**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that one resident (#44) was not abused by another resident (#55). The deficient practice could result in residents being physically and emotionally harmed. Findings include: Resident #44 was admitted on [DATE] with diagnoses that included bipolar disorder, generalized anxiety, unspecified mood disorder, and end stage renal disease. The care plan dated March 10, 2023 revealed that the resident has a potential for injury while smoking. The interventions included to observe the resident smoking, while in the designated area. The Minimum Data Set, dated [DATE] included a brief interview for mental status score of 15 indicating the resident was cognitively intact. An alert note dated April 24, 2023 at 6:56 p.m. revealed that resident #44 was assaulted by another resident on the patio at 5:30 p.m. The resident reported having a disagreement with the other resident and he began to hit him in the back of his head on the right side. The resident refused to go to the hospital. A progress note dated April 24, 2023 at 7:50 p.m. revealed that at approximately 5:30 p.m. the resident was sitting on the smoking patio, when another resident stood up and approached him unprovoked and punched him behind his right ear. The certified nursing assistant immediately separated both residents. The area behind the right ear was noted to have redness. Resident #44 denied any pain and stated did not need to go and be checked out. The resident was placed on a change of condition for monitoring. The provider assessed the resident with no new orders at this time. An Interdisciplinary Team (IDT) meeting note dated April 25, 2023 revealed that on April 24, 2023, the resident was sitting on the smoking patio with the other residents when another resident quickly stood up from his wheelchair and approached this resident, unprovoked, and punched him behind his right ear. A certified nursing assistant (CNA) witnessed the interaction and immediately stepped between the residents separating them. This resident chose to stay on the smoking patio. Resident #44 stated to the CNA that he didn't say anything to the other resident and that resident (#55) just got up and started hitting him. Resident #44 refused a skin assessment, but does have a small reddened area noted behind the right ear. The provider was in the facility and checked the resident. A care plan dated April 25, 2023 revealed that the resident has the potential for a mood problem, behavior problems related to depression, anxiety, bipolar disorder, mood disorder, irritability, and anger. On April 24, 2023, an incident was witnessed with another male resident. Interventions included to monitor/observe in mood/behaviors, fear of other residents and /or staff and notify provider if present. -Resident #55 was admitted on [DATE] with diagnoses that included unspecified mood affective disorder, psychoactive substance abuse, nicotine dependence, and dysphagia. The care plan dated March 10, 2023 revealed that the resident has a potential for injury while smoking. The interventions included to observe the resident while in the designated area. Review of the care plan dated March 14, 2023 revealed that resident #55 took anxiety medication related to anxiety as evidenced by restlessness. Interventions included to monitor/record occurrence of target behavior symptoms (restlessness) and document per facility protocol. Review of the care plan dated March 14, 2023 revealed that resident #55 was prescribed psychotropic medications related to a traumatic brain injury that induces psychosis as evidenced by paranoid delusions. Interventions included to monitor/record occurrence of target behavior symptoms (paranoid delusions) and document per facility protocol. The Minimum Data Set, dated [DATE] included a brief interview for mental status score of 14 indicating the resident was cognitively intact. A nurse progress note dated April 24, 2024 at 7:25 a.m. revealed that the resident was noted to have a significant change in mental status. The medical doctor was notified and received new orders for UA (Urinalysis)/ CMP (Compressive Metabolic Panel). The nursing note dated April 24, 2023 at 8:28 a.m. stated that the nurse received additional orders for a psych consult and additional labs as well. A physician note dated April 24, 2023 at 1:52 pm (late entry) included a history of present illness, which revealed that the resident had previously exhibited aggressive/violent behavior while in another skilled nursing facility. The nurse note dated April 24, 2023 at 3:41 p.m. revealed that the resident continues to have episodes of increased agitation in which the resident refuses to take medications and continue to not be able to redirect the resident. A nurse note dated April 24, 2023 at 6:35 p.m. revealed that the resident was transported to the hospital via 911 related to increased agitation. An interview was conducted on January 24, 2025 with a certified nursing assistant (CNA/staff #13), who stated that there is supposed to be at least one staff present when the residents are smoking to ensure the safety of the residents, which includes supervising the residents to ensure that they are not harming each other. She stated that if a resident was agitated and heading toward another resident, she would redirect the resident and if the resident hits another resident, it is abuse. An interview was conducted on January 24, 2025 at 3:11 p.m. with a licensed practical nurse (LPN/staff #21), who stated that staff should be able to recognize if there is a change in a resident's body language and know if a resident is becoming agitated. He stated that he and other staff have been trained on deescalating techniques and if a resident hits another resident, it is abuse. An interview was conducted with the Director of Nursing (DON/staff #1) on January 24, 2025 at 3:44 p.m. Staff #1 stated that it is her expectation that staff read cues when supervising the residents and if a resident has a diagnosis, the staff should be monitoring the behaviors. She also stated that all of the staff have received training on abuse and when a resident hits another resident, she considers it abuse. The facility policy, Abuse: Prevention of and Prohibition Against states that it is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that two residents (#20) and (#40) were free from abuse from other residents (resident #75). The deficient practice could result in further incidents of resident to resident abuse. Findings include: Regarding resident #20 and resident #75 -Resident #20 was admitted to the facility on [DATE], with diagnoses that included hemiplegia, urinary tract infection, gastroesophageal reflux disease, anxiety, and bipolar disorder. Review of the Discharge Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated that the resident had no cognitive impairment. A behavioral care-plan initiated September 24, 2024 revealed that the resident was at risk for impaired cognitive function related to hemiplegia and hemiparesis following cerebral infarction, with a noted intervention of monitor, document, and report to provider any changes in cognitive function, decision making ability, difficulty understanding others, and mental status. -Resident #75 was admitted to the facility on [DATE], with diagnoses that included post traumatic stress disorder, anxiety, attention deficit hyperactivity disorder, substance abuse, insomnia, and depression. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident had no cognitive impairment. A behavioral care-plan initiated September 26, 2024 revealed the resident was at risk for trauma related to history of trauma, and post-traumatic stress disorder, which a goal of no emotional, physical, or psychological problems by the review date of December 18, 2024 and noted interventions of anticipate and meet the residents needs and resident can be triggered by loud noises so provide a calm and quiet environment. A review of the clinical record progress notes for resident #20 dated September 30, 2024 at 12:46 a.m. revealed that the nurse knocked on resident #20's door, and upon opening resident #20 and resident #75 were raising their voices at each other. Resident #20 was out of bed moving her wheelchair and ambulating, at the same asking for her cellphone back from resident #75. Both residents continued raising their voice at each other, and resident #75 suddenly raised her voice and threatened resident #20 over the cell phone disagreement and threw the cell phone on the floor. An interview was conducted with a Certified Nursing Assistant (CNA/staff #55) on October 10, 2024 at 2:20 p.m. The CNA reported that resident #75 has had altercations with several residents. The CNA stated that resident #75 had psyche issues and would accuse residents of stealing her things like clothes and other belongings, even though the items were donated by the facility to resident #75. The CNA concluded that resident #75 was the instigator in the incident with resident #20. Regarding resident #40 and resident #75 -Resident #40 was admitted to the facility on [DATE], with diagnoses that included acute respiratory failure, pneumonia, heart disease, congestive heart failure, insomnia, and depression. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident had no cognitive impairment. A review of the clinical record progress notes for resident #40 dated October 3, 2024 at 10:00 a.m. revealed that resident #40 and resident #75 were engaged in a verbal exchange in the hallway. It was then observed that resident #75 raised her leg and made contact with resident #40 in the abdomen. It concludes that the residents were separated and resident #40 wished to continue to discharge as planned. An interview was conducted with a Certified Nursing Assistant (CNA/staff #91) on October 10, 2024 at 1:34 p.m. The CNA stated that resident #75 was alert and oriented, however she was also very behavioral. The CNA stated that she heard the resident's arguing from another room, darted out into the hallway where she witnessed resident #75 kick resident #40 in the chest. The CNA concluded that this was the first time she has seen resident #75 get physical but also stated that she had been verbally aggressive before. An interview was conducted with a Licensed Practical Nurse (LPN/staff #110) on October 10, 2024 at 2:50 p.m. The LPN stated that resident #75 was alert and oriented but was a textbook, druggie type of patient, and noted that she would yell out at staff and other residents. The LPN stated that resident #75 was put in a room by herself because she would cause problems any time she had a roommate. The LPN stated that resident #75 would make paranoid statements; and that, the staff would simply redirect her as best as they could. An interview with the Director of Nursing (DON/staff #15) was conducted on September 10, 2024 at 3:16 p.m. The DON stated that resident #75 had not been at the facility long; and that, she admitted on psychiatric medications. The DON stated that the resident on arrival was asking for dosage increases on her medications that were not appropriate. The DON stated that the first incident with resident #20 raised concerns, but she thought it was an isolated incident, and that they were separated immediately. The DON then stated that the second incident involving resident #40 and resident #75 confirmed the residents were arguing in the hall, and resident #75 raised her up and made physical contact between the two. The DON concluded that after the incident they put resident #75 on 1 to 1 with staff, and eventually had her petitioned to go to a psyche facility. The DON concluded that her expectation is that residents are separated when an incident occurs and reported appropriately. A review of facility policy titled 'Abuse: Prevention of and prohibition against' revised October of 2024 revealed that it is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident's property, and exploitation. It further revealed that willful as used in this definition of abuse, means the individuals must have acted deliberately, not that the individual must have intended to inflict injury or harm.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, review of records and review of policies and procedures, the facility failed to ensure that medical records were documented accurately and in accordance with accepted professional standards and practices for one resident (#12) regarding vital signs and blood glucose monitoring. The deficient practice could result in inaccurate records being documented for additional residents. Findings include: Resident #12 was re-admitted on [DATE] with diagnoses that included osteomyelitis of vertebra, sacral and sacrococcygeal regions, pressure ulcers of left buttock (stage 4), left hip (stage 4), right hip (stage 4), type 2 diabetes mellitus, and depression. A Quarterly MDS (Minimum Data Set) assessment dated [DATE] included that Resident #12 had intact cognition, required setup or clean up assistant for eating, and was incontinent of bowel/bladder. Review of June 2024 Medication Administration Records (MAR), revealed Resident #12 was administered insulin glargine (Lantus) on June 25, 2024 and June 26, 2024, with no record of Resident #12's blood sugar results. Review of June 2024 POC (point of care) Certified Nursing Assistant (CNA) Task documentation, revealed no evidence of vital signs performed on the evening shifts June 25, 2024 and June 27, 2024. Regarding Vital Sign Documentation: An interview was conducted on July 2, 2024 at 2:45 PM with CNA (staff #1), who stated that she was assigned to care for Resident #12 on the evening shift (2:00 PM - 10:00 PM) on June 28, 2024. The CNA stated that she completes documentation for all residents at the end of her shift, but did not complete documentation for Resident #12 that day. An interview was conducted on July 3, 2024 at 10:15 AM with a Licensed Practical Nurse (LPN/staff #2), who stated that CNA's are responsible for charting resident vitals in the medical record. An interview was conducted on July 3, 2024 at 12:20, with an LPN (staff #5) who stated the facility policy is for CNA's to complete vial signs twice a day, on the day and evening shifts, prior to the nurses' shift. The LPN stated that this is done to ensure that nurses can start medication pass immediately at the start of their shifts. An interview was conducted on July 3, 2024 at 11:53 AM, with CNA (staff #4), who stated that the 2-10 PM shift CNA's are required to complete vitals at 2:00 PM, and to document the results in the medical record. The CNA reviewed Resident #12's medical record and stated that there was no evidence that vitals during the 2:00 PM - 10:00 PM shifts on June 25, 2024 and June 27, 2024 had been conducted. The CNA further stated that this did not meet the facility requirements for documentation of resident's vitals. An interview was conducted on July 3, 2024 at 1:45 PM with the Director of Nursing (DON/staff #6), who stated that vitals should be conducted twice daily, and expected vitals to be conducted each nursing shift. The DON reviewed the medical record for Resident #12, and stated that there was no evidence that vitals had been obtained on June 25, 2024 and June 27, 2024 on the evening shift. The DON further stated that this did not meet her expectations and did not follow the facility policy. The DON stated the risk could include the potential to miss an acute change. Review of the facility policy titled, Documentation and Charting, included it is the policy of the facility to provide documentation of the resident's care, treatment, response to the care, signs, symptoms, as well as progress of the resident's care. Regarding Blood Sugar Monitoring: An interview was conducted on July 3, 2024 at 10:15 AM, with a Licensed Practical Nurse (LPN/staff #2), who stated that orders for medications/treatments come from the referring hospital, that would include blood sugar monitoring for resident's with diagnoses of type 2 diabetes mellitus. The LPN stated that the facility policy is to check blood sugar levels prior to administering insulin, any time insulin is ordered. The LPN also stated that the facility process for insulin administration included completing a blood glucose test prior to administrating insulin, and documenting the results in the medical record. The LPN stated that the risk of not monitoring blood sugars prior to administration of insulin could result in the resident's blood sugar bottoming-out, which could cause death. The LPN further stated that the standard of care for resident's with diabetes and insulin orders would be to check blood sugars twice a day and regularly monitor glucose levels. An interview was conducted on July 3, 2024 at 11:07 AM, with an LPN (staff #3), who stated that the facility policy is to monitor blood glucose levels as ordered, and the standard of care is to check blood glucose levels prior to administering insulin. The LPN reviewed the medical record and stated that Resident #12 received insulin on June 25, 2024 and June 26, 2024, but she found no evidence that a blood glucose test had been performed. The LPN also stated that Resident #12's blood glucose had not been monitored since June 12, 2024. The LPN further stated that the admission nurse should have called the provider for orders to monitor blood glucose levels, because Resident #12 had an order for insulin glargine (Lantus). An interview was conducted on July 3, 2024 at 1:45 PM with the Director of Nursing (DON/staff #6), who stated that blood glucose monitoring depends on the hospital orders and the patient. The DON further stated that insulin glargine (Lantus) is not held for low blood glucose levels, because it does not have immediate effects. The DON stated the standard of care for insulin administration would be to monitor for signs/symptoms of hypoglycemia, in lieu of physician orders for glucose monitoring. Review of the facility policy titled, Insulin Injections, revealed insulin injections and blood glucose monitoring will only be done following physician's orders. Lantus (insulin glargine injection) administration instructions included not to take Lantus during episodes of low blood sugar, test blood sugar levels while using insulin, such as Lantus. Individualize dosage based on metabolic needs, blood glucose monitoring, glycemic control, type or diabetes, and prior insulin use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, facility documents, and resident records, the facility failed to ensure 3 residents received medications in a timely manner. The sample size was 3. Findings include: 1) Resident #7 admitted to the facility on [DATE] with diagnoses that Osteomyelitis, Atherosclerotic Heart Disease, Anxiety Disorder, and Depression. According to the Minimum Data Set assessment completed on 12/29/2023, the Brief Interview for Mental Status revealed a score of 15 with suggested he was cognitively intact. He has an order dated 1/22/2024 for Ceftaroline Fosamil Intravenous Solution 600 MG (milligrams) intravenously two times a day for an infection of prosthetic knee joint. Review of his Medication Administration Report for January 2024, does not show any missed doses. His Ceftaroline IV medication is scheduled for 8:00 AM and 8:00 PM, with a leeway of 1 hour before and after. This means nursing staff is permitted to administer his medication between 7:00 AM to 9:00 AM, or 7:00 PM to 9:00 PM. However, on 1/2/2024, his 8:00 PM Cerftaroline dose was administered at 11:50 PM. On 1/4/2024 his 8:00 PM Cerftaroline dose was administered at 1:24 AM on 1/5/2024. On 1/5/2024 his 8:00 AM dose was administered at 10:24 AM and his 8:00 PM dose was administered at 10:19 PM. On 1/6/2024 his 8:00 PM dose was administered at 1:03 AM on 1/7/2024. On 1/7/24 his 8:00 AM dose was administered at 10:07 AM and his 8:00 PM dose was administered at 2:37 AM on 1/8/2024. In his care plan imitated on 12/22/2023, he has goals for his left knee infection to be free from complications with the intervention to administer antibiotic as per medical doctor orders. In a electronic Medication Administration Record (eMAR) note dated 1/1/2024 07:48 AM, it states his Ceftaroline Fosamil Intravenous Solution Reconstituted 600 MG is on order. A progress note dated 1/6/2024 2:25 PM revealed Nursing discussed concerns with resident regarding medication administration and times. Resident was informed about off site pharmacy and the facilities' need to wait for delivery when he first admitted to the facility. Medication administration discussed with resident which shows that, while some doses were given late, all doses have been documented as administered. Resident verbalizes understanding and voiced no further concerns. A subsequent eMAR note time stamped 1/12/2024 10:58 AM documents Ceftaroline Fosamil Intravenous Solution Reconstituted 600 MG unavailable. Pharmacy notified, MD notified. Hold. 2) Resident #9 was admitted on [DATE] with diagnoses that included Staphylococcal Arthritis, Left Knee Osteoarthritis, Tachycardia, and Cervical Disc Disorder With Myelopathy. Residnet # 9 had an order dated 1/11/2024 for 1000 mg of Vancomycin HCl Intravenous Solution every 12 hours for bone and joint infection until 01/20/2024. He also had an order dated 1/15/2024 for 2 grams of Ceftriaxone Sodium Solution Reconstituted every 24 hours for infection related to tachycardia. A review of his January MAR revealed a 7 was entered in place of administration of his Vancomycin on 1/8/2024, 1/9/2024 and 1/13/2024, as well as on 1/15/2024 for his Ceftriaxone. The chart code key indicates that a 7 means Other/See Nurse Notes. His Vancomycin medication is scheduled every 12 hours for 8:00 AM am and 8:00 PM, with 1 hour grace window before and after. This means nursing staff is permitted to administer his medication between 7:00 AM to 9:00 AM, or 7:00 PM to 9:00 PM. On 1/13/2024, his 8:00 AM dose of Vancomycin was administered at 10:18 AM and his 8:00 PM dose was administered at 10:00 PM. Resident #9's care plan initiated on 1/8/2024 revealed goal to be free of complications related to left knee infection with intervention to administer antibiotics as per orders. Corresponding eMAR notes for Vancomycin administration on 1/8/2024 10:19 PM reveal awaiting arrival from pharmacy. On 1/9/2024 at 1:07 PM: Followed up with pharmacy, medication will be delivered on 2:00 PM run, resident and MD aware, on 1/9/2024 at 8:00 PM, New order. Not yet in from pharmacy. On 1/13/2024 at 10:00 PM they took a vanco trough, with a progress note on 1/14/2024 at 4:34 PM stating Vancomycin was to be held and another trough taken due to previous trough being 36.7. Regarding Ceftriaxone, an eMAR note dated 1/15/2024 at 10:30 PM stated awaiting from pharmacy. 3) Resident #12 was admitted on [DATE] with diagnoses that included Cerebral Infarction, Hemiplegia And Hemiparesis, Type 2 Diabetes Mellitus, Hypertension, Hyperlipidemia, and Bipolar Disorder. According to a Brief Interview for Mental Status completed on 1/11/2024 by the interdisciplinary team, he score a 14 which indicates cognitive intactness. He had an order dated 1/4/2024 for 2 grams of Ceftriaxone Sodium Solution Reconstituted every 24 hours for Bacteremia. A review of his January Medication Administration Record (MAR) revealed a 7 was entered in place of administration of his Ceftriaxone on 1/4/2024, and a 10 on 1/5/2024. The chart code key indicates that a 7 means Other/See Nurse Notes and a 10 means hospitalized . There was no missed charting. His Ceftriaxone medication is scheduled at 2:00 PM every 24 hours, with an 1 hour grace window before and after. This means nursing staff is permitted to administer his medication between 1:00 PM and 3:00 PM. On 1/13/2024, his dose of Ceftriaxone was administered at 4:08 PM. On 1/10/2024, his dose was administered at 5:11 PM, and on 1/4/2024, it was administered at 4:08 PM. His care plan did not reflect any goals or interventions for antibiotics. An eMAR note for 1/4/2024 at 4:08 PM stated awaiting medications; patient just admitted to facility. During an interview conducted on 1/16/2024 at 1:17 PM with Resident #9, he stated he does not get his antibiotics on time. During an interview at 1:30 PM with Resident #12, he stated his medications are often late and he never gets his antibiotic on time. He states he will be told by the nurse that the pharmacy has not delivered it yet, or that there is a lot going on and they have a lot of patients. In an interview with a Licensed Practical Nurse (LPN/Staff #34) conducted on 1/16/2024 at 12:10 PM, she stated scheduled medications can be administered on hour before or one hour after the scheduled time, or they are considered late. She stated if antibiotics are given hours later it does not make them less effective. When asked why Resident #7's Ceftriaxone was not available on 12/23/2023, 12/26/2023, 1/1/2024 and 1/12/2024, she stated it was because the pharmacy only send so much IV medications and they will have to call to have more sent out. At 11:25 AM a chart review was completed with LPN (Staff #4) for resident #7 which revealed late administration on multiple occasions. She stated that even being given late doses, his condition would not worsen. She confirmed that he was given medications outside of parameters as it was supposed to be given within the hour before and hour after. During an interview on 1/16/2024 at 11:30 AM with Pharmerica, the Pharmacist Technician Supervisor, (Staff #78) stated they fill a 2 day supply which is 4 doses each time. He stated they track the medication and it will be sent out automatically. He stated they do not show any days where the pharmacy missed sending refills. He stated due to the stability of the medication, they can only send 2 days at a time. The Director of Nursing (DON/Staff #7, and the Clinical Resource Nurse, (Staff #20) were interviewed at 12:57 PM on 1/6/2024. The DON stated her expectation for administration of medications is that it should be within an hour of the scheduled time. This is for consistency and to make sure they do not get medications too close together. Regarding if it affects the effectiveness of the antibiotic, she stated they have a therapeutic level so not as much, but that it should still be passed on in report. Regarding the Ceftriaxone being so late so often, Staff #20 stated it is a a high cost medication and the half life of medication means they can only deliver 2 days at time. The pharmacy does have a morning and evening run, but she was unable to answer why there is such a discrepancy in times of administration. After reviewing the medication administration record for Residents #12, #9, and #7, she stated she would be doing an inservice on it now as she was not able to account for the wide time ranges. In the facility policy entitled Medication Administration- Administration of Drugs last updated on 6/2023, it details that the seven rights of medication administration are as follows in order to ensure safety and accuracy of administration . Right Time - Medications are administered within prescribed time frames.

Based on personnel file review, staff interview, and facility documentation and policy review, the facility failed to ensure the activities program was directed by a qualified professional. The deficient practice could result in the activities provided not meeting the assessed needs of the residents. Findings include: A review of the personnel file for the Activities Director (staff #33) revealed staff #33 was hired on July 11, 2022. Further review of staff #33's personnel file revealed she completed the Arizona State Board of Nursing approved Nurse Aide Training Program on December 16, 2022. Additionally, an undated receipt indicated that she completed and submitted a CNA (Certified Nursing Assistant) application which has not yet been approved. Additional review of staff # 33's personnel file revealed a receipt for Activities Professional Course enrollment dated July 10, 2023. A job description for Activities Supervisor signed by staff #33 on August 24, 2023 indicated the essential duties and responsibilities of the position was to plan, develop, organize, implement, evaluate, and direct the activities programs of the facility. Under qualifications, the education and/or experience indicated that the member must be a qualified therapeutic recreation specialist or an activities professional who is licensed by this state and is eligible for recertification a s recreation specialist or as an activities professional or must behave, as a minimum two years' experience in a social or recreational program within the last five years, one of which was a full-time in a patient activities program in a health care setting. Under certificates and licenses portion, it indicated that the member be licensed or registered, in the State in which practicing or completed a training course approved by the State. An interview was conducted with staff #33 on October 19,2023 at 11:02 a.m., staff #33 stated she does not have her certification as a qualified therapeutic specialist or as an activities professional but is currently enrolled in a program. Staff #33 stated she is the only facility staff in charge of activities and there is no corporate oversight for activities that she has to report to. Furthermore, she stated that she is strictly in charge of activities. The facility policy titled Verification of Licenses revised April 2004 indicated that it is the policy of the company to verify that all employees in positions which require licensure or certification, have a current license or other authorization to practice in the state in which they work. The facility policy titled Employment Applications revised January 2022 noted that the facility requires applicants for employment to complete an employment application and that it used to obtain information regarding the applicant's identification and qualifications for employment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and facility policy, the facility failed to ensure that risks and benefits of a psychotropic medication were explained to one resident (#34) prior to receiving the medication. The sample size was 5 residents. The deficient practice could result in residents and/or their representatives not being informed of the risks and benefits of psychotropic medications. Findings include: Resident #34 was admitted to the facility on [DATE] with diagnoses that included osteomyelitis of vertebra, major depressive disorder, anxiety disorder, nicotine dependence and other psychoactive substance use. The care plan initiated on July 31, 2022, revealed that the resident is prescribed antidepressant medication related to depression as evidenced by statements of sadness. Interventions included educating the resident, family/caregivers about risks, benefits and the side effects of the medication and giving antidepressant medications ordered by physician. Review of the physician's orders revealed an order dated July 31, 2022 dated for Nortriptyline HCL (an antidepressant) 75 mg (milligram) one capsule by mouth at bedtime (HS) for depression as evidenced by inability to sleep. The order was discontinued on August 3, 2022. The physician's order dated August 3, 2022 included for Nortriptyline HCL 75 mg one capsule by mouth at HS for depression statements of sadness. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated the resident received antidepressant medication every day during the 7-day lookback period of the assessment. The Medication Administration Record (MAR) for July 2022 and August 2022 revealed the medication Nortriptyline HCL 75 mg was given as ordered. Review of the clinical record revealed a consent for psychotropic medication Nortriptyline signed by the resident on August 12, 2022 which was 12 days after the medication was ordered. Review of progress notes revealed no documentation that the resident was informed of the risks and benefits of the medication Nortriptyline before August 12, 2022. An interview was conducted with a Licensed Practical Nurse (LPN/staff #88) on September 8, 2022 at 2:08 pm. He stated that when a resident has a new order for psychotropic medication, a medication consent needs to be signed before medication administration. He stated obtaining psychotropic medication consent is a part of the intake process during admission and is done by the nurses. The LPN stated the resident is educated on what psychotropic medication is ordered and its adverse reaction. The LPN stated obtaining a consent for psychotropic medication is important as it is the resident's right and law to know why they are on the medication. An interview was conducted with an LPN (staff #35) on September 8, 2022 at 2:43 pm. She stated that when a resident has a new order for psychotropic medication, the resident should have a psychotropic medication consent signed. The LPN stated the consent includes diagnosis and the resident is educated on what medication they are on, the side effects and what type of psychotropic medication it is. She stated the resident then can refuse or agree to the treatment, and the resident and the nurse has to sign the consent form. She stated Nortriptyline is an antidepressant and the resident would need a consent for the medication before its administration. An interview was conducted with the Director of Nursing (DON/staff #113) on September 8, 2022 at 3:37 pm. She stated that her expectation from the staff is for them to obtain psychotropic medication consent when a resident is ordered a psychotropic medication. She stated the consent should state the name of the psychotropic medication and the side effects. The DON stated the consent form is signed by the resident if the resident is able to sign, and the nurse. She stated a consent is important so that the resident is aware of the psychotropic medication ordered. The DON stated Nortriptyline is a psychotropic medication. She stated the facility audited psychotropic medication consents, found that the resident was missing a consent for Nortriptyline and a consent was obtained after the audit. The facility's policy titled Psychotropic medication, revised November 2021, revealed the use of psychoactive medication must first be explained to the resident, family member, or legal representative. The policy further stated a consent is to be obtained either from the resident or responsible party if the resident is unable to give consent. The policy stated a verbal consent may be obtained if no responsible person is available and the person obtaining the consent is to sign the consent once obtained. The policy stated to explain the potential negative outcomes of psychoactive medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and facility policies and procedures, the facility failed to ensure the physician was notified of one resident's (#126) low blood pressure. The sample size was 1. The deficient practice could result in delayed treatment. Findings include: Resident #126 was admitted to the facility on [DATE] with diagnoses of encephalopathy, severe protein malnutrition, dementia, atherosclerotic heart disease and hypertension. The late entry physician admission progress note dated [DATE] revealed the resident presented with significant hyponatremia and was very debilitated. The assessment included moderate protein calorie malnutrition, hypertension and CAD (coronary artery disease). A physician order dated [DATE] included Metoprolol Tartrate (antihypertensive) 25 mg (milligrams) 1 tablet by mouth two times a day for hypertension. This order was transcribed onto the MAR (medication administration record) for [DATE] and included the medication was administered as ordered. An encounter note dated [DATE] included the resident was alert and oriented, was recently hospitalized for hyponatremia and had assessments of CAD and hypertension. The care plan dated [DATE] revealed the resident had hypertension. The goal was that the resident will remain free from signs and symptoms of hypertension. Interventions stated to give anti-hypertensive medications as ordered, monitor for side effects such as orthostatic hypotension and increased heart rate or tachycardia, monitor for effectiveness of the medications and avoid taking the BP (blood pressure) reading after physical activity or emotional distress. The BP readings from [DATE] through 30, 2021 revealed warnings for readings that exceeded parameters on the following dates: -[DATE] and 29 - diastolic low of 60 exceeded; and, -[DATE] and 28 - systolic high of 139 exceeded The pulse rate for this period revealed a lowest pulse of 61 and highest pulse of 86. The weights and vitals summary included the following BP readings for [DATE] -At 6:35 a.m., the BP was 141/85 with a warning of systolic high of 139 exceeded; and, -At 4:01 p.m., the BP reading was 76/45. Included was a warning that read diastolic low of 60 exceeded and systolic low of 90 exceeded. The pulse rate was documented as 128 with a warning of high of 100 exceeded. A late entry physician progress note dated [DATE] at 5:38 p.m. included the resident was alert, had ongoing therapy, was getting stronger and had stable vitals; and that the vitals flow chart sheet had been reviewed. However, per the documentation, the BP was 141/85 and pulse was 66 on [DATE] at 6:35 a.m.; and, it did not include that the resident had a BP of 76/45 and pulse rate of 128 on [DATE] at 4:01 p.m. There was no indication in the documentation the provider was aware of the low BP and high pulse rate taken approximately an hour after the provider wrote the note. The weights and vitals summary revealed that on [DATE] at 7:07 a.m., the BP was 78/45 mmHg with a warning that diastolic low of 60 exceeded and systolic low of 90 exceeded; and pulse rate of 129 with a warning that the high of 100 exceeded. The daily skilled note dated [DATE] revealed a BP reading of 78/45 and a pulse of 129 taken on [DATE] at 7:07 a.m. Per the documentation, the resident was alert and oriented, with the heart rate and rhythm within baseline and had no cardiovascular changes observed. The note did not include whether or not the physician was notified of the low BP and high pulse rate. The weekly skilled review note dated [DATE] included a primary medical diagnosis of metabolic encephalopathy with recent hospitalization for increased confusion and fall; and that the resident was receiving medication management for hypertension and CAD. The plan was to continue nursing for monitoring blood sugars and treatment of depression, pain and nutritional support. The documentation did not include whether or not the resident's blood pressure and pulse rate reading was addressed; and that, the physician was notified. The order for Metoprolol was transcribed onto the MAR for [DATE]. Despite the documentation for a low BP and high pulse rate on [DATE] at 7:07 a.m., the MAR revealed that Metoprolol was administered as ordered to the resident at 8:00 a.m. on [DATE]. There was no evidence found in the clinical record that the physician was notified of the resident's BP and pulse rate reading on [DATE]. The MAR for [DATE] included Metoprolol was administered as ordered on [DATE] at 8:00 a.m. The weights and vitals summary revealed that on [DATE] at 3:08 p.m., the BP was 64/29 with a warning that diastolic low of 60 exceeded and systolic low of 90 exceeded; and pulse rate of 66 bpm. There were no BP and pulse rate readings prior to 3:08 p.m. A nursing note dated [DATE] at 4:10 p.m., included the resident was disoriented, was at baseline alert x 2 and was unable to understand the situation of this building being put into COVID outbreak status. A late entry daily skilled note dated [DATE] included BP reading of 64/29 and a pulse of 66 taken on [DATE] at 3:08 p.m. It also included the resident was alert and oriented x 2-3, was confused and needed to be redirected at times. Cardiovascular assessment included the heart rate and rhythm was within baseline, peripheral pulses present and no cardiovascular changes observed. A physician progress note dated [DATE] at 5:40 p.m. revealed the resident had no active complaints; and that medications, laboratory works and vital flow chart sheet had been reviewed. Per the documentation, BP was 64/29 and pulse was 66 taken on [DATE] at 3:08 p.m. The note further included that all other reviews of systems were negative unless stated otherwise in H&P. Physical examination included the resident had no distress and had coarse breath sounds. Assessments included hyponatremia, moderate protein calorie malnutrition, hypertension and CAD. The plan stated to continue physical therapy, bowel care protocol, medications and supportive care. The documentation did not include any interventions ordered or implemented to address the resident's low BP. The clinical record revealed no evidence that the resident's BP was rechecked, monitored and assessed after 3:08 p.m. on [DATE]. The MAR revealed that on [DATE] it was coded as 12 indicating that the BP was below set parameter. A nursing note dated [DATE] at 7:15 a.m. revealed that at 6:05 a.m. staff went into the resident's room to administer medications but the resident reported that she was not ready and for staff to come back. Per the documentation, at 6:25 a.m., staff entered the resident's room and found the resident with no pulse, no heart and no respiration. It included a code was called, CPR (cardiopulmonary resuscitation) was initiated and 911 was called. The note also included that at around 6:30 a.m. the fire department arrived and gave the time of death at 6:35 a.m. The eMAR (electronic MAR) note dated [DATE] at 9:35 a.m. included the resident was deceased . An interview was conducted on [DATE] at 9:07 a.m. with a Certified Nursing Assistant (CNA/staff #96) who stated she takes and records residents vital signs. The CNA stated that if the resident's BP reading is higher than set parameters or is extremely high, she will recheck it and then report the readings to the nurse. Further, the CNA stated that if the BP is low or extremely low, she will go get the nurse right away. During an interview with a Licensed Practical Nurse (LPN/staff #88) conducted on [DATE] at 11:17 a.m., the LPN stated that if he receives a report that BP readings for a resident is way too low, for example 60/30 or 78/40, he would call 911, call the physician and continue to monitor the resident while waiting for 911 to arrive. He stated he would also check the orders and will not give any antihypertensive medications at that time. In an interview with another LPN (staff #35) conducted on [DATE] at 9:24 p.m., she stated that a BP of 70ish/45 is low and if she receives a report about this reading, she would assess the resident for signs and symptoms, would notify the physician, DON (Director of Nursing) and family, would closely monitor the resident and would wait for orders. Staff #35 stated she will not necessarily call 911 because there are some residents who have BP running low but it is normal for that resident. She stated that if the resident has a low BP and is asymptomatic then she would not probably call 911. The LPN stated however, if the resident is manifesting symptoms, she would call 911. She further stated that stated either way, a symptomatic or asymptomatic resident with low BP, she would notify the physician, and the DON, assess/monitor the resident, wait for and implement orders when received. An interview was conducted on [DATE] at 10:15 a.m. with the DON (staff #113) who stated that if the BP was low and the physician was already aware that it was low, she would not necessarily call and notify the physician again of a low BP on the following day. Regarding resident 126, the DON provided copies of physician progress notes dated [DATE] and [DATE] and stated that based on these notes, the physician was aware the resident's BP was running low. She pointed out that on [DATE], the progress note indicated a BP reading of 64/29; and that the note indicated the physician reviewed the resident's BP. When asked whether or not the resident was seen by the physician and whether or not the physician was notified on [DATE] when the BP was 78/45, the DON stated there was no documentation found in the clinical record. The facility policy on Reporting Change of Condition included that it is their policy that all changes in resident condition will be communicated to the physician and documented. The facility policy on Documentation and Charting revealed that it is their policy to provide a complete account of the resident's care, treatment, response to care, signs, symptoms, etc., as well as the progress of the resident's care; and, guidance to the physician in prescribing appropriate medications and treatments. The facility policy on Quality of Care included it is their policy that residents are given the appropriate treatment and services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident in accordance with a written plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy review, the facility failed to meet professional standards of quality, by failing to ensure one resident (#6) received medications as ordered by the physician. The sample size was 5. The deficient practice could result in residents not receiving physician ordered medications and their pain not being relieved. Findings include: Resident #6 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Parkinson's disease, anxiety disorder, schizoaffective disorder, major depressive disorder, traumatic brain injury, and chronic pain syndrome. Physician orders dated February 16, 2022 and July 7, 2022 included Acetaminophen 325 MG (milligrams) 2 tablets by mouth every 6 hours as needed for pain 1-4. The order was discontinued on August 4, 2022. Review of the physician's orders dated March 2, 2022 and July 13, 2022 revealed Depakote Delayed Release (Divalproex Sodium) 250 MG by mouth every 8 hours for schizoaffective disorder as evidenced by mood lability. Review of the physician's orders dated July 8, 2022 revealed MS Contin Extended Release (Morphine Sulfate ER) 15 MG by mouth three times a day for pain management. Review of the Medication Administration Record (MAR) for July 2022 revealed no evidence that Depakote and MS Contin had been administered at 6:00 AM on July 12 and 23, 2022. Further review of the July 2022 MAR revealed evidence that Acetaminophen was administered for pain level of 5 on July 5, 2022, for pain level of 6 on July 8 and 11, 2022, and for pain level of 7 on July 22 at 8:39 AM and 3:35 PM. Review of the MAR for August 2022 revealed evidence that Acetaminophen was administered for a pain level of 7 on August 2, 2022, and August 3, 2022. An interview was conducted on September 9, 2022 at 8:38 AM with the Director of Nursing (DON/staff #113), who stated the facility policy is to follow physician orders as written, including any parameters. She reviewed the clinical record for August 2022 and stated that Acetaminophen had been administered outside of the ordered parameters. She further stated that the physician orders were not followed. The DON stated Depakote and MS Contin had not been administered according to physician orders, that the MAR showed no evidence that the medications had been administered on July 12 and 23, 2022. The DON stated this did not meet the facility expectation, and the medications had not been administered following physician orders. She also stated that Acetaminophen had not been administered following the ordered parameters for pain management in July 2022. She further stated it was administered outside of parameters, and that this did not meet facility expectations. Review of the facility's Administration of Drugs policy revealed medications must be administered in accordance with the written orders of the attending physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident and staff interviews, and policies and procedures, the facility failed to ensure one sampled resident (#31) received ostomy care in accordance with professional standards of practice. The deficient practice could result in untimely waste removal, unpleasant odor and skin breakdown. Findings include: Resident #31 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included encephalopathy, myopathy, paraplegia, colostomy, pressure ulcer stage 4, and anxiety disorder. An interview was conducted with resident #31 on September 8, 2022 at 9:51 AM, who stated that she does her own colostomy care at this time. The resident further stated she started doing her own colostomy care at the first of the year (2022). The resident also stated that the nurses were doing the colostomy care prior to January 2022. Resident #31 further stated that there were days that they missed providing the colostomy care in November 2021. Review of the physician's orders dated October 8, 2021 included colostomy care every shift, and change of colostomy appliance as needed for dislodgement or leakage. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was independent with cognitive skills for daily decision making. The assessment also revealed the resident required extensive assistance of one person with personal hygiene, and had an ostomy. Review of the Treatment Administration Record (TAR) dated October 2021 revealed no evidence that colostomy care was provided every shift as ordered on the following days: -Day shift: October 14-16, 18, 20, 22, 23, 28, 30. -Night shift: October 14, 20, 22, 28, 29. Review of the October 2021 progress notes revealed no evidence colostomy care was provided from October 14 through 30, 2021. Review of a care plan initiated on November 4, 2021 revealed a risk for activity daily living (ADL) self-care performance with interventions that the resident was totally dependent on staff for brief changes and colostomy care. Review of the TAR dated November 2021 revealed no evidence that colostomy care was provided every shift as ordered on the following days: -Day shift: November 3, 5, 10, 12,16, 18 - 23, 25, 26, 30 -Night shift: November 4, 8, 9, 11, 18, 22, 29, 30 Review of the November 2022 progress notes revealed no evidence that colostomy care was provided during the month of November. An interview was conducted on September 7, 2022 at 1:25 PM with a Licensed Practical Nurse (LPN/staff #35), who stated that colostomy care would be provided according to physician's orders. She also stated they would document and assess the stoma to make sure that everything was ok. The LPN further stated that the facility policy is to follow physician orders as written and to document and assess. The LPN reviewed the November 2021 TAR and stated that there were quite a few days that there was no evidence that the colostomy care had been completed per physician orders. She further stated that if the resident refused colostomy care it should be documented in the TAR. She also stated the risk of not completing colostomy care as ordered could result in an infection. An interview was conducted on September 9, 2022 at 10:26 AM with the Director of Nursing (DON/staff #113), who stated that the resident does a lot of the colostomy care on her own, but the facility policy is to follow physician orders as written. She reviewed the October 2021 TAR and stated that there was no evidence that colostomy care was provided on fourteen shifts. She reviewed the November 2021 and stated that there was no evidence of colostomy care being provided on 22 shifts. The DON stated that this did not meet the facility policy, and was not following the physician's orders for colostomy care. She also stated that the risk of not completing colostomy care as ordered could result in spilled bowel movement, and no assessment of the stoma. Review of the facility policy titled, Colostomy and Ileostomy Care, revealed that it is the policy of the facility that colostomy and ileostomy care will be provided for residents unless contraindicated by physician. Colostomy and ileostomy care will be used to cleanse the stoma and surrounding skin. Review of the facility policy titled, Documentation and charting revealed it is the facility policy to provide a complete account of the resident's care, treatment, and response to the care. Review of the facility policy titled, Physician Orders, revealed that it is the policy of the facility to accurately implement orders, medication, treatment and procedure orders, only upon the written order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews, and policy review, the facility failed to ensure one sampled resident (#375) had an order for oxygen use. The deficient practice could result in residents receiving oxygen without a physician order. Findings include: Resident #375 was admitted to the facility on [DATE] with diagnoses that included pre-excitation syndrome, unspecified systolic (congestive) heart failure, morbid (severe) obesity, type 2 diabetes mellitus and hypertension. The initial admission record dated September 4, 2022 stated the resident was alert and oriented X 4 (person, place, time, and situation). The initial admission record assessment stated the resident has a pulmonary diagnosis and COPD (Chronic Obstructive Pulmonary Disease). The assessment further included the resident had labored respirations, shortness of breath, trouble breathing when lying flat and trouble breathing with exertion. The assessment included that the resident used oxygen 2 liters per minute via nasal cannula. A review of the care plan for resident #375 revealed no care plan for oxygen. The physician note dated September 4, 2022 included the resident's respiratory assessment as some 'shortness of breath'. A review of the Weights and Vitals Summary revealed documentation that the resident's oxygen saturation was 92% on oxygen via nasal cannula on September 7, 2022 at 12:45 am. During an observation conducted of the resident on September 6, 2022 at 11:00 am, the resident was observed receiving oxygen at 2 Liters per minute via nasal cannula via concentrator. Following the observation, an interview was conducted with the resident. The resident stated that she is on 2 liters of oxygen. Another observation was conducted of the resident on September 7, 2022 at 3:05 pm. The oxygen concentrator was observed at the right side of the resident bed with nasal cannula tubing connected to the concentrator. However, further review of the clinical record did not reveal an order for the use of oxygen via nasal cannula. An interview was conducted with a Licensed Practical Nurse (LPN/staff #60) on September 7, 2022 at 2:19 pm. She stated that the physician's order is reviewed to determine how many liters of oxygen the resident is to receive. She stated the physician order for oxygen will include how often to check the resident's oxygen saturation. She stated oxygen is considered a treatment and if there is no order for the oxygen use, the physician should be made aware. The LPN stated an order for oxygen is needed if a resident is using oxygen. An interview was conducted with resident #375 on September 7, 2022 at 3:22 pm. She stated that she uses oxygen as she needs it. The resident stated she puts oxygen on herself and she is on 2 liters of oxygen. An interview was conducted with a Registered Nurse (RN/staff #94) on September 7, 2022 at 3:24 pm. She stated the resident who uses oxygen will have an order for oxygen in their clinical record. She stated the order will include how many liters of oxygen the resident should be on and whether it is PRN (as needed) or continuous. The RN stated an order for oxygen is important as it will let the nurse know if the resident needs oxygen and also let the agency nurse know how much oxygen the resident needs. She stated the resident #375 only used oxygen when she needed it and she put it on herself. She stated the resident did not use oxygen during the day but used oxygen mainly at night. The RN stated she did not know how much oxygen the resident was on. After reviewing the resident's clinical record, she stated that there was no order for oxygen use for resident #375. An interview was conducted with the Director of Nursing (DON/staff #113) on September 8, 2022 at 3:37 pm. The DON stated there should be an order for oxygen use if the resident is using oxygen. She stated if there is an emergency where the resident's oxygen is low, the nurses can enter the standing order for the oxygen. The DON stated it is important to have an order for oxygen so that the staff are aware of the resident's oxygen use and know how to regulate and titrate oxygen as needed for the resident. She stated an audit for oxygen use was done the other day and it was verified that resident #375 does not use oxygen. She stated the resident might have requested oxygen during the night and might have started oxygen during the night. The DON stated if oxygen is started at any point, it is her expectation that the nurses obtain an order for oxygen from the physician. The facility's policy titled Oxygen Administration (Mask, Cannula, Catheter) revised December 2021 stated the policy of the facility is that oxygen therapy is administered, as ordered by the physician or as an emergency measure until the order can be obtained. The policy further included the first procedure for oxygen administration is to obtain an appropriate physician's order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews and facility policies and procedures, the facility failed to ensure two residents (#116 and #121) were provided with showers or bathing. The sample size was 4. The deficient practice could result in residents' hygiene needs not being met. Findings include: The facility's bathing schedule revealed that showers are provided twice a week and residents receive showers based on their room numbers. The facility's skin observation- shower sheet included instruction to complete all bath or shower days. There was a section for comments and staff signatures. -Resident #116 was admitted on [DATE] with diagnoses of cerebral infarction, fracture of the sternum, obesity and COPD (chronic obstructive pulmonary disease). The resident was discharged on March 25, 2022. The ADL (activities of daily living) care plan dated January 25, 2022 included the resident having an ADL self-care performance deficit related to limited mobility, obesity, weakness, and bilateral lower leg swelling. The goal was to maintain the current level of function in ADLs. Interventions included extensive staff participation with toilet use, transfers, bed mobility; and limited extensive staff participation with personal hygiene and oral care. The daily skilled note dated March 17, 2022 included the resident was alert, oriented x 3 (person, place, and time), was independent with bed mobility, and required extensive assistance with one-person physical assistance with transfer and toilet use. The psychiatric note dated March 22, 2022 included staff reported that overall the resident had been compliant with treatment and care. Review of the CNA (Certified Nursing Assistant) documentation from March 1 through 31, 2021 revealed the bathing tasks were coded as NA (not applicable) and 8 indicating the activity itself did not occur from March 1 through March 31. The clinical record revealed no other documentation of showers provided to the resident. There was also no documentation of the reason/s why showers were not provided; and that, the resident refused showers. There was no evidence found that the resident was provided with showers from March 1 through 31, 2021. -Resident #121 was admitted on [DATE] with diagnoses of hemiplegia and hemiparesis, fluid overload, contracture and acute respiratory failure with hypoxia. The ADL care plan dated July 10, 2020 included the resident had ADL self-care performance deficit related to limited mobility from rib fracture. The goal was that the resident will safely perform ADLs. Interventions included encouraging the resident to discuss feelings about self-care deficit, one staff participation to reposition and turn in bed, and to encourage participation to the fullest extent possible with each interaction. Review of the CNA documentation from May 1 through 31, 2021 revealed the resident had a sponge bath on May 11 and a full bath only on May 25 (one out of 31 days). The documentation also coded NA (not applicable) and 8 indicating the activity itself did not occur on May 4, 7, 11, 14, 18 and 28, 2021; and the rest of the boxes were either marked as X or were left blank. The clinical record revealed no other documentation of showers provided to the resident. There was also no documentation of reason/s why showers were not provided; and that, the resident refused showers. There was no evidence found that the resident was provided with showers from May 1 through 31, 2021. During an interview with a CNA (staff #96) conducted on September 8, 2022 at 9:07 a.m., she stated that residents are scheduled for showers; and that the schedules are kept in the shower binder and/or posted at the nurse station. The CNA said that if a resident refuses showers, she will return a little later during the shift and ask the resident again; and, as long as she is still on shift, she will keep asking or at least ask the resident's preference for shower schedule. She said that if the resident still refuses, she will get the nurse as a witness that the resident refused; and, the resident has to sign the shower sheet. The CNA stated that if the resident preferred a sponge bath or bed bath, she will provide it as well and document it in the shower sheet. Further, she stated she could not recall any incident or a particular resident who refused to be showered or was not provided with showers for an entire month. In an interview with a Licensed Practical Nurse (LPN/staff #35) conducted on September 9, 2022 at 9:24 a.m., she stated the schedule for showers is located at the nurses' station and residents received showers according to this schedule. She stated that when showers are provided or when a resident refuses showers, the CNA will document it in the shower sheet and the nurses have to sign on the sheet. She said that way, the nurses will know when a resident refused a shower. An interview with the Director of Nursing (DON/staff #113) was conducted on September 9, 2022 at 11:00 a.m. The DON stated that residents receive showers according to their schedule which is located in a binder at the nurses' station. She stated that when a resident refuses, the staff will attempt to offer the shower throughout the shift; and if the resident still refuses the resident and the nurse will sign the shower sheet form. She stated that sometimes, they hold off signing the shower sheet related to resident refusal until the next shift because the resident may allow them to provide showers later during the day. The DON further said that if the resident still refuses, then it will be documented as refusal. Further, the DON stated there were no shower sheets found for residents #116 and #121. The facility policy on Services to Carry Out Showers and Bed Bath revealed that it is their policy that residents are given the appropriate treatment and services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident in accordance with a written plan of care. It also included showers and bed baths will be provided to residents in accordance with the resident's shower schedule provided; and that, showers and bed baths will be documented in the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation, resident and staff interviews, and policies and procedures, the facility failed to ensure bathing or showers were consistently provided to one resident (#31). The sample size was 4. The deficient practice could result in hygiene needs not being met. Findings include: Resident #31 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included encephalopathy, myopathy, paraplegia, colostomy, pressure ulcer stage 4, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Staff Assessment for Mental Status that the resident was independent of cognitive skills for daily decision making. The assessment indicated the resident required extensive assistance of one person with personal hygiene, and required physical help in part of bathing with a one-person physical assistance. Review of the Care Plan initiated on November 4, 2021 revealed a focus for activities of daily living self-care performance deficit related to impaired mobility. Interventions included extensive assistance with bathing twice a week and PRN (as needed). Review of the facility shower schedule revealed that resident #31 was scheduled to receive showers on Friday and Tuesday evenings. Review of the shower books on units one and two revealed a shower (form) that included an area to document: if a shower/bath or bed bath was provided, a body diagram to document any new skin areas observed, fingernails clean, toenails clean, nails clipped, need clipping, signature, date and the resident name and room number. Review of the shower books revealed no evidence of shower forms for resident #31. Review of the Bathing task for November 2021 revealed evidence that no showers were provided or refused: -November 4 through November 10, 2021, 6 days -November 14 through November 29, 2021, 15 days Review of bathing task dated July 2022, revealed no evidence that showers were provided or refused: -July 1 through July 14, 2022, 14 days, -July 18 through July 25, 2022, 7 days. No shower sheets were provided by the facility for July 2022. Review of the clinical record bathing tasks dated August 14, 2022 through September 7, 2022 revealed no evidence of a shower being provided or refused between August 16, 2022 and August 22, 2022, 7 days. Shower sheets for November through December 2021 were requested, and July through September 2022. The facility provided shower sheets for two days in August, no others were provided. An interview was conducted on September 7, 2022 at 1:25 PM with a Licensed Practical Nurse (LPN/staff #35), who stated the facility policy is to offer showers or baths twice a week following a schedule. She also stated that Certified Nursing Assistants will document on a shower sheet, and in the clinical record if the shower/bath was completed or refused. She reviewed the medical record and stated that there was no evidence that the resident received or refused a shower between August 15 and August 25, 2022. She also reviewed the shower book and was not able to locate the notebook. The LPN stated that the risk of not receiving consistent showers could result in new skin issues not being identified, and uncleanliness. An interview was conducted on September 8, 2022 at 8:38 AM with a Certified Nursing Assistant (CNA/staff #93), who stated that showers are offered twice a week. He also stated that they document if the shower was given or refused in the clinical record and on a shower sheet twice a week. He further stated that the shower forms are kept in a notebook, but he has only looked in it a couple of times. An interview was conducted on September 8, 2022 at 9:23 AM with a CNA (staff #56), who stated that the facility process is to offer showers two times a week, and they are documented in the clinical record and on a shower sheet. She also stated that it is the CNAs that complete documentation on the shower sheets. The CNA further stated that they document if the resident would refuse a shower in the clinical record and on the shower sheet. The CNA stated that they document that they refuse in both places and that a NA would be documented when it is not their shower day. An interview was conducted on September 8, 2022 at 9:51 AM with resident #31, who stated that she is now receiving showers twice a week. An interview was conducted on September 9, 2022 at 10:23 AM with the Director of Nursing (DON/staff #113), who stated the facility policy is to offer showers twice a week, following a shower schedule. She also stated that they are documented in the clinical record or on a shower sheet. The DON reviewed the shower sheets dated November 2021 and stated that there was no evidence the resident was provided showers for 21 days during the month. She also stated that there were 21 days in July 2022 that there was no evidence the resident was provided or refused showers. Staff #113 further stated that this does not meet her expectation, and could result in odors, rashes or skin changes. Review of the facility policy titled, Showers/Bed baths, revealed showers and bed baths will be provided to residents in accordance with the resident's shower schedule provided. Shower and bed baths will be documented in the medical record/POC. Review of the facility policy titled, Services to carry out, ADL, revealed bathing will be offered at least twice weekly, and PRN per resident request.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews, and facility policies and procedures, the facility failed to ensure care and services related to pressure ulcers were consistently provided to two residents (#124 and #125). The sample size was 3. The deficient practice could result in residents not receiving appropriate treatment for pressure ulcers. Findings include: -Resident #124 was admitted on [DATE] with diagnoses of aftercare following explanation of the hip joint prosthesis, local infection of the skin and subcutaneous tissue, obesity, peripheral vascular disease (PVD) and infection following a procedure. The care plan dated December 16, 2021 included the resident having pressure ulcer development related to limited mobility, weakness, full thickness wounds. Interventions included administering treatments as ordered and monitoring for effectiveness, following facility policies/protocols for the prevention/treatment of breakdown and weekly head to toe skin at risk assessment. The weekly skin assessment dated [DATE] revealed the resident had surgical incisions to the right hip, right and left knee that were all well approximated with staples; and had a full thickness open wound to the lateral and medial left lower leg. The skin care plan dated December 17, 2021 included the resident had actual impairment to skin integrity related to multiple fractures and left lower extremity full thickness open wounds; and that, the resident had potential impairment to skin integrity related to decreased mobility. Interventions stated to follow facility protocols for treatment of injury, monitor/document location, size and treatment of skin injury and report abnormalities, failure to heal, signs/symptoms of infection and maceration to the physician. The clinical record revealed weekly skin evaluations were completed after December 17, 2021. The weekly skin evaluations dated January 23, 2022 revealed the resident was back from the hospital. A skin assessment was completed and noted discolored purple area to the right heel. Further, it revealed that treatment was provided as ordered. The weekly skin pressure ulcer dated January 23, 2022 revealed an initial evaluation of a SDTI (suspected deep tissue injury) to the right heel described as a purple area, measuring 2.0 cm (centimeters) x 1.5 cm, with defined wound edges, normal surrounding tissue and had no exudate and odor. According to the assessment, the onset date was January 23, 2022. A physician order dated January 23, 2022 included to paint the right heel with betadine (topical antiseptic), apply ABD (abdominal pads) and wrap with kerlix every day shift for wound care. The weekly skin pressure ulcer dated January 30 and February 6, 2022 revealed the resident had SDTI to the right heel. The wound team administration record for January 2022 revealed the betadine treatment was administered to the right heel as ordered. The wound physician note dated February 11, 2022 included that on February 4, 2022, a new DTI (deep tissue injury) was picked up per nursing on return from the ED (emergency department) for evaluation of wounds; and had been using skin prep. Wound assessment included an unstageable pressure injury to the heel obscured full thickness skin and tissue loss and had a status of not healed. The note included dry/scaly peri-wound, measurements of 2 cm x 2.6 cm x 0.01 cm, with no discharge noted and 1-25% epithelialization and 51-75% eschar. Diagnosis revealed wound #8 Heel and dressing recommendation of skin prep and to cover with dry protective dressing. However, the note did not indicate whether the pressure injury was to the right or left heel. The weekly skin pressure ulcer dated February 13, 2022 included an unstageable pressure ulcer to the left heel with 100% black/brown eschar tissue, measuring 2.0 cm x 2.6 cm, defined wound edges, normal surrounding tissue and no exudate or odor. According to the documentation, the onset date for this wound was January 23, 2022. However, review of the clinical record revealed no evidence that the unstageable pressure ulcer was assessed and monitored until February 13, 2022. Further, there was no evidence found that treatment was provided to the left heel since January 23, 2022. The discharge MDS (Minimum Data Set) assessment dated [DATE] coded that the resident had no pressure ulcer/injury and had no unhealed pressure ulcer/injury. On September 8, 2022 at 2:55 p.m., documentation of any assessment and treatment done to the unstageable pressure ulcer to the left heel was requested from the Director of Nursing (DON/staff #113). The DON provided a handwritten note that read there was no treatment to the left heel; and that there was no wound to the left heel. -Resident #125 was admitted on [DATE] with diagnoses of intracranial abscess, toxic encephalopathy, severe protein calorie malnutrition and type II diabetes. The weekly skin evaluation dated February 6, 2021 revealed pressure wounds noted on the sacrum and bilateral buttocks; treatment was provided as ordered; and no other issues noted at this time. The weekly pressure ulcer dated February 6, 2021 included an unstageable pressure ulcer to the sacrum. The weekly skin evaluation note dated March 13, 2021 included the wound to the sacrum; and that there were no other areas of concern noted. Succeeding documentation in the clinical record revealed the pressure ulcer to the sacrum was assessed, monitored and provided treatment as ordered. The care plan dated April 11, 2021 included the resident had potential impairment to skin integrity related to weakness; and, had stage 3 pressure ulcer to the sacrum related to weakness and impaired mobility. Interventions stated to follow facility protocols for treatment of injury, administer medications and treatments as ordered, assess/record/monitor wound healing and weekly head to toe skin at risk assessment. The Braden Scale dated April 11, 2021 revealed a score of 17 indicating the resident was at low risk for pressure ulcer. The weekly evaluation dated April 11, 2021 included the resident had a sacrum open wound and no other areas of concern noted. The weekly pressure ulcer dated April 11, 2021 revealed a stage 3 pressure ulcer to the sacrum described as an open area with erythema to peri-wound. The weekly pressure ulcer dated April 18, 2021 revealed a stage 3 pressure ulcer to the left toe, measuring 1.5 cm x 0.5 cm x 0.1 cm, with scant serous exudate, pink wound bed, no odor, had defined wound edges and normal surrounding tissue. It also included the left toe continued with an open area, with treatment as ordered, and that the onset date for this wound was February 6, 2021. The clinical record revealed no evidence that the stage 3 pressure ulcer to the left toe was assessed and monitored until April 18, 2021. There was also no evidence found that a treatment was provided to the left toe from February 6, 2021 through April 18, 2021. Further review of the clinical record revealed the resident was discharged from the facility on April 19, 2021. During an interview with the DON (staff #3) conducted on September 8, 2022 at 10:48 a.m., the DON stated the facility has 3 wound nurse available 7 days a week; and that, the wound nurse assesses the wound on a weekly basis and documents in the electronic record. She stated that on admission, the nurse would assess the wound and the wound nurse would conduct an assessment the next day to ensure the assessment of the admitting nurse was correct. The DON also said that the floor nurses provide treatment and conduct an assessment on a weekly basis as well; however, the floor nurses cannot stage the wound but can only describe what they see. An interview was conducted on September 8, 2022 at 11:17 a.m. with a Licensed Practical Nurse (LPN/staff #88) who stated that upon admission, the resident is thoroughly assessed from head to toe by the nurse. He stated that only an RN (Registered Nurse) can do an assessment of the wound but any nurse can document what they see; that is a nurse can document size and the surrounding tissue. The LPN also stated that when a Certified Nursing Assistant (CNA) reports a wound, he would document the wound as he sees it and will call the provider for treatment if needed. In an interview with another LPN (staff #35) conducted on September 9, 2022 at 9:24 a.m., the LPN stated that a floor nurse can assess or document what is seen but cannot stage or say the type of wound. She said the wound nurse comes in on a daily basis; and, the wound doctor comes too but she does not how frequent. She said that treatment is provided on a daily basis and/or according to the treatment order. The LPN further stated that when she receives a report that a resident has a wound, she would assess, describe and document the wound and will notify the provider and the wound nurse In another interview conducted with the DON on September 9, 2022 at 11:00 a.m., she stated that any nurse that has confirmed training on wounds can assess the wound; however, she said the floor nurses are not allowed to do staging and identifying the type of wound. The DON said that when a resident is admitted , the floor nurse can describe the wound as they see it; then the wound nurse will assess the wound the following day. Regarding the pressure ulcer/injury of residents #124 and #125, the DON stated that they were data errors; and the nurses are expected to document in the progress note a clarification of the data error such as location of the wound. The facility policy on Wound Management included that it is their policy that a resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection and prevent new avoidable sores from developing. It also included that the nurse is responsible for assessing and evaluating the resident's condition on admission and readmission. It is expected that once a wound has been identified, assessed and documented, nursing shall administer treatment to each affected area as per the physician's order. All wound or skin treatments should be documented in the resident's clinical record at the time they are administered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** -Resident #67 was admitted to the facility on [DATE] at 7:15 p.m. with diagnoses of intracranial abscess and granuloma and periapical abscess with sinus. The physician order summary dated July 15, 2022 included an order for ampicillin-sulbactam sodium solution reconstituted 3 grams (2-1), use 3 grams intravenously four times a day for wound care for 18 days. The order was revised on July 16, 2022 at 7:04 a.m. to be given every six hours. The original and revised order were transcribed onto the medication administration record (MAR) for July to be administered at the following scheduled times: 8:00 a.m., 12:00 p.m., 4:00 p.m., and 8:00 p.m., and was then changed to 12:00 a.m., 6:00 a.m., 12:00 p.m., and 6:00 p.m., respectively. Upon further review, the MAR revealed the resident missed the scheduled dose at 8:00 p.m. on July 15, 2022. Review of a medication administration note at 3:02 a.m. stated New admit as of July 15, 2022 pending delivery of intravenous antibiotic . There was no evidence the physician was notified the antibiotic was not available and the resident missed a dose. Also, the pharmacy was not contacted at this time to get a status on the delivery of the antibiotic. Review of the medication administration note dated July 16, 2022 at 12:04 p.m. revealed the order for antibiotics was refaxed to the pharmacy. Review of a progress note dated July 16, 2022 at 12:32 p.m. revealed that two hours prior, at 10:00 a.m., the pharmacy was contacted to inquire about the antibiotic order. The progress note revealed the pharmacy staff stated the order in question cannot be seen on the chart and that the order had to be refaxed to be processed. (At which time the resident had already missed the second dose of antibiotic.) The progress notes further revealed the hospital was contacted in an attempt to obtain the medication; however, the charge nurse stated the medication can only be provided if the resident was readmitted to the hospital. The progress notes further noted that the estimated time of arrival for the antibiotic was unknown and this information was relayed to the resident's mother, the Director of Nursing (DON) and the physician. The resident's mother decided to have the resident transferred back to the hospital with the acknowledgement of the physician. A telephone interview was conducted on September 8, 2022 at 3:30 p.m. with a pharmacy technician (staff #110), who stated the antibiotic order was not received until 5:00 p.m. on July 16, 2022 and they were instructed to hold the medication because the resident was discharged . An interview was conducted on September 9, 2022 at 9:03 a.m. with an LPN (staff #35). She stated once the report has been received from the hospital, the resident and family are educated and consents are signed, the medication orders go directly into the resident's chart and are automatically sent to the pharmacy. She stated if medications have not arrived and the resident has missed a dose, she would notify the physician and contact the pharmacy to get an update status. She stated if the order was not received by the pharmacy, she would fax the order. An interview was conducted on September 9, 2022 at 9:51 a.m. with the DON (staff #113), who stated that once the referral packet is received from admission, orders are entered in the resident's chart, and the pharmacy receives those orders right away. She further stated that the arrival time of medications are dependent on a few factors, the date of submission because there is a cutoff time for when medications are ordered to receive them at a certain time (cutoff time is unknown to the DON at this time), the type of medication, the availability of the medication (back order), and insurance authorization. After reviewing the medication order for resident (#67), the DON stated she remembered the resident vividly. She stated that the intravenous medication in question was a specialty medication and the order had to be faxed. The DON stated that faxes are not recorded, there was no record that the medication was faxed when the resident arrived at the facility. The DON stated it was acceptable that the medication did not arrive until the following day and that the resident missed two doses because of when the order was submitted and because it was a weekend. She further added that the resident went to hospital because the resident's mother may have been a nurse and was upset that the resident missed two doses of the antibiotics even after it was explained to her the process of ordering antibiotics. The facility policy titled, Medication Administration: Administration of Drugs reviewed September 2022 stated the policy of the facility is that the medications shall be administered as prescribed by the attending physician. The policy stated if a medication is withheld, refused, or given other than at the scheduled time, the documentation will be reflected in the clinical record. The policy further stated that if a medication is unavailable and is not administered at the scheduled time, the documentation will be reflected in the clinical record, and physician notification and other information regarding the unavailable medication will be documented accordingly. Based on clinical record review, resident and staff interviews, and review of policy and procedures, the facility failed to ensure routine medications were consistently available for two residents (#34 and #67). The sample size was 5. The deficient practice could result in necessary medications not being available and not administered to residents as ordered by the physician. Findings include: -Resident #34 was admitted to the facility on [DATE] with diagnoses that included osteomyelitis of vertebra, major depressive disorder, anxiety disorder, nicotine dependence and other psychoactive substance use. A physician order dated July 29, 2022 included May hold medication until received from pharmacy. Regarding Relistor The physician's order dated July 31, 2022 included for Relistor (Methylnaltrexone Bromide) 150 mg (milligrams) three tablets by mouth one time a day for bowel care, may hold for loose stools. The order was discontinued September 8, 2022. Review of the August 2022 Medication Administration Record (MAR) revealed the resident did not receive Relistor every day except on August 5, 18 and 20, 2022. The MAR was marked as '2', a code that meant Hold/See Nurse Notes, on August 25, 26 and 31, 2022 and marked as '7', a code that meant Other/See Nurse Notes, the other days. The corresponding nurse notes revealed the following: -awaiting pharmacy delivery on August 1, 2, 3, 8, 9 and 28, 2022 - UA on August 4 and 11, 2022 -Medication on order on August 6, 12, 13, 16, 25, 26 and 30, 2022 -Medication unavailable on August 14, 21 and 27, 2022 -Pending pharmacy refill on August 19, 2022 The corresponding nurse note for August 7, 2022 stated medication unavailable. NP notified and will call back with possible alternative medication order. However, further review of the progress note did not reveal the NP (Nurse Practitioner) called back with an alternative medication order and did not reveal follow up with the NP. The order was not discontinued or changed. The corresponding nurse note for August 10, 15, 17, 22, 23, 24, 29 and 31, 2022 revealed no documented reason on why the medication was not administered. Review of the September 2022 MAR revealed the resident did not receive Relistor from September 1 through September 7, 2022. The MAR was marked as '2' on September 2, 5, 6 and 7, 2022 and marked as '7' on September 1, 3 and 4, 2022. The corresponding nurse notes revealed the following notes: -On order on September 1, 2022 -waiting for insurance to cover cost this medication/not given on September 2, 2022 -Medication unavailable on September 3, 2022 The corresponding nurse note for September 4, 2022 stated the medication was unavailable and the pharmacy was notified. Per the pharmacy the facility was notified of the cost of medication but the pharmacy never heard anything back. The note also stated will follow up with DON (Director of Nursing). The corresponding nurse note for September 5, 6, and 7, 2022 revealed no documented reason why the medication was not administered. Review of the progress notes did not reveal evidence the medication was administered or that the provider was notified from August 1 through 6, 2022, and August 8 through September 7, 2022. The progress note dated September 8, 2022 stated an order was received from the NP to discontinue Relistor. Regarding Linaclotide The physician's order dated August 7, 2022 included Linaclotide 145 mcg (micrograms) one capsule by mouth one time a day for bowel care. The order was discontinued on September 8, 2022. Review of the August 2022 MAR revealed the resident did not receive Linaclotide on August 8 through August 17, August 19, and August 23 through August 31, 2022. The MAR was marked as '2' on August 25, 26 and 31, 2022 and marked as '7' the other days. The corresponding nurse notes revealed the following: -Medication unavailable on August 8, 14 and 27, 2022 -awaiting pharmacy delivery on August 9 and 28, 2022 - UA on August 11, 2022 -Medication on order on August 12, 13, 16, 25, 26 and 30, 2022 -Pending pharmacy refill on August 19, 2022 The corresponding nurse note for August 10, 15, 17, 23, 24, 29 and 31, 2022 revealed no documented reason why the medication was not administered. Review of September 2022 MAR revealed the resident did not receive Linaclotide from September 1 through September 7, 2022. The MAR was marked as '2' on September 2, 5, 6 and 7, 2022 and marked as '7' on September 1, 3 and 4, 2022. The corresponding nurse notes revealed the following notes: -On order on September 1, 2022 -waiting for insurance to cover cost for this medication/ not given on September 2, 2022 -Medication unavailable on September 3, 2022 The corresponding nurse note for September 4, 2022 stated Medication unavailable, pharmacy notified and reported meds will be delivered this evening. The corresponding nurse note for September 5, 6, and 7, 2022 revealed no documented reason why the medication was not administered The nursing progress note dated September 8, 2022 stated the pharmacy was called several times to follow upon the Linaclotide medication. Prior authorization was not completed by the pharmacy. The physician was called to see if the medication could be replaced. The resident does not want an alternative medication. Waiting for the pharmacy and the physician to update. Will continue to follow-up. The progress note dated September 8, 2022 stated orders were received from the NP to discontinue Linaclotide. Review of the progress notes did not reveal evidence the medication was administered or that the provider was notified before September 8, 2022. An interview was conducted with the resident #34 on September 8, 2022 at 2:02 pm. The resident stated that she feels constipated most of the time and goes between constipation and diarrhea. An interview was conducted with the Licensed Practical Nurse (LPN/staff #88) on September 8, 2022 at 2:08 pm. He stated that when a medication is unavailable, the process is to reorder the medication, contact the provider and go from there. He stated when a medication is unavailable, he will document it on the MAR and provide the reason the medication was not administered. The LPN stated if a medication is not administered, the nurse has to document something in the nursing note stating why the medication was not administered. The LPN also stated he would notify the oncoming shift if the medication was still unavailable. An interview was conducted with an LPN (staff #35) on September 8, 2022 at 2:43 pm. She stated that when medication is unavailable, the process is to contact the pharmacy, then contact the doctor and also check the e-kit. She stated if the medication is still not available at the end of the shift then the nurse should check with the pharmacy, let the doctor know and communicate with the resident. The LPN stated the nurses then have to enter a progress note stating what they did including the notification to the doctor. She stated if the medication is not being sent due to the resident's insurance then the process is to let the doctor know and maybe get the medication changed to what the pharmacy recommends. She stated if a medication is not administered, there should be a notification to the doctor and there should be documentation in the progress note. The LPN stated it is very important for the resident to receive the medication they have been ordered as the residents are there to get better and missing the ordered medication can cause more problems with their health. A phone interview was conducted with the Pharmacy Technician (staff #114) on September 8, 2022 at 3:10 pm. She stated that resident's Relistor medication was never delivered and stated both of the medication, Relistor and Linaclotide were not sent out because of insurance issues. A phone interview was conducted with another Pharmacy Technician (staff #110) on September 8, 2022 at 3:15 pm. She stated that the medication Linaclotide is leaving at 6:00 pm for delivery that day. She stated Relistor and Linaclotide were not delivered as both the medications were not covered by the resident's insurance and the pharmacy was waiting for authorization from the facility to bill the facility. She stated when the insurance does not cover certain medications, the pharmacy sends out an email to the facility to notify the facility that the insurance will not cover the medication and if the facility will cover the bill or not. An interview was conducted with the Director of Nursing (DON/ staff #113) on September 8, 2022 at 3:37 pm. She stated that the facility has a standing order to hold the medication until the medication becomes available from the pharmacy. She stated when medication is unavailable, her expectation is for the nurses to contact the pharmacy to check the status of the medication order and to see whether there is an insurance issue that is causing delay in delivery. She stated the pharmacy might make the nurses think the medication is coming. The DON stated when the medication is not delivered, the nurses are to follow the hold order. She stated if the unavailable medication is a critical medication then her expectation is for the nurses to contact the doctor and receive orders from the doctor for any alternative medication. She stated if the pharmacy stated there is an insurance issue or they are waiting for prior authorization, her expectation is for the nurses to follow up with the pharmacy, contact the physician and document it in the progress notes. She stated if the medication is for bowel care, her expectation is to assess the resident to make sure the resident is not constipated. She stated when the medication is continuously unavailable the nurses should be calling the provider. The DON stated Relistor and Linaclotide are specialty medications and if they are not available, nurses have to review the hospital record to see if the resident was taking the medication and contact the provider. She stated she remembered a nurse asking her about the missing medication earlier last month, and she asked the nurse to reach out to the provider. The DON stated if the nurse did not receive an order for alternate medications and the medications were not delivered from the pharmacy, then her expectation is for the nurses to let the provider know so that the provider can address it. She stated when the insurance does not cover certain medications, an email is sent to the facility by the pharmacy and is handled by a staff at the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** -Resident #34 was admitted on [DATE] with diagnoses of pressure ulcer of sacral region, chronic pain, and osteomyelitis of vertebra, sacral and sacrococcygeal region. The physician order dated July 30, 2022 included Hydromorphone hydrochloride 4 MG by mouth every four hours as needed for pain level 1-10. Review of the care plan dated July 31, 2022 revealed the resident had acute/chronic pain related to impaired mobility, generalized weakness, and chronic history of pressure injury. The goal was the resident will voice a level of comfort. The intervention included anticipating the need for pain relief and responding immediately to any complaint of pain and following the pain scale to medicate as ordered. The MAR for July 2022 revealed the medication was administered for a pain level 0 on July 31, 2022. The MAR for August 2022 revealed the medication was administered for a pain level 0 on August 7 & 27, 2022. Review of the MAR for September 2022 revealed the medication was administered for a pain level 0 on September 3, 2022. Review of the progress notes revealed no evidence why the medication was administered outside of the ordered parameters. An interview was conducted with a Licensed Practical Nurse (LPN/staff #60) on September 7, 2022 at 9:54 a.m. She said when administering pain medication, she would assess the resident's pain utilizing the pain scale level 1-10, verify the order, and verify when the medication was given last. She stated she then records on the progress note when it was administered and what the verbalized pain level was, if the resident is able to communicate. The LPN also stated that in the event the resident does not have pain, the medication is held. An interview was conducted with the DON (staff #113) on September 7, 2022 at 10:11 a.m. She stated that her expectation with regards to administering pain medication is that the LPN would check valid orders, verify that the medication as needed falls within the parameter. The DON stated that it is an expectation that the nurse assess the pain level and that the assessed pain level falls within range. Upon review of the MAR, she stated that pain medication can be administered if the pain level is zero if it is given as prophylactic for wound care; however, review of the physician order and care plan for wound treatment revealed no order to administer pain medication prior to wound care. Review of the facility's Administration of Drug policy revealed medications must be administered in accordance with the written orders of the attending physician and that medications are administered according to appropriate indication. Based on clinical record reviews, staff interviews, and facility policy, the facility failed to ensure three residents (#6, #31, #34) received medications as ordered by the physician. The sample size was 5. The deficient practice could result in unnecessary medication administration. Findings include: -Resident #6 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Parkinson's disease, anxiety disorder, schizoaffective disorder, major depressive disorder, traumatic brain injury, and chronic pain syndrome. Review of the physician's orders dated July 7 and July 8, 2022 revealed the following orders: -Acetaminophen Tablet 325 milligrams (MG) 2 tablets by mouth every 6 hours as needed for pain 1-4, discontinued August 4, 2022. -Oxycodone HCL Concentrate 100 MG/5 milliliters (ml) 0.5 ml by mouth every 4 hours as needed for pain 5-10, discontinued August 4, 2022. Review of the July 2022 Medication Administration Record (MAR) revealed Oxycodone was administered for pain level of 1 on July 9, 2022, pain level of 0 on July 14, 15, 17, 30, 31, 2022, pain level of 3 on July 15, 2022, pain level of 2 at 12:32 PM on July 17, 2022, and for pain level of 2 on July 31, 2022. Review of the MAR for August 2022 revealed Oxycodone was administered for a pain level of 0 on August 3, 2022. An interview was conducted on September 9, 2022 at 8:38 AM with the Director of Nursing (DON/staff #113), who stated the facility policy is to follow physician orders as written, including any parameters. She reviewed the clinical record for August 2022 and stated that Oxycodone had been administered outside of the ordered parameters. She further stated that the physician orders were not followed, and the risk could result in administration of an unnecessary medication. The DON then reviewed the clinical record regarding July 2022 medication administration. She stated that Oxycodone had not been administered according to physician orders. The DON stated that this did not meet the facility expectation, and the medication had not been administered following physician orders. She also stated that Oxycodone had not been administered following the ordered parameters for pain management in July 2022. She further stated it was administered outside of parameters, and this did not meet facility expectations. She stated the risk could result in receiving pain medication unnecessarily. -Resident #31 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included encephalopathy, myopathy, paraplegia, colostomy, pressure ulcer stage 4, and anxiety disorder. Review of physician's orders revealed the following: -Oxycodone HCL 5 mg by mouth every 4 hours as needed for pain 5-10/10 dated January 15, 2022. -Metoprolol Tartrate Tablet 12.5 mg by mouth two times a day for hypertension, to hold if systolic blood pressure (SBP) is <100 or pulse <60 dated March 3, 2022. -Oxycodone HCL 10 mg by mouth every 6 hours as needed for pain 4-10/10 dated June 11, 2022. -Oxycodone HCL 10 mg by mouth every 6 hours as needed for pain 4-10/10 dated June 15, 2022. -Oxycodone HCL 10 mg by mouth every 6 hours as needed for pain 4-10/10 dated June 23, 2022. -Oxycodone HCL 15 mg by mouth every 6 hours as needed for pain 5-10/10 dated July 12, 2022. -Oxycodone HCL 15 mg by mouth every 6 hours as needed for pain 1-10/10 dated July 7, 2022. -Oxycodone HCL 15 mg by mouth every 6 hours as needed for pain 6-10/10 dated August 22, 2022. Review of the June 2022 MAR revealed the following: -Metoprolol was administered for an SBP of 94 on June 3, 2022. -Oxycodone was administered for a pain level of 0 on June 2, 2022. -Oxycodone was administered for a pain level of 0 on June 12, 2022. Review of the July 2022 MAR revealed the following: -Oxycodone was administered for a pain level of 0 on July 2 and 3, 2022. -Oxycodone was administered for a pain level of 1 on July 17, 2022. -Oxycodone was administered for a pain level of 0 on July 24, 2022. Review of the August 2022 MAR revealed Oxycodone was administered for: -a pain level of 5 on August 23, 24, 25, 26, 27, 28, 29, 2022. -a pain level of 4 on August 25, 27, 2022. -a pain level of 0 on August 29, 2022. -a pain level of 2 on August 30, 2022. Further review of progress notes revealed no evidence that the physician had been notified, or why the medications were administered outside of parameters. An interview was conducted on September 9, 2022 at 8:56 AM with the DON (staff #113), who stated that Oxycodone had been administered outside of parameters in August 2022. She also stated that there was no evidence that the physician had been notified, or why Oxycodone was administered. The DON reviewed the July 2022 MAR and stated that Oxycodone had been administered outside of pain parameters. Staff #113 reviewed the June 2022 MAR and stated that Metoprolol had been administered outside of the SBP parameters on June 3, 2022. She further stated that Oxycodone had been administered for a pain level of 0, which did not follow physician ordered parameters. Staff #113 stated that she did not see any evidence that the physician had been notified or why the medications were administered outside of parameters. The DON stated that this did not meet her expectations and that the medications had been administered unnecessarily. An interview was conducted on September 9, 2022 at 10:01 AM with a Registered Nurse (RN/staff #35), who stated that the facility policy is to follow physician's orders as written, including parameters. She further stated that it is the facility policy to document in the progress notes why a medication was not given, or why it was given outside of parameters.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, resident and staff interviews, and review of policy, the facility failed to ensure one resident (#58) had been assessed to safely self-administer arthritic ointment. The deficient practice has the potential for this resident to self-administer without knowledge of proper use and storage of the ointment. Findings include: Resident #58 was admitted to the facility on [DATE] with diagnoses that included bilateral hip osteoarthritis. In a review of a care plan dated June 16, 2020, related to chronic pain due to bilateral hip arthritis, the documentation revealed nursing staff was to administer analgesics as per physician orders. Physician orders dated September 29, 2020 revealed for Aspercreme with Lidocaine Cream 4% and to apply to the affected areas every 12 hours for arthritis. Per the quarterly Minimum Data Set assessment dated [DATE], the resident scored a 14 on the Brief Interview for Mental Status which indicated the resident had no cognitive impairment. In a review of the clinical record, and all current care plans, there was no evidence of a care plan that resident #58 had been safely assessed to self-administer arthritis ointment and keep it in the resident's room. In addition, there was no evidence of an assessment that indicated the resident had been assessed to safely administer any ointments. During a resident interview conducted on April 6, 2021 at 12:44 p.m. in the resident's room, a tube of ointment with the label CVS Muscle Rub on it, was observed on the resident's bed side table. The tube of ointment was approximately one-half full. Resident #58 stated that she can keep the ointment in her room and use it herself as there is no lidocaine in it. The resident stated she can use it as she needs for her hip pain. The resident further stated she has had the ointment in her room for a long time, maybe months. A Licensed Practical Nurse (LPN/staff #87) was requested to enter the room of resident #58. The LPN stated she observed a CVS tube of ointment laying on the resident's bedside table. She further stated it was an ointment used for arthritis and did not think it contained Lidocaine so it would be okay for the resident to have and to use. Staff #87 stated she did not know for sure if the resident had been safely assessed to use the ointment on her own. The LPN stated if the resident was assessed to safely apply the ointment it would be on the care plan. The LPN stated that because she was unsure, she would now remove the ointment from the room and keep it safely and securely stored in the medication cart. During an interview conducted with the Assistant Director of Nursing (ADON/staff #49) on April 6, 2021 at 1:55 p.m., staff #49 stated ointment could not be in the resident's room. The ADON stated the resident must be assessed to safely administer the ointment. The ADON also stated it would be documented on the care plan that the resident could self-administer. An interview was conducted with a Certified Nursing Assistant (CNA/staff #85) on April 7, 2021 at 8:42 a.m. Staff #85 stated that if she ever saw any medicine or ointment in a resident's room, she would need to let the nurse know right away. The CNA further stated medicines and ointments should not be left in a resident's room for safety reasons. An interview was conducted with an LPN (staff #86) on April 7, 2021 at 10:06 a.m. Staff #86 stated in order for residents to keep medicated ointments in their rooms, they would need a physician's order to make sure the resident was really safe to use it. Staff #86 stated usually none of the residents can have medications or ointments in their room because they may not know how to use it correctly and may not be safe with it. The LPN also stated it may not be safe for other residents, because other residents could take the medicine or ointment. The LPN stated all resident medications and treatments are to be kept in the medication cart which is locked to ensure all contents are safe from anyone else. After reviewing the clinical record for resident #58, the LPN stated the Aspercreme with Lidocaine was administered as ordered. Staff #86 stated if the resident had also been using the CVS muscle rub, in addition to the Aspercreme, it could cause potential problems such as maybe it was too much and not as ordered by the physician. An interview was conducted with the Director of Nursing (DON/staff #40) on April 7, 2021 at 2:24 p.m. The DON stated a resident has to be assessed to verify they are capable and safe to self-administer any medication, or ointment such as the CVS muscle rub. The DON stated the assessment has to be conducted before the resident can have medications or ointments in their room. The DON further stated the assessment for self-administration for treatments had not been completed for resident #58. The facility's policy regarding Self-Administration of Medications stated it is the policy of this facility to respect the wishes of alert and competent residents to self-administer. Purpose: To determine the ability of alert residents to participate in self-administration and to maintain the safety and accuracy of administration. The resident's cognitive, communication, visual, and physical ability to carry out this responsibility will be evaluated. If the resident is a candidate, this will be indicated in the clinical record. Nursing will be responsible for monitoring self-administered doses in the resident's medication administration record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, and staff interviews, the facility failed to ensure that a baseline care plan was developed for one resident (#382) regarding the use of oxygen. The deficient practice may result in the residents not being provided the services and person-centered care necessary to meet his/her needs. Findings include: Resident #382 was admitted to the facility on [DATE], with diagnosis that included Chronic Obstructive Pulmonary Disease (COPD) with acute exacerbation, obstructive sleep apnea, shortness of breath, acute pulmonary edema and encephalopathy. Review of the daily skilled nursing notes dated April 1, 2, 3, 4, and 5, 2021 revealed oxygen via nasal cannula. Review of the Weights and Vital Summary revealed the resident was receiving oxygen via nasal cannula on April 2, 4, 6, and 7, 2021. Multiple observations were conducted on April 5, 2021 of the resident in his room receiving oxygen via nasal cannula. Another observation was conducted of the resident on April 8, 2021 at 11:17 A.M. The resident was observed receiving oxygen at 3.5 liters via nasal cannula from an oxygen concentrator. However, review of the resident's baseline care plan did not include the resident was utilizing oxygen. An interview was conducted with a Certified Nursing Assistant (CNA/staff #66) on April 8. 2021 at 11:21 A.M. The CNA stated she has taken care of resident #382 two to three times and the resident has always been on oxygen. An interview was conducted with a Licensed Practical Nurse (LPN/staff #47) on April 8, 2021 at 11:29 A.M. The LPN stated the resident has been on 3.5 liters oxygen via nasal cannula since admission. An interview was conducted on April 8, 2021 at 1:31 P.M. with the Director of Nursing (DON/staff #40). She stated if the nurses are aware on how to initiate care plans, she encourages the nurses to initiate care plans. Staff #40 further stated that many of the nurses do not know how to initiate a care plan as the facility has a lot of new nurses. The DON stated that she or the Assistant Director of Nursing (staff #49) are the ones initiating residents' care plans until the new nurses are trained to do so. The DON agreed that there should be a care plan for resident #382 oxygen therapy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, resident and staff interviews, and policy review, the facility failed to ensure one resident (#280) was provided care and services in accordance with the physician order regarding tubigrip stockings. The deficient practice could result in residents' need not being met. Findings include: Resident #280 was admitted on [DATE] with diagnoses that included cellulitis of abdominal wall, lymphedema, unspecified atrial fibrillation and generalized edema. The initial admission record dated March 31, 2021 revealed the reason for admission was for physical and occupational therapy (PT/OT). The assessment further revealed that the resident was alert and able to make self-understood. The assessment revealed that the resident had edema in both ankles, inner and outer aspect and no supportive devices were in use. The care plan initiated on April 1, 2021 revealed the resident required assistance to restore function to maximum self-sufficiency for mobility characterized by positioning, locomotion and ambulation related to limited mobility. Interventions included to treat per physician orders. A physician order dated March 31, 2021 included to apply tubigrip stockings double layer from base of toes to just below the knees. The physician progress notes dated April 2, 2021 revealed the resident had a diagnosis of severe lymphedema, anasarca and the use of lymphedema wear was recommended if available. Review of the MAR (medication administration record) and the TAR (treatment administration record) for April 2021 revealed no documentation that the tubigrip stockings had been applied as ordered. During an observation of the resident conducted on April 5, 2021 at 12:35 p.m., the resident's legs were observed to be swollen and no stockings were observed on the resident's legs. The resident stated that she has a diagnosis of lymphedema and that she was not sure what was being done besides giving her Lasix (antidiuretic). Another observation was conducted of the resident on the afternoon of April 6, 2021. Again, no stockings were observed on the resident's legs. The resident stated she had PT that morning in her room and that her legs still hurt. The resident stated that her legs were beautiful when she was admitted to the facility from the hospital. The resident stated that it may have been due to being administered a diuretic and having a urinary catheter in place during the hospital stay. On April 7, 2021 at 9:50 a.m., an interview was conducted with a certified nursing assistant (CNA/staff #4). The CNA stated that it was the responsibility of the CNAs to check the CNA tasks screen for all residents on their assigned hall. The CNA stated there were no tasks listed related to tubigrip stockings for resident #280. An interview was conducted with a Licensed Practical Nurse (LPN/staff #36) at 10:09 a.m. on April 7, 2021. Staff #36 stated treatments for a resident are in the resident's electronic health record (EHR). The LPN stated that it is her responsibility to ensure tasks or treatments for a resident are done either by herself or a CNA. The LPN stated that there was no active task for tubigrip stockings in the EHR for resident #280. At 8:37 a.m. on April 8, 2021, an interview was conducted with the Director of Nursing (DON/staff #40). The DON stated that most often the CNAs are responsible for placement of any hose or stockings on a resident. The DON also stated that however, ultimately it is the nurse's responsibility to ensure that the task is completed. Staff #40 stated that sleeves and stockings are ordered through central supply. Regarding resident #280, the DON stated that she remembered entering the order for tubigrip stockings herself. Staff #40 further stated the resident had been in the facility for over a week and that all orders should be active. Later that day at 09:21 a.m., the DON stated that after reviewing the clinical record, the order for the tubigrip stockings was in the system and in the resident clinical record but had not been activated. The DON stated that it was a mistake and that it was missed. Staff #40 stated that tubigrip stockings were in the building and available for the resident. The facility's policy titled Physicians orders, reviewed August 2020 stated that it is the policy of the facility to accurately implement orders in addition to medication orders (treatment, procedures) only upon the written order of a person duly licensed and authorized to do so in accordance with the resident's plan of care. The policy further stated admission orders are reviewed with the physician upon admission based on the discharge instructions from the discharging facility and transcribed accordingly. The policy included medication, treatment or related procedure orders are transcribed onto the eMAR and eTAR accordingly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, resident and staff interviews, and policy review, the facility failed to ensure that one resident (#34) with an indwelling urinary catheter received appropriate care and services. The census was 82. The deficient practice could result in residents being at risk for urinary catheter complications and urinary tract infections. Findings include: Resident #34 was admitted to the facility on [DATE] with the diagnoses of urinary tract Infection (UTI), methicillin resistant staphylococcus aureus infection (MRSA), chronic cystitis and urinary retention. A physician order dated February 26, 2021 included indwelling catheter care every shift. The care plan dated February 26, 2021 revealed the resident had an indwelling urinary catheter related to obstructive uropathy. The goal was that the resident would remain free of catheter related trauma. Interventions included providing catheter care every shift and as needed. A review of the admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. The MDS assessment also revealed the resident had an indwelling urinary catheter. The MDS assessment included the resident required limited assistance of one person for bed mobility, transfer, toilet use and personal hygiene. Review of the physician orders revealed the previous order was discontinued on March 18, 2021 and another order dated March 18, 2021 ordered indwelling catheter care every shift. The Treatment Administration Record (TAR) for March 2021 revealed missing documentation for urinary catheter care on March 3, 7, 11, and 29 on the day shift; March 9 and 10 on the evening shift; and March 9, 10, and 30 on the night shift. A review of the TAR for April 2021 revealed missing documentation for urinary catheter care on April 6 and 7 on the night shift. An interview was conducted on April 6, 2021 at 12:30 p.m. with resident #34 who stated urinary catheter care is done once a day when staff empty the urine drainage bag in the morning. Resident #34 stated he does urinary catheter care himself on shower days. Resident #34 stated the facility staff does not perform urinary catheter care on the evening or night shifts. Resident #34 stated urinary catheter care is done just once a day by staff. An interview was conducted on April 7, 2021 at 10:53 a.m. with a Registered Nurse (RN/staff #33) who stated urinary catheter care is on the TAR and is a nursing responsibility. Staff #33 stated there is a standing physician order for urinary catheter care which states catheter care is done every shift. The RN reviewed the resident's clinical record and stated the resident had not received urinary catheter care that morning or at least it had not been charted as being done that morning. During an interview conducted on April 7, 2021 at 10:55 a.m. with a Licensed Practical Nurse (LPN/staff #83), the LPN stated she was a registry nurse. Staff #83 stated she was caring for resident #34 that shift and was not sure if the CNA had done the resident's urinary catheter care that morning or not. An interview was conducted on April 7, 2021 at 10:57 a.m. with a Certified Nursing Assistant (CNA/staff #84), who stated she was a registry CNA. Staff #84 stated she had performed urinary catheter care on resident #34 already that morning and that she would do it again around 1:15 p.m. Staff #84 stated urinary catheter care was emptying the urine drainage bag and making sure the tubing was not kinked. In an interview conducted on April 7, 2021 at 11:00 a.m. with an LPN (staff #47), the LPN stated urinary catheter care is a nursing task. Staff #47 stated he did not think CNAs were allowed to perform urinary catheter care. Staff #47 stated urinary catheter care consisted of cleaning the catheter insertion area and tubing with soap and water, assessing for drainage, discharge, leaking, pain and signs of infection. The LPN stated that urinary catheter care is on the TAR as a nursing task to be completed every shift. An interview was conducted on April 7, 2021 at 12:52 p.m. with resident #34, who stated urinary catheter care had not been performed that morning by any staff member. Another interview was conducted on April 8, 2021 at 9:20 a.m. with resident #34 who stated urinary catheter care had not been performed at all the day before (April 7, 2021) by any staff member. An interview was conducted on April 8, 2021 at 9:59 a.m. with a CNA (staff #85), who stated urinary catheter care is to be done every shift and can be done by either the nurse or the CNA. Staff #85 stated urinary catheter care is done by using the cleansing cloths or soap and water and wiping the insertions area 3 times and then wiping the tubing from front to back. Staff #85 stated he has had times when he does urinary catheter care or perineal care on residents and will find the resident is unclean. The CNA stated it is evident that care had not been performed. Staff #85 stated that he will then check the clinical record and see that it is documented that the care had been performed by the previous shift. Staff #85 stated that if the resident is cognitively intact and states they had not had perineal care or catheter care performed, he will believe them because he can tell from the condition of the area. At this time, staff #85 performed urinary catheter care on resident #34. Staff #85 performed hand hygiene and donned gloves prior to performing the urinary catheter care. Staff #85 proceeded to clean the urinary catheter tube with alcohol wipes from point of insertion down towards the urine drainage bag. Staff #85 then used a new alcohol wipe and cleaned the connection site of the urinary catheter and the urine drainage bag. Staff #85 removed the tape from resident #34 thigh which was stabilizing the urinary catheter and replaced the tape with a stat lock urinary catheter stabilization device. Staff #85 then removed his gloves and performed hand hygiene. After staff #85 completed the urinary catheter care, he was asked if alcohol wipes were acceptable for providing urinary catheter care and he answered yes. An interview was conducted on April 8, 2021 at 11:10 a.m. with Assistant Director of Nursing (ADON/staff #76) who stated urinary catheter care can be done by either the nurse or CNA. Staff #76 stated it was ultimately the nurse's responsibility to make sure urinary catheter care was performed. The ADON stated catheter care is a nursing task on the TAR and is to be done every shift as ordered. Staff #76 stated that while performing urinary catheter care, the urinary catheter is to be checked for patency and the area should be checked for signs of infections and discharge. Staff #76 stated the process to perform urinary catheter care is to perform hand hygiene, put on gloves and clean the insertion site with soap and water 3 times with a clean section of the washcloth each time; then using a clean area of the wash cloth, wipe the tubing from the insertion site back toward the urine draining bag away from the body. The ADON stated alcohol wipes are not acceptable to use for urinary catheter care. The ADON stated alcohol wipes can be used on the connection site of the catheter to the drainage bag but not on the peri area of the resident. Staff #76 stated if a resident performs their own urinary catheter care, it should be care planned and documented on the TAR as being completed by the resident. An interview was conducted on April 8, 2021 at 11:56 a.m. with the Director of Nursing (DON/staff #40), who stated urinary catheter care can be done by a CNA but is ultimately the nurse's responsibility to ensure it was completed as ordered. Staff #40 stated urinary catheter care consisted of washing the perineal area with soap and water or disposable cleansing cloths, and cleaning the catheter tubing from insertion to the connection of the drainage bag. The DON stated alcohol wipes can be used on the catheter tubing but not for perineal area cleaning. Staff #40 stated using alcohol wipes would not be detrimental but it is not acceptable. Staff #40 said if she saw a staff member using alcohol wipes, she would redirect the staff member. The DON stated it is her expectation that urinary catheter care would be done according to policy and using alcohol wipes is not according to policy. The DON stated she would expect urinary catheter care to be documented on the TAR and that missing documentation on the TAR is not acceptable. A facility's policy Catheter Care, Indwelling reviewed August 2019 stated it is the policy of this facility that each resident with an indwelling catheter will receive catheter care daily and as needed for soiling. The policy also stated the purpose is to promote hygiene, comfort and to decrease the risk of infection in catheterized residents. The policy included the care procedure as follows: Wash hands, put on gloves, using disposable wipes clean the insertion site in downward motion (front to back), using one wipe for one cleansing motion, clean the length of the Foley tubing 4 inches from the resident toward bag, repeat the procedure using the wipes to rinse the area as needed, dry the resident with cloth when completed. The policy also include documentation of catheter care is done under the toileting task in Point of Care (POC).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews, and policy review, the facility failed to ensure one resident (#382) had an order for oxygen use. The deficient practice could result in residents receiving oxygen without a physician order. Findings include: Resident #382 was admitted to the facility on [DATE], with diagnosis that included Chronic Obstructive Pulmonary Disease (COPD) with acute exacerbation, obstructive sleep apnea, shortness of breath, acute pulmonary edema and encephalopathy. Multiple observations were made on April 5, 2021 of the resident in his room receiving oxygen via nasal cannula. Another observation was conducted of the resident on April 8, 2021 at 11:17 A.M. The resident was observed receiving oxygen at 3.5 liters via nasal cannula from an oxygen concentrator. Review of the daily skilled nursing notes dated April 1, 2, 3, 4, and 5, 2021 revealed oxygen via nasal cannula. Review of the Weights and Vital Summary revealed the resident was receiving oxygen via nasal cannula on April 2, 4, 6, and 7, 2021. However, review of the clinical record did not reveal an order for oxygen use via nasal cannula. An interview was conducted with a Certified Nursing Assistant (CNA/staff #66) on April 8, 2021 at 11:21 A.M. Staff #66 stated that she has taken care of resident #382 two to three times and the resident has always been on oxygen. An interview was conducted with a Licensed Practical Nurse (LPN/staff #47) on April 8, 2021 at 11:29 A.M. The LPN stated that staff knows how much oxygen a resident is on from the physician's orders. After reviewing the physician's orders for resident #382, the LPN stated he was unable to find an order to administer oxygen. Staff #47 further stated oxygen could not be administered without a physician's order. The LPN stated the resident has been on 3.5 liters of oxygen via nasal cannula since admission. He further stated he remembered he entered the orders for the resident on admission. The LPN then reviewed the hospital discharged orders and noted resident had an order for 2 liters of oxygen. Staff #47 stated that he forgot to enter the order for oxygen. An interview was conducted on April 8, 2021 at 1:31 P.M. with the Director of Nursing (DON/staff #40), who stated that when a new admission is anticipated, the admission packet is created and assigned to a nurse. She then stated the nurse is responsible for entering orders, printing them and faxing them to the pharmacy. Staff #40 stated she and the assistant DON will help with entering orders if the nurses are busy and have a lot of admissions. The DON further stated that she and the ADON will conduct chart checks the next day to make sure all orders are entered and consents are signed. She stated if any of the orders are missed, the missed orders are added and education is provided to the nurses. The DON stated that it is important that there are physician orders to follow for a resident. The facility's Oxygen Administration policy stated that it is the policy of the facility that oxygen therapy is administered by licensed nurses as ordered by the physician or as a nursing measure and an emergency measure until the order can be obtained. The policy further revealed the purpose is to provide sufficient oxygen. The policy included the resident's clinical record will include that oxygen is to be administered, when and how often oxygen is to be administered, type of oxygen device to use, etc.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, clinical record review, and policy reviews, the facility failed to ensure multiple residents were treated with respect and dignity by failing to respond to their request for assistance in a timely manner, failing to knock before entering residents' rooms, and failing to provide one resident (#71) privacy when requested. The census was 82. The deficient practice could negatively impact the psychosocial well-being of residents. Findings include: Regarding call lights: An observation was conducted on April 6, 2021 at 11:00 a.m. The call light for room [ROOM NUMBER] was on. Staff responded to the call light at 11:20 a.m. Staff were observed standing in the hall talking during this time frame. An observation was conducted on April 6, 2021 at 11:06 a.m. The call light was on for room [ROOM NUMBER]. Staff responded to the call light at 11:19 a.m. Staff were observed in the hall talking during this time frame. An observation was conducted on April 7, 2021 at 7:50 a.m. The call light was on for room [ROOM NUMBER]. Staff responded to the call light at 8:05 a.m. Staff were observed in the hall during this time frame talking to each other and walking past the call light. An observation was conducted on April 7, 2021 at 9:18 a.m. The call light was on for room [ROOM NUMBER]. The call light was answered at 9:41 a.m. An observation was conducted on April 7, 2021 at 10:00 a.m. The call light for room [ROOM NUMBER] came on. A certified nursing assistant (CNA) was observed sitting in the nurses' station. The CNA was observed looking at the call light signal on the wall in the nurses' station. The CNA then continued looking at the computer in the nurses' station. The CNA was observed responding to the call light for room [ROOM NUMBER] at 10:16 a.m. An observation was conducted on April 7, 2021 at 10:03 a.m. The call light for room [ROOM NUMBER] was observed on. Staff were observed in the hall near room [ROOM NUMBER]. A staff member was observed responding to the call light at 10:19 a.m. An observation was conducted on April 7, 2021 at 1:10 p.m. The call light for room [ROOM NUMBER] was on. Staff were observed in the hall near the room. A staff member responded to the call light at 1:29 p.m. An observation was conducted on April 8, 2021 at 8:24 a.m. The call light for room [ROOM NUMBER] was on. A nurse was observed at the medication cart near room [ROOM NUMBER] looking at the call light and then turning and walking away from room [ROOM NUMBER]. A staff member responded to the call light at 8:40 a.m. An observation was conducted on April 8, 2021 at 9:11 a.m. The call light was on for room [ROOM NUMBER]. The call light was answered by staff at 9:32 a.m. An interview was conducted with one of the residents on April 7, 2021. The resident stated that the resident has seen staff ignoring call lights so someone else will answer the call light. The resident stated that the resident has heard staff talking in the hall outside of the resident's room for long periods of time. The resident also stated that call lights have been answered more quickly this week because the surveyors are in the building. In an interview conducted with another resident on April 7, 2021, the resident stated staff will answer the call light, say they will be back and never come back to change the wet brief. The resident stated one morning when told the resident's brief needed to be changed, the CNA said she was busy taking residents vital signs and that the resident would have to wait. On April 7, 2021, another resident stated the CNAs ignore the residents' call lights. The resident stated that if a call light comes on near the end of the staff shift, the staff will ignore the call light and leave it for the next shift to answer. The resident also stated that the CNAs have said they do not like to change residents' briefs between 6:00 a.m. and 9:00 a.m. because they are taking residents' vital signs and have to pass meal trays. On April 7, 2021, a couple of residents stated staff will ignore call lights at night, will walk past the call lights that are on. One of the residents said the resident has had to go into the hall to get staff to help. The residents stated it is worse at shift change. The other resident said the resident has seen CNAs sitting at the desk in the nursing station not answering call lights. Another resident stated on April 7, 2021, that staff has turned off the resident's call light, said they would be back, and never come back. An interview was conducted with another resident on April 7, 2021 who stated the staff ignore call lights on the evening and the night shift. The resident stated staff can be heard in the hall talking and laughing. The resident stated staff start ignoring call lights between 9:30 p.m. and 10:38 p.m. and will leave the call lights for the next shift to answer. The resident also stated staff are not helpful, and difficult to get for assistance from 2:00 p.m. to 6:00 a.m. The resident said some staff are rude and rushing implying residents are a nuisance and taking up their time. The resident also said staff have been more responsive to call lights this week during the day because the surveyors are in the facility. During an interview conducted with a CNA (staff #5) on April 7, 2021 at 9:02 a.m., the CNA stated that she tries to answer call lights as soon as possible. In an interview conducted with another CNA (staff #86) on April 8, 2021 at 9:16 a.m., the CNA acknowledged call lights are ignored during report. At 9:33 a.m. on April 8, 2021, an interview was conducted with a CNA (staff #85) who stated that nurses and CNAs will be standing around talking, charting, and will ignore call lights that are on. The CNA stated that call lights have been on for 1 ½ to 2 hours, but the average time is probably about 10 minutes which is too long. Staff #85 said nurses will not answer call lights and will ask where the CNA is. Staff #85 stated the nurses expect the CNAs to answer the call lights. The CNA also stated that the registry staff have no initiative to ask for help and are found sitting at the desk. Staff #85 said the registry staff will go on break and not tell anyone, leaving an area uncovered. An interview was conducted with a Licensed Practical Nurse (LPN/staff #24) on April 8, 2021 at 10:07 a.m., who stated the CNAs will disappear for 2-3 hours and will not respond to radio calls. The LPN stated the administrative staff are aware of the issue but it continues. In an interview with an LPN (staff #36) on April 8, 2021 at 10:18 a.m., the LPN stated there are co-workers that ignore their work and leave the work for others to complete. The LPN stated staff are not focused on their job. During an interview conducted with the Director of Nursing (DON/staff #40) on April 8, 2021 at 1:43 p.m., the DON stated that it is hard to put a time limit on call light response time. Staff #40 stated that she would expect staff to respond to the call light as soon as possible. Staff #40 also stated that she expects staff from other areas to assist with answering call lights. The DON further stated that she has had residents complain about call light response times, but that she has not been able to substantiate any issues. The DON stated staff has complained about the registry staff not pulling their weight and not working, and that she has acted upon those complaints. The facility's Call Light Policy reviewed August 2020 revealed it is the policy of the facility to provide the resident a means of communication with nursing staff. Answer the light/bell in a reasonable time frame, turn off the call light/bell, listen to the resident's request/need, respond to the request (if the item is not available or you are unable to assist, explain to the resident and notify the charge nurse for further instructions), leave the resident comfortable, and place the call device within the resident's reach before leaving the room. Regarding knocking before entering residents' rooms: During lunch observations conducted on April 5, 2021 at: -11:51 a.m. Staff observed to enter room [ROOM NUMBER] without knocking or announcing her entrance. -11:53 a.m. Staff observed to enter room [ROOM NUMBER] without knocking or announcing her entrance. -11:54 a.m. Staff observed to enter room [ROOM NUMBER] without knocking or announcing her entrance. During random observations conducted on April 6, 2021 at: -9:48 a.m. Staff observed to enter room of 143 without knocking or announcing her entrance. -10:01 a.m. Staff observed to enter room [ROOM NUMBER] without knocking or announcing her entrance. Regarding privacy: Resident #71 was admitted to the facility on [DATE] with diagnoses that included diabetes and aftercare following hip surgery. Per a quarterly Minimum Data Set assessment dated [DATE], the resident scored a 15 on the Brief Interview for Mental Status, which indicated no cognitive impairment. An interview was conducted with resident #71 on April 5, 2021 at 10:05 a.m. The interview took place in the resident's room. The resident requested the door be closed so he could speak in private. During the interview, there was a slight knock on the door and then the door was observed to be opened. The resident had not been heard to verbally respond to the knock. A staff member entered the room. The resident immediately told the staff member that he was being interviewed and wanted some privacy and asked her to leave. The staff member stated it was time for her to check on all of her residents so she had to stay in the room to check. The staff member was then observed to go beyond the bed of resident #71 and into the area where there were two other residents in their beds. Within approximately 1-2 minutes the staff was observed to exit the room. The resident then stated this type of behavior happens. The resident stated the staff member should have knocked and not entered until he said it was okay to enter. The resident also stated there were no call lights on for any of the residents, so the staff could have waited and did her checking at a later time. He stated he had the right to be interviewed in privacy and not be interrupted by anyone. An interview was conducted with a CNA (staff #85) on April 7, 2021 at 8:22 a.m. The CNA stated that before any staff can enter a resident's room, it is important to announce themselves and knock. Staff #85 stated it was important for the resident to know someone was coming in and who it was. Staff #85 further stated if a resident is talking with someone and then tells the staff they need to wait and give him his privacy, then the staff should give the resident privacy and leave the room. The CNA stated it was a resident's right to have privacy and the staff need to listen to the residents. An interview was conducted with an LPN (staff #86) on April 7, 2021 at 10:07 a.m. The LPN stated all staff are supposed to knock or call out with their name and title before they enter a resident's room. The LPN stated the resident has a right to know who is coming so they are not frightened or surprised. An interview was conducted with the DON (staff #40) on April 7, 2021 at 2:24 p.m. The DON stated all staff are to knock or announce their entrance prior to going into a resident's room. Staff #40 stated this is to make sure residents know someone is coming into their room and that it must be done all of the time. The DON further stated that all residents have a right to privacy. The DON said if the residents ask the staff for privacy, then the staff must stop and listen to the resident and respect the wishes of the resident. According to a facility's policy regarding dignity and respect, it is the policy of the facility that all residents be treated with kindness, dignity, and respect. The staff shall display respect for residents when speaking with them as constant affirmation of their individuality and dignity as human beings. Residents shall be treated in a manner that maintains their privacy. Staff members shall knock before entering a resident's room. A facility's policy regarding resident rights stated it is the policy of this facility that all resident rights be followed per state and federal guidelines. The resident has the right to be treated with consideration, respect and full recognition of his dignity and individuality.

Based on resident and staff interviews, facility documentation, and policy review, the facility failed to ensure there was sufficient nursing staff to meet the needs of residents. The deficient practice resulted in residents' needs not being met. The census was 82. Findings include: Interviews were conducted with multiple resident regarding staff response time to residents' call lights and nursing services. On April 5, 2021 interviews conducted with residents revealed the following: -A resident stated there is not enough nursing staff. The resident stated on the night shift the wait to have the call light answered is long. The resident stated the wait is so long, the resident is incontinent of urine. -A resident stated there is not enough staff on the night shift. The resident stated more Certified Nursing Assistants (CNA) are needed. The resident stated medications are administered to the resident 20-30 minutes past the time they are due. -Another resident stated that the evening shift is short staffed, that the resident has to wait one to two hours for medications, including pain medications. -Another resident stated staff takes a long time to answer call lights. The resident stated the resident had to yell for help due to a fall and bloody nose because the call light was out of reach. The resident stated staff could be heard in the hall but no one responded for five minutes. -A resident stated the resident has had to wait up to two hours for a brief change. The resident stated the resident has to wait for several hours at night for medications. The resident stated staffing is really bad on the weekends. -Another resident stated there was not enough staffing, that the wait for a brief change is up to two hours. The resident also stated the resident has had to wait several hours for medications on the night shift. -A resident stated staff are frequently slow to answer call lights and has waited one to two hours to have a soiled brief changed. On April 7, 2021 resident interviews conducted revealed the following: -A resident stated the wait for help is so long the resident urinates in the brief and then has to lie in the wet brief a long time waiting for staff to answer the call light. -A resident stated the wait time on the night shift is over 30 minutes. The resident stated the night shift is always short staffed. -Another resident stated the evenings and early mornings are the worse for staff answering the call light. The resident stated staff are hurried and do not spend enough time to meet the need. The resident said the call light is usually answered within 30 minutes but has had to wait up to two hours for someone to answer the call light. -Another resident stated the night shift has been slow to answer the call light. The resident also stated medications have been administered to the resident late on the night shift. The resident further stated the resident's brief was not changed all night. -Another resident stated staff had not changed the resident's brief all night and that no one answered the call light all night. The resident stated staff did not give the resident's medications last night. -A resident stated the call response time has been 30 to 45 minutes and that medications were late on the night shift. -Another resident stated the resident receives medications late on the night shift. The resident stated the wait time is 30 to 45 minutes for staff to answer the call light. -A resident stated that staff does not reposition the resident every 2 hours. The resident stated the wait time for staff to answer the call light has been 30 to 45 minutes. The resident stated the wait time has been over 30 minutes for the resident's soiled brief to be changed. -A resident stated that the resident is often incontinent waiting for the call light to be answered. The resident stated the resident has yelled out calling for help. The resident stated medications are given late on the evening and night shift. The resident also stated that other residents have been heard yelling out for help on the night shift. The resident stated it is not unusual to wait 30 minutes for some one to answer the call light. An interview was conducted with a CNA on April 7, 2021. The CNA stated the CNA to resident ratio is too high. The CNA stated because of feeling rushed when in a resident's room, there has been times the resident did not receive enough attention because there was not enough staff. The CNA stated that if a CNA calls off work, the CNA is not replaced. The CNA further said there is usually one call off a day. In an interview conducted with another CNA on April 8, 2021, the CNA stated more CNAs are needed per shift. The CNA stated the CNA to resident ratio is high, 1:14 today, and the CNA is also expected to help other CNAs. According to the CNA, the CNA feels rushed and there is not enough time with resident to meet their needs. On April 8, 2021, an interview was conducted with another CNA who stated staffing is inconsistent. The CNA stated there are a lot of call offs and no shows. The CNA stated the CNAs are expected to pick up the workload and work short-handed. The CNA stated rarely is there a replacement for staff that calls out. The CNA also stated the CNA to resident ratio is too high and resident acuity is high. The CNA stated there is not enough time to give quality time and care to a resident due to rushing to care for the next resident. In an interview conducted with a Licensed Practical Nurse (LPN) on April 8, 2021, the LPN stated response to call lights is slow. The LPN stated the average response time is probably about 15 minutes. An interview was conducted with another LPN on April 8, 2021. The LPN stated the facility is understaffed and the staff to resident ratio is too high. The LPN stated in order to complete the work, the LPN has to rush due to being understaffed. On April 7, 2021 at 12:44 p.m., an interview was conducted with the Staffing Coordinator (staff #52), who stated she staffs according to the staffing guide ladder provided by administration. Staff #52 stated staff to resident ratio is based on daily census and that there are usually 6 CNAs for the day and evening shifts, and 4 CNAs for the night shift. Staff #52 stated there are fewer CNAs on the night shift because there is less work on the night shift and the residents are usually sleep. The Staffing Coordinator stated she plans the schedule out a month ahead. Staff #52 stated the schedule is reviewed on a day to day basis based on whether the census increase or decrease and staff availability. Staff #52 stated that for staff that calls off, her plan for finding coverage is to first contact staff that have been scheduled off and call the registry. The Staffing Coordinator stated she has had no issues getting staff to pick up shifts and that she will schedule herself if there are no CNAs available. She also stated if a nurse is needed, the Director of Nursing (DON), assistant DON, or the Minimum Data Set nurse will step in and work. Staff #52 stated 50% of the CNAs currently employed are registry and 25% of the nurses employed are registry. An interview was conducted with the DON (staff #40) on April 8, 2021 at 1:43 p.m. The DON stated the staff to resident ratio varies. The DON stated the staffing ladder is used to make the initial schedule and then the schedule is adjusted accordingly. The DON stated that based on the current staffing patterns, the needs of the residents have been met including showers, meals and personal care but that it has been challenging. The DON said there was a huge turnover last year and that staff has complained that there is to many registry staff. The DON stated that it is hard to put a time limit on call light response time. Staff #40 stated that she would expect staff to respond to the call light as soon as possible. Staff #40 also stated that she expects staff from other areas to assist with answering call lights. The DON further stated that she has had residents complain about call light response times, but that she has not been able to substantiate any issues. The facility's Call Light Policy stated call lights will be answered in a reasonable time frame, respond to the resident request and leave the resident comfortable. The facility's assessment stated the purpose is to provide services to residents in the facility ensuring that each resident is provided care that allows the resident to maintain or attain their highest practicable physical, mental and psychosocial well-being. The assessment included the types of care that the facility's resident population requires and that are provided included promptly responding to resident requests for assistance to the bathroom/toilet in order to maintain continence and promote resident dignity. The facility assessment stated that based on the resident population and their needs for care and support, the following is a description of the general approach to staffing to ensure there is sufficient staff to meet the needs of the residents at any given time. The description included the facility considers both census numbers and acuity levels that impact staffing needs, and staffs accordingly. The description also included the general staffing plan meets the needs of the residents at any given time. The description revealed the facility hires and schedules staff for an average census (90), including staff to cover vacation and sick time and that the census average has been fairly consistent at 87. As needed staff are scheduled or staff are scheduled overtime for additional coverage and that as the census drops, nursing staff hours also drop. Also included was that if necessary, the facility has contracts in place for temporary agency personnel for Registered Nurses (RNs), LPNs, and CNAs. If the facility needs to activate its Emergency Operations Plan, the Emergency Staffing policy is implemented which included the total number of CNAs needed would be 20-35 and the total number of licensed nurses providing direct care needed would be 8-10.

Based on observations, staff interviews, policy review and the Center for Disease Control (CDC) guidelines, the facility failed to ensure infection control standards were maintained regarding the use of personal protective equipment (PPE), hand hygiene, and the handling of soiled laundry. The deficient practice could lead to the spread of infections. Findings include: Regarding PPE and hand hygiene A Certified Nursing Assistant (CNA/staff #64) was observed on April 6, 2021 at 2:40 p.m. with her gown untied at the waist as she entered a resident's room who was on isolation precautions. The CNA was also wearing gloves, eye protection, and a mask. Staff #64 exited the resident's room with the gown remaining untied at the waist, walked down the hall and leaned forward to fill a pitcher with ice and water. The gown fell forward and exposed her back. She stood up, adjusted the gown, walked back to the resident's room and handed the full pitcher to the resident in bed A. Staff #64 then doffed her gown and gloves and exited the room. The CNA was not observed to perform hand hygiene. Staff #64 then proceeded across the hall to another resident's room who was on isolation precautions. The CNA donned a gown and only tied the gown at the neck, then pulled gloves out of her pocket and donned them. The CNA preceded to help the resident out of the bed and then she stripped the bed of linen. Staff #64 then doffed her gown and gloves, and exited the room. The CNA was not observed to perform hand hygiene. Staff #64 went down the hall to the linen closet and donned a new N95, gown and gloves, and reentered the resident room. The gown was observed tied at the waist and neck. On April 7, 2021 at 9:12 a.m., a Licensed Practical Nurse (LPN/staff #83) was observed to walk into a resident's room who was on isolation precautions to administer medications. The LPN was wearing eye protection and a surgical mask. The LPN was not observed to don a gown prior to entering the resident's room. At 9:14 a.m., an interview was conducted with the LPN (staff #83). Staff #83 stated that she was oriented to the hall during report. She stated there was no formal orientation for registry staff. The LPN stated that she was told she should look for a PPE cart by a resident's door, or signs indicating the resident was on isolation precautions. The LPN stated that if she was just giving the resident medication, she was allowed to go into the room without full PPE. The LPN stated that she did not give the resident insulin, but that she did check the resident's blood sugar. She stated she did have to get within 3 feet of the resident to obtain the blood sugar, but that the resident had fully extended her arm and hand. On April 7, 2021 at 10:14 a.m., an LPN (staff #36) who was wearing eye protection and a mask, was observed to enter two different residents' rooms who were on isolation precautions to administer medications. The LPN was not observed to don a gown and gloves prior to entering the two rooms. An LPN (staff #83) was observed on April 7, 2021 at 12:01 p.m. to enter a resident's room who was on droplet precaution with her gown not tied at the neck or the waist. Following the observation, the LPN stated that her gown was not tied. Staff #83 also stated that there was no risk to her or the resident as long as the gown was pulled all the way up. Regarding Soiled Laundry and hand hygiene An interview was conducted with the housekeeping supervisor (staff #17) on April 6, 2021 at 9:37 a.m. Staff #17 stated laundry staff are to wear full PPE when processing laundry for residents' rooms who are on isolation precautions. Staff #17 stated laundry staff are to remove the yellow bags of laundry from isolation rooms and place the bags in an empty laundry cart. She stated the yellow bags of laundry are to be tied before leaving the resident's room. She said the bags of laundry are put into the washer immediately and that staff are to disinfect the laundry cart after use. Staff #17 stated that isolation soiled laundry is never mixed with non-isolation soiled laundry. On April 6, 2021 at 11:47 p.m., a housekeeping staff (staff #45) was observed entering a resident's room who was on isolation precautions. Staff #45 was observed wearing eye protection and a mask. Staff #45 was not observed to perform hand hygiene or don a gown and gloves. A PPE cart was outside the resident's room and there was signage on the resident's door indicating the resident was on isolation precautions. Staff #45 had left the soiled laundry cart outside the resident's room. She retrieved a bin of soiled gowns in the resident's room and took it to the soiled laundry cart in the hall and dumped the loose gowns into the cart. Staff #45 then covered the soiled laundry cart. On April 6, 2021 at 12:31 p.m., staff #45 was observed carrying soiled gowns out of residents' rooms who were on isolation precautions and placing the gowns in the soiled laundry cart. Staff #45 was observed to change her gown between the residents' rooms, but was not observed to tie the gowns. She was observed holding the soiled gowns against her body as she transported the gowns from residents' rooms. Staff #45 was also observed to remove soiled gowns from the dirty linen closet in the hall without donning a gown. Staff #45's mask and eye protection remained in place during the observation and she was wearing gloves. At 12:36 p.m., staff #45 still donned in eye protection and a mask, was observed to don a gown and tie the gown at the neck before entering a resident's room who was on isolation precautions. Staff #45 was observed to carry a bin of soiled gowns to the doorway of the resident's room and put the gowns in the laundry cart by dumping the soiled gowns from the bin into the laundry cart. She was wearing gloves. At 12:38 p.m., staff #45 was observed to dump overfull bins of soiled gowns into the laundry cart which she had left outside the residents' rooms. She then went across the hall to a different resident's room and changed gloves but did not perform hand hygiene. She then donned a clean gown, tied it at the neck and entered the resident's room. The laundry cart containing the soiled gowns was left uncovered in the hall between rooms. Staff #45 then dumped another overfilled bin into the laundry cart. She doffed her gloves and threw them in the trash. Staff #45 took off her gown and pushed the gown down into the dirty laundry cart. On April 7, 2021 at 8:32 a.m., an interview was conducted with staff #45 with the assistance of staff #17 to translate as needed. Staff #45 stated that she collected isolation laundry separate from the regular laundry. She said the regular laundry was picked up first. She said the isolation laundry was kept in a covered cart and taken straight to the laundry room. Staff #45 stated that she was instructed to wear full PPE when going into residents' rooms who are on isolation precautions. Staff #45 stated that she kept the mask and shield on, and changed gloves and gowns between resident rooms. She stated that she identified which rooms were on isolation precautions, by the signs posted and the red trash bags in the rooms. She said she was also told by nursing staff which rooms were isolation rooms. She said that there were yellow bags available for use in the isolation rooms for laundry. She stated her process was that she pulled the laundry cart in front of the resident's door, don and tie a gown at the neck, perform hand hygiene, put gloves on, and enter the resident's room. She said she would take the bin of soiled gowns to the laundry cart and dump the bin of soiled gowns into the cart. She said she would then doff the gown and place the gown into the soiled laundry cart. Staff #45 stated that she would then proceed to the next resident's room, perform hand hygiene and repeat the process. An additional interview was conducted on April 7, 2021 at 8:50 a.m. with the housekeeping supervisor. Staff #17 stated that she reminded staff daily on the process for isolation laundry. Staff #17 stated the process is to leave the laundry cart in the hall outside the resident's room door, put on a gown, tie it at the neck, perform hand hygiene and put on gloves. She said gloves and gown are to be changed between each resident's room and hand hygiene is to be performed anytime gloves are changed. Staff #17 stated the expectation is that the laundry staff empty the bin of soiled gowns into the laundry cart. She said she did not see a problem with emptying the soiled gowns into the laundry cart since the cart was covered between residents' rooms. When asked, staff #17 stated the gown should be tied at the waist also. Staff #17 stated if PPE is not use properly, there was a risk of contamination to both staff and residents. She said if the gown is not tied at the waist, it could fall open causing the staff to be exposed. On April 7, 2021 at 1:36 p.m., an interview was conducted with the Infection Preventionist (IP/staff #49). She stated that there has been ongoing education regarding PPE usage and donning and doffing and that she relies on peer review/auditing for compliance. She said registry staff may be included in the in-services but if the registry staff was not there for an in-service, nothing was in place to educate registry staff on PPE. The IP stated isolation gowns are to be tied at the top and bottom, and not put on over the head. The IP stated hand hygiene is required between every glove change. Staff #49 stated laundry staff should be donning a gown and gloves before entering residents' rooms that are on isolation precautions. She said the laundry staff is to put soil gowns into yellow bags, tie the yellow bag and put the bag into the laundry cart and that the cart should be covered. She stated that by not following this process, there could be a safety concern for staff and residents. An interview was conducted on April 8, 2021 at 8:49 a.m. with the Director of Nursing (DON/ staff #40). She said that when donning a gown, the gown is to be tied at the neck and at the waist regardless of the reason for entering a resident's room on isolation precautions. The DON stated that hand hygiene must be done before donning PPE, when changing gloves, and upon exiting the resident's room. The DON said that not using PPE properly put staff and residents at increased risk for all pathogens. The DON further stated that they have been educating and reeducating staff. Staff #40 stated that reusable soiled gowns should go into the bins in the residents' rooms after use. She said the isolation laundry is to be put in the yellow bag that is lining the bin, the yellow bag is to be removed from bin, tied and put into the laundry cart which is kept covered between rooms. Staff #40 stated the cart is taken to the laundry. She said that no soiled gowns were to be loosely thrown in to the bins. The DON stated the laundry staff should replace the yellow bag liner when the laundry is picked up. The DON was informed no yellow bags were in the bins. The facility's policy titled Droplet Precautions/ Isolation and Prevention dated November 4, 2020 revealed that it is the policy of the facility to protect against droplet transmission of infectious agents. The policy stated that the facility will follow transmission-based precautions recommended by the CDC and local public health. The facility policy titled soiled linen dated May 2017 revealed that soiled linen should not be held against the uniform while transporting. It further revealed that plastic can liners should be used to line the soiled lined container. The CDC guidance regarding the use of PPE when caring for patients with confirmed or suspected COVID-19 revealed that PPE must be donned correctly before entering the patient area (isolation room). The guidance revealed that hand hygiene is to be performed using hand sanitizer prior to donning the PPE. The guidance further stated that all ties on the gown are to be tied. Gloves are to be worn and should cover the cuff of the gown. Hand hygiene is to be performed before donning PPE and after doffing PPE, upon exit of the patient room. The CDC guidance Guidelines for Environmental Infection Control in Health-Care Facilities revealed that the laundry process starts with the removal of used or contaminated textiles, fabrics, and/or clothing from the region which the contamination occurred. Handling contaminated laundry with a minimum of agitation can help prevent the generation of potentially contaminated lint aerosols in patient-care areas. Contaminated textiles and fabrics are placed into bags or other appropriate containment in this location; these bags are then securely tied or otherwise closed to prevent leakage.