**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility did not provide care and treatment by professional standards of practice to maintain a resident's highest practicable level of physical well-being by not assessing and/or treating a post-medication error for 1 out of 3 residents (R) reviewed for medication errors, R8. -R8 was given the wrong medications of Eliquis 5 mg, metoprolol 12.5 mg, and omeprazole 40 mg. R8 was not assessed every 4 hours for 24 hours as per physician order. Findings include: Example 1 R8 was admitted to the facility on [DATE], with diagnoses including Parkinson disease, Alzheimer's disease unspecified, unspecified dementia, irritable bowel syndrome with constipation, essential hypertension, obstructive sleep apnea, and spinal stenosis. Surveyor reviewed medication error, dated 06/14/25, which stated, in part, incident details include R8 was given wrong medications listed as Eliquis 5 mg, metoprolol 12.5 mg, and omeprazole 40 mg. The resolution for this error was that R8's provider gave an order for monitoring R8 every 4 hours for the next 24 hours. Surveyor reviewed vitals and assessments for R8, which states in part, -On 06/15/25 at 4:07 AM, R8 is monitored for medication error. Baseline neurologically, vital signs blood pressure 106/69, heart rate 71, respirations 20, and oxygen 97% on room air. R8 has no complaints at this time and will continue to monitor. Surveyor found no other documentation of vitals and assessments completed every 4 hours for the next 24 hours for R8. On 06/24/25 at 3:40 PM, Surveyor interviewed DON B and asked DON B what the expectation is for staff to monitor R8 after a medication error as provider orders stated monitor every 4 hours for the next 24 hours. DON B reported to Surveyor that the nursing staff should have monitored R8 every 4 hours for 24 hours including vital signs and head to toe assessment. DON B reported to Surveyor that the assessments and vitals were not completed for R8 every 4 hours as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure medications were administered under professional standards of clinical practices for 3 of 3 residents (R) reviewed for medication errors, R6, R8 and R7. -R6 received ciprofloxacin 500 mg twice a day for 3 days and should have received 250 mg twice a day for 3 days, and ciprofloxacin did not have an expiration label on it. -R8 received the wrong medications, including Eliquis 5 mg, metoprolol 12.5 mg, and omeprazole 40 mg. -R7's self-administration assessment stated R7 required assistance and nurse left Eliquis, melatonin, omeprazole, and metoprolol in a medicine cup at R7's bedside, left the room, and did not ensure R7 took the medications. Example 1 Surveyor reviewed medication error, dated 06/16/25, which stated, in part, R6 received the wrong dose of ciprofloxacin 500mg twice a day on 06/14/25, 06/15/25, and 06/16/25. R6 was supposed to receive ciprofloxacin 250 mg twice a day for 3 days. Incident details include Registered Nurse (RN) I, who transcribed physician orders incorrectly with no expiration date placed in the Electronic Health Record (EHR). Licensed Practical Nurse (LPN) F administered extra doses of ciprofloxacin twice a day on 06/14/25, 06/15/25, and 06/16/25. The resolution for this error was that education was given to RN I and LPN F about residents' rights of medication administration. On 06/24/25 at 10:10 AM, Surveyor interviewed Director of Nursing (DON) B and asked DON B what kind of education RN I received pertaining to R6's medication error of incorrect dose and no expiration label for ciprofloxacin. DON B reported to Surveyor that on the medication error report, DON B noted that resident's rights of medication administration education was given to RN I and LPN F. Surveyor asked DON B if RN I was educated on the transcription error, as it was not documented on the medication incident report form. DON B reported to Surveyor that DON B did not document that transcription education was provided but would go provide education to RN I and document this education. Example 2 Surveyor reviewed medication error, dated 06/14/25, which stated, in part, that R8 received wrong medications. R8 received Eliquis 5 mg, metoprolol 12.5 mg, and omeprazole 40 mg. Incident details include R8 was given the wrong medications but had no effects, vitals stable, and sleeping. The resolution was that R8's provider gave an order for the nurse to monitor R8 every 4 hours for the next 24 hours. Surveyor did not find any documentation of vital signs being monitored every 4 hours for the next 24 hours and any education provided to LPN G after the medication error. On 06/24/25 at 10:10 AM, Surveyor interviewed DON B and asked DON B if any education was provided to LPN G. DON B reported that documentation of education was not on the medication incident report, but education was completed. On 06/24/25 at 10:19 AM, Surveyor interviewed Nursing Home Administrator (NHA) A and asked NHA A if any education was provided to LPN G. NHA A reported to Surveyor that this event was not the first incident LPN G had, so LPN G was terminated at some point after finding multiple medication errors. Evidence of education was not provided to Surveyor. Example 3 R7 was admitted to the facility on [DATE], with diagnoses including essential hypertension, end stage renal disease, contracture of left and right hand, anxiety disorder, noncompliance with medication regimen, unstable angina, diabetes mellitus type 2, and congestive heart failure. R7's minimum data set (MDS) assessment, completed on 05/20/25, confirmed R7 scored 15/15 during a Brief Interview for Mental Status (BIMS), indicating intact cognition. R7 requires supervision and set-up assistance with eating and oral hygiene. R7 requires substantial maximal assistance with transferring, dressing lower body, putting on/taking off footwear, personal hygiene, showering/bathing, and toileting. Surveyor reviewed R7's self-administration of medication assessment which stated in part, .-On 03/02/25, all questions such as administering of medications answer- b) Assistance required . Surveyor reviewed medication error, dated 06/20/25, which stated, in part, incident details include R7 has order for self-administration of medications, nurse left night medications at bedside, and did not follow up to check that R7 took medications of Eliquis, melatonin, omeprazole, and metoprolol. The resolution was educating nurse on self-administration orders and to follow up in one hour to ensure R7 received medications. On 06/24/25 at 3:40 PM, Surveyor interviewed Director of Nursing (DON) B and asked DON B process for self-administering medications. DON B reported to Surveyor that nurses are supposed to assess residents first to make sure they can safely administer their own medications. Surveyor asked DON B if R7 had a self-administer assessment completed. DON B reported to Surveyor that R7 has a physician order that R7 can self-administer medications, but that DON B would investigate the self-administering further. DON B reviewed self-administer medication assessment completed on 03/02/25 and reported to Surveyor that DON B reviewed and R7 was deemed to require assistance with medications. DON B reported to Surveyor that DON B will have staff re-evaluate self-administering abilities and update R7's chart as needed. DON B reported to Surveyor that staff should have followed up with R7 to make sure R7 did not miss R7's important medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 to help prevent the development and transmission of communicable diseases and infections. This had the potential to affect 48 residents (R). Physical Therapy Assistant (PTA) C and Registered Nurse (RN) O entered R5's room without proper Personal Protective Equipment (PPE) who is on airborne precautions for parainfluenza infection. Findings include: Surveyor reviewed facility policy titled, Isolation-Initiating Transmission Based Precautions, states in part, .-Transmission-Based Precautions will be initiated when there is reason to believe that a resident has a communicable infectious disease. Transmission-Based Precautions may include Contact Precautions, Droplet Precautions, or Airborne Precautions. #5. When Transmission-Based Precautions are implemented, the Infection Preventionist (or designee) shall: a. Ensure that protective equipment (i.e., gloves, gowns, masks, etc.) is maintained near the resident's room so that everyone entering the room can access what they need . Surveyor reviewed facility policy titled, Personal Protective Equipment, states in part, .- Objectives: 1. To prevent the spread of infections; 2. To prevent soiling of clothing with infectious material; -Miscellaneous: 1. Use gowns only once and then discard into an appropriate receptacle inside the exam or treatment room. 2. Clean reusable or disposable gowns may be worn in most circumstances. 3. Use gowns only when indicated or as instructed. 4. Follow established handwashing procedures. 6. When use of a gown is indicated, all personnel must put on the gown before treating or touching the resident. 7. Gowns shall be large enough to cover all of the wearer's clothing, and they must be tightly cuffed at the sleeves. 8. After completing the treatment or procedure, gowns must be discarded in the appropriate container located in the room. 10. Soiled gowns must not be worn in break rooms, lobbies, or into any area in which contamination of equipment is likely to occur . R5 was admitted to the facility on [DATE], with diagnoses including metabolic encephalopathy, polyneuropathy, diabetes mellitus type 2, bacterial infection unspecified, and heart failure. Surveyor reviewed R5's progress notes, which state in part, -On 06/23/25 at 1:26 PM, R5 having a cough this morning, Robitussin administered, COVID tested and negative, DON notified, R5 placed on droplet precautions. -On 06/24/25 at 9:45 AM, Writer obtained nasal swab for respiratory panel ordered per provider, sent to lab. -On 06/24/25 at 6:48 PM, Received respiratory panel back today, parainfluenza 3 virus detected. R5 on droplet precautions and will remain on for 7 days until 07/01/25. On 06/24/25 at 9:17 AM, Surveyor observed PTA C enter R5's room with no PPE on. PTA C started working with R5 in room on Physical Therapy (PT) exercises. On 06/24/25 at 9:28 AM, Surveyor observed RN O standing outside R5's room. Surveyor interviewed RN O and asked RN O what precautions R5 is on. RN O reported to Surveyor that R5 is on droplet precautions. Surveyor informed RN O that PTA C is in R5's room with no PPE on. RN O immediately reported to Surveyor that PTA C is supposed to have PPE on before entering R5's room. RN O called PTA C out of R5's room and explained to PTA C that PTA C needs mask, shield, gown, and gloves on when providing cares in R5's room. PTA C reported to RN O that she did not realize this and PTA C applied PPE and entered back into R5's room. On 06/24/25 at 9:33 AM, Surveyor observed PTA C exit R5's room and doffed gown, face shield, and gloves. Surveyor observed PTA C continue walking down hallway and exited the unit without proper hand hygiene or removing face mask from R5's room. On 06/24/25 at 9:36 AM, Surveyor observed RN O donning a face shield, gown, and gloves. RN O entered R5's room to swab R5 for a respiratory panel. Surveyor did not observe RN O apply a face mask under the face shield before entering R5's room. On 06/24/25 at 9:45 AM, Surveyor observed RN O exit R5's room and doffed PPE. Surveyor did not observe RN O doff a face mask. Surveyor interviewed RN O and asked if RN O was supposed to have placed a mask on under the face shield when in R5's room on droplet precautions. RN O reported to Surveyor that RN O applied face mask while inside R5's room but should have applied outside room before entering R5's room to decrease chances of spreading infection. On 06/24/25 at 10:18 AM, Surveyor interviewed Director of Nursing (DON) B and asked DON B what the expectations are for proper PPE usage with R5 on droplet precautions. DON B reported to Surveyor that all staff are to use appropriate PPE such as mask, face shield, gown, and gloves with droplet precautions. Surveyor informed DON B of observation of RN O and PTA C not utilizing appropriate PPE when entering R5's room. DON B reported that staff should have worn the appropriate PPE before entering R5's room and when exiting doffing the PPE entirely and sanitizing hands before walking onto the next task.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not ensure a system of records of receipt and disposition of all controlled drugs in sufficient detail to reconcile accurately. This affected 12 out of 49 residents (R) in the facility. (R1, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, and R14) The facility did not ensure medications were administered under professional standards of clinical practices for residents. This had the potential to affect all residents on 1 of 2 floors in the facility. Findings include: Facility policy titled, Administering Medications, dated 2019, states in part, .#22. The individual administering the medication initials the resident's Medication Administration Record (MAR) on the appropriate line after giving each medication and before administering the next ones. #23. As required or indicated for a medication, the individual administering the medication records in the resident's medical record: g. The signature and title of the person administering the drug . Facility policy titled, Documentation of Medication Administration, dated 2022 reviewed on, states in part, .#2. Administration of medication is documented immediately after it is given. #3. g. initials, signature and title of the person administering the medication . Example 1 Surveyor reviewed medication errors for the past 6 months. -On 03/30/35, medication error report indicates staff did not give R7 Lorazepam medication as it was not signed out on narcotic count sheet. Director of Nursing (DON) B indicated staff to not sign out medication on the narcotic book until medication is given to R7. - On 03/30/35, medication error report indicates staff did not give R4 Clonazepam medication as it was not signed out on narcotic count sheet. DON B indicated staff to not sign out medication on the narcotic book until medication is given to R4. -On 04/13/25, medication error report indicates staff gave R5 an extra dose of oxycodone due to staff prepping medication in advance and another nurse not knowing it was prepped ahead and gave another ½ dose to R5. DON B educated nurses on not prepping medications ahead of time before administering. -On 04/13/25, medication error report indicates R6 was given an extra dose of tramadol. One nurse set up medication and the second nurse went to administer medications and took out an extra tramadol tab. DON B educated nurses on not prepping medications ahead of time before administering and only administering medications in which the individual nurse prepares themselves. DON B indicated to sign out medication on the narcotic book when the narcotic is removed from the pill pack. Surveyor reviewed facility's investigation pertaining to narcotic diversion that occurred on 03/03/25. Facility reviewed R1, R8, R9, R10, R11, R12, R13, R14, and R4's MAR from 03/03/25 and found controlled medications signed out, which indicated that Licensed Practical Nurse (LPN) L administered R1, R8, R9, R10, R11, R12, R13, R14, and R4's-controlled medications to residents on 03/03/25. Through investigation, the facility found R1 who was in hospital on [DATE], and R8, R9, R10, R11, R12, R13, R14, and R4 did not receive the controlled medications signed out by LPN L on 03/03/25 as documented. Facility called police and notified Department of Health Services within two hours of the facility knowing that there were missing narcotics. Police found LPN L had oxycodone, lorazepam, and hydrocodone in LPN L's possession. Facility terminated LPN L and began pain assessments on R8, R9, R10, R11, R12, R13, R14, and R4. Facility found no concerns with R8, R9, R10, R11, R12, R13, R14, and R4's pain levels. DON B started narcotic reconciliation audits weekly. On 04/28/25 at 12:43 PM, Surveyor observed LPN D sitting at the nurse's station with two narcotic books on desk and LPN D signing out narcotics and documenting quantity of narcotics left in locked narcotic box. On 04/28/25 at 12:45 PM, Surveyor interviewed LPN D and asked what LPN D was doing with the narcotic books. LPN D indicated that LPN D gave narcotics to several residents and was currently signing out R4's Clonazepam. Surveyor asked LPN D what the normal process is for signing out narcotics after giving narcotics to residents. LPN D stated, I know this process isn't right and I should have signed the narcotics out as I gave each one to each resident. LPN D indicated that LPN D just knows when LPN D gave the controlled medications and leaves sticky notes for self on the medication cart across the nurse's station if LPN D forgets. Surveyor asked LPN D to show Surveyor the locked narcotic box located in the medication cart across from the nurse's station. LPN D got up from the nurses' station and walked across the nurse's station to the medication cart and unlocked the narcotic box. Surveyor asked LPN D to show Surveyor R4's Clonazepam card. Surveyor observed R4's Clonazepam card that was labeled with 30 tabs on the card. Surveyor asked LPN D to show Surveyor R4's Clonazepam count sheet out of the narcotic book. Surveyor observed on R4's Clonazepam count sheet quantity started with 30 tabs and noted LPN D signed out, Gave 1 tab of Clonazepam at 12:00 PM. Surveyor asked LPN D how there were 30 tabs accounted for in R4's Clonazepam card, but the count sheet that LPN D signed, indicated 29 tabs of Clonazepam left in R4's Clonazepam card. LPN D immediately apologized to Surveyor and stated, Well I did not give this medication yet, but I was signing it out. LPN D indicated that LPN D did the documentation incorrectly and was going to go back and give the Clonazepam but did not yet. Surveyor asked LPN D it was normal to sign controlled medications out of the count book before pulling from the card. LPN D indicated that LPN D performed the wrong process and knows that LPN D should not have done that, but LPN D stated, It has just been so busy here today. LPN D indicated that facility process is to sign out the narcotic or controlled medication once the medication is pulled and administered to R4. LPN D indicated that LPN D should not have signed out before giving the medication. On 04/28/25 at 2:35 PM, Surveyor interviewed Director of Nursing (DON) B and asked DON B what is DON B's expectation for signing out narcotic count sheets when administering a controlled medication. DON B indicated that LPN D approached DON B and let DON B know that LPN D messed up by signing out a controlled medication before giving the controlled medication making the count off in the narcotic book. DON B indicated that DON B's expectation is that nurses do not prep medications ahead of time or sign out medications that have not been given first. DON B's expectation was that LPN D give R4's Clonazepam and sign out the medication in the narcotic book once the medication was administered. DON B indicated that LPN D should have counted how many tabs were left in R4's Clonazepam card then documented the correct quantity on narcotic count sheet. Surveyor asked DON B how often DON B audits to make sure the narcotic count sheets are accurate, and they are being signed out appropriately. DON B indicated that audits started back in beginning of March 2025, and DON B performs the audits weekly. Surveyor tried reviewing narcotic count sheets and DON B indicated the narcotic count sheets were being audited as we were speaking. Surveyor asked DON B if there are any discrepancies with the narcotic sign out count sheets. DON B indicated that in fact there were some missing signatures on narcotic count for shift change. Surveyor requested a copy of the narcotic sign out sheet. DON B indicated that DON B understands that LPN D still is not utilizing the correct process for narcotic count to prevent narcotic diversion and will handle the situation immediately. Surveyor asked if DON B thinks there is still an issue with narcotic count and facility's process. DON B indicated that DON B has educated staff, but DON B can see that staff are still having issues and DON B will reeducate. On 04/28/25 at 2:55 PM, Surveyor reviewed narcotic sign out sheets and observed on 04/10/25 missing second signature on night shift for narcotic count. On 04/25/25, day shift was missing two signatures for narcotic count. Example 2 On 04/29/25 at 10:42 AM, Surveyor interviewed Nursing Home Administrator (NHA) A and asked NHA A if facility was aware of any delegation of tasks, treatments, and/or administering of medications from nurses to Certified Nurse Assistants (CNA)s. NHA A indicated there was a recent event in March where a resident observed LPN C delegating medication administration to a CNA. NHA A indicated that Trained Medication Aide (TMA) M was acting as a CNA on 03/19/25 but then stayed about two hours after day shift to help LPN C pass medications. On 04/29/25 at 10:47 AM, Surveyor interviewed LPN C and asked if LPN C had ever delegated medication administration to a CNA. LPN C indicated that LPN C has never allowed a CNA to pass medications. LPN C indicated the facility has TMAs. LPN C indicated that on 03/19/25 LPN C was overwhelmed with a recent fall on that evening shift and asked TMA M to stay and help pass medications. LPN C indicated that LPN C prepped all medications and would hand them to TMA M to administer the medications to whichever residents LPN C delegated the medication pass. Surveyor asked LPN C if LPN C followed TMA M in the rooms while TMA M passed medications. LPN C stated, Well I was in close proximity like in the room next to the other room [TMA M] was in. I did not physically go into the rooms [TMA M] administered medications but that shouldn't matter as [TMA M] is trained to administer medications. Surveyor asked LPN C what the process is for preparing and administering medication to residents. LPN C indicated that medications are to be prepared right when LPN C is about to administer the medications to residents and should be the nurse who is prepping the medication to administer the medication. Surveyor asked if LPN C remembers which residents TMA M administered medications to on 03/19/25. LPN C indicated that LPN C had TMA M help with most of all medications needing to be administered. Surveyor asked LPN C who signed out the medications in the MAR. LPN C indicated that LPN C documented that LPN C administered all medications on the evening shift of 03/19/25. Surveyor asked LPN C if LPN C did not administer the medications, why was it documented that LPN C administered the medications. LPN C indicated that LPN C knew better, and TMA M should have signed the medications that TMA M administered. Surveyor asked LPN C what the process for medication administration is and not falsifying documentation. LPN C indicated that LPN C should have had TMA M prep, administer, and document the medications that TMA administered. LPN C indicated next time LPN C will not prepare medications ahead and delegate someone else to give the medications. On 04/29/25 at 11:43 AM, Surveyor interviewed DON B and asked DON B's expectation for medication administration. DON B indicated nurses are to follow facility policy. Surveyor asked DON B if it was acceptable for LPN C to prepare residents medications and then delegate TMA M to administer the medications. DON B indicated that TMA M can administer medications as TMA M is trained. Surveyor asked DON B what the process or expectation for documenting medications when administered to residents. DON B indicated that LPN C should have not prepared medications ahead and delegated TMA M to administer medications and LPN C should not have documented that LPN C gave the medications when TMA M is the one who administered the medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility did not ensure they were monitoring the effectiveness of psychotropic drugs. Behavioral monitoring was not completed as outlined in the comprehensive care plan to determine effectiveness of the medication for 1 of 3 residents (R) reviewed (R2). Findings include: The facility policy titled, Behavioral Assessment, Intervention, and Monitoring, dated 03/2019, states in part: .Management -#1. The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress, and potential safety risk to the resident, and develop a plan of care. -#10. When medications are prescribed for behavioral symptoms, documentation will include: b. potential underlying causes of the behavior, c. other approaches and interventions tried prior to use of antipsychotic medications. e. specific target behaviors and expected outcomes. h. monitor for efficacy and adverse consequences. Monitoring -#1. If the resident is being treated for altered behavior or mood, the team will seek and document any improvements or worsening in the individual's behavior, mood, or function. -#2. New or emergent symptoms will be documented and reported. -#3. Interventions will be adjusted based on the impact on behavior and other symptoms, including any adverse consequences related to treatment . R2 was admitted to the facility on [DATE] and had diagnosis that include unspecified dementia, mild with behavioral disturbance, ischemic cardiomyopathy, and congestive heart failure. R2's Minimum Data Set (MDS) assessment, dated 08/16/24, indicated that R2 has a Brief Interview for Medical Status of 00, which indicates R2 has a severe impairment. R2's care plan included the following interventions: BEHAVIORS care plan: -Update provider on progressing dementia behaviors of wandering, invading other personal space initiated on 11/16/22. -Re-direct R2 from going into other rooms/spaces, re-direct R2 from other residents at the table when eating initiated on 06/07/24. -Administer behavior medications as ordered by provider. Assess for effectiveness and for side effects on medication on-going, update provider as needed initiated on 09/14/24. -Discuss with family best approaches initiated on 09/14/24. -Provide diversional activities during episodes of inappropriateness/disruptive behavior initiated on 09/14/24. -Re-direct R2 from male residents, when sitting at table, do not place her next to male, only across the table initiated on 09/14/24. -Refer to interdisciplinary team for review as needed initiated on 09/14/24. R2's doctors' orders read: -Monitor and document any increased behaviors due to Seroquel decrease every shift. -Behavior monitoring: targeted behavior: wandering, getting into others personal space leading to altercations, kicking at staff, history of slapping to others, Interventions: Redirect from others, offer food, reassure her. If behavior is present, document in nurses' notes: Behavior, interventions used and effectiveness of the interventions every shift. -Lorazepam give 0.5mg by mouth every 4 hours as needed for anxiety/behavioral disturbances related to Dementia. -Lorazepam give 0.5mg by mouth in the afternoon related to Dementia. -Citalopram Hydrobromide 10 mg tab by mouth in the evening related to Dementia. -Seroquel 25mg tab, give 12.5 mg by mouth two times a day related to Dementia with mild behavioral disturbances. Surveyor reviewed R2's medication administration record (MAR) and Treatment Administration Record (TAR) for September, October, November, and December. Documentation on MAR and TAR for all 4 months periodically present that R2 had behaviors but no documentation found on specific behaviors, interventions utilized, and the effectiveness of the interventions. Surveyor reviewed R2's progress notes for September, October, November, and December. R2's progress notes did not have documentation noted when behaviors occurred, what behaviors were assessed, what interventions were implemented, and how effective were the interventions put into place to decrease R2's behaviors. On 12/02/24 at 9:25 AM, Surveyor interviewed R3 and asked R3 if R3 ever had any residents wander into R3's room or any inappropriate behavior occur to R3. R3 indicated that R3 has a stop sign velcroed to door because other residents wander into R3's room, but sometimes R2 blows right through the door into R3's room. R3 indicated that last night on 12/01/24 in the evening time R2 wheeled into R3's room and began trying to rub R3's hand and kissing R3's arm. R3 told R2 no and to leave. R3 indicated R3 told staff shortly after R2 wheeled back out of R3's room. On 12/02/24 at 11:50 AM, Surveyor interviewed Registered Nurse (RN) C and asked if RN C knew of any instances of inappropriate behaviors and wandering with R2 in the past and from 12/01/24 in the evening into R3's room. RN C indicated that earlier in the afternoon on 12/01/24 RN C was walking into R3's room to pass medications. RN C stated, [R2] did wander into [R3's] room and [RN C] redirected [R2] out of [R3's] room, and then [RN C] wheeled [R2] out of [R3's] room. RN C indicated that R2 always wanders into other rooms, and that the floor is a memory care unit. Surveyor asked RN C why this episode was not charted in the nurse progress notes or on the MAR/TAR. RN C indicated that RN C's usual process is RN C will monitor for inappropriate behaviors and wandering from R2 and then redirect if need be and document the behaviors in the Electronic Health Record (EHR). RN C indicated that since RN C was right there with R2 that RN C felt the behavior was observed and did not need to be charted. Surveyor asked RN C if it was facility policy to not document behaviors. RN C indicated the facility policy is that behaviors are documented in the MAR/TAR and then a progress note will be attached to that documentation so that progress notes show intervention being utilized and if effective for that set behavior. On 12/02/24 at 12:15 PM, Surveyor interviewed Director of Nursing (DON) B and asked DON B what expectation was for behavior charting and monitoring inappropriate behaviors to decrease incidents from happening. DON B indicated that it is DON B's expectation that all behaviors are documented in the TAR and then in the progress notes the exact behavior needs to be documented with what intervention was implemented, and how effective was the intervention. DON B indicated documentation of behaviors assists the team with ordering and changing psychotropic medications to make sure the medications are working properly. Surveyor asked DON B if DON B was aware of R2 wandering into R3's room on 12/01/24 and the lack of documentation noted in the EHR. DON B indicated that DON B was not aware but conversed with RN C who admitted that RN C did not document in R2's chart the behavior from 12/01/24. Surveyor asked DON B why R2 has yes documented in the MAR/TAR for behaviors throughout September, October, November, and December chart but no other documentation on what the behavior was at that time, what interventions were placed, and how effective the intervention was that was implemented. DON B indicated that DON B did not realize staff were not documenting accurately as provider ordered for R2.

Based on interview and observation, the facility failed to have qualified onsite dietary manager. This has the ability to affect 40 out of 40 residents. Facility has not had a Dietary Manager since 07/06/2023. Findings include: On 08/29/23 at 10:50 a.m., Surveyor entered kitchen and [NAME] D stated if Surveyor was looking for the dietary manager, the facility does not have one. On 08/29/23 at 12:30 p.m., Surveyor interviewed Nursing Home Administrator (NHA) A and asked about the Dietary Manager. NHA A stated the facility has not had a Dietary Manager since 07/06/23. NHA A stated NHA A checks on dietary and has Human Resources (HR) L supervise dietary part-time. NHA A and HR L do not have a dietary certification. NHA A stated Dietary Aide (DA) M orders food for the dietary department and updates the resident tray tickets regarding diets and likes/dislikes. NHA A stated NHA A consults and refers to the facility Dietician as needed, and the Dietician is onsite at the facility every two weeks. NHA A stated the Dietician works remotely as well and reviews changes in resident conditions, updates diets, etc. NHA A stated a Dietary Manager will be starting in two weeks. NHA A stated the Dietary Manager is in a program for certification and has a preceptor, but has not completed the program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and record review, the facility did not ensure each resident received care consistent to prevent Pressure Injuries (PIs) from developing for 1 of 2 sampled residents (R)2. R2 is at moderate risk for PI development. R2 was observed in bed with both heels on the mattress. This is evidenced by: R2 was admitted to facility on 01/22/21. Diagnoses include dementia with behavioral disturbance, Type 2 Diabetes Mellitus, repeated falls, depression, weakness, and need for assistance with personal cares. R2's Power of Attorney (POA) is activated. Minimum Data Set (MDS), dated [DATE], indicated R2's cognition is severely impaired. R2 is at risk for development of pressure related injuries. R2 requires a Hoyer (mechanical lift) for transfers and has recently been using a Broda chair (positional wheelchair) for mobility. R2 scored 13 during Braden Scale for Predicting Pressure Sore Risk, completed on 04/26/23, indicating moderate risk for development of PI. R2's nutritional assessment, completed on 04/23/23, confirmed a recent significant and unintended weight loss. R2's care plan included the following: ACTIVITIES OF DAILY LIVING: Self-care deficit related to diagnoses/conditions including advanced Alzheimer's Disease, anxiety, aggressive behavior, weakness, and decreased mobility as evidenced by her need for assistance with her Activities of Daily Living. Date Initiated: 01/22/2021, Revision on 08/02/2021. PRESSURE RELIEF: has a pressure relief mattress, and cushion in wheelchair. Float her heels on a pillow when she is in bed. REPOSITIONING: Every 2-3 hours. 06/06/23 from 7:28 AM-9:50 AM, Surveyor observed R2 in her bed, R2's heels were not floated on a pillow and were directly on the mattress. 06/06/23 at 9:50 AM, interview with Certified Nursing Assistant (CNA) E. CNA E stated that R2 has a wedge pillow to float her heels on while in bed. CNA E and Surveyor observed that R2's heels were not placed on a pillow and were directly on the mattress. CNA E could not locate the wedge pillow. 06/06/23 at approximately 9:55 AM, interview with Licensed Practical Nurse (LPN) D. LPN D stated that R2 is to have her heels floated on a pillow while in bed. LPN D stated that maybe R2's wedge pillow was in the laundry. During this interview CNA E stated that she had found R2's wedge pillow in her bed near R2's headboard. 06/06/23 at 4:23 PM, interview with Assistant Director of Nursing (ADON) C and Director of Nursing (DON) B confirmed that R2's heels should be floated on a pillow when R2 is in bed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not ensure the resident environment is free from accidents for safe smoking, affecting 2 of 2 residents reviewed for smoking (R12 and R37). R12 indicated she maintains her smoking materials in her coat pocket or dresser drawer in her room and goes out to smoke on her own without any devices worn for smoking. R12's smoking assessment was not complete, to ensure safety interventions were in place on R12's smoking care plan. R37 indicated she maintains her smoking materials in her room and does not wear any apron or other devices while smoking. R37's smoking assessment was not complete, to ensure safety interventions were in place on R37's smoking care plan to prevent injury while smoking. This is evidenced by: Surveyor reviewed the facility policy titled Accident Prevention-Smoking Policy dated as last reviewed on 10/2022. The policy in part reads: Policy: The facility shall establish and maintain safe resident smoking practices. Guidelines: Any smoking-related privileges, restrictions and concerns shall be noted in the care plan and all personnel caring for the resident shall be alerted to the issues. Example 1 On 06/05/23 at 10:07 AM, Surveyor observed R12 outside from the end of hallway. R12 was smoking a cigarette. R12 smoked the cigarette without issues and extinguished the cigarette in an ashtray. On 6/05/23 at 10:18 AM, Surveyor spoke with R12 regarding smoking at the facility. R12 indicated she maintains her cigarettes and lighter in her room, sometimes in the dresser drawer and sometimes in her jacket pocket. R12 further expressed she is able to go outside to the smoking area at the end of her hall when she wants. R12 expressed she does not wear a smoking apron or any other device while smoking. Surveyor reviewed R12's record and noted the following: R12's most recent annual Minimum Data Set (MDS) assessment and noted she understands, is understood and is cognitively intact. R12 requires extensive staff assistance for dressing and has limited range of motion of both upper and lower extremities. R12's most recent Smoking Safety Evaluation completed 04/28/23 notes: Does resident do or have the following: poor vision or blindness, balance problems while sitting or standing, total or limited range of motion in arms or hands, insufficient fine motor skills needed to safely hold cigarette, lethargic/falls asleep easily during tasks or activities, burns skin, clothing, furniture or other, drops ashes on self. All are marked no. Follow the facility policy on location and time of smoking: marked yes Concerns: Does the resident display any of the following safety concerns: unable to light cigarette safely, unable to hold a cigarette safely, unable to extinguish a cigarette safely, unable to extinguish a cigarette safely, unable to use an ashtray and extinguish a cigarette. All marked no. Evaluation: Resident utilizes tobacco, poor vision or blindness-no, balance problems while sitting or standing-no, total or limited range of motion in arms or hands-no, insufficient fine motor skills needed to safely hold cigarette-no, lethargic/falls asleep easily during tasks or activities-no, burns skin, clothing, furniture or other-no, drops ashes on self-no. Follow the facility policy. Concerns: able to light cigarette safely, able to hold a cigarette safely, able to extinguish a cigarette safely, able to use an ashtray and extinguish a cigarette. Comments: There are no comments. R12's care plan indicated: Focus: Smoking: potential for injury related to smoking, date initiated: 5/28/2021. Goal: Will be free of injury related to smoking through next review date. Interventions/Tasks: All smoking materials to be kept at the nurse's station Check for burns on hands daily on the afternoon shift, report to charge nurse of social services. Encourage/Assist with smoking apron or any other adaptive equipment to promote safety while smoking. R12's Certified Nursing Assistant (CNA) care plan ([NAME]) indicates: Safety: all smoking materials to be kept at the nurse's station. On 6/06/23 at 12:34 PM, Surveyor spoke with Certified Nursing Assistants (CNA) H and O and Registered Nurse (RN) P about R12's smoking. CNAs H and O and RN P indicated they work with R12 routinely. All indicated R12 maintains her cigarettes and lighter in her room. R12 goes out to smoke when she wants without supervision or any adaptive equipment, such as a smoking apron, and has since she moved to their floor about a year ago. CNAs H and O and RN P expressed R37 is also able to go out when she wants to smoke without supervision or adaptive wear such as an apron. R37 also maintains her smoking materials in her room. Example 2 On 6/05/23 at 10:49 AM, Surveyor spoke with R37 about smoking. R37 expressed she goes out to smoking area to smoke when she wants without supervision. R37 expressed she keeps her smoking materials in room and does not wear any adaptive wear such as a smoking apron. Surveyor reviewed R37's record and noted: R37's most recent quarterly MDS dated [DATE] notes she understands, is understood and is cognitively intact. R37 has range of motion impairments to both upper and lower extremities. R37's most recent Smoking Safety Evaluation completed 6/28/22 notes: Does resident do or have the following: poor vision or blindness, balance problems while sitting or standing, insufficient fine motor skills needed to safely hold cigarette, lethargic/falls asleep easily during tasks or activities, burns skin, clothing, furniture or other, drops ashes on self. All are marked no. Follow the facility policy on location and time of smoking: marked no Total or limited range of motion in arms or hands: yes Concerns: Does the resident display any of the following safety concerns: unable to light cigarette safely, unable to hold a cigarette safely, unable to extinguish a cigarette safely, unable to extinguish a cigarette safely, unable to use an ashtray and extinguish a cigarette. All marked no. There is no evaluation, summary, or comments for recommendations on R37's safe smoking recommendations. R37's care plan indicated: Focus: Smoking: potential for injury related to smoking, date initiated: 06/23/2022. Goal: Will be free of injury related to smoking through next review date. Interventions/Tasks: Check for burns on hands daily on the afternoon shift, report to charge nurse of social services. Encourage/Assist with smoking apron or any other adaptive equipment to promote safety while smoking. Of note: the care plan does not indicate where R37's smoking materials are to be maintained. R37's Certified Nursing Assistant (CNA) care plan ([NAME]) does not indicate any interventions related to R37's safe smoking. On 06/06/23 at 1:02 pm, Surveyor spoke with Director of Nursing (DON) B about R12 and R37's smoking. DON B indicated both R12 and R37 go out to smoke on their own and do not need supervision while smoking. Surveyor and DON B reviewed R12's and R37's smoking assessments. DON B expressed the assessment summaries/comments are not complete but should include recommendations for safe smoking that are care planned for the residents. DON B expressed she would expect staff to follow R12's and R37's care plans for safe smoking. DON B further expressed R12 and R37 need to be reassessed for smoking as the assessments are not complete as she was unaware on how to complete the summary/comments in the point click care system for R12 and R37's safe smoking recommendations. The care plans will need to be updated once the assessments are completed.

Based on record review and interviews, the facility did not implement their abuse policy in regard to screening for 7 of 8 employees. Caregiver and criminal background checks were not completed for Certified Nursing Assistant (CNA) (CNA H, I, J, and K), Licensed Practical Nurse (LPN) L, Dietary Manager (DM) M, and Laundry Aide (LA) N. Out of state background checks were not completed for DM M and LA N. Findings include: The facility policy, entitled Abuse Prevention Program, Screening of Employees with a last revised date of 08/2022 reads in part, Background checks are completed per state guidelines on each employee. On 06/05/23, Surveyor requested Caregiver and Criminal background checks for a sample of 8 employees. On 06/06/23, the employee background information was reviewed. CNA H, J, and LPN L were all hired on 10/01/22. Caregiver and criminal background checks were not completed until 06/05/23. The Background Information Disclosure (BID) was not completed by the employees until 06/05/23. CNA K was hired on 10/25/22. Caregiver and criminal background checks were not completed. CNA I was hired on 11/10/22. Caregiver and criminal background checks were not completed until 06/05/23. The BID was not completed by the employees until 06/05/23. DM M was hired on 05/22/23 and indicated on the BID they had lived in Florida and Arizona. Surveyor requested the background checks for the other states from the Business Office Manager (BOM) G. BOM G was not aware that the other states needed to be checked. LA N was hired on 05/15/23 and indicated on the BID that they lived in Indiana. Surveyor requested the background check for the other state from BOM G. BOM G was not aware that the other states needed to be checked. On 06/06/23 at about 11:15 AM, Surveyor interviewed BOM G and asked if they ran the background checks for the employees after Surveyor gave them the sample of eight staff. BOM G indicated yes. On 06/06/23 at about 11:30 AM, Surveyor interviewed Nursing Home Administrator (NHA) A and asked about the background checks being run upon hire. NHA A indicated that they were hired on 03/06/23 as a contract staff and was not aware the background checks were not completed until an employee requested to look at their personal file and things were missing. NHA A indicated that they started an audit on all employee files but were not able to complete it before we entered.

Based on observation, interview and record review, the facility did not ensure nutritional values are maintained when altering food consistencies to minced and moist and pureed consistencies. This has the potential to affect 12 of 43 sampled and supplemental residents who eat this food consistency (R5, R8, R2, R4, R35, R24, R18, R20, R41, R15, R25 and R292). Cook Q was observed pureeing scrambled eggs and bacon using hot water as a thinning agent. [NAME] Q expressed there are no recipes, no policy or any directions that tell her what she is to use to modify food to ensure nutritional value. This is evidence by: On 06/06/23 at 7:10 AM, Surveyor observed [NAME] Q pureeing scrambled eggs and bacon. [NAME] added the eggs to the robocoup to puree then proceeded to the hot water thermos to pour water to pitcher. [NAME] Q did not measure the water and added it to the eggs to puree the consistency. [NAME] Q repeated this process with bacon. Surveyor asked [NAME] Q how she knows what and how much liquid she needs to add to foods to modify the consistency. [NAME] Q expressed the facility is in the process of updating menus and recipes. There are no directions on what to use and how much to use to modify the food consistency. [NAME] Q further expressed she uses hot water to modify all hot foods to maintain the temperature of the foods. Surveyor asked [NAME] Q how she knows she is maintaining food's nutritional values. [NAME] Q indicated she has had no training on modifying foods and what and how much liquid should be used. [NAME] further expressed she does not know, and her background is in restaurants with starting in nursing home approximately 6-7 months ago. The Dietary Manager recently started employment and the former manager did not train her. On 6/06/23 at 1:29 PM, Surveyor and Dietary Manager (DM) R reviewed the recipes used in the kitchen and noted the recipes do not include any instructions on modifying food items to ensure the proper nutrition is maintained. DM R expressed the recipes should include instructions for both the minced and moist and puree diets. DM R further expressed she has not been trained on recipes needed to modify food consistencies as her background is in the restaurant field. DM R expressed there are no other directions in the kitchen to direct staff on proper methods needed to modify food consistency to maintain nutritional values. Surveyor requested a list of residents who receive these diets. On 6/06/23 at 2:23 PM, Surveyor spoke with the facility's consulting Registered Dietician (RD) S who has consulted for the facility 6 years. Surveyor asked RD S about diet modifications of consistency and what should be used to modify the diets to maintain nutritional values. RD S indicated recipes should show directions on amount of food used for servings and the items needed to be added to maintain or improve nutritional values when foods are modified. The recipes should be with all recipes in a book in the kitchen, so the cooks know what to use and how much is needed. Surveyor asked RD if hot water should be used to modify all hot foods. RD S expressed the menus/recipes are reviewed and signed by a RD to approve and ensure nutritional values are maintained. RD S further expressed the cooks at the facility were making decisions daily on what and how to cook. In December, new menus and recipes were approved which should have included recipe modifications. Food items need to be the proper texture and proper nutrition. Hot water for everything does not sound right. Water is not proper, staff should use something with nutritional value like bread or dairy products. Not water. Staff should have recipes for food items, they need to be printed and in book to be available to the cooks. That's a problem. Guidance and training in kitchen have been an issue. Staff are not ensuring nutritional values for residents. Surveyor requested the facility policy related to diet modifications and any recipes the facility may have for diet modifications. On 06/06/23 at 2:53 PM, Nursing Home Administrator (NHA) A informed Surveyor no recipes or policy was found and will be put in place going forward. On 06/07/23 at 9:30 AM, DM R provided Surveyor with recipe for scrambled eggs she obtained from the facility's food vendor. The recipe indicates whole milk should be used with scrambled eggs when modifying the constancy. The recipe includes instructions on amount of eggs and milk to use when pureeing scrambled eggs. Surveyor reviewed the list of residents receiving a minced and moist or puree diet. The list included R5, R8, R2, R4, R35, R24, R18, R20, R41, R15, R25 and R292.

Based on observation, interview and record review, the facility did not prepare, store, or distribute foods in a safe and sanitary manner. The facility practices have the potential to affect all 43 residents. Facility staff do not cover beverages that are poured by staff on the wings and delivered to residents in their rooms. Cook Q did not allow the thermometer to air dry after wiping with alcohol and before inserting into resident foods. Dietary Aide (DA) T used alcohol-based hand rub (ABHR) as a means to sanitize her hands in the kitchen. ABHR is not an approved means to sanitize hands when food handling in the kitchen. The refrigerators and freezers where resident foods are brought into the facility do not have complete logs of monitoring for safe storage temperatures. The freezer on the first floor showed evidence of melted ice cream in the freezer. The temperature of the refrigerator was outside parameters for safe storage of foods. The facility did not monitor water temperatures for the water heater that is stored in the basement and circulates water to the basement kitchen and basement laundry area. Surveyor monitored water temperatures and identified fluctuations within conditions where Legionella and other opportunistic pathogens grow best (77-108 degrees Fahrenheit). This is evidenced by: Example 1 On 06/05/23 at 11:52 AM, Surveyor observed meal service for lunch on the first floor. Surveyor observed Certified Nursing Assistants (CNA) H and CNA I preparing resident food trays at the food cart. CNA H and CNA I poured beverages of milk, juice and coffee and placed the beverages on the trays of the residents served in the dining room. CNA H and CNA I proceeded to pour beverages for resident room trays. The beverages were placed on resident trays and transported to them in their room up the hallway. The beverages were not covered during distribution to residents in their rooms. On 06/06/23 at 8:18 AM, Surveyor observed meal service on the first floor for breakfast. Surveyor observed staff, including Medical Records/CNA F distribute trays and the beverages were not covered when distributed to residents in their rooms. Beverages included milk, juice, and coffee. Following the observation, Surveyor spoke with CNA F about the observation. CNA F expressed she assists with passing of trays on an ability basis. The beverages that are poured on the wing are not covered during transport to residents in their rooms as there is nothing sent up from the kitchen on the cart to cover them with. CNA F expressed this has been the facility procedure since she can remember and has been on staff a couple of years. On 06/07/23 at 9:12 AM, Surveyor spoke with Dietary Manager (DM) R and Nursing Home Administrator (NHA) A about the observations. DM R expressed the facility will be looking at different means of distributing resident room trays. Staff should not transport resident meal trays up the hall without foods and fluids being covered as it poses a risk of contamination. Surveyor requested and received a list of residents who routinely eat in their rooms that the observed practice could potentially affect. Surveyor was provided a list including the following residents (R26, R32, R28, R244, R38, R29, R9, R7, R31, R14, R36, R21, R13, R33, R16, R24, R19, R39, R6, R23, R20, R37 and R12). Surveyor requested the facility policy on safe food distribution. At time of exit nothing was provided. Example 2 On 06/06/23 at 7:10 AM, Surveyor observed [NAME] Q placing foods on the steam table in preparation for breakfast service. [NAME] Q used a thermometer to take the food temperatures. Surveyor observed [NAME] Q wipe the thermometer with an alcohol preparation pad and immediately insert into food items to check the temperatures. Surveyor asked [NAME] Q if she needed to allow the thermometer probe to air dry after wiping with alcohol and before inserting into foods. [NAME] Q responded she was not aware of the need to wait and has never seen a policy about needing to air dry the thermometer before inserting into foods. [NAME] Q expressed she has been on staff 6-7 months, comes from a restaurant background and has received little to no training since starting. On 06/06/23 at 1:29 PM, Surveyor spoke with DM R about the observation. DM R expressed she had just started employment a few weeks ago and her background is in restaurants. DM R further expressed she would expect the probe to be fully air dried with no residual alcohol. She would expect staff to wait 10-15 seconds to allow the thermometer to air dry of alcohol before inserting into resident foods to prevent contamination. Surveyor requested and received the facility policy titled Food Temperatures dated 02/25/2019. The policy states in part: Food temperatures will be taken and recorded when food is removed from oven or refrigerator, at the start and end of service at each meal. Wipe thermometer with alcohol pad and wait 10 seconds before putting in foods. Example 3 On 06/06/23 at 7:10 AM, Surveyor observed Dietary Aide (DA) T with readying foods and other items in preparation of breakfast meal service. DA T removed her gloves and used ABHR to clean her hands after filling pitchers with water and proceeding to another task. Surveyor asked DA T about the observation. DA T indicated she is trained in safe serve food handling and believes hand sanitizer is an okay method for hand hygiene in the kitchen. On 6/06/23 at 1:13 PM, Surveyor spoke with DM R about the observation. DM R indicated she believes the facility uses Wisconsin Food Code for the kitchen policies. The expectation is for staff to wash their hands using soap and water in the kitchen per the food code. Surveyor requested and received the kitchen's staff hand washing procedure titled Hand Washing dated 06/25/2012. The policy in part states: Policy: Food service employees shall keep their hands clean. The procedure outlines hand washing with the use of soap and water. The policy does not include the use of ABHR as a means for food service workers to clean their hands. Example 4 On 06/06/23 at 1:58 PM, Surveyor and NHA A observed the first-floor freezer/refrigerator where resident foods are stored. The freezer showed dried residual melted ice cream on the bottom and side shelves. The refrigerator with resident food items thermometer read 50 degrees Fahrenheit. Surveyor and NHA A proceeded to the third floor and observed the refrigerator and freezer clean and temperatures within safe storage range. Surveyor requested and reviewed the logs of the first and third floor refrigerator/freezer temperatures that were logged. The logs noted Temperature standards: 40 degrees Fahrenheit or below for cooler and 0 degrees Fahrenheit or below for freezer. The logs were void of any recorded temperatures for the months of March and April 2023. The logs for May 2023 noted the following: First floor: recorded 14 of 31 days with temperatures above the noted temperature standards as: 05/04/23, 05/15/23 and 05/17/23: freezer at 10 degrees Fahrenheit. 05/06/23: Freezer at 14 degrees Fahrenheit. 05/07/23: Freezer at 12 degrees Fahrenheit. 05/22/23: Freezer at 6 degrees Fahrenheit. 05/25/23: Freezer at 8 degrees Fahrenheit. Third floor: recorded 13 of 31 days with temperatures above the noted temperature standards as: 05/07/23, 05/16/23 and 05/21/23: freezer at 8 degrees Fahrenheit and 05/22/23 at 10 degrees Fahrenheit. 05/04/23: Refrigerator above 40 degrees Fahrenheit 11 of the 13 days recorded ranging from 42-52 degrees Fahrenheit. On 6/07/23 at 9:12 AM, Surveyor spoke with DM R and NHA A about the observation. DM R indicated dietary staff should be checking the refrigerators daily for cleanliness and appropriate temperatures. If the refrigerators and freezers are not clean bacteria, germs and mold can grow and contaminate residents' foods. Temperatures should be logged when they are checked to ensure the storage temperature is safe. If the temperature is out of range, it needs to be reported immediately and action taken. DM T further stated she needs to establish a routine where staff monitor the refrigerators and freezers daily and communicate any concerns so action can be taken immediately to ensure residents foods are stored safely. Surveyor reviewed the policy titled Water Management, Legionella Testing which is dated as most recently reviewed on 10/2022. The policy in part states: The facility handles and maintains its water supply in accordance with recommendations of the CDC (Centers of Disease Control). The community will demonstrate measures to minimize the risk of Legionella and other opportunistic pathogens in the building water systems through a documented water management program. Surveyor requested and received the CDC publication titled Developing a Water Management Program to Reduce Legionella Growth and Spread in Buildings dated 06/05/2017. The publication in part reads: Legionnaires Disease is a serious type of pneumonia caused by bacteria called Legionella, that live in water. Legionella can make people sick when they inhale contaminated water from buildings water systems that are not adequately maintained. Factors internal to buildings that lead to Legionella growth: Water temperature fluctuations: Provide conditions where Legionella grows best (77-108 degrees Fahrenheit). Water Pressure changes: Can cause biofilm to dislodge. On 06/06/23 at 7:05 AM, Surveyor entered the kitchen and proceeded to the hand washing sink to wash hands. Surveyor noted the water temperature to be cooler than expected. Surveyor allowed the water to run for one minute and checked the temperature of the water. The water temperature was noted as 81 degrees Fahrenheit. Surveyor observed [NAME] Q and Dietary Aide (DA) T wash their hands in the sink several times. Surveyor asked [NAME] Q and DA T to allow the water to run and again checked the temperature. The temperature ranged from 80-85 degrees Fahrenheit. Surveyor observed [NAME] Q using a sink near the food preparation area. The water temperature was checked and noted to be 105 degrees Fahrenheit after allowing the water to run. Surveyor observed the dishwasher machine log of wash and rinse temperatures and noted wash and rinse temperatures which were much higher and within the acceptable hot water dish machine temperatures. Surveyor asked [NAME] Q and DA T what other sinks are used in the kitchen. [NAME] Q expressed the 3-compartment sink is not used as it leaks. Surveyor spoke with [NAME] Q and DA T about the water temperatures in the sinks observed. Both indicated the water temperatures fluctuate and have been low for several months. [NAME] Q expressed she has been on staff 6-7 months and the water has been like that since she started. DA T indicated she has been on staff a few years and the water issues were worse before they replaced a water heater several months ago. The water has not improved with replacing the water heater. Surveyor asked [NAME] Q and DA T if they had reported the water concerns to anyone. Both indicated their manager had just started a few weeks ago. They did not report the concern to their former or current manager. Surveyor asked if either had reported the concern to maintenance and both reported they had not. During the observation Surveyor observed DA T filling water pitchers intended for resident consumption from the sink in the kitchen. On 06/06/23 at 8:52 AM, Surveyor and Maintenance Director (MD) U reported to the kitchen. Surveyor asked MD U about acceptable water temperatures. MD U indicated the water temperatures in the building should be 110 degrees Fahrenheit for Legionella prevention. The facility's water management plan indicates water temperatures should be 110-115 degrees Fahrenheit. Surveyor took the temperature of the sink in the food preparation area and the temperature fluctuated between 97-99 degrees Fahrenheit after a good run of water. The hand washing sink in the dish room ranged from 82-84 degrees Fahrenheit after running the water. The hand washing sink in the kitchen was much the same in fluctuation as noted above when checked by the Surveyor. MD U expressed this is the first hearing of sink water temperature concerns in the kitchen. MD U expressed several months ago the facility had issues with the water temperatures. The facility replaced the water heater several months ago and he was not aware the water temperatures were a problem after replacing the water heater. Surveyor requested and received the facility policy for water management. On 06/06/23 at 1:15 PM, Surveyor spoke with Dietary Manager (DM) R about the water temperatures. DM R confirmed she had started employment a couple weeks ago and was aware of the cold-water issues but had not contacted maintenance about the water. Surveyor requested and received an invoice showing the facility was billed for installing one hot water heater on 01/01/23. On 06/07/23 at 9:45 AM, MD U spoke with Surveyor while touring the basement water system. MD U showed Surveyor where the water heater and water holding tank were located. MD U explained the facility had previously had two water heaters that fed the basement laundry and kitchen. When the hot water heater had issues several months ago two water heaters were replaced with one. The building's basement is supposed to operate with two. MD U suspects that when the laundry wash machine is running it is pulling the hot water from the holding tank that is being circulated as it is closest to the tank. Surveyor observed the tank to be located just outside the laundry department. The water that remains in the tank circulating has to travel 65-70 yards to feed the kitchen. The water temperatures are fluctuating and not being maintained above the requirement to prevent the spread of Legionella as the one water heater is not sufficient to do so.

Based on observations, interviews, and record review, the facility did not determine safe self administration of medications for 1 out of 6 residents (R12) observed during the medication administration task. R12 was handed her medication by the nurse to self-administer. There was no assessment to ensure R12 was able to safely administer her medications. The nurse did not conduct any follow-up to ensure R12 actually took the medications. Also, there was no physician order or care plan noting R12 was permitted to self-administer her medications. This is evidenced by: R12 has medical diagnoses that include, but are not limited to, Disorientation, Major Depressive Disorder, Wernicke's Encephalopathy, Alcohol Dependence, Unspecified Dementia with Behavioral Disturbance, and Other Symptoms and Signs Involving Cognitive Function and Awareness. According to R12's most recent Minimum Data Set Assessment (MDSA) dated 05/12/22, R12 has a BIMS (Brief Interview of Mental Status) score of 14/15, indicating R12 is cognitively intact. On 5/31/22 at 4:37 PM, Surveyor observed RN M (Registered Nurse) dispense medications to R12 at the nursing station. RN M placed a squirt of Voltaren 1% Gel into a medication cup and handed it to R12 over the nursing desk. She then dispensed the following medications into a medication cup and handed them to R12 over the nursing desk: - Olanzapine 2.5 MG (Milligram)1 tab - Tylenol 325 MG two tablets - Lorazepam 0.5 MG 1/2 tablet RN M stated to Surveyor that R12 is able to self-administer her medications. R12 then took the Voltaren Gel and the pills down the hall to her room. RN M did not go to R12's room to ensure the medications were actually taken, or that R12 applied the Voltaren gel to the correct location. The Physician Order for the Voltaren Gel was to apply to the left foot four times each day. In reviewing the Medical Record for R12, Surveyor was unable to locate a Physician Order for self-administration. Also, there was no care plan or assessment indicating R12 was safely assessed to self-administer her medications. On 6/1/22 at 3:59 PM, Surveyor interviewed Director of Nursing (DON) B regarding the expected practice for residents with self administration of medications. DON B stated, The expectation is that if a resident desires to self administer their medication, they are to first have an assessment completed that reviews cognitive ability to understand the medication, it's use and how to take it. They also need to be able to take it correctly. There must be a physician order to self administer. We only have one resident currently in-house that is able to do this. (R12) should not be self-administering her medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure referral for a Preadmission Screen and Resident Review (PASRR) Level II screen for 1 Resident (R30) of 2 residents reviewed for PASRR II was completed. R30 did not have a PASRR Level II screening completed and had diagnoses that would qualify for a referral for a PASRR Level II screening to the state mental health agency. Findings include: R30 was admitted to the facility on [DATE] from the hospital, and has diagnoses that include: schizoaffective disorder, vascular dementia, and mild cognitive behavior. R30's PASRR Level 1 screen completed on 07/16/21, indicates the resident is suspected of having a serious mental illness. In section B, short term exemptions hospital discharge exemption for 30 day Maximum was checked: Yes. Additional directions below section B read in part if you have answered YES to any of the items in Section B if during the short-term stay it is established that the person will be staying for a longer period of time than permitted above, the person must be referred for a Level II Screen on or before the last day of the permitted time period. During review of R30's medical record, Surveyor did not locate a PASARR II in R30's paper file or electronic medical record. On 06/01/22 at about 8:30 am, Surveyor asked Social Service Director (SSD) L for a copy of R30's PASARR II. At 9:30 am she brought me a copy of the PASARR I. On 06/01/22 at 1:25 pm, Surveyor went to SSD L's office and asked if she was able to find a PASARR II for R30. SSD L indicated no. Surveyor asked if that meant it was not done. SSD L indicated probably not, it was before my time here. Surveyor asked if she was going to do anything now that she knew it was not completed. SSD L indicated she was going to complete a PASARR II. On 06/02/22 at 11:25 AM, SSD L came into conference room with R30's PASARR II filled out with today's date on it and said it needed to be faxed yet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Example 3: R7 was admitted to the facility on [DATE]. R7 was [AGE] years old. R7 had a BIMS of 15, indicating they were cognitively intact. R7 had diagnoses of Chronic Lymphocytic Leukemia of B-cell type in relapse, Chronic Kidney Disease, Congestive Heart Failure, and Pressure Ulcer of the Sacral Region, Stage 4. R7 had been admitted to the facility with the Stage 4 ulcer having acquired it at a previous placement. Surveyor reviewed R7's MDS (Minimum Data Set) of 3/14/2022 upon admission. Section C indicated a BIMS of 15 (cognitively intact), Section GG noted that R7 needed assist with bed mobility, transfers, and ADLs. Section M, which refers to skin conditions, notes the presence of a pressure injury, and that R7 was at risk for pressure injuries. On 6/1/22 at approximately 11:00AM, Surveyor observed RN C perform wound care for R7. RN C positioned R7 on the left side, after providing privacy. It was noted that R7 did have an air mattress on the bed with assist bars and a trapeze. RN C gathered supplies, and after wiping the over the bed side table, RN C removed the gauze and other dressing materials from the packages. RN C then washed hands with soap and water and applied gloves. RN C removed the old dressings, removed gloves and then applied new gloves without washing hands in between glove changes. RN C stated that the wound had decreased in size since admission. RN C washed the wound with Vashe wound solution. The order stated that Acetic Acid should be used to cleanse wound, but if not available Vashe solution could be used. After cleansing the wound, RN C did wound measurements with the wound being 8.5cm at the widest point, 4.8cm in length, and 2.5cm at the deepest point. After measuring, RN C applied Algene which is an antibacterial silver which was cut to fit the wound bed. RN C then applied Aquacel over that. At this point, RN C removed gloves and did not wash hands, RN C then applied the ABD over the top of the wound and secured it with tape. RN C dated the tape and washed hands prior to leaving the room. Surveyor interviewed RN C after the wound care regarding hygiene practices. Surveyor asked what the standard practice is for changing gloves during wound care. RN C stated that she should wash hands before applying gloves. On 6/1/22, Surveyor interviewed DON B. Surveyor asked what the expectations were for glove changes during wound care. DON B stated to sanitize or wash hands in between all glove changes. Surveyor reviewed the Comprehensive Medical Record of R7. Record review indicated that R7's wound had decreased in size since admission to the facility and was being measured and documented. Review of Physicians Orders regarding wound care revealed that wound care treatments were being applied as ordered. Upon admission, R7's sacral wound measured 8 x11cm. The last measurements done by the wound care facility showed it measuring 7.5cm x 8.5cm which was an improvement. Noted on MD orders that R7 should be reminded to change positions every 2 hours. Surveyor reviewed R7's Care Plan and noted that the care plan did not address the pressure injury, nor did it specify what treatments were current or what interventions were in place. Surveyor did observe a pressure mattress, cushion to wheelchair Surveyor reviewed R7's progress notes and noted that treatments and measurements were being done as ordered. Surveyor reviewed the facility policy entitled: Nursing Services-Policy and Procedure Manual for Long-Term Care, Skin and Wound Management. Under the heading Dressings, Dry/Clean, re: Steps in the procedure, there were 24 steps to this procedure. Steps 5, 8, 12, 19, and 23 direct nursing personnel to wash and dry hands thoroughly between glove changes. An article entitled, Wound Care Infection Prevention Recommendations for Long-Term Care Facilities-Minnesota Department of Health, states under Hand Hygiene, Perform hand hygiene before starting wound care for each resident (including before retrieving wound care supplies, and before and after donning gloves) and after doffing gloves. It further states, Wear gloves during all stages of wound care including when applying new dressings. [NAME] them after performing hand hygiene. During an individual resident's treatment doff gloves every time when going from dirty to clean surfaces or supplies and before caring for another resident. The facility put R7 at risk for infections in the pressure injury by not performing proper hand hygiene during dressing changes. Based on observation, interview, and record review, the facility did not provide care consistent with professional standards to prevent development of a pressure injury for three of three residents (R) reviewed for pressure injuries (PI). (R145, R1, R7) R145 was admitted to the facility with an unstageable PI to the left heel. Staff did not complete weekly assessments of wound condition with measurements per professional standards of practice, did not follow pressure-relieving interventions on the care plan, and did not perform wound care per orders. R1 had chronic pressure injuries to the buttocks and upper thighs. Staff did not complete weekly assessments of wound condition with measurements per professional standards of practice. R7 was admitted with a stage 4 pressure injury. R7 does not have a care plan addressing the pressure injury. Staff did not perform wound care in a manner to prevent infection for R7. Findings include: According to the National Pressure Injury Advisory Panel's (NPIAP) Prevention and Treatment of Pressure Ulcers/Injuries Quick Reference Guide 2019: Pressure injuries should be assessed at least weekly to monitor the progress toward healing. A uniform, consistent method for measuring pressure injuries should be used to facilitate meaningful comparisons of measurements across time. The physical characteristics of the wound bed and surrounding skin and soft tissue should be assessed. Example 1: R145 was admitted to the facility on [DATE]. R145's diagnoses included, in part: sepsis, hypokalemia, altered mental status, metabolic encephalopathy, alcohol dependence, muscle weakness, and abnormalities of gait and mobility. Record review identified the following Skin/Wound Note dated 04/29/22, which stated in part, Skin assessment: .Bilateral heels covered with a foam type dressing. Noted approx. [approximately] 3X3 cm [centimeter] dark pressure area on left heel. Nothing noted on right heel at this time. Heels floated while in bed . Record review identified the following physician order dated 04/29/22: LEFT HEEL DTI [deep tissue injury]: Keep covered with bordered heel foams. Change every 3 days. Peel back bordered drg [dressing] every shift to assess. Float heels with Prevalon boots when in bed. Record review identified the following physician order dated 05/27/22: LEFT HEEL WOUND CARE: Left heel has a small stable scab. (PI [pressure Injury] Unstageable). Surrounding skin with boggy, blanching erythema. Keep covered with a heel foam changed drg [dressing] every 3 days or PRN as needed. Float heels when in bed with a boot or pillow under calf. R145's comprehensive care plan did not contain a problem or focus related to skin or wounds. The Activities of Daily Living/Baseline Care Plan and Certified Nursing Assistant (CNA) Bedside [NAME], initiated on 04/29/22, included the following interventions, in part, .5. PRESSURE RELIEF: pressure relief mattress. Cushion in wheelchair. FLOAT HEELS ON A WEDGE PILLOW . Record review identified no documentation of weekly assessments of the wound with measurements and description of the wound bed and surrounding tissues. On 06/01/22, at 10:50 AM, Surveyor interviewed Registered Nurse (RN) C, who stated R145 came to facility with unstageable wound to the left heel. RN C stated nurses should be documenting wound assessments weekly in the progress notes. RN C stated there should be a skin/wound care plan related to this problem. RN C stated R145 should have heels floated off the bed surface whenever in bed. On 06/01/22, at 11:10 AM, Surveyor interviewed Certified Nursing Assistant (CNA) I, who stated there was a CNA care plan in the electronic chart that tells them if a resident had any specific instructions for skin care, or positioning to reduce pressure. CNA I was not aware of any specific instructions for pressure relief or positioning for R145. On 06/01/22, at 1:31 PM, Surveyor interviewed CNA H, who stated they did not put any special boots on R145's heels or elevate the heels off the bed when putting R145 in bed to lay down. CNA H was not aware of any special instructions to float R145's heels when in bed. On 06/02/22, at 7:52 AM, Surveyor observed R145 lying in bed with pajamas on. R145 was awake, but stated CNAs had not yet assisted her with getting up and dressed for the day. R145 was lying flat on her back with both heels directly on the bed. Surveyor did not observe a pillow visible under R145's legs, and no Prevalon boots were visible on R145's feet or anywhere in the room. Surveyor asked R145 if staff put any boots on her feet when she was in bed, or if they put a pillow under her legs to elevate her heels off the bed while she slept. R145 stated, No. On 06/01/22, at 2:14 PM, Surveyor observed Licensed Practical Nurse (LPN) J perform wound care on R145. LPN J entered R145's room with supplies on a plastic tray, and placed the tray on the over bed table. R145 explained to R145 she was going to complete wound care for the heel. LPN J requested R145 transfer to the bed for the procedure, but resident refused. LPN J washed hands with soap and water in the bathroom, and turned off faucet with a paper towel. LPN J applied clean gloves. LPN J removed the sock from R145's right foot and observed there was no dressing in place on the heel. Surveyor observed the heel and noted a dark area at the center, but no scab or open areas noted. LPN J did not palpate the heel or ask R145 if there was any pain in the area. LPN J placed R145's bare heel on the stocking on the floor. LPN J took a bottle of sterile water from the tray and attempted to open it with gloves on. LPN J was unable to get safety seal off top of bottle after removing cap. LPN J removed the gloves and placed them on the over bed table beside the tray with supplies. LPN J did not wash hands or use hand sanitizer after removing the gloves. LPN J attempted to remove the safety seal with bare hands. LPN J was unable to remove the safety seal from the bottle, so left the room to retrieve a different bottle. LPN J did not wash hands or use hand sanitizer when leaving room. LPN J returned to room a few minutes later with a new bottle of sterile water and a towel. LPN J place the towel under R145's right foot. LPN J used hand sanitizer and opened the bottle of sterile water and placed it on the tray. LPN J applied clean gloves without washing hands or using hand sanitizer. LPN J placed several pieces of gauze on the towel under R145's right foot and poured sterile water on the gauze. LPN J used the wet gauze to wipe the right heel. LPN J then took the bottle of sterile water and poured it over R145's right heel. LPN J took some dry gauze and patted the right heel dry. LPN J took a border foam dressing and applied it to R145's right heel. LPN J replaced R145's sock over the dressing. LPN J took the wet towel and placed it in a hamper. LPN J threw the used dressing supplies in the garbage. LPN J took off the gloves and threw them in the garbage. Without washing hands or using hand sanitizer, LPN J picked up the tape and bottle of sterile water and placed them in a drawer. LPN J picked up the tray and exited R145's room. LPN J placed hand sanitizer in free hand from a dispenser in the hallway, and walked down the hall. Surveyor reviewed the documentation in R145's medical record and noted all documentation and wound orders referred to a wound on the left heel. On 06/01/22, at 2:40 PM, Surveyor interviewed LPN J about which heel had a pressure injury. LPN J looked at R145's medical record and stated it was supposed to be the left heel, but she did the wound care on the right heel. LPN J went back to R145's room and verified there was currently a dressing on the left heel. LPN J stated she would go back and change the dressing on the left heel. Surveyor reviewed the use of gloves and hand hygiene during the wound care observation with LPN J. LPN J stated she should have used hand sanitizer, or washed her hands each time after removing soiled gloves prior to putting on new gloves, or going on to other tasks. LPN J stated she did not use hand sanitizer or wash hands each time after removing soiled gloves during the observation. On 06/02/22, at 9:34 AM, Surveyor interviewed Director of Nursing (DON) B about the above observations and interviews. DON B stated R145 did have orders and interventions on the care plan instructing staff to float R145's heels when in bed. DON B stated the above observations and interviews indicated staff did not follow the plan of care, which would put R145 at risk for delayed wound healing and possible further skin breakdown. DON B stated the standard of practice and expectation of the facility was for nursing staff to assess residents with wounds at least weekly. DON B stated nurses should document that assessment with measurements and condition of wound bed and surrounding skin in the medical record. DON B stated after review of R145's medical record, it was evident staff was not assessing and documenting R145's wound on a weekly basis. DON B stated based on the above wound care observation, LPN J did not perform wound care on the correct heel and did not follow proper hand hygiene after removing soiled gloves during the procedure. Example 2: R1 was admitted to the facility on [DATE] with the following diagnoses in part, methicillin resistant staphylococcus aureus infection, major depressive disorder, acute and chronic respiratory failure with hypoxia, and unstageable pressure ulcer. On 05/31/22, at 10:19 AM, Surveyor interviewed R1, who stated she had sores on the bottom from the bedpan and wheelchair. R1 the nurse was changing bandages on the sores about every three days. Surveyor observed an alternating pressure air mattress on R1's bed. Record review identified R1's annual Minimum Data Set (MDS) assessment, dated 03/28/22, documented R1 was at risk for PI, and had 2 unstageable PIs. The record review did not identify consistent weekly documentation of wound assessments with measurements and description of wound beds and surrounding skin. On 06/01/22, at 10:50 AM, Surveyor interviewed RN C who stated stated R1 had chronic pressure injuries below each buttocks and upper thighs caused from the wheelchair cushion because R1 was very large and refused to reposition and spend time in bed. RN C stated R1 was told because of morbid obesity it was not good for her internal organs to lay on her side, so she only lays on her back in bed. RN C stated also due to R1's size and difficulty with movement, R1 often requested to use the bed pan instead of commode and this irritated the PI's on R1's bottom. RN C stated nursing staff should be assessing and documenting the condition of the wounds weekly. On 06/02/22, at 9:37 AM, Surveyor interviewed DON B about the facility policy and her expectation on wound assessment and documentation for residents who have wounds. DON B stated wounds should be assessed with measurements and description of wound condition weekly. DON B stated she had reviewed R1's medical record and identified that there was not consistent weekly documentation of R1's wounds with measurements.

Based on observations, interviews, and record reviews, the facility did not ensure 1 of 5 residents reviewed for unnecessary medications (R16) were free from unnecessary medications. R16 has a history of delusions and hallucinations. R16 is prescribed Seroquel, an antipsychotic medication. The facility does not have behavior monitoring to identify and treat the targeted behaviors or a care plan to direct staff with useful and effective interventions to alleviate the behaviors. Nursing does not evaluate the use of the medication in order to determine whether the medication is effective, needs to be adjusted, or if it is still needed to allow R16 to function at her highest practicable mental, physical, and psychosocial well-being. This is evidenced by: R16 was admitted to the facility 1/4/22 with medical diagnoses that include, but are not limited to, Vascular Dementia with Behavioral Disturbance, Other Symptoms and Signs Involving Cognitive Functions and Awareness, and Visual Hallucinations. R16's history indicated that she was treated at the hospital 11/5/21 for psychiatric symptoms with increased delusions and hallucinations at home. The History and Physical also stated that R16 was having increased agitation and comments of physically harming others. There is also mention that R16 had been taking the Seroquel at home, 25 Milligrams (MG) at bedtime. The hospital physician increased the dosage to 50 MG. The Psychiatric consult dated 11/7/21 also makes mention of R16 having homicidal ideations. R16's Physician Orders upon admission included Quetiapine Fumarate (Seroquel) Tablet 25 MG, Give 25 mg by mouth at bedtime for (left blank). Note: There is no diagnosis listed to support this order. In reviewing the Minimum Data Set Assessments (MDSAs) completed for R16 (admission 1/8/22 and Quarterly 4/5/22), R16 has been identified on both for hallucinations and delusions. R16's BIMS (Brief Interview of Mental Status) score on the most recent MDSA was 8/15, indicating impaired cognitive status. A dictation made by Advanced Practice Nurse Practitioner on 5/3/22 indicates that R16's hallucinations have improved since being prescribed the Seroquel. In reviewing Behavior Monitoring for R16, 3/1/22 - 5/31/22, Surveyor noted that the facility monitors R16 for hallucinations and delusions. Also noted, was that very few behaviors were documented. However, in reviewing the EMAR (Electronic Medication Administration Record) and comparing this to the Interdisciplinary Team Progress (IDT) Notes for this same time period, Surveyor noted the following: Note: The EMAR entries direct staff to .Document in nurses notes: behavior, interventions used and effectiveness of interventions every shift . MARCH 2022: EMAR indicates R16 displayed behaviors on 3/4/22 and 3/15/22 and these entries refer the reader to the IDT Progress Notes. In reviewing the IDT note for each of these days, there is an entry indicating there was a behavior on 3/4/22 (7:03 AM) and 3/15/22 (7:41 PM), but there is no description of what the behavior was or what interventions were attempted, or whether the intervention was effective or ineffective. The Behavior Monitoring Report indicates R16 displayed no behaviors during March. APRIL 2022: EMAR indicates R16 displayed behaviors on 4/5/22, 4/10/22, and 4/25/22. - The IDT notes indicate behaviors were displayed on 4/5/22 (5:08 PM) but there is no description what the behaviors were, what interventions were attempted, and whether the interventions were effective. - The IDT also notes R16 had behaviors on 4/10/22 (8:32 PM) in which R16 was, .talking aloud and complaining about cleanliness, slapping the bathroom door and using very foul language. There are no interventions attempted listed. There also was no follow-up documentation to indicate if the behavior continued or stopped. - The IDT notes indicate behaviors were displayed on 4/25/22 (10:52 PM) but there is no description what the behavior was, what interventions were attempted, and whether the interventions were effective. The Behavior Monitoring indicates R16 displayed no behaviors during April. MAY 2022: The EMAR indicates R16 displayed behaviors on 5/9/22, 5/10/22, 5/15/22, 5/19/22, 5/21/22, 5/22/22 x2, 5/25/22, and 5/28/22 is left blank with no documentation. - The IDT notes indicate R16 had behaviors on 5/9/22 (11:13 PM) of crying and repeating, the scenario many times . It does not state what the scenario is or whether this was even a behavior considered harmful to R16 or others. The documentation also does not indicate what interventions were used or whether the interventions were effective. The Behavior Monitoring Report indicates no behaviors on this date. - The IDT note indicated R16's behavior of 5/10/22 of being, .very upset about a half dozen bugs in window ledge . worried she won't be able to sleep because of the fear of bugs . Again, this is really not a behavior if the bugs were present, the note does not indicate if this is the case, and the documentation does not indicate how this is harmful to R16 or others. The Behavior Monitoring Report indicates no behaviors on this date. - 5/12/22 The Behavior Monitoring Report indicates R16 was displaying yelling/screaming at 8:03 AM. This is not listed in the IDT notes or on the EMAR. The IDT also notes behavior displayed by R16 on 5/15/22 but again, there is no description what the behavior was, what interventions were attempted, and whether the interventions were effective. The Behavior Monitoring Report indicates no behaviors on this date. - The 5/19/22 Behavior Monitoring Report indicates R16 displayed yelling, screaming, and abusive language at 5:50 PM on this date. Note: This is not listed in the IDT notes or on the EMAR. The IDT note time listed for the behavior of 5/19 is at 10:43 PM. There is no entry indicating R16 was yelling and screaming and using abusive language in this note, so the reader has no way of knowing if this entry refers to the behavior displayed earlier in the day, at the time of documentation, or if the nurse documented the behavior later, at the end of the shift. The 5/19/22 (10:43 PM) IDT note makes mention of R16 being tearful and upset about another resident coughing and sneezing in the dining area. She was upset and anxious. Again, the reasonable person could be upset over such actions of another person coughing and sneezing where food is served. This does not explain how this behavior may be harmful to R16 or others. Also there are no interventions listed that staff attempted and were or were not effective. - The IDT notes of 5/21 (8:55 AM) and 5/22 (7:43 AM and 3:06 PM) indicate R16 displayed behaviors but again there is no description what the behavior was, what interventions were attempted, and whether the interventions were effective. There are no entries for the behaviors R16 displayed on 5/25 or 5/28/22 in the IDT notes or the Behavior Monitoring Report. Surveyor then reviewed the Care Plan (CP) the facility formulated for R16's behaviors and interventions. The following was noted: 1. COGNITION: Alteration in cognition related to dementia: (Start date 1/4/22 with no updates or revisions made) GOAL: Will continue to be up daily and make eye contact with conversation through the next review date · Give cues as needed for daily cares, activities · Keep Legal Representative updated regarding status · Review medications and record possible causes of cognitive deficit: new medications or dosage increases; anticholinergics, opioids, benzodiazepines, recent discontinuation or addition, omission or decrease in dose of benzodiazepines, drug interactions, errors or adverse drug reactions, drug toxicity Note: These are the only three interventions listed for this particular area. 2. PSYCHOTROPIC MEDICATION: (R16) uses Seroquel related to hallucinations (1/4/2022) The resident will be/remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment through review date. (Start date 1/4/22 with no updates or revisions made) · Administer PSYCHOTROPIC medications as ordered by physician. Monitor for side effects and effectiveness Q (every) -SHIFT. · Consult with pharmacy, MD to consider dosage reduction when clinically appropriate at least quarterly. · Discuss with MD, family re ongoing need for use of medication. Review behaviors/interventions and alternate therapies attempted and their effectiveness as per facility policy. · Educate the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms of (SPECIFY: psychotropic medication drugs being given). · Monitor/document/report PRN any adverse reactions of PSYCHOTROPIC medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person. · Monitor/record occurrence of for target behavior symptoms (SPECIFY: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others. etc.) and document per facility protocol. These CPs list no actual behaviors that may be detrimental or harmful to R16 or others or that may impede on others spaces or body. On 6/2/22 at 1:50 PM, Surveyor interviewed DON B (Director of Nursing) related to staff expectations regarding behavior monitoring. DON B stated that staff are to document behaviors on the EMAR, which triggers the nurse to complete behavior charting specific to that resident and the behavior. They are to chart what exactly the behavior was, what interventions did the nurse implement, and was the intervention effective. When asked the reasoning behind the documentation, DON B stated, It gives us an awareness of (R16's) behaviors and what works, what doesn't, and what can be tried to alleviate the behaviors. (R16) doesn't impede on others but will yell and swear if a resident gets in her space. She can become very angry . Sometimes little things are very upsetting to her . DON B further stated that she pulls up the 24 hour summary every day. These consist of various topics such as falls, incidents, behaviors, any 'as needed' medications given, etc.We then talk about it in stand-up meeting every morning. Each quarter, if a resident has behaviors, we evaluate what behaviors the resident had and how often, what interventions were done, and whether they were effective or not, and whether we feel the doctor should complete medication review and either Gradual Dose Reduction or increase the medication. All depends on what is documented by nursing. If the documentation isn't there and there isn't a description of the actual behaviors and what does or does not work, then our evaluation is pretty much useless because we don't have the accurate data to evaluate and make a determination. DON B went on to state that staff are also to ensure behaviors are addressed on the care plans and revise them as behaviors change or interventions no longer become effective and new ones have been identified as alleviating the behaviors. DON B stated, Without these pieces, the resident could be harmed and the care would not be done as it should be as the staff really won't know how to care for the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Example 7: R18's most recent MDS had an ARD/Target date of 04/12/22, R18's completion date was 06/01/22. This MDS was not completed in a timely manner. Example 8: R2's most recent MDS had an ARD/Target date of 04/06/22, R2's completion date was 06/01/22. The MDS was not completed in a timely manner. On 6/1/22 at 3:56 PM, Surveyor interviewed the Nursing Home Administrator (NHA) A and Director of Nursing (DON) B regarding the use of an MDSA Coordinator and who is responsible to complete the MDSAs. NHA A stated there currently was no staff in-house that completes these assessments. He further stated a Corporate MDS Coordinator who works off-site has been completing them. DON B stated that she has reached out to the corporate office several times and offered to assist with the completion of the MDSAs, as she was aware they were being completed late. She stated that she only required some training to do these, but Corporate Office has refused her offer and there are no staff in-house with the knowledge to complete them. On 6/2/22 at 12:56 PM, Surveyor telephoned the Corporate MDS Coordinator, MDSC N and interviewed her regarding her process of completing the MDSAs. MDSC N stated that there is no MDSA Coordinator in three of the Corporation's facilities and that she is completing the assessments for all the residents in all three facilities. She stated that at one point in time, she was completing them for five facilities. MDSC N stated, .I know I have fallen behind, but I do the best that I can. I do the majority of the assessments off-site but do try to get into the buildings when I can. I have not been to Aspen in some time . It's a challenge to get all of the assessments completed in the required time frames . I know that some are severely late, but I think I have them all caught up now, as of today . MDSC N further stated that she was in the hospital for three weeks during the month of April and there was no back-up MDS Coordinator while she was off work, resulting in many very late assessments. Example 6: R28 was admitted to the facility on [DATE]. R28's last MDS had an ARD date of 4/26/22. During record review it was noted that the following sections of the MDS were done late: Section A 5/31/22, Section C 5/19/22, Section D 5/19/22, Section E 5/19/22, Section G 5/31/22, Section GG 5/31/22, Section H 5/31/22, Section I 5/31/22, Section J 5/31/22, Section L 5/31/22, Section M 5/31/22, Section N 5/31/22, Section O 5/31/22, Section P 5/31/22, and Section Q 6/1/22. These sections were submitted late. Example 3: R1 was admitted to the facility on [DATE] with diagnoses including, in part, Methicillin resistant staphylococcus aureus infection, major depressive disorder, acute and chronic respiratory failure with hypoxia, and unstageable pressure ulcer. Surveyor reviewed R1's medical record which identified the annual MDS assessment was due no later than 04/11/22. The record indicated the MDS assessment was not completed until 05/31/22. This assessment was completed 50 days late. Example 4: R17 was admitted to the facility on [DATE] with diagnoses including in part, spondylosis lumbosacral region, scoliosis, osteoarthritis of the knee, pain in left thigh, difficulty walking, paroxysmal atrial fibrillation, and heart disease. Record review identified the most recent MDS assessment completed for R17 was a quarterly MDS with an assessment reference date of 01/10/22. The next MDS assessment was due no later than 04/26/22. As of 06/02/22 that MDS assessment was not completed, which was 37 days overdue. Example 5: R145 was admitted to the facility on [DATE], with diagnoses including in part, sepsis, metabolic encephalopathy, altered mental status, and repeated falls. Record review further indicated R145 had an unstageable pressure injury to the left heel. R145's admission MDS was due no later than 05/13/22. Record reviewed identified the admission MDS was completed on 6/01/22, which was 19 days late. Record review identified R145 was rehospitalized on [DATE] for symptoms of a stroke and returned to facility on 5/27/22. As of 06/02/22 there was no entry MDS started on R145's medical record. Based on interviews and record reviews, the facility did not complete and submit Minimum Data Set Assessments (MDSAs) in the required time frames for 4 of 12 sampled and 4 supplemental sampled residents (R16, R345, R1, R17, R145, R28, R18, R2) - R16, the most recent Quarterly MDSA had an Assessment Reference Date (ARD) of 4/5/22 but was not completed until 5/31/22, or 40 days overdue. - R345 was admitted to the facility 5/11/22. As of 6/1/22, the MDSA was not completed. - R1's most recent MDS assessment was completed 12/26/21. R1's next MDS was an annual assessment due no later than 04/11/22. R1's annual MDS assessment was completed on 5/31/22, which was 50 days late. - R17's most recent MDS assessment was completed 01/10/22. R17's next Quarterly MDS was due no later than 04/26/22. As of 06/02/22 R17's MDS assessment was not completed, which was 37 days overdue. - R145 was admitted to the facility on [DATE]. R145's admission MDS assessment was due no later than 05/13/22. The admission MDS was completed on 06/01/22, which was 19 days late. - R28's most recent MDSA had an ARD date of 4/26/22. This assessment was not submitted in time according to the RAI (Resident Assessment Instrument) Manual. - R18's most recent MDS had an ARD/Target date of 04/12/22, R18's completion date was 06/01/22. - R2's most recent MDS had an ARD/Target date of 04/06/22, R2's completion date was 06/01/22. This is evidenced by: According to Chapter 2 of Version 3.0 RAI Manual (Resident Assessment Instrument), an admission MDSA must be completed within 14 calendar days after an individual is admitted to the facility. Chapter 2, page 2-21 goes on to further state, . Federal statute and regulations require that residents are assessed promptly upon admission (but no later than day 14) and the results are used in planning and providing appropriate care to attain or maintain the highest practicable well-being . The RAI Manual continues to state in regards to the timing for completing the MDSAs in Section 5.2: - For all non-admission MDSAs, the MDS Completion Date must be no later than 14 days after the previous ARD (Assessment Reference Date). This would include Annual Assessments. - For all admission Assessments, the MDS Completion Date must be no later than 13 days after the Entry Date (Date of admission plus 13 days) - Quarterly Assessments: The Assessment Reference Date and MDS Completion Dates must be no later than 92 days from previous ARD and the Transmission Date must be no later than 14 days from the Completion Date. During a complaint investigation and verification visit conducted 3/21/22, the facility was found to be out of compliance with the timing of MDSAs. The facility completed a plan of correction, which was accepted on 3/30/22. However, the facility was found to have continued noncompliance with this current Recertification and complaint Survey. Example 1: R16 had an admission assessment with an ARD date of 1/8/22. Upon review of the MDSAs completed for R16, the most recent Quarterly MDSA had an ARD of 4/5/22. In reviewing this MDSA, the facility completed sections A, G, H, I, J, L, M, N, O and P on 5/31/22, 40 days overdue. Example 2: R345 was admitted to the facility 5/11/22. Based on this admission date (Day 1 of the MDSA timing period), the facility should have completed an MDSA dated 5/25/22. As of this writing (6/1/22) an MDSA remains In Progress and not yet completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Example 5: R40 was admitted to the facility on [DATE], and has diagnoses that include anxiety disorder, depression, COPD, and Essential (Primary) Hypertension. R40 has doctors orders for Coumadin which is an anticoagulant (AC). Review of R40's care plan, there is no mention in the care plan related to the AC and what side effects to look for when taking an AC. On 6/1/22 at 3:30 PM, Surveyor interviewed Director of Nursing (DON) B regarding the care plan process. DON B stated that resident care plans should address resident weaknesses as well as their strengths and high risk medications. Example 3: R7 was admitted to the facility on [DATE]. R7 was [AGE] years old. R7 had a BIMS of 15, indicating they were cognitively intact. R7 had diagnoses of Chronic Lymphocytic Leukemia of B-cell type in relapse, Chronic Kidney Disease, Congestive Heart Failure, and Pressure Ulcer of the Sacral Region, Stage 4. R7 had been admitted to the facility with the Stage 4 ulcer having acquired it at a previous placement. On 6/2/22, Surveyor reviewed R7's Comprehensive medical record. Surveyor reviewed the care plan available in the record. The care plan did not address the fact that R7 had a wound, what interventions were in place, or what treatments were being done. On 6/2/22, Surveyor reviewed R7's physician orders and medication list. It was noted that R7 was taking Eliquis 5mg twice daily. This is an anticoagulant (drugs that prolong clotting time of blood.) Surveyor reviewed R7's care plan. The care plan did not address the use of an anticoagulant, what precautions staff needed to use or be aware of when a person is taking this medication, nor any other interventions. On 6/2/22, Surveyor reviewed R7's CNA care card, the place where CNAs are given directives in caring for each resident. R7's care card did not inform the CNAs of any need to monitor for bleeding, nor any special directives needed due to R7 having a pressure injury, such as reminders to reposition every 2 hours. On 6/1/22 at approximately 11:00AM, Surveyor observed R7's wound care. Wound care consisted of cleansing the wound with Vashe wound solution, application of antibacterial silver agent, Aquacel applied over that, and then the wound is measured and redressed. Wound care was done weekly by the wound care clinic and then daily at the facility. On 6/2/22 at approximately 10:30AM, Surveyor interviewed DON B regarding Care Plans. Surveyor asked DON B if they could show Surveyor where on R7's care plan it speaks to the presence of a pressure injury. DON B stated they were unable to find that. Surveyor asked DON B to explain the care planning process. DON B stated that she had been adding to the care plans. DON B further stated that she had been doing the care plans as when DON B speaks with the rest of the nursing staff, they say they have not been trained on how to do or revise a care plan in PCC ([NAME] Click Care, an electronic health record system). DON B had set up a training with the IT department to educate the nursing staff, but no staff showed up to the training. DON B stated there is not a solid care plan process right now. Surveyor asked who did original care plans when a resident was admitted to the facility. DON B stated that the Activity Director puts in the standard care plan template. The Activity Director is not a nurse. DON B then tries to update it. When Surveyor asked DON B what the expectations were for updating care plans, DON B stated that nurses should update the care plans as things change with the residents. Surveyor asked if that was being done, and DON B stated no. 6/2/22 at 10:45AM, Interview with CNA E who has worked here for 53 years. Surveyor asked if there were any special things the CNA needed to do for R7 because of the pressure injury. CNA E stated that the aides don't do anything with that; when they wash up R7, they call a nurse in when they get to the area with the pressure injury. Surveyor asked if there were any reminders or special things a CNA might need to be aware of for R7 due to the pressure area, and if this was on R7's care card, CNA E stated no. On 6/1/22, Surveyor interviewed RN G regarding care plans. Surveyor asked who normally is responsible for care plans; RN G stated the DON. Surveyor asked if the corporate MDS person possibly did this and RN G stated they were not sure. RN G further stated that the nurses don't update the care plans, and that the DON had been doing it lately. RN G stated that they had not been directed to update care plans, and that if it needed to be done they would contact the DON. On 6/2/22 at approximately 12:30PM, Surveyor interviewed the AD F (Activity Director) regarding care plans. Surveyor asked AD F about the process for doing care plans. AD F stated that when she first meets a resident, they do an activity assessment and from that they are able to tell a resident's interests, preferences, and disabilities. AD F stated that they enter the baseline care plan template into PCC. AD F stated the charge nurse is to assess the resident and do the nursing part as the AD is not qualified to do that; the only thing the AD does is enter the template. The facility care plans were not complete nor updated when conditions changed with residents. Based on observation, interview, and record review, the facility did not develop and implement a comprehensive person-centered care plan for 4 of 12 Residents (R) reviewed (R145, R7, R40, R345.) - The facility did not ensure care plan interventions to promote healing and prevent further development of pressure injuries were carried out consistently by staff for R145 or R7. - The facility did not develop a care plan for bleeding risks for residents receiving anticoagulant medications for 3 residents (R145, R7, R40). - R345 had no Care Plans developed to address his falls or behavioral tendencies. This is evidenced by: Example 1: R145 was admitted to the facility on [DATE] with diagnoses including in part, sepsis, hypokalemia, altered mental status, metabolic encephalopathy, myocardial infarction, alcohol dependence, repeated falls, aphasia following cerebrovascular disease, muscle weakness, abnormalities of gait and mobility, and cerebral infarction (stroke). Record review identified the following Skin/Wound Note dated 04/29/22, which stated in part, Skin assessment: .Bilateral heels covered with a foam type dressing. Noted approx. [approximately] 3X3 cm [centimeter] dark pressure area on left heel. Nothing noted on right heel at this time. Heels floated while in bed . Record review identified the following physician order dated 04/29/22: LEFT HEEL DTI [deep tissue injury]: Keep covered with bordered heel foams. Change every 3 days. Peel back bordered drg [dressing] every shift to assess. Float heels with Prevalon boots when in bed. Record review identified the following physician order dated 05/27/22: LEFT HEEL WOUND CARE: Left heel has a small stable scab. (PI [pressure Injury Unstageable). Surrounding skin with boggy, blanching erythema. Keep covered with a heel foam changed drg [dressing] every 3 days or PRN as needed. Float heels when in bed with a boot or pillow under calf. R145's comprehensive care plan did not contain a problem or focus related to skin or wounds. The Activities of Daily Living/Baseline Care Plan and Certified Nursing Assistant (CNA) Bedside [NAME], initiated on 04/29/22, included the following interventions, in part, .5. PRESSURE RELIEF: pressure relief mattress. Cushion in wheelchair. FLOAT HEELS ON A WEDGE PILLOW . On 06/01/22, at 10:50 AM, Surveyor interviewed Registered Nurse (RN) C, who stated R145 came to facility with an unstageable wound to the left heel. RN C stated there should be a skin/wound care plan related to this problem. RN C stated R145 should have heels floated off the bed surface whenever in bed. On 06/01/22, at 11:10 AM, Surveyor interviewed Certified Nursing Assistant (CNA) I, who stated there was a CNA care plan in the electronic chart that tells them if a resident had any specific instructions for skin care, or positioning to reduce pressure. CNA I was not aware of any specific instructions for pressure relief or positioning for R145. On 06/01/22, at 1:31 PM, Surveyor interviewed CNA H, who stated they did not put any special boots on R145's heels or elevate the heels off the bed when putting R145 in bed to lay down. CNA H was not aware of any special instructions to float R145's heels when in bed. On 06/02/22, at 7:52 AM, Surveyor observed R145 lying in bed with pajamas on. R145 was awake, but stated CNAs had not yet assisted her with getting up and dressed for the day. R145 was lying flat on her back with both heels directly on the bed. Surveyor did not observe a pillow visible under R145's legs, and no Prevalon boots were visible on R145's feet or anywhere in the room. Surveyor asked R145 if staff put any boots on her feet when she was in bed, or if they put a pillow under her legs to elevate her heels off the bed while she slept. R145 stated, No. On 06/02/22, at 9:34 AM, Surveyor interviewed Director of Nursing (DON) B about the above observations and interviews. DON B stated R145 did have orders and interventions on the care plan instructing staff to float R145's heels when in bed. DON B stated the above observations and interviews indicated staff were not following the plan of care, which would put R145 at risk for delayed wound healing and possible further skin breakdown. R145's medical record contained the following physician order: Coumadin, an anticoagulant (drugs that prolong clotting time of blood) 5 milligrams (mg) daily at bed time, start date 05/31/22, end date 6/2/22. Surveyor reviewed R145's medical record. No bleeding risk care plan or monitoring for bleeding risk was identified on R145's comprehensive care plan. No nursing orders to monitor for bleeding or abnormal bruising were identified on R145's medical record. On 06/02/22, at 9:34 AM, Surveyor interviewed DON B about the facility policy for monitoring residents for signs of symptoms of bleeding when on blood thinner medications. DON B stated it should be on the resident's comprehensive care plan, Medication Administration Record (MAR) or Treatment Administration Record (TAR) to monitor for signs or symptoms of abnormal bruising or bleeding. Surveyor asked for documentation to show this was in place on R145's care plan, MAR, or TAR. Surveyor did not receive any documentation showing R145's care plan, MAR, or TAR included instructions for staff to monitor for signs and symptoms of abnormal bruising or bleeding. Example 2: R345 has medical diagnoses that include, but are not limited to, Cerebral Infarction due to Occlusion or Stenosis of the Right Middle Cerebral Artery, Dysphasia, and Major Depressive Disorder. R345 was admitted [DATE] and there is no Minimum Data Set Assessment yet available to review. FALLS: The facility completed a Fall Risk Evaluation on 5/11/22: score 12 (At Risk). Areas completed included: - (4) Intermittent confusion - (0) No falls past 3 months - (2) Chair bound - requires restraints and assist with elimination - (0) Adequate vision - (1) Requires use of assistive devices (i.e. cane, w/c, walker, furniture) - (0) No changes in B/P from laying to stand - (0) No high risk Rx's past 7 days - (4) 3 or more predisposing diagnoses present Falls for R345 were then reviewed and Surveyor noted the following incidents: - 5/14/2022 at 3:13 PM: R345 was found lying on the floor on his left side, in his room. The resident was reminded to use the call light and signage was posted in his room to call for assistance. - 5/15/22 at 8:52 PM: Staff entered R345's room to respond to his call light and witnessed him fall to the floor. R345 was again reminded to use the call light for assistance and a floor mat was placed on the floor beside his bed. On 5/19/22, R345 was moved to a different unit and into a room near the nursing station so that he could be monitored more closely. In reviewing the Care Plan completed for R345, Surveyor noted there was no plan to address his falls and interventions for staff to use to attempt to prevent additional falls from occurring. Under the Activities of Daily Living Care Plan, the facility did enter one intervention, which was to remind R345 to call for assistance. There were no other interventions listed to assist staff in addressing R345's fall prevention. Behavior care plan: R345 was currently being monitored for sexually inappropriate behaviors towards staff and utilizes: - Risperidone Tablet 0.25 MG, Give 1 tablet by mouth at bedtime (Antipsychotic) - Sertraline HCl Tablet 100 MG, Give 1 tablet by mouth in the morning (Antidepressant) On 6/2/22 at 1:58 AM, Surveyor interviewed LPN O (Licensed Practical Nurse) and asked her what R345's behaviors consisted of. LPN O stated that R345 can become intrusive and sexually inappropriate to the younger girls. LPN O also stated that R345 has periods in which he won't sleep for two or three days. R345 also gets very anxious when the telephone rings and will repeatedly ask if it is his family calling, and wants to go home. LPN O stated that with each of these tendencies, R345 is easily redirected. At 12:11 PM, Surveyor interviewed CNA E (Certified Nursing Assistant) regarding R345's behaviors. CNA E stated that R345 gets overly friendly with some of the girls, grabs breast or pats them on the back end. She stated the behaviors are infrequent and R345 is easily redirected and will stop when it is brought to his attention that the behavior is inappropriate. In reviewing the behavior monitoring completed, it was noted R345 displayed sexually inappropriate behaviors 5 times since admission on [DATE]: - 5/17/22 at 2159 and 2225 - 5/18/22 at 2159 and 2246 - 5/31/22 at 1138 On 6/1/22 at 3:18 PM, Surveyor interviewed Director of Nursing (DON) regarding the care plan process. DON stated that resident care plans should address resident weaknesses as well as their strengths. If a resident is a fall risk the care plan should address interventions to assist staff in fall prevention. The DON stated if a resident requires behavior monitoring, a care plan should be formulated to assist staff in non-pharmaceutical interventions to use that are effective for the resident to curb the behaviors. There was no Care Plan located to direct staff on effective interventions in order to attempt to prevent falls from occurring or to identify R345's behaviors and interventions to apply should R345 manifest them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Example 4: R14 was admitted to the facility on [DATE], and has diagnoses that include chronic pain, osteoarthritis, dementia, major depressive disorder, hypertension, and difficulty walking. R14's Minimum Data Set (MDS) assessment indicated that R14 has a Brief Interview for Mental Status (BIMS) of 08. A score of 08 indicates the resident is moderately cognitively impaired. Review of R14's medical record on 05/31 - 06/02/22 revealed no documentation of lesser restrictive devices being tried prior to the use of bed rails on R14's bed. Review of R14's current physician orders did not include include any orders for bed rail usage. Review of R14's medical record did not reveal any assessments for the risk of entrapment in relation to the bed rail use. Review of R14's care plan does not mention the use of side rails Example 5: R30 was admitted to the facility on [DATE], and has diagnoses that include, vascular dementia, mild cognitive behavior, and schizoaffective disorder Review of R30's medical record on 05/31 - 06/02/22 revealed no documentation of lesser restrictive devices being tried prior to the use of bed rails on R30's bed. Review of R30's current physician orders did not include include any orders for bed rail usage. Review of R30's medical record did not reveal any assessments for the risk of entrapment in relation to the bed rail use. Review of R30's care plan does not mention the use of side rails Example 6: R40 was admitted to the facility on [DATE], and has diagnoses that include, hypertension, anxiety disorder, depression, and osteoarthritis Review of R40's medical record on 05/31 - 06/02/22 revealed no documentation of lesser restrictive devices being tried prior to the use of bed rails on R40's bed. Review of R40's current physician orders did not include include any orders for bed rail usage. Review of R40's medical record did not reveal any assessments for the risk of entrapment in relation to the bed rail use. Review of R40's care plan does not mention the use of side rails Example 7: R7 was admitted to the facility on [DATE]. R7 was [AGE] years old. R7 had a BIMS of 15, indicating they were cognitively intact. R7 had diagnoses of Chronic Lymphocytic Leukemia of B-cell type in relapse, Chronic Kidney Disease, Congestive Heart Failure, and Pressure Ulcer of the Sacral Region, Stage 4. R7 had been admitted to the facility with the Stage 4 ulcer having acquired it at a previous placement. On 6/2/2022, Surveyor observed R7 to have assist rails, trapeze, and an air mattress on their bed. On 6/2/2022, Surveyor did a record review of R7's comprehensive medical record. It was noted that there was no side rail assessment for need or safety present in R7's medical record. Example 8: R29 was admitted to the facility on [DATE]. R29 had diagnoses of Alzheimer's disease with late onset, Dementia with Behavioral Disturbance, Visual and Auditory Hallucinations, and muscle weakness. R29 was on hospice services. R29 had a BIMS (Brief Interview for Mental Status) score of 0, which indicates severe cognitive difficulties. On 5/31/2022, Surveyor observed R29 to be in bed. R29 had a inverted mattress and assist bars. On 6/2/22, Surveyor did a review of R29's comprehensive medical record. There was no assessment for need or safety for the assist rails. Example 9: R41 was admitted to the facility on [DATE]. R41 had diagnoses of Multiple Sclerosis, Dementia without behavioral disturbance, and reduced mobility. R41 used a custom made high backed wheelchair that had to be maneuvered by staff. R41 has a BIMS of 03, which indicated severe cognitive impairment. On 5/31/22, Surveyor observed that R41 had assist side rails on their bed. On 6/2/22, Surveyor reviewed R41's Comprehensive Medical Record. There was no assessment for side rail need or safety available in the record. Based on observation, interview, and record review, the facility did not ensure correct use of bed rails by not following manufacturer's recommendations and specifications for installing and maintaining rails for 11 of 12 residents (R) utilizing bed rails. (R1, R145, R31, R14, R30, R40, R7, R29, R41, R345, and R16.) *The facility did not attempt to use appropriate alternatives before installing bed rails. *The facility did not assess residents for risk of entrapment when utilizing bed rails. *The facility did not review the risks and benefits of bed rails and obtain informed consent prior to the installation of bed rails. This is evidenced by: Facility Policy entitled, Proper Use of Side Rails, stated in part, .General Guidelines .3. An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's: a. Bed mobility; b. Ability to change positions, transfer to and from bed or chair, and to stand and toilet; c. Risk of entrapment from the use of side rails; and d. That the bed's dimensions are appropriate for the resident's size and weight. 4. Use of side rails will be addressed in the resident care plan .7. Documentation will indicate if less restrictive approaches are not successful, prior to considering use of side rails. 8. The risks and benefits of side rails will be considered for each resident. 9. Consent for side rail use will be obtained from the resident or legal representative, after presenting potential benefits and risks .10. Manufacturer's instructions for the operation of side rails will be adhered to. 11. The resident will be checked periodically for safety relative to side rail use .13. When side rail usage is appropriate, the facility will assess the space between the mattress and side rails to reduce the risk for entrapment . On 06/01/22, at 1:43 PM, Surveyor interviewed Licensed Practical Nurse (LPN) J who was not aware of any bed rail safety assessments being done for residents. LPN J stated if a resident needed bed rails, maintenance applied them to the beds. LPN J was not sure if maintenance staff did any kind of safety assessment when installing the rails. On 06/02/22, at 8:50 AM, Surveyor interviewed Maintenance Director (MD) K about bed rails. MD K stated the maintenance department was responsible for installing the rails on resident beds. MD K had been told all the beds they had in the facility were compatible with the different rails and mattresses they had, but MD K did not have any manufacturer's guidelines that they referred to in order to verify the equipment was compatible. MD K stated they did not do any measurements or assessments of risk areas when installing the bed rails. MD K stated he did not do any formal documentation of routine maintenance or assessments of beds and rails, but when doing the every 6 month assessment of electrical outlet safety, he also did assessments of the equipment. MD K stated the housekeeping staff also checked bed rails when they clean the beds. If housekeeping noted any loose rails they let maintenance staff know, but no formal documentation of this was done. On 06/02/22, at 9:35 AM, Surveyor interviewed DON B, who stated she did not realize a grab bar was considered a bed rail. DON B stated they did have a bed rail assessment that nursing staff completes on admission, but it did not include the assessment for safety and risk of entrapment. DON B stated they had not been assessing for safety or risk of entrapment for the residents who had any type of rail or grab bar on their beds. DON B stated they had not been doing any risk/benefit discussions with the residents or their representatives, or getting a signed informed consent prior to installation of the rails. Example 1: R1 was admitted to the facility on [DATE] with the following diagnoses in part, methicillin resistant staphylococcus aureus infection, major depressive disorder, acute and chronic respiratory failure with hypoxia, and unstageable pressure ulcer. R1's annual Minimum Data Set (MDS), dated [DATE], indicated R1 required extensive assistance with bed mobility and transfers, and had a history of 2 falls since admission to the facility. On 05/31/22, at 10:53 AM, Surveyor observed two half side rails on the upper half of R1's bed. Surveyor observed an alternating pressure air mattress on R1's bed. Surveyor interviewed R1 about the rails and air mattress. R1 stated she did not know if staff measured the rails and mattress when installing them. R1 did not remember anyone talking to her about risks and benefits of using the rails with the air mattress, and did not remember signing a consent form for the rails. Review of R1's medical record identified the following: No bed rail safety assessment with risk for entrapment, no orders for bed rail identified in physician orders, no care plan for bed rails or documentation of trial of alternatives, and no consent form with discussion of risks and benefits identified on the medical record. Surveyor asked Director of Nursing (DON) B for the above documentation. No documentation was received. On 06/02/22, at 9:35 AM, Surveyor interviewed DON B regarding the use of bedrails with air mattress use. DON B stated they were not aware of the increased risk of entrapment if an air mattress was added to a resident bed with bed rails, and had not been doing any additional assessments or measurements for risk of entrapment. Example 2: R145 was admitted to the facility on [DATE] with diagnoses including in part, sepsis, hypokalemia, altered mental status, metabolic encephalopathy, myocardial infarction, alcohol dependence, repeated falls, aphasia following cerebrovascular disease, muscle weakness, abnormalities of gait and mobility, and cerebral infarction (stroke). R145's admission MDS assessment, dated 5/3/22, indicated R145 required extensive assistance for bed mobility and transfers, and had a history of falls prior to admission to the facility. On 05/31/22, at 12:05 PM, Surveyor observed two grab bars on upper half of R145's bed. Surveyor also observed an air mattress on R145's bed. Review of R1's medical record identified the following: No bed rail safety assessment with risk for entrapment, no orders for bed rail identified in physician orders, no care plan for bed rails or documentation of trial of alternatives, and no consent form with discussion of risks and benefits identified on the medical record. Surveyor asked Director of Nursing (DON) B for the above documentation. No documentation was received. Example 3: R31 was admitted to the facility on [DATE] with diagnoses including in part, vascular dementia, muscle weakness, abnormalities of gait and mobility, hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of the body) following a stroke affecting non-dominant side, and history of falling. Record review identified R31's quarterly MDS assessment, dated 03/10/22, indicated R31 had severe cognitive impairment. The assessment also indicated R31 required limited assistance with bed mobility and transfers, and had limited range of motion impairment on one side of both upper and lower extremities. On 05/31/22, at 2:33 PM, Surveyor observed two grab bars on the upper half of R31's bed. Review of R31's medical record identified the following: No bed rail safety assessment with risk for entrapment, no orders for bed rail identified in physician orders, no care plan for bed rails or documentation of trial of alternatives, and no consent form with discussion of risks and benefits identified on the medical record. Surveyor asked Director of Nursing (DON) B for the above documentation. No documentation was received. Example 10: R345 was admitted to the facility 5/11/22 with medical diagnoses that include, but are not limited to, Cerebral Infarction due to Unspecified Occlusion or Stenosis of the Right Middle Cerebral Artery, Atrial Fibrillation, Major Depressive Disorder, and Recurrent, Moderate, and Circadian Rhythm Sleep Disorder. Upon initial screening of R345 on 5/31/22 at 10:40 AM, Surveyor noted grab bars were attached to his bed on both sides. The device was shaped similar to the side of a walker, or a squared topped A that is 6 inches wide and approximately 1 1/2 feet high. Record review was completed and there was no Minimum Data Set Assessment completed. Section G (Functional Abilities) was in process. Further review of R345's medical record found no enabler bar safety assessment with risk for entrapment, no Physician Orders for the bed rail, and no care plan for the bar. Also, there was no consent form with discussion of risks and benefits identified in the medical record. Surveyor interviewed Director of Nursing (DON) B for the above documentation. No documentation was received. Example 11: R16 was admitted to the facility 1/4/22 with medical diagnoses that include, but are not limited to, Epilepsy, Vascular Dementia with Behavioral Disturbance, Other Symptoms and Signs Involving Cognitive Functions, and Awareness and Visual Hallucinations. Upon initial screening of R16, Surveyor noted grab bars were attached to her bed on both sides. The device was shaped similar to the side of a walker, or a squared topped A that is 6 inches wide and approximately 1 1/2 feet high. According to the most recent Minimum Data Set Assessment (MDSA), which was a Quarterly assessment dated [DATE], R16 is independent with bed mobility. Further review of R16's medical record found no enabler bar safety assessment with risk for entrapment, no Physician Orders for the bed rail, and no care plan for the bar use. Also, R16 had no consent form with discussion of risks and benefits identified in the medical record. Surveyor interviewed Director of Nursing (DON) B for the above documentation. No documentation was received.

Based on observations, interviews, and record reviews, the facility did not ensure of a medication administration error rate of 5% or less. During the medication administration task, Surveyor observed 7 errors out of 29 opportunities by three staff, resulting in an error rate of 24.14%. The following errors were observed: 1. Voltaren 1% analgesic gel dosage was not measured accurately for two residents (R12 and R24) in which incorrect dosages were given; 2. Short-acting Insulin was given 59 minutes prior to meal for R9; and 3. Four medications were missed for R9. This is evidenced by: Example 1: On 5/31/22 at 4:37 PM, Surveyor observed RN M (Registered Nurse) dispense medications to R12. RN M placed a squirt of Voltaren 1% Gel into a medication cup and handed it to R12 over the nursing desk. R12 took the medication to her room to self-administer. RN M stated to Surveyor that R12 gets this to her left foot and is able to put it on by herself. A review of R12's Physician Orders was completed. On 3/25/21 an order for Voltaren 1% gel was ordered and directions for this medication were, Apply to left foot topically four times a day for gout, apply 4 grams of gel to affected area/joint . Note: Tubes of Voltaren Gel contain a measuring card in which dosages of 2 grams and 4 grams is indicated with a pre-drawn area on the card. The correct procedure for this medication is that the nurse would apply the gel to the card for the dosage ordered, and then place this either into a medication cup or with gloves on, apply to the location ordered for the resident. The gel was not measured out in which the wrong dosage was given to R12. On 6/1/22 at 12:37 AM, Surveyor interviewed Director of Nursing (DON) B regarding the administration of Voltaren Gel. Example 2: On 6/1/22 at 6:58 AM, Surveyor observed RN C dispense the following medications into a medication cup to administer to R9: - Tramadol 50 MG (Milligrams) 1 tablet - Lisinopril 20 MG 1 tablet - Omeprazole 20 MG, 1 tablet - Pregabalin 75 MG, 1 tablet - Ferosul 325 MG, 1 tablet - Duloxetine DR (Delayed Release) 60 MG RN C entered the room, placed the cup of medications onto the over-the-bed table, and proceeded to set supplies up to draw blood from R9. In the process of setting up these supplies, the medication cup spilled over, dropping all the medications onto the floor. RN C, with the assistance of Surveyor, picked up these medications, and RN C placed them into the top drawer of the medication cart. RN C then went to the medication cart and dispensed a new supply of these same 6 medications into a medication cup, checking each against those in the previous medication cup in the drawer, with Surveyor again observing. RN C administered these medications to R9 at 7:26 AM. Upon reconciliation of the medications administered, Surveyor noted 4 medications ordered for that same time frame not given. These orders were: - Acetaminophen 1000 MG (Milligrams) every morning Monday, Tuesday, Wednesday, Thursday and Friday; - Cholecalciferol 50 MCG (Microgram) every morning; - Bupropion Extended Release 150 MG every morning; and - Amlodipine Besylate Tablet 5 MG every morning. At 2:32 PM, Surveyor approached RN C and asked the time scheduled for these four missed medications. RN C stated she did not know because she does not work the floor often. Together, RN C and Surveyor checked and verified medication orders with those given by RN C. The four medications were scheduled to be given with the other six medications listed above. RN C recalled not giving the four listed medications and stated, I can't believe I did that. I missed four medications. This is a total of 4 medication errors, as these were not given. Example 3: On 6/1/22 at 7:07 AM, RN C (Registered Nurse) administered 4 units Humalog Insulin to R9's lower left abdomen. The Physician Order for Humalog was to administer 4 units subcutaneously in the morning with breakfast for diabetes (Start Date 05/24/2022). R9 was served her morning meal at 8:06 AM, R9 began to eat immediately after she was served. This was 59 minutes after administration of the insulin. Note: Humalog Insulin is a fast-acting insulin. The Humalog Lispro website (Humalog.com) directs the professional on administration, stating, If you are taking Humalog or Insulin Lispro Injection, inject it under your skin within 15 minutes before or right after you eat a meal. On 06/01/22 at 11:22 PM, Surveyor interviewed RN C regarding her knowledge with the administration of Humalog insulin. RN C stated, It should be given just prior to the meal. Surveyor explained the observation made and the time R9 received her meal. RN C stated, I know I was late on her. I don't normally work the floor and was behind on medication pass, but yes, normally it would be given just before the resident eats their meal. At 12:37 PM, Surveyor interviewed Director of Nursing (DON) B regarding medication administration. DON stated, Nurses are to check to ensure it is the correct dose, the right person, administer the insulin; after eating is what I do but will check policy. It should be within 5-10 minutes of a meal. Example 4: On 6/1/22 at 11:05 AM, Surveyor observed LPN J (Licensed Practical Nurse) apply Voltaren 1% Gel to R24. The following technique was observed: LPN J gloved and placed a dime sized bead on her fingertips. She then rubbed this onto R24's right shoulder. LPN J then squeezed out another dime sized bead onto her gloves and rubbed this onto R24's left shoulder. Again, LPN J squeezed out another dime sized bead onto her glove and applied this to R24's left knee and squeezed out another dime-sized bead onto her glove and applied this to R24's right knee. The tube of Voltaren instructs to apply 4 grams to lower extremities and 2 grams to upper extremities twice daily. Further directions instruct to .Use the dosing card provided to measure the amount of (medication) topical gel to be applied . R24's Physician Orders state to apply to both shoulders and knees topically two times a day, 4 grams to lower extremities and 2 grams to upper extremities (1/19/22). These doses were not measured out to ensure the correct dosage was applied to each area. At 11:11 AM, Surveyor asked LPN J if she is aware of dosing cards for Voltaren. LPN J stated, If there is, I don't know where they are. LPN J then searched the treatment cart and located another tube in a plastic bag with a dosing strip. LPN J then stated, I have never seen these before. Surveyor then explained the reasoning behind the cards is so the appropriate dose can be administered and that R24 should be monitored so that if R24 complains that the medication is ineffective, this could be the cause. On 6/1/22 at 12:37 AM, Surveyor interviewed Director of Nursing (DON) B regarding the administration of Voltaren Gel. DON B stated Voltaren should be applied as ordered, where ordered. Staff should check each resident's pain level prior to applying and place the gel into a medication cup, take to the resident's room, and rub onto the area ordered. DON B was asked how staff are to ensure the correct dosage is being applied. DON was unaware there was a dose card supplied with the medication in order to ensure accuracy of dosage administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 06/01/22 at 10:11 AM, Surveyor observed RN C sitting behind the nurses desk with surgical mask under her lips. On 06/01/22 at 10:13 AM, Surveyor observed CNA H standing on the opposite side of the nursing desk with goggles on her head and a surgical mask on talking with R246. Residents were in this area where staff were observed to not be using goggles correctly or having the facemask cover the nose and mouth. Based on observations, interviews, and record review, the facility failed to ensure that proper PPE(Personal Protective Equipment) was worn to prevent the spread of COVID-19. This has the potential to affect residents near the nurses' station and R7. The facility failed to use proper hand hygiene techniques for wound care for 1 of 2 (R145) residents observed for wound care. Three staff were not wearing eye protection to prevent the spread of Covid in a county with a high transmission rate. Masks were observed being worn below the nose by one staff member. Staff did not perform proper hand hygiene after removing soiled gloves during wound care observations for R145. This is evidenced by the following: Surveyor reviewed Infection Control policies and education. The policy states that their practices are based on recommendations of the Centers of Disease Control (CDC). Reviewed the Facility policy entitled: Nursing Services-Policy and Procedure Manual for Long-Term Care, Skin and Wound Management. Under the heading Dressings, Dry/Clean, re: Steps in the procedure. There were 24 steps to this procedure. Steps 5, 8, 12, 19, and 23 direct nursing personnel to wash and dry hands thoroughly between glove changes. The CDC document at https://www.cdc.gov/coronavirus/2019-ncov/hep/infection-control-recommendations.html states that eye protection (i.e., goggles or a face shield that covers the front and sides of the face) should be worn during all patient care encounters. According to the Centers for Disease Control and Prevention guidance for Responding to COVID-19 in Long-Term Care Facilities, health care personnel working in facilities located in counties with substantial or high transmission: eye protection (i.e., goggles or a face shield that covers the front and sides of the face) should be worn during all patient care encounters. At the time of the survey, [NAME] County community transmission was rated as high. NHSN data for the week of 5/8/2022 showed that the vaccination rate for residents in the building was at 97.9% and staff was 98.6% vaccinated (excludes those with exemptions.) 6/2/22, Surveyor observed sign by station where the staff are screened into the building: ALL STAFF: CNAs, Nurses, Therapy and Activities, a face shield or goggles must be worn at all times during direct patient care, anytime you are within 6 feet of resident. On 6/1/22 at approximately 10:00AM, Surveyor observed CNA D in the hallway, where residents were present, with cheater glasses on but not wearing goggles or a face shield. Surveyor asked what the proper PPE was for resident care areas. CNA D stated a mask. Surveyor asked about eye protection. CNA D stated they had not been told they needed to wear them and that at other facilities they had worked at they did not wear them. On 6/1/22 at approximately 11:30AM, Surveyor observed wound care for R7 being done by RN C, who is also the charge nurse. As RN C was performing the wound care, Surveyor noted that RN C had goggles on top of their head and surgical mask beneath the nose. While observing this wound care, Surveyor asked what the standard of practice for PPE is when in patient care areas or patient encounters, and RN C stated mask and goggles, further stating that they knew they had goggles on top of head instead of on face. On 6/2/22 at approximately 10:45AM, Surveyor interviewed CNA E regarding what the proper PPE is for patient care areas. CNA E stated they needed to wear goggles and a mask pulled up over the nose in resident care areas. CNA E further stated that if there was a COVID-19 positive resident they would need gloves, gowns, goggles, and an N95 mask when working with them. On 6/1/22, Surveyor interviewed DON B. Surveyor asked what the expectation is for PPE in general resident areas. DON B stated mask and goggles. DON B was not aware some staff were not wearing goggles. Example: On 06/01/22, at 2:14 PM, Surveyor observed Licensed Practical Nurse (LPN) J perform wound care on R145. LPN J entered R145's room with supplies on a plastic tray, and placed the tray on the over bed table. R145 explained to R145 she was going to complete wound care for the heel. LPN J requested R145 transfer to the bed for the procedure, but resident refused. LPN J washed hands with soap and water in the bathroom, and turned off faucet with a paper towel. LPN J applied clean gloves. LPN J removed the sock from R145's right foot and observed there was no dressing in place on the heel. Surveyor observed the heel and noted a dark area at the center, but no scab or open areas noted. LPN J did not palpate the heel or ask R145 if there was any pain in the area. LPN J placed R145's bare heel on the stocking on the floor. LPN J took a bottle of sterile water from the tray and attempted to open it with gloves on. LPN J was unable to get safety seal off top of bottle after removing cap. LPN J removed the gloves and placed them on the over bed table beside the tray with supplies. LPN J did not wash hands or use hand sanitizer after removing the gloves. LPN J attempted to remove the safety seal with bare hands. LPN J was unable to remove the safety seal from the bottle, so left the room to retrieve a different bottle. LPN J did not wash hands or use hand sanitizer when leaving room. LPN J returned to room a few minutes later with a new bottle of sterile water and a towel. LPN J place the towel under R145's right foot. LPN J used hand sanitizer and opened the bottle of sterile water and placed it on the tray. LPN J applied clean gloves without washing hands or using hand sanitizer. LPN J placed several pieces of gauze on the towel under R145's right foot and poured sterile water on the gauze. LPN J used the wet gauze to wipe the right heel. LPN J then took the bottle of sterile water and poured it over R145's right heel. LPN J took some dry gauze and patted the right heel dry. LPN J took a border foam dressing and applied it to R145's right heel. LPN J replaced R145's sock over the dressing. LPN J took the wet towel and placed it in a hamper. LPN J threw the used dressing supplies in the garbage. LPN J took off the gloves and threw them in the garbage. Without washing hands or using hand sanitizer, LPN J picked up the tape and bottle of sterile water and placed them in a drawer. LPN J picked up the tray and exited R145's room. LPN J placed hand sanitizer in free hand from a dispenser in the hallway, and walked down the hall. On 06/01/22, at 2:40 PM, Surveyor interviewed LPN J about the use of gloves and hand hygiene during the wound care observation for R145. LPN J stated she should have used hand sanitizer or washed her hands each time after removing soiled gloves prior to putting on new gloves, or going on to other tasks. LPN J stated she did not use hand sanitizer or wash hands each time after removing soiled gloves during the observation. On 06/02/22, at 9:34 AM, Surveyor interviewed Director of Nursing (DON) B about the above observations and interview. DON B stated based on the above wound care observation, LPN J did not follow proper hand hygiene after removing soiled gloves during the wound care procedure. DON B stated it was facility policy and proper procedure to wash hands or use hand sanitizer immediately after removing soiled gloves before moving on to another task.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Example 4: R14 was admitted to the facility on [DATE], and has diagnoses that include chronic pain, osteoarthritis, dementia, major depressive disorder, hypertension, and difficulty walking R14's Minimum Data Set (MDS) assessment indicated that R14 has a Brief Interview for Mental Status (BIMS) of 08. A score of 08 indicated the resident is moderately cognitively impaired. Observation of R14's bed: Surveyor observed handrails on both sides of the upper bed. Review of R14's medical record did not identify any documentation of regular maintenance of bed, rails, or mattress. Example 5: R30 was admitted to the facility on [DATE], and has diagnoses that include vascular dementia, mild cognitive behavior, and schizoaffective disorder Observation of R30's bed: Surveyor observed handrails on both sides of the upper bed. Review of R30's medical record did not identify any documentation of regular maintenance of bed, rails, or mattress. Example 6: R40 was admitted to the facility on [DATE], and has diagnoses that include: hypertension, anxiety disorder, depression, and osteoarthritis. Observation of R40's bed: Surveyor observed handrails on both sides of the upper bed. Review of R40's medical record did not identify any documentation of regular maintenance of bed, rails, or mattress. Example 7: R7 was admitted to the facility on [DATE]. R7 was [AGE] years old. R7 had a BIMS of 15, indicating they were cognitively intact. R7 had diagnoses of Chronic Lymphocytic Leukemia of B-cell type in relapse, Chronic Kidney Disease, Congestive Heart Failure, and Pressure Ulcer of the Sacral Region, Stage 4. R7 had been admitted to the facility with the Stage 4 ulcer having acquired it at a previous placement. On 6/2/2022, Surveyor observed R7 to have assist rails, trapeze, and an air mattress on their bed. On 6/2/2022, Surveyor did record review of R7's comprehensive medical record. It was noted that there was no side rail assessment for need or safety, nor had maintenance inspected the bed for mattress and side rail compatibilities. Example 8: R29 was admitted to the facility on [DATE]. R29 had diagnoses of Alzheimer's disease with late onset, Dementia with Behavioral Disturbance, Visual and Auditory Hallucinations, and muscle weakness. R29 was on hospice services. R29 had a BIMS (Brief Interview for Mental Status) score of 0, which indicates severe cognitive difficulties. On 5/31/2022, Surveyor observed R29 to be in bed. R29 had a inverted mattress and assist bars. On 6/2/22, Surveyor did a review of R29's comprehensive medical record. There was no assessment for need or safety for the assist rails. There was no evidence that Maintenance had done any inspections to determine if the mattress and side rails were safe and compatible. Example 9: R41 was admitted to the facility on [DATE]. R41 had diagnoses of Multiple Sclerosis, Dementia without behavioral disturbance, and reduced mobility. R41 used a custom made high backed wheelchair, that had to be maneuvered by staff. R41 has a BIMS of 03, which indicated severe cognitive impairment. On 5/31/22, Surveyor observed that R41 had assist side rails on their bed. On 6/2/22, Surveyor reviewed R41's Comprehensive Medical Record. There was no assessment for side rail need or safety available in the record. There was no evidence that Maintenance had done any inspections to determine safety and that mattress and side rail were compatible. Based on observation, interview, and record review, the facility did not provide routine maintenance of bed rails for 11 of 12 sampled residents with bed rails. (R1, R145, R31, R14, R30, R40, R7, R29, R41, R345, and R16). This is evidenced by: On 06/02/22, at 8:50 AM, Surveyor interviewed Maintenance Director (MD) K about bed rails. MD K stated they did not do any measurements or assessments of risk areas for the bed rails. MD K stated he did not do any formal documentation of routine maintenance or assessments of beds and rails, but when doing the every 6 month assessment of electrical outlet safety, he also did assessments of the equipment. MD K stated the housekeeping staff also checked bed rails when they clean the beds. If housekeeping noted any loose rails they let maintenance staff know, but no formal documentation of this was done. On 06/02/22, at 9:35 AM, Surveyor interviewed DON B, who stated she was not aware of any routine maintenance schedule for resident beds, rails, or mattresses. Example 1: R1 was admitted to the facility on [DATE] with the following diagnoses in part, methicillin resistant staphylococcus aureus infection, major depressive disorder, acute and chronic respiratory failure with hypoxia, and unstageable pressure ulcer. On 05/31/22, at 10:53 AM, Surveyor observed two half side rails on the upper half of R1's bed. Surveyor observed an alternating pressure air mattress on R1's bed. Surveyor interviewed R1 about the rails and air mattress. R1 stated she did not know if staff measured the rails and mattress when installing them. R1 did not know if staff did any routine maintenance checks of her bed, mattress, or rails. Review of R1's medical record did not identify any documentation of regular maintenance of bed, rails, or mattress. Example 2: R145 was admitted to the facility on [DATE] with diagnoses including in part, sepsis, hypokalemia, altered mental status, metabolic encephalopathy, myocardial infarction, alcohol dependence, repeated falls, aphasia following cerebrovascular disease, muscle weakness, abnormalities of gait and mobility, and cerebral infarction (stroke). On 05/31/22, at 12:05 PM, Surveyor observed two grab bars on upper half of R145's bed. Surveyor also observed an air mattress on R145's bed. Review of R145's medical record did not identify any documentation of regular maintenance of bed, rails or mattress. Example 3: R31 was admitted to the facility on [DATE] with diagnoses including in part, vascular dementia, muscle weakness, abnormalities of gait and mobility, hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of the body) following a stroke affecting non-dominant side, and history of falling. On 05/31/22, at 2:33 PM, Surveyor observed two grab bars on the upper half of R31's bed. Review of R31's medical record did not identify any documentation of regular maintenance of bed, rails or mattress. Example 10: R345 was admitted to the facility 5/11/22 with medical diagnoses that include, but are not limited to, Cerebral Infarction due to Unspecified Occlusion or Stenosis of the Right Middle Cerebral Artery, Atrial Fibrillation, Major Depressive Disorder, and Recurrent, Moderate, and Circadian Rhythm Sleep Disorder. Upon initial screening of R345 on 5/31/22 at 10:40 AM, Surveyor noted grab bars were attached to his bed on both sides. The device was shaped similar to the side of a walker, or a squared topped A that is 6 inches wide and approximately 1 1/2 feet high. A review of the record was completed and Surveyor was unable to locate evidence of routine maintenance completed on the grab bar. Nor was there a safety assessment to identify potential entrapment risks. Surveyor interviewed Director of Nursing (DON) B for the above documentation. No documentation was received. Example 11: R16 was admitted to the facility 1/4/22 with medical diagnoses that include, but are not limited to, Epilepsy, Vascular Dementia with Behavioral Disturbance, Other Symptoms and Signs Involving Cognitive Functions and Awareness, and Visual Hallucinations. Upon initial screening of R16, Surveyor noted grab bars were attached to her bed on both sides. The device was shaped similar to the side of a walker, or a squared topped A that is 6 inches wide and approximately 1 1/2 feet high. A review of R16's medical record was conducted, and Surveyor was unable to locate evidence of routine maintenance completed on the grab bar. Nor was there a safety assessment to identify potential entrapment risks. Surveyor interviewed Director of Nursing (DON) B for the above documentation. No documentation was received.