Based on observation, interview, record review, and facility policy review, the facility failed to ensure the licensed nursing staff clarified a medication order with the physician. The pharmacy sent empagliflozin 10 milligrams (mg) to the facility 26 times from 10/2024 to 03/2025 and the licensed nursing staff never informed the physician that the medication was being delivered and the pharmacy never notified the physician that the medication had been ordered by the resident's cardiologist for 1 (Resident #28) of 4 residents observed for medication administration. Findings included: A facility policy titled, Medication Ordering and Receiving from Pharmacy updated 03/2024, revealed Medication are administered only upon the clear, complete and signed order of a person lawfully authorized to prescribe. The policy specified, (b) If the order is from a prescriber other than the attending physician, the order is verified with the current attending physician. An admission Record indicated the facility admitted Resident #28 on 10/09/2023. According to the admission Record, the resident had a medical history that included diagnosis of hypertensive heart disease and type 2 diabetes mellitus. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/18/2025, revealed Resident #28 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #28's Care Plan Report, indicated a focus area initiated 10/10/2023 and revised 10/16/2023, that indicated the resident had diabetes mellitus with neuropathy and hyperglycemia. Interventions directed staff to administer diabetes medication as ordered by the doctor. During a concurrent interview and medication administration observation on 03/25/2025 at 8:22 AM, Licensed Vocational Nurse (LVN) #1 removed four pills, to include empagliflozin 10 milligrams (mg), from a medication cup and did not administer the medication to Resident #28. LVN #2 stated she did not administer the medication because she could not determine if the medication was supposed to be administered. Resident #28's Order Summary Report that contained active orders as of 03/01/2025, revealed no evidence of a physician order that directed the staff to administer empagliflozin 10 mg to the resident. Resident #28's Medication Administration Record [MAR] for the timeframe 03/01/2025 - 03/31/2025, revealed no evidence of the transcription of a physician's order for empagliflozin 10 mg. During an interview on 03/25/2025 at 8:58 AM, LVN #1 stated she removed empagliflozin from Resident #28's medication cup as the medication was not listed on the resident's MAR and there was no physician's order. During an interview on 03/27/2025 at 1:04 PM, the Pharmacy Consultant stated the order for empagliflozin 10 mg for Resident #28 was never ordered through the facility's Primary Physician and the resident had never been on empagliflozin 10 mg since admission to the facility. During an interview on 03/27/2025 at 1:19 PM, the Pharmacist stated the pharmacy received the prescription for empagliflozin 10 mg directly from Resident #28's cardiologist's office on 10/02/2024. Per the Pharmacist, the medication had been sent every week in the medication roll to the facility. A New Prescription Summary from Resident #28's cardiologist, revealed an order dated 10/02/2024, for empagliflozin 10 mg, take one tablet by mouth every morning. The pharmacy Fill History, revealed the pharmacy dispensed empagliflozin 10 mg to the facility 26 times from 10/03/2025 to 03/26/2025. During an interview on 03/27/2025 at 2:06 PM, LVN #4 stated he worked twice a week and gave Resident #28 their day-shift medications. LVN #4 stated that when he gave the medication, he verified the medication to the MAR then placed the medication into the medication cup. LVN #4 stated he noticed Resident #28 had a empagliflozin 10 mg to be given at the 8:00 AM, but he never saw it on the resident's MAR or in their orders, so he took it out, took it to the medication room, placed the pill in the destruction box, and informed his supervisor. LVN #4 stated he never gave the medication to the resident. According to LVN #4, the process would be to contact the pharmacy and let them know about the medication was always in the resident's roll of medications, but there was no order for it. During an interview on 03/27/2025 at 2:16 PM, LVN #2 acknowledged that LVN #4 told him about the empagliflozin medication in Resident #28's medication rolls and that it was not ordered or on the resident's MAR. LVN #2 stated he faxed the pharmacy but could not remember when. During an interview on 03/27/2025 at 2:47 PM, LVN #3 stated Resident #28 had the medication empagliflozin in their pills, to be given at 8:00 AM. LVN #3 stated she always took the medication out, did not administer it to the resident, destroyed the medication, and notified her supervisor. LVN #3 acknowledged she never called the pharmacy to report the medication. During a follow-up interview on 03/27/2025 at 3:00 PM, the Pharmacist stated the pharmacy never received an order to discontinue the empagliflozin 10 mg medication and there had been no information or communication about the medication from the facility. According to the Pharmacist, if a facility nurse called and stated there was not a physician order for the medication, they would instruct the staff to send over an order to discontinue the medication. During an interview on 03/27/2025 at 3:41 PM, Resident #28's Primary Physician (PP) stated he took over care of the resident in late February 2025. The PP stated the empagliflozin medication was ordered by the resident's cardiologist back in October of 2024, and the pharmacy should have never sent it to the facility, if he did not order it. The PP stated he expected that if a medication was not listed on a resident's MAR and there was no order for the staff to call the pharmacy or physician for clarification. The PP stated the doctor who ordered the medication should have sent a note to the facility and he would have reviewed it to determine if the resident needed it. The PP stated neither the pharmacy nor the facility called him about the issue. During an interview on 03/27/2025 at 3:54 PM, the Director of Nursing (DON) stated her expectations were if the facility did not have an order for a resident's medication, the nurse should call the pharmacy and let them know that a medication did not have an order, and it needed to be stopped. The DON stated that no one told her that the medication. The DON stated the nurse should also call the physician and tell him that the medication came without an order, and he could manage it and/or discontinue it. During an interview on 03/27/2025 at 4:06 PM, the Administrator stated her expectation would be that the nurse and the DON follow the facility policy.

Based on observation, interview, record review, and facility policy review, the facility failed to maintain a medication error rate of 5 percent (%) or less. There were two errors out of 35 opportunities, which resulted in a 5.71% medication error rate for 1 (Resident #28) of 4 residents observed for medication administration. Findings included: A facility policy titled, Medication-Administration revised 01/01/2012, revealed Purpose To ensure the accurate administration of medications for resident in the Facility. Policy I. Medication will be administered directed by a Licensed Nurse and upon the order of a physician or licensed independent practitioner. II. No medication will be used for any patient other than the patient for whom it was prescribed. An admission Record indicated the facility admitted Resident #28 on 10/09/2023. According to the admission Record, the resident had a medical history that included a diagnosis of primary open-angle glaucoma, bilateral. Resident #28's Order Summary Report that contained active orders as of 03/01/2025, revealed an order dated 12/17/2024, for [brand name] ophthalmic solution 2-0.5 %, instill one drop in both eyes two times a day for glaucoma and an order dated 12/06/2023, for vitamin c oral tablet 500 milligrams, give one tablet by mouth two times a day for supplement. During medication administration observation on 03/25/2025 at 8:22 AM, Licensed Vocational Nurse (LVN) #1 failed to administer Resident #28's [brand name] ophthalmic solution eye drops and vitamin c tablet according to physician orders. During an interview on 03/25/2025 at 11:37 AM, LVN #1 acknowledged that she did not give Resident #28 vitamin c or the [brand name] eye drops. LVN #1 stated she did not give the medications but acknowledged she placed her initials on the resident's electronic medication administration record as if the medication had been administered. During an interview on 03/25/2025 at 12:50 PM, the Director of Nursing stated she expected a nurse to verify the medication order while the medication was being prepared for administration. During an interview on 03/27/2025 at 4:06 PM, the Administrator stated she expected a nurse to follow the policy.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure gloves were changed between dirty and clean tasks for 2 (Resident #7 and Resident #76) of 2 sampled residents reviewed for pressure ulcer/injury. Findings included: A facility policy titled, Dressings- Application, revised 01/01/2012, indicated, Remove dressings and discard into plastic bag. The policy indicated, Remove and discard non-sterile disposable gloves in plastic bag at bedside. Wash hands before and after each procedure. A facility policy titled, Hand Hygiene, revised 09/01/2020, indicated, The following situations require hand hygiene: After contact with blood, other body fluids, secretions, excretions, mucous membranes, non-intact skin, wound drainage and soiled dressing. 1. An admission Record indicated the facility admitted Resident #7 on 02/12/2025. According to the admission Record, the resident had a medical history that included a diagnosis of stage 3 sacral pressure ulcer. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/19/2025, revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS indicated the resident had one or more unhealed pressure ulcers/injuries. Resident #7's Order Summary Report, with active orders as of 03/22/2025, contained an order dated 03/22/2025, that directed staff to clean the coccyx stage 3 pressure injury with normal saline, pat dry, apply medical honey gel, and cover daily. Resident #7's Care Plan Report, included a focus area initiated 03/26/2025, that indicated the resident had a stage 3 pressure injury to the coccyx. Interventions directed staff to administer treatments as ordered and monitor for effectiveness. During an observation on 03/26/2025 at 9:15 AM, Licensed Vocational Nurse (LVN) #1 provided wound care for Resident #7. LVN #1 with gloved hands removed a dressing from the resident's coccyx. Without changing gloves or performing hand hygiene, LVN #1 obtained gauze and normal saline and cleaned the open pressure ulcer with the same gloved hands. LVN #1 then removed her gloves, washed her hands, reapplied gloves, and completed the wound care. During an interview on 03/26/2025 at 12:26 PM, LVN #1 stated when she cleaned a wound, she used gloves because the wound was soiled. LVN #1 stated she changed gloves after she cleaned the wound because then the wound was considered clean to apply the treatment. LVN #1 stated she set up a clean barrier for the supplies to have a clean area. LVN #1 stated the wound dressing was considered dirty that she removed. LVN #1 stated she set up gauze in separate piles, and after she removed the dressing she reached over to the clean area slowly, got the gauze and normal saline, cleaned the wound, and then removed gloves, washed her hands, and applied gloves to finish treatment. During an interview on 03/26/2025 at 2:13 PM, the Infection Preventionist (IP) stated the process for changing gloves during wound care was if anything dirty was touched then change gloves and perform hand hygiene before touching anything clean. The IP stated if the staff removed a soiled dressing they should perform hand hygiene before they touched clean supplies. The IP stated that the treatment nurse should have changed her gloves after she removed the dressing during wound care. According to the IP, not changing gloves after removing the dressing was dirty and that was an infection control issue. During an interview on 03/27/2025 at 9:42 AM, the Director of Nursing (DON) stated it was important to change gloves between dirty and clean because it was for infection control. The DON stated LVN #1should have changed her gloves after she removed the dressing. The DON stated her expectation was for gloves to be changed after removing a dressing during wound care because that was dirty to clean and they should always change gloves. During an interview on 03/27/2025 at 9:50 AM, the Administrator stated the importance of changing gloves between dirty and clean tasks so staff did not cross contaminate items. The Administrator stated LVN #1 should have changed her gloves at the time she removed the dressing from the resident's coccyx before she touched the gauze and normal saline on the clean area. The Administrator stated she expected gloves to be changed between dirty and clean tasks. 2. An admission Record indicated the facility admitted Resident #76 on 10/03/2023. According to the admission Record, the resident had a medical history that included diagnoses of Alzheimer's disease and encounter for palliative care. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/03/2025, revealed Resident #76 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS indicated the resident had one or more unhealed pressure ulcers/injuries. Resident #76's Care Plan Report, indicated a focus area initiated 03/26/2024, that indicated the resident had a stage 3 coccyx pressure ulcer. Interventions directed the staff to administer treatments as ordered and monitor the effectiveness. Resident #76's Order Summary Report with active orders as of 03/01/2025, revealed an order dated 02/10/2025, that directed the staff to clean the resident's coccyx stage 3 pressure injury and peri wound with betadine solution, pat dry, apply Dakin's solution, moisture gauze to the wound base and cover with foam boarder every day and evening shift. During an observation of wound care on 03/26/2025 at 10:14 AM, Licensed Vocational Nurse (LVN) #1 removed the soiled dressing from the resident's coccyx area and placed it in the bag. LVN #1 then proceeded to reach over with her soiled gloved hand and picked up several clean 4x4 gauze and proceeded to pat dry the resident's buttock and area around the pressure ulcer. LVN #1 then picked up several clean 4x4s and placed them into the betadine solution and proceeded to clean around and into the deep pressure ulcer. After cleaning the entire area, LVN #1 discarded the betadine soaked 4x4s into the plastic bag, removed her gloves, and washed her hands with soap and water. During an interview on 03/26/2025 at 10:31 AM, LVN #1 stated that the removal of the soiled dressing and the cleansing of the wound was all one step. LVN #1 stated the dressing was dirty, and the patting and cleaning of the wound with the betadine solution was also a dirty part of the procedure. LVN #1 stated she did not need to change her gloves after she removed a dirty dressing because she was not done cleaning the dirty wound. During an interview on 03/26/2025 at 3:47 PM, the Director of Nursing (DON) stated that her expectation would be that each nurse would follow the policy and procedure for hand hygiene and dressing application. The DON stated the nurse who completed Resident #76's wound care should have removed her soiled gloves and washed her hands after she removed the soiled dressing from the resident's coccyx wound before she began to clean it. During an interview on 03/26/2025 at 3:51 PM, the Regional Quality Assurance Nurse stated her expectations were that the nurse should remove their gloves and wash their hands after they removed a soiled dressing from a resident's wound and prior to cleaning the wound. During an interview on 03/27/2025 at 10:22 AM, the Administrator stated the nurse should change her gloves between dirty and clean tasks and follow the facility policy and procedures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain essential equipment in a safe operating condition when one of three boiler system (a device that heats water) burner tray was full of dust, debris, and water deposits across burners used to heat water for resident's shower rooms and residents room sink faucets. This failure contributed for a non-functioning boiler system and scheduled residents' showers on 1/11/25 were not provided. Findings: During an interview on 1/13/25 at 1:10 PM with Resident 2, Resident 2 stated she did not get a shower on Saturday. The CNA run the water for 20 minutes, but it did not get warm enough for me to take my shower. Resident 2 stated the facility had not told her when she will get a shower. During an interview on 1/13/25 at 1:45 p.m. with Maintenance Director (MD), the MD stated on 1/11/25 Saturday he received a call from the Director of Staff Development (DSD) the facility had no hot water to use for residents' showers. The MD stated he called and directed the Maintenance Assistant (MA) to check the facility water temperature. The MD stated the MA informed him the shower room water temperature was not warm enough to provide residents showers. The MD stated on 11/12/25 Sunday he went to the facility and checked the two-shower room water temperature. The MD stated the water temperature was below 90 degrees Fahrenheit (a temperature scale) and was lukewarm to cold. The MD stated he sent out a group text to all facility departments and the facility Administrator did not reply. The MD stated he called several plumbing companies but would not be available to come to facility until Monday. During an interview on 1/13/25 at 2: 45 p.m., with the DSD, the DSD stated, she was in the facility on 1/11/25 Saturday and facility staff informed her there was no hot water for residents' showers. The DSD stated, she sent a group text to the Administrator (ADM), MD and Maintenance Assistant (MA). The DSD stated the MD responded and informed her the MA was in the facility. The DSD stated she informed all nursing staff to not provide showers because there was no hot water. During an interview on 1/13/25 at 3: 20 p.m., with the ADM, the ADM stated, facility does not have showers scheduled on Sundays. The ADM stated she was made aware of the lack of hot water on the two-shower room on 1/13/25 Monday at around 10 a.m. The ADM stated, she was informed the laundry and kitchen had hot water. During an interview on 1/14/25 at 9:40 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated he was scheduled to work on 1/11/25 Saturday A.M. shift. LVN 1 stated he was informed by staff at around 9 am the shower water was not hot enough to provide showers to residents. LVN 1 stated he immediately informed the DSD. LVN 1 stated residents have the right to have essentials for bathing and showering. LVN 1 stated residents have the right to be able to shower at comfortable water temperature. LVN 1 stated the facility did not meet the residents needs for bathing and showering due to inadequate water temperature. During an interview on 1/14/25 at 10:35 a.m., with the DSD, the DSD stated, she was informed by LVN 1 on Saturday morning regarding the lack of hot water in the shower rooms. The DSD stated she informed ADM, MD, and MS on 1/11/25 at 11:44 am the water was cold. The DSD stated residents have the right to have their showers on their scheduled days and as requested. During an interview on 1/14/25 at 11:00 a.m., with CNA 4, CNA 4 stated she was assigned to work on 1/11/25 Saturday A.M. shift. CNA 4 stated she was not able to shower her residents on Saturday because there was no hot water in the shower rooms. CNA 4 stated the residents have the right to be showered on their scheduled shower days. CNA 4 stated the facility bears the responsibility to meet residents needs to have a shower at the desired water temperature. During an interview on 1/14/25 at 12 p.m., with the ADM, the ADM stated she was notified by a group text on 1/11/25 Saturday the shower rooms did not have hot water. The ADM stated she did not receive a text message on 1/12/25 Sunday indicating the hot water issue had not been resolved. The ADM stated the hot water heater was essential part of the facilities residents to maintain a quality of life and to provide a homelike environment. The ADM stated residents have the right to shower at a comfortable water temperature. During an interview on 1/28/25 at 1:13 p.m. with the MD, the MD stated he does know when the last time the boiler was check by an outside vendor (a company or individual that sells goods or services) for maintenance. The MD stated he does not have an instruction for use for the old boiler. The MD stated he called the boiler company and was told he just needs to flush the boiler system monthly. The MD stated for preventative maintenance he checks the outside of the boiler for dust and flushed the system monthly. The MD stated the burner tray was located inside of the boiler and was full of dust and debris, the vendor told him it was from years of neglect. The MD stated the burner tray helps with the ignition of the boiler. The MD stated he does not have the expertise to check the inside of the boiler. The MD stated the vendor told him the boiler was old and needs to be replace and should be check annually by a professional for preventive maintenance. During a review of a document titled INVOICE from the {Name of Plumbing Company} dated [DATE], the document invoice indicated, .Found left hand water heater off and not lighting. Burner tray is full of dust and debris, showing water deposits across burners, .Replaced ignition module to restore heater to service . During a review of the facility's P&P titled, Water Temperatures, dated 01/12/2012, the P&P indicated, to ensure the health, safety, and comfort of residents, visitors and facility staff .The facility ensures water is maintained at temperatures suitable to meet the resident's needs .Water heaters that service resident rooms, bathrooms. Common area, and tub/shower areas are set to temperatures per state regulations. During a review of the facility's P&P titled, Unusual Occurrences Reporting, dated 05/30/2024, the P&P indicated, The facility reports the following events by phone and in writing to the appropriate State or Federal agencies .Interruptions of essential services (heating, air conditioning, food, water, linens sewage, or needed medical supplies) provided by the facility .Unusual occurrences are reported to the appropriate agency within 24 hours by telephone and then confirmed in writing .The facility conducts and documents timely and thorough investigations into all unusual occurrences and takes corrective action as appropriate .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Level l Preadmission Screening and Resident Review (PASRR-The State is required to ensure that every person entering a Medicaid certified Nursing Facility [NF] receives a Level I screening and if necessary a Level II evaluation to ensure that their NF residence is appropriate and to identify what specialized services they may need) was completed for one of five sampled residents (Resident 74) when Resident 74 was re-admitted to the facility on [DATE]. This failure had the potential for Resident 74 to not receive the necessary and appropriate psychiatric level of treatment and evaluation in the facility. Findings: During a review of Resident 74's admission Record (AR), dated 1/25/24, the AR indicated, Resident 74 was re-admitted to the facility on [DATE] with diagnoses which included adjustment disorder with disturbance of conduct and depression (sadness). During a concurrent interview and record review on 1/25/24 at 10:24 a.m. with Minimum Data Set Nurse (MDSN), Resident 74's PASSR dated 8/5/23 was reviewed. The MDSN stated the PASSR was completed at the general acute care hospital (GACH) and a copy was sent to the facility when Resident 74 was admitted in the facility on 8/7/23. MDSN stated Resident 74 was sent out to GACH and was away for more than 24 hours and was re-admitted in the facility on 10/30/23. MDSN stated she was not able to find a PASSR assessment for Resident 74 when re-admitted in the facility and there should have been one. MDSN stated the facility staff are responsible for completing the PASSR assessment for resident re-admitted to the facility. MDSN stated for new admission, GACH's are responsible for completing the assessment and send a copy to the nursing facility. MDSN stated the consequences of not having a PASSR completed was the facility will not get re-imburssed for services provided and missed opportunity to asses for mental health and not able to provide the care needed to address the mental health issue. During an interview on 1/26/24 at 2:05 p.m. with the admission director (AD), she stated Resident 74 was admitted to the GACH and re-admitted back to the facility on [DATE]. AD stated there should have been a PASSR assessment completed when Resident 74 was re-admitted and it was the responsibility of the facility staff to complete the assessment. AD stated it was the responsibility of the licensed nurse to complete the assessment. The AD stated, . No one has noticed that there was no PASSR assessment until now . During an interview on 1/26/24 at 5:05 p.m. with the administrator (ADM) 1, she stated the licensed nurses in the facility are responsible in completing a PASSR assessment for residents re-admitted in the facility. ADM 1 stated her expectation was to make sure the PASSR was completed on the day of admission. ADM 1 stated PASSR assessment was important because it is a tool for mental health screening. During a review of facility's policy and procedure (P&P) titled, Pre-admission Screening Resident Review (PASRR), dated 8/15/16, the P&P indicated, . PASRR must be completed by midnight of the date of admission or the facility will not be able to bill for any dates service . The facility MDS coordinator will be responsible to access and ensure updates to the PASRR is done .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident 12's admission Record dated 1/25/24, indicated Resident 12 was admitted to the facility on [DATE] with diagnoses which included dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities) with other behavioral disturbance (any persistent and repetitive pattern of behavior that violates societal norms or rules, seriously impairs a person's functioning), Depression (a constant feeling of sadness and loss of interest, which stops you doing your normal activities), schizoaffective disorder (a mental health disorder that is marked by a combination of hallucinations, mood disorder symptoms, such as depression or mania[elevated energy level or activity]) bipolar type (includes episodes of mania and sometimes major depression). During a review of Resident 12's Brief Interview for Mental Status assessment dated [DATE], the BIMS assessment score was 2 out of 15 which indicated Resident 12 had severe cognitive deficit. During an observation on 1/23/24, at 9:56 a.m., in Resident 12's room, Resident 12 laid in bed with eyes closed. Resident 12 did not respond when spoken to. During a review of Resident 12's Order Summary Report dated 1/25/24, the Order Summary Report indicated .Monitor target behaviors for use of Quetiapine (medication used to treat mental health conditions including bipolar disorder and schizophrenia) D/T [due to] bipolar disorder manifested by episodes of unusual change of mood from depress to mania or vice versa every shift indicate Y[yes] if behaviors exist, N[no] if no behaviors indicated . During a review of Resident 12's Medication Administration Record (MAR) dated 1/1/24, the MAR indicated no behaviors on day shift, 16 behaviors on evening shift and no behaviors on night shift between 1/1/24 and 1/24/24. During a review of Resident 12's Behavior Monitoring and Interventions Report dated 1/25/24, Behavior Monitoring and Interventions report indicated no behaviors observed for report .Date Range: 2024-01-01 to 2024-01-25 . During a concurrent interview and record review on 1/25/24, at 11:24 a.m., with Licensed Vocational Nurse (LVN) 3), Resident 12's Care Plan (CP), dated 10/1/22 was reviewed. The CP indicated, . Focus: The resident uses psychotropic medications (Quetiapine medications) r/t [related to] Behavior management DX [diagnosis] bipolar disorder . Interventions: Monitor/record occurrence of for target behavior symptoms q shift . LVN 3 stated Resident 12's CP did not identify specific behaviors nursing staff needs to monitor and did not specify the number of behavioral episodes when to notify the physician. LVN 3 stated the specific behavior, and the frequency of behavior should be documented, and care planned for the physician to review, provide appropriate medication therapy, and for nursing staff to implement behavioral interventions. During a telephone interview on 1/26/24 8:13 AM with Pharmacist (PharmD) 1, PharmD 1 stated Resident 12's Care Plan should have a targeted behavioral goal indicated for psychotropic medications to ensure resident safety and manage drug regimen to determine medication dosage effectiveness in controlling Resident 12's specific targeted behaviors. During a review of the facility's policy and procedure (P&P), titled, Comprehensive Person-Centered Care Planning, dated November 2018, the P&P indicated, . Policy It is the policy of this Facility to provide person-centered, comprehensive and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain the highest physical, mental and psychosocial well-being . Procedure .IV. Comprehensive Care Plan a. within 7 days from the completion of the comprehensive MDS [Minimum Data Set] assessment [a standardized assessment tool that measures health status in nursing home residents], the comprehensive care plan will be developed. All goals, objectives, interventions, etc. from the current baseline care plan will be included in the resident's comprehensive care plan Based on observation, interview and record review, the facility failed to ensure a comprehensive, person-centered care plan (a plan that provides direction for individualized care of the resident) was developed and implemented to meet the identified needs for two of 37 sampled residents (Resident 11, Resident 12) when: 1. Resident 11 did not have a care plan for the change of texture of his dessert. This failure had the potential to result for Resident 11's dietary safety needs to go unmet which could lead to aspiration or choking, and poor oral intake. 2. Resident 12's care plan for the used of Quetiapine (a psychotropic [medications that affect the mind, emotions, behavior] medication used to treat several kinds of mental health conditions) did not identify a targeted behavioral goal (the actual undesirable/unwanted behaviors that occurs as a result of a medical behavior) This failure had the potential to result for Resident 12 to receive unnecessary psychotropic medication and decreased psychosocial wellbeing. Findings: 1. During a concurrent observation and interview on 12/23/24 at 12:14 p.m. in the dining room, Resident 11 was observed eating in the dining room. Resident 11's meal ticket indicated puree dessert. Resident stated he did not know what his dessert was and did not like it. During a review of Resident 11's admission Record (AR), (a document containing pertinent resident profile information) dated 1/25/24, the AR indicated, Resident 11 was admitted to the facility on [DATE], with diagnoses which included convulsions, muscle weakness and paranoid schizophrenia (pattern of behavior where a person feels distrustful and suspicious of other people and acts accordingly). During a review of Resident 11's Minimum Data Set (MDS-a resident assessment tool used to identify resident cognitive, physical abilities and needs) assessment dated [DATE], the MDS assessment indicated Resident 11's Brief Interview for Mental Status (BIMS-screening tool used to assess resident cognition status) 0-15 scale (0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit) assessment score was 10 out of 15 which indicated Resident 11 had moderate cognitive deficit. During a concurrent interview and record review on 1/26/24 at 8:49 a.m. with the Dietary Supervisor (DS), she stated she was not aware when Resident 11's dessert texture was changed to puree and was not able to find documentations it was discussed to Resident 11. The DS stated there was no care plan for the change of diet texture and a care plan should have initiated. The DS stated it was her responsibility to initiate a care plan. During a concurrent interview and record review on 12/26/24 at 9:55 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 11's Electronic Medical Record (EMR), undated was reviewed. LVN 1 stated she was not aware Resident 11's dessert texture was changed to puree. LVN 1 stated Resident 11's changed of dessert texture was not document on the EMR. LVN 1 stated the changed of dessert texture should have been care planned to monitor for aspiration and poor oral intake from the change of texture. During a concurrent interview and record review on 1/26/24 at 4:35 p.m. with the Director of Nursing (DON), Resident 11's EMR, undated was reviewed. The DON stated she was not aware Resident 11's dessert diet texture was changed. The DON stated there was no documentations in Resident 11's EMR to reflect the change. The DON stated the changed should have been care planned and the physician notified. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Person-Centered Care Planning, dated 11/18, the P&P indicated, . Additional changes or updates to the resident comprehensive care plan will be made based on the needs of the resident . The comprehensive care plan will be periodically reviewed and revised . the comprehensive care plan will also be reviewed and revised at the following times: Onset of new problems . Other times as appropriate or necessary .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide services which met professional standards of care for one of three sample residents (Resident 46) when the nasal cannula (a flexible tube that goes around your head and into your nose and helps deliver supplemental oxygen) and humidifier (a plastic bottle designed to attached to oxygen machines and add moisture to the end users oxygen) for Resident 46 was undated. This failure placed Resident 46 at risk for respiratory infection which could lead to serious medical condition. Findings: During a concurrent observation and interview on 1/23/24 at 9:45 a.m. in room [ROOM NUMBER] A during the initial tour, Resident 46 was lying in bed, with the oxygen concentrator (medical device that can help patient/resident breath) turned on and set at 2(two).5(five) L (liters-unit of measurement). The nasal cannula and humidifier did not have label with date when it was changed last. Resident 46 stated his nasal cannula tubing had not been replaced recently and was not sure how much oxygen he was supposed to be receiving. Resident 46 stated he needs the oxygen for his breathing. During a concurrent observation and interview on 1/23/24 at 10:40 a.m., with Licensed Vocational Nurse (LVN) 4, LVN 4 checked the oxygen nasal cannula and humidifier of Resident 46 and stated the nasal cannula and humidifier did not have label to indicate the date when it should be changed. LVN 4 stated the practice was for the night shift nurse to change the nasal cannula and humidifier once a week. LVN 4 stated the nasal cannula, and the humidifier should have been dated to ensure it has been changed. During a review of Resident 46's clinical record titled, Record of Admission, dated 1/25/24 Resident 46 was admitted to the facility on [DATE], with diagnoses which included, atrial fibrillation (irregular, often rapid heart rate that commonly causes poor blood flow), obstructive sleep apnea (throat muscles relax and block the airway). During an interview on 1/26/24 at 4:30 p.m. with the director of nursing (DON), the DON stated her expectation was for licensed nurses to follow the facility policy and practice to change the nasal cannula and humidifier weekly and label with the date it was changed. The DON stated it was an infection control issue. During a review of the facility's policy and procedure (P&P) titled, Oxygen Therapy, dated 11/17, the P&P indicated, .The humidifier and tubing should be changed no more than every 7 days and labeled with the date of change . Oxygen tubing, mask and cannulas will be changed no more than every seven (&) days and as needed. The supplies will be dated each time they are changed. Humidifier equipment will be maintained and/or changed per manufacturer's guidelines or no more than every 7 days. They will be dated each time they are changed . During a professional reference review retrieved from https://www.emphysemafoundation.org/index.php/about-uss/privacy/97-therapeutic-toolbox-articles/519-managing-supplemental-oxygen-supplies#:~:text=Clean%20oxygen%20concentrator%20filters%20weekly,replace%20the%20nasal%20cannula%20immediately. titled, Managing Supplemental Oxygen Supplies, dated 2023, For people living with chronic obstructive pulmonary disease (COPD), supplemental oxygen is one of the most important therapies available when they experience reduced oxygen levels. But effectively managing oxygen can be challenging. To help, the National Heart, Lung, and Blood Institute (NHLBI), part of the National Institutes of Health (NIH), has published tips for doing so, including managing tubing, keeping supplies clean, and practicing oxygen safety . Keeping it clean . Ideally, nasal cannulas should be replaced every two weeks and the long oxygen tubing attached to stationary equipment every three months.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 299) received treatment and care in accordance with professional standards of practice when Resident 299's serum glucose (a type of sugar in the body) were not reported to the physician according to the physician's orders. This failure placed Resident 99 at risk for hypoglycemia (when the level of glucose in the blood drops below what is healthy), or hyperglycemia (high blood glucose), and hospitalization. Findings: During a review of Resident 299's admission Record, dated 1/25/24, the admission record indicated, Resident 299 was admitted to the facility on [DATE] with diagnoses which included muscle weakness, urinary tract infection (UTI- infection in any part of the urinary system-kidneys, ureters or bladder), diabetes mellitus (when the body can not produce enough hormone called insulin (used to regulate sugar in the body), or the insulin it produces is not effective), spinal stenosis (when the space inside the backbone becomes too small), heart failure (the heart is unable to pump blood around the body properly), and transient ischemic attacks (mini stroke or when there is a temporary disruption of the blood supply to a part of the brain). During a review of Resident 299's Minimum Data Set (MDS-a resident assessment tool used to identify resident cognitive [pertaining to reasoning memory and judgement] and physical functional level) assessment, dated 1/14/24, the MDS indicated Resident 299's Brief Interview for Mental Status (BIMS- screening tool used in nursing home to assess cognition) assessment score was 15 out of 15 (0-15 scale [0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit]) which indicated Resident 299 had no cognitive deficit. During a review of the facility's job description titled RN Staff Nurse, undated, the job description indicated, . provides nursing care as prescribed by physician/health care professional in accordance with the legal scope of practice, any Board of Licensing restrictions, and within established standards of care, polices and procedures . Administers professional services and provide care consistent with allowing residents to attain or maintain his or her highest practicable physical, mental, and emotional well-being utilizing the nursing process of assessing, planning, implementing, and evaluating patient care . completes medical treatments as indicated and ordered by the physician . During a concurrent observation and interview on 1/24/24, at 9:28 a.m., Resident 299 was lying in bed, in clean gown and in no apparent distress. Resident 299 stated, when she was at home, she had episodes where her serum glucose would get very low. Resident 299 stated, at the facility, the staff had been checking her Finger Stick Blood Sugar (FSBS - one method of glucose monitoring) for about a week but have stopped now. Resident 299 stated, she had talked to the physician about adjusting her insulin when she first was admitted . During a concurrent interview, and record review, on 1/24/24, at 3:50 p.m., with Registered Nurse (RN) 1, Resident 299's physician orders titled Order Summary Report, dated 1/24, and Medication Administration Record, dated 1/24, were reviewed. RN 1 stated, the provider had adjusted the dosage of the insulin for Resident 299 when she was admitted . RN 1 stated, the treatment order was for Resident 299's to have FSBS before meals for 7 days, call the provider if the results are greater than 350 or less than 70 and then fax the results to the provider. RN 1 stated, in summary, during the 7 days, Resident 299 had one result of 84, two times greater than 300 and several in the 100 to 200 range. RN 1 stated, the ordered started on 1/9/24 and ended on 1/15/24. RN 1 stated, the results were not faxed to the provider. RN 1 stated, the provider's order was not followed. RN 1 stated, the provider did not have the information to evaluate the change in the medication. During a concurrent interview and record review on 1/25/24, at 10:30 a.m., with the Director of Nursing (DON), Resident 299's physician orders titled Order Summary Report, dated 1/24, and Medication Administration Record, dated 1/24, were reviewed. DON stated, she had not been able to find that the provider had been notified about the FSBS results for the 7 days. DON stated, the nurse did not follow the provider orders and the facility policies. During a review of the facility's Policy and Procedure (P&P) titled Physician Orders, August 21, 2020, the P&P indicated, . VIII. Whenever possible, the licensed nurse receiving the order will be responsible for documenting and carrying out the order . XII. Documentation pertaining to physician orders will be maintained [in] the Resident's medical record . XIII. The current month's administration records will be maintained in the MAR and TAR binders . During a professional reference review, retrieved from Lippincott Manual of Nursing Practice 10th Edition, dated 2014, page 16-17 indicated, Standards of practice General Principles .The practice of professional nursing has standards of practice setting minimum levels of acceptable performance for which its practitioners are accountable .These standards provide patients with a means of measuring the quality of care they receive .A deviation from the protocol should be documented in the patient's chart with clear, concise statements of the nurse's decisions, actions, and reasons for the care provided, including any apparent deviation . Legal claims most commonly made against professional nurses include the following departures from appropriate care: failure to assess the patient properly or in a timely fashion, follow physician orders, follow appropriate nursing measures, communicate information about the patient, adhere to facility policy or procedure, document appropriate information in the medical record . Failure to formulate or follow the nursing care plan . During a professional review titled, Does a Nurse Always Have to follow a Doctor's Orders? undated, retrieved from https://www.registerednursing.org/does-nurse-always-follow-doctors-orders/ indicated, .nurses cannot just randomly decide which order to follow and which not to follow. Unless there is a safety concern or an order that conflicts with personal or religious beliefs, failing to carry out orders can be grounds for discipline by the employer as well as the board of nursing, as it could be deemed 'neglect .

Based on observation, interview and record review, the facility failed to store, prepare and serve food in accordance with professional standards for food safety when Dietary Supervisor (DS) did not wear a hairnet while walking around in the dry storage area inside the kitchen. This failure had the potential to cause foodborne illness to residents, staff and visitors. Findings: During a concurrent observation and interview on 1/23/24 at 8:50 a.m. with the DS and Registered Dietitian (RD) in the kitchen, DS was observed not wearing a hair net while walking around inspecting foods inside the dry storage room. DS excused herself after a few minutes and left the dry storage room. The RD stated the DS left because she was not wearing a hair net. The RD stated the practice and the expectation was for everyone who enters the kitchen to wear a hair net. During an interview on 1/25/24 at 9 a.m. with the Dietary Aide (DA), he stated the expectation was for hair net to be worn upon entry into the kitchen and wash hands before starting any work. The DA stated it was important to wear hair net to avoid hair falling on to foods served to resident. During an interview on 1/26/24 at 9:20 a.m. with DS, the DS stated she was not wearing a hair net when doing a walk through in the kitchen with surveyor and RD. The DS stated she forgot to put on a hair net and the practice was to wear a hair net before entering the kitchen. The DS stated it was an infection control issue and did not want any hair in residents food. The DS stated she wanted everything in the kitchen kept clean and sanitary. During an interview on 1/26/24 at 5:20 p.m. with the administrator (ADM) 1, she stated the expectation and practice was to ensure anyone entering the kitchen are expected to wear a hair net as soon as they set foot in the kitchen. ADM 1 stated it was an infection control issue and to ensure there are no hair in the food served to residents. During a review of facility's policy and procedure (P&P) titled, Dietary Department-Infection Control for Dietary Employee, dated 11/9/16, the P&P indicated, . To ensure that the dietary department is maintained in a sanitary condition in order to prevent food contamination and growth of disease producing organism and toxins . Personal cleanliness is required in sanitary food preparation A. Clean working attire will be worn B. Clean hair-covered with an effective hair restraint while in all kitchen and food storage areas. (And beard/mustache covering when applicable) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain a safe, and homelike environment for 13 of 37 sampled residents when the ceiling light in the dining room was not working and did not provide adequate lighting to meet residents needs. This failure resulted for 13 residents in the facility who routinely used the dining room to have decreased visibility inside the dining room which had the potential to result in eye straining, falls and accidents. Findings: During an observation on 1/23/23 at 12:10 p.m. in dining room A, there were ten ceiling light box covers observed, there was one light box located on the back corner of the dining room that was not working. The back corner of the dining room did not have adequate lighting. During a concurrent observation and interview on 1/23/24 at 12:14 p.m. with Resident 87 in the dining room, the ceiling light above Resident 87's dining room table was observed off and area was observed with dim lighting. Resident 87 stated during dinner the dining room was dark and was difficult to see during meals. Resident 87 stated she had requested the facility to replace the light bulbs. During a review of Resident 87's admission Record (a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), indicated Resident 87 was admitted to the facility on [DATE] diagnosis included, . Hemiplegia (paralysis of one side of the body) affecting the right dominant side . During a review of Resident 87's Minimum Data Set (MDS- a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment dated [DATE], the MDS indicated Resident 87's Brief Interview for Mental Status (BIMS - screening tool used to assess resident cognitive level) score was 15 out of 15 (0-7 indicated severe cognitive impairment - [memory loss, poor decision making-skills] 8-12 moderate cognitive impairment, (13-15) cognitively intact) which indicated Resident 87 was cognitively intact. During a concurrent observation and interview on 1/23/24 at 12:15 p.m. with Resident 73 in the dining room, the ceiling light above Resident 73's dining room table was observed off and area was observed with dim lighting. Resident 73 stated the dining room was too dark to eat during dinner and was a safety concern when moving around in the dining room. During a review of Resident 73's admission Record, the admission Record indicated, Resident 73 was admitted to the facility on [DATE], diagnosis included, . encounter for orthopedic aftercare (recovery program after surgery) following surgical amputation (removal of a limb) . legal blindness . During a review of Resident 73's MDS, dated 1/11/24, the MDS indicated Resident 73's Brief Interview for Mental Status score was 15 out of 15, indicating Resident 73 was cognitively intact. During a concurrent observation and interview on 1/24/24 at 3:28 p.m. with the Assistant Maintenance Supervisor (AMS) inside the dining room. The AMS stated the ceiling light had not worked for at least a year and was in the process for replacement approval from administration. The AMS did not provide the work order for the light fixture upon request and stated the maintenance supervisor would provide it. During an interview on 1/25/24 at 9:08 a.m. with the Maintenance Supervisor (MS), the MS stated dining room ceiling light had not worked for a year. The MS stated the back corner of the dining room was dark but had not received grievances or complaints from residents. The MS stated he was waiting to find the best pricing to fix the ceiling light. The MS did not provide the work order for the light fixture upon request. During a review of facility's, Resident Council Minutes (RCM), dated 1/16/24, the RCM indicated, . List of topics discussed and recommendations, and old business requiring further action . Maintenance light in dining room needs covers and light bulbs need to be replaced . During an interview on 1/26/24 at 9:30 a.m. with the Activities Director (AD), the AD stated the residents was concern of the dining room ceiling light not working. The AD stated the residents wanted to know when the facility would fix ceiling lights. The AD stated maintenance was notified of the ceiling lights not working. During an interview on 1/26/24 at 9:35 a.m. with the Director of Nurses (DON), the DON stated 13 residents routinely used the dining room. The DON stated the facility's expectation was to provide adequate lighting for residents to ensure safety when residents performed dining task. The DON stated maintenance was responsible to fix the ceiling light in dining room. The DON stated the residents concern was valid, the dining room was dark and was hard for residents to see during dinner. During a review of the facility's policy and procedure (P&P) titled, Maintenance Services, dated 1/1/12, indicated, . the maintenance is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times . maintaining the building in good repair and free from hazards . maintaining lighting levels that are comfortable . establishing priorities in providing repair service .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards and practices for five of five sampled residents (Resident 24, Resident 36, Resident 80, Resident 42 and Resident 56) when Physician Orders for Life Sustaining Treatment (POLST- a portable form with instructions for emergency medical care that travels with a resident) was not completed in its entirety. These failures had the potential for Resident 24, Resident 36, Resident 80, Resident 42 and Resident 56's medical information to not be readily accessible and portable in case of an emergency. Findings: During a review of Resident 24's Physician Orders for Life Sustaining Treatment (POLST), dated 11/3/20, the back side of the POLST form that provides resident information, supervising physician, and additional contact information was not completed. During a review of Resident 24's admission Record (a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), indicated Resident 24 was admitted to the facility on [DATE]. During a review of Resident 24's Minimum Data Set (MDS- a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment dated [DATE], the MDS indicated Resident 24's Brief Interview for Mental Status (BIMS - screening tool used to assess resident cognitive level) score was 15 out of 15 (0-7 indicated severe cognitive impairment - [memory loss, poor decision making-skills] 8-12 moderate cognitive impairment, (13-15) cognitively intact) which indicated Resident 24 was cognitively intact. During a review of Resident 36's Physician Orders for Life Sustaining Treatment (POLST), dated 6/13/23, the back side of the POLST form was not completed. During a review of Resident 36's admission Record, indicated Resident 36 was admitted to the facility on [DATE]. During a review of Resident 36's Minimum Data Set (MDS- a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment dated [DATE], the MDS indicated Resident 36's Brief Interview for Mental Status score was 3 out of 15 (0-7 indicated severe cognitive impairment - [memory loss, poor decision making-skills] which indicated Resident 36 had severe cognitive impairment. During a review of Resident 80's Physician Orders for Life Sustaining Treatment (POLST), dated 6/7/23, the back side of the POLST form was not completed. During a review of Resident 80's admission Record, indicated Resident 80 was admitted to the facility on [DATE]. During a review of Resident 42's Minimum Data Set (MDS- a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment dated [DATE], the MDS indicated Resident 42's Brief Interview for Mental Status score was 15 out of 15 (13-15 cognitively intact) which indicated Resident 42 was cognitively intact. During a review of Resident 42's Physician Orders for Life Sustaining Treatment (POLST), dated 8/15/22, the back side of the POLST form was not completed. During a review of Resident 42's admission Record, indicated Resident 42 was admitted to the facility on [DATE]. During a review of Resident 56's Physician Orders for Life Sustaining Treatment (POLST), dated 8/21/23, the back side of the POLST form was not completed. During a review of Resident 56's admission Record, indicated Resident 56 was admitted to the facility on [DATE]. During a review of Resident 56's Minimum Data Set (MDS- a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment dated [DATE], the MDS indicated Resident 56's Brief Interview for Mental Status score was 6 out of 15 (0-7 indicated severe cognitive impairment). During a concurrent interview and record review on 1/24/24 at 9:27 a.m. with Licensed Vocational Nurse (LVN) 2, Resident 36's POLST form, dated 6/13/23 was reviewed. The POLST indicated, the back of the form was not completed to its entirety. LVN 2 stated it was expected that the POLST form be completed because the form gives information on Resident 36's code status and full treatment in an emergency. During a concurrent interview and record review on 1/24/24 at 9:30 a.m. with LVN 2, Resident 56's POLST form, dated 8/21/23 was reviewed. The POLST indicated, the back of the form was not completed. LVN 2 stated the back of the POLST form was not completed to its entirety and it was important to have the physician information filled out on the POLST to know the physician discussed the form with Resident 56 or resident representative (RP). During an interview on 1/24/24 at 10:14 a.m. with Registered Nurse Supervisor (RNS), the RNS stated it was important that the back of the POLST form to be completed with Nurse Practitioner (NP) or Physician information to know who the supervising health care provider was. RNS stated it was important to have additional contact information for the facility staff to know who to call in case of emergency. During an interview on 1/24/24 at 10:24 a.m. with LVN 1, LVN 1 stated it was important to have the backside of the POLST form completed to have signatures of completion and to make the form official. LVN 1 stated the facility process was for the nurse to initiate the POLST form completion and it was followed up by the social services department. During an interview on 1/24/24 at 10:49 a.m. with the Social Services Director (SSD), the SSD stated it was the responsibility of the social services department to ensure that the POLST form be completed to its entirety. The SSD stated the POLST should have been completed on the back to ensure staff was given the complete form during an emergency. During an interview on 1/26/24 at 20:49 a.m. with the Director of Nurses (DON), the DON stated it was the expectation for the POLST be completed to its entirety. The DON stated it was important to have the additional contact in the POLST if available during an emergency. During a review of the facility's policy and procedure titled, Physician Orders for Life-Sustaining Treatment (POLST), dated 6/3/2020, indicated, . A completed and signed POLST form is a legal physician order that is immediately actionable . The POLST form must be completed, signed, and dated, include the practitioner's medical license number and be signed by the resident, resident's representative or the resident's health care decision maker . During a review of a professional reference titled, American Nurses Association: Principles of Nursing Documentation, dated 2010, page 8 indicated, .Patient documentation frequently is used by professionals who are not directly involved with the patient's care. If patient documentation is not timely, accurate, accessible, complete, legible, readable, and standardized, it will interfere with the ability of those who were not involved in and are not familiar with the patient's care to use the documentation .

Based on observation, interview, and record review, the facility failed to maintain a safe environment with an effective infection prevention and control program to prevent the transmission of communicable diseases (illnesses that are spread from one person to another) or infections (occurs when harmful germs enters the body and cause illnesses) when licensed nurse (LN) and certified nursing assistant (CNA) provided care to Resident 2, Resident 7, Resident 8, Resident 9, and Resident 10 without performing hand hygiene (technique to clean the hands, including hand washing with soap and/or the use of alcohol based hand rubs) in between residents. This failure had the potential to place residents at increased risk for cross-contamination (the physical transfer of harmful bacteria from one person to another which could cause infections) and spread of communicable diseases. Findings: During an observation on 5/16/23, at 10:10 a.m., in the hallway outside of Resident 2's room, CNA 1 entered Resident 2's room and donned (put on) a pair of gloves without performing hand hygiene. CNA 1 proceeded to provide care for Resident 2. During a concurrent observation and interview on 5/16/23, at 10:31 a.m., with Licensed Vocational Nurse (LVN) 3, in front of the nurse's station, LVN 3 entered Resident 7, Resident 9, and Resident 10's room without performing hand hygiene and provided care to the residents in the room. LVN 3 stated, he did not perform hand hygiene prior to entering and exiting Resident 7, Resident 9, and Resident 10's room. LVN 3 stated, he should have performed hand hygiene prior to entering and after exiting a resident's room and when providing care in between residents to prevent cross-contamination. During an observation on 5/16/23, at 10:36 a.m., in front of the nurse's station, CNA 2 donned a pair of gloves without performing hand hygiene, entered Resident 7, Resident 9 and Resident 10's room and provided care to the residents in the room. During a concurrent observation and interview on 5/16/23, at 10:45 a.m., with CNA 2, in front of the nurse's station, CNA 2 performed hand hygiene, entered Resident 8's room, donned a pair of gloves and after providing care to Resident 8, CNA 2 removed her gloves and exited Resident 8's room without performing hand hygiene. CNA 2 stated, she should have performed hand hygiene prior to donning and doffing (removing) of gloves and entering and exiting Resident 7, Resident 9, Resident 10's room and Resident 8's room. CNA 2 stated, she should have performed hand hygiene when providing care in between residents to prevent cross contamination. CNA 2 stated, residents could get sick from an infection. During a concurrent interview and record review, on 5/16/23, at 5 p.m., with the Infection Preventionist (IP), the facility's policy and procedure (P&P) titled, Hand Hygiene, dated 9/1/20 was reviewed. The P&P indicated, .The following situations require appropriate hand hygiene: .immediately upon entering and exiting a resident room . The IP stated the expectations was for the licensed nurse and CNA to perform hand hygiene prior to and after providing resident care to residents. The IP stated the importance of hand hygiene was to prevent the spread of infections in the facility. The IP stated, by not following the P&P for Hand Hygiene, licensed nurse and CNA could transmit communicable diseases and cause residents to developed infections. The IP stated, licensed nurse and CNA did not follow the facility P&P on Hand Hygiene and should have. During an interview on 5/16/23, at 5:37 p.m., with the Administrator (ADM), the ADM stated, the expectations was for the direct care staff to perform hand hygiene prior to entering and exiting resident's room, and prior to and after providing care to residents. The ADM stated the importance of hand hygiene was to provide the best environment for residents and to prevent the spread of infections. During a review of the facility's P&P titled, Hand Hygiene, dated 9/1/20, the P&P indicated, .To establish the use of appropriate hand hygiene for all Facility staff, healthcare personnel (HCP), Residents, volunteers and visitors while at the Facility .The Facility considers hand hygiene as the primary means to prevent the spread of infections. Hand hygiene means cleaning your hands by handwashing (washing hands with soap and water), antiseptic hand wash or antiseptic hand run (i.e. alcohol-based hand rub (ABHR) including foam or gel) .Facility staff are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare associated infections (HAI) [infections people get while they are receiving health care for another condition] .Facility staff follow the hand hygiene procedures to help prevent the spread of infections to other staff, Residents, volunteers and visitors . During a professional reference review from the National Institute of Health, the article titled, Hand Hygiene (Article), dated 8/1/22, the Article indicated, .Handwashing practices in the patient care setting began in the early 19th century. The practice evolved over the years with evidential [based on evidence] proof of its vast importance and coupled with other hand-hygienic practices, decreased pathogens [a tiny living thing] responsible for . hospital-acquired infections (HAI). Contaminated [dirty] hands of healthcare providers are a primary source of pathogenic [capable of causing disease] spread. Proper hand hygiene decreases the proliferation [to grow by rapid production] of microorganisms [a living thing that can be seen only through a microscope (an instrument that can be used to observe small objects)], thus reducing infection risk and overall healthcare costs, length of stays, and ultimately, reimbursement. According to the Centers for Disease Control and Prevention (CDC), hand hygiene is the single most important practice in the reduction of the transmission of infection in healthcare settings .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to develop and implement a person-centered care plan for one of one sampled resident (Resident 6) when Resident 6 acquired multiple bruises on his left and right arms from IV (Intravenous -a needle with tube, inserted into a vein to give medications or fluids) line infiltration (when the IV solution leaks into the tissue or skin around the insertion site) and a care plan was not implemented to monitor healing of the bruises. This failure had the potential for Resident 6's IV infiltration and bruising not being monitored for skin infection and bleeding complications. Findings: During a review of Resident 6's admission Record (document containing demographic information and medical diagnoses) undated, the admission Record indicated Resident 6 was admitted to the facility on [DATE]. During a concurrent observation and interview, on 1/31/22, at 10:40 a.m., with Resident 6, in Resident 6's room, Resident 6 was observed with red and purple skin discoloration areas on his right and left arms. Resident 6 stated approximately a week ago a doctor poked his arms to draw his blood. Resident 6 stated the doctor could not find a vein and kept poking him. During a review of Resident 6's Minimum Data Set (MDS- a comprehensive assessment of resident's functional capabilities and helps nursing home staff identify health problems and care needs) dated 1/24/22, the MDS assessment indicated, Resident 6's Brief Interview for Mental Status (BIMS assessment of attention, orientation, and memory) assessment score was 15 out of 15 possible points which indicated Resident 6 was cognitively intact (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment). During a concurrent interview and record review, on 2/2/22, at 11:37 a.m., with Registered Nurse (RN) 1, Resident 6's nursing note dated 1/23/22, at 10:30 p.m. was reviewed. The nursing noted indicated, [on] 1/26/22 Resident IV line found infiltrated during rounds of changing shift . RN 1 stated Resident 6's arms appeared bruised from the IV infiltration. RN 1 reviewed the Situation Background Assessment Recommendations [SBAR]) Summary ., dated 1/23/22, at 10:40 p.m., the SBAR Summary note indicated, Resident found IV line clogged and infiltrated. RNs tried 4 times. But, still unable to locate good veins . RN 1 reviewed the Long Term Care Evaluation (LTCE) Weekly note dated 2/2/22, at 4:27 a.m., RN 1 stated the skin portion of the evaluation did not address Resident 6's IV infiltration and bruises to his right and left arms. RN 1 reviewed Resident 6's care plan and stated a care plan should have been initiated for IV infiltration and bruises. During a concurrent interview and record review, on 2/3/22, at 9:25 a.m., with Licensed Vocational Nurse (LVN) 4, Resident 6's LTCE assessment, dated 2/2/22 at 4:27 a.m. was reviewed. LVN 4 stated she completed the LTCE assessment dated [DATE] at 4:27 a.m. LVN 4 stated she was aware Resident 6 had bruising from the IV infiltration and stated, I did not mention it [infiltration and bruising] in the assessment. LVN 4 stated, My note is not accurate and the note should have mentioned the infiltration and bruising. During an interview on 2/3/22, at 2:20 p.m., with the Director of Nursing (DON), the DON stated Resident 6 was admitted to the skilled nursing facility in June 2019. The DON stated Resident 6 was alert and oriented. The DON stated Resident 6 was on IV fluids and his IV had infiltrated which resulted in the bruising. The DON stated on 2/2/22 she observed Residents 6's arms with the bruising. The DON stated a care plan should have been developed because staff were aware how Resident 6 obtained the bruising and the staff needed to monitor Resident 6's arms for complications and to provide the proper care. During a concurrent interview and record review, on 2/3/22, at 3:46 p.m., with the DON, the facility policy and procedure (P&P) titled, Skin and Wound Management, dated 1/1/12 was reviewed. The DON reviewed the P&P and stated, . Licensed Nurse will complete the Weekly Skin Evaluation for each resident . Treatments of skin problems, wounds and non-pressure ulcers will be assessed and completed by the License Nurse . A Licensed Nurse will report any changes in resident skin condition to the attending physician, Director of Nursing Services (DNS), the interdisciplinary team (IDT)-Skin Committee, and the responsible party . The Licensed Nurse will document the status of all skin conditions at least weekly or as otherwise indicated in the resident's Care Plan . The DON stated a LTCE assessment note dated 2/2/22 at 4:27 a.m. was completed but there was no skin evaluation for 1/26/22 and it should have been completed. The DON stated the LTCE assessment note for 2/2/22 at 4:27 a.m. indicated, .No Skin issues noted. Skin is WNL [Within Normal Limits]. The DON stated the assessment documented in the LTCE note was not an accurate assessment of Resident 6's bruises. The DON stated the licensed nurses should describe the skin condition, cause of the injury and a care plan for the concern should have been initiated. The DON stated this was not done and should have been done. During a review of the facility's P&P titled, Skin and Wound Management dated 1/1/12, the P&P indicated, .Documentation, A. The Licensed Nurse will document the status of all skin conditions at least weekly or as otherwise indicated in the resident's Care Plan .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident 34's Face Sheet (FS-document containing demographic information and medical diagnosis), dated 2/2/22, the FS indicated, Resident 34 was admitted on [DATE] with a history of CVA (cerebral vascular accident [stroke], cerebral palsy (a congenital disorder of movement, muscle tone, or posture), hemiplegia (paralysis of one side of the body), aphasia (loss of ability to understand or express speech), dysphagia (difficulty of swallowing), G-tube (gastrostomy tube [tube inserted into the stomach to provide nutrients]), and muscle weakness. During a review of Resident 34's Diet Order, (DO) dated 7/7/21, the DO indicated, (brand name) a nutritional supplement used to add calories and protein twice a day was ordered from 7/7/21 through 12/21/21. During an interview on 2/1/22, at 10:15 a.m., with Resident 34, Resident 34 stated, I weighed 171 pounds on admission. Now I weigh 134 pounds [37-pound weight loss]. Resident 34 stated he was losing weight because he did not like the food he was served in the facility. Resident 34 stated, The puree bread is too doughy. Resident 34 stated he received tube feeding supplements via his G-tube after meals. During a review of Resident 34's Weight and Vitals Summary (WVS), dated 2/3/22, the WVS indicated, Resident 34 had severe weight loss (greater than 10% weight loss in a six-month period) since admission. On 5/6/21, Resident 34 weighed 149.4 lbs (pounds). On 11/1/21, Resident 34 weighed 131.9 pounds which is a 11.71 % loss. On 2/2/21, Resident 34 weighed 162.8 lbs. On 8/2/21, Resident 34 weighed 134.6 pounds which is a 17.32 % weight loss. During a review of Resident 34's Nutrition/Dietary Note (NDN), dated 7/7/21, the NDN indicated, the Registered Dietitian 2 (RD 2) documented Resident 34 had significant weight change 6.60%, -8.6 pounds times five weeks related to inadequate oral intake as evidenced by oral intake 0-25% of most meals. RD 2 documented to add the nutritional intervention of nutritional supplement [brand name] twice a day starting 7/7/21. Nutritional supplement was to be served at breakfast and dinner and to monitor and evaluate weights, oral intake, and acceptance of nutritional supplement twice a day. During a concurrent interview and record review, on 2/3/22, at 1:19 p.m., with the Registered Dietician Director of Operations (RDDO), Resident 34's Nutrition/Dietary Notes (NDN), were reviewed. The RDDO indicated on the NDN, dated 6/11/21, Some weight loss was anticipated as we attempted to wean dependence from TF (tube feeding). Diet: Puree and nutritional supplement [brand name] BID [twice a day] with breakfast and dinner. The RDDO stated the nutritional supplement was added as an oral supplement on 8/18/21, 9/15/21, and 12/21/21 Nutritional/Dietary Notes. During a concurrent interview and record review, on 2/3/22, at 2:39 p.m., with the Director of Nursing (DON), Resident 34's Medication Administration Records (MAR), dated September 2021 and October 2021 was reviewed. The DON stated the nutritional supplement order was not documented on the MAR and was not administered for September 2021 and October 2021. During a review of the facility's policy and procedures (P&P) titled, Physician Orders, dated 8/21/20, the P&P indicated, .IX. Medication and treatment orders will be transcribed onto the appropriate resident administration record (e.g., medication administration record (MAR) or treatment administration (TAR) . XII. Documentation pertaining to the physician orders will be maintained in the Resident's medical record. Based on observation, interview and record review, the facility failed to provide services which meet professional standards of quality for two of five sampled residents (Residents 34, and 47) when: 1. Resident 47 was administered oxygen (medical gas) at 4 liters (L- unit of measurement) per minute by way of nasal cannula (tubing used to deliver oxygen) instead of oxygen at 2L in accordance with the Physician's order for shortness of breath. This failure resulted in Resident 47 receiving a higher dose of oxygen than ordered from the physician and had the potential for compromised lung function due to high doses of oxygen. 2. Resident 34 was not administered his nutritional supplement (supplement containing vitamins, minerals, and extra calories) for the month of September 2021 and October 2021 according to the physician's order. This failure resulted in Resident 34 not receiving his nutritional supplement and had the potential to contribute to Resident 34's ongoing weight loss. Findings: 1. During a concurrent observation and interview, on 1/3/22 at 11:52 a.m., with License vocational nurse (LVN) 3, in Resident 47's room, Resident 47 was in bed with her eyes closed, and connected to an oxygen concentrator (a medical device used for delivering oxygen to individuals with breathing-related disorders). Resident 47 oxygen concentrator was set to deliver oxygen at 4 L per minute (pm) by way of nasal cannula (oxygen tubing). LVN 3 stated Resident 47's oxygen levels should have been set to deliver oxygen at 2 Lpm. LVN 3 stated she did not check the settings of the oxygen concentrator at the start of her shift (work schedule) and had not checked Resident 47 was receiving double the dose of oxygen that he was prescribed. LVN 3 stated she should have checked the oxygen concentrator setting to make sure Resident 47 was received the correct oxygen dose. LVN 3 stated too much oxygen would cause oxygen poisoning. During a concurrent interview and record review, on 1/3/22, at 11:55 a.m., with LVN 3, Resident 47's Physician Orders, dated 1/11/22 were reviewed. The Physician Orders indicated, .Oxygen at 2 LPM [liters per minute] via [by way] Nasal Cannula to keep oxygen saturation (the amount of oxygen traveling through the body in your blood) at or above 92% as needed for shortness of breath . LVN 3 stated she should have followed the physician's order. During a concurrent interview and record review, on 2/2/22, at 11:35 a.m., with the Director of Nursing (DON), Resident 47's Physician Orders, dated 1/11/22 and the facility's policy and procedure (P&P) titled, Oxygen Therapy, dated 11/2017 was reviewed. The Physician Orders indicated, Oxygen at 2 LPM via Nasal Cannula to keep oxygen saturation at or above 92% as needed for shortness of breath. The P&P indicated, To ensure the safe storage and administration of oxygen in the facility. Oxygen is administered under safe and sanitary conditions to meet resident needs. License Nursing staff will administer oxygen as prescribed . Administer oxygen per physician orders . The DON stated LVN 3 should have followed Physician's order for Resident 47's oxygen administration. During a review of Resident 47's admission Record dated 1/11/22, the admission Record (document containing resident demographic information and medical diagnosis) indicated Resident 47 was admitted to the facility with a diagnosis of Acute and Chronic Respiratory Failure with Hypoxia (a condition in which blood does not have enough oxygen). During a review of the professional reference retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2688103/ titled, Bench to bedside review: Oxygen as a drug dated 2/24/2009, indicated, .Oxygen is one of the most widely used therapeutic agents. It is a drug in the true sense of the word, with specific biochemical and physiologic actions, a distinct range of effective doses, and a well-defined adverse effect at high doses . During a review of the professional reference retrieved from https://myhealth.ucsd.edu/RelatedItems/3,90904, titled, Understanding Oxygen Toxicity dated 1/2020, indicated, Oxygen toxicity is lung damage that happens from breathing in too much extra (supplemental) oxygen. It's also called oxygen poisoning. It can cause coughing and trouble breathing. In severe cases it can even cause death. When you breathe, oxygen from the air enters your lungs and goes into your blood. The oxygen then goes to all parts of the body through the blood. It keeps organs and tissues working normally. But too high a level of oxygen can harm lung tissues. The tiny air sacs (alveoli) in the lung may fill with fluid. Or they may no longer inflate (collapsed lung). The lungs then can't take in air normally. This can make it harder for the lungs to send oxygen into the blood .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to perform a comprehensive resident assessment and ensure treatment was initiated in accordance with professional standards of practice for one of one sampled resident (Resident 6) when Resident 6's skin was not accurately assessed to develop an individualized treatment and monitoring plan to monitor multiple bruising on Resident 6's left and right arms. This failure had the potential to result in Resident 6 not receiving treatment and monitoring to the multiple bruises on Resident 6's left and right arms which placed Resident 6 at risk for undetected bleeding and skin infection. Findings: During a review of Resident 6's admission Record (document containing demographic information and medical diagnosis), undated, the admission Record indicated, Resident 6 was admitted to the skilled nursing facility on [DATE]. During a concurrent observation and interview, on 1/31/22, at 10:40 a.m., with Resident 6, in Resident 6's room, Resident 6 was observed with red and purple areas to his right and left arms. Resident 6 stated about a week ago a doctor poked his arms to draw his blood. Resident 6 stated the doctor could not find a vein. During a review of Resident 6's Minimum Data Set (MDS- assessment used to identify resident care needs) assessment, dated 1/24/22, the MDS assessment indicated, Resident 6 was cognitively intact with a Brief Interview for Mental Status (BIMS- an evaluation of attention, orientation and memory recall) score of 15 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment). During a concurrent interview and record review, on 2/2/22, at 11:37 a.m., with Registered Nurse (RN) 1, Resident 6's Alert note, dated 1/23/22 at 10:30 p.m. was reviewed. The Alert note indicated, .Resident IV [Intravenous (IV- giving medications or fluids through a needle and tube inserted into a vein] line found infiltrated (when the IV solution leaks into the tissue or skin around the insertion site) during rounds of changing shift . RN 1 stated Resident 6's arms appeared bruised from an old intravenous. RN 1 reviewed the .[Situation Background Assessment Recommendations (SBAR)] Summary ., dated 1/23/22, at 10:40 p.m., the noted indicated, Resident found IV line clogged and infiltrated. RNs tried 4 times. But, still unable to locate good veins . RN 1 reviewed the Long Term Care Evaluation (LTCE) (Weekly note) dated 2/2/22 at 4:27 a.m., RN 1 stated the skin portion of the evaluation did not address Resident 6's bruises to his right and left arms. RN 1 reviewed Resident 6's care plan and stated she initiated Resident 6's care plan on 2/2/22 and added the new focus, The resident has potential/actual impairment to skin integrity RN 1 stated a care plan should have been initiated for this concern. During concurrent interview and record review, on 2/3/22, at 9:25 a.m., with Licensed Vocational Nurse (LVN) 4, Resident 6's LTCE, dated 2/2/22 at 4:27 a.m. was reviewed. LVN 4 stated she completed the assessment for LTCE, dated 2/2/22 at 4:27 a.m. LVN 4 stated she was aware Resident 6 had bruising from the IV and stated, I did not mention it in the assessment. LVN 4 stated, My note is not accurate and the note should have mentioned the old bruising. During an interview on 2/3/22, at 2:20 p.m., with the Director of Nursing (DON), the DON stated Resident 6 was admitted in June 2019. The DON stated Resident 6 was alert and oriented. The DON stated Resident 6 was on IV fluids and his IV was infiltrated and the physician was called. The DON stated on 2/2/22 she observed Residents 6's arms and the bruising was fading. The DON stated a care plan should have been developed because staff were aware how Resident 6 obtained the bruising and the staff needed to monitor Resident 6's and provide the proper care. During a concurrent interview and record review, on 2/3/22, at 3:46 p.m., with the DON, the facility's policy and procedure (P&P) titled, Skin and Wound Management, dated 1/1/22, was reviewed. The DON reviewed the P&P and stated, . Licensed Nurse will complete the Weekly Skin Evaluation for each resident . Treatments of skin problems, wounds and non-pressure ulcers will be assessed and completed by the License Nurse . A Licensed Nurse will report any changes in resident skin condition to the attending physician, Director of Nursing Services (DNS), the interdisciplinary team (IDT)-Skin Committee, and the responsible party . The Licensed Nurse will document the status of all skin conditions at least weekly or as otherwise indicated in the resident's Care Plan . The DON stated a LTCE note for 2/2/22 at 4:27 a.m. was completed but there was no LTCE weekly skin evaluation for 1/26/22 and should have been completed. The DON stated the LTCE note for 2/2/22 at 4:27 a.m. indicated, .No Skin issues noted. Skin is WNL . The DON stated what was documented in the LTCE note was not an accurate assessment of Resident 6's bruises. The DON stated the licensed nurses should describe the skin condition and a care plan should have been initiated. The DON stated Resident 6's skin should have been monitored but was not. During a review of the facility's P&P titled, Skin and Wound Management dated 1/1/22, the P&P indicated, .Procedure, II. Skin and Wound Management . A. A Licensed Nurse will complete the Weekly Skin Evaluation for each resident .C. Treatments of skin problems, wounds and non-pressure ulcers will be assessed and completed by the License Nurse . D. A Licensed Nurse will report any changes in resident skin condition to the attending physician, Director of Nursing Services (DNS), the interdisciplinary team (IDT)-Skin Committee, and the responsible party .III. Documentation, A. The Licensed Nurse will document the status of all skin conditions at least weekly or as otherwise indicated in the resident's Care Plan . Skin and Wound Management dated 1/1/12, was reviewed. The DON reviewed the P&P and stated, . Licensed Nurse will complete the Weekly Skin Evaluation for each resident . Treatments of skin problems, wounds and non-pressure ulcers will be assessed and completed by the License Nurse . A Licensed Nurse will report any changes in resident skin condition to the attending physician, Director of Nursing Services (DNS), the interdisciplinary team (IDT)-Skin Committee, and the responsible party . The Licensed Nurse will document the status of all skin conditions at least weekly or as otherwise indicated in the resident's Care Plan .

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 48) received food prepared in a form that meets individual swallowing needs during the lunch meal service on 2/2/22. This failure had the potential to place Resident 48 at increased choking risk and decreased nutritional intake. Findings: During a concurrent observation and record review on 1/31/22, at 12:05 p.m., in the kitchen, during the lunch meal service, the kitchen serving steam table had puree salad, puree chili, and puree cornbread. Resident 48's lunch meal ticket was reviewed. The lunch meal ticket indicated, Liquid Puree. Resident 48's plate had three scoops of puree food. Resident 48 was not served a liquid puree diet. During a concurrent interview and record review, on 1/31/22, at 12:25 p.m. with the Registered Dietitian (RD) 1 in presence of the Registered Dietician Director of Operations (RDDO), the RDDO stated he was not sure what was the liquified puree diet. RD 1 stated the liquified puree diet was a diet that consisted of food items puree to a drinkable consistency that was served in mugs. He stated the facility had a recipe for liquified puree diet to ensure the diet was the appropriate consistency and nutritional value equivalent. RD 1 confirmed that Resident 48 was supposed to receive a liquified puree diet that should have been served in drinkable mugs. During a review of Resident 48's Diet Order, dated 1/28/22, the Diet Order indicated, Resident 48 was on a fortified (enriched with butter or milk to add nutrients to food) puree (blended) liquid diet in mugs with thin liquids. Resident 48 had a history of muscle weakness and dysphagia (difficulty to swallow). During a record review of the facility's recipe titled, Liquefied Pureed Diet, dated 2020, the recipe description indicated, The liquefied pureed diet is designed for residents who have difficulty eating solid food from a spoon or fork, whether assisted by staff or self-initiated. The diet would be considered for those who have more success consuming foods in liquid form from a mug, cup, or glass. The texture of all foods served will be smooth, free of lumps and liquefied adequately to flow freely from a mug. The regular servings for a pureed diet are to be served and then thinned to a drinkable consistency using appropriate fluids. This is done to ensure proper nutrition . During a review of Resident 48's Diet Order, dated 1/28/22, the Diet Order indicated, Resident 48 was on a fortified (enrichment such as butter or milk used to add nutrients to food) puree (blended) liquid diet in mugs with thin liquids. Resident 48 had a history of muscle weakness and dysphagia (difficulty to swallow). During a record review of the facility's recipe titled, Liquefied Pureed Diet, dated 2020, the recipe description indicated, The liquefied pureed diet is designed for residents who have difficulty eating solid food from a spoon or fork, whether assisted by staff or self-initiated. The diet would be considered for those who have more success consuming foods in liquid form from a mug, cup, or glass. The texture of all foods served will be smooth, free of lumps and liquefied adequately to flow freely from a mug. The regular servings for a pureed diet are to be served and then thinned to a drinkable consistency using appropriate fluids. This is done to ensure proper nutrition .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure resident medical records were complete and contained accurately assessment documentation in accordance with professional standards of practice for one of one sampled resident (Resident 6) when Licensed Vocational Nurse (LVN) 4 did not document Resident 6 bruising on his left and right arms from the intravenously (IV -is a pliable tubing with a needle used to administer hydration fluids, medication, blood, or nutrients in the vein) insertions. This failure resulted in an inaccurate and incomplete clinical record for Resident 6 and resulted in Resident 6's bruising to go without monitoring or treatment. Findings: During a concurrent interview and record review, on 2/3/22, at 9:25 a.m., with Licensed Vocational Nurse (LVN) 4, Resident 6's Long Term Care Evaluation (LTCE), assessment dated [DATE] at 4:27 a.m. was reviewed. LVN 4 stated she completed the LTCE assessment dated [DATE] at 4:27 a.m. LVN 4 stated she was aware Resident 6 had bruising from the multiple IV insertions on his left and right arms. LVN 4 stated, I did not mention it in the assessment note. LVN 4 stated, My note is not accurate, and the note should have accurate assessment documentation of the bruising. During a concurrent interview and record review on 2/3/22, at 2:20 p.m., with the Director of Nursing (DON), Resident 6's LTCE assessment form, dated 2/2/22 at 4:27 a.m. was reviewed. The DON stated the LTCE assessment form indicated, No Skin issues noted. Skin is WNL [Within Normal Limits]. The DON stated the assessment documentation written was not an accurate assessment of Resident 6's skin condition and inaccurately documented Resident 6 did not have bruising when he had multiple bruises of his left and right arms. The DON stated LVN 4 should have accurately assessed and accurately documented Resident 6's skin condition in the clinical record. During a professional reference review, retrieved from Lippincott Manual of Nursing Practice 10th edition dated 2013, page16 and 17 indicated, .Departure from Standards of Care . licensed nurses need to make prompt, accurate [assessment] entries in a patient's medical record.

Based on observation, interview and record review the facility failed to maintain a safe environment when one of three Housekeeping (HK) carts, HK cart 3 was left in the hallway unattended and cleaning product [brand name] was accessible to residents. This practice failed to ensure environment was maintained safe for Residents. Findings: During an observation on 1/31/22, at 11:20 a.m., in the hallway, HK cart was unattended and unlocked with cleaning products [brand name] accessible to residents. During a concurrent observation and interview on 1/31/22, at 11:33 a.m., with HK 3, in the hallway, HK cart was unlocked with cleaning products. HK 1 stated, HK cart should not be left unattended and cleaning products should be locked inside the HK cart for the safety of residents that could have access and use products beyond their intended use. During a concurrent interview and record review on 2/3/22, at 2:00 p.m., with the Director of Nursing (DON), the facility's P&P titled, Housekeeping - Supplies and Equipment, dated 1/1/12, was reviewed. The DON stated facility staff should not leave HK cart unattended and cleaning products should not be accessible to Residents. The DON stated HK staff should have kept or returned HK cart at the storage space when not in use and should not have been left unattended in the hallway. The DON stated cleaning products should not be accessible to residents and should be locked inside the HK cart. The DON stated the facility's P&P titled Housekeeping - Supplies and Equipment should be followed for resident safety. During a review of the facility's policy and procedure (P&P) titled, Housekeeping - Supplies and Equipment dated 1/1/12, the P&P indicated, Purpose . To ensure that housekeeping supplies and equipment necessary to maintain the Facility are readily available . Equipment is kept in good working order at all times, available day and night to meet the residents' needs . Housekeeping supplies and equipment are stored in the Housekeeping Supply Room . Housekeeping Staff are responsible for: .Returning the equipment to its proper storage place after using it and cleaning it . Checking supply carts each day before beginning work to make sure it has the correct type and amount of supplies . Return the cart to its proper storage place .

Based on interview and record review, the facility failed to ensure nursing staff possessed appropriate competencies and skills sets to provide nursing and related services to assure resident safety for one of one Director of Staff Development (DSD) when the DSD did not have a process in place to verify the mandatory staff dementia (the loss of cognitive function)competency trainings and in-services of Registry staff (contracted staff). This failure had the potential to place resident who suffer from dementia care at risk when placed under the care of a registry staff who did not complete the required dementia competency training and in-services mandated by State and Federal regulations. Findings: During an interview on 2/3/22, at 10:07 a.m., with the DSD, the DSD stated she had been employed at the facility as the DSD coordinator for three years and had DSD experience since 2006. The DSD stated annual mandatory Abuse and Dementia (the loss of cognitive function) competency trainings were required for all nursing staff upon hire and annually. The DSD stated the facility began to utilize Registry staff in 2021, during the staffing shortage. The DSD stated Registry staff were not required to complete the mandatory dementia competency training at the facility. The DSD stated the facility had a staffing contract with the registry to provide staff when the facility had staffing shortages. The DSD stated she did not know if Registry staff had completed mandatory dementia competency staff training with their perspective Registry's. When the DSD was asked to provide a sample of the Registry staff's training and in-services from the registry staff personnel file. The DSD stated she did not have registry staff files and would have to call the Agency's Director for information. During an interview on 2/3/22, at 4:57 p.m., with the Director of Staff Development Consultant (DSDC), the DSDC stated all staff including Registry staff was expected to follow the facility's policy and procedures on State and Federal mandatory competency training requirements. The DSDC stated the facility did not have a system to ensure registry staff had the required competency training. The DSDC stated the facility failed to follow up with the registry agency to ensure registry staff had all the mandatory dementia competency training that was required. The DSDC stated it was the DSD's responsibility to verify with the registry agency that Registry staff completed the required competency training and in-services prior to the employment start date and that did not occur. During a concurrent interview and record review on 2/3/22, at 5:36 p.m., with the DSD, the facility's job description titled, Director of Staff Development was reviewed. The DSD's job description indicated, The DSD is responsible for planning, implementation, direction, and evaluation of the facility's educational programs for all employees and quality assurance and improvement in the facility . General duties and responsibilities: Orientation . Provide all documents supporting orientation to the facility's policy and procedures for maintenance in the individual employees file folders . Administrative: Maintains all in-service records on all employees in current, neat, and orderly fashion . The DSD stated the expectation of the facility DSD was to follow the DSD facility's job description. The DSD stated she should have created an employee file that contained registry staff completed required competency trainings and in-services prior to employment start date and kept a record of the trainings and in-services in the Registry staff's personnel file.

Based on observation, interview, and record review, the facility failed to ensure the kitchen sanitation water bucket used to sanitize food preparation and distribution surface kitchen areas contained manufacturer's recommended concentration levels of quaternary ammonium (a group of chemicals used for killing bacteria, fungi, and viruses) for sanitization (to reduce the number of disease-causing pathogens). This failure had the potential to spread foodborne illness (disease or period of sickness caused by food contamination) to residents that were served meals from the kitchen. Findings: During a concurrent observation and interview, in the facility's kitchen on 2/1/22, at 10:35 a.m., [NAME] 2 was observed wiping the kitchen counter with a rag from a red water bucket. [NAME] 2 stated the red bucket contained sanitizer used to minimize cross contamination. [NAME] 2 stated he did not know the name of the liquid sanitizer she used but demonstrated the test strip used to test the level of the sanitizer in the red water bucket. [NAME] 2 dipped the test strip into the water in the red bucket and stated sanitizer level I the water measured 200 ppm (parts per million) when compared to the levels on the bottle manufacture recommended level. [NAME] 2 stated he left the test strip in for 10 seconds and counted by saying 1 pause, 2 pause etc. [NAME] 2 stated he left the test strip in for longer than 10 seconds. [NAME] 2 was asked to recheck the level again counting to 10 using 1 one thousand 2 one thousand etc. The test strip was compared to the levels on the sanitizer manufacture recommended level and [NAME] 2 stated the level was 150 ppm. [NAME] 2 stated the sanitizer level was not okay. The Dietary Supervisor (DS) confirmed the sanitizer level was at or below 150 ppm and that it was not high enough to ensure sanitation of surface areas and the water needed to be changed. During a concurrent observation, interview, and record review in the facility's kitchen on 2/1/22, at 3:03 p.m., the (brand name) sanitizer poster on the kitchen wall was reviewed with the (DS). The DS stated the (brand name) sanitizer needed to be above 200 ppm in order to be effective. During an interview with the Registered Dietician (RD) 1 on 2/2/22, at 2:40 p.m., RD 1 stated he expected the sanitizing water buckets to be at 200 ppm per manufacturer's sanitizer guidelines. RD 1 stated water buckets of sanitizer should not be used if it did not contain the standard level of sanitization. RD 1 stated the facility did not have a policy and procedure for red water bucket sanitizer guidelines but provided the policy and procedure for cleaning pots and pans with quaternary ammonium. During a review of the facility's policy and procedure (P&P) titled, Pot and Pan Cleaning, dated 10/1/14, the P&P indicated, .ii. Record the PPM on Form A - pot and pan sanitizer log. 200 ppm is the required minimum for quaternary sanitizer. During a review of the professional reference retrieved from https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/cfrsearch.cfm?fr=178.1010, titled, FDA U.S. Food and Drug Administration . Subpart B - Substances Utilized To Control the Growth of Microorganisms, dated 1/6/22 indicated, Solutions identified in paragraph (b)(10) of this section shall provide not more than sufficient trichloro melamine [sanitizer chemical] to produce 200 parts per million of available chlorine and either sodium lauryl sulfate [sanitizer chemical] at a level not in excess of the minimum required to produce its intended functional effect or not more than 400 parts per million of dodecyl benzenesulfonic acid [sanitizer chemical].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a safe environment with an effective infection prevention and control program to prevent the development and transmission of communicable (spreads from one person to another) disease and infections when: 1. One of two direct care staff Certified Nurse Assistant (CNA) 3 did not perform hand hygiene (techniques to clean the hands, including handwashing with plain and antimicrobial soaps and/or the use of alcohol-based hand rubs) after touching mask and before putting on Personal Protective Equipment (PPE). 2. One of two direct care staff Licensed Vocational Nurse (LVN) 1 in the yellow zone (residents exposed to virus were observed) did not ensure N95 (respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne [transported by air] particles) mask appropriately fit her face. 3. Clean items were not stored in space free from cross contamination. 4. The call light for Resident 478 was picked up off the floor and given to Resident 478 before it was sanitized. 5. Two of four sampled oxygen concentrators (for Resident 475 and 480) outer covering and filter were found with lint and dust. This failure had the potential to expose Resident 475 and 480 and staff to contaminants and contribute to the increased risk of developing respiratory infections (infections that happen in the lungs, chest, sinuses, nose, and throat). Findings: 1. During a concurrent observation and interview on 1/31/22, at 11:14 a.m., with the Infection Preventionist (IP) in the hallway, CNA 3 was observed touching the front of her mask, CNA 3 did not perform hand hygiene and donned (to put on) PPE. CNA 3 entered resident's room and provided care to Resident 475. The IP stated CNA 3 should have performed hand hygiene after she touched the front of her mask and before donning PPE to prevent the spread of infection. During a concurrent interview and record review on 2/3/22, at 1:45 p.m., with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Hand Hygiene was reviewed. The DON stated facility staff should have performed hand hygiene after touching the front of mask and before donning of PPE. The DON stated the facility's P&P titled Hand Hygiene should be followed to prevent infection and the spread of germs and diseases. During a review of the facility's policy and procedure (P&P) titled, Hand Hygiene, dated 9/1/20, the P&P indicated, . Purpose . To establish the use of appropriate hand hygiene for all Facility staff, healthcare personnel (HCP), Residents, volunteers, and visitors while at the Facility . Policy . The Facility considers hand hygiene as the primary means to prevent the spread of infections. Hand hygiene means cleaning your hands by handwashing (washing hands with soap and water), antiseptic hand wash or antiseptic hand rub (i.e. alcohol-based hand rub (ABHR) including foam or gel) . Procedure . Facility staff follow the hand hygiene procedures to help prevent the spread of infections to other staff, Residents, volunteers and visitors . Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub with 60-95% alcohol) . D. Facility staff, healthcare personnel (HCP), Residents, visitors, and volunteers must perform hand hygiene to prevent the transmission of Hospital Acquired Infections (HAI's) . E. The following situations require appropriate hand hygiene . Before donning . of Personal Protective Equipment (PPE) . 2. During a concurrent observation and interview on 1/31/22, at 10:39 a.m., with the IP, in the hallway of yellow zone, LVN 1 was observed talking to physician with her nose not covered with N95 mask. The IP stated, in the yellow zone everyone should wear N95 mask appropriately. The IP validated LVN 1 was not wearing her N95 mask appropriately to ensure employee was protected. The IP stated LVN 1 should wear her N95 mask appropriately to prevent infection. During a concurrent interview and record review on 2/3/22, at 2:05 p.m., with the DON, the facility's P&P titled, Personal Protective Equipment dated 1/1/12 and Respiratory Protection Program dated 9/9/21 was reviewed. The DON stated, Facility staff should wear N95 mask covering the nose and mouth and ensure an adequate fit of N95 mask to prevent spread of infection. The DON stated facility's P&P should be followed. During a review of the facility's policy and procedure (P&P) titled, Personal Protective Equipment dated 1/1/12, the P&P indicated, Purpose . To ensure the availability of personal protective equipment as required . Policy . Personal protective equipment appropriate to specific task requirements is available at all times . Procedure . Facility Staff required to perform tasks that may involve exposure to blood/body fluids are provided appropriate protective clothing and equipment . The type of protective clothing and equipment to be used is based on . The likelihood of exposure . The probable route of exposure; and the overall working conditions and task requirements . Masks . Face masks are only be handled by the strings when being removed . Face masks are changed when they become moist or soiled . Facility Staff who fail to use personal protective equipment when indicated will be disciplined . During a review of the facility's policy and procedure (P&P) titled, Respiratory Protection Program dated 9/9/21, the P&P indicated, Purpose . To reduce employee exposure to infectious agents in the workplace through the proper use of respirators during an during an influenza or other respiratory disease emergency or pandemic . Policy . The Facility will provide its employees with a safe work environment. Respiratory protection is provided at no cost to the employees. The implementation of this respiratory protection program is provided as a means of giving the highest levels of protection to employees during an influenza or other respiratory disease emergency or pandemic, as defined by Cal/OSHA (California Division of Occupational Safety and Health - provides free safety and health assistance to employers, with the goal of preventing occupational injuries and illnesses) . The [Respiratory protection Program Administrator] RPPA with the IP are responsible for administering the program. Duties of the RPPA and IP include the following: . Identify work areas, processes or tasks that require respiratory protection. This means identifying patient care practices and other circumstances likely to present a transmission risk during an infectious respiratory disease emergency or respiratory pandemic . Monitor respirator use to confirm that respirators are used in accordance with their certification . Training will cover the following . Proper and improper fit and usage, limitations and capabilities for maintenance, cleaning and storage . Inspecting, donning and doffing, user seal checks and troubleshooting . Respirator Fit Testing . Fit tests are conducted to determine that the respirator fits the user adequately and that a good seal can be obtained. Respirators that do not seal do not offer adequate protection . 3. During a concurrent observation and interview on 1/31/22, at 11:10 a.m., with the IP, in yellow zone at room [ROOM NUMBER], clean diapers were observed opened and exposed at the counter near the sink. The IP validated room [ROOM NUMBER] was shared by two residents. The IP stated, clean diapers should be kept in residents' cabinet to prevent cross contamination. During a concurrent interview and record review on 2/3/22, at 1:50 p.m., with the DON, the facility's P&P titled, Infection Control - Policies & Procedures dated 1/1/12 was reviewed. The DON stated, Facility staff should not place clean items such as opened diapers at the counter near the sink. The DON stated clean items should be stored in a sanitary and clean environment. The DON stated the counter near the sink was not considered a clean area. The DON stated the facility's P&P titled Infection Control - Policies & Procedures should be followed to prevent infection and the spread of germs (microorganism, especially one which causes disease) and infection. During a review of the facility's policy and procedure (P&P) titled, Infection Control - Policies & Procedures dated 1/1/12, the P&P indicated, Purpose . To provide infection control policies and procedures required for a safe and sanitary environment . Policy . The Facility's infection control policies and procedures are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections . Procedure . The Facility's infection control policies and procedures are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections Objectives . Maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors . Provide guidelines for the safe cleaning and reprocessing of reusable resident care equipment . 4. During a concurrent observation and interview on 2/1/22, at 9:20 a.m., in Resident 478's room, Resident 478 was lying in bed and the call light was on the floor. CNA 4 picked up the call light and set it on top of Resident 478's lap. CNA 4 stated he should have wiped it off with a sanitizer wipe before he gave it to Resident 478. CNA 4 stated there was nothing in the room to disinfect (clean and to destroy bacteria) the call light. During an interview on 2/2/22, at 3:44 p.m. with the IP, the IP stated the staff should not pick up a call light on the floor and give it to Resident 478 without cleaning it. The IP stated, The problem is infection control. The IP stated they needed to clean it up with a sanitizer cloth right away. The IP stated, It could cause contamination and Residents [Resident 478] could get an infection. During an interview on 2/3/22, 3:18 p.m., with the DON, the DON stated, [The call light] should be cleaned first before handing it to a Resident. They should wipe it with the sanitizer before giving it to Residents [Resident 478]. During a review of the facility's Policy and Procedure (P&P) titled, Cleaning and Disinfection of Resident-Care Items and Equipment, dated 1/2022 the P&P indicated, The P&P indicated, . Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC [Centers for Disease Control and Prevention] recommendations for disinfection and the OSHA (Occupational Safety and Health Administration, a government agency in-charge of monitoring the working conditions of workers enforcing standards, providing training, outreach, education and assistance) .non-critical items are those that come in contact with intact skin but not mucous membranes .some items that can come in contact with non-intact skin for a brief period of time are usually considered non-critical surfaces as well and are disinfected with intermediate-level disinfectants .ethyl or isopropyl alcohol . During a review of professional reference retrieved from https://professionals.wrha.mb.ca/old/extranet/ipc/files/manuals/acutecare/Pull_Cords_and_Call_Bells.pdf titled, INFECTION PREVENTION & CONTROL COMMUNICATION FORM PULL CORDS AND CALL BELLS, , dated 7/2017, the professional reference indicated, .Call bells have been linked to transmission of microorganisms and outbreaks. Pull cords are not regularly changed between patients and can become easily contaminated .Microorganisms and contaminated material migrate under the button and contaminate the inside of push button call bells. Call bells have been directly implicated in hospital outbreaks. An investigation into one hospital outbreak found evidence of heavily contaminated fecal material inside of a disassembled call bell. String cords cannot be physically cleaned between patients and may harbor organisms. Improper cleaning of the physical environment has been related to transmission of many types of pathogenic organisms, e.g. C. difficile . [a germ that causes severe diarrhea and colitis -an inflammation of the colon]. 5. During an observation on 1/31/22, at 10:30 a.m., in Resident 475's room, Resident 475 was resting in bed, and had a nasal cannula connected to an oxygen concentrator. The oxygen concentrator did not have an air filter on the back of the machine. The area approximately four inches wide by eight inches in length was observed as a grid for a filter and was covered with white fuzzy substance. During a concurrent observation and interview on 2/1/22, at 11:20 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 entered Resident 475's room to exchange the oxygen concentrator machine that had a light flashing on it. LVN 1 stated the machine needed to be serviced. LVN 1 stated it was normal to get dust from the air and wiped off the grid with a wet paper towel. During a concurrent observation and interview on 2/1/22, at 11:33 a.m., with the Maintenance Supervisor (MS) in the oxygen storage room, the MS stated the oxygen concentrator that had been in Resident 475's room was replaced due to a malfunction, and it was missing the exterior filter at the back of the machine. The MS stated, When it was cleaned, [the filter] wasn't put back .whoever set it [in the oxygen storage room] should have verified that it [filter] was there. The MS stated he could not find replacement filters in the storage room. The MS stated the exterior filter was another barrier for contaminants and would affect the life of the internal filter. The MS stated, I don't have a date on the cassette bacteria filter inside and it's missing the exterior filter. During a concurrent observation and interview on 2/1/22, at 12:00 p.m., with the MS, the MS lifted the filter off the oxygen machine that had been used by Resident 480. The filter showed scattered clumps of white substance. The MS stated the filter did not look like it had been cleaned recently. During an interview on 2/3/22, at 3:14 p.m., with the DON, the DON stated she had no knowledge of the maintenance for oxygen concentrators. The DON stated, I am not well versed on the schedule for cleaning the filters. My expectation is to follow their policy. I don't know what it is. The DON stated she did not know how this practice would affect the health of the Residents. During an interview on 2/3/22, at 3:34 p.m., with LVN 1, LVN 1 stated it was the responsibility of the nurse to check the concentrator and clean the filter weekly. During an interview on 2/3/22, at 4:24 p.m., with the Administrator (ADM), the ADM stated, They [Nurses and maintenance] should have followed the policy who would clean [the oxygen concentrator and filter] and follow up. That's how we make sure things are being completed and the Residents are safe. During an interview on 2/3/22, at 4:49 p.m., with the MS, the MS stated there was no tracking of the oxygen concentrators being used. The MS stated his audit system did not track what was checked on each concentrator and when they were checked. During a review of Resident 480's PO, dated 1/25/22, the PO indicated, a physician's order, OXYGEN AT 2LPM [liters per minute] VIA NASAL CANNULA TO KEEP OXYGEN AT OR ABOVE 92 AS NEEDED FOR SOB [shortness of breath]. During a review of Resident 475's Physician Orders [PO] dated 1/26/22, the PO indicated, a physician's order, OXYGEN AT 2 LPM [liters per minute, unit of measurement] VIA NASAL CANULA TO KEEP O2 [oxygen] SAT [saturation of oxygen in the blood] AT OR ABOVE 90% PRN [as needed] FOR SHORTNESS OF BREATH DX [diagnosis] CHF [congestive heart failure- the heart is unable to provide sufficient pump action to circulate blood]. During a review of the facility policy and procedure (P&P) titled, Oxygen Therapy dated 11/2017, the P&P indicated, .Oxygen is administered under safe and sanitary conditions to meet resident needs. Licensed Nursing staff will administer oxygen as prescribed .If oxygen concentrators are used, the filters will be cleaned per manufacturer's guidelines .There will be a log maintained to identify each time the filters are changed . During a review of the Manufacturer's Instructions for Use (IFU) titled, Caring for Your [Company Name] Oxygen Concentrator, (undated), the document indicated, The air filter and connector should be cleaned at least once a week. To clean, follow these steps: Remove the air filter, located on the back of the unit .Wash in a solution of warm water and dishwashing detergent .Rinse thoroughly with warm tap water and towel dry. The filter should be completely dry before reinstalling.