**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not report an alleged violation involving mistreatment/misconduct within 24 hours of the event to the State Survey Agency. This occurred for 1 of 3 residents (R) reviewed. (R1)An incident involving R1 and Registered Nurse (RN) C occurred on 07/17/25. RN C did not transcribe a physician order to discontinue an anticoagulant medication and administered the medication without a physician order. The facility did not report the misconduct to the State Survey agency until 07/24/25.The facility policy titled, Abuse - Alleged Incidents of Caregiver Misconduct and Injuries of Unknown Origin, dated May 2025, states, . All alleged violations involving, abuse, neglect, exploitation, mistreatment, misappropriation of a resident property or injuries of unknown source are to be reported immediately to the Administrator and the appropriate units DON of the facility no later than 2 hours after the allegation is made. All alleged violations will be reported, no later than 24 hours, to other officials (including the State Survey Agency .)R1 was admitted to the facility on [DATE] with diagnoses that include congestive heart failure, chronic blood clots in vein, anemia, ovarian and rectal cancer, and GI bleed. R1's most recent Minimum Data Set (MDS) dated [DATE] indicated that R1 has a Brief Interview for Mental Status (BIMS) score of 15/15 indicating intact cognition. R1 is able to eat with set up, independent with bed mobility, and requires partial moderate assistance for transfer and toileting.Misconduct occurred on 07/17/25 at 1841 (6:41 PM) and was discovered on 07/18/25. Misconduct incident report states, Resident [R1] was having some bleeding issues and was on anticoagulant medication. Nurse discussed with physician and received an order to discontinue the medication. Resident (R1) who is her own person insisted on getting the medication, per residents rights, nurse did administer the medication causing a medication error. The nurse was following resident wishes and did not follow doctor order.The initial facility reported incident was submitted to the state agency on 07/24/25 with the final report. Under the brief summary of incident, facility noted, Added this incident to the final report (submitted when did not have access to system) see follow up report. The initial report was submitted with the final report on 07/24/25 at 9:43 AM.On 08/11/25 at 12:55 PM, Surveyor interviewed Nursing Home Administrator (NHA) A and asked about the timing of the initial report. NHA A stated they were aware the initial report was late because there were a lot of issues going on at the same time and NHA A had trouble getting into the system.

Based on observation, record review and interview, the facility staff did not conduct hand hygiene when warranted while providing care to 1 of 3 residents observed for cares (R7). Certified Nursing Assistant (CNA) C did not perform hand hygiene when warranted when proving morning cares to R7. This is evidenced by: Surveyor requested and received the facility policy title Hand Hygiene-Employee which was dated as most recently revised on 9/24. The policy in part read: Policy: Hand hygiene continues to be the single most important thing employees can do to prevent the transmissions of infection. Consistent proper hand hygiene practices are critical in preventing the spread of infections. It is the policy of this facility that all employees follow proper hand hygiene techniques. Below is a list of some situations that require hand hygiene: ~Before and after resident contact. ~Before and after assisting a resident with toileting. ~Before putting on gloves. ~After removing gloves. On 11/12/24 at 6:46 AM, Surveyor observed CNA C assist R7 with her morning care. CNA C assisted R7 to the bathroom to sit on the toilet. CNA C washed her hands and donned gloves to remove R7's brief. R7's brief was soiled with bowel movement. CNA C obtained a clean brief from the cupboard in R7's bathroom. CNA C obtained garbage bags and placed R7's pants and soiled brief in bags. CNA C did not remove her gloves, perform hand hygiene and don clean gloves. CNA C applied lotion to R7's legs and feet and applied her tubi-grip stockings on her legs. CNA C placed R7's clean brief and clean pants on her legs. CNA C placed R7's shoes on and proceeded to sink to wet washcloths. CNA C washed R7's face after removing R7's top and bra. CNA C again wet washcloths at sink and applied soap to cloths. CNA C washed, rinsed and dried R7's back, under arms, under her breasts and her arms. CNA C did not remove her gloves, perform hand hygiene and don clean gloves and proceeded to place R7's bra, apply deodorant under her arms and don a clean shirt on R7. CNA C proceeded to brush R7's dentures at sink which were provided to R7 to place in her mouth. CNA C did not remove her gloves, perform hand hygiene and don clean gloves after washing R7's upper body and before proceeding to handle R7's dentures. CNA C removed her gloves, performed hand hygiene and donned clean gloves to brush R7's hair. CNA C placed a gait belt around R7's waist and wet and applied soap to cloths. CNA C used a peri wipe to wipe bowel movement from R7's buttocks after R7 was assisted to stand with walker. CNA C washed, rinsed and dried R7's buttocks. CNA C removed her gloves and tossed gloves to the garbage. CNA C did not perform hand hygiene and pulled up R7's brief and pants. CNA C walked R7 from the bathroom with walker and brought over R7's wheelchair to assist R7 to sit in wheelchair. CNA C removed R7's gait belt and brought R7 her glasses. CNA C proceeded to make R7's bed with her bare hands that had not been washed. CNA C returned to the bathroom to bag dirty linens. CNA C used hand gel and preceded to take R7's dirty linens to the soiled utility room. CNA C returned to R7's room and propelled R7 in her wheelchair from her room up the hallway. On 11/12/24 at 1:25 PM, Surveyor spoke with CNA C about the observation and expectations related to hand hygiene. CNA C indicated she should have removed her gloves, performed hand hygiene and donned clean gloves whenever going from dirty task to clean. Surveyor asked CNA C why hand hygiene should be done when going from dirty task to clean task. CNA C responded for infection control. On 11/13/24 at 7:55 AM, Surveyor spoke with Director of Nursing (DON) B about the observation and the facility expectation related to hand hygiene. DON B indicated she would expect staff to remove gloves, perform hand hygiene and don clean gloves whenever going from a dirty task to a clean task for infection control practices, to prevent the transmission of infection.

Based on observation, record review and interview, the facility did not ensure the handwashing sink in the facility kitchen maintained a minimal acceptable water temperature. The facility practice had the potential to affect all residents. The handwashing sink's water temperature in the facility kitchen reached 73 degrees Fahrenheit after being ran for 2 minutes. Culinary Staff Aide (CSA) D and Culinary Manager (CM) E indicated low water temperatures have been occurring for several months and staff continued to use the sink as their means of handwashing in the kitchen. This is evidenced by: Surveyor requested and received the facility policy titled Handwashing -Food Service which was dated as most recently revised 11/12/24 and 10/18/22, prior to the current survey. The policy in part read: How to wash hands: ~Wet hands and forearms with warm water (minimum 100 degrees Fahrenheit) and apply an antibacterial soap . Surveyor requested and received the facility standard of practice titled Food Service Management-By Design published by Association of Nutrition and Food Service Professionals which was dated as revised most recently in 2015. The standard of practice indicated in part: ~Dining services personnel must be provided a sink specifically intended for washing hands. ~Must provide water at a temperature of at least 100 degrees Fahrenheit . Surveyor also reviewed the Food and Drug Administration (FDA) Food Code dated as most recently updated in 2022. The FDA Food Code in part read: 5-202.12 Handwashing Sink, Installation. (A) A Handwashing sink shall be equipped to provide water at a temperature of at least 29.4 degrees C (85 degrees F) through a mixing valve or combination faucet. On 11/12/24 at 10:54 AM, Surveyor entered kitchen to observe food service. Surveyor went to the handwashing sink in the kitchen to perform handwashing and noted the water barely lukewarm. Surveyor ran the water for 2 minutes and requested CM E take the temperature of the water from the faucet. CM E filled a glass with the water and immediately took the water temperature. Surveyor and CM E observed the water to be 73 degrees Fahrenheit. After checking the water temperature, Surveyor spoke with CSA D about handwashing at the sink and the water's temperature. CSA D expressed she has worked in the kitchen since springtime and uses the sink for handwashing. CSA D indicated the water temperature has been cool off and on since she started in the kitchen. CSA D further indicated she cannot wait for water to warm up for 2 minutes thus she proceeds with handwashing when the water is turned on. Surveyor also spoke with CM E after checking the water temperature. CM E expressed the water temperature being lukewarm is not unusual since the sink was replaced in the spring sometime around February or March of 2024. CM E confirmed staff continued to use the sink as their means of handwashing in the kitchen after the sink was replaced even though the temperature of the water was lukewarm off and on.

Based on interview and record review, the facility did not ensure accurate reporting of the mandatory submission of staffing information based on payroll data to the Centers for Medicare and Medicaid Services (CMS). This has the potential to affect all 31 residents residing in the facility. The facility failed to enter accurate data in their Payroll Based Journal (PBJ) system which triggered that they failed to have licensed nursing coverage on 6 days. This is evidenced by: Centers for Medicare & Medicaid Services (CMS) Electronic Staffing Data Submission Payroll-Based Journal, Long-term Care Facility Policy Manual, dated June 2022, states in part: Chapter 1: Overview, 1.1 introduction .(U) mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS.1.2 Submission Timelines and Accuracy. Direct care staffing and census data will be collected quarterly and is required to be timely and accurate . Report Quarter: staffing and census data will be collected for each fiscal quarter. Staffing data includes the number of hours paid to work by each staff member each day within a quarter. Census data includes the facility's census on the last day of each of the three months in a quarter. The fiscal quarters are as follows: Fiscal Quarter, Date range: 1 October 1 - December 31, (quarter 1) 2 January 1 - March 31, (quarter 2) 3 April 1 - June 30, (quarter 3) 4 July 1 - September 30 (quarter 4) . PBJ Staffing Data Report, CASPER Report (Certification and Survey Provider Enhanced Reports) 1705D for Fiscal year Quarter 3 2024 (April 1 - June 30), ran on 11/06/24 indicates the following: failed to have Licensed Nursing Coverage 24 Hours/Day Triggered = Four or More Days Within the Quarter with <24 Hours/Day Licensed Nursing Coverage. See Infraction Dates on Page 2, if triggered. Infraction Dates 04/14 (SU); 04/21 (SU); 05/25 (SA); 06/08 (SA); 06/09 (SU); 06/23 (SU). On 11/11/24 at 2:00 PM, Surveyor interviewed Nursing Home Administrator (NHA) A related to the triggered days for licensed nursing coverage. NHA A stated she was certain this was caused by a data entry error. NHA stated that they had licensed staff working and would provide the needed information. NHA A would provide scheduled staff postings, and payroll data, which proved staff worked, and would determine where the reporting errors occurred. On 11/11/24 at 3:30 PM, the facility provided evidence to show that staff had worked and where the errors in reporting occurred, which included the following information: 6.85 hours from the night shift of 04/13/24 did not show on the 4/14/24 report. 6.47 hours manually entered on 04/19/24 actually belong on 04/20/24. 6.48 hours manually entered on 04/20/24 actually belong on 04/21/24. 6.78 hours were not entered on 05/25/24 report. 8 hours on 06/08/24 and 8 hours on 06/09/24 were entered into the wrong facility's PBJ system instead of this facility's system. 7.25 hours worked by agency staff on the night shift did not carry over to the 06/23/24 report.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring all allegations of abuse were reported immediately to the administrator or ensure the reporting of a reasonable suspicion of a crime in accordance with section 1105B of the Act to law enforcement for 1 of 3 residents (R) reviewed. This is evidenced by: The facility policy entitled Abuse-Alleged Incidents of Caregiver Misconduct and Injuries of unknown Origin, dated 11/09/2016 last revised 10/23 states in part, All staff will be trained to immediately report to the administrator or designee, Any form of abuse, . should be reported immediately to the Administrator or Director of Nursing. The Elder Justice Act requires notification of local law enforcement authorities of any situation where there is a potential criminal offense. R1 was admitted to the facility on [DATE] and has diagnoses that include mild cognitive impairment, anxiety disorder, and chronic respiratory failure with hypoxia. R1's progress notes dated 11/21/23 at 1941 state in part that after returning to her room following supper, Certified Nursing Assistant (CNA) C was assisting R1 with her cares when R1 slapped CNA C across the face. R1 was convinced, screaming that she was inappropriately being touched. R1 stated that she wanted to call the police. R1 was wondering why no one believed her and also stated she was scared. Licensed Practical Nurse (LPN) D documented that it took some convincing that R1 was safe here and that no one here would ever try to hurt her, but R1 still remains adamant that everyone was out to get her. Surveyor interviewed Nursing Home Administrator (NHA) A on 11/30/23 at 12:45 PM. Surveyor asked when NHA A was informed of the allegation of abuse. NHA A stated that she was not informed of the allegation of abuse until the next day, after it occurred. When Surveyor asked if the police were informed of the allegation, NHA A stated that they were not notified. When asked if the facility policy includes informing the police, NHA A stated that the facility policy states to contact the police.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not prevent further potential abuse or mistreatment while an investigation was in progress, after an allegation of mistreatment was made against Certified Nursing Assistant (CNA) C. This is evidenced by: The facility policy and procedure entitled Abuse-Alleged Incidents of Caregiver Misconduct and Injuries of unknown Origin, dated 11/09/2016 last revised 10/23 states in part, Immediately upon learning of an incident of resident mistreatment or discovering an injury of unknown source, nursing staff must take the necessary steps to protect all residents from possible subsequent incidents of mistreatment, neglect, exploitation, or injury by removing the individual under suspicion from duty until the investigation is completed. R1 was admitted to the facility on [DATE] and has diagnoses that include mild cognitive impairment, anxiety disorder, and chronic respiratory failure with hypoxia. R1's progress notes dated 11/21/23 at 1941 state in part that after returning to her room following supper, CNA C was assisting R1 with her cares when R1 slapped CNA C across the face. R1 was convinced, screaming that R1 was inappropriately being touched. R1 stated that she wanted to call the police. R1 was wondering why no one believed her and also stated she was scared. Licensed Practical Nurse (LPN) D documented that it took some convincing that R1 was safe here and that no one here would ever try to hurt her, but still remains adamant that everyone was out to get her. On 11/30/23 at 1:50 PM, Surveyor interviewed the Director of Nursing (DON) B. Surveyor asked if CNA C had been removed from providing cares to residents following the allegation of mistreatment. DON B stated that CNA C did not provide any further cares to R1 and that R1's care plan was changed to No male care givers. DON B stated that according to the facility policy CNA C should have been sent home until the investigation was completed, but that was not done. When asked what time CNA C actually worked until that night, DON B stated that she could pull CNA C's time punches to see when he worked until. A short time later DON B returned with the time punch details for CNA C which showed that CNA C worked until 6 AM on 11/22/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility did not provide necessary treatment and services, consistent with professional standards of practice, related to comprehensive weekly assessments of Pressure Injuries (PI) for 1 of 1 residents (R21) reviewed. R21 was admitted to the facility with multiple wounds, including a Stage III PI to the right heel. The facility did not complete weekly wound assessments of R21's wounds. This is evidenced by: According to the NPIAP (National Pressure Injury Advisory Panel) a comprehensive wound assessment should be completed weekly and should consist of the following information: - location of the wound; - category/stage of the wound; - size of the wound; - tissue type(s); - description of the wound bed and periwound; - a description of the wound edges; - the presence of any sinus tracts, undermining or tunneling; - the presence of exudate or drainage; - the presence of necrotic tissue or slough; - the presence of odor; - the presence/absence of granulation tissue and/or epithelialization; and - the current treatment being utilized. *According to the NPIAP/EPUAP, Weekly assessments provide an opportunity for the health care professional to detect early complications and the need for changes in the treatment plan. R21 was admitted to the facility on [DATE]. Medical Diagnoses for R21 include but are not limited to Congestive Heart Failure, Renal Failure, Diabetes Mellitus, Autonomic Neuropathy, Venous Insufficiency, Edema, Pressure Ulcer Right Heel Stage 3, Pressure Ulcer Right Buttock- Stage II, Pressure Ulcer Left Buttock- Stage II, Pressure Ulcer of Other Site- Stage II (Scrotum), Pressure Ulcer of Other Site- Stage 1 (Left Inner Thigh), Pressure Ulcer of Left Heel- Stage I, Acquired Absence of Left Second Toe and right fifth toe, Hypertensive Heart and Chronic Kidney Disease Stage 3, Atrioventricular Block- Second Degree and Age-Related Physical Debility. According to the admission Minimum Data Set Assessment (MDSA) completed for R21, dated 9/1/22, R21 had a Brief Interview for Mental Status score (BIMS) of 15, indicating that R21 is alert and oriented with full cognitive abilities. This MDSA also indicated that R21 has no behaviors associated with refusal or rejection of cares and treatments. R21 also was assessed on this MDSA as requiring extensive assistance of staff for such areas of bed mobility, bathing, dressing, personal hygiene, toileting assistance and transfers. R21 is non-ambulatory and has limitations in Range of Motion of both upper and lower extremities. R21 is incontinent of bowel function and has an indwelling Foley catheter for urination. According to this MDSA, R21 was assessed as having two Stage I PI's, three Stage II PI's and one Stage III PI upon admission. The Care Plan (CP) devised for R21 identified the following: 1. Self Care Deficit related to a lack of feeling in the legs and feet and decreased feeling in the hands due to neuropathy. This CP indicated that R21 needs extensive assist with cares and that R21 was able to direct his own cares. This CP indicated that R21 sleeps in a recliner chair rather than a bed and does not like to be positioned onto his sides. 2. Impaired Skin Integrity and the potential for further skin breakdown related to infrequent repositioning due to resistance, neuropathy with impaired sensation in both upper and lower extremities, kidney disease, diabetes, dry skin, edema and dependence on others for assistance with cares. This area of the CP indicates the presence of multiple areas of skin breakdown, including Stage II PI's on right and left buttocks, Stage III PI on the right heel and also skin impairment on left outer ankle, scrotum, glans penis, shins, and anterior ankle. In reviewing the CP interventions, Surveyor noted appropriate approaches were in place to assist in the prevention of further breakdown and the healing of current skin issues. On 10/10/22 at 2:28 PM, Surveyor approached R21 for interview and requested permission at that time to observe the treatments completed by nursing of his wounds. R21 granted permission on this date. On the morning of 10/11/22 at 7:19 AM, when the treatment was to be completed, R21 requested Surveyor to not observe, stating, I would prefer you didn't. As a result of R21's request, Surveyor relied on interviews and record reviews to determine the healing or progression of R21's wounds. R21 was noted throughout the survey to be either sitting or reclining in his chair. On 9/1/2022, the facility completed a Braden PI Risk Assessment for R21 and scored R21 as 15, indicating a mild risk for PI development. Physician dictation dated 8/31/22 (admission to this facility): - Left buttock stage II 5 cm (Centimeters) x 4 cm with no depth calculated - Right buttock stage II 5.0 cm x 10.0 cm - Scrotum three small blisters - Right Heel stage III 1 inch x 0.75 inches (not measured according to standards of practice in centimeters for consistency) - Left Heel stage I 1 cm x 1.5 cm Note calculations were from previous facility in Minnesota and not from this facility. Surveyor reviewed treatment orders for R21's wounds and noted they were appropriate and when nursing documented worsening of the wounds the treatments were altered accordingly. Also of note, the facility implemented Arginaid and supplements to enhance wound healing. Of concern is that the facility did not complete comprehensive weekly assessments of R21's wounds. The following assessments were located and reviewed: - 8/25/22: admission Located on a Weekly Skin Assessment 1. Right Heel: 3.7 cm L (Length) x 2.7 cm W (Width) Stage III 2. Left Outer Ankle (Lateral) circular 1 cm diameter blister 3. Right Buttock: 18 cm L x 71 cm W Stage II Note: there was no correction for this entry, which indicates an error in measurement as 71 cm is comparable to 27 inches or 2.3 feet wide, which is substantially wider than R21. 4. Left Buttock: no measurements 5. Scrotum blister: Unstageable with no measurement of size 6. Glans penis: - Blister: Length = 0.7, Width = circular Unstageable This assessment is not a comprehensive assessment including the description of each wound. Without a comprehensive assessment, nurses completing future assessments cannot formulate a critical nursing analysis of wound healing or worsening to determine if treatments or interventions need to be adjusted. There also was no measurement of the Left Heel wound with this assessment. On 8/31/22, Surveyor noted the following measurements located on a Weekly Skin Assessment: 1. Right Heel: 1 inch L x .75 inch W stage III 2. Left Heel: 1.0 cm L x 1.5 cm W 3. Right Buttock: 5.0 cm L x 10.0 cm W stage II 4. Left Buttock: 5.0 cm x 4.0 cm stage II There was no comprehensive assessment including the description of each wound. This entry also does not indicate the status of the Glans Penis, scrotum, or left ankle wounds. There are no notes or assessments for the dates of 9/7/22, 9/14/22 or 9/21/22. There were no other Weekly Skin Assessments completed for R21. However, Surveyor did locate measurements of the following in the Interdisciplinary Progress Notes (IDTPN's): - 9/23/2022 11:30 Skin/Wound Note Data: Area to R heel measures 2.5 x 3.0 cm circular L heel measures .75 x .75 cm circular. Both sites cleansed with NS and calcium alginate applied and wrapped. Area is crusted and scabbed . This is not a comprehensive wound assessment and it does not indicate the condition or size of the right and left buttocks or the Glans Penis, Scrotum or left ankle. - 9/30/2022 13:17 Skin/Wound Note Late Entry: Data: Open area to buttock measures 1.3 cm X 2 cm area no s/s of infection noted new butterfly Mepilex applied. Open area right heel measures 2.2 cm X 1.2 cm moderate amount of discharge noted to old dressing, new dressing applied no s/sx of infection noted. Open area to left heel measures 1 cm X 1.5 cm no discharge noted to old dressing, no s/sx of infection noted new dressing applied This entry does not decipher between the left or right buttock and also does not include measurements of the left or right heel, Glans Penis, Scrotum or Left Ankle wounds. - 10/7/22 Skin/Wound Note Data: Resident has stage 3 wound to right heel. Measurements are 1.8 cm x 1 cm. Peri area is dry with small amount of scabbing noted to edge. Small amount of serousanguineous drainage on old dressing. No odor present. Wound bed is clean. Left heel is dry scabbed over wound bed. No drainage present on old dressing. Outer edges of scabbed area is 1.0 cm x 1.4 cm . The assessment does not include the wounds on the Glans Penis, Scrotum, right and left buttocks, or Left Ankle. Missing is an assessment of these areas for the date of 10/5/22. A second entry was documented on this same date: - 10/7/2022 10:58 Skin/Wound Note Data: Resident has excoriated area to buttocks. Left buttocks area measures 6 cm x 6 cm. Right buttocks measures 7 cm x 7 cm. Has a spot on right buttocks that is open measuring 3 cm x 0.5 cm . No detailed comprehensive assessment completed and no details of other wounds On 10/11/22 at 11:00 AM, Surveyor interviewed R21 again regarding his wounds. R21 stated that he doesn't sleep in the bed because he experiences too much pain in his shoulders and he prefers to sleep in the recliner. When questioned on whether staff reposition him in the recliner, R21 stated, Well, I will tell you that they do encourage me to do so. I am not always favorable to that. I am not comfortable on my side in the chair. They do stand me several times during the day and two or three times during the evening shifts with a standing lift. But, quite honestly, I refuse more often than I accept. I just don't wish to be disturbed when I am comfortable. At 1:01 PM, Surveyor interviewed Director of Nursing (DON) B regarding wound assessments. DON B stated there is no wound nurse in the facility and it is the responsibility of the Day Shift nurse to complete dressing changes and weekly wound assessments. They then document on the Skin wound notes. DON B stated that she maintains a wound log, stating, . I review the wound notes daily and go through my log, I keep in a binder in my office. I will make changes in my log according to the nurses assessment and I also go out on the floor and update the nurses and tell them who needs an assessment and to document it . Surveyor and DON B reviewed the assessments that were located for R21, and the inconsistent location of assessments, as some were in the IDT PN's and some were on Weekly Skin Assessments. DON B stated nursing should be assessing wounds every week. DON B also indicated the facility will need to educate on where nursing should document wound assessments for consistency.

Based on interview and record review, the facility did not ensure 1 of 3 Certified Nursing Assistants (CNAs) randomly reviewed, underwent annual competency skills checks and performance reviews to ensure they had the skill sets to assure resident safety and maintain the highest practicable physical, mental and psychosocial well-being of each resident. This is evidenced by: As part of the Sufficient and Competent Nurse Staffing task, Surveyor randomly selected three CNAs to review for competency skills checks and performance reviews to determine proficiency in required areas of resident care, such as resident rights, preventing and reporting abuse/neglect, dementia management, person-centered care, and communication, as well as providing basic cares such as bathing, dressing, oral care, providing toileting assistance, repositioning, restorative care, mobility assistance, and identification of changes in condition. The three randomly selected staff members were: 1. CNA J: was hired on 9/14/22. 2. CNA K: was hired on 8/14/20. 3. CNA L: was hired on 5/19/22. There were no annual skills check or performance review completed for CNA K. On 10/12/22 at 1:43 PM, Surveyor interviewed Director of Nursing (DON) B regarding the facility process for verification of CNA annual competency and performance reviews. DON B stated that she does not have annual skills checks and performance reviews for CNA K.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Example 3 Resident (R) 5 was admitted to the facility on [DATE], with diagnoses including, in part, Alzheimer's disease and unspecified cerebrovascular disease. R5's Minimum Data Set (MDS) assessment, dated 10/08/22, identified staff was unable to complete a Brief Interview for Mental Status. This indicated R5 had a severe cognitive impairment. The MDS assessment further indicated R5 had no behaviors exhibited during the assessment period. Review of R5's medical record identified the following physician's order, quetiapine fumarate (antipsychotic medication), give 25 milligrams by mouth twice per day for behavioral disorders associated with dementia. Record review identified a recommendation, dated 05/31/22, for gradual dose reduction (GDR) of the quetiapine due to risk of adverse side effects from the use of antipsychotic medications for residents with dementia. The physician declined the recommendation, stating attempted dose reductions in the past resulted in poor behaviors returning. On 10/10/22 at 10:45 AM, Surveyor observed R5 sitting in a Broda chair at the table in the Meadow dining room. R5 was occasionally mumbling unintelligible words, but otherwise sitting still and quiet. On 10/11/22 at 11:05 AM, Surveyor observed R5 sitting in a Broda chair in the Meadow dining room holding a doll. R5 was occasionally mumbling unintelligible words. No behaviors observed. On 10/11/22 at 2:12 PM, Surveyor observed R5 sitting in a Broda chair in the courtyard picking at dead flowers in a planter. No verbalization or behaviors noted. Review of R5's medical record did not identify any daily behavior monitoring or regular evaluations of quantity and quality of behaviors, or response to antipsychotic medications. On 10/12/22 at 8:04 AM, Surveyor interviewed CNA D, who stated R5 did not have any behaviors. CNA D stated they were not monitoring for, or documenting any behaviors for R5 at this time. On 10/12/22 at 10:18 AM, Surveyor asked DON B for behavior monitoring documentation for R5. No regular behavior monitoring with monthly review of quantity and quality of behaviors was received. DON B stated they did not do monthly behavior meetings to evaluate behaviors and response to psychotropic medications. Based on observations, interviews and record reviews, the facility did not ensure 3 of 4 residents reviewed for psychotropic monitoring (R4, R14 and R5) were receiving these medications based on clinical needs. R4, R14, and R5 did not have behavior monitoring completed to justify usage. This prevented the nurse from making a qualitative and quantitative critical nursing analysis of the residents' behaviors and a determination on whether the medications were effective or required adjustments. This is evidenced by: On 10/12/22 at 7:48 AM, Surveyor interviewed Director of Nursing (DON) B related to behavior monitoring and the facility's process for justification for the usage of psychotropic medications. DON B stated, We don't hold monthly behavior meetings in which we discuss medications and behaviors. We do morning meetings and when a resident does have some behaviors during the day or night, it is brought up then. There really is no formal behavior monitoring completed other than our morning meetings. When asked if there is a quantitative and qualitative review of each resident's behaviors to determine if psychotropic medications were effective or in need of adjustment, DON B stated that there currently is not. Example 1 R4 has medical diagnoses that include but are not limited to Anxiety Disorder with Depression and Mood Disorder. The most recent Minimum Data Set Assessment (MDSA) completed for R4 was a Quarterly assessment dated [DATE]. According to this MDSA, R4 has a Brief Interview for Mental Status (BIMS) score of 5/15, indicating advanced cognitive impairment. R4 is also coded as having no behaviors. A review was then completed of the previous two MDSAs, a significant change in status assessment dated [DATE] and a Quarterly assessment dated [DATE]. Each of these assessments also indicate that R4 had no behaviors during those assessment periods. Surveyor then reviewed the Care Plan for R4. The following problems were included: 1. Potential for Alteration in Mood/Behavior related to Loss of independence Manifested by Per my wife, the reason I am on Duloxetine is because I have anxiety and dementia as well as hallucinations and delusions of seeing bugs and thinking they are crawling all over me. I have also had some feelings that I am losing my rights to live. Manifested by the Presence of mood indicators and use of psychotropic medications - NOTE: Pharmacist recommendations of Gradual Dose Reduction (GDR) of medications have been declined by my primary physician as she feels that reduction would result in the return of unstable/impulsive behaviors. - Mood Indicators: I have reported that I have/had: little interest or pleasure in doing things; felt down, depression or hopeless; had trouble falling or staying asleep; felt tired or had little energy; felt bad about myself; had trouble concentrating; had thoughts that I would be better off dead or of hurting myself in some way. When questioned about whether or not I had a plan to hurt myself, I stated yes but would not say what I would do or would talk about flying out the window but then I would fall. My mood indicators and their frequencies tend to fluctuate from day-to-day and even throughout the day. - Mood/Behavior: I am usually pleasant and like to joke and visit but I am also disruptive - yelling/calling out and may resist/reject cares at times. I am also unkind at times and have said things like, I thought I got rid of you yesterday - you're a pain in my a--. I have also had delusions and hallucinations, mostly in regard to my parents and dog, all of whom I believe are still alive when they are not. In reviewing the medication regimen for R4, Surveyor noted that included in the daily medications administered were the following: A. Antipsychotic Seroquel, 25 Milligrams (MG) one tablet in the evening for Dementia with Behavioral Disturbance. Initiated 12/5/21. Note: The Pharmacy Consultant completed a review of R4's medications 5/31/22 and again 6/25/22 as a response to a recent fall, and recommended GDR of the Seroquel. In response to the recommendation of 5/31/22, MD wrote: Previous attempts at dose reductions has resulted in uncontrolled harmful behaviors. Dated 6/10/22 In response to the 6/25 recommendation, MD wrote on 6/28/22, Patient is not ambulatory, fall was a roll out of bed. Currently stable and adjustments in past has resulted in poor behaviors. B. Antidepressant 1. Duloxetine HCl Capsule Delayed Release Particles 30 MG, Give 1 capsule by mouth one time a day for Depression To be given with a 60 mg to total 90 mg 2. Duloxetine HCl Capsule Delayed Release Particles 60 MG, Give 1 capsule by mouth one time a day for Depression To be given with a 30 mg to total 90 mg On 1/14/22, the Duloxetine was increased to 90 MG QD (every day) related to an increase in angry behaviors. Original order was 60 MG (12/5/21) QD Mood scores were then reviewed and Surveyor noted the following: - 6/13/22= 3 - 7/6/22=7 - 10/6/22=6 Frequent observations were conducted by Surveyor throughout the survey in which R4 repeatedly yelled out when he was in bed. On 10/11/22 at 1:00 PM, Surveyor interviewed DON B regarding the use of psychotropic medication use and the facility process for determining justification, including behavior monitoring. DON B stated R4 has never had a reduction in the Duloxetine, only an increase. What happened was that we had two different pharmacies. The first made a recommendation to schedule a GDR on 6/15/22 then we switched over to our current pharmacy and they scheduled it to be addressed 9/15/22 but they didn't do it either. So what they were doing was sending me and (sister facility) the reports all mixed in together instead of separating the two facilities. We could not keep up with reviewing the reports, receiving sometimes 50-60 reports. So, many did not get addressed with the physicians. We then did talk to them and the pharmacy now separates the two facility reports. DON B further stated, So, (R4's) doctor never did receive the recommendation to decrease the Duloxetine, or to address its continued use. There also was no report to flag us that it needed to be addressed because of the change over in the pharmacies. On 10/12/22 at 9:40 AM, Surveyor interviewed Certified Nursing Assistant (CNA) O regarding R4's behaviors. CNA O stated that R4 . can be a handful, has good days and bad days. He yells at us, pounds on the chair, pushes things away. He is very demanding of attention. Sometimes can be verbally abusive to us. Surveyor then asked CNA O how R4's behaviors are documented and tracked. CNA O stated, We document the behaviors in the computer and report to the nurse and she documents on them in her charting. Surveyor then requested CNA O to look up R4's behaviors in the computer where she would document. There was no area located in which CNA staff were to document R4's behaviors. Of concern is, there was no behavior documentation located that indicates a thorough critical nursing analysis was completed of R4's behaviors and the medications he is receiving. Example 2 R14 has medical diagnoses that include but are not limited to Alzheimer's Disease, Dementia with Behavioral disturbance, Major Depressive Disorder, Anxiety Disorder, Personality Disorder and Delusional Disorder. R14 has both short-term and long-term memory impairment and severe decision-making abilities. In reviewing the Minimum Data Set Assessments (MDSAs) completed for R14, the following was noted: 1. admission dated 12/12/21: - No behaviors - Mood 10/27 - Antipsychotic and Antidepressant use 2. Quarterly dated 3/7/22 - No behaviors - Mood 7/27 - Antipsychotic and Antidepressant use 3. Quarterly dated 6/6/22 - No behaviors - Mood 6/27 - Antipsychotic and Antidepressant use 4. Quarterly dated 8/2/22 - No behaviors - Mood 7/27 - Antipsychotic and Antidepressant use There has been no Gradual Dose Reduction (GDR) attempted or documented as being clinically contraindicated on any of the above four MDSAs. Surveyor then reviewed R14's Care Plan and noted the following: 1. Alteration in Mood/Behavior related to Dementia, anxiety, depression, personality disorder, delusional disorder manifested by a history of exit-seeking, suicide threats, threats to harm staff and wife, restlessness, agitation, resistance to cares manifested by the need for use of antidepressant and antipsychotic medications to manage my depression, anxiety, and behaviors STRENGTH: Medication reductions have taken place. Risperidone reduction 10/15/20 but unsuccessful due to increase in anger, agitation, annoyance with any stimulation, repetitive vocalizations; dose increased back to previous dose 10/19/2020. STRENGTH: Successful reduction of one of my antidepressants - Trazodone - dose was decreased on 08/20/20 for one week and then discontinued. - Interventions to lessen my potential for or actual mood/Behavior symptoms: 1. Offer/provide one on one for me to express my feelings/thoughts/concerns. 2. Encourage involvement in daily decision making 3. Reinforce strengths 4. Report pain indicators 5. Report changes in ability 6. Invite and assist with activities 7. Encourage reminiscence 8. Medication use - MOOD INDICATORS: (MDS) I have reported and/or indicated that I have/had: little interest or pleasure in doing things; felt tired and/or had little energy; trouble concentrating on things; being short-tempered/easily annoyed. These indicators and their frequency tend to fluctuate. - MOOD/BEHAVIOR: I am at increased risk for mood and behavior issues. I have a history of delusions and being verbally abusive. I could get angry very quickly and it was often difficult to distract me. - Allow me time to answer questions and to verbalize myself if I should attempt to do so. - Observe for and report to nurse any behaviors such as: tearfulness, anxiousness, pacing, wandering, exit-seeking behavior, making negative statements about wanting to be here, decrease/lack of social interaction with others (withdrawn) - Encourage and assist me with making own decisions regarding daily care. - Engage me in conversation with team members and other residents daily. - Engage me/my family/caregivers in discussion about care and living environment: discuss procedures, treatments, medications, and changes in condition as needed/desired. - Adjust personal care needs according to my changing abilities. Encourage participation to the extent I wish to or am able to be involved. - Trials to reduce my medications as indicated. A review was then completed of R14's medication regimen. Included in his administration use were the following medications: A. Antipsychotic- 1. Risperidone Tablet 0.25 MG, Give 1 tablet orally two times a day for dementia with behavioral disturbances. give with 0.5 mg for total dose = 0.75 mg (12/5/21) 2. Risperidone Tablet 0.5 MG, Give 1 tablet orally two times a day for dementia with behavior disturbances. to be taken with 0.25 mg for total dose = 0.75 mg (12/5/21) The Consultant Pharmacist completed a review of R14's Risperidone on 5/31/22 and recommended the following: . receives Risperdal 0.75 mg two times daily for expressions or indications of distress related to dementia (e.g., Behavioral and Psychological Symptoms in Dementia, dementia with psychosis). RECOMMENDATION: Please attempt a gradual dose reduction (GDR), with the end goal of discontinuation . R14's Physician responded on 6/10/22 Previous dose reduction resulted in return of poor behaviors that were difficult to control. B. Antidepressant: Sertraline HCl Tablet 50 MG, Give 1 tablet by mouth in the evening for dementia with behavioral disturbances. (12/8/21) Pharmacy Consultant reviewed the Sertraline on 6/25/22 and requested a GDR of the Sertraline to 25 MG QD dose. MD responded 6/28/22 Previous attempts at dose reductions has resulted in uncontrolled behaviors including yelling out, poor appetite and sleep patterns. Continue. The Physician did note in dictation on 7/12/22 that, . mood and behaviors related to advanced Dementia appear to be stable with Risperidone and Sertraline. Overall doing well and we will continue with patient's current plan of care without any changes . Frequent observations were made of R14 throughout the survey and noted that R14 does not manifest any behaviors. R14 was always noted to be sitting in the Broda chair either in his room or in the dining room and always appeared asleep with the exception of meal service. On 12/12/22 at 9:40 AM, Surveyor interviewed CNA O regarding R14's behaviors. CNA O stated that R14 really doesn't have any behaviors. She stated he . screams occasionally. He really doesn't communicate and when he screams out, it's most likely related to being incontinent of bowel. Years ago, he had some aggressive behaviors . Surveyor then requested CNA O to look up R14's behaviors in the computer where she would document. There was no area located in which CNA staff were to document R4's behaviors. There was no behavior documentation located that indicates a thorough critical nursing analysis was completed of R14's behaviors and the medications he is receiving.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility did not ensure 4 of 4 residents reviewed (R6, R4, R14 and R17) received appropriate treatment and services regarding implementation of their written restorative programs. - R6 was to ambulate twice daily as part of his Restorative Program. This exercise was not consistently followed through. - R4 was to receive Range of Motion exercises with the use of weights. This was not being completed. - R14 was to receive Range of Motion to upper and lower extremities. This was not being completed. - R17 was to receive Range of Motion exercises to the right upper extremity. This was not being completed. This is evidenced by: On 10/12/22 at 11:10 AM, Surveyor interviewed Director of Nursing (DON) B regarding Restorative programs. DON B stated therapy evaluates residents upon admission or if a resident declines in their ambulation status, the Physician is updated and may sometimes order therapy to work with the resident. Once therapy is finished, they may recommend a Restorative Program for the resident, which is carried out by the Certified Nursing Assistant (CNA) staff. DON B stated that the Night Shift nurse is the facility Restorative Nurse and she puts together an individualized plan for each resident that therapy recommends. DON B stated the Restorative Nurse enters the plan into the CNA Computer Charting and the information is communicated to the CNAs through internal messaging and, often copies of diagrams of exercises the resident is to be doing, are placed into the Restorative Binder at the CNA charting station. Sometimes, diagrams of exercises are also placed on the bulletin boards in the resident's room. For the first four weeks, the Restorative Nurse monitors the new program weekly and may make changes in response to how many repetitions should be done or complaints of pain a resident may be experiencing with exercise. The nurse may make alterations dependent on the resident's response. DON B further stated, at the end of each month, the Restorative Nurse then is to evaluate the progress or effectiveness of the program for each resident and make changes to the plan if needed. It is her responsibility to monitor that the program is being done and to document in the Interdisciplinary Team Progress Notes (IDTPNs). Example 1 R6 has medical diagnoses that include but are not limited to Alzheimer's Disease with Late Onset, Neuralgia and Neuritis, Periprosthetic Fracture around Internal Prosthetic Ankle Joint, Right Elbow Arthropathy and Presence of a Right Artificial Knee Joint. The facility's most recent Minimum Data Set Assessment (MDSA) completed for R6, was a quarterly assessment dated [DATE]. According to this assessment, R6 has a Brief Interview of Mental Status (BIMS) score of 10/15, indicating minor cognitive impairment. Also according to this MDSA, R6 has no behaviors and is independent with bed mobility and transfers, and has limitations of upper and lower extremities on the right side. R6 also requires assistance of staff to ambulate in the hall with a front wheeled walker but has not ambulated during this MDSA assessment period. Surveyor reviewed R6's Care Plan (CP) for Restorative programs or therapy and noted the facility identified R6 for the following: 1. Alteration in Mobility Restorative Maintenance Strength. - Encourage me to participate in my restorative/maintenance program every day and praise my accomplishments. - Encourage me to walk every day and praise my accomplishments. - Nurse review and document at least monthly - Nursing Rehabilitation: Walking 1 On the unit with fww (full wheeled walker) up to 200 feet, three times daily every day. (initiated 6/3/22). On 10/10/22 at 9:45 AM, Surveyor interviewed R6 and noted there were limitations of his right shoulder, which was visibly deformed. R6 stated that walking is difficult with his knees as he has broken both of them over the years. He stated that there is pain associated with them but They aren't going to change it; I've had this for years. R6 further stated that . One day I was out shoveling, and was in a hurry and I fell. I landed on both my knees and this shoulder (right). That was years ago . Surveyor then reviewed Restorative documentation from 7/1/22 - 10/13/22 and noted the following: July 2022: There were 62 shifts in which R6 should have been ambulated (every day, twice each day). - Four shifts were documented that R6 was ambulated - three shifts documented resident refused Of the remaining 55 shifts, staff documented either 0 minutes or Not Applicable. August 2022: There were 62 shifts in which R6 should have been ambulated - Four shifts in which R6 was ambulated - Seven shifts in which it was documented that R6 refused, all on Evening Shift Of the remaining 51 shifts in which R6 was to be ambulated, staff documented either 0 minutes or Not Applicable. September 2022 (60 shifts) - Four shifts in which R6 was ambulated - Five shifts in which it was documented that R6 refused, all on Evening Shift Of the remaining 51 shifts, in which R6 was to be ambulated, staff documented either 0 minutes or Not Applicable. On 10/12/22 at 9:31 AM, Surveyor approached R6 again and asked him what exercise program he has in place. R6 stated, I am supposed to walk down the hall. They don't walk me. The walker is sitting there (points to a walker that is resting against wall) waiting for them to walk me but they don't have the time. I am supposed to walk up and down the hallways. I walk a little in my room from the bathroom to the window when I can. If I didn't I would lose that ability, and I don't want to get worse. I want to get better. At 9:40 AM, Surveyor interviewed Certified Nursing Assistant (CNA) O. CNA O was employed by the facility for 7 years. Surveyor asked CNA O what restorative program is being completed for R6. CNA O stated, We don't really do anything with him. He's pretty mobile, walks in his room, can walk by himself in the hall. CNA O was then asked by Surveyor to check in the computer charting on whether R6 has a program and if so, what R6's program consisted of. In reviewing the computer record, CNA O stated, I guess we are supposed to ambulate him in the hall. His chart states to ambulate up to 200 feet in the hall three times a day. I didn't know that. Surveyor then reviewed nursing documentation for the past 4 months that was to be completed by the Restorative Nurse and noted that there was none completed from 6/1/22 to present. Example 2 R4 has medical diagnoses that include, but are not limited to Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left (non-dominant) side, Primary Osteoarthritis of Knee and Left Hip, Low Back Pain, Right Hip Trochanteric Bursitis, Intervertebral Disc Degeneration- Lumbar Region, Spondylosis of Lumbosacral Region and Pain in both legs. The most recent Minimum Data Set Assessment (MDSA) completed for R4 was a Quarterly assessment dated [DATE]. According to this MDSA, R4 has a BIMS score of 5/15, indicating advancing cognitive impairment and he has no behaviors. Also according to this MDSA, R4 requires extensive assistance of staff for bed mobility, transfers and is non-ambulatory. R4 has Range of Motion (ROM) limitations of both of his arms and both of his legs. In reviewing R4's Care Plan (CP), Surveyor noted the following problems identified by the facility: 1. Cognitive and physical limitations related to stroke activity. Has left Hemiparesis, weakness, arthritis and pain and requires extensive to total assist with cares - Due to multiple strokes, the ROM in my arms is impaired, left greater than right, and both legs. Per Physical Therapy (01/24/22), I am to get out of bed with the use of a full-body mechanical lift; all other transfers are done with a standing mechanical lift - use a full-body mechanical lift if I am unable/not willing to stand. A Broda chair, which I use for positioning and comfort purposes, is my primary mode of locomotion; I may or may not move myself but if I do, it is not very far. 2. Alteration in Mobility Restorative/Maintenance Strength (Initiated 6/2/22) - Encourage me to participate in my restorative/maintenance program every day and praise my accomplishments - Nurse review and document at least monthly (6/2/22) - Active ROM 1 pound to 2 pound weights, twice for 10 repetitions of both shoulders to include flexion, elbow flexion, chest presses, and wrist flexion. Increased cues and encouragement to complete tasks.(8/10/22) - Active ROM to right leg and left leg, per illustration every day (initiated 6/2/22 and revised 6/11/22). Surveyor asked CNAs where the illustration could be located. They directed Surveyor to R4's room and hanging on the bulletin board in R4's room was the illustration that showed four different exercises with an individual sitting in a chair and performing: 1. Hip Flexion exercise with ankle weights 2. Knee extension with ankle weights 3. Hip adduction with ankle weights 4. Ankle Flexion with weights placed over tarsal area of foot (toes) On 10/12/22 at 9:40 AM , Surveyor interviewed CNA O regarding the program they are to incorporate into R4's care for restorative. CNA O stated that R4 receives Passive ROM exercises to each extremity every day with morning cares. Surveyor then had CNA O review R4's Restorative directions in the computer, where the staff complete their documentation. The following was written for R4: 1. Active ROM, 1 lb (pound) to 2 lb weights, twice for 10 repetitions of both shoulders to include flexion, elbow flexion, chest presses, and wrist flexion. Increased cues and encouragement to complete tasks. 2. Active ROM, right and left legs per illustration, once every day Surveyor reviewed documentation completed by staff regarding the upper extremities Restorative Program from 9/13/22 - 10/11/22 and noted R4 refused on 9 days and all other dates were marked as 0 minutes or not applicable. For the lower extremity program, the staff documented that R4 refused once. All other entries were documented as Not Applicable. Surveyor then reviewed the Restorative Nurses' monthly evaluations of R4's Restorative Program and noted that there were none completed in the current electronic record, which started 6/1/22 to present. Example 3: R14 has medical diagnoses that include but are not limited to Alzheimer's Disease, Dementia with Behavioral Disturbance, Polyneuropathy and Osteoarthritis. The most recent Minimum Data Set Assessment (MDSA) completed was a Quarterly assessment dated [DATE]. According to this assessment, R14 has both short-term and long-term memory impairment with severely impaired daily decision-making skills. R14 requires extensive assistance of staff for bed mobility, transfers, bathing, dressing and personal hygiene. R14 is non-ambulatory and transfers with the use of a mechanical lift. R14 has Range of Motion (ROM) limitations of both of his upper and lower extremities. In reviewing the Care Plan devised by the facility, Surveyor noted the facility identified the following needs: 1. Self care Deficit related to Cognitive and physical limitations. 2. Alteration in Mobility, Restorative/Maintenance Strength. - Encourage me to participate in my restorative/maintenance program every day and praise my accomplishments. - Nurse review and document at least monthly (6/2/22) - Active ROM both lower extremities per illustration once daily every day. - Passive ROM Left upper extremity 10 -15 repetitions once daily every day, shoulder flexion, elbow flexion, wrist flexion, and supination/pronation (6/2/22 and last revised 8/10/22). On 10/12/22 at 9:40 AM, Surveyor interviewed CNA O regarding R14's Restorative program. CNA O stated that R14 is to receive Passive ROM every day with cares. Surveyor then reviewed the CNA documentation from 9/13/22 - 10/11/22 and noted that R14 received 3 minutes of Active ROM to lower extremities on two days (9/15/22 and 10/6/22). There was no documentation located for the Passive ROM to R14's upper extremity. Surveyor went to locate the Restorative Nurse's review of R14's Restorative Program and noted that there was none completed from 6/1/22 to present. Example 4 R17 has medical diagnoses that include but are not limited to Hemiplegia and Hemiparesis following Cerebrovascular Accident affecting Non-Dominant (Left) side, Low Back Pain and Contractures of the right and left ankle. The most recent Minimum Data Set Assessment completed for R17 was a Quarterly assessment dated [DATE]. According to this assessment, R17 has Range of Motion (ROM) limitations of both upper and lower extremities and requires extensive assistance of staff for daily tasks of bed mobility, bathing, dressing, personal hygiene and toilet use. R17 is non-ambulatory and transfers with the use of a mechanical lift. R17 has no behaviors and scored a BIMS score of 10/15, indicating mildly impaired cognitive status. In reviewing R17's Care Plan, Surveyor noted the facility identified the following needs for R17: 1. Self-Care Deficit related to Dementia, History of strokes, contractures both arms and legs. · My left side is paralyzed due to a stroke and I have contractures of both arms and legs, so I have very little movement. 2. Alteration in Mobility Restorative Maintenance Strength. · Encourage me to participate in my restorative/maintenance program every day and praise my accomplishments. · Passive ROM Right Upper Extremity 10 repetitions once daily, every day. On 10/10/22 at 11:57 AM, Surveyor interviewed R17 regarding his functional abilities. R17 stated that he has a bum hand from a stroke. At the time of the interview, both of R17's hands were rolled up into fists. There were no cloths or splints noted to be used. On 10/12/22 at 9:40 AM, Surveyor interviewed CNA O regarding the Restorative Program in place for R17. CNA O stated that R17 receives ROM every day with his cares. Surveyor then requested CNA O to verify his Restorative Program in the computer and noted that R17 was to receive 10 repetitions of Passive ROM to the right upper extremity every day. There was no program in place for the lower extremities. Surveyor then reviewed the documentation completed from 9/13/22 - 10/11/22 to verify the program was being followed and noted that R17 received ROM to the upper extremity only two times: - 9/15/22 10 repetitions - 9/25/22 5 repetitions All other dates were charted as Not applicable. Surveyor then reviewed R17's record to verify the Restorative Nurse was reviewing and evaluating R17's Restorative Program and noted there were no entries made in the past four months.

On 10/10/22 at 10:40 a.m., Surveyor observed Dietary (D) I in the kitchen serving brunch to 13 residents. D I used the same pair of single use gloves, placed bacon on a plate with tongs, placed eggs on the same plate with a spoon and buttered toast and placed toast on the plate. D I put two pieces of bread into the toaster and pushed down the toaster with same gloved hands. D I placed eggs on plate with spoon and bacon on plate with tongs for another resident. D I took lid off new butter dish and began buttering more toast that came out of the toaster. On 10/11/22 at 8:00 a.m., Surveyor observed Unit Helper (UH) E without a hairnet on in the kitchen. Observed UH E with single use gloves open refrigerator and touch multiple items in the refrigerator. UH E opened a drawer, removed a pen and wrote on large juice box with single same gloves. UH E poured a glass of milk and placed milk back in refrigerator with same gloves on. UH E poured juice in a glass and returned box of juice to refrigerator. UH E picked up silverware and put it on the tray. Poured a cup of coffee and placed on bedside table and took to Resident (R20). On 10/11/22 at 8:05 a.m., Surveyor observed UH E wash hands and place new gloves on. With gloved hands UH E picked up bread, placed in toaster and pushed down toast. UH E then wrapped up bread bag, put cereal back into cupboard, picked up jelly, took lid off butter, picked up toast from toaster and buttered toast all with the same gloved hands and placed on R20's plate. UH E then removed gloves, washed hands and picked up plate and took to R20's room. On 10/11/22 at 8:30 a.m., Surveyor interviewed UH E about touching bread, toaster, cupboard doors, refrigerator and butter lid with the same gloves. UH E replied, I should have taken my gloves off and washed my hands and put new gloves on before touching bread or toast. On 10/11/22 at 8:38 a.m., Surveyor interviewed UH E about wearing hairnets while in the kitchen and UH E replied, Yes we are, but sometimes we don't. Based on observation, interview and record review, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. This has the potential to affect all residents in the facility. - Facility did not ensure foods were stored at safe ranges to prevent spoilage by not consistently checking refrigerator and freezer temperatures. -Facility did not ensure foods were cooked to safe temperatures, and held for serving at safe temperatures by not consistently checking food temperatures after cooking and prior to service. - Facility did not ensure dishes and cookware were properly sanitized by not consistently checking dishwasher temperatures and chemical sanitization levels in the three-compartment sink. -Staff touched ready to eat foods with contaminated gloves. -Staff observed preparing food for residents in Meadow kitchenette without hairnets on. Findings include: Refrigerator and Freezer Temperatures: Facility Policy entitled Food and Non-Food Storage, revised 9/27/22, stated in part: .Refrigerator units equipped with a built-in thermometer gauge also have a manual thermometer located within the unit. Temperatures are recorded from the interior manual thermometer and are documented twice daily-AM and PM .Freezer units are equipped with a built-in thermometer gauge and also have a manual thermometer located within the unit. Temperatures are recorded from the interior manual thermometer and are documented twice daily-AM and PM. On 10/10/22 at 8:44 AM, Surveyor conducted an initial tour of the kitchen with Dietary Manager (DM) C. DM C stated dietary staff was supposed to check the refrigerator and freezer temperatures twice per day and record the temperatures on the log sheets. Surveyor observed the October 2022 log sheet titled Walk In Refrigerator Temperature chart had only one recorded temperature on 10/10/22. The dates from 10/01/22 through 10/09/22 were blank. The October 2022 log sheet titled PM Walk in Refrigerator Temperature chart had no temperatures logged on 10/04/22, 10/05/22, 10/08/22, and 10/09/22. Surveyor requested the September logs for the Walk in Refrigerator and noted one log had 15 days in September with no recorded temperatures and the second log for September had 13 days with no recorded temperatures. Surveyor noted the October 2022 log sheet titled AM Prep Cooler Refrigerator Temperature Chart had only one temperature logged on 10/10/22. The dates from 10/01/22 through 10/09/22 were blank. The October 2022 log sheet titled PM Prep Cooler Refrigerator Temperature Chart had four dates with no temperature recorded. Surveyor asked for the September log sheets and noted the AM log had 15 days with no temperatures recorded, and the PM Prep Cooler log had 14 days with no temperature recorded. Surveyor noted the October 2022 log titled AM Freezer Temperature Chart had only one temperature recorded on 10/10/22. The previous days of the month were blank. The October 2022 log titled PM Freezer Temperature Chart had four dates with no temperatures recorded. Surveyor interviewed DM C about the missing dates on the log sheets. DM C stated they hoped staff had checked the temperatures of the various refrigerators and freezer and just forgot to record it on the log, but they could not prove the temperatures were checked. Surveyor asked how they could verify the refrigerators and freezers were keeping foods at a safe temperature range on those dates with no temperatures recorded. DM C stated they could not. Foods cooked and held at safe temperatures: On 10/11/22 at 10:15 AM, Surveyor observed Dietary (D) F checking the food temperatures prior to placing in the steam table for lunch service in the main dining room. D F stated the Food Temperature Flow Sheet had not been updated since they moved to their new building, and it did not have a spot to record lunch temperatures, so D F wrote those temperatures on a post it note and attached to the Flow Sheet. Surveyor noted there were several dates on the October Food Temperature Flow Sheet with no food temperatures recorded, and 9 days on the September Flow Sheet with no food temperatures recorded. D F stated they either forgot to check the food temperatures on those dates, or did not record the temperatures on those dates. On 10/11/22 at 10:40 AM, Surveyor observed D G serving brunch in the Meadow dining room. D G informed Surveyor they checked the temperature of the foods on the steam table prior to service and logged them on the flow sheet. Surveyor noted there were multiple dates on the flow sheet that were blank. D G stated dietary staff probably got busy and forgot to check the food temperatures on those dates. D G stated all dietary staff had been taught to check food temperatures before serving. On 10/11/22 at 11:55 AM, Surveyor interviewed DM C about missing food temperatures on multiple dates in September and October on the Food Temperature Flow Sheets and no noon or lunch food temperatures recorded on the flow sheets. DM C stated they hoped staff checked the food temperatures and just forgot to record them on the flow sheet, but could not confirm that. DM C stated they needed to update their flow sheet to create a place to record the lunch meal temperatures. DM C could not verify that foods were cooked to safe temperatures or held at safe temperatures on the multiple dates with no food temperatures recorded. Manual and machine dish washing: Facility policy entitled Dish Machine Operation, revised 10/2022, stated in part: .All flatware, serving dishes, and cookware will be cleaned, rinsed, and sanitized after each use. The dish machine will be checked prior to meals to assure proper functioning and appropriate temperatures .Ware washing process will occur twice a day - AM (Continental & Brunch) and PM (Dinner) .Turn on and fill dish machine. Once filled, run a few empty racks through the system. Check temperature readings for wash - 160 degrees or greater and rinse - 180 degrees or greater . On 10/11/22 at 10:49 AM, Surveyor observed D H washing dishes with the dish machine. D H checked the wash and rinse temperatures on Dishwasher Temperature charts. Surveyor noted there were multiple dates on the September and October Dishwasher Temperature charts with no temperatures recorded. D H stated if no temperatures were logged, they probably did not check the wash and rinse temperatures. Facility policy entitled Manual Ware Washing, revised 10/2022, stated in part: .Fill sanitizer compartment sink with desired depth. Use automatic product dispenser on wall by turning knob clockwise until it holds. When level reached, turn dispenser knob counterclockwise until it stops. Check the sanitizer level with the PH test paper. Levels should be between 150-400 PPM [Part Per Million]. Record reading on log. This is to be logged twice a day, AM and PM . Surveyor noted the September and October PPM Log 3rd Sink had no entries in the AM column of the log, except on 10/10/22. The PM column on both the October and September logs had multiple dates with no entries. On 10/11/22 at 10:34 AM, Surveyor interviewed D F who stated they check the sanitization sink with a test strip one time in the morning when they first fill it and the PM cook checks it again when the refill the sanitization sink. D F stated they only check it once per shift, and they did not recheck with a test strip if they refilled the sanitizer sink. Surveyor asked how D F would know if the sanitization sink was at the proper level for sanitizing the dishes, if they did not test it. D F stated they did not know. Surveyor asked why there were no entries on the log for the AM shift for the entire month of September and only one entry on the October log. D F stated it was probably done, but not logged. D F could not verify that the sanitization sink was at the proper levels on the dates with no PPM logged. On 10/11/22 at 11:55 AM, Surveyor interviewed DM C about missing dish machine temperatures and PPM levels for the sanitization sink on the September and October logs. DM C stated they hoped the staff did the required checks and just did not log them, but could not verify the checks were done. Surveyor asked if DM C could verify that dishes and cookware were being properly sanitized consistently to prevent food borne illness based on the missing documentation on the logs. DM C could not verify this. Staff touching ready to eat foods with contaminated gloves: Facility policy entitled Infection Prevention-Food Handling-Meals, revised 2/22, stated in part: .Dietary staff are to wear gloves when coming into contact with food and in performing certain food handling tasks. It may be necessary to change gloves and wash hands periodically throughout meal pass. If gloved hands come in contact with other surfaces (door handles, cabinets, etc.) during meal pass, gloves are to be removed, hands washed, and new gloves donned . On 10/11/22 at 10:47 AM, Surveyor observed D F wash hands and apply gloves in the main dining room. D F picked up several plate holders and placed on trays. D F picked up and carried a plate to the kitchen, grabbed the handle of the refrigerator to open, took out a container with pre-made pancakes, and opened the packaging of the pancakes. With the same gloves which had touched all of those surfaces, D F picked up three pancakes and placed them on the plate. D F picked up the pancake container and placed it back in the refrigerator. D F took a container with pre-cooked sausages out of the refrigerator and removed the cover of the container. With the same gloves, D F picked up sausages and placed them on the plate. D F covered the plate with plastic wrap and carried it out to the dining room. On 10/11/22 at 11:55 AM, Surveyor interviewed DM C and explained above observation and other Surveyor observations of staff touching foods such as pancakes and toast with potentially contaminated gloves. DM C stated the gloves had touched other potentially contaminated surfaces, the staff should remove gloves, wash hands and apply clean gloves prior to touching ready to eat foods. Preparing foods in kitchenette without hair covering: Facility policy entitled Meal & Snack Service stated in part: .If making multiple items such as an Omelet, pancake, and toast - a hairnet is to be worn . On 10/11/22 from 7:30 AM to 8:00 AM, Surveyor observed CNA D and Unit Helper (UH) E prepare continental breakfasts for several residents in the Meadow kitchenette. Both CNA D and UH E were observed making toast, microwaving and cutting up premade omelets without hair nets on. On 10/11/22 at 11:55 AM, Surveyor interviewed DM C and explained the observation of staff preparing continental breakfasts for residents in the Meadow kitchenette without hairnets on. DM C stated if the staff was preparing and handling food items in the kitchenette they should have hair nets on.