**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of 17 sampled residents (Resident 25) received good grooming and personal hygiene care when resident did not receive complete fingernail care. This failure resulted in Resident 25 to feel helpless and placed him at risk for developing infections and hurting himself with long, pointed fingernails. Findings: A review of Resident 25's Face Sheet, printed 8/7/24, indicated resident was originally admitted to the facility on [DATE] with diagnoses of quadriplegia (loss of strength on all four limbs) and cerebrovascular disease (a condition that affects flow of blood in the brain and spine). A review of Resident 25's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 6/8/24, indicated Resident 25 was understood and was able to understand others. The MDS indicated Resident 25's Brief Interview of Mental Status (BIMS, an assessment for cognition status) score was eight out of 15 which indicated moderately impaired cognition. Further review of the MDS showed resident was dependent (Helper does all the effort. Resident does none of the effort to complete the activity. Or the assistance of two [2] or more helpers is required for the resident to complete the activity) for personal hygiene and grooming. During a review of Resident 25's Care Plan for Activities of Daily Living (ADL, activities related to personal care), dated 6/24/16, indicated Resident 25 would be provided with needed assistance to maintain comfort and dignity. During a concurrent observation and interview on 8/5/24, at 7:12 a.m., with Resident 25, resident was awake lying in bed, watching the television. Resident's bilateral hands were contracted without any brace or splint applied, with long and pointed (shaped like a rounded inverted letter V) fingernails to left hand (1/8 inch beyond the tip of his fingers). Resident 25 stated he did not remember why his right-hand fingernails were clipped and the left-hand fingernails were not. Resident 25 stated he preferred all his fingernails clipped evenly. During a concurrent observation and interview on 8/5/24, at 7:35 a.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated fingernails of non-diabetic residents are trimmed by the CNAs. CNA 1 stated resident fingernails should be trimmed short to prevent scratches that can lead to infection. During an interview on 8/7/24, at 2:28 p.m., with the Director of Staff Development (DSD), DSD stated staff were expected to assist dependent residents to perform ADL care and provide nail care. The DSD stated it was very important for the dignity of the residents. DSD also stated fingernail care when not provided, could result in skin injury from scratching and possible infection. A review of the facility's undated Lesson Plan titled, Fingernails/Toenails, Care of, indicated, The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections .Nail care includes daily cleaning and regular trimming. Proper nailcare can aid in the prevention of skin problems around the nail bed. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure consistent intervention and recommendation was carried out for tube feeds according to patient needs for (Resident 44) while tube feeds was the sole source of nutrition. This failure resulted in an unintended, unplanned weight gain of 21.27% in one year creating potential risks including: 1. Increased Risk of Cardiovascular Disease: Excess weight can lead to increased strain on the heart, potentially causing or worsening conditions such as hypertension, heart disease, and stroke. 2. Development or Worsening of Diabetes: Weight gain, particularly in the abdominal area, can lead to insulin resistance and increase the risk of developing type 2 diabetes or exacerbate existing diabetes. 3. Worsening of Respiratory Issues: Extra weight can compress the chest and diaphragm, making it harder for bed-bound patients to breathe and increasing the risk of respiratory problems, including sleep apnea. 4. Pressure Ulcers (Bedsores): Increased body weight can put additional pressure on areas of the body that are in constant contact with the bed or wheelchair, raising the risk of developing pressure ulcers. 5. Mobility and Joint Issues: Although bed-bound patients may have limited mobility, weight gain can put additional stress on joints and muscles, potentially leading to or exacerbating joint pain and mobility issues. 6. Increased Risk of Infections: Excess weight can lead to compromised immune function, making it harder for the body to fight infections and increasing susceptibility to illnesses. 7. Psychological Impact: Weight gain can affect a patient's self-esteem and mental health, potentially leading to feelings of depression or anxiety. 8. Wound Healing : Weight gain can affect blood flow to tissues, which can slow down the healing process of wounds or surgical sites. During review of Resident 44's Resident Face Sheet dated 8/7/2024, the Resident Face Sheet indicated Resident 44 was admitted to the facility on [DATE] and readmitted after hospitalization 6/09/2024. Past medical history included Chronic Respiratory failure with ventilator (breathing machine) dependency and tracheostomy (surgical opening in the windpipe for breathing), hypertension (high blood pressure), hyperlipidemia (high fat levels the blood) , diabetes, gastrostomy tube (tube in stomach for feeding), difficulty swallowing. A review of Resident 44's Weight Report dated 8/6/24 indicated: weight change from admit % change from admit 7/1/24 191 33 21.27% 6/1/24 190.5 33 20.95% 5/3/24 192 34.5 21.90% 4/2/24 189 31.5 20.00% 3/2/24 186.5 29 18.41% 2/3/24 185.5 29.3 17.97% 1/2/24 183 25.5 16.19% 12/4/24 177.5 19.7 12.51% 11/4/24 175.6 18.1 11.497.56% 10/3/24 169.4 11.9 7.56% 9/3/24 168 10.5 6.67% 8/1/23 166 0.5 5.40% 7/1/23 157.2 -0.3 -0.19% 6/1/23 156.8 -0.7 -0.44% 5/1/23 158 0.5 0.32% 4/3/23 158.5 1.3 0.83% 3/16/23 157.5 During review of Resident 44's Registered Dietician Notes dated 8/25/2023, indicated Resident 44 received Glucerna 1.5 at 75 ml/hour x24 hours. Registered Dieticiaan (RD) recommended a rate change to 70 ml/hr x24 hours. During review of Resident 44's Registered Dietician Notes dated 9/19/2023, indicated Resident 44 received Glucerna 1.5 at 75 ml/hour x24 hours. Registered Dieticiaan (RD) recommended a rate change again to 70 ml/hr x 24 hours. During review of Resident 44's Resident Progress Notes dated 9/21/2023, indicated physician was notified of RD recommendation and approved. Rate was changed to 70 ml/hr x24 hours During review of Resident 44's Registered Dietician Notes dated 11/02/2023, indicated Resident 44 had 7.76% weight increase over 3 months. Resident 44 was receiving Glucerna 1.5 at 70 ml/hour x24 hours. RD documented significant weight gain 7.6% over 3 months. During review of Resident 44's Registered Dietician Notes dated 3/05/2024, indicated Resident 44 received Glucerna 1.5 at 70 ml/hour x24 hours. Registered Dietician (RD) recommended changing rate to Glucerna 1.2 70 ml/hr x22 hours. Also indicates Notable weight gain changes r/t edema. During review of Resident 44's Enteral Administration History dated 3/01/2024-3/31/2024, indicated Resident 44 was receiving Glucerna 1.5 at 70 ml/hour x24 hours. During review of Resident 44's Observation Detail list report date 03/07/2024, indicated significant 11.01% weight gain over previous six months. During review of Resident 44's Enteral Administration History dated 4/01/2024-4/30/2024, indicated Resident 44 was receiving Glucerna 1.5 at 70 ml/hour x24 hours. During review of Resident 44's Enteral Administration History dated 5/01/2024-5/31/2024, indicated Resident 44 was receiving Glucerna 1.5 at 70 ml/hour x24 hours. During review of Resident 44's Registered Dietician Notes dated 5/30/2024, indicated RD was notified facility out of stock of Glucerna 1.5. RD recommends Nephro 65 ml/hr for 20 hours. During review of Resident 44's Enteral Administration History dated 5/31/2024-6/04 /2024, indicated Resident 44 was received Nephro at 65 ml/hour x20 hours twice per day. During review of Resident 44's Registered Dietician Notes dated 7/01/2023, indicated Resident 44 was receiving Nephro 65 ml/hour x20 hours. Registered Dieticiaan (RD) recommended changing tube feeding to Glucerna 1.5 at 67 ml/hr x22 hours During review of Resident 44 Registered Dietician Notes dated 7/8/2024, indicated RD notified facility out of stock of Glucerna 1.5. RD recommends Glucerna 1.2 850 ml/hr for 22 hours. A review of facility policy and procedure (P&P) titled, Weight Measurements - indicated weights should be obtained weekly, monthly or according to physician order. Additionally the policy indicates progressive weight loss or gain is noted and reported to residents attending physician, family or responsible party and documented in medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being for one of 17 sampled residents (Resident 43, receiving hemodialysis [a process of filtering the blood of a person whose kidneys are not working normally] treatment) when: 1. Licensed Nurse (LN) was not fully knowledgeable about the management of care in the event of Resident 43's arterial-venous fistula (a direct connection between the artery and a vein for dialysis access) site complications, post dialysis treatment. This failure resulted in the potential that staff may not correctly perform the proper intervention and prompt physician notification for a resident's dysfunctional access site condition after return from dialysis treatment. 2. LNs failed to ensure Resident 43 received Renagel (a phosphate binder used to lower high blood phosphorus [an essential mineral found in the blood to help form strong bones, teeth, and muscles] levels in patients who are in dialysis due to severe kidney disease) as ordered three times a day with meals, and to inform the physician of missed doses during dialysis treatment days. This failure resulted in Resident 43's elevated phosphorus level and had the potential to cause harm to resident's heart. Findings: 1. A review of Resident 43's Face Sheet, printed 8/7/24, indicated resident was originally admitted to the facility on [DATE] with diagnoses of diabetes mellitus (high blood sugar) and end-stage renal disease (ESRD, permanent kidney failure that requires dialysis or kidney transplant). A review of Resident 43's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 5/29/24, indicated Resident 43 was dependent on renal dialysis due to diagnosis of ESRD. A review of Resident 43's Physician Order Report, for 7/7/24 - 8/7/24, indicated: Start date 6/11/24 - new dialysis schedule starting 6/8/24 (Tuesday and Saturday) from 9:30 a.m. - 1 p.m. Start date 4/8/24 - AV shunt fistula to left upper arm check for bruit (auscultation of shunt for swooshing sound), and thrill (lightly palpate for vibration of shunt), signs and symptoms of bleeding, and infection every shift. A review of Resident 43's Care Plan, dated 9/19/22, indicated Diagnosis: ESRD (on renal dialysis) Risk for: electrolyte imbalance (too much or not enough of certain minerals in the body), infection, bleeding, and fatigue. Access site: left arm. Approach start date: 9/19/22, indicated check access site for any signs/symptoms (s/s) of bleeding, swelling, infection, and inform Assistant Physician (AP). During a concurrent interview and record review on 8/6/24, at 9:45 a.m., with Registered Nurse Supervisor (RNS), Resident 43's electronic clinical records indicated resident went to Dialysis Center every Tuesday and Saturday, between 9:30 a.m. to 1 p.m. RNS stated upon Resident 43's return from dialysis, post-dialysis form was checked for new orders, resident vital signs checked, and AV fistula site/dressing assessed. RNS stated she was unsure of what interventions to do with the AV fistula in case of major bleeding to the site. RNS stated she would put a tourniquet (to temporarily constrict and control blood flow and should only be used when other methods, such as pressure dressings have failed) on the resident's arm. RNS stated she needed further training on dialysis. During an interview on 8/7/24, at 2:32 p.m., with the Director of Staff Development (DSD), DSD stated post-dialysis, residents' AV fistula should be assessed and monitored for bruit and thrill, bleeding, and infection to the site. DSD further stated, with heavy bleeding put pressure on the fistula site and call 911. DSD stated all licensed staff needed to be in-serviced on hemodialysis. 2. A review of Resident 43's Physician Order Report, for 7/7/24 - 8/7/24, indicated: Start date 7/22/24 - Renagel tablet 800 milligrams (mg) - take two (2) tabs (1600 mg total) by mouth three times a day with meals for phosphate binder. With meals: 8:00 a.m., 12:00 p.m., and 5:30 p.m. A review of Resident 43's Medication Administration History (MAH), for 7/1/24 - 7/31/24, indicated LN initials on Renagel tablet doses were parenthesized (not administered or not charted, see Reasons/Comments) on the following dates during 12 p.m. administration time: 7/23/24, 7/27/24, and 7/30/24, with Reasons/Comments that indicated, Not administered: Resident unavailable. Comment: out for dialysis. Further review of Resident 43's MAH, for 8/1/24 - 8/7/24, indicated LN initials on Renagel tablet doses were parenthesized on the following dates during 12 p.m. administration time: 8/3/24 and 8/6/24, with Reasons/Comments that indicated, Not administered: Resident unavailable. Comment: out for dialysis. A review of Resident 43's Dialysis Center's Lab Draw Report, Result Release Date 5/30/24, indicated a phosphate level of 5.3 mg/deciliter(dL) high (H), (normal range 2.4-5.1). Result Release Date 6/08/24, indicated phosphate level of 5.2 mg/dL H, and Result Release Date 7/4/24, indicated phosphate level of 5 mg/dL. A review of Resident 43's Care Plan, dated 9/19/22, indicated Diagnosis: ESRD (on renal dialysis) Risk for: electrolyte imbalance (too much or not enough of certain minerals in the body), infection, bleeding, and fatigue. During a concurrent interview and record review on 8/7/24, at 10:14 a.m., with Licensed Vocational Nurse 1 (LVN 1), Resident 43's electronic clinical record indicated an order for Renagel 1600 mg three times a day with meals. LVN 1 confirmed that on Tuesdays and Saturdays, Resident 43 left for dialysis after breakfast, takes a snack bag with her, and returned to facility around 2 p.m. during the morning shift. LVN 1 stated resident does not take the 12 p.m. dose of Renagel during dialysis days as shown on the MAH. LVN 1 stated Renagel, when not taken as ordered, can increase resident's level of phosphorus, and can cause hypocalcemia (low calcium level in the blood). LVN 1 confirmed she does not send Renagel with Resident 43 whenever resident went to dialysis. LVN 1 was unable to provide documentation that Medical Doctor 1 (MD 1) or Dialysis Center were informed of multiple missed 12 p.m. Renagel doses during dialysis days. During a concurrent telephone call and record review on 8/7/24, at 12:51 p.m., with MD 1, Resident 43's medication and lab results were discussed. MD 1 stated he was aware of resident's missed 12 p.m. doses of Renagel on multiple dialysis days but could not recall who informed him or when facility had last informed him. Resident 43's high levels of phosphorus were discussed and MD 1 stated resident's phosphorus level run on higher end of normal (normal range 2.4 - 5.1). For June 2024 - resident's phosphorus level was 5.2 mg/dL, July 2024 - 5 mg/dL, and on May 2024, a phosphate level of 5.3, which was outside the normal range. MD 1 stated since Resident 43 was constantly on high side of phosphorus levels, resident will have to take her 12 p.m. dose of Renagel with meals when at the dialysis center. A review of the facility's policy and procedure (P&P) titled, Hemodialysis, printed 8/7/24, dated 10/12/23, indicated, To provide residents with safe, accurate, and appropriate care, assessments and interventions to improve resident outcomes. Hemodialysis devices may only be accessed by medical personnel who have received training and demonstrated clinical competency regarding use of these devices .Hemodialysis access devices are surgically placed and removed .Vascular access may be accomplished in one of three ways: a. Arterio-venous fistula (AVF) .Post Hemodialysis Care .3. Mild bleeding from site (post dialysis) can be expected. Apply pressure to insertion site and contact dialysis center for instructions. 4. If there is major bleeding from site (post-dialysis), apply pressure to insertion site and contact emergency services and dialysis center. Verify that clamps are closed on lumens. This is an emergency. Do not leave resident alone until emergency services arrives .8. Monitor laboratories work up. Notify Physician as ordered or when laboratory values are abnormal .Pre and post Dialysis Documentation .Medication given, Medications sent with resident to the dialysis center, meal provision during dialysis . Resident 43 was unavailable for interview during the time of survey.

Based on interview and record review, the facility failed to ensure the Kitchen Manager (KM) had completed the required six hours of inservice training on the specific California dietary service requirements contained in California Code of Regulations (CCR) Title 22 prior to assuming full time duties as a dietetic services supervisor at the health facility, This failure resulted in the KM not possessing competencies and skills for California to carry out food and nutrition functions, potentially putting residents at risk for foodborne illness. Findings: During an interview on 8/5//24, at 11:00 AM, with KM, KM stated she worked full time and was certified as a dietary manager. KM stated she does not have 6 hours of inservice training on the specific California dietary service requirements. During an interview on 8/5//24, at 11:00 AM, with Registered Dietician (RD), RD stated she had not administered or developed the required six hour inservice training for the KM.

Based on observation, interview and record review, the facility failed to ensure nursing staff had physician order, facility policy and training to use enteral tube (tube placed into a surgically create hole leading into the gastrointestinal tract) clog removal tool and followed facility expectations when performing enteral tube clog removal care for two of 16 sampled residents (Resident 274 and 45) who were receiving medications through an enteral tube. This failure had the potential for enteral tube perforation or gastrointestinal damage when nursing staff inserted plastic clog removal tool into Resident 274 and 45's enteral tube without physician order, facility policy or training on use of the clog removal tool. Findings: A record review of Resident 274's admission record indicated Resident 274 was admitted for gastrostomy care, tracheostomy care, muscle wasting and atrophy, and chronic respiratory failure. During a review of Resident 274's physician orders set titled, Physician Order Report: 8/1/24-8/31/24, undated, the orders set indicated Resident 274 had enteral tube orders to Check tube for placement/patency every shift. Special Instructions: Verifying for enteral tube placement: 1. Physical assessment, 2. Aspiration of gastric contents, 3. Auscultation (injection of air into the enteral tube). During a review of Resident 274's physician orders titled, General Order: Resident 274, undated, the orders indicated Resident 274 had a physician's order for may use a declogger when indicated if unable to declog, may change the g-tube dated 8/8/24, at 10:36 a.m., created by the Director of Nursing (DON). A review of Resident 45's admission record indicated Resident 45 was admitted for gastrostomy care, tracheostomy care, chronic respiratory failure and dysphagia (difficulty swallowing). During a review of Resident 45's physician orders set titled, Physician Order Report: 8/1/24-8/31/24, undated, the orders set indicated Resident 45 had enteral tube orders to Check tube for placement/patency every shift. Special Instructions: Verifying for enteral tube placement: 1. Physical assessment, 2. Aspiration of gastric contents, 3. Auscultation (injection of air into the enteral tube). Resident 45 did not have an order to use a clog removal for an occluded enteral tube. The order set indicated Resident 45 did not have a physician order to use the plastic clog removal tool. During a concurrent observation and interview on 8/7/24, at 11:10 a.m., with Registered Nurse 3 (RN 3), RN 3 was at Resident 274's bedside performing a medication pass. Using a large syringe with the plunger pulled out, RN 3 attached the syringe in Resident 274's enteral tube and poured 40 mL of water into the syringe body. RN 3 stated the enteral tube was clogged because the water did not instill into the enteral tube. RN 3 then massaged the enteral tube itself but was unsuccessful in unclogging it. RN 3 stated they would obtain a device to unclog Resident 274's enteral tube and left the room. RN 3 returned with a plastic clog removal tool. The packaging on the device indicated it was 39.5 centimeters in length and was used to unclog occluded enteral tubes. RN 3 inserted the clog removal tool approximately 2/3 of its length into Resident 274's enteral tube to unclog it but was unsuccessful in removing the occlusion. RN 3 used the clog removal tool a second time and inserted the clog removal tool into Resident 274's enteral tube until the handle of the tool reached the opening of the enteral tube. RN 3 had successfully unclogged the tube and finished the medication pass. During a concurrent observation and interview on 8/7/24, at 11:32 a.m., with RN 3, RN 3 was at 45's bedside performing a medication pass. Using a large syringe with the plunger pulled out, RN 3 attached the syringe in Resident 45's enteral tube and poured 40 mL of water into the syringe body. RN 3 stated the enteral tube was clogged because the water did not instill into the enteral tube. RN 3 then massaged the enteral tube itself but was unsuccessful in unclogging it. RN 3 exited the room obtained another clog removing tool and entered Resident 45's room. RN 3 inserted the clog removing tool into Resident 45's enteral tube and was able to unclog the tube. During a concurrent record review and interview on 8/8/24, at 8:48 a.m., with the Director of Nursing (DON), the facility inservice records for enteral tube management was reviewed. The DON stated she had not performed any inservice or training on the use of the clog removal tool and was unaware it was being used in non-emergency situations. The DON was unable to describe the procedure in its use but stated it was used in emergencies only. The DON stated nursing staff were expected to unclog an enteral tube by massaging the tube or instilling warm water or an enzymatic solution to unclog the tube. The DON stated if an enteral tube remained clogged nursing staff were expected to contact the provider for enteral tube replacement or obtain an order to use the plastic clog removal if there is an emergency. During a concurrent interview and record review on 8/8/24, at 8:48 a.m., with the DON, two facility policy and procedures (P&P) both titled, Enteral Feedings - Safety Precautions RC3 0406.02, one dated 1/8/24 and other undated, were reviewed. The DON stated the P&P dated 1/8/24 was the P&P staff were expected to follow and did not have a procedure for the use of the clog removal tool. The DON stated the undated P&P had an additional section which included clog removal tool indications for use and instructions for use. The DON stated she was unable to access the undated version at the online resource typically used to obtain P&P and the undated P&P was given to her by the facility's corporate office. During a concurrent record review and interview on 8/8/24, at 9:05 a.m., with Director of Staff Development (DSD), RN 3's orientation record was reviewed. The orientation record did not include training on the use of the clog removal. The DSD stated she did not perform any training on the use of the plastic clog removal tool. During a concurrent interview and record review on 8/8/24, at 9:30 a.m., with RN 3, the P&P titled, Enteral Feedings - Safety Precautions RC3 0406.02, undated, was reviewed. RN 3 stated the facility did not have training or inservice on the use of the plastic clog removal tool and had not reviewed the P&P. RN 3 stated the tool was intended to be used for emergency purposes. RN 3 stated if an enteral tube remained clogged after massage or instilling warm fluid, the provider needed to change the tube.

Based on observation, interview and record review, the facility failed to ensure 14 controlled medications (substances that have an accepted medical use, medications which fall under US Drug Enforcement Agency (DEA) Schedules II-V, and have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence) from the Director of Nursing (DON) controlled medications cabinet were documented and destroyed according to state law and facility policy. This failure had resulted in 14 controlled medications not being destroyed and had the potential for drug diversion. Findings: During an interview on 8/8/24, at 10:45 a.m., with the DON, the DON stated Pharmacist Consultant 1 (PC 1) was the primary pharmacist who performed monthly destruction of controlled medications with the DON. The DON described the procedure for the disposal of controlled medications: 1. Nurse brings the discontinued controlled medications to the DON. 2. Every month, the DON and PC 1 reconciled and destroyed the controlled medications. 3. PC 1 destroyed controlled medications by placing the substance in plastic bucket and pouring water in until the controlled medications were dissolved. 4. The plastic bucket would be covered and locked in a biohazard container room for monthly pickup by a biohazardous waste disposal company. During a concurrent observation, interview and record review on 8/8/24, at 11:11 a.m., with the DON, the controlled medications cabinet in the DON's office was inspected. Upon inspection of the controlled medications cabinet the following medications were found: 1. One bottle of Norco (a pain relieving medication) 5-325 mg (milligram, unit of measurement) tablets with 45 tablets and two boxes of fentanyl patches containing 5 patches each box for a discharged resident. The associated count sheet did not indicate date of receipt of the medication, 2. One bottle of Hydromorphone (a pain relieving medication) 4 mg tablets with 60 tablets in the bottle for a discharged resident. The label on the bottle indicated an expiration date of 9/23/2023. There was no documentation associated with the bottle, 3. One bottle of lorazepam (a medication to reduce anxiety) 2mg per mL (milliliter, unit of measurement) liquid solution with 19 mL in the bottle with no resident label. The label indicated an expiration date of March 2024. There was no documentation associated with the bottle, 4. One bottle of Norco 5-325 and one bottle of Norco 10-325 for a discharged resident. The label on the Norco 5-325 indicated an expiration date of 8/2023. There was no documentation associated with the bottle, 5. One bottle of morphine (a pain relieving medication) 20mg/5mL liquid solution with 275mL in the bottle for a discharged resident. A note, dated 8/19/21, was affixed to the bottle and read No count sheet. Hospice Supply, 6. One box containing a bottle of morphine 100mg/5mL liquid solution for a discharged resident. A label on the box indicated an expiration date of 2/2023. There was no documentation associated with the bottle, 7. One empty bottle of morphine liquid solution for a discharged resident. There was no documentation associated with the bottle, 8. One bottle of morphine liquid solution and one bottle of lorazepam liquid solution for a discharged resident. The label on the morphine bottle indicated an expiration date of 8/2022. The label on the bottle of lorazepam indicated an expiration date of 9/2022. There was no documentation associated with the two medications, 9. A plastic bag with one empty bottle of lorazepam with a worn out illegible label for a discharged resident. A document found in the bag titled Controlled Drug Record, undated, indicated the medication was received by a nurse on 1/2/21, 10. One bottle of morphine 20 mg/mL liquid solution for a discharged resident. There was no documentation associated with the bottle. 11. One sheet of packaged alprazolam (a medication to reduce anxiety) 0.25 mg tablets containing 53 tablets for a discharged resident. The DON stated an associated record titled Controlled Drug Record, undated, indicated no tablets were administered and the sheet originally contained 56 tablets. The record indicated an expiration date of 2/2022. 12. One sheet of packaged Norco 5-325 mg tablets for a discharged resident. The label on the sheet indicated a package date of 9/26/2019, there was no expiration date on the label. There was no documentation associated with the medication. The DON stated she did not destroy the controlled medications because she did not know the procedure for destroying controlled medications without documentation of its receipt and date of discontinuation. During a concurrent observation and interview, on 8/8/24, at 2:17 p.m., with Pharmacist Consultant 2 (PC 2), the 14 controlled medications were observed on the DON's office desk. PC 2 was completing documentation to destroy the controlled medications. PC 2 stated the facility was expected to destroy controlled medications 90 days after receiving them. PC 2 stated the facility's use of water to dissolve controlled medications was not an acceptable destruction method. During a review of facility policy and procedure (P&P) titled, Medication Destruction, undated, the P&P indicated the facility destroy controlled medications in accordance with state and federal guidelines .the pharmacist and Director of Nursing/registered nurse designee document that drugs were destroyed .record the destruction of controlled substances in the drug destruction log book, as required by state and federal law. During a review of facility P&P titled, Disposal of medications, syringes, and needles Disposal of Medications, dated 1/23, the P&P indicated the director of nursing and consultant pharmacist will monitor for compliance with federal and state law and regulations regarding the disposal of medications .mixing medications with an undesirable substance, such as used coffee grounds or kitty litter .will further ensure the drugs are not diverted .dispose of discontinued medications within 90 days of the date the medication was discontinued .outdated medications, contaminated or deteriorated medications, and the contents of containers with no label shall be destroyed according to the above policy. The policy did not indicate water was an appropriate substance for destruction of controlled medications.

Based on observation, interview, and record review. the facility failed to ensure cooks had education and skill to puree food properly for 11 of 11 residents receiving a pureed diet when they over processed and over mechanicalized food, which was watery, bland and without flavor. This failure resulted in residents being at risk for decreased satiety and nutrition intake which could result in weight loss. Findings: During an observation on 8/5/24, at 11:30 a.m., [NAME] 1 (C-1) used a handheld slotted strainer to place vegetables (mixed vegetables-cauliflower and broccoli) from cooking vessel into the blender. C-1 proceeded to puree the vegetables, periodically checking the consistency. Upon completion C-1 poured the remaining liquid into the blender which resulted in 6 cups of product. The end result was a pourable product, which resembled a slightly thick cream soup. C-1 was required to add 3-ounces of thickener, yielding vegetables which resembled a thin, pourable pudding texture. This resulted in the addition of excess cooking water being inadvertently added to blender, diluting the nutritional value of the pureed item. The C-1 did not taste vegetable puree upon completion according to procedure. During an observation on 8/6/24, at 11:20 a.m., in the kitchen, C-1 transferred carrots from the cooking vessel into the blender without draining them, resulting in cooking water being added to the blender. The added cooking water diluted the carrot puree. C-1 did not taste the vegetable puree after completion. During a concurrent observation and interview on 8/6/24, at 12:30 p.m., with Kitchen Manager (KM) and Registered Dietician (RD) in the conference room, a test tray was provided. Two Surveyors and KM stated the pureed carrots lacked flavor, were watery, and needed seasoning. RD chose not to perform taste test. During a review of a facility quantified recipe titled, Seasoned Carrots FRZ PU, dated April 4, 2024, the recipe indicated carrots and food thickener as the only ingredients. The recipe did not include water listed as an ingredient. During a review of Inservice/Training Attendance Record for Pureed Food,dated 1/6/2022, the training record and roster indicated education on how to puree food and adherence to recipe was delivered to dietary staff. During review of Lesson Plan Pureed Food, undated, the lesson plan described the expected procedure for pureed food. Steps included review of recipe, following recipe, and tasting food to make sure the texture, consistency and flavor is appropriate for palatability.

Based on observation and record review, the facility failed to follow menu portions when serving orzo, baked apples and Boston cream pie. This failure resulted in residents receiving portion sizes in excess or below their required needs per physician order or dietician recommendation, potentially putting residents at risk for inability to maintain normal body weight and receiving acceptable nutritional values. Findings: During a concurrent observation and record review on 8/5/24, at 12:15 p.m., in the kitchen, Dietary Aide (DA-1) served ½ cup of orzo to 24/24 Controlled Carbohydrate (CCHO - a diet to keep carbohydrate consumption at a steady level) diet residents. The Spring/Summer 2024 Diet Spreadsheet, indicated CCHO diet residents should receive 1/3 cup of orzo. During a concurrent observation and record review on 8/5/24, at 12:30 p.m., in the kitchen, DA-1 used a #12 scoop (2.5-3 oz) to serve baked apples for both regular and CCHO diets. The Spring/Summer 2024 Diet Spreadsheet indicated a #10 scoop (3-4 oz) is required for serving baked apples for both regular and CCHO diets. During a concurrent observation and record review on 8/6/24, at 12:30 p.m., in the kitchen, DA-1 served residents a 1x2 inch square of Boston cream pie. The Spring/Summer 2024 Diet Spreadsheet indicated residents should receive a 2x3 inch square of Boston cream pie.

Based on observation, interview, and record review, the facility failed to ensure the juice machine was cleaned according to manufacturer's instructions when the machine was not flushed weekly and the bar gun was soaked in hot water. This failure resulted in improper sanitation and the risk for transmission of foodborne illness to 56 residents receiving juice. Findings: During a concurrent observation and interview on 8/5/24, at 10:00 a.m., in the kitchen, Kitchen Aide 1 (KA-1) soaked the juice bar gun from the juice machine in a large pitcher of hot water (water with steam emanating from vessel). KA-1 stated the required cleaning included submerging and soaking the bar gun (nozzle) daily to prevent blockages or clogs caused by sugar build-up. KA-1 stated the juice bag junction (connection to juice bag) is disconnected and rinsed when each juice bag is empty. KA-1 stated they do not use a log to document the cleaning or a cleaning schedule. During a review of Lyons Bag in the Box Equipment Cleaning Procedure, the procedure indicated the bar gun should be soaked daily in luke warm water (water that is neither hot nor cold) only. The procedure also stated weekly flushing of all hoses, pumps and bar gun lines was required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure infection control policy and procedure was followed for 10 of 23 sampled (Residents 21, 16, 32, 60, 3, 27, 51, 273, 272 and 59) residents when: 1. staff did not use sterile gloves when performing sterile tracheostomy (artificial airway at the throat which is kept open with a tube inserted into the opening) suctioning (procedure to remove secretions from the respiratory tract by vacuum) on Resident 21, 2. staff did not perform hand hygiene when switching between three residents (Resident 16, 32, and 60) who needed tracheostomy care, 3. facility did not have equipment to change suction canisters (a plastic container connected to a vacuum which stores liquid from suctioning) for Resident 3, 32 and 60 and did not have equipment to change the ventilator circuit (plastic tubing which connects a tracheostomy to a ventilator [a machine used to help a resident breath mechanically]) for Resident 51, 4. staff allowed open system tube feeding lines (a system to deliver tube feed fluid which includes a bag that can be opened to add more tube feed fluid) to be used for more than 24 hours for Residents 32, 273, 272 and 44, 5. licensed nurse did not cleanse wound with normal saline before applying wound treatment. These failures placed the residents at risk of wound, respiratory and gastrointestinal infection and had the potential for residents to be hospitalized . Findings: 1. A review of Resident 's admission record indicated Resident 21 was admitted for acute respiratory failure, attention for tracheostomy, seizures, dysphagia and type 1 diabetes. During a record review of Resident 21's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 7/4/2024, indicated Resident 21 received tracheostomy care including suctioning, oxygen therapy. During a record review of Resident 21's care plan titled, Respiratory Presence of tracheostomy, dated 6/3/24, the care plan indicated Resident 32 receive tracheostomy care which included suctioning as needed. During a concurrent observation and interview on 8/6/24, at 11:15 a.m., Resident 21 was in their room in bed waiting for a nurse to perform tracheostomy suctioning. Resident 21 stated they were sounding junky and needed to be suctioned. Resident 21 stated they were not in respiratory distress. As Resident 21 spoke they sounded like phlegm was partially occluding the tracheostomy. During a continuous observation on 8/6/24, at 11:29 a.m., Registered Nurse Supervisor 2 (RNS 2) was at Resident 21's bedside preparing to perform tracheostomy suctioning with a disposable suction catheter (a sterile one time use catheter used to suction tracheostomy openings). Wearing non-sterile gloves, RNS 2 opened the disposable suction catheter packaging. With the same gloves, RNS 2 grasped the suction catheter, removed it and attached it to the suction machine. The sterile gloves remained in the package. Continuing to use the same gloves, RNS 2 uncoiled the suction catheter, inserted the suction catheter into Resident 21's tracheostomy and began suctioning. Respiratory therapist (RT) entered the room and observed the suctioning process. After suctioning Resident 21's tracheostomy, RNS 2 discarded the suction catheter. RNS 2 then discarded the packaging with the sterile gloves still in the packaging. During an interview on 8/6/24, at 2:33 p.m., with RNS 2, RNS 2 stated nursing staff were expected to wear sterile gloves when performing tracheostomy cleaning using disposable suction catheters. RNS 2 stated disposable suction catheter came packaged with sterile gloves. RNS 2 stated sterile gloves would keep the suction catheter sterile when inserted into the tracheostomy. RNS 2 stated the suction catheter needed to remain sterile to avoid respiratory infection. During an interview on 8/7/24, at 12:38 p.m., with Respiratory Therapist (RT), RT recalled observing RNS 2 perform tracheostomy suctioning on Resident 21 without use of sterile gloves. RT stated nursing staff were expected to use sterile gloves and sterile technique when using disposable suction catheters. RT stated after she started overseeing the respiratory practice of the nursing staff, she had observed nursing staff were not consistently using sterile gloves when performing tracheostomy suctioning. During an interview on 8/7/24, at 2:51 p.m., with infection preventionist (IP), the IP stated nursing staff were expected to adhere to sterile technique including using sterile gloves when performing tracheostomy suctioning using disposable suction catheters to prevent respiratory illness. During an interview on 8/9/24, at 9:23 a.m., with the Director of Nursing (DON), the DON stated all staff were expected to adhere to hand hygiene policy during which included performing hand hygiene when moving to care for another resident in the same room. The DON stated nursing staff were expected to use sterile gloves to prevent residents from contracting respiratory illness. During a record review of facility policy and procedure titled, Procedure-sterile suctioning, undated, indicated when using a disposable suction catheter, nursing staff put sterile glove on your dominant hand. 7. Grasp sterile suction catheter with gloved hand and suction tubing attached to the suction source with your ungloved hand .do no touch the sterile catheter with your ungloved hand. 2. A review of Resident 32's admission record indicated Resident 32 was admitted for anoxic brain damage (brain damage due to lack of oxygen), attention for tracheostomy, attention to gastrostomy, dysphagia and chronic respiratory failure. The record also indicated Resident 32 was on transmission-based precautions (also called Isolation Precautions, are actions implemented in addition to standard precautions that are based upon the means of transmission for the infectious agent in order to prevent or control infections), for methicillin resistant staphylococcus aureus (MRSA, an antibiotic resistant bacteria), carbapenem resistant enterobacterales (CRE, an antibiotic resistant bacteria) and carbapenem resistant Acinetobacter baumannii (CR-AB, an antibiotic resistant bacteria) in the sputum. During a record review of Resident 32's MDS, dated [DATE], indicated Resident 32 received tracheostomy care including suctioning, oxygen therapy and was completely dependent on nursing staff for all aspects of medical and personal hygiene care. During a record review of Resident 32's physician order set titled, Physician Order Report: 8/1/24-8/31/24, undated, the order set indicated Resident 32 had physician orders for isolation contact precaution (a type of transmission-based precaution requiring nursing staff to wear gown and gloves to prevent spread of infection) due to MRSA, ordered on 6/25/2020, and suction tracheal secretions every two hours PRN (as needed), ordered on 8/15/2022. During a record review of Resident 32's care plan titled, Respiratory Presence of tracheostomy, dated 6/3/24, the care plan indicated Resident 32 receive tracheostomy care as ordered and per protocol. A review of Resident 60's admission record indicated Resident 60 was admitted for anoxic brain damage, respiratory failure, care for tracheostomy and care for gastrostomy. During a record review of Resident 60's MDS, dated [DATE], indicated Resident 60 received tracheostomy care including suctioning, oxygen therapy and was completely dependent on nursing staff for all aspects of medical and personal hygiene care. During a record review of Resident 60's physician order set titled, Physician Order Report: 8/1/24-8/31/24, undated, the order set indicated Resident 60 had physician orders for suction tracheal secretions q2h, ordered on 7/23/24. The order set indicated Resident 60 had a medication order for ipratropium-albuterol (a mediation to help breathing) nebulization (a method to administer medication by inhalation of a gaseous form of medication) every 6 hours including an administration time at 9:00 a.m A review of Resident 16's admission record indicated Resident 16 was admitted for respiratory failure, care for tracheostomy and care for gastrostomy. During a record review of Resident 16's MDS, dated [DATE], indicated Resident 16 received tracheostomy care including suctioning, oxygen therapy and was completely dependent on nursing staff for all aspects of medical and personal hygiene care. During a concurrent observation and interview on 8/5/24, at 9:46 a.m., with Respiratory Therapist (RT), RT was in Resident 32, 16 and 60's room performing respiratory care on Resident 16. RT was wearing a gown and gloves. While performing tracheostomy care on Resident 16, Resident 32 could be heard coughing and had coarse breath sounds. RT paused Resident 16's care and Resident 32 needed to be suctioned. RT removed their gloves and disposed of them in a trash receptacle. Without performing hand hygiene, RT donned a new pair of gloves and went over to Resident 32 to perform tracheostomy suction. After suctioning Resident 32, RT removed their gloves and without performing hand hygiene, donned a new pair of gloves. RT stated they would perform tracheostomy suctioning prior to administering Resident 60's ipratropium-albuterol nebulizer medication. RT walked to Resident 60's bedside and began to setup oxygen tubing to administer the nebulizer treatment. Using the same pair of gloves and without performing any hand hygiene, RT suctioned Resident 60's tracheostomy. RT administered the ipratropium-albuterol to Resident 60. After administering the nebulizer treatment, RT removed their gown and gloves and exited the room. During an interview on 8/7/24, at 2:51 p.m., with the IP, the IP stated all staff were expected to perform hand hygiene when changing care between residents whether they were on transmission-based precautions or not. IP stated residents with tracheostomies were at higher risk of respiratory infection and adherence to hand hygiene was important to prevent infection. During an interview on 8/9/24, at 9:23 a.m., with the Director of Nursing (DON), the DON stated all staff were expected to follow infection prevention policy including hand hygiene policy when changing care between residents. During a review of facility P&P titled, Policy: Hand Hygiene, dated 2/2017, the P&P indicated all personnel shall follow the hand washing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors .use an alcohol-based hand rub .for the following situations .before and after direct contact with residents; .before preparing or handling medications .before and after handling an invasive device .after contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; .after removing gloves .the use of gloves does not replace hand washing/hand hygiene. 3. During an observation on 8/5/24, at 9:39 a.m., Resident 60's suction canister attached to Resident 60's dedicated suction equipment was inspected. The lid of the canister had a date 7/21/24 written on it and the canister was approximately half full with cloudy white liquid. During an observation on 8/5/24, at 10:04 a.m., Resident 32's suction canister attached to Resident 32's dedicated suction equipment was inspected. The lid of the canister was undated, and the canister was half full with a cloudy white liquid. A review of Resident 's admission record indicated Resident 3 was admitted for respiratory failure, attention for tracheostomy, seizures, dysphagia and type 1 diabetes. During a record review of Resident 3's MDS, dated [DATE], indicated Resident 3 received tracheostomy care including suctioning, oxygen therapy. The MDS indicated Resident 3 had was able to use their upper extremities for cares of living such as eating and drinking but was completely dependent on staff to transfer out of bed and to get dressed. During a concurrent observation and interview on 8/5/24, at 7:49 a.m., with Resident 3, Resident 3's suction canister was inspected. Resident 3 stated he was able to perform suctioning of his mouth by himself. Resident 3 stated the staff were responsible for changing the suction canister. The lid of the canister had a date 7/6 written on it and the canister was approximately 75% full with cloudy white liquid. A review of Resident 's admission record indicated Resident 51 was admitted for respiratory failure and attention for tracheostomy. During a record review of Resident 51's MDS, dated [DATE], indicated Resident 51 received tracheostomy care including tracheostomy care, suctioning and oxygen therapy. The MDS indicated Resident 51 had was non-verbal and was completely dependent on staff for all aspects of care. During an observation on 8/5/24, at 9:26 a.m., Resident 51 was in their room in bed with a ventilator circuit attached to their tracheostomy. At the end closest to the resident, the ventilator circuit had a mix of dry and wet red-brown residue on inside of the tube. During a concurrent observation and interview on 8/7/24, at 12:45 p.m., with RT, the storage closet for respiratory supplies was observed. RT stated the facility did not have enough supplies to change respiratory care equipment as required by the facility policy. Inspection of the storage closet indicated there were no ventilator circuits or suction canisters. RT stated there were suction canisters were expected to be changed weekly. RT stated Resident 51's ventilator circuit was soiled and needed to be changed but there were no ventilator circuits to change it. RT stated she did not know how long Resident 51's current ventilator circuit was in use because it was not dated. RT stated there were many rooms which needed suction canister changes, but the respiratory supply closet did not have any suction canisters. During an interview on 8/7/24, at 2:51 p.m., with IP, the IP stated equipment related to tracheostomy care needed to be changed regularly to prevent bacterial growth in the equipment which could potentially lead to respiratory infection. IP stated staff needed to label the equipment with a date to ensure equipment was replaced appropriately. During an interview on 8/9/24, at 9:23 a.m., with the DON, the DON stated the respiratory care contractor was responsible for stocking and ordering respiratory care equipment. The DON stated there had been past issues with a previous respiratory therapist ordering enough respiratory care equipment. During a review of facility P&P titled, Changing Disposable Equipment, Respiratory, Infection Control, undated, the P&P indicated disposable equipment must be labeled with a date and respiratory equipment such as suction canisters were changed every week on Sunday nights and ventilator circuits were changed on the first Sunday of each month. During a review of facility P&P titled, Policy: Hand Hygiene, dated 2/2017, the P&P indicated all personnel shall follow the hand washing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors .use an alcohol-based hand rub .for the following situations .before and after direct contact with residents; .before preparing or handling medications .before and after handling an invasive device .after contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; .after removing gloves .the use of gloves does not replace hand washing/hand hygiene. 4. During a record review of Resident 32's enteral feeding administration record titled, Enteral Administration History: 8/1/24-8/8/24, dated 8/8/24, the record indicated on 8/4/25, at 1:31 p.m., Resident 32 received Jevity (a type of tube feed) 1.5. The record indicated Resident 32 received Jevity 1.2 on 8/2/24, 8/3/24 and 8/4/24. During an observation on 8/5/24, at 7:15 a.m., Resident 32's tube feeding lines and pump was inspected. Resident 32's tube feeding circuit was administered through an open system and contained two bags which was filled with water and approximately 75 mL of tube feeding liquid. Resident 32 was receiving tube feed fluid through the gastric tube at a rate of 50 ml/hour. A label affixed to the bag with tube feed liquid indicated the tube feeding circuit was initiated on 8/3/24 with no start time. A review of Resident 273's admission record indicated Resident 273 was admitted for anoxic brain damage, lack of coordination, care for gastrostomy, care for tracheostomy and dysphagia. During a record review of Resident 273's MDS, dated [DATE], indicated Resident 273 received nutrition through a feeding tube. The MDS indicated Resident 272 was not able to make their needs known and was completely dependent on nursing staff for all aspects of medical and personal care. During a record review of Resident 273's enteral feeding administration record titled, Enteral Administration History: 8/1/24-8/8/24, dated 8/8/24, the record indicated Resident 273 was administered Jevity 1.5 at 65 mL/hr from 8/1/24 to 8/6/24. During an observation on 8/5/24, at 7:15 a.m., Resident 273's tube feeding lines which led into Resident 273's gastric tube was inspected. Resident 273's tube feeding line was administered through an open system and contained two bags which was filled with water and approximately 100 mL of tube feeding liquid. Resident 273 was receiving tube feed fluid through the gastric tube at a rate of 65 ml/hour. A label affixed to the bag with tube feed liquid indicated the tube feeding line was initiated on 8/3/24 at 11:00 a.m. A review of Resident 272's admission record indicated Resident 272 was admitted for disorder of muscle, care for tracheostomy, failure to thrive, dysphagia and care for gastrostomy. During a record review of Resident 272's MDS, dated [DATE], indicated Resident 272 received nutrition through a feeding tube. The MDS indicated Resident 272 was able to make their needs known but was completely dependent on nursing staff for all aspects of medical care. During a record review of Resident 272's tube feeding record titled, I&O Monitoring Administration Record: 8/1/24-8/9/24, dated 8/9/24, the record indicated Resident 272 received tube feeding from 8/1/24 to 8/9/24 on all three shifts. During an observation on 8/5/24, at 7:46 a.m., Resident 272's open system tube feeding line and tube feeding pump was inspected. The pump indicated Resident 272 was receiving tube feed at a rate of 50 mL/hr. The label affixed to the bag containing tube feed was dated 8/3/24 with no time. During a concurrent interview and record on 8/7/24, at 2:51 p.m., with IP, images of tube feeding lines observed on 8/5/24 were reviewed. IP stated the images showed residents were using an open system tube feed line, and the tube feed lines needed to be changed every 24 hours. IP stated open system feeding lines were at risk for bacterial growth in the system and could cause gastrointestinal issues and was an infection risk. During an interview on 8/9/24, at 9:23 a.m., with the DON, the DON stated nursing staff were expected to change tube feeding lines every 24 hours for residents who received tube feeding through open system systems. During a review of facility P&P titled, Enteral Feedings - Safety Precautions, dated 1/8/24, the P&P indicated nursing staff change administration sets for open-systems enteral feedings at least every 24 hours. 5. A review of Resident 59's Face Sheet, printed 8/7/24, indicated Resident 59 was admitted to the facility with multiple diagnoses which included diabetes mellitus (high blood sugar in the body) with diabetic neuropathy (diabetic nerve damage which often affect the legs and feet). A review of Resident 59's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 6/13/24, indicated Resident 59 had clear speech, was understood, and was able to understand others. Further review of the MDS showed Resident 59 was at risk of developing pressure ulcers/injuries related to his diagnoses. A review of Resident 59's Physician Order, start date 8/7/24, indicated right lateral foot venous stasis ulcer (wound caused by problems with blood flow): Clean area with normal saline (NS, mixture of water and salt with a salt concentration of 0.9%), pat dry, paint area with betadine (a topical antiseptic used for skin disinfection) then leave air to dry daily x 14 days then re-evaluate. A review of Resident 59's Care Plan, dated 5/14/24, indicated Right Lateral Foot Border Venous Stasis, Treatment (Tx) as ordered: cleanse with NS . During Resident 59's concurrent wound treatment observation and interview on 8/7/24, at 9:32 a.m., with the Treatment Nurse (TN), resident's wound to right lateral foot venous stasis ulcer treatment was performed. TN painted resident's right lateral foot with the betadine-soaked gauze directly to the resident's foot without cleansing the area with NS, as indicated in the treatment order. TN stated she should have cleansed the wound before applying the betadine solution to avoid infection. During an interview on 8/7/24, at 2:24 p.m., with the Director of Staff Development (DSD), DSD stated Wound Treatment Procedure should be followed according to the physician's order. If there was an order for NS, then the wound should be cleansed with NS before the application of the ordered solution or ointment. A review of the facility's policy and procedure (P&P) titled, Wound Care and Treatment, undated, indicated, . Wash tissue around the wound that is usually covered by the dressing, tape, or gauze with antiseptic or soap and water .Apply treatments as indicated .

Based on interview, and record review, the facility failed to provide preventive care for pressure injury/ulcer (PI/PU, injury to skin and underlying tissue resulting from prolonged pressure) consistent with professional standards of practice for one of eight sampled residents (Resident 8) when Resident 8's physician's order of turning and repositioning every two hours was not consistently implemented. This failure resulted in Resident 8's sacral (lower back near the crease of the buttocks) wound to get worse and had the potential for Resident 8's skin condition to get worse, develop complications, and/or possible development of other pressure related injuries. Findings: A review of Resident 8's clinical record indicated Resident 8 was admitted July of 2023 and had diagnoses that included respiratory failure (a serious condition that develops when the lungs can't get enough oxygen into the blood and makes it difficult for a person to breathe on his own), nontraumatic subdural hemorrhage (a condition where a pool of blood is formed between the brain and the skull causing structural, biochemical or electrical abnormalities in the brain), and resistance to multiple antibiotics. A review of Resident 8's admission Minimum Data Set (MDS- an assessment tool used to guide care) Cognitive Patterns, dated 7/19/23, indicated Resident 8 was rarely or never understood. A review of Resident 8's admission MDS Skin Conditions, dated 7/19/23, indicated Resident 3 was at risk of developing pressure ulcers/injuries, had zero unhealed pressure ulcers/injuries, and had moisture associated skin damage (MASD- general term for inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, sweat, wound drainage, saliva, or mucus). A review of Resident 8's Wound Management Detail Report, dated 7/14/23, indicated, Patient [Resident 8] with skin redness and multiple skin excoriation [area where the skin is scraped] in coccyx [very bottom area of the lower back], bilateral [both sides] buttocks, and bilateral groin . A review of Resident 8's physician's order, dated 8/4/23, indicated, TURNING AND REPOSITIONING EVERY 2 HOURS AND AS NEEDED Every Shift; Shift 1 07:00 AM - 03:00 PM, Shift 2 03:00 PM - 11:00 PM. Shift 3 11:00 PM - 07:00AM. The order was discontinued on 12/6/23. A review of Resident 8's Wound Management Detail Report, dated 9/27/23, indicated, Noted sacral wound open area measuring 11 x 5 cm [centimeters- unit of measurement] with irregular edges .with noted dti [deep tissue injury- a serious form of PI which presents as purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear] measuring 3 x 2.6 cm, no drainage, no odor, no pain . During a concurrent interview and record review on 3/12/24 at 10:13 a.m. with the Director of Nursing (DON), Resident 8's clinical record was reviewed. The DON confirmed that there was no documentation that Resident 8 was turned and repositioned every 2 hours on the following dates and shifts: 8/7/23- Shift 2 8/8/23- Shift 1 8/11/23- Shift 3 8/13/23- Shift 1 8/18/23- Shift 3 8/25/23- Shift 1 8/26/23- Shift 3 9/7/23- Shift 1 9/12/23- Shift 1 9/13/23- Shift 1 9/14/23- Shift 1 9/21/23- Shift 1 10/15/23- Shift 1 10/17/23- Shift 1 11/13/23- Shift 1 The DON stated Resident 8 was bedbound (patients who has become very weak and is no longer able to move easily, which made them confined to their bed) and needed turning and repositioning in bed. The DON further stated, .I know, if it's [turning and repositioning every 2 hours] not documented, it's not done .There are 4 opportunities [of turning and repositioning Resident 8] in every shift; 8 hours per shift .So the risk [if resident 8 was not turned or repositioned every 2 hours] is, because of heat and moisture, the potential for skin breakdown will increase .There are no documentations that she was refusing to be turned or repositioned. A review of Resident 8's Wound Management Detail Report, dated 10/24/23, indicated Resident 8 had an Unstageable pressure ulcer (PU-full-thickness tissue loss type of pressure injuries in which the base is obscured) on the sacrum measuring 11.7 x 13 cm, with 60% (percent- measurement of one part in every hundred) slough (a dead tissue, usually cream or yellow in color), and with moderate serosanguineous (pale red or pink, thin and watery) exudate (secretion). A review of Resident 8's hospital admission records, encounter date of 11/15/23, indicated, .MUSCULOSKELETAL [relating to muscles, bones, and other tissues that gives the body its structure, support and lets the body move]: .base of sacral decubitus [other term for PI/PU] with areas of necrosis [death of body tissue] and foul odor. Thickened surrounding skin. A review of the facility's policy and procedure (P&P) titled, Pressure Ulcer & Skin Care Management, undated, indicated, 9. The nursing staff reviews the pressure ulcer prevention and treatment procedures with the resident's physician .b. The licensed nurse implements the wound care treatment procedures in accordance with current standards of practice.

Based on observation, interview, and record review, the facility failed to ensure proper handling and delivery of respiratory care consistent with the facility's policy and procedures (P&P) and the professional standards of practice for three out of eight sampled residents (Resident 3, Resident 5, and Resident 7) when: 1. Resident 3's nasal cannula (a medical device with two prongs that is connected to an oxygen source used to deliver supplemental oxygen directly into the nostrils) was not labeled with the date it was first used; 2. Resident 5's nasal cannula and nebulizer (machine that turns liquid medicine into a mist that can be easily inhaled) simple facemask and tubing was not labeled with the date it was initially used and Resident 5's physician's orders for oxygen therapy were not followed; and, 3. Resident 7's nasal cannula was not labeled with the date it was first used and Resident 7 had no physician's order for the use of oxygen therapy. These failures had the potential to result in unsafe and unsanitary delivery of oxygen to Resident 3, Resident 5, and Resident 7. Findings: 1. A review of Resident 3's clinical record indicated Resident 3 was admitted January of 2024 and had diagnoses that included respiratory failure (a serious condition that develops when the lungs can't get enough oxygen into the blood and makes it difficult for a person to breathe on his own), chronic obstructive pulmonary disease (COPD- a group of diseases that causes airflow blockage and breathing-related problems), and dementia (memory loss that interferes with daily functions). A review of Resident 3's Minimum Data Set (MDS- an assessment tool used to guide care) Cognitive Patterns, dated 1/23/24, indicated Resident 3 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 6 out of 15 which indicated Resident 3 had a severely impaired cognition. A review of Resident 3's MDS Special Treatments, Procedures, and Programs, dated 1/23/24, indicated Resident 3 had oxygen therapy while he is a resident in the facility. A review of Resident 3's active physician's order, dated 1/17/24, indicated, O2 [oxygen] @ [at] 5 LITERS/MINUTE [lpm- unit of measurement for oxygen administration] FOR SOB [shortness of breath] WHEEZING [a high-pitched whistling sound made while breathing which is a sign that a person may be having breathing problems] CONGESTION [sic] Q [every] SHIFT . During a concurrent observation and interview on 3/11/24 at 11:17 a.m. with Resident 3 in Resident 3's room, Resident 3 was observed using an oxygen concentrator at 5 lpm delivered via nasal cannula. Resident 3's nasal cannula was not labeled with the date of when it was first used. Resident 3 confirmed the observation. Resident 3 stated she does not know when the last time her nasal cannula was changed. During a concurrent observation and interview on 3/11/24 at 11:31 a.m. with Licensed Nurse (LN) 1 in Resident 3's room, LN 1 confirmed that Resident 3's nasal cannula was not labeled with the date it was first used. LN 1 stated, It [nasal cannula] should have the date [when it was first used] .So we know when to change it [nasal cannula] .It's [regularly changing nasal cannula] to prevent infection. 2. A review of Resident 5's clinical record indicated Resident 5 was admitted February of 2024 and had diagnoses that included respiratory failure, COPD, and diabetes mellitus (a chronic condition causing too much sugar in the blood that can affect lung function and breathing). A review of Resident 5's MDS Cognitive Patterns, dated 2/9/24, indicated Resident 5 had a BIMS score of 14 out of 15 which indicated Resident 5 had an intact cognition. A review of Resident 5's MDS Special Treatments, Procedures, and Programs, dated 2/9/24, indicated Resident 5 had oxygen therapy while he is a resident in the facility. A review of Resident 5's active physician's order, dated 2/9/24, indicated, O2 3 LPM VIA NASAL CANNULA. Special Instructions: APPLY O2 3LPM VIA NC [nasal cannula] (CONTINUES) [sic] FOR OXYGEN THERAPHY [sic] . A review of Resident 5's active physician's order, dated 2/9/24, indicated, albuterol sulfate solution [a liquid medicine used to prevent and treat symptoms caused by lung diseases which is administered via nebulizer] for nebulization .Special Instructions: Give 1 vial [a cylindrical container use for holding liquid medicines] every 6 hours as needed for SOB or wheezing . A review of Resident 5's active physician's order, dated 2/9/24, indicated, ipratropium-albuterol solution [a liquid medicine used to prevent and treat symptoms caused by lung diseases which is administered via nebulizer] for nebulization .Special Instructions: ADMINISTER 3 ML [milliliters- unit of measurement] Q 6 HOURS ATC [around the clock] FOR SOB WHEEZING CONGESTION [sic] . A review of Resident 5's active physician's order, dated 2/29/24, indicated, budesonide suspension [a liquid medicine used to prevent and treat symptoms caused by lung diseases which is administered via nebulizer] for nebulization .Special Instructions: Administer 2ml via nebulizer q 12 hours as needed for SOB WHEEZING CONGESTION [sic] . A review of Resident 5's active physician's order, dated 3/5/24, indicated, formoterol fumarate solution [a liquid medicine used to prevent and treat symptoms caused by lung diseases which is administered via nebulizer] for nebulization .Special Instructions: Administer 1 vial via nebulizer BID [twice a day] for SOB and Wheezing . During a concurrent observation and interview on 3/11/24 at 11:36 a.m. with Resident 5 in Resident 5's room, Resident 5 was observed using an oxygen concentrator at 4.5 lpm delivered via nasal cannula which was not labeled with the date it was first used. Resident 5 was also observed to be using a nebulizer for her breathing treatment delivered via simple facemask which was also not labeled with the date it was first used. Resident 3 confirmed the observation. Resident 3 stated she does not know when the last time her nasal cannula and simple facemask was changed. During a concurrent observation and interview on 3/11/24 at 11:46 a.m. with LN 2 in Resident 5's room, LN 2 confirmed that Resident 5's nasal cannula, simple facemask, and respiratory tubing were not labeled with the date it was first used. LN 2 also confirmed that Resident 5's oxygen flow rate was set at 4.5 lpm. LN 2 stated, They [nasal cannula, simple facemask, and respiratory tubing] should be labeled with paper tape .Should be labeled with date, Resident initials and room number .So we [staff] know when it [nasal cannula, simple facemask, and respiratory tubing] was last changed and who is it for .[This is] To prevent infection, to make sure it ' s [nasal cannula, simple facemask, and respiratory tubing] clean. It ' s for infection control. A review of Resident 5's care plan approach, dated 1/9/24, indicated, Provide oxygen as prescribed. During a concurrent interview and record review on 3/12/24 at 8:46 a.m. with the Director of Staff Development (DSD), Resident 5's clinical records was reviewed. The DSD confirmed that Resident 5's order for oxygen therapy is at 3 lpm. The DSD stated, .We need to follow the doctors order. If it's [oxygen] given higher [than the physician's order], the risk is hyperoxygenation [a condition in which the body is exposed to an unusual high amount of oxygen causing respiratory and/or neurological problems] .It [administering higher rate of oxygen than what is ordered] will cause health problems . A review of the facility's policy and procedure (P&P) titled, Oxygen Administration, dated 12/18/23, indicated, A resident will need oxygen therapy when hypoxemia (low oxygen in blood) occurs .clinical examinations will determine the adequacy of oxygen therapy .9. Turn the unit on to the desired flow rate . 3. A review of Resident 7's clinical record indicated Resident 7 was admitted January of 2024 and had diagnoses that included heart failure (a condition in which the heart cannot pump oxygen-rich blood efficiently to the rest of the body affecting lung function and breathing), end stage renal disease (occurs when the gradual loss of kidney function reaches an advanced state where kidneys no longer work as they should to meet the body's needs), and dependence on renal dialysis (the process of removing excess water, particles, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). A review of Resident 7's MDS Cognitive Patterns, dated 1/14/24, indicated Resident 7 had a BIMS score of 12 out of 15 which indicated Resident 7 had a moderately impaired cognition. During a concurrent observation and interview on 3/11/24 at 2:44 p.m. with Resident 7 in Resident 7's room, Resident 7 was observed using an oxygen concentrator at 2 lpm delivered via nasal cannula. Resident 7's nasal cannula was not labeled with the date of when it was first used. Resident 7 confirmed the observation. Resident 7 stated she does not know when the last time her nasal cannula was changed. During a concurrent observation and interview on 3/11/24 at 2:55 p.m. with Treatment Nurse (TN) in Resident 7's room, TN confirmed that Resident 7's nasal cannula was not labeled with the date it was first used. TN stated, We [staff] usually label it [nasal cannula] . we [staff] put the date, time, and initial it [nasal cannula] .For infection control. During a concurrent interview and record review on 3/11/24 at 4:36 p.m. with the Infection Preventionist (IP), Resident 7's clinical records were reviewed. The IP confirmed that there was no physician's order for Resident 7's use of oxygen therapy. The IP stated, It ' s [not having a physicians order for oxygen therapy] not safe .we always need to have a doctor's order [for oxygen therapy] as a standard of practice. During an interview on 3/12/24 at 10:13 a.m. with the Director of Nursing (DON), the DON stated, .[My] expectation is to change it [nasal cannula, simple facemask, and respiratory care tubing] every week .Label it [nasal cannula, simple facemask, and respiratory care tubing] with date, time, and nurse initial .It ' s infection control risk if it's [nasal cannula, simple facemask, and respiratory care tubing] not changed every week. The DON also stated, .if the resident needs it [oxygen therapy], there should be an order before the resident receives it [oxygen therapy]. Whoever applied the oxygen should communicate with their supervisor to ensure that the order [for oxygen therapy] is there . The DON further stated, .[I] expect it [physician's order for oxygen therapy] to be followed .To ensure the correct [oxygen] regulation is given [to the resident]. If it ' s [oxygen therapy delivery] higher [than what is ordered], it could cause hyperoxygenation and it could result to respiratory problems . A review of the Centers for Medicare and Medicaid Services (CMS) document titled, Respiratory Therapy (Respiratory Care), revised 7/22/21, indicated, There must be a specific written order by the physician for all respiratory therapy (respiratory care) services. (https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=34430) A review of the facility's P&P titled, Care and Handling of Respiratory Equipment, undated, indicated, Care should be exercised in handling respiratory equipment to prevent contamination .5. Equipment should be changed based on the following schedule: a. Change within every seven days .Cannula and humidifier, Simple facemask, Oxygen tubing . Based on observation, interview, and record review, the facility failed to ensure proper handling and delivery of respiratory care consistent with the facility's policy and procedures (P&P) and the professional standards of practice for three out of eight sampled residents (Resident 3, Resident 5, and Resident 7) when: 1. Resident 3's nasal cannula (a medical device with two prongs that is connected to an oxygen source used to deliver supplemental oxygen directly into the nostrils) was not labeled with the date it was first used; 2. Resident 5's nasal cannula and nebulizer (machine that turns liquid medicine into a mist that can be easily inhaled) simple facemask and tubing was not labeled with the date it was initially used and Resident 5's physician's orders for oxygen therapy were not followed; and, 3. Resident 7's nasal cannula was not labeled with the date it was first used and Resident 7 had no physician's order for the use of oxygen therapy. These failures had the potential to result in unsafe and unsanitary delivery of oxygen to Resident 3, Resident 5, and Resident 7. Findings: 1. A review of Resident 3's clinical record indicated Resident 3 was admitted January of 2024 and had diagnoses that included respiratory failure (a serious condition that develops when the lungs can't get enough oxygen into the blood and makes it difficult for a person to breathe on his own), chronic obstructive pulmonary disease (COPD- a group of diseases that causes airflow blockage and breathing-related problems), and dementia (memory loss that interferes with daily functions). A review of Resident 3's Minimum Data Set (MDS- an assessment tool used to guide care) Cognitive Patterns, dated 1/23/24, indicated Resident 3 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 6 out of 15 which indicated Resident 3 had a severely impaired cognition. A review of Resident 3's MDS Special Treatments, Procedures, and Programs, dated 1/23/24, indicated Resident 3 had oxygen therapy while he is a resident in the facility. A review of Resident 3's active physician's order, dated 1/17/24, indicated, O2 [oxygen] @ [at] 5 LITERS/MINUTE [lpm- unit of measurement for oxygen administration] FOR SOB [shortness of breath] WHEEZING [a high-pitched whistling sound made while breathing which is a sign that a person may be having breathing problems] CONGESTION [sic] Q [every] SHIFT . During a concurrent observation and interview on 3/11/24 at 11:17 a.m. with Resident 3 in Resident 3's room, Resident 3 was observed using an oxygen concentrator at 5 lpm delivered via nasal cannula. Resident 3's nasal cannula was not labeled with the date of when it was first used. Resident 3 confirmed the observation. Resident 3 stated she does not know when the last time her nasal cannula was changed. During a concurrent observation and interview on 3/11/24 at 11:31 a.m. with Licensed Nurse (LN) 1 in Resident 3's room, LN 1 confirmed that Resident 3's nasal cannula was not labeled with the date it was first used. LN 1 stated, It [nasal cannula] should have the date [when it was first used] .So we know when to change it [nasal cannula] .It's [regularly changing nasal cannula] to prevent infection. 2. A review of Resident 5's clinical record indicated Resident 5 was admitted February of 2024 and had diagnoses that included respiratory failure, COPD, and diabetes mellitus (a chronic condition causing too much sugar in the blood that can affect lung function and breathing). A review of Resident 5's MDS Cognitive Patterns, dated 2/9/24, indicated Resident 5 had a BIMS score of 14 out of 15 which indicated Resident 5 had an intact cognition. A review of Resident 5's MDS Special Treatments, Procedures, and Programs, dated 2/9/24, indicated Resident 5 had oxygen therapy while he is a resident in the facility. A review of Resident 5's active physician's order, dated 2/9/24, indicated, O2 3 LPM VIA NASAL CANNULA. Special Instructions: APPLY O2 3LPM VIA NC [nasal cannula] (CONTINUES) [sic] FOR OXYGEN THERAPHY [sic] . A review of Resident 5's active physician's order, dated 2/9/24, indicated, albuterol sulfate solution [a liquid medicine used to prevent and treat symptoms caused by lung diseases which is administered via nebulizer] for nebulization .Special Instructions: Give 1 vial [a cylindrical container use for holding liquid medicines] every 6 hours as needed for SOB or wheezing . A review of Resident 5's active physician's order, dated 2/9/24, indicated, ipratropium-albuterol solution [a liquid medicine used to prevent and treat symptoms caused by lung diseases which is administered via nebulizer] for nebulization .Special Instructions: ADMINISTER 3 ML [milliliters- unit of measurement] Q 6 HOURS ATC [around the clock] FOR SOB WHEEZING CONGESTION [sic] . A review of Resident 5's active physician's order, dated 2/29/24, indicated, budesonide suspension [a liquid medicine used to prevent and treat symptoms caused by lung diseases which is administered via nebulizer] for nebulization .Special Instructions: Administer 2ml via nebulizer q 12 hours as needed for SOB WHEEZING CONGESTION [sic] . A review of Resident 5's active physician's order, dated 3/5/24, indicated, formoterol fumarate solution [a liquid medicine used to prevent and treat symptoms caused by lung diseases which is administered via nebulizer] for nebulization .Special Instructions: Administer 1 vial via nebulizer BID [twice a day] for SOB and Wheezing . During a concurrent observation and interview on 3/11/24 at 11:36 a.m. with Resident 5 in Resident 5's room, Resident 5 was observed using an oxygen concentrator at 4.5 lpm delivered via nasal cannula which was not labeled with the date it was first used. Resident 5 was also observed to be using a nebulizer for her breathing treatment delivered via simple facemask which was also not labeled with the date it was first used. Resident 3 confirmed the observation. Resident 3 stated she does not know when the last time her nasal cannula and simple facemask was changed. During a concurrent observation and interview on 3/11/24 at 11:46 a.m. with LN 2 in Resident 5's room, LN 2 confirmed that Resident 5's nasal cannula, simple facemask, and respiratory tubing were not labeled with the date it was first used. LN 2 also confirmed that Resident 5's oxygen flow rate was set at 4.5 lpm. LN 2 stated, They [nasal cannula, simple facemask, and respiratory tubing] should be labeled with paper tape .Should be labeled with date, Resident initials and room number .So we [staff] know when it [nasal cannula, simple facemask, and respiratory tubing] was last changed and who is it for .[This is] To prevent infection, to make sure it's [nasal cannula, simple facemask, and respiratory tubing] clean. It's for infection control. A review of Resident 5's care plan approach, dated 1/9/24, indicated, Provide oxygen as prescribed. During a concurrent interview and record review on 3/12/24 at 8:46 a.m. with the Director of Staff Development (DSD), Resident 5's clinical records was reviewed. The DSD confirmed that Resident 5's order for oxygen therapy is at 3 lpm. The DSD stated, .We need to follow the doctors order. If it's [oxygen] given higher [than the physician's order], the risk is hyperoxygenation [a condition in which the body is exposed to an unusual high amount of oxygen causing respiratory and/or neurological problems] .It [administering higher rate of oxygen than what is ordered] will cause health problems . A review of the facility's policy and procedure (P&P) titled, Oxygen Administration, dated 12/18/23, indicated, A resident will need oxygen therapy when hypoxemia (low oxygen in blood) occurs .clinical examinations will determine the adequacy of oxygen therapy .9. Turn the unit on to the desired flow rate . 3. A review of Resident 7's clinical record indicated Resident 7 was admitted January of 2024 and had diagnoses that included heart failure (a condition in which the heart cannot pump oxygen-rich blood efficiently to the rest of the body affecting lung function and breathing), end stage renal disease (occurs when the gradual loss of kidney function reaches an advanced state where kidneys no longer work as they should to meet the body's needs), and dependence on renal dialysis (the process of removing excess water, particles, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). A review of Resident 7's MDS Cognitive Patterns, dated 1/14/24, indicated Resident 7 had a BIMS score of 12 out of 15 which indicated Resident 7 had a moderately impaired cognition. During a concurrent observation and interview on 3/11/24 at 2:44 p.m. with Resident 7 in Resident 7's room, Resident 7 was observed using an oxygen concentrator at 2 lpm delivered via nasal cannula. Resident 7's nasal cannula was not labeled with the date of when it was first used. Resident 7 confirmed the observation. Resident 7 stated she does not know when the last time her nasal cannula was changed. During a concurrent observation and interview on 3/11/24 at 2:55 p.m. with Treatment Nurse (TN) in Resident 7's room, TN confirmed that Resident 7's nasal cannula was not labeled with the date it was first used. TN stated, We [staff] usually label it [nasal cannula] . we [staff] put the date, time, and initial it [nasal cannula] .For infection control. During a concurrent interview and record review on 3/11/24 at 4:36 p.m. with the Infection Preventionist (IP), Resident 7's clinical records were reviewed. The IP confirmed that there was no physician's order for Resident 7's use of oxygen therapy. The IP stated, It's [not having a physicians order for oxygen therapy] not safe .we always need to have a doctor's order [for oxygen therapy] as a standard of practice. During an interview on 3/12/24 at 10:13 a.m. with the Director of Nursing (DON), the DON stated, .[My] expectation is to change it [nasal cannula, simple facemask, and respiratory care tubing] every week .Label it [nasal cannula, simple facemask, and respiratory care tubing] with date, time, and nurse initial .It's infection control risk if it's [nasal cannula, simple facemask, and respiratory care tubing] not changed every week. The DON also stated, .if the resident needs it [oxygen therapy], there should be an order before the resident receives it [oxygen therapy]. Whoever applied the oxygen should communicate with their supervisor to ensure that the order [for oxygen therapy] is there . The DON further stated, .[I] expect it [physician's order for oxygen therapy] to be followed .To ensure the correct [oxygen] regulation is given [to the resident]. If it's [oxygen therapy delivery] higher [than what is ordered], it could cause hyperoxygenation and it could result to respiratory problems . A review of the Centers for Medicare and Medicaid Services (CMS) document titled, Respiratory Therapy (Respiratory Care), revised 7/22/21, indicated, There must be a specific written order by the physician for all respiratory therapy (respiratory care) services. (https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=34430) A review of the facility's P&P titled, Care and Handling of Respiratory Equipment, undated, indicated, Care should be exercised in handling respiratory equipment to prevent contamination .5. Equipment should be changed based on the following schedule: a. Change within every seven days .Cannula and humidifier, Simple facemask, Oxygen tubing .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program for a census of 78 residents when: 1. Three facility staff entered a contact isolation precaution room (an isolation precaution implemented when a patient infected with a bacteria, virus, or other microorganism which is transmittable through direct or indirect contact with the patient or the patient ' s environment) without using all the required personal protective equipment (PPE); and, 2. Resident 3 and Resident 7's nasal cannula, and Resident 5's respiratory care tubing were not labeled with the date it was initially used. These failures resulted in an increased risk for cross-contamination (movement or transfer of harmful bacteria from one person, object, or place to another), potential exposure of Resident 3, Resident 7, and Resident 5 to germs, and may cause infection among residents, staff, and visitors. Findings: 1. During an observation on 3/11/24 at 12:58 p.m., room [ROOM NUMBER] had a red STOP sign posted on the left side of the door which indicated, CONTACT PRECAUTIONS. EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another patient. Below the STOP sign was also a signage which indicated, SEQUENCE FOR PUTTING ON PERSONAL PROTECTIVE EQUIPMENT (PPE) . 1. GOWN . 2. MASK OR RESPIRATOR . 3. GOGGLES OR FACE SHIELD . 4. GLOVES . Certified Nurse Assistant (CNA) 3 was observed entering room [ROOM NUMBER] only wearing facemask. During a concurrent observation and interview on 3/11/24 at 1:01 p.m. with Certified Nursing Assistant (CNA) 3, in front of room [ROOM NUMBER], CNA 3 confirmed that she entered room [ROOM NUMBER] and provided care to resident in bed A while only wearing facemask. CNA 3 stated she was aware that the residents in room [ROOM NUMBER] were on contact isolation precaution and she knows about the sign posted at the door that everyone needs to wear gloves and gown before entering the room. CNA 3 further stated, .The risk [of not wearing the required PPE] is I might get infected During an observation on 3/11/24 at 4:20 p.m. in front of room [ROOM NUMBER], a male facility staff, wearing navy blue scrub suit, was observed entering room [ROOM NUMBER] wearing only facemask. The staff talked to Resident in bed A, touched the bed rails and personal items of the resident in bed A. During a concurrent interview and record review on 3/11/24 at 4:36 p.m. with the Infection Preventionist (IP), the IP confirmed that room [ROOM NUMBER] was on contact isolation precaution and the resident in bed A was incontinent. The IP stated she would expect that everyone going inside room [ROOM NUMBER] to wear the required PPE such as gloves and gown, especially when doing patient care to the residents. The IP further stated, . [Staff entering room [ROOM NUMBER] should wear gloves and gown] Because they [staff] might get infected, and they [staff] can give it [infection] to other staff or residents . During an interview on 3/12/24 at 10:13 a.m. with the Director of Nursing (DON), the DON stated, .[I] expect the [contact isolation precaution] signage [posted on the door] should be followed .Donning [putting on] and doffing [removing] of the [required] PPE .They [staff] should do hand hygiene, wear gloves and gown when entering the room [room [ROOM NUMBER]] and doing patient care . [staff should] Do another donning and doffing every time the staff re-enters the room [room [ROOM NUMBER]] .The risk [of not wearing the required PPE] is they [staff] can get it [infection] and spread it [infection]. During a concurrent observation and interview on 3/12/24 at 11:39 a.m. with Licensed Nurse (LN) 3, in front of room [ROOM NUMBER], LN 3 was observed coming out from room [ROOM NUMBER] wearing only facemask and gloves. LN 3 confirmed that he entered room [ROOM NUMBER] and provided care to resident in bed A while only wearing facemask and gloves. LN 3 stated he was aware that the residents in room [ROOM NUMBER] were on contact isolation and knows that he should wear both gloves and gown before entering room [ROOM NUMBER]. LN 3 stated, Yes, I am supposed to wear gown too .It ' s [wearing the required PPE] for infection control. A review of the facility's policy and procedure (P&P) titled, Transmission Precautions: Contact, dated 4/7/23, indicated, 2. Gloves and Hand Hygiene. Wear clean, non-sterile gloves when entering the room .Do this to avoid transfer of microorganisms to other residents or environments. 3. Gowns. Wear a clean, non-sterile gown upon entering the resident's room if you anticipate substantial contact between your clothing and the resident, environmental surfaces, or items in the room. Wear gown if the resident is incontinent . 2a. A review of Resident 3's clinical record indicated Resident 3 was admitted January of 2024 and had diagnoses that included respiratory failure (a serious condition that develops when the lungs can't get enough oxygen into the blood and makes it difficult for a person to breathe on his own), chronic obstructive pulmonary disease (COPD- a group of diseases that causes airflow blockage and breathing-related problems), and dementia (memory loss that interferes with daily functions). A review of Resident 3's Minimum Data Set (MDS- an assessment tool used to guide care) Cognitive Patterns, dated 1/23/24, indicated Resident 3 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 6 out of 15 which indicated Resident 3 had a severely impaired cognition. A review of Resident 3's MDS Special Treatments, Procedures, and Programs, dated 1/23/24, indicated Resident 3 had oxygen therapy while he is a resident in the facility. A review of Resident 3's active physician's order, dated 1/17/24, indicated, O2 [oxygen] @ [at] 5 LITERS/MINUTE [lpm- unit of measurement for oxygen administration] FOR SOB [shortness of breath] WHEEZING [a high-pitched whistling sound made while breathing which is a sign that a person may be having breathing problems] CONGESTION [sic] Q [every] SHIFT . During a concurrent observation and interview on 3/11/24 at 11:17 a.m. with Resident 3 in Resident 3's room, Resident 3 was observed using an oxygen concentrator at 5 lpm delivered via nasal cannula. Resident 3's nasal cannula was not labeled with the date of when it was first used. Resident 3 confirmed the observation. Resident 3 stated she does not know when the last time her nasal cannula was changed. During a concurrent observation and interview on 3/11/24 at 11:31 a.m. with Licensed Nurse (LN) 1 in Resident 3's room, LN 1 confirmed that Resident 3's nasal cannula was not labeled with the date it was first used. LN 1 stated, It [nasal cannula] should have the date [when it was first used] .So we know when to change it [nasal cannula] .It ' s [regularly changing nasal cannula] to prevent infection. 2b. A review of Resident 7's clinical record indicated Resident 7 was admitted January of 2024 and had diagnoses that included heart failure (a condition in which the heart cannot pump oxygen-rich blood efficiently to the rest of the body affecting lung function and breathing), end stage renal disease (occurs when the gradual loss of kidney function reaches an advanced state where kidneys no longer work as they should to meet the body's needs), and dependence on renal dialysis (the process of removing excess water, particles, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). A review of Resident 7's MDS Cognitive Patterns, dated 1/14/24, indicated Resident 7 had a BIMS score of 12 out of 15 which indicated Resident 7 had a moderately impaired cognition. During a concurrent observation and interview on 3/11/24 at 2:44 p.m. with Resident 7 in Resident 7's room, Resident 7 was observed using an oxygen concentrator at 2 lpm delivered via nasal cannula. Resident 7's nasal cannula was not labeled with the date of when it was first used. Resident 7 confirmed the observation. Resident 7 stated she does not know when the last time her nasal cannula was changed. During a concurrent observation and interview on 3/11/24 at 2:55 p.m. with Treatment Nurse (TN) in Resident 7's room, TN confirmed that Resident 7's nasal cannula was not labeled with the date it was first used. TN stated, We [staff] usually label it [nasal cannula] . we [staff] put the date, time, and initial it [nasal cannula] .For infection control. 2c. A review of Resident 5's clinical record indicated Resident 5 was admitted February of 2024 and had diagnoses that included respiratory failure, COPD, and diabetes mellitus (a chronic condition causing too much sugar in the blood that can affect lung function and breathing). A review of Resident 5's MDS Cognitive Patterns, dated 2/9/24, indicated Resident 5 had a BIMS score of 14 out of 15 which indicated Resident 5 had an intact cognition. A review of Resident 5's MDS Special Treatments, Procedures, and Programs, dated 2/9/24, indicated Resident 5 had oxygen therapy while he is a resident in the facility. A review of Resident 5's active physician's order, dated 2/9/24, indicated, O2 3 LPM VIA NASAL CANNULA. Special Instructions: APPLY O2 3LPM VIA NC [nasal cannula] (CONTINUES) [sic] FOR OXYGEN THERAPHY [sic] . A review of Resident 5's active physician's order, dated 2/9/24, indicated, albuterol sulfate solution [a liquid medicine used to prevent and treat symptoms caused by lung diseases which is administered via nebulizer] for nebulization .Special Instructions: Give 1 vial [a cylindrical container use for holding liquid medicines] every 6 hours as needed for SOB or wheezing . A review of Resident 5's active physician's order, dated 2/9/24, indicated, ipratropium-albuterol solution [a liquid medicine used to prevent and treat symptoms caused by lung diseases which is administered via nebulizer] for nebulization .Special Instructions: ADMINISTER 3 ML [milliliters- unit of measurement] Q 6 HOURS ATC [around the clock] FOR SOB WHEEZING CONGESTION [sic] . A review of Resident 5's active physician's order, dated 2/29/24, indicated, budesonide suspension [a liquid medicine used to prevent and treat symptoms caused by lung diseases which is administered via nebulizer] for nebulization .Special Instructions: Administer 2ml via nebulizer q 12 hours as needed for SOB WHEEZING CONGESTION [sic] . A review of Resident 5's active physician's order, dated 3/5/24, indicated, formoterol fumarate solution [a liquid medicine used to prevent and treat symptoms caused by lung diseases which is administered via nebulizer] for nebulization .Special Instructions: Administer 1 vial via nebulizer BID [twice a day] for SOB and Wheezing . During a concurrent observation and interview on 3/11/24 at 11:36 a.m. with Resident 5 in Resident 5's room, Resident 5 was observed using an oxygen concentrator at 4.5 lpm delivered via nasal cannula which was not labeled with the date it was first used. Resident 5 was also observed to be using a nebulizer for her breathing treatment delivered via simple facemask which was also not labeled with the date it was first used. Resident 3 confirmed the observation. Resident 3 stated she does not know when the last time her nasal cannula and simple facemask was changed. During a concurrent observation and interview on 3/11/24 at 11:46 a.m. with LN 2 in Resident 5's room, LN 2 confirmed that Resident 5's nasal cannula, simple facemask, and respiratory tubing were not labeled with the date it was first used. LN 2 stated, They [nasal cannula, simple facemask, and respiratory tubing] should be labeled with paper tape .Should be labeled with date, Resident initials and room number .So we [staff] know when it [nasal cannula, simple facemask, and respiratory tubing] was last changed and who is it for .[This is] To prevent infection, to make sure it ' s [nasal cannula, simple facemask, and respiratory tubing] clean. It ' s for infection control. During an interview on 3/12/24 at 10:13 a.m. with the Director of Nursing (DON), the DON stated, .[My] expectation is to change it [nasal cannula, simple facemask, and respiratory care tubing] every week .Label it [nasal cannula, simple facemask, and respiratory care tubing] with date, time, and nurse initial .It ' s infection control risk if it's [nasal cannula, simple facemask, and respiratory care tubing] not changed every week. A review of the facility's P&P titled, Care and Handling of Respiratory Equipment, undated, indicated, Care should be exercised in handling respiratory equipment to prevent contamination .5. Equipment should be changed based on the following schedule: a. Change within every seven days .Cannula and humidifier, Simple facemask, Oxygen tubing .

Based on observation and interview, the facility failed to ensure medications were secure for a census of 76, when 3 medication carts were found unlocked and unattended. This failure had the potential to expose residents, staff, and visitors to unauthorized access to medications, resulting in possible injury or drug diversion. Findings: During an observation on 3/7/24 at 12:49 p.m., in the sub-acute hall, 3 medication carts up against the wall, side by side were unattended and unlocked. During a concurrent observation and interview on 3/7/24 at 12:55 p.m., with the Licensed Nurse (LN) 1, LN 1 confirmed the carts with prescription medications were unlocked. LN 1 stated, We lock the carts usually before we leave them. We all have keys. Just to be safe from anyone, residents or staff, getting into the cart. During an interview on 3/7/24 at 4:05 p.m., with the Director of Nursing (DON), the DON stated, I would expect the nurses to lock the carts before leaving them, for the safety of the other residents which could get into them and take the medications. During a review of the facility ' s policy and procedure (P&P) titled, Use of Medication Cart, undated, the P&P indicated, The nursing staff uses the medication cart to systematically distribute physician ordered medications to residents .Lock the medication cart with the key or the locking bar.

Based on observation, interview, and record review, the facility failed to accurately code rehabilitative services and functional status for one of 18 sampled residents (Resident 5) Minimum Data Set (MDS - an assessment tool to guide resident care) assessment. This failure resulted in an inaccurate reflection of Restorative Nursing Aide (RNA) interventions and functional status for Resident 5 and had the potential for Resident 5 to not receive care to meet their needs. Findings: During a record review of Resident 5's admission Record, the record indicated Resident 5 was admitted to the facility on 7/2002. The record indicated Resident 5 had a diagnosis of quadriplegia (condition where all four extremities have paralysis of varying degree). During a concurrent observation and interview with Resident 5, on 9/1/22, at 8:45 a.m., Resident 5 was lying in bed. Resident 5 was able to move upper extremities minimally and was not able to move lower extremities at all. Resident 5 stated he had contractures in both hands. Resident 5 stated he was dependent on staff to assist him with everything such as eating, toileting and being moved to wheelchair because of his quadriplegia and contractures. During a record review of Resident 5's physician orders, dated 3/23/22, the order indicated Resident 5 received RNA treatments including splint application three times a week until order end date 6/23/22. During a review of Resident 5's care plan titled, Joint Mobility limitations, dated 6/24/16, the care plan indicated to provide ROM (Range of Motion) exercises during care. During a concurrent interview and record review with MDS Coordinator (MDSC), on 9/2/22, at 11:14 a.m., section O of Resident 5's MDS assessment, dated 6/9/22, and Resident 5's Restorative Nursing record, dated 6/1/22 through 6/30/22, were reviewed. The MDS assessment indicated Resident 5 received 0 days of Passive Range of motion and 0 days of splint (device placed on extremities to preserve mobility and function) assistance whereas, Restorative Nursing record indicated Resident 5 received 15 minutes of passive range of motion and 120 minutes of splinting on 6/4/22. MDSC stated MDS assessment should reflect the RNA services provided between the period from 6/2/22 through 6/9/22. MDSC stated he utilized Resident 5's clinical records and his own observations to complete the MDS assessment. MDSC stated Resident 5's MDS assessment was an inaccurate reflection of RNA services that were provided to Resident 5 during the 7-days look back period from 6/9/22. A review of Resident Assessment Instrument (RAI) manual dated 10/2019 indicated, Restorative Nursing Programs .Steps for Assessment 1. Review the restorative nursing program notes and/or flow sheets in the medical record. 2. For the 7-day look-back period, enter the number of days on which the technique, training or skill practice was performed for a total of at least 15 minutes during the 24-hour period. During a concurrent interview and record review with MDSC, on 9/1/22, at 1:29 p.m., Resident 5's MDS assessment for functional status, dated 6/9/22 was reviewed. The assessment indicated Resident 5 did not have any impairment in Functional Limitation in Range of Motion for upper and lower extremities. MDSC stated because Resident 5 was non-functional due to quadriplegia and contractures, Resident 5 did not have any impairment in range of motion for both upper and lower extremities. MDSC stated because all Resident 5's ADLs (activities of daily living, activities related to personal care) were taken care of by staff, Resident 5's limited ROM and contractures could not affect normal functions of ADL or place Resident 5 at risk of injury. During an observation and interview on 8/31/22, at 10:38 a.m., with Certified Nursing Assistant (CNA 7), Resident 5 was watching television in his room. CNA 5 stated Resident 5 was totally dependent on staff for activities of daily living. CNA 5 stated Resident 5 was not able to use his extremities other than ability to use the touch call bell (a call light system used to call for help by just touching the sensor). During a concurrent interview and record review with Director of Nursing (DON), on 9/2/22, at 11:14 a.m., section G of Resident 5's MDS assessment was reviewed. DON stated Resident 5's contractures were a limit in range of motion and placed resident at risk of injury but stated she did not know how the field should be coded. A review of Resident Assessment Instrument (RAI) manual dated 10/2019 indicated, Code 2, impairment on both sides: if resident has an upper and/or lower extremity impairment on both sides that interferes with daily functioning or places the resident at risk of injury.

Based on observation, interview and record review, the facility failed to follow the fall prevention care plan for one of one sampled resident (Resident 40) when Resident 40 did not receive frequent monitoring every 15 minutes after experiencing three falls within a one month period. This failure resulted in Resident 5 experiencing three falls, not receiving individualized care and placing Resident 5 at risk of further falls and avoidable injuries. Findings: During a review of Resident 40's undated admission Record, the record indicated Resident 40 was admitted to the facility in 2018, with diagnoses of muscle weakness, difficulty walking, and dementia with behavioral disturbance (a group of thinking and social symptoms that interferes with daily functioning such as memory loss and judgement). During a record review of Resident 40's Minimum Data Set (MDS- a standardized resident assessment and care screening tool), dated 7/23/22, indicated Resident 40 had moderately impaired cognitive function (mental function of acquiring knowledge and understanding through experiences and thought). The MDS indicated Resident 40 required extensive assistance of two- staff with bed mobility and transfers. During a record review of the Fall Risk Care Plan, dated 8/2/22, the care plan indicated Resident 40 was at risk for falls. The care plan indicated to monitor Resident 40 frequently every 15 minutes. During a record review of the Observation Detail List Reports for Fall, dated 8/27/22, the report indicated Resident 40 had three incidents of unwitnessed falls, and the most recent fall was on 8/27/22. The record indicated Resident 40 was found lying on his left side on the floor in his room and the physician ordered to conduct a frequent monitoring every 15 minutes. During an observation and interview on 8/31/22, at 8:30 a.m., Resident 40 was lying in bed. Resident 40 stated he fell out of bed twice recently. During an interview on 8/31/22 at 8:35 a.m., with Certified Nursing Assistant (CNA 5) in the Resident 40's room, CNA 5 stated she was unaware of Resident 40's recent falls and monitored Resident 40 only twice a shift, unless his call light was on. During an interview on 8/31/22, at 8:40 a.m., with Registered Nurse (RN 2), the charge nurse for Resident 40, stated Resident 40 had a recent fall on 8/27/22. RN 2 stated Resident 40 had another incident of fall in the same room prior to 8/27/22 but did not remember the exact date for that fall. RN 2 further stated staff were required to monitor Resident 40 every 15 minutes and document in the safety checks in the Electronic Health Record (EHR). During an interview on 9/01/22, at 12:18 p.m., with Director of Nursing (DON), the DON stated Resident 40 had a recent fall on 8/27/22, 8/13/22 and 8/2/22. DON stated staff were to monitor Resident 40 every 15 minutes and document in safety checks in the EHR. The DON stated there was no documentation done for frequent monitoring for Resident 40's post fall since 8/27/22 until 9/1/22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow the physician's order for one of three sampled residents (Resident 26) with a risk of developing pressure sores when the physician's order to apply heel protectors for Resident 26 was not followed. This failure put Resident 26 at risk for developing pressure ulcers or injury to both heels. Findings: Review of Resident 26's undated Face Sheet indicated Resident 26 was admitted to the facility on [DATE] with diagnoses which included Hemiplegia and hemiparesis (muscle weakness on one side of the body making it hard to perform everyday activities like eating or dressing; may also cause loss of balance), disorder of muscle, and lack of coordination. Resident 26 was observed from 8/30/22 through 9/1/22 at various times. Resident 26 was observed lying on his back in bed without heel protectors at all times. During an interview with Licensed Vocational Nurse (LVN) 1, on 9/1/22, at 11:55 a.m., LVN 1 stated she was not aware Resident 26 needed heel protectors, but later verified that there was a physician's order for CNAs (certified nursing assistants) to apply bilateral heel protectors for up to 12 hours daily or as tolerated. CNAs/LN (certified nursing assistants/licensed nurses) to monitor skin integrity for redness, open areas, swelling, circulation and pain before and after application. During an interview on 9/1/22, at 12:10 p.m., with Restorative Nursing Assistant (RNA) 1, RNA 1 stated Resident 26's heel protectors were supposed to be applied by CNAs, while RNA 1 was responsible for applying splints. A review of Resident 26's care plan, dated 8/12/22, indicated Resident 26's heel protectors will be applied to both feet to relieve pressure. Review of Resident 26's MDS (Minimum Data Set, a standardized comprehensive assessment to guide care) indicated Resident 26 was totally dependent on staff for all activities of daily living including shifting positions in bed. Resident 26's MDS Section M regarding skin and ulcer/injury treatments included pressure reducing device for bed, turning and repositioning program, and application of nonsurgical dressings. Resident 26's MDS indicated his Brief Interview for Mental Status (BIMS, a tool that evaluates memory and orientation) score was three out of 15 which indicated severe impaired mental function. A review of the facility's policy and procedure titled, Pressure Ulcer & Skin Care Management, dated 8/20/20, indicated the purpose of the Pressure Ulcer/Injury and Skin Care Management was to reduce the risk of new pressure ulcers/injuries developing and implements treatment procedures in accordance with professional standards of practice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure appropriate indwelling catheter (a tube inserted into the urinary bladder which drains urine into a drainage bag outside the body) care for one of eight sampled residents (Resident 179) when Resident 179's. This deficient practice had the potential for Resident 179 to develop an infection or a urinary tract infection. Findings: A review of Resident 179's undated Face Sheet indicated Resident 179 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure (serious condition that makes it difficult to breathe on your own). During an observation on 8/30/22, at 10:05 a.m., at Resident 179's bedside, Resident 179's indwelling catheter bag was full and there was urine in the tubing. During an interview on 8/30/22, at 10:25 a.m., with Registered Nurse (RN) 1, RN 1 stated resident 179's indwelling catheter bag was overflowed. RN 1 stated the night shift Certified Nursing Assistant (CNA) should have emptied the drainage bag, or the day shift nurse should have noticed this during their rounds at the start of the shift. During a record review of Resident 179's physician order report, dated 9/1/22-9/30/22, it indicated Resident 179's drainage bad to be emptied at least every shift. Review of the facility's policy and procedure (P&P) titled, Indwelling Catheter Care, dated 3/00, indicated, Routine catheter care helps prevent infections and other complications, and is usually performed daily. The P&P further indicated, Empty the collection bag at least every 8 hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow the tracheostomy care policy and procedure and provide one of 23 residents (Resident 35) tracheostomy (a surgical opening on the neck for placing a breathing tube) care consistent with professional standards of practice when Resident 35's tracheostomy had thick greenish matter around the tracheostomy opening and soiled dressing around the stoma site (the opening in the neck where the tracheostomy tube is placed). This deficient practice placed Resident 35 at risk for airway obstruction, skin irritation, and infection. Findings: Review of Resident 35's undated Face Sheet indicated Resident 35 was admitted to the facility on [DATE] with diagnoses including Acute Respiratory Failure (a condition that makes it difficult to breathe on your own), and encounter for attention to tracheostomy (use of tracheostomy for breathing). During observation on 8/30/22, at 11:10 a.m., at Resident 35's bedside, Resident 35 had thick greenish matter which looked like mucus around the stoma and around the tracheostomy mask (a device used to deliver oxygen from the opening of the neck into the trachea (windpipe or are where your voice box connects to your lungs). The dressing around Resident 35's stoma was heavily soiled with the thick greenish matter. During an interview with Respiratory Therapist (RT) 1, on 8/30/22, at 11: 20 a.m., RT 1 stated Resident 35 frequently coughed, which caused the thick greenish matter in her trachea to come out. Resident 35 required frequent suctioning and stoma dressing changes to prevent skin irritation around the stoma site. During a concurrent observation and interview with Infection Preventionist (IP), on 8/31/22, at 10:05 a.m., Resident 35's tracheostomy mask was filled with thick greenish matter. Resident 35 had dried patches of these thick greenish matter over her upper chest, and the Resident 35's stoma dressing was severely soaked with the same matter. IP stated Resident 35 needed suctioning and tracheostomy care more often to keep Resident 35 clean and more comfortable. Review of Resident 35's Physician Order Report dated 9/1/22-9/30/22, indicated Resident 35 was ordered tracheostomy care every shift three times a day. A review of the facility's undated policy and procedure titled, Tracheostomy Care indicated, Tracheostomy care is the process of aseptically cleaning the tracheostomy tube and stoma site. The buildup of mucus and the rubbing of the tracheostomy tube can irritate the skin around the stoma. The skin around the stoma should be cleaned at least twice a day to prevent odor, irritation, and infection 7. Suction the tracheostomy as often as necessary .

Based on interviews and record reviews, the facility failed to complete 17 of 18 sampled residents' (Residents 6, 9, 32, 33, 11, 27, 16, 3, 5, 2, 10, 29, 4, 21, 37, 12 and 19) Minimum Data Set (MDS - an assessment tool to guide resident care) assessments within 92 calendar days. This failure resulted in Residents 6, 9, 32, 33, 11, 27, 16, 3, 5, 2, 10, 29, 4, 21, 37, 12 and 19 to not receive a timely assessment and had the potential to delay resident's care based on their individual physical and psychosocial needs. Findings: During a concurrent interview and record review with MDS coordinator (MDSC), on 9/1/22, at 12:07 p.m., Section Z of the MDS assessments for 18 residents were reviewed. Review of the completion dates of last two MDS assessments for 17 residents indicated: Residents 6, 9, 11, 3, 5, 2, 10, 4, and 12 did not have a completed MDS assessment between 3/2022 and 8/2022. Residents 32, 33, 27, 16, 29, 21, 19 did not have a completed MDS assessment between 4/2022 and 8/2022. Resident 37 did not have a completed MDS assessment between 1/2022 and 6/2022. MDSC stated the MDS assessments for Residents 6, 9, 32, 33, 11, 27, 16, 3, 5, 2, 10, 29, 4, 21, 37, 12 and 19 were completed late. MDSC stated he followed the Resident Assessment Instrument (RAI - guide for completing MDS assessment) manual as a guide to complete the assessments. MDSC stated his prolonged unplanned absence caused the assessments to go uncompleted. During an interview with Director of Nursing (DON) and MDS Supervisor (MDSS), on 9/2/22, at 10:57 a.m., DON and MDSS stated a remote MDS coordinator was available but was unable to complete MDS assessments for the 17 residents. DON stated late completion of MDS assessments placed Residents 6, 9, 32, 33, 11, 27, 16, 3, 5, 2, 10, 29, 4, 21, 37, 12 and 19 at risk of not receiving individualized care. A review of MDS 3.0 RAI manual's RAI-OBRA required Assessment Summary chart, dated 10/2019, indicated quarterly assessments are required to be completed every 92 calendar days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a concurrent observation and interview on 8/31/22, at 9:30 a.m., with CNA 6, Resident 75's toenails for both feet were observed. Resident 75's toenails were long, hardened, thickened, and yellowish brown in color. CNA 6 stated Resident 75's toenails were very hard, and CNA 6 did not feel comfortable cutting them. During a concurrent interview and record review on 8/31/22, at 10:47 a.m., with Registered Nurse (RN) 1, Resident 75's active orders section in the electronic health record was reviewed. RN 1 stated the physician ordered a podiatry consult for Resident 75 on 5/16/22 but the podiatrist did not evaluate and treat Resident 75. During an interview on 9/02/22, at 10:21 a.m., with the DON, the DON stated clinical staff were expected to follow up on ancillary referrals at least weekly. DON was unable to find any documentation on the podiatry referral for Resident 75 since the referral was ordered on 5/16/22. During a record review of facility policy and procedure titled, Resident Care 1: Basic Resident Care- Foot Care, dated 3/2000, indicated, Purpose: to promote cleanliness and prevent infection a licensed nurse, therapist, or podiatrist must trim toenails of a diabetic resident. Based on observation, interview, and record review, the facility failed to ensure three of five sampled residents (Resident 51, 43 and 75) received grooming and personal hygiene care when: 1. Resident 51 and 43 had long, sharp fingernails with black matter underneath on both hands; and 2. Resident 75 did not receive toenail care. These failures resulted in Residents 51, 43 and 75 to feel helpless and placed them at risk for developing infections and hurting themselves with long nails. Findings: 1. During a review of Resident 51's Face Sheet, printed 9/2/22, the face sheet indicated Resident 51 was originally admitted to the facility on [DATE] and had medical diagnoses including hemiplegia (weakness of one side of body) and hemiparesis (loss of strength on one side of the body) following cerebral infarction (Stroke) affecting unspecified side. During a record review of Resident 51's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 5/21/2022, the MDS Section G indicated, Resident 51 was totally dependent on staff for showers and needed extensive assistance to maintain personal hygiene and grooming. The MDS indicated Resident 51's Brief Interview of Mental Status (BIMS, an assessment for cognition status) score was three out of 15 and indicated severe mental impairment. During a concurrent observation and interview on 8/30/22, at 10:33 a.m., with Licensed Vocational Nurse (LVN) 2, Resident 51 had long sharp fingernails and black matter underneath on both hands. LVN 2 stated Resident 51 can dig long nails into his own hands and cause scratches, skin tear and infection. During a review of Resident 51's Care Plan-ADL [Activities of daily living, activities related to personal care] self -care deficit, revised on 8/5/22, the care plan goal indicated Resident 51 will be provided with needed assistance to maintain comfort and dignity. During an interview on 9/1/22, at 10:00 a.m., with Director of Nursing (DON), DON stated staff were expected to assist Resident 51 to perform ADL care and provide nail care. The DON stated it was very important for the dignity of Resident 51. DON stated the long nails could dig into the contracted palms of Resident 51. DON also stated when nail care was not provided, it could result in skin injury from scratching, nail deformity and possible infection. During a review of Resident 43's Face Sheet, printed 9/2/22, the face sheet indicated Resident 43 was originally admitted to the facility on [DATE] and had medical diagnoses including Unspecified dementia (memory loss) with behavioral disturbance. During a record review of Resident 43's MDS, dated [DATE], the MDS Section G indicated, Resident 43 was totally dependent on staff for showers and needed extensive assistance to maintain personal hygiene and grooming. The MDS indicated Resident 43's BIMS score was seven out of 15 and indicated severe mental impairment. During a concurrent observation and interview on 8/30/22, at 11:18 a.m., with CNA 4, Resident 43 had long sharp dirty fingernails on both hands. CNA 4 stated Resident 43 can carry bacteria under his nails, and it can cause infection. During a review of Resident 43's Care Plan-ADL self -care deficit, revised on 8/5/22, the care plan indicated to enhance Resident 43's ability to perform ADLs at the highest practicable level. During an interview on 9/1/22, at 10:00 a.m., with the DON, the DON stated Resident 43 needed assistance to perform ADL care including showering and grooming. DON stated it was very important for the dignity of the resident. DON also stated when nail care is not provided there is risk for skin integrity damage, pain, and infections. During a review of the facility's Policy and Procedure (P&P) titled, Fingernail Care, dated 3/2000, the P&P indicated, Purpose- Care of fingernails promote circulation to the hands and helps prevent small tears around the nails that could lead to infections.

Based on observation, interview, and record review, the facility failed to ensure three of seven sampled residents (Resident 15, 27 and 484) received medications without an error. The facility's medication pass observation during the survey resulted in seven errors out of 25 opportunities and indicated a medication error rate of 28 percent (%). This failure placed Residents 15, 27 and 484 at risk for not getting the full therapeutic effect of their prescribed medications and had the potential to result in undesired health care outcomes. Findings: During a record review of Resident 484's admission Record Report, dated 9/2/22, it indicated Resident 484 was admitted to the facility on 8/2022 with diagnosis of Type 2 diabetes mellitus (a chronic condition which affects the way body process blood glucose levels). During a record review of Resident 484's Physician orders, dated 9/1/22-9/30/22, the orders indicated Resident 484 had an to administer Metformin (diabetes medication) 1000 milligrams (mg) by mouth two times a day with breakfast and dinner. Further review of Resident 484's Physician orders indicated to administer Multivitamin (supplement) one tablet orally daily. During a medication pass observation on 9/1/22, at 8:29 a.m., Licensed Vocational Nurse (LVN) 2 prepared one tablet of Metformin 1000 mg and one tablet of Daily Vitamin formula plus Iron in a medication cup and administered to Resident 484. LVN 2 did not give and or offer any food to Resident 484 at that time. During an interview on 9/1/22, at 11:35 a.m., with LVN 2, LVN 2 stated breakfast was served at 7 a.m., and she gave the medication to Resident 484 at 08:29 a.m. LVN 2 checked the medication card and stated the medication card's instructions was to give Metformin with meals. LVN 2 stated she should have given the medication with meals. LVN 2 also stated she gave the wrong Multivitamin to Resident 484. During a record review of Resident 15's admission Record Report, dated 9/2/22, it indicated Resident 15 was admitted to the facility on 4/2022. During a medication pass observation on 9/01/22, at 10:36 a.m., LVN 2 prepared Daily Vitamin formula plus Iron one tablet in a medication cup and administered it to Resident 15. During a record review of Resident 15's Physician orders, dated 9/1/22-9/30/22, it indicated to administer one tablet of Multivitamins with minerals (supplement) by mouth daily. During an interview on 9/1/22, at 11:35 a.m., with LVN 2, LVN 2 stated she did not have Multivitamins with minerals in the medication cart and administered the wrong medication to Resident 15. During an interview on 9/2/22, at 9:21 a.m., with the Director of Nursing (DON), the DON stated nurses must follow physicians' orders to administer medications to the residents. The DON stated Metformin was given with meals for proper absorption of medication. During a review of the facility's policy and procedures (P&P), dated 3/2000, titled, Medication Pass Guidelines, the P&P indicated, Medications are administered in accordance with the written orders of the attending physician. During a record review of Resident 27's admission Record Report, dated 9/2/22, it indicated Resident 27 was admitted to the facility in 2/2022. During a Med pass observation on 9/1/22, at 9:25 a.m., LVN 2 prepared, crushed, and administered Resident 27's medication by pushing all four medications with a syringe and piston through Resident 27's gastrostomy tube (GT, a tube that allows a person to receive nutrition and medications directly through the stomach): Levetiracetam oral solution 100 mg/ml, 5 ml (a medication for seizures) Metformin HCL 500 mg one tab (a medication that regulates blood sugar levels) Metoprolol tartrate 50 mg one tab (a medication to regulate blood pressure) Aspirin 81 mg one tablet. During an interview on 9/01/22, at 9:59 a.m., with LVN 2, LVN 2 stated it was her routine practice where she administered medications via GT by pushing the syringe piston. LVN 2 later stated she should have given the medications by gravity to Resident 27. During an interview on 09/02/22, at 9:21 a.m., with the DON, the DON stated the medication nurse should have given the medication via GT by gravity flow because pushing the medications via syringe piston placed Resident 27 at risk of acid reflux and gastrointestinal (stomach and intestines) irritation. During a review of the facility's P&P, dated 7/2009, titled, Medication via Gastrostomy tube, the P&P indicated, b. attach syringe without piston to end of feeding tube .c. Flush tube with at least 50 ml of water or as Physician orders .d. Deliver medication slowly and steadily.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure safe medication and biological storage when: 1. Seven expired hypodermic needles (needle used to inject a substance), one expired COVID-19 (a respiratory virus) antigen test kit were stored in the medication storage room; 2. One expired intravenous (IV) connector and Maxitrol (medication to treat swelling of the eye) eye ointment for a resident no longer in the facility (Resident 485) was found in the subacute Medication Cart 2; and 3. 10 loose pills and Resident 72's Humalog (blood sugar medication) was opened for more than 28 days were stored in the Medication Cart 2. These failures had the potential of exposing residents to drugs and biologicals with questionable potency and efficacy. Findings: 1. During a concurrent observation and interview on [DATE], at 10:30 a.m., with Registered Nurse (RN) 4, in the medication storage room, seven hypodermic needles with expiration date [DATE] and one COVID-19 antigen test with expiration date 11/2021 were stored in a medication storage drawer. RN 4 stated it was not ok for the expired needles and COVID antigen test to be in the drawer of the medication room. 2. During a concurrent observation and interview with RN 1 on [DATE], at 11:00 a.m., subacute unit Medication Cart 2 had one needleless IV connector with expiration date [DATE] and Resident 485's Maxitrol eye ointment with open date of [DATE]. RN 1 stated Resident 485 was not in facility anymore. 3. During an observation and concurrent interview with Licensed Vocational Nurse (LVN) 3 on [DATE], at 11:18 a.m., Station 1 Medication Cart 2 had 10 loose pills and Resident 72's Humalog insulin vial with open date of [DATE] in the medication drawer. LVN 3 stated once insulin vials were opened, insulin vials were to be discarded after 28 days. LVN 3 stated the opened Humalog insulin vial should have been discarded on [DATE]. LVN 3 was unable to identify the loose pills. During an interview on [DATE], at 12:25 p.m., with the Director of Nursing (DON), the DON stated the expired needles, COVID antigen test, IV connector, medications for discharged residents, insulin opened for more than 28 days, and loose tablets should not be in medication storage areas and should have been disposed. DON stated expired biologicals and medications placed the residents at risk for harm and cross contamination. A review of the facility's policy and procedures titled, Medication Storage/ Storage of Medication, dated 1/2021, indicated, Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked soiled or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal. A review of www.Humalog.com, an online medication reference tool for Humalog insulin use, dated 04/2021, indicated, Opened Humalog vials must be thrown away 28 days after first use, even if they still contain insulin.

Based on interview and record review, the facility failed to follow its pneumonia vaccination policy and procedure for three of five sampled residents (Residents 5, 6, and 70) when the pneumococcal vaccine was not provided to Residents 5, 6, and 70. This failure had the potential for Resident 5, 6 and 70 to contract and develop a pneumococcal infection. Findings: During an interview and record review on 9/2/22, at 10:10 a.m., with the Infection Preventionist (IP), Resident 5, Resident 6, and Resident 70's immunization records were reviewed. IP stated he could not find any prior history of pneumococcal vaccination for Residents 5, 6 and 70. IP stated Residents 5, 6, and 70 stayed in the facility for more than one year. IP stated the facility obtained a verbal consent for pneumococcal vaccination from Resident 5 on 8/1/22 and Resident 70 on 8/8/22. IP stated he did not obtain consent from Resident 6 for the pneumococcal vaccination. During a review of facility's policy and procedure (P&P) titled, Policy: Pneumococcal Vaccine, dated 6/22/22, the P&P indicated, prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. Assessments of pneumococcal vaccination status will be conducted within five (5) working days of the resident's admission if not conducted prior to admission.

Based on observation, interview, and facility document review, the facility failed to store, prepare, and distribute food in a safe and sanitary manner when: 1. Expired food items were found in the dry storage rack in kitchen; 2. Freezer 1 temperature was not reaching Zero (0) degree Fahrenheit and lower; 3. There was no air gap (a gap of air between the floor and a drainpipe to prevent backflow of sewage into the equipment) for food preparation sink; 4. There was no proper air gap in the ice machine; 5. Microwave was not cleaned and had food residue on the top inside surface; and 6. Kitchen counter under the steamer was sticky and dusty. These failures had the potential to cause food borne illnesses for 59 residents who received food from the kitchen for a facility census of 75. Findings: 1. During a concurrent observation and interview on 8/30/22, at 9:30 a.m., with Registered Dietician (RD), the dry storage rack in the kitchen had 1 X 28 oz ground cinnamon, 1 X 28 oz chili powder, 1 X 28 oz bay leaves with use by date 8/13/22. RD stated the ground cinnamon, chili powder and bay leaves were expired and should be removed. During a concurrent observation and interview on 8/30/22, at 9:30 a.m., with RD, the dry storage rack in the kitchen had 1 X 28 oz ground white pepper with use by date 3/22/22. RD stated the ground white pepper were expired and should be removed. During a concurrent observation and interview on 8/30/22, at 9:30 a.m., with RD, the dry storage rack in the kitchen had 1 X 28 oz granulated onion with use by date 6/7/22. RD stated the granulated onion was expired and should be removed. During an interview on 9/2/22, at 12:04 p.m., with the Dietary Manager (DM), the DM stated spices should be discarded after one year of opening as per the facility policy which was indicated by the use by date on the labels. A review of facility's document titled, Food storage principles, it indicated, Procedure- 3.a. Discard foods that have exceeded their expiration date. 2. During a concurrent observation and interview on 8/13/22, at 9:20 a.m., the temperature of Freezer 1 was 16-degree Fahrenheit. RD stated the freezer was opened for restocking. During a follow-up observation and interview on 8/31/22, at 1:45 p.m., the Freezer 1 temperature was 18 degrees. RD confirmed the temperature of freezer should be 0 degrees and lower. During a review of the facility's document titled, Nutrition therapy essentials quality assessment for performance improvement, the assessment done by RD for the month of August 2022 indicated, the Refrigerator and freezers- 5. Freezer temperature are at or below 0 degrees, as Not Met. During a review of the facility's undated Policy and Procedure (P&P) titled, Sanitation and Infection Control- Freezer Storage, the P&P indicated, Procedures: 3. The freezer should be maintained at a temperature equal to or less than zero-degree Fahrenheit. 3. During a concurrent observation and interview on 8/30/22, at 9:30 a.m., with RD, the drainpipe from the sink connected directly into the grease trap so there was no air gap for kitchen emergency sink. RD confirmed there was no air gap. During an interview on 8/30/22, at 12:29 p.m., with the DM, the DM stated she did not see a proper air gap under the emergency use sink in the kitchen. 4. During a concurrent observation and interview on 8/31/22, at 9:00 a.m., with RD, the drainpipe from the ice machine inside the lower drain cup had no air gap. RD confirmed there was no proper air gap. During an interview on 9/1/22, at 11:10 a.m., with the DM, the DM stated she did not notice the air gap in the ice machine. DM further stated the air gap was important to prevent contamination and back flow. During a review of the facility's P&P titled, Air gap-general, revised on 11/2018, the P&P indicated, Guidelines: (a) All steam tables, ice machines and bins, food preparation sinks, ware washing sinks, display cases, walk-in refrigeration units, and other similar equipment that discharge liquid waste shall be drained by means of indirect waste pipes, and all wastes drained by means of indirect waste pipes, and all wastes drained by them shall discharge through an airgap into a floor sink or other approved type of receptor. According to the 2017 Federal Food Code, a direct connection may not exist between the sewage system and a drain originating from equipment in which food, portable equipment, or utensils are placed. 5. During a concurrent observation and interview on 8/31/22, at 9 a.m., with DM, the kitchen microwave had spots of residue on the inside top and inside side surface. There was buildup of brown residue resembling crumbs on the hinge of microwave door. DM confirmed the microwave was not clean. During an interview on 9/01/22, at 12:02 p.m., with [NAME] 1, [NAME] 1 stated the microwave should be cleaned after every single use. 6. During a concurrent observation and interview on 8/31/22, at 9 a.m., with DM, the kitchen counter under the steamer was sticky and dusty. DM stated the cook/aide is responsible to clean the counter after use. During an interview on 9/01/22, at 12:02 p.m., with [NAME] 1, [NAME] 1 stated they must clean the counters after use every day. During a review of the facility's P&P titled, Dietary Cleaning, released on 4/15/2001, the P&P indicated, Purpose- Proper cleaning and sanitation of equipment ensures removal of residual food, chemicals, and bacteria.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff followed proper standard and transmission-based precautions to prevent the spread of infection when: 1. Laundry Staff (LS 1) stored personal items in the clean linen/laundry area; 2. Oxygen (O2) tubing was not labeled and dated for Residents 34, 39, and 57; 3. Licensed Vocation Nurse (LVN) 2 did not perform hand hygiene during medication administration; and 4. LVN 2 did not clean/disinfect the shared blood pressure (BP) machine and medication tray in between residents; and These failures had the potential to result in cross contamination and spread of infections for Residents 34, 39, 57 and other residents in the facility. Findings: 1. During a concurrent observation and interview on 9/01/22, at 1:33 p.m., LS 1, a [NAME]-colored sweater, grayish blue sweater, brown sweater, pink purse, a personal plant, a coffee maker, a refrigerator with one opened soda can and one unopened soda can, carrots, one Jello, strawberries, one water bottle, grapes, jelly spread jar, coffee creamer, one cucumber, two pieces fried chicken, peach yogurt 32 oz., and two flans were in the clean linen area. The wooden cabinet underneath the refrigerator had an unlabeled bag of bread, cereal, canned foods, a water bottle, and tea bags. The wooden desk next to the refrigerator had a paper grocery bag containing three bunches of raw kale, two bunches of green onions, and carrots. There were also foam cups, a bottle of omega 3, a bottle of Tylenol 350 mg, and a bottle of vitamin D on the desk. LS 1 stated all the above items belonged to LS 1 and it was fine to keep her personal items in the clean linen area where they stored clean laundry and linens for the residents residing in the facility. During an observation and interview on 9/01/22, at 1:49 p.m., with Maintenance Director (MD 1), the facility's clean laundry linen area was observed. MD 1 stated he supervised the laundry area and laundry staff. MD 1 stated the personal items were already in the clean linen area when he started working at the facility and was unsure if it was okay for those items to be there. During an interview on 9/02/22, at 9:12 a.m., with Infection Preventionist (IP), IP stated he inspected the laundry area daily and was aware of the staff's personal items stored in the clean linen area. IP stated he did not see an issue with it because they were not touching the clean linens. During an interview on 9/02/22, at 9:04 a.m., with the Director of Nursing, the DON stated personal items should not be stored in the clean linen area because there was a risk of cross contamination. DON further stated she was not aware of this practice at the facility. During a review of the facility's policy and procedure (P&P) titled, Linen Storage, dated 4/15/01, the P&P indicated, no resident's and/or staff member's personal belongings will be stored alongside the soiled, isolation, or clean linen closets/carts. During a review of the facility's P&P titled, Personnel Belongings Storage, dated 11/2018, the P&P indicated, no employee personal belongings will be stored in the linen closet(s) . may store belongings in the employee lounge, nurses' station, and designated offices . 3. During the medication pass observation on 9/1/22, at 8:29 a.m., LVN 2 prepared Resident 484's medications in a medication tray and without performing hand hygiene, administered the medications to Resident 484. During the medication pass observation on 9/1/22, at 9:25 a.m., LVN 2 prepared Resident 27's medications and grabbed a pair of gloves, put in her pocket, went inside Resident 27's room, got water in a water cup from faucet in Resident 27's room. Without performing hand hygiene, LVN 2 then donned the gloves from her pocket, checked Resident 27's bowel sounds with a stethoscope she had around her neck. Without performing hand hygiene and changing gloves, LVN 2 administered morning medications via gastrostomy tube (GT, a tube that allows a person to receive nutrition and medications directly through the stomach) to Resident 27. During an interview on 9/1/22, at 9:59 a.m., LVN 2 stated hand hygiene should be done after doffing (removing) gloves and before donning (putting on) new gloves to prevent spread of infection. During a review of facility's P&P titled, Hand Hygiene, dated 2/2017, the policy indicated, Use alcohol-based hand rub containing at least 62% alcohol or alternatively use soap anti-microbial or non-antimicrobial and water for the following situations: .before and after direct contact with residents; before preparing or handling medications . 4. During a medication administration observation on 9/1/22, at 8:20 a.m., LVN 2 did not sanitize the BP cuff in between Residents 58 and 484, before and after checking their blood pressure. In addition, LVN 2 did not clean/disinfect the medication tray in between Residents 484 and 58, before and after administering medications to them. During an interview on 9/01/22, at 9:59 a.m., LVN 2 stated she was supposed to wipe the BP cuff and medication tray with Clorox bleach germicidal wipes before and after checking Resident 58 and 484's BP. LVN 2 further stated this practice prevented the risk of spread of infection. During a review of the facility's P&P titled, Cleaning and Disinfecting of Medical Equipment, dated 11/2020, the P&P indicated, reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment) . During a review of Resident 39's admission Record printed on 9/1/22, the admission Record indicated Resident 39 was originally admitted to the facility on [DATE] and had medical diagnoses including acute respiratory failure (fluid buildup in air sacs in lungs diminishing its ability to release oxygen into blood) with Hypoxia (low level of oxygen in body tissues). During a record review of Resident 39's physician orders Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 7/26/22, the MDS Section C indicated Resident 39's Brief Interview of Mental Status (BIMS, an assessment for cognition status) score was 15 out of 15 and indicated intact mental impairment. During an interview and observation on 8/30/22, at 11:16 a.m., at Resident 39's bedside, Resident 39's oxygen tubing was not dated and labeled. Resident 39 stated he received oxygen therapy for the last six to seven months. During a concurrent interview and record review on 8/31/22, at 8:18 a.m., with Registered Nurse (RN) 4, Resident 39's Physician orders were reviewed. RN 4 stated Resident 39 had an as needed order for 2 LPM (liters per minute) oxygen for supplementation. During a concurrent observation and interview on 8/31/22, at 8:20 a.m., with LVN 2, the oxygen tubing for Resident 39 was not dated and labeled. LVN 2 stated if the oxygen tubing is not dated and labeled, then staff do not know when it was changed, and the tubing should be discarded. During an interview on 9/2/22, at 8:07 a.m., with IP, IP stated oxygen tubing should be changed every Sunday and it should be dated and labeled. IP stated it is important to prevent infections. IP stated unchanged tubing could cause moisture build up and bacterial growth in the tubes. IP further stated this could cause infections. During a review of the facility's P&P titled, Oxygen Administration, revised 11/2020, the P&P indicated, Steps in the procedure . 7. Check the tubing connected to the oxygen cylinder to assure that it is free of kinks. Label the tubing with date initiated. Tubing is changed weekly and whenever necessary. 2. During an observation on 8/30/22, at 10:36 a.m., in Resident 34's room, oxygen tubing was noted undated and unlabeled. During a subsequent observation in Resident 57's room, oxygen tubing was observed with no label and no date. During a concurrent observation and interview on 8/31/22, at 9:15 a.m., with Registered Nurse (RN) 2, oxygen tubing for Residents 34 and 57 were still unlabeled and undated. RN 2 confirmed Resident 34 and 57's tubing were unlabeled and undated. RN 2 stated oxygen tubings were usually dated when they were changed every Friday or Saturday. RN 2 further stated if oxygen tubings were not dated, then staff would not know if it was changed and it could lead to potential infections. During an interview on 9/2/22, at 9:32 a.m., with the Director of Nursing (DON), the DON stated her expectations are oxygen tubings are changed every week with a change sticker applied and if the tubings were not changed, there was a risk for infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide an environment that promoted dignity while dining for one of 22 (Resident 9) sampled residents when Certified Nursing Assistant (CNA) 1 remained standing while assisting Resident 9 with his meal. For Resident 9, this deficient practice had the potential to result in Resident 9 receiving an undignified dining assistance. Findings: Review of the Resident Face Sheet, printed 8/27/19, indicated Resident 9 admitted to the facility with diagnoses that included hemiplegia (muscle weakness to one side of the body) and dysphagia (difficulty swallowing). During an observation on 8/27/19, at 7:48 a.m., Resident 9 was sitting up in bed, CNA 1 stood on the left side of Resident 9's bed and assisted Resident 9 with breakfast. Review of Resident 9's Minimum Data Set, dated [DATE], indicated Resident 9 required the extensive assistance of one staff person for eating. In an interview on 8/27/19, at 7:48 a.m., CNA 1 stated she remained standing during while she fed Resident 9. CNA 1 stated she should sit down when feeding Resident 9 to observe him swallowing. During an interview on 8/27/19, at 8:33 a.m., the Director of Staff Development (DSD) stated CNAs are supposed to be seated when they feed the residents. DSD also stated that if the staff is short, they can always adjust the height of the bed to get a good view of the resident during feeding assistance. Review of facility policy, Assisting the Resident to Eat, effective 3/00, indicated, .Assist the resident as necessary. If the resident needs to be fed .Sit at eye level in front of the resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, for one (Resident 1) of 22 sampled residents, the facility failed to transmit Resident 1's admission and quarterly Minimum Data Sets (MDS - an assessment tool used to direct care) within the allowable timeframes after completing Resident 1's admission and quarterly MDS assessments. This deficient practice resulted in the delay of resident-specific information to reflect Resident 1's overall status, necessary for the provision of care. Findings: Review of the Resident Face Sheet, dated 8/28/19, indicated Resident 1 was admitted to the facility on [DATE] and re-admitted to the facility on [DATE]. Review of the facility's document titled CMS Submission Report MDS 3.0 NH Final Validation Report, not dated, indicated Resident 1's admission MDS was submitted to the Center for Medicare and Medicaid Services (CMS) on 1/29/19. Further review of this document, indicated the target date was 1/19/19. Review of a document titled CMS Submission Report MDS 3.0 NH Final Validation Report, not dated, indicated Resident 1's quarterly MDS was submitted to CMS on 6/20/19. Further review of this document, indicated the target date was 4/21/19. During a concurrent interview and record review with the Minimum Data Set Coordinator (MDSC) on 8/28/19 at 11:43 a.m., MDSC stated Resident 1's admission MDS, dated [DATE], was transmitted late on 1/29/19, and Resident 1's quarterly MDS, dated [DATE], was submitted late on 6/20/19. Review of the facility's policy and procedure titled Resident Assessment Instrument (RAI) Process, release date 11/15/01, indicated .20. Transmit the assessment or tracking form to the state database. Facilities must transmit to the state at least every 7 days

Based on observation, interview, and record review, for one of 22 sampled residents (Resident 79) the facility failed to provide the necessary care to maintain personal hygiene when Resident 79 did not receive assistance with shaving for a week. This failure resulted in Resident 79 having long facial and neck hair growth. Findings: Review of Resident 79's Minimum Data Set (MDS - a resident assessment tool used to guide care), dated 7/3/19, indicated Resident 79 required the extensive physical assistance of one staff person for personal hygiene that included combing his hair and shaving his facial hair. The MDS also indicated Resident 79 was cognitively intact (had the ability to clearly think, reason, and remember). In an observation and concurrent interview on 8/26/19, at 8:59 a.m., Resident 79 was noted with visible facial hair down to the neck. Resident 79 stated he needed a shave badly and it had been a week since he was last shaved. During concurrent interviews on 8/27/19, at 7:43 a.m., the Director of Nursing (DON) stated it was the Certified Nursing Assistants' (CNAs) responsibility to shave the residents. During an interview on 8/29/19 at 12:16 p.m., CNA 2 stated residents are shaved as needed, because it grows back right away. CNA 2 also stated shaving the residents can be done either during morning care or even better, during showers. In an interview on 8/29/19 at 12:44 p.m., DSD stated shaving the residents should be done during showers or as needed, and when the residents ask to be shaved. Review of facility policy Shaving a Male Resident, dated 3/00, indicated the facility's purpose to facilitate personal hygiene and personal appearance for a male resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, for one of 22 sampled residents (Resident 17), the facility failed to ensure that drugs were stored in accordance with the manufacturer's instructions for use when Resident 17's Lantus insulin (injectable medication that treats diabetes) vial was stored in the medication cart beyond use by date. This failure had the potential to result in diminished efficacy of these medications. Findings: Review of Resident 17's Face Sheet, printed 8/29/19, indicated Resident 17 was admitted to the facility with diagnoses that included Type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar). Review of Resident 17's Physician Order Report, dated 8/1/19 - 8/29/19, indicated Resident 17 had a physician's order to receive 23 units of Lantus (a blood sugar medication) at bedtime every night. During an observation and concurrent interview with Licensed Vocational Nurse (LVN) 2 on 8/28/19, at 2:03 p.m., Medication Cart 3 had Resident 17's Lantus insulin vial that was opened on 7/29/19, with a use by date of 9/26/19. LVN 2 stated that once opened, insulin vials were to be discarded after 28 days. LVN 2 stated the opened Lantus insulin vial should have been discarded on 8/26/19 (two days beforehand) and that she made a mistake of labeling the use by date. According to Lexicomp, an online medication reference tool, indicated instructions to store in use vials at room temperature and use within 28 days. [Reference:https://online.[NAME].com/lco/action/doc/retrieve/docid/gdh_f/511421?searchUrl=%2Flco%2Faction%2Fsearch%3Fq%3Dlantus%26t%3Dname%26va%3Dlantus#sts].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain accurate medical records on one ( Resident 133) of 22 sampled residents when Resident 133 did not have an entry tracking record completed upon returning to the facility. This deficient practice resulted in Resident 133 not being listed on the Center for Medicare and Medicaid Services (CMS) facility census and had the potential for Resident 133 to not receive care and services that were needed. Findings: Review of Resident 133's Face Sheet, dated 8/28/19, indicated Resident 133 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of the CMS Long Term Care Survey Process (LTCSP) census, indicated Resident 133 was not listed in the system. Review of a document titled MDS 3.0 Assessments, not dated, indicated Resident 133's entry tracking for 8/6/19 due status was late. During an interview with the Minimum Data Set Coordinator (MDSC) on 8/26/19 at 10:42 a.m., MDSC stated Resident 133 was initially admitted to the facility on [DATE]. MDSC stated Resident 133 was discharged to the acute hospital on 7/19/19 and returned to the facility on 8/6/19. MDSC stated an entry tracking record should have been done and submitted to CMS at that time, but MDSC stated he did not complete and submit the entry tracking record at that time. Review of the CMS Resident Assessment Instrument (RAI) Version 3.0 Manual, dated 10/18, indicated .page 2-15. Reentry refers to the situation when all three of the following occurred prior to this entry: the resident was previously in this facility and was discharged return anticipated and returned within 30 days of discharge. Upon the resident's return to the facility, the facility is required to complete an Entry tracking record . Review of the facility's policy and procedure titled Medical Record Management, release date 12/18/02, indicated .A complete medical record contains an accurate and functional representation of the resident's actual experience in the facility. The medical record must contain enough information to show the facility knows the status of the resident, has adequate plans of care, and provides sufficient evidence of the effects of care provided