Assessment Instrument, The comprehensive care plan is an interdisciplinary communication tool. It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. The care plan should be revised on an ongoing basis to reflect changes in the resident and the care that the resident is receiving. R55 was admitted to the facility on [DATE] with a diagnosis that includes Alzheimer's disease with late onset, dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance, and anxiety disorder. R55's most recent quarterly Minimum Data Set (MDS) dated [DATE] stated a Brief Interview of Mental Status (BIMS) score of 3/15 indicating R55 is cognitively impaired. Surveyor requested and reviewed R55's care plan initiated on 12/30/2024 which states in part: Problem: Mood State Increased mood and behavior problems related to diagnosis of Alzheimer's disease with late onset and Anxiety Disorder. R55 is very angry, verbally, and physically abusive, resistive to cares and has delusional thoughts. Long Term goal Target Date: 04/02/2025 [R55] will not harm herself or others when she becomes anxious or confused. Approach- Approach start date 12/30/24 Give Trazadone as ordered. Monitor for effectiveness and report potential side effects. Monitor and record behaviors each shift: Physical aggression to others, Verbal aggression towards others, Delusional thoughts, threats of harm. Three Times a Day Surveyor reviewed R55's behaviors documentation: Documentation states in part, 03/30/2025 13:11[1:11 p.m.] -Res was reported to be walking out of her room when another res approached her and contact with her breast. Res screamed out, she hit me in the boob. No further contact, Res removed from one another's area. No injury noted to either breast. Call placed to POA and Administrator to update. Surveyor reviewed R55's charting notes: On 3/30/2025 at 1:18 p.m., Licensed Practical Nurse (LPN), E documented in part, It was reported by staff that resident approached another resident and made contact with her Breast area and the other res yelled out. Staff immediately intervened, removed res for one another's areas. No further incident noted. Message left for POA to call back for update regarding event, and call made to Administration for updated. Further documentation was noted on 3/31/25 and 4/1/25 of R55 behaviors including, Spitting, swearing, yelling, throwing things, mocking anyone that is speaking, following staff into resident rooms, slamming doors. CNA tried to give her something to drink and she knocked the glass over. She is getting upset when someone looks at her and upset if talked to or looked at and upset if not looked at or talked to. PRNs were given. Surveyor review Progress Note documented by LPN E on 4/01/2025 at 9:30 which states in part, Resident walked past another resident that was sitting in the common area watching television and punched at the back of her head. Resident [resident name] jumped up and started yelling at her. Writer immediately intervened and removed resident from situation. She was placed with a CNA while writer spoke and checked on [resident name]. [Resident name] stated she was alright. As long as no one cuts my hair I'll be alright. [Resident name] appears irritated but denies fear. Writer then brought resident into charting room and had her speak with her son/daughter-in-law. This calmed her down. Further documentation from LPN E on 4/1/25 at 14:26 is as follows Resident is screaming at people and throwing chairs and other objects she comes in contact with. Staff are following her at a safe distance to keep her from other residents. LPN E documented that NHA A was updated and NHA A is scheduling another 1:1 for her. R55's medications were adjusted. On 4/9/25, Surveyor requested from NHA A all documentation of interventions and updates that were done since R55's behaviors escalated. A recently constructed timeline was provided by NHA A indicating the facility is providing 1 on 1 care to R55, starting on 4/1/25 and when family was not available. Direction for 1 on 1 supervision of R55 was reportedly given but not documented until 4/8/25, after survey was initiated. On 4/09/25 at 8:55 AM, Surveyor interviewed NHA A. NHA acknowledges there should have been documentation of R55's interventions and R55's care plan should have been updated to indicate changes made.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not ensure a resident with limited mobility receives appropriate restorative services, and assistance to maintain or improve mobility with the maximum practicable independence for 2 out of 6 sampled residents (R3 and R9). R3 and R9's passive range of motion (PROM) exercise programs were not completed as ordered. The programs were not reviewed and assessed for appropriateness. This is evidenced by: Example 1 R3 was admitted to the facility on [DATE]. R3's current diagnoses include Alzheimer's disease, dementia, constipation, hypertension, neuralgia, osteoarthritis of knee, muscle weakness, spinal stenosis, pain, transient ischemic attack, anxiety, dysphagia, hemiplegia and hemiparesis, dysphagia, atrial fibrillation, cognitive communication deficit. R3's Minimum Data Set (MDS), dated [DATE], documented R3's Brief Interview for Mental Status (BIMS) score as having severely impaired cognition. R3 is dependent on staff for all activities of daily living (ADL). R3's care plan with the approach start date of 05/22/2020 read in part, Restorative: LLE (left lower extremity) gentle PROM (passive range of motion) in bed bending hip knee and ankle sliding leg out to the side. 2. Gentle BLE (bilateral lower extremities) ankle stretching in bed to prevent contractures. 3. Gentle UE (upper extremities) PROM all joints 5 reps each. Once a day on Mon, Tue, Wed, Thu, Fri, 06:45 - 14:45. Review of restorative nursing logs documenting the number of minutes PROM was completed. The month of January staff provided PROM for 1 minute one day, 2 minutes on three days, 5 minutes on nine days, 6 minutes on two days, 10 minutes on one day and 15 minutes on one day and did not complete PROM on 01/17/25. The month of February staff provided PROM for 2 minutes on one day, 3 minutes on three days, 4 minutes on two days, 5 minutes on five days, 6 minutes on three days, 7 minutes on two days, 10 minutes on two days, 15 minutes on one day, and did not complete PROM on 02/18/25. The month of March staff provided PROM for 2 minutes on two days, 3 minutes on two days, 5 minutes on eleven days, 6 minutes on two days, 15 minutes on one day and did not complete PROM on 03/14/25. On 04/08/25 at 1:15 PM, Surveyor interviewed Certified Nursing Assistant (CNA) J and asked when R3's PROM is completed. CNA J indicated ROM is completed with morning cares. Example 2 R9 was admitted on [DATE]. R9's current diagnoses include multiple sclerosis, dysphagia, acute right heart failure, pulmonary hypertension, neuralgia and neuritis, vitamin D deficiency, myalgia, pain, hypertension, paraplegia, pressure ulcer of sacral region stage 4, colostomy, muscle weakness, and peripheral venous insufficiency. MDS, dated [DATE], a quarterly assessment documented BIMS score of 11/15, meaning R9 has moderately impaired cognition. R9 has impairment to 1 side upper extremity and both sides of lower extremity. R9 requires maximum staff assistance for upper body dressing and personal hygiene. R9 is dependent on staff assistance for showering, lower body dressing, bed mobility and transfers. R9 has no behaviors of rejecting cares from staff. R9's care plan dated 04/11/24, Category: Restorative: R9 is at risk for contractions r/t (related to) MS. Long term goal target date: 06/26/25: R9 will be able to bend bilateral knees and elbows with assistance. Approach start date: 04/11/24: Restorative Program: Stretching program 10x each day QHS (every bedtime). See bulletin board for program specifics. At bedtime: HS 7:00 PM - 11:30 PM). Review of restorative nursing logs documenting the number of minutes PROM was completed. The logs started documentation on 03/25/25 with no previous data available. Staff provided PROM on 03/25/25 and 03/26/25 for 6 minutes, 03/27/25 and 03/28/25 for 12 minutes, 03/29/25 PROM was not completed, 03/30/25 for 10 minutes, 03/31/25 PROM not completed, 04/01/25 for 10 minutes during the AM shift and 5 minutes during the PM shift, 04/02/25 for 6 minutes, 04/03/25, 04/04/25, 04/05/25 and 04/06/25 PROM was not completed, 04/07/25 for 10 minutes, and 04/08/25 PROM was not completed. On 04/07/25 at 11:39 AM, Surveyor interviewed R9 asking if ROM is completed as ordered. R9 stated having contractures to her legs and the exercises are listed on the bulletin board. R9 likes to have ROM completed at bedtime and R9 needs to ask staff to complete ROM otherwise it does not get done. On 04/09/25 at 2:31 PM, Surveyor interviewed Registered Nurse (RN) C about ROM program assessments and monitoring. RN C indicated there is no review of the program and therapy would be consulted to evaluate if a decline was noted. Staff should be documenting when the resident refuses. Surveyor reviewed R3's number of minutes to complete PROM and R9's logs not being completed. RN C stated R9's ROM tracking was entered incorrectly prior and was not tracked. Surveyor asked if assessments of the program were completed would this issue have been identified. RN C indicated if the assessments of the program were completed it would have been caught.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to provide pharmaceutical services related to the accurate administration of inhaled medication for 1 of 2 residents (R), (R19) reviewed. This is evidenced by: Facility policy titled, Administering Medications, with a revised date of 04/2019, states in part: .22. As required or indicated for a medication, the individual administering the medication records in the resident's medical record: c. the route of administration; d. the injection site (if applicable) R19 was admitted to the facility on [DATE] with a pertinent diagnosis of allergic rhinitis. R19's orders noted calcitonin spr 200/act instill one spray into 1 nostril once daily - alt nostril daily. On 04/09/25 at 7:24 AM, Surveyor observed medication administration performed by Licensed Practical Nurse (LPN) H. Surveyor observed LPN H administer the nasal spray into R19's right nostril. Surveyor observed LPN H document medication as administered. No documentation of which nostril was noted. On 04/09/25 at 7:38 AM, Surveyor interviewed LPN H regarding documentation of medication. LPN H stated that staff used to document which nostril the spray was administered, but it went it away a while ago. LPN H stated that she works everyday with R19 and knows which nostril to administer the medication. On 04/10/25 at 10:24 AM, Surveyor interviewed Director of Nursing (DON) B regarding observation. DON B stated that nursing staff are expected to document the location a medication is administered to ensure accurate medication adminnistration and was unaware this was not being completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Example 2 R8 was admitted to the facility on [DATE]. R8's current diagnoses include Alzheimer's disease, muscle weakness, essential tremor, pulmonary hypertension, major depressive disorder, congestive heart failure, pain, dementia, depression, chronic kidney disease stage 3a, generalized anxiety disorder, insomnia, and type 2 diabetes mellitus. MDS dated [DATE] documented R8 having a BIMS score of 9/15 indicating R8 has moderately impaired cognition. The MDS documented R8 as having delirium, inattention and disorganized thinking. R8 has delusions, verbal behavioral directed toward others, and other behaviors not directed toward others. Review of physician order documented, 01/30/25 cephalexin capsule; 250 mg; amt: 1 capsule; oral Special Instructions: For UTI Prevention Once A Day; 08:00 01/13/25 melatonin tablet; 5 mg; amt: 10 mg; oral, Special Instructions: Give with Hydroxyzine 50 mg every HS PRN BETWEEN 2000-0200. At Bedtime - PRN HS dx: insomnia 01/13/25 melatonin tablet; 5 mg; amt: 5 mg; oral Special Instructions: GIVE BETWEEN 2000-0200 if needed At Bedtime - PRN HS. R8 was treated with antibiotic cephalexin for a UTI on 01/22/25 - 01/29/25 for lab results of >100,000 CFU/ML Escherichia coli (e coli). The previous UTI was treated on 09/23/24 - 09/30/24. No further documentation of previous UTIs was noted. Surveyor was not able to identify the physician's rationale for continued antibiotic prophylactic use. Surveyor requested information of the prophylactic antibiotic use, and no further information was provided. On 04/10/25 at 11:12 AM, Surveyor interviewed infection preventionist, Registered Nurse (RN) C, about antibiotic tracking and surveillance for R8 since R8 is on a prophylactic antibiotic. RN C asked Surveyor, What do you mean? Surveyor asked RN C what criteria RN C uses to indicate that R8 met the criteria for being on an antibiotic for E. coli and then after going forward as prophylactic. Surveyor asked if it was appropriate for antibiotic used to treat a culture of 100,000 CFU's for E.Coli. RN C indicated that RN C does not know and just does what the doctor ordered. RN C stated, I am not a doctor. I don't know. RN C stated, The NP (nurse practitioner) decides what residents should be on and is hard to change NP's mind. RN C indicated that NP just orders a urinalysis on everyone, especially R8, and if we don't do what that person wants, that person and family come after us. Surveyor asked if there is any rationale to show the antibiotic medication is needed for R8. RN C said, No. Example 3 R9 was admitted on [DATE]. R9's current diagnoses include multiple sclerosis, dysphagia, acute right heart failure, pulmonary hypertension, neuralgia and neuritis, insomnia, vitamin D deficiency, myalgia, pain, hypertension, paraplegia, pressure ulcer of sacral region stage 4, colostomy, muscle weakness, and peripheral venous insufficiency. MDS, dated [DATE], a quarterly assessment documented BIMS score of 11/15, meaning R9 has moderately impaired cognition. R9 has impairment to 1 side upper extremity and both sides of lower extremity. R9 requires maximum staff assistance for upper body dressing and personal hygiene. R9 is dependent on staff assistance for showering, lower body dressing, bed mobility and transfers. R9 has no behaviors of rejecting cares from staff. Review of physician order documented, 02/10/25 melatonin tablet; 5 mg; amt: 5 mg; oral Special Instructions: PRN between 0000-0300 for insomnia Once A Day - PRN R9 does not have a sleep care plan developed with non-pharmacological interventions to promote sleep. R9's medical record did not have sleep assessments and tracking of sleep to determine sleep patterns and effectiveness of the medication. On 04/09/25 at 1:58 PM, Surveyor interviewed Director of Nursing (DON) B about sleep behavior monitoring and physician rationale for continued medication use. DON B indicated sleep assessments are completed quarterly and the person completing the assessment would interview staff and ask what the resident's normal sleep pattern is. Surveyor asked if the staff interviewed are the same staff on day and night shift to identify the sleep patterns. Surveyor asked how are you accurately collecting data to support the need for the sleep medication. Surveyor asked if all staff are reporting and documenting when all residents are asleep or awake. DON B stated she understands the need to collect data to support the medication use. Surveyor asked if there was a sleep care plan with non-pharmacological intervention to promote sleep. DON B indicated there was not a complete assessment and there is not a care plan. Based on observation, interview and record review, the facility did not ensure that a resident's drug regimen was free from unnecessary medications for 3 of 5 residents (R) reviewed for unnecessary medications (R35, R8, R9). R3 is on medications for sleep, without adequate indication for use for the medications melatonin and trazadone. R8 receives an antibiotic daily for urinary tract infection (UTI) prevention. R8 receives a sleep aid of melatonin and hydroxyzine for sleep without adequate indication for use and no sleep care plan with non-pharmacological interventions to promote sleep. R9 receives melatonin for sleep without adequate indication for use and no sleep care plan with non-pharmacological interventions to promote sleep. Example 1 Findings include: The facility policy titled Behavioral Assessment, Intervention, and Monitoring, dated 2001, states: 1. Residents will have minimal complications associated with the management of altered or impaired behavior. 2. Behavioral symptoms are identified using facility-approved behavioral screening tools and the comprehensive assessment. Comprehensive Resident Assessment . 2. As part of the comprehensive assessment, staff evaluate (based on input from the resident, family and caregivers, review of the medical record and general observations): . d. the resident's previous patterns of coping with stress, anxiety, and depression. Cause Identification: 1. The IDT (interdisciplinary team) evaluates new or changing behavioral symptoms to identify underlying causes and address any modifiable factors that may have contributed to the resident's change in condition, including: a. physical or medical changes (for example) . b. emotional, psychiatric, and/or psychological stressors (for example) . c. functional, social, environmental factors for example (3) sleep disturbances. Interventions and Management: 1. The care plan includes as a minimum: a. description of the behavioral symptoms, including: (1) frequency; (2) intensity; (3) duration; (4) outcome; . (7) precipitating factors or situations. b. targeted and individualized interventions for the behavioral and /or psychosocial symptoms; c. the rationale for the interventions and approaches; d. specific and measurable goals for targeted behaviors; and e. how the staff will monitor the effectiveness of the interventions. 4. Interventions are individualized and part of an overall care environment that supports physical, functional, and psychosocial needs, and [NAME] to understand, prevent, or relieve the resident's distress or loss of abilities. R35 was admitted to the facility on [DATE] and was admitted with the diagnoses that include bilateral primary osteoarthritis of knee, chronic pain syndrome, unspecified hip pain, anxiety, and vascular dementia with other behavioral disturbances. Surveyor reviewed R35's orders and noted the following: Melatonin tablet; 3 mg; Amount to Administer: 1 tab; oral At Bedtime trouble sleeping - started 12/31/2024 - Open Ended Trazodone tablet; 150 mg; Amount to Administer: 75 mg; oral At Bedtime Notify NP if behaviors worsen started- started 12/31/2024 - Open Ended R35's Minimal Data Set (MDS) assessment, dated 1/7/2025, indicates that R35 has moderate cognitive impairment, and is rated to be dependent to needing substantial assistance for personal cares, and movement. R35 has no impairment to the upper body but impairment to the lower body. R35's care plan, dated 1/13/25, does not include plan for sleep management. Surveyor reviewed in computer and the printed copy; no sleep management embedded in any of the problem areas in the care plan. Surveyor reviewed R35's medical records, no assessment or monitoring of sleep patterns or tracking of sleep quality completed. On 4/9/24, at 8:34 AM, Surveyor interviewed Director of Nursing (DON) B. DON B stated there is no sleep assessment or specific care plan for sleep issues to determine the effectiveness or need for the medication. DON B stated we do not monitor sleep. DON B stated there is no expectation of nightly or weekly nursing notes about a resident's sleep pattern.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Example 2 R8 was admitted to the facility on [DATE]. R8's current diagnoses include Alzheimer's disease, muscle weakness, essential tremor, pulmonary hypertension, major depressive disorder, congestive heart failure, pain, dementia, depression, chronic kidney disease stage 3a, generalized anxiety disorder, insomnia, and type 2 diabetes mellitus. MDS dated [DATE] documented R8 having a BIMS score of 9/15 indicating R8 has moderately impaired cognition. The MDS documented R8 having delirium, inattention and disorganized thinking. R8 has delusions, verbal behavioral directed toward others, and other behaviors not direct toward others. Review of physician order documented, 03/22/24 buspirone tablet; 10 mg; amt: 20 mg; oral, Twice A Day AM 07:00 - 10:30, PM 15:00 - 18:30 DX: generalized anxiety disorder 12/12/22 haloperidol tablet; 0.5 mg; amt: 1 tab; oral Twice A Day AM 07:00 - 10:30, PM 15:00 - 18:30 Dx: generalized anxiety disorder 06/11/24 mirtazapine tablet; 30 mg; amt: 30 mg; oral At Bedtime HS 19:00 - 22:30 major depressive disorder 12/14/22 trazodone tablet; 100 mg; amt: 2 tabs; oral At Bedtime HS 19:00 - 22:30 dx insomnia R8 uses trazodone to promote sleep. R8 does not have a sleep care plan developed with non-pharmacological interventions to promote sleep. R8's medical record did not have sleep assessments and tracking of sleep to determine sleep patterns and effectiveness of the medication. Pharmacist medication review dated 02/17/25 requested for a dose reduction for haloperidol, trazadone, mirtazapine, buspirone, and hydroxyzine. The physician wrote Noted, will consider. The physician did not provide a rationale to continue the medications without a dose reduction. On 04/09/25 at 1:58 PM, Surveyor interviewed Director of Nursing (DON) B about behavior monitoring and physician rationale for continued medication use. DON B stated sleep assessments are completed quarterly and the person completing the assessment would interview staff and ask what the resident's normal sleep pattern is. Progress notes would have documented issues. DON B understands the need to collect data to support the medication use. DON B stated Nurse Practitioner (NP) reviews the charting and talks with staff. Surveyor reviewed with DON B the pharmacy recommendations and the NP did not address and provide the rationale of why a GDR would be a detriment or negative effect to the resident. Surveyor asked if there was a sleep care plan with non-pharmacological intervention to promote sleep. DON B indicated there was not an assessment or care plan. Based on interview and record review, the facility did not ensure residents (R) who were prescribed psychotropic medication were comprehensively assessed for qualitative and quantitative data for individualized targeted behaviors and non-pharmacological interventions implemented for 2 of 4 residents (R1, R8) reviewed. R1 received trazodone, an antidepressant medication, for insomnia. The facility did not implement monitoring interventions to determine the effectiveness of the medication. R8 uses trazodone, an anti-depressant medication, to promote sleep with no adequate indications for use and no non-pharmacological intervention to promote sleep. R8 uses antipsychotic medication and psychotropic medications. Pharmacist requested a gradual dose reduction (GDR), and physician did not provide rationale to continue medication. This is evidenced by: Facility policy titled, Behavioral Assessment, Intervention, and Monitoring, with a revised date of 02/2025, states in part: Comprehensive Resident Assessment 2. As part of the comprehensive assessment, staff evaluate .: a. the resident's usual patterns of cognition, mood, and behavior; Cause Identification 1. The IDT thoroughly evaluates new or changing behavioral symptoms to identify underlying causes and address any modifiable factors that may have contributed .including: a. physical or medical changes b. emotional, psychiatric, and/or psychological stressors c. functional, social, or environmental factors Interventions and Management 3. The care plan includes, as a minimum: a. a description of the behavioral symptoms, including: (1) frequency; (2) intensity; (3) duration; (4) outcomes; (5) location; (6) environment; and (7) precipitating factors or situation. b. targeted and individualized interventions for the behavioral and/or psychosocial symptoms; c. the rationale for the interventions and approaches; d. specific and measurable goals for targeted behaviors; and e. how the staff will monitor effectiveness of the interventions. 9. Non-pharmacologic approaches are used to the extent possible to avoid or reduce the use of psychotropic medications to manage behavioral symptoms. 10. If psychotropic medications are prescribed for behavioral symptoms, documentation includes: a. rationale for use; b. potential underlying causes of the behavior; c. non-pharmacological approaches and interventions tried prior to the use of psychotropic medications; e. specific target behaviors and the expected outcomes; f. dosage; g. duration; h. monitoring for efficacy and adverse consequences . Example 1 R1 was admitted to the facility on [DATE] with pertinent diagnoses of depression and insomnia. R1's quarterly Minimum Data Set (MDS) assessment dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of 11/15 indicating moderate cognitive impairment, makes self understood and able to understand others. Medications administered include antidepressants. Review of R1's physician orders noted on 01/09/24 trazodone 100 mg Special instructions: trouble sleeping at bedtime. Review of R1's care plan identified no sleep hygiene care plan was developed with non-pharmacological interventions to promote sleep. Review of R1's medical record did not identify a sleep assessment with sleep patterns was completed prior to the start of medication and during use of the medication to determine the need for the medication or effectiveness of the medication. On 04/10/25 at 10:45 AM, Surveyor interviewed Director of Nursing (DON) B regarding expectations for use of psychotropic medications. DON B stated that residents prescribed psychotropic medications, such as R1 using trazodone for insomnia, should have a sleep assessment completed and continued documentation of sleep patterns to determine efficacy. DON B also stated that non-pharmacological interventions should be documented to assist in promoting good sleep hygiene. DON B stated recognition that R1 should have had a sleep assessment completed prior to initiating the use of a psychotropic medication and a comprehensive care plan to promote sleep in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not maintain documentation of screening, education, and ensure offering of current Coronavirus 19 (COVID) vaccination for 1 of 5 residents (R) reviewed. (R1) This is evidenced by: The facility policy titled Influenza and Pneumococcal Vaccinations, dated March 2022, does not refer to COVID vaccinations. This was the only policy provided when requested. Two requests for a related policy were made. The CDC COVID 19 Staying Up to Date with Covid 19 Vaccines states in part: Everyone ages 6 months and older should get a 2024-2025 COVID 19 vaccine. It is especially important to get your 2024-2025 COVID 19 vaccine if you are ages 65 and older, are at high risk for severe Covid-19, or have never received a COVID 19 vaccine. R1 was admitted to the facility on [DATE] and was admitted with the diagnoses that include: Alzheimer's disease, edema, urinary tract infection, polyneuropathy, chronic kidney disease stage 3b, dementia, depression, anxiety disorder, tremor, bipolar disorder, and insomnia. Surveyor reviewed R1's electronic medical record and noted it did not contain documentation of R1 being screened and offered COVID 19 Immunization for 2024-2025 vaccination year. Surveyor requested documentation of immunization documentation in print. No documentation was available. On 04/10/2025 at 8:05 AM, Surveyor interviewed Infection Preventionist (IP) C regarding immunizations. IP C stated that staff and residents are offered immunizations every year. If there is a Power of Attorney (POA) for the resident, then IP C sends them a letter with the education and consent form and follows up with the POA for questions and consent. IP C stated if the resident is their own person, then IP C educates and gets the consent from them. IP C will get Surveyor copies of all Influenza, Pneumonia, and COVID consents and declinations for 2024/2025 vaccinations and the policy. On 4/10/2025 at 8:56 AM, IP C provided Surveyor with written copies of consent and declination forms. IP C stated this is what IP C could find. There was no COVID consent or declination form for R1. Surveyor asked IP C about COVID paperwork. IP C stated IP C did not think R1 needed to be approached again because she had declined in 2023. On 4/10/2025 at 11:46 AM, IP C stated to Surveyor that she checked with pharmacy for consents and declinations and that was all we have.

Based on interview, observation and record review, the facility did not take action through documenting grievances, conducting a thorough investigation of the issues identified or provide resolution of the concerns brought to the attention of facility staff regarding missing laundry items. This affected R27, R42, R47, R44, and R4. This is evidenced by: Procedure for completing complaint reports: 1. All sections in complaint/grievance box must be completed entirely. 2. 2. After the complaint is recorded determine if a complaint is related to misappropriation. If the answer is Yes, the Administrator must be notified immediately. 3. In documentation of investigation box, the person in charge in the building will need to start the initial investigation. This may include interviews with staff or other residents, observations, memos posted to particular staff, etc. Use the back of form to contribute other details of investigation. 4. If a plan can be implemented right away, please implement and resolve the complaint. 5. If further investigation needs to occur, etc. The IDT will assist and resolve the complaint . Surveyor reviewed resident council meeting minutes for months December 2024-March 2025: -December 2024 resident council meeting minutes stated in part, [R27] said that his laundry has not been getting back to him as quickly as he would like, He is unsure if the clothing is getting lost before finding its way to him, but he would like to see them get back sooner. Surveyor reviewed Grievance logs: -On 01/07/25, grievance report filed by R42 who reported blue printed bathrobe was stolen. Documentation noted bathrobe was found in laundry on 01/08/25 and returned. Bathrobe was then marked with resident name in case it accidentally goes to laundry in the future. -On 01/08/25, grievance report filed by R47 who reported that he is missing a multicolored quilt that he received as a gift. Quilt was located in lower drawer of cabinet in room and now is gone. Documentation noted after staff searched, quilt was found in laundry services and returned to R47. On 04/09/25 10:30 AM, Surveyor met with resident council president R27, R44 and R4. R27 indicated that R27 had several missing clothing items over the last year. R27 reported the missing clothing items to staff members. R27 indicated the facility never could find R27's pants and shirts. R27 indicated that facility did not replace the missing items. R27 just let the missing items go and did not bring it up again until during resident council meetings. R27 indicated that activities aide usually helps find missing items. R44 spoke and indicated that R44 was missing several clothing items as well. R44 could not describe items. R4 indicated that R4 was admitted back August 2024 and had a beautiful grey, black, white fur coat that went missing. R4 indicated that R4 let a staff member know about the missing fur coat and R4 has never seen R4's fur coat again. R4 stated, I must keep a journal every day, and whenever an item goes to laundry, I write down the description of item and the date. When the item is returned to my room, then I cross it off so that I know I am getting my items of clothing back. On 04/09/25 at 11:01 AM, Surveyor toured laundry services with Laundry Director (LD) L. Surveyor asked LD L what the process for inventory is on residents' new clothes on admission and how unlabeled clothes are processed in the laundry department. LD L indicated that LD L's expectation would be that when residents are admitted , or any new clothing items come into the building that the Certified Nursing Assistants (CNA)s check inventory and bag the clothing items and mark on bag that clothes need labeling and send down to laundry to be labeled. LD L indicated what is happening is that CNAs are either labeling resident clothes with permanent marker and then it is not legible, or they are not labeling the clothing items at all. LD L then stated, Look at this clothing cart and how many items are unlabeled. Surveyor noted approximately 80 different pieces of clothing on unlabeled clothing cart. Surveyor asked LD how long the unlabeled clothing cart has been this way. LD L indicated that LD L has only been managing this site for a couple months and the facility has had the unlabeled clothing cart issue since LD L started. On 04/09/25 at 11:26 PM, Surveyor interviewed Nursing Home Administrator (NHA) A and asked NHA A what the process is for labeling resident clothes. NHA A indicated there is not a clear process for labeling clothes. NHA A indicated that NHA A's expectation is that the CNAs will process new admission or new articles of clothing for a resident by placing clothes in a bag then labeling on front needs labeling and send the bag down to laundry so that LD L can process and label the clothing. NHA A indicated that if there is a missing item, staff will reach out to LD L. NHA A indicated that usually the item is found, and things are resolved. NHA A indicated that if residents complain of missing items or clothes, social services or the activities department will try to find the missing items and resolve the concern. NHA A stated, I hear about missing clothing items being resolved all the time and don't think about it much. Surveyor indicated to NHA A that there are about 80 articles of clothing not labeled on the unlabeled clothing cart in laundry in the basement. NHA A did not indicate any prompt efforts to resolve the missing clothing issue or have evidence of actively working toward a resolution for this resident concern. NHA A indicated the process for staff labeling unmarked clothes has been a part of the annual training for the last 14 years but could not provide documentation of training for staff to Surveyor. NHA A then stated, I did not realize there was such a problem with missing items grievances or complaints are to be filled out when items are missing that are of value, personal or financial. We replace things lost, especially when personal or financial value after talking to family. Surveyor asked NHA A if NHA A knew of any recent missing items. NHA A indicated that NHA A is not aware of anything recently but that NHA A's expectation is that staff members report the concern or grievance from residents who may not know how to formally file a grievance and then facility will look into missing items. On 4/9/25 at 2:55 PM, Surveyor was at nursing station in 100 wing when resident approached desk. R44 was attempting to communicate a need but was unable to verbalize. R44 was motioning to his clothing and attempting to verbalize needing something. RN I asked if R44 was referring to pads and R44 responded, Yes! Pants! On 4/9/25 at 3:05 PM, Surveyor observed R44 attempting to go through the locked doors that go to basement. Surveyor observed a staff member ask R44 what R44 needed. R44 indicated needed downstairs while R44 was pulling at R44's pants. Staff member indicated to R44 that staff member would let activities department know to search down in laundry room for R44's pants. On 4/10/25 at 12:00 PM, Surveyor interviewed Director of Nursing (DON) B and asked DON B what the process is for resolving grievances related to missing laundry. DON B indicated that DON B recognizes the potential for lost/missing items due to the incorrect labeling process for residents' clothing. DON B acknowledged that this concern of missing laundry items has not been resolved by the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record reviews, the facility staff failed to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, to develop comprehensive person-centered care plans to meet residents' goals for pain for or adequately assess and treat pain for 5 of 5 residents (R) reviewed (R49, R1, R24, R30 and R35). -Facility did not provide adequate pain relief, properly assess for pain, or develop a pain care plan for R49, R35 and R1. -R24 had no non-pharmacological interventions for pain. Care plan did not include resident's desired/tolerable pain level or follow-up pain assessment. -R30 received tramadol (an opioid medication) for pain. The facility did not implement pain assessments or interventions to determine the effectiveness of the medication. This is evidenced by the following: Facility policy titled, Pain Assessment and Management, dated last reviewed on October 2022, states in part, .General Guidelines: 1. The pain management program is based on a facility -wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management . 3. Pain management is a multidisciplinary care process that includes the following: a. Assessing the potential for pain; b. Recognizing the presence of pain; c. Identifying the characteristic of pain; d. Addressing the underlying causes of pain; e. Developing and implementing approaches to pain management; f. Identifying and using specific strategies for different levels and sources of pain; g. Monitoring for the effectiveness of interventions; and h. Modifying approaches as necessary. 5. Acute pain (or significant worsening of chronic pain) should be assessed every 30-60 minutes after the onset and reassessed as indicated until relief is obtained. Assessing Pain: 3. Assess the resident whenever there is a suspicion of new pain or worsening of existing pain. 4. Assess pain using a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level. 5. During the pain assessment gather the following information as indicated from the resident: c. Characteristics of pain: 1. Location of pain, 2. Intensity of pain (as measured on a standardized pain scale), 3. Characteristics of pain (e.g., aching, burning, crushing, numbness, burning, etc); 4. Pattern of pain (e.g., constant pain or intermittent); and 5. Frequency, timing, and duration of pain. Defining Goals and Appropriate Interventions: 1. The pain management interventions are consistent with the residents' goals for treatment which are defined and documented in the care plan. Pain management interventions reflect the sources, types, and severity of pain. 2. Pain management interventions shall address the underlying causes of resident's pain. Monitoring and Modifying Approaches: 1. Monitor the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain. 2. Monitor the resident by performing a basic assessment with enough detail and, as needed, with standardized assessments tools (e.g., approved pain scales, etc) and relevant criteria for measuring pain management (e.g., target signs and symptoms). 5. Contact the prescriber immediately if the resident's pain or medication side effects are not adequately controlled. #6. If pain has not been adequately controlled, the multidisciplinary teal, including the physician, shall reconsider approaches and make adjustments as indicated . Example 1 R49 was admitted to the facility on [DATE] with diagnoses including encounter for palliative care, anxiety disorder, bipolar disorder, restlessness and agitation, alcoholic cirrhosis of liver without ascites, alcohol dependence, sleep disorder, personal history of suicidal behaviors, post-traumatic stress disorder, depression, and chronic pain. R49's Minimum Data Set (MDS) assessment, completed on 12/30/24, confirmed R49 scored 9/15 during Brief Interview for Mental Status (BIMS), indicating moderate cognition impairment. MDS indicated that R49 had chronic pain and was on an opioid for pain management. Surveyor reviewed pain assessments: -On 10/29/25, staff assessed R49's pain to be 9/10 pain. -On 11/04/25, staff assessed R49's pain of 9/10 pain. -On 12/29/24, staff assessed R49's pain of 10/10 frequent pain occurring more often. -On 02/05/25, staff assessed R49's pain of 10/10 frequent pain occurring more often. -On 03/31/25, staff assessed R49's pain to be 9/10 pain. Surveyor reviewed R49's care plan and did not find a pain care plan implemented to address R49's chronic and acute pain needs upon admission and during R49's care in the facility to present 04/10/25. R49's physician orders indicate: -General opioid monitoring for the following side effects will be monitored for while resident is on an opioid: -tolerance (more medication may be needed to achieve the same level of pain relief). -Medication is stopped, or a dose is held or missed. -Increased sensitivity to pain, constipation, nausea, vomiting, and dry mouth. Sleepiness, dizziness, and/or confusion. Depression, itching and sweating. Respiratory depression. Report to provider any noted side effects ordered on 10/29/2024. -Fentanyl 75mcg, give schedule II patch every 72 hours; 1 patch transdermal, check placement of patch every shift ordered on 11/21/24. -Lorazepam 1mg tab, give 2 tabs as needed every 4 hours for anxiety, nausea, and agitation ordered on 11/25/24. -Belbuca (buprenorphine hcl) - Schedule III film; 450 mcg; amt: 450 mcg; buccal every 12 Hours at 8:00 AM and 8:00 PM, ordered on 03/26/2025. -Oxycodone - Schedule II tablet; 5 mg; amt: 5 mg; oral special instructions: give for severe pain every 4 Hours as needed start date of 10/29/24. ordered on 03/28/2025. Surveyor reviewed R49's progress notes and assessments: -On 12/03/2024 at 6:32 AM (late entry), At 1:30 AM, Resident reports having terrible pain 10/10 in back. Requested and was given prn oxycodone which was effective, but didn't last long enough and pain came back rated 10/10 at 2:30 AM. Again, resident requested prn pain Rx, and it wasn't time yet. Repositioning and warm cloth offered but declined. Resident did not want to move at that time. This writer brought pain Rx at 4:20 AM. Resident was crying at that time. She says she is having terrible pain and needs her pain Rx ordered more often. Currently prn oxycodone 10 mg is q 3 hours. Resident reports her pain this AM was not controlled, and she is requesting to have it every 2 hours prn. Complaint of pain in right ribs and hip that travels down her leg. Message of the above left for Nurse Practitioner (NP). -On 12/04/2024 at 11:14, Serum labs obtained and taken to [town name] lab. In addition, NP written note to continue using as needed Lorazepam as an adjunct for pain. -On 12/08/2024 at 5:18 AM, Resident did awake approximately 2:15 AM and requested prn pain Rx for right hip, leg, and foot pain rated 10/10 which was given. Resident was weepy at that time. 1:1 given and effective. Offer given to reposition, and Res declined. Also offered warm pack but declined. Currently is resting quietly with HOB elevated 30 degrees, eyes closed, respiration 16, even, and non-labored. No facial grimace or other outward sx's of pain noted. -On 12/08/2024 at 7:15 AM, This writer noted Resident fentanyl patch had not been changed for > 3 days. (Order reads to change q 3 days). This writer and RN applied a new fentanyl patch. Also gave Resident prn pain Rx at 6:15 AM due to complain of pain in right hip, leg, and foot. Charge nurse updated of the above and will notify on-call MD, contact person, and hospice of med error. Resident cognition remains per baseline, and she is currently resting quietly in bed with eyes closed. Also, the above information printed and put in N.P. folder to update her. Surveyor found no other documentation addressing R49's pain during 11/30/24-12/10/24. The fentanyl patch was not placed on 12/3 or 12/6 as ordered. R49 did continue to utilize the prn oxycodone 3-5 times per day. Pain levels were not consistently documented on the MAR to determine R49's pain levels during this time. No new orders or interventions were put into place for R49's pain increase during the medication error of no Fentanyl patch being administered to R49 as physician orders stated. Surveyor did not find any assessments of pain for R49 after the increase in pain on 12/03/24, or after increase in pain on 12/04/24, and after increase in pain on 12/08/24. Medication error report review: -On 12/08/24, medication error was found that R49's Fentanyl patch 75 mcg was last applied on 11/30/24 and was noted it had not been changed since that date. Physician was notified with no new orders but to contact hospice. Clarified order in the Electronic Medication Administration Record (E-MAR). -On 12/08/2024 at 9:30, Doctor was updated about med error. No new orders. Hospice called and will update RN. Message left for POA to call facility for an update. -On 12/09/2024 at 6:50 AM, Resident complain of pain x1 during the night. This writer offered re-positioning, but Res declined. She was weepy at that time and was given prn oxy at 0110 for right hip and leg pain rated 10/10 which was effective. -On 12/09/2024 at 9:34 AM, NP noted fentanyl patch change incident. No new orders. Surveyor notes that pain medication is given with a pain level prior, but the post pain level is not entered in Medication Administration Record on a routine basis. Surveyor reviewed R49's Hospice progress notes: -On 12/04/24, Resident requesting her as needed pain medication more often. NP ordered to consult Hospice and use R49's as needed Lorazepam as an adjunct as well, which was not used. -On 12/09/2024 at 2:22 PM, Meeting held with Hospice, SS, NP, and nursing to discuss an update on the resident's plan of care. Hospice's official end date of service will be 12/24. At that time, care will be transferred to facility. NP is working with Palliative Services to see if they will work with the patient. Currently, there is no other option to take over. POA however wants to continue to move towards progressive care rather than a hospice approach. Currently, she is often sleeping or reporting that she is in pain. -All other Hospice progress notes indicate no pain assessment was completed as nurse states, could not complete pain assessment due to R49 in and out of sleep for all hospice visits. Surveyor reviewed NP visits and emergency room (ER) visits: -On 02/10/25- NP visit indicated, the plan after visit: A thorough discussion was had with the patient and her caregiver today. I explained that I had a thorough discussion with the doctor, who included there is nothing that we can offer to help the patient. We discussed that injections would not be helpful due to the patient already being on palliative care. We discussed that a total hip replacement would not be necessary. I discussed with the patient that we do not manage narcotic pain medications long term. I explained that a pain specialist would be a resource to help manage the patient's pain long term. All of the patient's questions were answered and she will follow up as needed. -On 03/13/2025 at 7:59 AM, Social Services Review: Resident complained of pain in knees and hips. NP will refer to pain clinic and palliative care regarding pain management. -On 03/23/2025 at 5:23 AM, Resident requested PRN pain medication. She stated that her pain is uncontrollable, and she stated that she needs to go to the ED for this as nothing is helping and if it does there is relief for a very short time. She stated that she wants to have her pain meds increased and she is not able to move the right leg much. She will not use the wheelchair to use the bathroom, so two staff have to assist her to the bathroom for safety. She stated that she needs to be sent over now. Call placed to her POA and she was okay with her being sent over. Updated that EMS would be called now. emergency room (ER) visits -On 03/23/25, ER visit note: Resident reports of bilateral hip pain and bilateral distal femur pain/knee pain. R49 does have a chronic underlying avascular necrosis involving bilateral hips. I suspect this is most likely etiology of her pain and likely progression of this disease. Unfortunately, resident has been evaluated by orthopedic surgery earlier on in her course of her nursing home stay and was determined not to be a candidate for injections or surgical management and was referred for pain management primarily as she was on hospice/palliative. -On 03/26/2025 at 3:39 PM, Resident requested pain medication for her right hip and knee. She stated that she wanted an extra dose of oxycodone. Writer let her know that we are not allowed to give an extra dose unless it is ordered by the doctor. She stated that she will call the doctor and get that changed. She then later stated that she felt like she might need to go to the ER again. Gave her different pain medication at that time and writer and CNA repositioned her in bed. Asked her what she was wanting from the ER. She stated that she wanted more pain meds. Repositioned her and she is now asleep at this time. -On 03/31/25, Addressing pain, Insurance issues for Orthopedic treatments for the pain in hips. Continues to decline. Observations: On 04/08/25 at 9:13 AM, Surveyor observed R49 in dining room to eat breakfast. R49 stated out loud in dining room with multiple staff members present, My back of knee hurts so bad right now. On 04/08/25 at 9:21 AM, Surveyor observed R49 request pain medication from Licensed Practical Nurse (LPN) H. Surveyor observed LPN H cut film and give to R49. At 9:25 AM, Surveyor interviewed LPN H and asked what LPN H's process is in assessing R49's pain and treating R49's pain appropriately. LPN H indicated that usually R49 will come to LPN H for pain medications, so LPN H waits for R49 to approach. Surveyor asked LPN H if LPN H usually asks R49 what pain level is and how does LPN H assess R49's pain as facility protocol entails. LPN H indicated that R49 whispered R49's pain was 8 out of 10, so LPN H gave pain medication as requested. LPN H stated, That is usually all I do. On 04/08/25 at 10:02 AM, Surveyor interviewed R49 and asked how R49 feels about how the facility manages R49's pain. R49 indicated the facility really has not completed much for R49 other than changing some medications around sometimes. Surveyor asked R49 if R49 can remember back in December if R49 had an increase in pain levels. R49 indicated that R49 remembers something went wrong with R49's Fentanyl patch and R49 stated, I remember being in an excruciating pain of 10/10. Facility had to give me more Oxycodone at the time. R49 indicated that R49 is supposed to see a specialist but facility has not set this up yet and R49's pain is still 10/10 at times during some days. On 04/09/25 at 12:52 PM, Surveyor interviewed Director of Nursing (DON) B and noted that in the Electronic Health Record (EHR) that R49 went several days without coverage of pain medication for R49's Fentanyl patch order and suffered increasing pain, which had to be supplemented with as needed medications. DON B indicated that a medication error form was filled out. DON B indicated that DON B did not place any new interventions into place for R49. Surveyor asked DON B if R49 had a pain care plan in place and what are some interventions put into place for R49 to manage R49's acute and chronic pain. DON B indicated that R49 does not have a pain care plan. Surveyor asked DON B what DON B's expectation is for R49's pain management. DON B indicated that all staff should be assessing pain adequately by using a numerical scale or FACES scale as appropriate for residents and ask how often pain is occurring, describe the pain, and rate the pain. Staff should be following back up with R49 after giving the pain medication to help assess if pain is being managed appropriately. DON B indicated that comprehensive pain assessments are to be conducted upon admission, quarterly, as needed, and with any increase in pain. Surveyor indicated to DON B that Surveyor could not find any comprehensive pain assessments during 11/30/24-12/10/24 when R49 had increased pain related to the missed doses of Fentanyl patch application. DON B indicated staff should have been assessing R49 closely for the increase in pain. Surveyor asked DON B if the facility has set up pain specialist services for R49. DON B indicated the facility has not set up services at this time as R49 has had some insurance issues, but they have been working on this. Surveyor asked DON B what steps the facility put into place to manage R49's pain management other than prescribing pain medications. DON B indicated they do offer nonpharmacological interventions, which R49 refuses. R49 does not have a care plan in place listing these interventions. Example 2 R1 was admitted to the facility on [DATE] with pertinent diagnoses of diabetes mellitus type 2 and polyneuropathy. R1's quarterly Minimum Data Set (MDS) assessment dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of 11/15 indicating moderate cognitive impairment, makes self understood and able to understand others. R1 is noted to receive scheduled and as needed pain medications, pain presence is constantly, no non-medication interventions used, pain interferes with day-to-day activities occasionally, and numerically rates pain as 10/10. R1's care plan, dated 09/26/23, with a target date of 01/01/25, states: [R1] has chronic back pain that limits activity and sleep. Interventions include verbalize relief with PRN non-pharmacologic interventions, administer PRN medications as ordered, trial heat, ice, muscle rub, etc. as non-pharmacologic options. Of note: care plan did not include update of new pain areas noted on the medication administration record (MAR). Surveyor was unable to locate documentation of non-pharmacological interventions used, pain assessment to include resident's desired/tolerable pain level, or follow-up pain assessment. Review of R1's orders noted: 11/27/23 OPIOID MONITORING: The following side effects will be monitored for while resident is on an opioid: -tolerance (more medication may be needed to achieve the same level of pain relief). -Medication is stopped, or a dose is held or missed. -Increased sensitivity to pain. -Constipation. -Nausea, vomiting, and dry mouth. -Sleepiness, dizziness, and/or confusion. -Depression. -Itching and sweating. -Respiratory depression. Report to provider any noted side effects; Of note: no documentation was noted monitoring for the adverse reactions of constipation, sleepiness, respiratory depression, or pain tolerance associated with opioid use. 11/27/23 bisacodyl delayed release 5 mg once a day PRN for constipation; 11/27/23 Milk of Magnesia 400 mg/5 ml give 30 ml once a day PRN for constipation; 03/06/24 Miralax powder 17 g once a morning PRN for constipation; 03/25/24 Senna Plus 8.6-50 mg 2 tabs once a day for constipation; 01/27/25 hydrocodone-acetaminophen 5-325 mg (opioid medication) give 2 tabs four times daily for pain; 03/04/25 assess need for PRN oxycodone every 6 hours; 03/24/25 oxycodone 20 mg/dL (opioid medication) give 0.25 ml (5 mg) every 4 hours as needed for severe pain Of note: multiple entries did not include numerical pain scale to assess pain or location; MAR did not include numerical pain scale to evaluate efficacy. Review of R1's progress notes noted: 04/08/2025 17:26 Medication Error: It was reported to me that R1 received noon dose of Norco too early. No adverse effects noted. NP notified via phone and she is in agreement with plan to monitor vital signs Q shift for the remainder of the day (pms, nocts). NP to see R1 tomorrow to f/u on recent concerns and medication changes. R1 and son notified and neither had any concerns. R1 voiced her frustrations regarding the pain in her left foot and is requesting something for pain at this time. She declined offer of ice and elevation stating, nothing else helps. Updated pm nurse of resident's request. resident takes an Antidepressant Medication. Of note: this is the only mention of non-pharmacological interventions for pain noted in R1's medical record. R1 was assessed routinely after this incident for respirations, blood pressure, heart rate, and level of consciousness. No abnormal assessments noted. Review of R1's intake/output noted: On 04/03/25, R1 had 3 bowel movements. Between 04/04/25 - 04/09/25, documentation notes no bowel movement. Of note: No bowel assessment noted. R1 is noted to eat between 25-75% of all meals during this time period. No documentation of nausea or vomiting noted. Review of R1's medication administration record (MAR) noted: 04/08/25 at 9:38 AM administered PRN oxycodone 0.25 ml/5 mg; PRN reason: Pain; Comment: L foot -(no time noted) PRN result - Follow-up: Somewhat effective Of note: no pain scale used to assess pain prior to administration or follow-up for efficacy. No documentation of respiratory assessment completed. 04/08/25 at 9:40 AM (scheduled 8:00 AM) administered hydrocone-acetaminophen 5-325 mg 2 tabs; Late Reason: administered late; Comment: Care Prioritized Of note: no pain scale used to assess pain prior to administration or follow-up for efficacy. No documentation of respiratory assessment completed. 04/08/25 at 11:27 AM (scheduled 12:00 PM) administered hydrocone-acetaminophen 5-325 mg 2 tabs Of note: no pain scale used to assess pain prior to administration or follow-up for efficacy. No documentation of respiratory assessment completed. No administration documented for Milk of Magnesia for PRN constipation noted between 04/04/25-04/09/25. No administration documented for bisacodyl for PRN constipation noted between 04/04/25-04/09/25. No administration documented for Miralax for PRN constipation noted between 04/04/25-04/09/25. On 04/08/25 at 9:04 AM, Surveyor observed R1 struggling to wheel self in wheelchair in hallway and began to cry. Surveyor asked R1 why she was upset. R1 stated that she was angry and frustrated because of recent health changes and pain. Surveyor asked where R1 was having pain. R1 stated her foot and pointed to her left foot. On 04/08/25 at 11:45 AM, Surveyor observed R1 sitting in wheelchair in room sleeping. On 04/08/25 at 12:04 PM, Surveyor observed staff member wake R1 and state it was time for lunch. Staff wheeled R1 into dining room. Shortly after being seated at dining table in wheelchair, Surveyor observed R1 close eyes and appear to be sleeping. On 04/08/25 at 12:06 AM, Surveyor observed staff approach R1 and rub her shoulder. Staff asked R1 if she was sleepy today. R1 opened eyes, looked at staff, did not verbalize a response, and closed eyes again. On 04/08/25 at 12:23 PM, Surveyor observed Certified Nursing Assistant (CNA) N wake R1 and ask if she was going to eat today. R1 opened eyes and looked at CNA N, but did not verbalize a response. CNA N then began assisting R1 with meal. Surveyor observed R1 to consume approximately 15% of meal. On 04/08/25 at 12:54 PM, Surveyor observed CNA N assist R1 back to room. CNA N transferred R1 to recliner and positioned for comfort. Surveyor observed R1 close eyes and appear to be sleeping before CNA N left room. On 04/08/25 at 2:22 PM, Surveyor observed R1 sitting in wheelchair with eyes closed and appeared to be sleeping. On 04/08/25 at 2:23 PM, Surveyor interviewed Director of Nursing (DON) B regarding observation and record review. DON B stated the expectation is for nurses to give the scheduled pain medication first, wait 30-60 minutes, reassess pain, and then determine if additional PRN medication should be administered. DON B stated that it would not be acceptable practice for nurses to give both scheduled and PRN opioid pain medications at the same time and then to administer the next scheduled opioid 30 minutes early. DON B stated that R1 should be assessed after receiving the multiple doses of opioids. On 04/10/25 at 10:45 AM, Surveyor interviewed DON B regarding pain assessments and care plans. DON B stated the expectation is for nurses to complete a pain assessment with all administrations of pain medication. DON B stated the pain assessment should include, at a minimum, a pain score, location, and characteristic for both the initial and follow-up documentation. DON B stated that recent review of resident's MARs have been documented inconsistently in this area and the facility is working on fixing this. Surveyor asked DON B if residents receiving high-risk medications, like opioids, should have a care plan in place to monitor for adverse effects. DON B stated that residents receiving opioids should have a care plan in place to monitor for things like constipation, level of sedation, respirations, etc. DON B stated the charge nurse reviews all residents' bowel movements daily and are expected to administer a PRN medication if it has been at least 3 days since the last bowel movement. DON B was unable to state why R1 had not had an intervention during this timeframe. Example 3 R24 was admitted to the facility on [DATE] with pertinent diagnoses of chronic pain syndrome, malignant neoplasm of breast and lung, constipation, and dorsalgia (back pain). R24's annual MDS assessment dated [DATE] noted a BIMS score of 11 indicating moderately impaired cognition, makes self understood, and understands others. R24 received scheduled pain medications, as needed pain medications was offered, and did not receive non-medication interventions for pain. R24's care plan, dated 10/09/23, with a target date of 06/27/25, states: [R24] requires more assistance from staff .experiencing more anxiety and pain with end of life. Interventions include monitoring for signs and symptoms of tolerance, administering scheduled and as needed medications, and perform non-pharmacologic pain interventions such as heat, cold pack, repositioning, pillow support . Of note: no documentation found for non-pharmacological interventions being used. Care plan did not include resident's desired/tolerable pain level or follow-up pain assessment. Review of R24's orders noted: 03/27/25 morphine extended release 30 mg four times daily Special Instructions: cancer pain give in addition to the 60 mg 03/27/25 morphine extended release 60 mg four times daily Special Instructions: cancer pain give in addition to the 30 mg 03/24/25 morphine concentrate 100 mg/5 ml (20 mg/ml) give 15 mg four times daily 03/24/25 morphine concentrate 100 mg/5 ml give 0.5 ml-1.0 ml (10-20 mg) Special Instructions: pain/restlessness/dyspnea GIVE IRREGARDLESS OF SCHEDULED DOSES! Every one hour as needed Of note: documentation with administration did not include pain scale or location with initial or follow-up administration. 10/19/2023 OPIOID MONITORING: The following side effects will be monitored for while resident is on an opioid: -tolerance (more medication may be needed to achieve the same level of pain relief). -Medication is stopped, or a dose is held or missed. -Increased sensitivity to pain. -Constipation. -Nausea, vomiting, and dry mouth. -Sleepiness, dizziness, and/or confusion. -Depression. -Itching and sweating. -Respiratory depression. Report to provider any noted side effects Of note: no documentation was noted monitoring for the adverse reactions of constipation, sleepiness, respiratory depression, or pain tolerance associated with opioid use. On 04/10/25 at 10:45 AM, Surveyor interviewed DON B regarding pain assessments. DON B stated this should have been initiated on admission and revised at least quarterly to include resident's tolerable pain level, pain level before and after pain medication administration, location, duration, characteristics, and non-pharmacological pain interventions. DON B stated that all of this should have been documented and monitored to assess for efficacy and changes. Example 4 R30 was admitted to the facility on [DATE] with pertinent diagnoses of reduced mobility and diabetes mellitus type 2 with diabetic neuropathy. R30's admission Minimum Data Set (MDS) assessment dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of 13 indicating cognition is intact. R30 receives scheduled and as needed pain medications. Review of R30's physician orders noted on 03/14/25 tramadol 50 mg three times a day; and tramadol 50 mg Special instructions: as needed for pain every 6 hours. Review of R30's care plan identified no pain care plan was developed to include specific and measurable goals and non-pharmacological interventions. Review of R30's medical record did not identify a pain assessment to include frequency, intensity, duration, outcomes, location, or precipitating factors to determine efficacy and monitor for change in pain characteristics. On 04/10/25 at 10:45 AM, Surveyor interviewed DON B regarding R30's use of a pain regimen. DON B stated recognition that R30 should have had a comprehensive pain assessment completed upon admission to identify cause and establish a baseline care plan to address pain concerns. DON B also stated that a detailed pain assessment should have been completed with each administration of a scheduled or as needed pain medication to include a pain score, location, and characteristic prior to administration and a follow-up assessment of, at minimum, a pain score to determine efficacy and have effective pain management. Example 5 R35 was admitted to the facility on [DATE] with the diagnoses that include bilateral primary osteoarthritis of knee, chronic pain syndrome, unspecified hip pain, anxiety, and vascular dementia with other behavioral disturbances. R35's MDS assessment, dated 1/7/25, indicates that R35 has moderate cognitive impairment, and is rated to be dependent to needing substantial assistance for personal cares and activities of daily living. R35 is dependent for mobility, staff use a mechanical lift to transfer from bed to chair and to shower/bathe chair. R35 has no impairment to the upper body but impairment to the lower body. R35's care plan, dated 1/13/25, does not include pain management. Surveyor found no pain management care plan or approaches for pain management embedded in other care planned areas either, including the general section titled health maintenance. R35 has an order in the eMAR for OPIOID MONITORING: The following side effects will be monitored for while resident is on an opioid: -tolerance (more medication may be needed to achieve the same level of pain relief). -Medication is stopped, or a dose is held or missed. -Increased sensitivity to pain. -Constipation. -Nausea, vomiting, and dry mouth. -Sleepiness, dizziness, and/or confusion. -Depression. -Itching and sweating. -Respiratory depression. Report to provider any noted side effects. 12/31/2024 - Open Ended On 4/8/25 at 8:09 AM, Surveyor interviewed R35 while sitting alone in dining room. R35 denied pain currently. R35 stated that movement hurts the most. R35 stated as long as R35 gets medication on time, R35 usually does not have a lot of pain. R35 stated R35 has other medications they can give R35 when that happens. On 4/8[TRUNCATED]

Based on interview and record review, the facility did not designate a person to serve as the director of food and nutrition services who had completed the minimum qualification requirements for the position. This practice could potentially affect all 60 residents residing in the facility. This is evidenced by: On 4/7/25 at 9:10 AM, Surveyor conducted initial tour of the kitchen with Dietary Manager (DM) D. Surveyor interviewed DM D and requested verification of DM D's qualifications. DM D directed Surveyor to the two certifications on her office wall. On 4/8/25, Surveyor was provided copies of the certifications. In review of the DM certification, Surveyor noted it is for a Food Protection Manager which is accredited by the American National Standards Institute (ANSI)-Conference for Food Protection (CFP). Completed 2023-8-10 and valid through 2028-8-10 from the Always Food Safe Company. On 4/9/2025 at 8:50 AM, Surveyor interviewed Nursing Home Administrator (NHA) A, as DM D was unavailable. Surveyor asked if the facility has a full-time dietician in house. NHA A indicated they do not. The dietician is fully remote. Surveyor asked for any evidence the dietician was monitoring compliance in the kitchen. NHA A did not provide any information. NHA A reported the facility's understanding was the DM certification fell under the state qualifications listed in the SOM F801 483.60 (a) (2) (i) .(C) Has similar national certification for food service management and safety from a national certifying body. Surveyor investigated the certification further and informed NHA A the certificate provided does not meet requirements for Certified Dietary Manager.

Based on observation, interview and record review, the facility did not ensure the safety of food handling in accordance with professional standards for food service safety. The facility practices had the potential to affect all 60 residents. Foods stored in the walk-in-cooler were not labeled and dated and the Head [NAME] did not allow the thermometer probe to air dry after cleaning with isopropyl alcohol prior to inserting into foods items intended to be served to residents for lunch. This is evidenced by: The facility policies titled, Food Receiving and Storage revised December 2008, states in part, 7. All foods stored in the refrigerator or freezer will be covered, labeled and dates (use by date). The Food and Drug Administration (FDA) Food Code states in part, 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface SANITIZING solutions), before contact with food. On 4/07/25 at 9:10 AM, during initial tour of the kitchen with Dietary Manager (DM) D, Surveyor observed several opened foods in the walk-in-cooler had been opened but were not labeled with an opened date or use by date. These foods included sliced tomatoes, repackaged sour creams, opened bag of shredded cheese, a tray of individually portioned salads (coleslaw, potato salad, Jello salads) and pre-poured juice in cups. These foods were covered and on a tray; however, nothing on the tray was labeled or dated resulting in the potential for foodborne illness to spread. During this initial tour, Surveyor interviewed DM D, who reported the expectation would be that opened and/or prepared foods would be dated with an opened or prepared on date or a use by date. DM D did remove potentially hazardous foods and dispose of them. On 4/08/25 at 11:17 AM, Surveyor observed Head [NAME] G take temperature of foods to be served. During checking temperature of the foods, Head [NAME] G would stick probe into isopropyl alcohol probe wipe packet, rub probe end and immediately stick in next food item without waiting to let air dry as directed. This was done with 5 of the 9 foods that were checked during observation. On 4/08/25 at 11:44 AM, Surveyor interviewed Head [NAME] G, who reported she was trained on checking temperatures of foods a long time ago. Head [NAME] G reported she was unsure of when that would have been. Head [NAME] G reported she was not aware of the amount of time to allow cleaner to dry or that probe needs to dry and acknowledged she does not allow probe cleaning wipe to dry before checking temperature between foods. On 4/09/25, Surveyor informed Nursing Home Administrator A of the deficiencies in food preparation and storage that were observed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Example 3 Facility policy titled, Enhanced Barrier Precautions, dated 05/01/24, states in part: It is the policy of this facility to implement enhanced barrier precautions for the preventions of transmission of multidrug-resistant organisms . 2. Initiation of Enhanced Barrier Precautions: b. An order for enhanced barrier precautions will be initiated for residents with any of the following: 1. Wounds and/or indwelling medical devices (e.g., central lines, urinary catheters .) even if the resident is not known to be infected or colonized with a MDRO. The facility policy titled, Handwashing/Hand Hygiene revised October 2023 states in part, Indications for Hand Hygiene . c. after contact with blood, body fluids, or contaminated surfaces; d. after touching a resident; e. after touching a resident's environment; f. before moving from work on soiled body site to a clean body site on the same resident; and g. immediately after glove removal. R9 was admitted on [DATE]. R9's current diagnoses include multiple sclerosis, resistance to multiple antibiotics, dysphagia, acute right heart failure, pulmonary hypertension, neuralgia and neuritis, insomnia, vitamin D deficiency, myalgia, pain, hypertension, paraplegia, pressure ulcer of sacral region stage 4, colostomy, muscle weakness, and peripheral venous insufficiency. MDS dated [DATE], a quarterly assessment documented BIMS score of 11/15, meaning R9 has moderately impaired cognition. R9 has impairment to 1 side upper extremity and both sides of lower extremity. R9 requires maximum staff assistance for upper body dressing and personal hygiene. R9 is dependent on staff assistance for showering, lower body dressing, bed mobility and transfers. R9 has no behaviors of rejecting cares from staff. On 04/09/25 at 10:34 AM, Survey observed cares being provided by Certified Nursing Assistant (CNA) J. R9 has a sign on the outside of room door for enhanced barrier precautions. CNA J sanitized hands and applied gloves and gown. CNA J completed R9's upper body and peri care appropriately. After cleansing buttocks and applying barrier cream, CNA J removed gloves and did not complete hand hygiene. CNA J touched R9 to position in bed. CNA J did not complete hand hygiene and applied clean gloves. Then CNA J rolled resident, finished putting on brief, pulled pants up and applied the Hoyer sling. CNA J removed gloves, did not perform hand hygiene and applied clean gloves. CNA J applied heel protective boots to R9's feet. CNA J, with same gloved hands, touched the soiled plastic linen bags on the floor to move out of the way. With the contaminated gloves, CNA J placed a pillow between R9's legs. CNA J removed gloves, and without hand hygiene, gave R9 the call light and bed remote. CNA J removed gown and did not perform hand hygiene. CNA J moved R9's overbed tray table next to R9's bed. CNA J went to the bathroom, washed hands and with clean hands turned the faucet off. CNA J gathered garbage and the soiled linen bag and brought to the soiled utility room. On 04/09/25 at 10:56 AM, Surveyor interviewed CNA J about proper hand hygiene technique and glove use. CNA J indicated hand hygiene was not completed after removing soiled gloves. Surveyor asked what the proper technique for handwashing is when turning the faucet off. CNA J indicated she turned the faucet off with her clean hands but should have used a paper towel. On 04/09/25 at 2:31 PM, Surveyor interviewed RN C about hand hygiene and the observation with CNA J. RN C indicated staff have been trained and yesterday RN C reviewed with CNA J of proper hand hygiene practices. Based on observation, interview and record review, the facility did not establish and 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. -The facility did not a have a clear water management process or plan in effect to prevent transmission of Legionella infection. This has potential to effect 60 of 60 residents reviewed. -The facility did not have a tracking program in place for the early detection of infected and exposed residents (R) and staff for COVID-19 and Norovirus during an outbreak. -R9 is on enhanced barrier precautions and staff did not perform proper hand hygiene practices during personal cares. -R1 has an indwelling catheter and was not on EBP -Staff did not perform proper hand hygiene during personal cares for R33. This is evidenced by the following: Example 1 Surveyor reviewed the facility policy titled, Water Management Program to Reduce Legionella Growth and Spread, dated last reviewed in September 2017. The policy did not have control measures for the building water system to prevent the spread of legionella described in the policy or on the flow diagram, addressing unoccupied rooms and the vacant North wing to decrease the spread of opportunistic waterborne pathogens. On 04/10/25 at 10:39 AM, Surveyor interviewed infection preventionist, Registered Nurse (RN) C, and asked who oversees the water management program. RN C indicated that RN C, Nursing Home Administrator A, and Maintenance work together to complete water management. Surveyor asked if RN C had control points and any corrective actions to address stagnation and decrease spread of Legionella for the unoccupied rooms and vacant north wing. RN C indicated that everyone completes flushes on Fridays for the vacant north wing but didn't know any other unoccupied rooms need to be flushed as well. Surveyor asked where that description of flushing on Fridays is occurring. RN C indicated that Flush Friday is just something that we know to do but it is not described in the facility water management policy. RN C indicated that RN C would update the water management policy to show control points and corrective actions needed when flushing vacant north wing and any unoccupied rooms in the facility. Example 2 Surveyor reviewed infection surveillance logs dated from February 2024-present. Surveyor found missing documentation on all line lists for surveillance to include complete: -Symptoms onset date. -Location/last worked. -Culture/test type and result. -Treatment parameters. -Isolation type/date start and end. -Resolution date and times for infections. Surveyor reviewed facility Influenza outbreak dated sometime in February. Surveyor could not find the exact start day of Influenza outbreak and what measures were placed to prevent the spread of infection. Surveyor could not find last worked dates for staff members that became infected and worked in the facility to decrease the spread of infection. Surveyor found missing documentation on all line lists for surveillance to include complete: -Culture/test type and result. -Treatment parameters. -Isolation type/date start and end. In Influenza outbreak summary, Surveyor could not find when isolation and proper PPE usage was underway, any audits of hand hygiene, proper PPE usage, or any education to staff to decrease the spread of Influenza. Surveyor reviewed facility COVID-19 outbreak dated sometime in September. Surveyor could not find the exact start day of COVID-19 outbreak and what measures were placed to prevent the spread of infection. Surveyor could not find last worked dates for staff members that became infected and worked in the facility to decrease the spread of infection. Surveyor found missing documentation on all line lists for surveillance to include complete: -Culture/test type and result. -Treatment parameters. -Isolation type/date start and end. -Return to work dates. In COVID-19 outbreak summary, Surveyor could not find when isolation and proper PPE usage was underway, any audits of hand hygiene, proper PPE usage, or any education to staff to decrease the spread of Influenza. On 04/10/25 at 10:39 AM, Surveyor interviewed RN C after reviewing facility's IC surveillance lists and asked RN C what is RN C's process for managing and decreasing the spread of infection. RN C indicated that she follows the CDC guidelines and keeps track of infections monthly. Surveyor asked RN C what the process is and expectations for sick employees. RN C indicated that the expectation is for staff to stay home and call staffing recruiter if symptomatic. Staff Specialist K will take sick calls and make referrals to staff on what staff should do as far as testing goes and when to return to work. Surveyor asked RN C if Staff Specialist K has training on consulting with staff about their sickness and actions to take going forward. RN C indicated that everyone is trained at the onboarding orientation on staying home when sick. RN C indicated that Staff Specialist K does not hold a CNA license or Nurse license and is not medically trained. Surveyor asked RN C to provide Surveyor with Staff Specialist K's training pertaining to how to consult with and make corrective actions for staff when sick. RN C indicated that RN C does not have any formal training that has been completed for Staff Specialist K. RN C indicated that before staff can return to work the staff member brings a form physically into the building and has charge nurse review the form to decide if sick employee is ok to return. RN C reviewed online spreadsheet with Surveyor in which Surveyor observed a staff member who had fever, migraine, and vomiting on 03/09/25 at 5:30 AM, and the staff member returned to work on 03/10/25 at 4:30 AM. RN C indicated that the staff member probably shouldn't have come back into work until over 24-hour fever free. Surveyor asked RN C to provide the spreadsheet to Surveyor to document the facility's process. In review of spreadsheet Surveyor asked RN C how RN C keeps track of what tests are performed to minimize the spread of infection. RN C indicated that Staff Specialist K has the COVID-19 test available to staff to test if symptomatic, but RN C does not have any other tests in place such as influenza or RSV. Surveyor asked RN C if RN C suggests staff members go get tested for anything else. RN C indicated that it is up to staff members if they want to see a doctor or not and get tested for other things. Surveyor asked RN C how RN C keeps track of testing on spreadsheet, resolution date, what precautions or isolation needed, and location of where employees had worked if staff were working sick while on shift. RN C indicated that RN C is not tracking location of employees worked unless an outbreak, resolution dates were not updated on spreadsheet accurately, and testing for infections is not being offered or suggested unless COVID-19. Surveyor asked RN C if RN C thought it was appropriate that staff needed to bring in their form and physically walk into building without properly making sure the staff member was still not currently sick. RN C indicated that RN C's line lists are not as thorough as they should be, and knows the process needs to be fixed as it is not decreasing the spread of infection. Example 4 R1 was admitted to the facility on [DATE] with pertinent diagnoses of chronic kidney disease stage, edema, and urinary tract infection. Review of R1's care plan identified no urinary catheter care plan in place to prevent the spread of infection. Review of R1's orders noted: 04/04/25 Foley Catheter for Urinary Retention. Of note: no order for enhanced barrier precautions (EBP) was noted. On 04/08/25 at 11:58 AM, Surveyor observed a transmission sign outside of R1's room stating, Contact Precautions. A personal protective equipment (PPE) cart was observed outside of room. No other precaution sign was noted. R1 was observed sitting in wheelchair in room. R1 had a urinary catheter hanging below wheelchair inside a dignity bag. Surveyor observed urinary catheter tubing exiting the bottom of R1's right pant leg with clear yellow urine. On 04/08/25 at 12:04 PM, Surveyor asked Registered Nurse (RN) I what the contact precaution sign outside of R1's room was for. RN I stated that it was for R1's roommate. On 04/10/25 at 10:24 AM, Surveyor interviewed Nursing Home Administrator (NHA) A regarding observation. NHA A stated that R1 should have had EBP order initiated when the urinary catheter was placed. NHA A stated recognition that this had the potential to spread infection and put R1 and other residents at risk. Example 5 On 4/07/25 at 10:46 AM, Surveyor observed CNA F use sit to stand to transfer R33 from a wheelchair to the toilet. R33 remained on the toilet. On 4/07/25 at 10:56 AM, CNA F put on gloves and provided incontinence care for R33. CNA F wiped liquid stool from resident buttocks and perineal area. After getting bowel movement (BM) on gloves, CNA F used a disposable wipe to clean off her gloves. CNA F continued to provide incontinence cares for R33 without changing her gloves. After cleaning the BM, CNA F removed the gloves, did not practice any form of hand hygiene, and without donning new gloves put R33's clean incontinence pad on and pulled up her pants. CNA F then moved sit to stand lift, transferred R33 into her wheelchair, and removed R33's transfer belt for stand lift. CNA F continued without gloves to push R33 in the wheelchair to door before CNA F stopped and used hand sanitizer. On 4/07/25 at 11:01 AM, Surveyor interviewed CNA F who reported she had hand hygiene training last month. When Surveyor asked CNA F what should be done when there are visibly soiled gloves, CNA F reported she was not aware the gloves should be changed and not wiped cleaned. CNA F reported she is aware that she should use hand hygiene when leaving room. Surveyor pointed out that hand hygiene was not practiced immediately after removing soiled gloves. On 4/08/25 at 8:29 AM, Surveyor interviewed Licensed Practical Nurse (LPN) E who reported her expectations would be that if gloves are visibly soiled they be removed, and that hand hygiene should be performed immediately when gloves are removed. On 4/10/25 at 8:45 AM, Surveyor interviewed RN C, who reported the expectation would be soiled gloves be removed, not wiped clean, and hand hygiene be performed immediately after removing gloves, and after resident incontinence cares. RN C acknowledged further infection control/hand hygiene education is required and will be provided.

Based on interview and record review, the facility did not establish an Infection Prevention and Control Program (IPCP) that must include, at a minimum, the following elements: An Antibiotic Stewardship Program that includes antibiotic use protocols and a system to monitor antibiotic use. This has the potential to affect all 60 residents in the building who may utilize antibiotics. The facility did not ensure a standard of practice for antibiotic use or surveillance was being utilized in the facility's antibiotic stewardship program. This is evidenced by: The Facility policy titled Antibiotic Stewardship Program, dated 10/23, states in part: The Infection Preventionist is responsible for monitoring; investigating and setting forth a control plan to prevent unnecessary infections. The IP is responsible for monitoring and trending the facility infection incidence rates and this information is reviewed quarterly assurance committee with the interdisciplinary team and medical director each at least quarterly . Surveyor reviewed infection surveillance logs dated from February 2024-March 2025. Surveyor found missing documentation on all line lists for infection surveillance to include complete: -Symptoms onset date. -Culture/test type and result. -Treatment parameters. Such as Antibiotics of choice and when started and stopped. -Resolution date and times for infections. On 04/10/25 at 11:12 AM, Surveyor interviewed Infection Preventionist, Registered Nurse (RN) C, about antibiotic tracking and surveillance. RN C indicated that RN C receives a printout from Health Direct on who was on antibiotics for the month. Surveyor asked RN C when RN C receives this report. RN C indicated the report is sent roughly two weeks after residents are started on antibiotics for that month and that is when RN C is reviewing antibiotic use. Surveyor asked RN C how RN C is tracking infections, what kind of antibiotics residents are put on, and how RN C knows when residents are started on antibiotics and is it the correct antibiotic. RN C asked what Surveyor meant. RN C indicated that RN C leaves that up to the doctor to decide on antibiotic use. RN C stated, I am not a doctor. I don't know. Surveyor asked RN C what criteria is used to determine if an antibiotic is needed or that residents are on the correct antibiotic for their infections. RN C indicated to Surveyor that RN C is unsure what Surveyor is talking about. RN C indicated she does not have a process in place for monitoring correct antibiotic use for residents. Surveyor asked RN C what criteria RN C utilizes such as the McGeer's or Loeb's criteria. RN C indicated RN C was not using either the McGeer's or Loeb's criteria at all. Surveyor referred RN C to the CDC guidelines for monitoring antibiotic use and utilizing McGeer's or Loeb's. RN C indicated that she would start utilizing the McGeer's or Loeb's criteria.

Based on interview, the facility did not ensure residents (R) received adequate supervision in transferring with a mechanical lift to prevent the risk of falling. This occurred for 3 of 3 residents. (R5, R6 and R7). Findings include: On 09/25/24 at 1:31 PM, Surveyor interviewed Certified Nurse Assistant (CNA) C and asked CNA C about any staffing concerns. CNA C indicated that last week on 09/14/24 during day shift around 1:15 PM, CNA C had to be on CNA C's own to transfer three residents (R5, R6 and R7) to bed via Hoyer lift. CNA C indicated that CNA C knew that CNA C shouldn't be transferring R5, R6 and R7 on CNA C's own but had no choice. Surveyor asked CNA C to explain the events of the day. CNA C indicated that the other CNA working with CNA C had to leave for a family emergency and that left CNA C short on west wing. On 09/25/24 at 5:15 PM, Surveyor interviewed Nursing Home Administrator (NHA) A and Director of Nursing (DON) B and asked if NHA A and DON B if aware there was a shortage of staff on 09/14/24. DON B indicated that no one called DON B, so DON B did not know that. NHA A indicated that NHA A was made aware that following Monday on 09/16/24 that CNA C was short on west wing. Surveyor asked NHA and DON B if NHA A and DON B were aware that CNA C had to transfer R5, R6, and R7 with a Hoyer lift to bed alone. NHA A and DON B indicated NHA A and DON B did not know this information. NHA A indicated that if NHA A and DON B knew there was a staffing emergency then NHA A and DON B could have tried to fix the issue. NHA A and DON B indicated that transferring residents via Hoyer by oneself is not ok. NHA A and DON B indicated NHA A and DON B's expectation is Hoyer lifts are always two people.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility did not ensure that 1 of 6 sampled residents (R) who are unable to carry out activities of daily living received the necessary services to maintain personal hygiene (toileting/incontinence care). (R7) Findings include: R7 was admitted to the facility on [DATE], with diagnoses including chronic obstructive pulmonary disease (COPD), unspecified dementia, muscle weakness, diabetes mellitus, urge incontinence, scoliosis, and dysphagia. R7's minimum data set (MDS) assessment, completed on 02/17/24, confirmed R7 scored 03 during a Brief Interview for Mental Status (BIMS), indicating severely impaired cognition. R7 is incontinent of urine and frequently incontinent of bowels. R7 requires set-up assistance with eating. R7 requires substantial maximal assistance from staff for personal hygiene, showering/bathing, toileting, transferring, dressing lower body, and putting on/taking off footwear. R7's care plan was initiated on 02/25/20, and included the following interventions: PERSONAL HYGIENE care plan implemented on 11/26/23: -The resident requires maximal assistance. BOWEL AND BLADDER care plan: -Continent/incontinent uses toilet and incontinent products such as briefs and soaker pads implemented on 05/24/23. -Check frequently and as required for incontinence. Wash, rinse, and dry perineum. Change clothing as needed after incontinence episodes. URINARY INCONTINENCE care plan implemented on 02/25/20: -Apply moisture barrier to the skin. -Nursing staff must prompt and encourage to void upon awakening, before and after meals, and at bedtime. PRESSURE ULCER/INJURY care plan implemented on 02/25/20: -Keep clean and dry as possible. Minimize skin exposure to moisture. -Keep linens clean, dry, and wrinkle-free. NUTRITIONAL STATUS care plan: -Observe for any problems with chewing or swallowing food implemented on 02/25/20. -Encourage and assist with eating as needed implemented on 11/23/22. -Is able to feed self with supervision and eats meals in ADR implemented on 03/07/23. Surveyor reviewed no other interventions revised or updated since 11/26/23. Observations were continuous from 03/04/24 9:59 AM- 03/04/24 12:41 PM: On 03/04/24 at 9:59 AM, Surveyor observed R7 sitting in a wheelchair in R7's room. On 03/04/24 at 11:45 AM, Surveyor observed R7 pushed out of the room and into the assisted dining room (ADR). Surveyor did not observe R7 toileted. On 03/04/24 at 12:41 PM, Surveyor observed R7 sitting in a wheelchair and pushed to the nurse's station. Surveyor did not observe R7 toileted before or after being pushed to the nurse's station. Observations were continuous from 03/05/24 7:35 AM- 03/05/24 11:23 AM: On 03/05/24 at 7:35 AM, Surveyor observed Certified Nurse Assistant (CNA) I take R7 into ADR to prep for breakfast. R7 was sitting in the wheelchair. On 03/05/24 at 8:55 AM, Surveyor observed CNA K push R7 out of ADR and into the activity room. On 03/05/24 at 11:20 AM, Surveyor observed staff bring R7 out of the activities room and bring R7 to the nurse's station. Surveyor did not observe R7 toileted. On 03/05/24 at 11:23 AM, Surveyor observed CNA I and CNA K push R7 to R7's room and enter into R7's room to transfer R7 to the toilet. Surveyor observed R7 stand with assistance and pivot to stand in front of the toilet. Surveyor observed R7's pants soaked wet with urine on the bottom of R7's pants where R7 sits in a wheelchair. CNA I pulled R7's pants down and changed R7's soiled brief, then pulled R7's wet pants back up over clean brief. CNA I and CNA K walked R7 back to the wheelchair with a walker and gait belt. CNA I and CNA K exited R7's room and left R7 to watch TV in R7's room. Observations were continuous from 03/06/24 8:05 AM- 03/06/24 9:25 AM: On 03/06/24 at 8:05 AM, CNA I exited R7's room and wheeled R7 down to the ADR in a wheelchair. On 03/06/24 at 8:20 AM, Surveyor observed R7 receive a breakfast tray. CNA J set up the breakfast tray for R7 and stated, Ok, it is time to eat. On 03/06/24 at 8:35 AM, Surveyor observed R7 to be sleeping at the dining table. CNA J stated to R7, It's time to wake up and eat. Surveyor observed R7 wake a little and grab milk to drink. Surveyor observed R7 pick toast up and take a few bites. Surveyor did not observe R7 eat anything else on plate. On 03/06/24 at 8:47 AM, Surveyor observed CNA I approach R7 and told R7, Let's go to your room real fast I want to show you something. R7 asked, Show me what? I am not done eating my food. CNA I indicated that CNA I had stuffed animals in R7's room to see. R7 stated again, I am not done with my food. CNA I indicated to R7 that CNA I would bring R7 back to breakfast once CNA is done in R7's room. On 03/06/24 at 8:57 AM, Surveyor observed CNA L pick up R7's breakfast tray and place it on the dirty meal cart. Surveyor interviewed CNA L and asked how much R7 had eaten for breakfast. CNA L indicated R7 only ate the tops 25% of breakfast but drank about 480mls. On 03/06/24 at 9:00 AM, Surveyor observed CNA I enter into ADR and walk around the table checking on other residents. CNA I did not bring R7 back to the ADR. On 03/06/24 at 9:13 AM, Surveyor observed CNA I sit down to help assist another resident with a meal. Surveyor did not observe R7 in the ADR. Surveyor observed R7's breakfast tray on the dirty meal cart. On 03/06/24 at 9:22 AM, Surveyor observed CNA I take the last resident out of the ADR. On 03/06/24 at 9:25 AM, Surveyor observed R7 in R7's room watching TV at the bedside table. Surveyor did not observe breakfast tray in R7's room. Surveyor reviewed behavior monitoring from 09/07/23-03/07/2024. Surveyor did not find documentation on 03/05/24 for the day shift on any behavior changes or resistance to care from R7. On 03/06/24 at 12:32 PM, Surveyor interviewed CNA I and asked why R7 had to go to R7's room during breakfast and why R7 was not brought back to ADR to finish breakfast. CNA I indicated that R7 needed to receive a blood sugar check by the nurse in R7's room. CNA I indicated that at that time CNA I felt like R7 no longer wanted breakfast. Surveyor asked CNA I if CNA I had asked R7 if she was done with breakfast, and CNA I indicated no that CNA I thought R7 was done. On 03/07/24 at 8:34 AM, Surveyor interviewed Director of Nursing (DON) B and asked what the expectation was for staff to bring R7 back to ADR to finish breakfast. DON B indicated the expectation was that R7 be allowed to finish R7's breakfast especially since R7 is diabetic. Surveyor asked DON B about expectations for staff to change soiled briefs and any saturated clothes such as pants from an incontinence episode. DON B indicated that facility never wants residents sitting in wet briefs or clothes. DON B indicated expectation would be CNAs change the soiled brief and soiled pants in a timely fashion. DON B indicated that for some residents with behavior issues it's a tricky situation getting residents toileted, but staff should readdress every 5-10 minutes to get the resident dry and the staff document any behaviors in the electronic health record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not ensure residents received adequate supervision and assistance with eating to prevent the risk of choking. This occurred for 2 of 2 residents (R) reviewed for eating, (R3 and R7). Findings include: Example 1: R3 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease, dysphagia, gastro-esophageal reflux disease, dementia, and type 2 diabetes mellitus. R3's Minimum Data Set (MDS) assessment, completed on 11/21/23, confirmed R3 scored 05 during a Brief Interview for Mental Status (BIMS), indicating severely impaired cognition. R3 requires supervision and set-up assistance with eating. R3 requires substantial maximal assistance from staff for personal hygiene, showering/bathing, toileting, transferring, dressing lower body, and putting on/taking off footwear. R3's care plan was initiated on 09/26/19, and included the following interventions: ACTIVITIES OF DAILY LIVING (ADL) care plan: Feeding needs to be fed at meals in the assisted dining room (ADR) implemented on 07/03/23. NUTRITIONAL STATUS: -Diet: national dysphagia diet level 3 (NDD3), a mechanical soft diet with ground meats implemented on 11/04/21. -speech therapy (ST) recommends alternate bites with sips 2:1. Small sips of liquid ½ tsp in size were implemented on 11/06/23. -Dietary supplement twice a day implemented on 11/06/23. Surveyor reviewed no other interventions revised or updated since 11/26/23. Speech therapy initial evaluation on 02/19/24 indicates that R3 requires 50-75% supervision at mealtime. Speech therapy progress notes state in part: -On 02/18/24 R3 swallowing has become more and more difficult to do, she has been noted holding food and fluids in her mouth for long periods of time, appears that she is afraid to make any attempts, even with crushed pills and liquids. -On 02/19/24 NP gave the okay for the resident to be evaluated and treated by speech therapy to evaluate R3 for issues with swallowing issues. -On 02/20/24 Speech Therapy recommendation: ST recommending discontinue waiting for the end of meals to present drinks/liquids. Alternate bites with sips 2:1. Small sips of liquid 1/2 tsp. size. CP updated. -On 02/26/24 Speech Therapy recommends no straws for drinking thin liquids. -On 02/27/24 Speech Therapy indicated that R3's current diet can eat NDD3 diet textures, feeder assist for cognitive deficits/reminders to continue eating. -On 02/28/24 Speech Therapy indicated R3's current diet able to eat NDD3 diet textures, no straws for drinking to prevent aspiration, and needs cues to alternate bites with sips. -On 03/05/24 Speech Therapy indicated R3 continue regular cups for liquids, NDD3, no straws for drinking to maximize safety. Observations were continuous from 03/05/24 9:05 AM- 03/05/24 9:45 AM: On 03/05/24 at 9:05 AM, Surveyor observed Certified Nurse Assistant (CNA) I exit ADR leaving R3 in ADR to finish breakfast. Surveyor observed R3 still had eggs in front of R3 and a strawberry supplemental shake with a glass of milk on a tray sitting in front of R3 on the table. On 03/05/24 at 9:16 AM, Surveyor observed CNA I come back into ADR to ask R3 if R3 wanted to go to the activity room or sit in ADR and finish breakfast fluids. R3 indicated that R3 wanted to stay and finish the drink. CNA I grabbed the food tray and placed on the dirty food cart. On 03/05/24 at 9:18 AM, Surveyor observed CNA I exit the ADR. On 03/05/24 at 9:27 AM, Surveyor observed housekeeping cleaning all around in ADR. Surveyor did not observe any other CNAs come into ADR. On 03/05/24 at 9:43 AM, Surveyor observed R3 call out and say, Hey! R3 was observed sitting at the ADR table with a glass of strawberry supplement in front of R3 and a glass of milk. On 03/05/24 at 9:45 AM, Surveyor observed Registered Nurse (RN) M ask R3 if R3 was ready to go back to R3's room. RN M grabbed R3 and wheeled R3 from ADR back to the east unit. On 03/05/24 at 9:51 AM, Surveyor interviewed Speech Therapist (ST) N and asked about R3's therapy with eating and expectations of staff assisting/cueing R3 during meals in the ADR. ST N indicated that R3 has improved tremendously with therapy. ST N indicated that adaptive cups were trialed but R3 seemed to not have a big difference with adaptive cups. ST N indicated that R3 needs cueing/reminder for the intervention put into place on 11/06/23 with the rule being for every 2 bites take 1 sip of liquid. Surveyor asked ST N what the expectation is for staff supervising residents who need supervision or are working with speech therapy in the ADR. ST N indicated that ST N is unaware what the policy is for supervision in the ADR. ST N indicated as for R3 there isn't anything specific in orders other than R3 needing cueing/supervision and to be taking 2 bites and 1 sip with meals to prevent aspiration. On 03/05/24 at 9:56 AM, Surveyor interviewed CNA I and asked about supervision in the ADR. CNA indicated that if residents need assistance usually CNAs stay in ADR. On 03/05/24 at 10:00 AM, Surveyor interviewed Director of Nursing (DON) B and asked what expectations are for supervision in the ADR. DON B indicated that some residents are in the ADR for just set-up purposes but if residents need cueing such as 2 bites then 1 sip, then supervision would need to be in ADR at all times. DON B indicated that some residents in the ADR are for cueing and working with ST N and expectations would be for those residents to always have supervision. On 03/05/24 10:15 AM, Surveyor interviewed Dietician O and asked about diet for R3 and if Dietician O has any input in staff providing supervision for residents in the ADR. Dietician O indicated that Dietician O does not have any input with supervision in the ADR and that the nursing staff decides that. Dietician O indicated that R3 is NDD3, a mechanical soft diet with ground meats. Example 2 R7 was admitted to the facility on [DATE], with diagnoses including chronic obstructive pulmonary disease (COPD), unspecified dementia, muscle weakness, diabetes mellitus, urge incontinence, scoliosis, and dysphagia. R7's MDS assessment, completed on 02/17/24, confirmed R7 scored 03 during a BIMS, indicating severely impaired cognition. R7 requires set-up assistance with eating and oral hygiene. R7 requires substantial maximal assistance from staff for personal hygiene, showering/bathing, toileting, transferring, dressing lower body, and putting on/taking off footwear. R7's care plan was initiated on 02/25/20, and included the following interventions: NUTRITIONAL STATUS: -Observe for any problems with chewing or swallowing food implemented on 02/25/20. -Encourage and assist with eating as needed implemented on 11/23/22. -Is able to feed self with supervision and eats meals in ADR implemented on 03/07/23. -Consistent carbohydrate, low cholesterol, low fat, no added salt diet, Per ST, NDD3, ground meat, no particle foods implemented on 09/08/23. Surveyor reviewed no other interventions revised or updated since 11/26/23. Progress notes state in part: - On 12/08/2023, quarterly nutrition assessment, continues consistent low fat, low cholesterol, NAS, NDD3, a mechanical soft diet with ground meats and no particle foods. Eats meals in ADR and needs encouragement and supervision. Observations were continuous from 03/05/24 9:05 AM- 03/05/24 9:45 AM: On 03/05/24 at 9:05 AM, Surveyor observed CNA I exit ADR leaving R7 in ADR to finish breakfast. Surveyor observed R7 still had eggs, toast, rice krispies cereal, milk, and juice in front of R7 on a tray sitting in front of R7 on the table. On 03/05/24 at 9:17 AM, Surveyor observed CNA I come back into ADR to ask R7 if R7 wanted to go to the activity room or sit in ADR to finish breakfast. R7 indicated that R7 wanted to stay and finish eating food. On 03/05/24 at 9:18 AM, Surveyor observed CNA I exit the ADR. On 03/05/24 at 9:27 AM, Surveyor observed housekeeping cleaning all around in ADR. Surveyor did not observe any other CNAs come into ADR. On 03/05/24 at 9:45 AM, Surveyor observed RN H ask R7 if R7 was ready to go back to R7's room. RN H grabbed R7 and wheeled R7 from ADR back to the east unit at the nurse's station. On 03/05/24 at 9:51 AM, Surveyor interviewed ST N and asked about R7's therapy with eating and expectations of staff assisting/cueing R7 during meals in the ADR. ST N indicated that R7 had difficulties swallowing back in July of 2023 and was evaluated. ST N indicated that R7 does need supervision and cueing during mealtime in the ADR to remain safe from choking.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Example 2 R15 was admitted to the facility on [DATE], with diagnoses including multifocal right nephrolithiasis and left upper pole nephrolithiasis. R15 has a suprapubic catheter to avoid chronic moisture and for urine retention. R15's Minimum Data Set (MDS) assessment, completed on 01/03/24, confirmed R15 scored 15 during a Brief Interview for Mental Status (BIMS), indicating cognitively intact. R15 requires maximal assistance with personal hygiene, toileting, transferring, dressing lower body, and putting on/taking off footwear. Observations: On 03/05/24 at 10:45 AM, Surveyor observed CNA I, CNA K, and CNA J enter R15's room for suprapubic catheter care and transfer into the wheelchair. Surveyor observed CNA K use wipes to cleanse the entry site of the suprapubic area where the catheter inserts into pubis area. R15 requested gauze be applied as it feels better when it is on. CNA J stated CNA J would apply gauze in a little while once the peri area is cleansed. CNA J and CNA I rolled R15 from side to side. CNA J took the soiled brief out from under R15 and then tucked a new clean brief under R15. CNA J rolled R15 to her back and grabbed a clean gauze pad package. CNA J opened the package, and with the same dirty gloves, pulled the clean gauze pad out of the package, placed the gauze on R15's catheter insertion site and wrapped the gauze around the catheter tube. CNA J proceeded with rolling R15 to tuck Hoyer's sling. Surveyor did not observe the removal of gloves or hand hygiene between changing the soiled brief and placing the clean gauze around R15's suprapubic catheter site. On 03/05/24 at 11:20 AM, Surveyor interviewed CNA J and asked about hand hygiene during resident cares and applying clean gauze to suprapubic catheter site. CNA J indicated that usually during cares when gloves become soiled or contaminated by something dirty, CNA J usually makes sure gloves should be removed and hands sanitized then reapply new gloves before applying a dressing to the suprapubic area. On 03/05/24 at 2:15 PM, Surveyor interviewed Director of Nursing (DON) B and asked about expectations for glove change and hand hygiene during R15's suprapubic care. DON B indicated that strict hand hygiene should be adhered to. CNA J should have changed gloves after changing R15's soiled brief, and tucking Hoyer sling under bottom before applying new gauze to suprapubic insertion site. Example 3 R7 was admitted to the facility on [DATE], with diagnoses including chronic obstructive pulmonary disease (COPD), unspecified dementia, muscle weakness, diabetes mellitus, urge incontinence, scoliosis, and dysphagia. R7's minimum data set (MDS) assessment, completed on 02/17/24, confirmed R7 scored 03 during a brief interview for mental status (BIMS), indicating severely impaired cognition. R7 requires set-up assistance with eating and oral hygiene. R7 requires substantial maximal assistance from staff for personal hygiene, showering/bathing, toileting, transferring, dressing lower body, and putting on/taking off footwear. R7's care plan was initiated on 02/25/20, and included the following interventions: MULTIDRUG-RESISTANT ORGANISM (MDRO)- VANCOMYCIN-RESISTANT ENTEROCOCCI (VRE) care plan implemented on 11/09/21: -Gowns or aprons must be worn when the possibility of contamination of clothes with blood or body fluids is anticipated. -Wear gloves if touching any body of fluids or mucous membranes or nay surface or equipment with any body fluids or mucous membranes. Observations: On 03/05/24 at 11:23 AM, Surveyor observed CNA I and CNA K enter R7's room on isolation for contact precautions related to VRE in urine. Surveyor was to observe R7 transfer to the toilet. CNA I and CNA K brought CNA K's gait belt in for safety during the transfer. Surveyor observed CNA I and CNA K apply the gait belt to R7's waist. Surveyor observed R7's pants wet with urine on the bottom of R7's pants. CNA I pulled R7's pants down and changed the soiled brief, then pulled the wet pants back up and readjusted the gait belt with dirty gloved hands. CNA I and CNA K walked R7 back to the wheelchair with a walker and gait belt. CNA I took the gait belt off R7 once R7 sat in a wheelchair. CNA I laid gait belt back on R7's bed and finished placing wheelchair pedals on R7's wheelchair. CNA I stated to CNA K to not forget CNA K's gait belt. CNA I grabbed gait belt off R7's bed for CNA K and exited R7's room. Surveyor observed CNA I exit R7's room, take the contaminated gait belt from the isolation room and lay it on the nurse's station desk. Surveyor did not observe proper sanitization of gait belt. On 03/05/24 at 2:15 PM, Surveyor interviewed DON B and asked about expectations for gait belt usage in an isolation room. DON B indicated that staff is expected to keep gait belts in the resident's room who is on isolation and only use for that particular resident. Based on observation, interview and record review, the facility did not maintain an infection and control program to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. -Improper hand hygiene/glove use for Foley catheter care and during dressing change for suprapubic catheter for 2 of 2 residents with catheters. (R15, R54) -Improper infection control procedure for resident on contact precautions. (R7) Findings: The facility policy entitled, Handwashing/Hand Hygiene last revised August 2015, stated in part: .7. Use an alcohol-based hand rub containing at least 70% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .b. Before and after direct contact with residents . .e. Before and after handling an invasive device (e. g., urinary catheters, IV access sites) . .h. Before moving from a contaminated body site to a clean body site during resident care . .g. Before handling clean or soiled dressings, gauze pads, etc . .k. After handling used dressings, contaminated equipment, etc . .m. After removing gloves . .8. Hand hygiene is the final step after removing and disposing of personal protective equipment . Example 1 Resident (R) 54 was admitted on [DATE] with a Brief Interview of Mental Status (BIMS) of 07 which indicates severe cognitive impairment. R54 has diagnoses that include stage 3 pressure ulcer and urine retention. R54 has an indwelling Foley catheter to avoid chronic moisture and for urine retention. On 03/05/24 at 7:24 AM, Surveyor observed Certified Nursing Assistant (CNA) I empty R54's Foley catheter. CNA I emptied the Foley catheter drain bag into a graduate with proper standards of care observed with this. Then with the same contaminated gloves, CNA I took the graduate and emptied it into the toilet and went over to the sink and turned on the water by touching the faucet with the contaminated gloves. CNA I filled the graduate and emptied it into the toilet. CNA I then removed the gloves and used Alcohol Based Hand Rub (ABHR) to clean CNA I's hands. On 03/05/24 at 7:28 AM, Surveyor observed cares provided to R54 by CNA I. CNA I performed proper hand hygiene with ABHR and put on single use gloves. CNA I applied asper cream to R54's lower legs bilaterally, then wrapped the lower legs with ace wraps from the ankle to the knees. Foley catheter bag was pulled through the pant legs. R54's pink pants were pulled up the legs to the knees. Gripper socks were placed on R54's feet bilaterally. Gown was removed to upper body. CNA I washed R54's arm pits and under the breasts bilaterally. CNA I placed a long-sleeved shirt on the resident. R54's attends was removed starting with the tape in front. CNA I began to clean around the Foley catheter insertion site without changing gloves and without proper hand hygiene when moving from dirty to clean body location. The skin around the catheter was cleaned. The catheter tube itself was cleaned moving from the site outward. The peri area was then dried with a towel. R54 was then repositioned onto the left side, and CNA I cleaned R54's buttock as there was stool present. CNA I then removed gloves, performed hand hygiene using ABHR and put on clean single use gloves. CNA I then put a new attend on R54. CNA I then removed gloves and exited room without performing any hand hygiene.

Based on observation, interview and record review, the facility did not ensure residents (R) were treated with respect and dignity and cared for in a manner to enhance their quality of life. Facility staff stood over R4, R6, R28 and R20 while assisting them to eat. Facility staff used a clothing protector, the edge of a spoon, and rim of a cup to wipe R28, R32 and R4's face during dining. Findings include: Facility policy entitled, Assistance with Meals, last revised March 2022, stated in part, .Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: a. not standing over residents while assisting them with meals .avoiding the use of bibs or clothing protectors instead of napkins, unless requested by the resident . On 03/04/24 at 12:06 PM, Surveyor observed Certified Nursing Assistant (CNA) D assisting R28 and R4 to eat their noon meal. CNA D stood between both residents the entire time while assisting them to eat. On 03/04/24 at 12:36 PM, Surveyor observed CNA E walk over to R28 and assisted R28 to take a few more bites of lunch and a drink of milk while standing over R28's chair. At 12:42 PM, Surveyor observed CNA E walk over to R20 and assist R20 to take a few more bites of food while standing over R20's chair. At 12:45 PM, Surveyor observed CNA E walk over to R6 and assist R6 to take a few more sips of a shake while standing over R6's chair. On 03/05/24 from 8:22 AM to 8:40 AM, Surveyor observed CNA C seated between R4 and R32 to assist them with eating breakfast. Each time CNA C gave R4 or R32 a drink or a bite of food, CNA C used the edge of the spoon to scrape excess food off from around R4 or R32's lips or chin. CNA C also frequently used the clothing protector to wipe R4 or R32's lips or chin after a bite of food or drink of liquid. At 8:40 AM, CNA C began giving R4 sips of a thick white liquid. After each sip, CNA C used the rim of the cup or the clothing protector to wipe the white liquid from R4's upper lip. At 8:42 AM, Surveyor observed CNA F using the clothing protector to wipe R28's mouth and chin while assisting R28 to eat hot cereal. On 03/05/24 at 12:05 PM, Surveyor observed CNA C assist R4 and R32 to eat lunch. Surveyor observed CNA C frequently wipe both resident's mouths with clothing protector, or scrape around their mouth and chin with a spoon after giving a bite of food or drink of liquids. On 03/05/24 at 2:55 PM, Surveyor interviewed Director of Nursing (DON) B and explained the observations of staff standing over residents while assisting them to eat, or using a clothing protector or spoon to wipe resident's faces instead of a napkin while assisting them to eat. DON B stated their expectation was for staff to sit beside residents while assisting them to eat. DON B stated staff was expected to use a napkin instead of a clothing protector or spoon to wipe resident's mouths while assisting them to eat.

On 03/04/24 at 11:51 AM, Surveyor observed Certified Nurse Assistant (CNA) Q take hand antibacterial wipes and wipe R54's hands with wipe before lunch. CNA Q pulled another wipe out and started wiping R27's hands. CNA Q threw the wipe away, pulled out another wipe and then went over to R264's hands and wiped R264's hands. CNA Q threw that wipe away, pulled out another wipe and then went over to R31's hands and wiped R31's hands. Surveyor did not observe hand hygiene performed before, between, or after wiping hands of each resident. On 03/04/24 at 12:00 PM, Surveyor observed CNA Q deliver R264's tray. CNA Q grabbed silverware and started taking caps off milk and hot food. Surveyor did not observe hand hygiene after setting R264's lunch tray. On 03/04/24 at 12:06 PM. Surveyor observed CNA Q deliver R11's tray. R11 requested CNA Q to place peanut butter on bread. CNA Q grabbed piece of bread with left bare hand and spread peanut butter on bread with right bare hand and spoon. CNA Q handed the bread to R11 with CNA Q's left bare hand. R11 ate the peanut butter covered bread. Surveyor did not observe hand hygiene performed before or after assisting R11 with lunch meal. On 03/04/24 12:41 PM, Surveyor interviewed CNA Q and asked about hand hygiene practices during mealtimes. CNA Q indicated that usually CNA Q performs hand hygiene between cares of residents. When CNA Q is in the dining room CNA Q uses hand hygiene when CNA Q thinks of it or when CNA Q needs to. Surveyor asked CNA Q about touching bread with bare hands and CNA indicated that CNA Q shouldn't have touched bread with bare hands. On 03/05/24 at 8:10 AM, Surveyor observed CNA I deliver R264's tray to R264. CNA I grabbed toast with left bare hand and spread jelly with knife on the toast with right hand. Surveyor did not observe CNA I perform hand hygiene prior to touching R264's toast with bare hand. Surveyor observed CNA I use hand sanitizer after setting up toast for R264. On 03/05/24 08:13 AM, Surveyor observed CNA I pick up tray off cart and deliver R11's tray to R11. CNA I grabbed toast with left bare hand and spread jelly with knife on the toast with right hand. Surveyor observed CNA I wash hands after and then continue delivering food trays. On 03/05/24 at 8:16 AM, Surveyor observed CNA I pick up tray off cart and deliver R3's tray to R3. CNA I grabbed knife with right bare hand and spread on one piece of toast then took left bare hand and grabbed corner of toast with left bare hand and took right bare hand and finished spreading jelly on toast. Surveyor observed CNA I wash hands after and then continue delivering food trays. On 03/05/24 at 2:15 PM, Surveyor interviewed Director of Nursing (DON) B and asked about expectations for hand hygiene during meals time in the dining room and assisting residents with applying jelly, and butter to toast. DON B indicated that hand hygiene should be performed and apply gloves when touching food. Based on observation, interview and record review, the facility failed to store, prepare and distribute food under sanitary conditions. Touching ready to eat foods with contaminated gloves had potential to affect 48 of 58 residents. Not taking temperatures of pureed and liquidized food. Improper hand hygiene by staff for R54, R27, R264 and R31. Bare hand touching of toast for 3 of 3 (R264, R11, R3) residents observed. Findings include: The facility policy, entitled Food Preparation and Service revised on November 2010, reads in part, Gloves can also become contaminated and/or soiled and must be changed between tasks. On 03/05/24 at 11:35 AM, Surveyor observed Dietary Aide (DA) T setting up trays for the tray line. DA T had gloves on, picked up a tray, then a meal slip, put a napkin and silverware on the tray, then with the same dirty gloves grabbed bread and placed it on the tray. On 03/06/24 at 9:53 AM, Surveyor interviewed Dietary Manager (DM) R and read the above observation to DM R and asked if that was the way bread should be served. DM R indicated that's the way DM R was trained when DM R started in the kitchen. On 03/05/24 at about 11:45 AM, Surveyor observed [NAME] S grab a piece of chicken with the same gloved hands cook was dishing up plates with. [NAME] S took the chicken off the bone with same gloved hands that had touched the plates and other contaminated surfaces. Then with the same contaminated gloves grabbed a knife and finished cutting up the chicken. [NAME] S did not change gloves and continued to serve up plates with the same contaminated and now greasy gloves. On 03/06/24 at 9:54 AM, Surveyor interviewed DM R and asked if Surveyor's observation was the appropriate use of gloves. DM R indicated no. The facility policy, entitled Food Temperatures reads in part Take and record the temperatures for all items at all meals. On 03/05/24 at 11:20 AM, Surveyor entered kitchen to watch [NAME] S take temperatures of food. [NAME] S took the temperatures of chicken, mashed potatoes and corn then asked if there was anything else Surveyor wanted to see [NAME] S take a temperature of. Surveyor asked [NAME] S if staff take temperature of the pureed food. [NAME] S indicated, Not really, it's really hot if you get splashed with it you would get burnt. On 03/06/24 at 9:57 AM, Surveyor interviewed DM R and asked if the kitchen staff is to be taking temperatures of the pureed food. DM R indicated yes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility did not ensure that a resident with a weight gain had the physician consulted for a change in treatment for 1 of 24 sampled residents (R50). R50 has diagnosis of edema and there is no evidence of physician notification with weight gain. Findings include: R50 was admitted to the facility on [DATE], and has diagnoses that include dementia, edema, muscle weakness, and stage 3 chronic kidney disease. R50's doctor orders included R50 to be weighed 2 times a week. On 11/21/22, R50 weighed 253.8 pounds. On 11/25/22, R50 weighed 261 pounds which is a 7.2 lb. weight gain in 4 days. There is no documentation in R50's progress notes that the physician was notified. Surveyor reviewed after visit summaries in R50's medical chart from Nurse Practitioner (NP) G. On 12/06/22, NP G saw R50 for a follow up visit, after visit summary read in part an increase in lower extremity (LE) swelling, family requested fluid restriction be lifted. NP G increased R50's Torsemide to 40 mg daily. The visit summary reveals the medical provider did adjust medications with noted increased edema, 11 days after noted weight increase that was not reported to the physician. Surveyor reviewed R50's weights. On 01/23/23, R50 weighed 254 pounds, on 01/27/23 at 3:37 AM R50 weighed 258 pounds, and on 01/27/23 at 7:14 AM R50 weighed 263 pounds which is a 9 pound weight gain in 4 days. There is no documentation in R50's progress notes that the physician was notified. On 02/07/23 at about 11:50 AM, Surveyor interviewed Director of Nursing (DON) B and asked what the guidelines were for notifying the physician if a resident has edema and a weight gain. DON B indicated that weight guidelines might be in the care plan, DON B looked at the care plan and indicated they were not in the care plan. DON B then reviewed the physician orders and indicated that there are no parameters in R50's physician orders. On 02/07/23 at about 12:35 PM, Surveyor interviewed Licensed Practical Nurse (LPN) E and asked if a resident with edema has a weight gain when would they notify the physician. LPN E indicated that if they have a weight gain of 5 pounds in a week they would notify the physician. Surveyor asked about the weight gain for R50 from 11/21/22 to 11/25/22 where R50 had a weight gain of 7.2 lbs. LPN E was looking at the medical record and indicated they would have to get back to Surveyor. On 02/07/23 at about 1:25 PM, Surveyor interviewed Registered Nurse (RN) F, who is also the Case Manager and asked if they would expect staff to contact the physician if a resident with edema has a weight gain of 7.2 pounds in 4 days. RN F indicated yes if it was significant. Surveyor asked RN F if the physician would have wanted to be notified of the weight gain. RN F indicated probably. Surveyor asked RN F who monitors resident weights. RN F indicated that the dietician is really good about monitoring the weights and if a resident's weight is flagged that the dietician is really good about contacting the Nursing Home Administrator (NHA) A and letting them know an assessment should be done. Surveyor asked RN F if R50's weights were flagged. RN F indicated while scrolling through R50's weights that it doesn't look like R50's weights were flagged. Surveyor asked RN F in R50's situation where there was a weight gain of 7.2 pounds in 4 days should staff have addressed this with the physician. RN F indicated yes.

Based on observation and interview, 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 during 1 of 2 observations of wound care. Registered Nurse (RN) C did not perform hand hygiene when changing gloves during R16's wound care treatment. This is evidenced by: Review of facility's policy titled Handwashing/Hand Hygiene, with revised dated of August 2019, read in part: .Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .b. Before and after direct contact with residents; .d. Before performing any non-surgical invasive procedures; .g. Before handling clean or soiled dressings, gauze pads, etc.; h. Before moving from a contaminated body site to a clean body site during resident care; .j. After contact with blood or bodily fluids; k. After handling used dressings, contaminated equipment, etc.: m. After removing gloves; . On 02/06/23 at 9:37 a.m., Registered Nurse (RN) C applied Personal Protective Equipment (PPE) appropriately before entering R16's room. RN C had a basket of supplies with cup of solution. RN C with bare hands gathered the garbage can from the bathroom. RN C did not perform hand hygiene and applied gloves and positioned R16. RN C removed the soiled wet pad and old dressing and removed gloves. RN C did not perform hand hygiene, applied clean gloves, placed a barrier under R16's buttocks, wet the gauze with the solution and applied to coccyx wound. RN C indicated the order is to soak the area for about 20 minutes and return to continue with treatment. RN C removed gloves and PPE and gathered garbage. RN C brought garbage to soiled utility room and brought garbage bin back to R16's room and sanitized hands. RN C returned at 10:00 a.m., applied PPE appropriately and entered room. RN C removed gauze and measured area and removed part of the wound packing. RN C removed gloves, did not perform hand hygiene and applied clean gloves. RN C cut and applied the aquacel into the wound with a cotton tip swab and applied a pad. Certified Nursing Assistant (CNA) D assisted RN C and rolled R16, and CNA D taped the pad into place. RN C and CNA D with the same gloved hands transferred R16 with the full body mechanical to the wheelchair. At 10:55 a.m., Surveyor interviewed RN C asking about when should hand hygiene be completed when providing wound care. RN C indicated sanitizing before applying PPE and when changing gloves and if gloves get soiled. When going from a dirty area to a clean area the gloves should be changed, and hands sanitized. Surveyor asked RN C when she was providing R16's wound care should hand hygiene be performed when observed removing gloves and applying clean gloves without hand hygiene. RN C indicated she did not have hand sanitizer near her and did not sanitize hands.