**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to issue the Notice of Medicare Non-Coverage (NOMNC, informs beneficiaries on how to file an appeal before their insurance coverage ends) timely for two of three sampled residents (Resident 80 and 81). This deficient practice had the potential to result in residents not being able to exercise their right to file an appeal. Findings: During a review of Resident 80's face sheet (a document that contains a summary of a resident's personal and demographic information) and NOMNC, it indicated Resident 80 was admitted to the facility on [DATE] and her stay was paid by Medicare (federal health insurance for anyone age [AGE] and older, and some people under 65 with certain disabilities) until 11/1/23. The NOMNC also indicated it was signed by the resident one day prior to her last day of Medicare coverage on 10/31/23. During a review of Resident 81's face sheet and NOMNC, it indicated Resident 80 was admitted to the facility on [DATE] and her stay was paid by Medicare until 1/19/24. The resident was discharged on 1/20/24, and the NOMNC was signed by the resident's responsible party on the discharge day. During an interview on 5/1/24 11:29 a.m. with the Social Services Designee (SSD), the SSD stated usually the facility issues the NOMNC 72 hours prior to a resident's last covered date. For Resident 80, the NOMNC should have been delivered on 10/30/23, because it required at least 48 hours window for the resident to file an appeal. For Resident 81, her initial discharge date was on 1/18/24, but she had a change in condition, so the facility held the discharge and issued a new NOMNC that day. During an interview on 5/1/24 at 11:47 a.m. with the Patient Care Coordinator (PCC), the PCC stated the facility should have issued a NOMNC on 1/18/24 with last covered date 1/20/24 for Resident 81 to be compliant with the regulation. During a review of the facility provided Centers for Medicare & Medicaid Services (CMS) form instruction (FI), titled Form Instruction for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123, OMB Approval 0938-xxxx, the FI indicated, The NOMNC must be delivered at least two calendar days before Medicare covered services end or the second to last day of service if care is not being provided daily.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the plan of care for one of 25 sampled residents (Resident 1) was individualized and revised to reflect the resident's current care needs and interventions. This failure had the potential to result in not meeting the residents' needs. Findings: During an observation on 4/30/24 at 9:10 a.m., in the resident's room, Resident 1 was sitting at the edge of the bed with the two upper side rails in upright position. Review of Resident 1's clinical record indicated she was admitted on [DATE] with a diagnosis of Cellulitis of the left hand. Review of Resident 1's care plans indicated care plans for problems addressing return activities of daily living status to a safe level of function and at risk for fall. There was no care plan addressing the use of side rails. During a concurrent interview and record review on 4/30/24 at 10:43 a.m., with Registered Nurse (RN) B, RN B reviewed the care plans of Resident 1 and stated the care plan for side rails are incorporated in the care plan addressing risk for fall. RN B further stated there was no care plan for the use of side rails. During a concurrent interview and record review on 4/30/24 at 1:21 p.m., with RN C, RN C reviewed the care plans for Resident 1and stated they use the fall care plan to address the side rails. RN C further stated there was no care plan specific for the use of side rails. During an interview on 5/2/24 at 1:10 p.m., with the Director of Nursing (DON), the DON stated there was no specific care plan for side rails. The DON stated the facility has no policy specific for side rails.

Based on observation and interview, the facility failed to ensure two of 25 residents (Residents 74 and 79)'s foot boards of their beds were properly locked. This failure had the potential to negatively affect the residents' well-being and increased the risk of accidents or injuries to the residents. Findings: During a concurrent observation and interview on 4/29/24 at 3:34 p.m. in Resident 74's room, there was a six-inch (a unit of length or distance) gap between Resident 74's mattress and the foot board of the bed. The resident stated he did not like the bed. During a concurrent observation and interview on 4/29/24 at 3:40 p.m. in Resident 79's room, there was a six-inch gap between Resident 79's mattress and the foot board of the bed. The resident had just finished his Physical Therapy session with Physical Therapist (PT) D, PT D stated, all beds are adjustable, the gap between the foot board and the mattress was here when she got here this morning, she had to check with the resident's nurse to find out why there was a gap. During a concurrent observation and interview on 5/2/24 at 8:55 a.m. in Resident 74's room with Registered Nurse (RN) E, there was still a gap between the food board and the mattress, and the resident's blanket had fallen into the gap. RN E stated maybe when the resident slid down to the foot of the bed, the foot board was pushed. RN E and Certified Nursing Assistant (CNA) F then pushed the foot board back until there was no more gap. During an interview on 5/2/24 at 9:50 a.m. with CNA F, CNA F stated she double checked the bed, the foot board just needed to be pushed back in and locked in place. She further stated there should be no gap between the mattress and the board because it can potentially cause the resident to get injured. During an interview on 5/2/24 at 11:28 a.m. with RN G, RN G stated if there was a gap between the mattress and the foot board, potentially the resident can slide down and get injured. During an interview on 5/2/24 at 1:20 p.m. with the Director of Nursing, the DON stated the staff should make sure the foot board was locked and secured, the mattress could slide down due to there was a gap. During a review of the facility's policy and procedure (P&P), titled Fall Mitigation PC-4039, the P&P indicated, Hospital Bed Safety Features & Exit Alarm 2. Before leaving the patient room, check that iBED awareness lights are illuminating green. Key Point: The lights flash amber if the bed does not meet the safety parameters set. i. Review the digital display control panel at the foot of the bed to determine the alert and adjust the bed to appropriate configuration. [ .] iii. Set the bed to the appropriate configuration (set brake, raise side rail, etc.).

Based on observation, interview, and record review, the facility failed to ensure the proper use of side or bed rails ((adjustable rigid bars attached to the side of a bed) for 25 of 25 sampled residents (Residents 122, 120, 175, 70, 73, 1, 79, 125, 72, 126, 71, 74, 76, 128, 171, 75, 172, 127, 123, 173, 78, 121, 174, 77, and 170) when: 1. The facility failed to assess for the risk of entrapment from side rails prior to use of side rails for 25 of 25 residents (Residents 122, 120, 175, 70, 73, 1, 79, 125, 72, 126, 71, 74, 76, 128, 171, 75, 172, 127, 123, 173, 78, 121, 174, 77, and 170). 2. The facility failed to review the risks and benefits of side rails with the resident or resident representatives (RP) and obtain informed consent (a process which patients are given important information, including possible risks and benefits, about a medical procedure or treatment) prior to the use of side rails for 25 of 25 residents (Residents 122, 120, 175, 70, 73, 1, 79, 125, 72, 126, 71, 74, 76, 128, 171, 75, 172, 127, 123, 173, 78, 121, 174, 77, and 170). 3. The facility failed to attempt alternative measures prior to the use of side rails for 25 of 25 residents (Residents 122, 120, 175, 70, 73, 1, 79, 125, 72, 126, 71, 74, 76, 128, 171, 75, 172, 127, 123, 173, 78, 121, 174, 77, and 170). 4. The facility failed to ensure physician orders were obtained prior to the use of the side rails for 25 of 25 residents (Residents 122, 120, 175, 70, 73, 1, 79, 125, 72, 126, 71, 74, 76, 128, 171, 75, 172, 127, 123, 173, 78, 121, 174, 77, and 170). These failures had the potential to put all 25 residents at risk of entrapment and serious injury. Findings: Review of the U.S Food and Drug Administration (FDA) Hospital Bed Safety Workgroup Clinical Guidance for the Assessment and Implementation of Bed Rails in Hospitals, Long Term Care Facilities, and Home Care Settings, dated April 2003, indicated the FDA issued a Safety Alert entitled, Entrapment Hazards with Hospital Bed Side Rails. This alert indicated National surveys of patient deaths occurring in the bed environment demonstrate the risk of entrapment when a patient slips between the mattress and bed rail or when the patient becomes entrapped in the bed rail itself. The population at risk for entrapment are patients who are frail or elderly or those who have conditions such as agitation, delirium, confusion, pain, uncontrolled body movement . that cause them to move about the bed or try to exit from the bed. During an observation on 4/29/24 at 9 a.m., in the resident's room, Resident 120's bed had 4 side rails installed with the two upper side rails in the upright position. During an observation on 4/29/24 at 9:10 a.m., in the resident's room, Resident 121's bed had 4 side rails installed with the two upper side rails in the upright position. During an observation on 4/29/24 at 9:14 a.m., in the resident's room, Resident 175's bed had 4 side rails installed with the three side rails in the upright position. During an observation on 4/29/24 at 9:16 a.m., in the resident's room, Resident 122's bed had 4 side rails installed with the two upper side rails in the upright position. During an observation on 4/29/24 at 9:24 a.m., in the resident's room, Resident 125's bed had 4 side rails installed with the two upper side rails in the upright position. During an observation on 4/29/24 at 9:29 a.m., in the resident's room, Resident 126's bed had 4 side rails installed with the two upper side rails in the upright position. During an observation on 4/29/24 at 9:37 a.m., in the resident's room, Resident 128's bed had 4 side rails installed with the two upper side rails in the upright position. During an observation on 4/29/24 at 9:38 a.m , in the resident's room, Resident 173's bed had 4 side rails installed with one upper side rail in the upright position. During an observation on 4/29/24 at 9:41 a.m., in the resident's room, Resident 127's bed had 4 side rails installed with the two upper side rails in the upright position. During an observation on 4/29/24 at 9:50 a.m., in the resident's room, Resident 123's bed had 4 side rails installed with the two upper side rails in the upright position. During an observation on 4/29/24 at 11:32 a.m., in the resident's room, Resident 170's bed had 4 side rails installed with the two upper side rails in the upright position. During an observation on 4/29/24 at 2:54 p.m., in the resident's room, Resident 70's bed had 4 side rails installed with the two upper side rails in the upright position. During an observation on 4/29/24 at 3:31 p.m., in the resident's room, Resident 71's bed had 4 side rails installed with the two upper side rails in the upright position. During an observation on 4/29/24 at 3:31 p.m., in the resident's room, Resident 72's bed had 4 side rails installed with the two upper side rails in the upright position. During an observation on 4/29/24 at 3:31 p.m., in the resident's room, Resident 73's bed had 4 side rails installed with the two upper side rails in the upright position. During an observation on 4/29/24 at 3:31 p.m., in the resident's room, Resident 75's bed had 4 side rails installed with the two upper side rails in the upright position. During an observation on 4/29/24 at 3:31 p.m., in the resident's room, Resident 76's bed had 4 side rails installed with the two upper side rails in the upright position. During an observation on 4/29/24 at 3:33 p.m., in the resident's room, Resident 74's bed had 4 side rails installed with the two upper side rails in the upright position. During an observation on 4/29/24 at 3:42 p.m., in the resident's room, Resident 79's bed had 4 side rails installed with the two upper side rails in the upright position. During an observation on 4/30/24 at 9:22 a.m., in the resident's room, Resident 171's bed had 4 side rails installed with the two upper side rails in the upright position. During an observation on 4/30/24 at 9:22 a.m., in the resident's room, Resident 174's bed had 4 side rails installed with the two upper side rails in the upright position. During an observation on 4/30/24 at 9:22 a.m., in the resident's room, Resident 172's bed had 4 side rails installed with the two upper side rails in the upright position. During an observation on 4/30/24 at 10:23 a.m., in the resident's room, Resident 1's bed had 4 side rails installed with the two upper side rails in the upright position. During a concurrent interview and record review on 4/30/24 at 10:53 a.m., with Registered Nurse (RN) B, RN B reviewed the electronic records of some residents, then RN B stated that all residents were assessed and informed about the use of side rails but there was no documentation about the risk and benefits for the use of side rails given to all residents. RN B further stated there was no need for physician orders for the use of side rails unless if it was used as a restraint. RN B also stated there was no alternatives to the use of side rails discussed with any of the residents and their responsible parties. During a concurrent interview and record review on 4/30/24 at 1:21 p.m., with RN C, RN C reviewed all the 25 residents' electronic records and stated that all the residents must always have the side rails in the upright position. RN C stated that no alternatives were used because every patient (meant Resident) must have the two side rails up. RN C further stated the use of side rails does not need to have a consent and physician orders. RN C also stated that residents were assessed and informed of the risk and benefits of the use of side rails verbally but there was no documentation done. RN C also stated there was no policy for the use of side rails. During an observation on 5/1/24 at 2:55 p.m., in the resident's room, Resident 77's bed had 4 side rails installed with the two upper side rails in the upright position. During an observation on 5/1/24 at 2:57 p.m., in the resident's room, Resident 78's bed had 4 side rails installed with the two upper side rails in the upright position. During an interview on 05/02/24 at 1:10 p.m., with the Director of Nursing (DON), the DON stated there was no alternatives for the use of side rails. The DON stated consent and physician order were not required because the use of side rails was an intervention used to prevent falls. The DON stated that assessment was done for the prevention of falls and not for the use of side rails. The DON also stated they have no side rails policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure food items were labeled properly and expired food were not stored in the kitchen and accessible to be used in preparing foods for 23 of 25 residents. This practice had the potential to result in the residents ingesting expired food, which can result in foodborne illnesses. Findings: During a concurrent observation and interview on 4/29/24, at 8:43 a.m., with [NAME] A, in the walk-in refrigerator, three stalks of [NAME], and two bunches of cilantro were noted to be in a clear plastic container on the top shelf. No dates or labels were noted on the produce or the container which held the produce. Another clear plastic container held approximately 7 green squash with no labels on the produce or the container. [NAME] A stated there are no labels on these produce or the containers, they are supposed to have a receive date and a use by date. During a review of the facility's policy and procedure (P&P) titled, Food Safety: Storage Handling, Preparation, serving, dated 2019, the P&P indicated, 4. Food is covered, labeled, dated, and used within the specified time periods, and is stored off the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure proper storage of medical supplies when expired hypodermic safety needles (medical tool, designed for safe one-time use, to inject or extract fluids from the body via a thin hollow tube with a sharp tip), were stored in an active use area inside the medication storage room. This deficient practice had the potential for use of expired medical tools on residents. Findings: During an observation and interview at the medication storage room [ROOM NUMBER] (MSR 1) with registered nurse A (RN A), on [DATE] at 12:20 p.m., five hypodermic safety needles, labeled with expiration dates for [DATE], were stored among medical supplies for active use on residents. RN A confirmed the five hypodermic safety needles were expired and stated that they should have been discarded.

Based on observation and interview, the facility failed to ensure garbage was disposed of properly in the outside garbage area when a dumpster lid was left open, garbage and linen bags were left outside the dumpsters, and garbage was on the ground. This failure had the potential to attract vermin (pests or animals that spread diseases). Findings: During an observation and interview at the facility's garbage area with the Dietetic Technician, Registered (DTR) on 5/3/23 at 9:59 A.M., two plastic containers, one small white plastic container, two plastic utensils, cardboard, multiple blue gloves, a water bottle, and a cardboard box lay on the ground outside of the trash dumpsters. A clear bag filled with contents was on top of a trash bin, and a blue bag filled with contents was on the ground between dirty linen containers. A dumpster containing cardboard had an open lid. During a concurrent interview with the DTR, the DTR confirmed the observation and stated, It should not look like this. During an observation and concurrent interview on 5/3/23 at 4:00 P.M. with Environmental Services F (EVS F) at the facility's designated garbage area, EVS F stated, It is dirty . trash should not be on the ground. During an observation and interview at the facility's garbage area with the Infection Preventionist (IP) on 5/4/23 at 8:21 A.M., a garbage dumpster was propped open with overflowing garbage bags. Three black garbage bags sat outside of the dumpster. Surgical masks and multiple gloves were on the ground outside of the trash bins. Flies were present. The IP confirmed the situation could attract vermin. During an observation and interview at the facility's garbage area with EVS G on 5/5/23 at 11:48 A.M., there were multiple gloves, a water bottle, a large rusted can labeled diced pears, cardboard, and two small containers on the ground near the trash bins. Flies were present. EVS G confirmed the observation. Review of The U.S. Food and Drug Administration's 2022 Food Code section 5-501.116 indicated, Cleaning Receptacles: Storage areas for garbage and refuse containers must be constructed so that they can be thoroughly cleaned in order to avoid creating an attractant or harborage for insects or rodents. In addition, such storage areas must be large enough to accommodate all the containers necessitated by the operation in order to prevent scattering of the garbage and refuse. Outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents.

Based on observation, interview, and record review, the facility failed to implement infection prevention and control strategies when a certified nursing assistant with long fingernails took care of residents. This failure resulted in increased risk of disease transmission to residents via long fingernails, which provide more area(s) where microbes may harbor compared to short fingernails. Findings: During an observation at station AA (ST AA) on 5/4/23 at 8:35 a.m., certified nursing assistant B (CNA B) was in a hallway with long fingernails going to a resident's room. During an interview with the infection preventionist (IP) on 5/4/23 at 9:25 a.m., the IP confirmed that certified nursing assistants should maintain short nails for infection control purposes. During an interview with CNA B on 5/4/23 at 9:54 a.m., she confirmed that she should have maintained her fingernails trimmed short for infection control purposes, but forgot to. Review of the facility's policy and procedure Professional Appearance and Grooming Standards: Nails, effective December 2022, indicated, All employees must be properly groomed . Maximum nail length of natural nail tips is 1/4 inch (unit of length).

Based on observation, interview and record review, the facility failed to ensure sanitary conditions were maintained for one of three ice machines when an ice machine had a brown-yellow substance in an interior part of the machine was exposed to ice. This failure had the potential to cause food-borne illnesses (an illness caused by food or water contaminated with bacteria, viruses, parasites or toxins). The ice machine was used to provide ice for the residents. Findings: During an observation and concurrent interview, with Engineering Services Technician C (EST C) on 5/3/23 at 10:25 A.M., at nurses' station AA's clean utility room, the rim of an ice chute (a dispensing tube of the interior bucket of the ice machine) was wiped with a clean white paper towel to check for residuals. The wiping yielded a brown-yellow substance onto the clean paper towel. EST C acknowledge this observation and stated he was unsure what the substance was. During an observation and concurrent interview with EST D and the Director of Nursing (DON) on 5/3/23 at 11:43 A.M., EST D and the DON acknowledged the brown-yellow substance from the ice machine. EST D confirmed the last preventive maintenance on the ice machine was in 4/2023 and stated, I may have missed that part. During an interview and concurrent record review, with EST E on 5/5/23 at 2:24 P.M., the preventive maintenance (PM) logs indicated the last PM for the ice machine was completed 12/9/22. EST E confirmed the sticker on the side of the machine, dated 4/2023, was an additional cleaning. The Nursing Station AA ice machine log lacked a PM entry on 4/2023. Review of the facility's policy Environment of Care: Inspecting, Testing and Maintenance, dated 2021, indicated, The Engineering Services technicians perform assigned activities and return completed documentation to managers . All documentation of the maintenance activity will be completed by the Engineering Services technicians, reviewed by the appropriate supervisor, and filed or the information entered into the work order system.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure allegations of abuse were reported in a timely manner by staff for one of 22 residents (Resident 61), when after hearing of an alleged abuse, certified nursing assistant A (CNA A) did not report the allegation to anyone. This failure had the potential of other residents potentially being abused. Findings: During an interview with Resident 61 on 10/8/19 at 11 a.m., she stated the physical therapist B (PT B) had hurt her during her physical therapy session on 10/7/19. During an interview with the administrator (ADM) on 10/8/19 at 3:33 p.m., when told of the abuse allegation, she stated it was the first time she had heard of the abuse allegation. During a telephone interview with CNA A on 10/10/19 at 9:43 a.m., she stated Resident 61 had told her of the abuse allegation. CNA A stated she did not tell anybody. CNA A stated she told Resident 61 to report it. The facility's policy and procedure, General Patient Care: [NAME] House Abuse Prevention Program, dated 03/2017, indicated .As mandated reporters, employees are required to report any knowledge of known or suspected abuse and/or neglect of a resident immediately to the Ombudsman, State of California Department of Public Health (CDPH), and the facility Abuse Prevention Program Coordinator/Administrator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop, revise, and/or implement a person-centered care plan (a document which provides direction for individualized care of the resident; a means of communicating and organizing the residents' new and ongoing problems and nursing actions of a constantly changing staff; includes an ongoing identification of the resident's existing and changing needs, goals, and interventions to address these needs) for three of 12 sampled residents (163, 166 and 168) when: 1. For Resident 163, the facility did not develop a care plan that identified and addressed redness and wounds of the right buttock. 2. For Resident 166, the facility did not develop an activity care plan to include her individual activity preferences; facility staff did not implement 1:1 activities as indicated on the care plan. 3. For Resident 168, the facility did not update the care plan for a medication kept at the bedside. These failures had the potential to result in the residents not receiving the appropriate care necessary to maintain their highest level of well-being. Findings: 1. A review of the clinical record for Resident 163 indicated she was admitted to the facility on [DATE] with an admission diagnosis of cellulitis (bacterial skin infection) of the left leg. Resident 163 had a brief interview for mental status (BIMS, a tool to assess cognitive status) score of 15 (scores of 13-15 indicate intact cognition). During an interview with Resident 163 on 10/09/19 at 9:13 a.m., she stated she had a wound on her back side that developed in the hospital. During an interview and concurrent record review with the minimum data set coordinator (MDS, an assessment tool) on 10/10/19 at 9:32 a.m., she reviewed Resident 163's clinical record and an admission skin assessment dated [DATE], indicated a wound on Resident 163's upper buttock area. Further review of Resident 163's clinical record, indicated the following skin assessments and interventions: 9/29/19: moist buttocks redness and application of foam dressing. 9/30/19: moist buttocks redness and application of calmoseptine (moisture barrier) 10/1/19: moist buttocks redness and application of calmoseptine (moisture barrier) 10/2/19 no buttocks wound assessment was done 10/3/19: no buttocks wound assessment was done 10/4/19: buttock redness 10/5/19: no buttocks wound assessment was done 10/6/19: no buttocks wound assessment was done 10/7/19: buttock redness 10/8/19: no buttocks wound assessment was done 10/9/19: buttock redness During the concurrent interview, the MDS Coordinator stated there was no care plan that identified the presence of a buttock wound or interventions to treat the wound. The MDS Coordinator stated Resident 163 had a care plan for impaired skin integrity but the facility's computer program was unable to personalize Resident 163's care plans to include identification of her actual buttock wound and specific treatment for that wound. Review of the facility's undated policy, General Patient Care Policy: Pressure Injury and Wound Care, indicated nursing staff, upon identification of an issue with skin integrity should update and maintain the resident's individualized care plan. 2. A review of the clinical record for Resident 166 indicated she was admitted to the facility on [DATE] with a diagnosis of pelvic fracture (broken bone) and had a BIMS score of 15. During an interview with Resident 166 on 10/8/19 at 10:32 a.m., she stated she was blind and deaf and she was unable to watch television or to leave her bed and she was not offered alternate room activities since her admission. Resident 166 stated she discussed activities with someone over a week ago and would like to be involved in some things during her stay. Review of Resident 166's Activity Assessment dated 9/28/19, indicated Resident 166 was hard-of-hearing and blind and had a preference for activities in her room including cards and games. Review of Resident 166's Activity Care Plan dated 9/27/19, indicated to provide 1:1 activities if resident does not prefer group activity. There was no evidence in Resident 166's Clinical Chart 1:1 activities were provided. During an interview with the activity coordinator (AC) on 10/10/19 at 8:36 a.m., she stated she had other responsibilities at the facility and had not yet set up any activities for Resident 166 in her room. The AC stated, she should have offered Resident 166 an activity such as reading the newspaper to her. Review of the facility's undated policy, Westland House Activity Assessment, indicated each resident's activity plan shall be part of the overall plan of care . shall include consideration of individual interests, former life-style . and include identified limitations and precautions. 3. A review of the clinical record for Resident 168 indicated she was admitted to the facility on [DATE] and had a history of asthma (a lung condition which causes difficulty with breathing) and she had a BIMS score of 14. During an interview and concurrent observation with Resident 168 on 10/8/19 at 10:03 a.m., she stated she kept medication at her bedside for her asthma, while pointing to an inhaler (a portable device for administering a drug which is to be breathed in) on her bedside table. Resident 168 stated she needed to have it next to her to use it when she was unable to breathe. Review of Resident 168's Physician Orders, dated 10/7/19, indicated ipratropium-albuterol (IA, medication to control symptoms of asthma) inhaler two puffs, four times per day for shortness of breath: OK to keep at patient's bedside. Review of Resident 168's undated Respiratory Care Plan, indicated the use of the IA inhaler during incidents of shortness of breath was not included in the list of interventions, nor was the direction to keep the IA inhaler at the resident's bedside for urgent use for episodes of shortness of breath. During an interview with the administrator (ADM) on 10/10/19 at 11:30 a.m., she stated the program used in the facility's electronic clinical record program did not allow for personalization of the care plan. The ADM stated they needed to work with the computer program company to add this ability to their system. Review of an article at (http://lippincottsolutions.lww.com/blog.entry.html/2014/08/11/nursing_care_plans-J2v6.html) indicated the nursing care plan should drive every single thing done with the patient . clinical reasoning, diagnosis, and appropriate treatment planning is a key component of professional nursing practice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. A review of the clinical record for Resident 163 indicated she was admitted to the facility on [DATE] with an admission diagnosis of cellulitis (bacterial skin infection) of the left leg and she had a brief interview for mental status (BIMS, a tool to assess cognitive status) score of 15 (scores of 13-15 indicate intact cognition). During an interview with Resident 163 on 10/9/19 at 9:13 a.m., she stated she had a wound on her back side that developed in the hospital. During an interview and concurrent record review with the MDS Coordinator on 10/10/19 at 9:32 a.m., the admission Assessment of 9/29/19, indicated a wound on Resident 163's upper buttock area. Further review of Resident 163's Daily Assessments, indicated inconsistent assessments and treatments of the buttock wound. The MDS Coordinator stated she was unable to find evidence for an exact description, location of the wound on the buttocks or if it had been treated from 9/29/19 to 10/10/19 except as listed below: 9/29/19: moist buttocks redness and application of foam dressing. 9/30/19: moist buttocks redness and application of calmoseptine (moisture barrier) 10/1/19: moist buttocks redness and application of calmoseptine (moisture barrier) 10/2/19 no buttocks wound assessment was done 10/3/19: no buttocks wound assessment was done 10/4/19: buttock redness 10/5/19: no buttocks wound assessment was done 10/6/19: no buttocks wound assessment was done 10/7/19: buttock redness 10/8/19: no buttocks wound assessment was done 10/9/19: buttock redness A review of Resident 163's Physician Order Report, dated 10/9/19, indicated to clean area with saline, pat dry, apply hydrophilic (mixes with water) wound dressing cream (a zinc oxide-based paste used to maintain a moist wound healing environment; usually covered by a foam dressing) as needed. The Physician order did not specify the area to be treated. During an observation of Resident 163's wound with the director of staff development (DSD) and RN C on 10/10/19, at 12:45 p.m., a round, cantaloupe sized, dark reddened area which extended from the rectum to the right side of Resident 163's buttock was visible. At the upper left and right and lower edges of the reddened area were three small open oval shaped, nickel sized open wounds, each with a small amount of depth. The wound was covered with a white ointment and left open to air inside Resident 163's brief. During an interview with RN C, she stated the appearance of the large reddened area and three small wounds were the same since 10/9/19. RN C stated she asked for a wound care consult in the morning of 10/10/19 and obtained a wound treatment order on 10/9/19. RN C stated she had not measured the wound. During an interview with the DSD on 10/10/19 at 12:50 p.m., she stated the nursing staff should have followed the same wound care standards as those practiced at the acute hospital. The nursing staff should have daily assessed the wounds and abnormal skin conditions, they should have described the location and characteristics and measurements of wounds to make sure the wounds were not getting larger or deteriorating. The DSD stated part of assessment would be to know if a wound is improving or getting worse, based on earlier detailed assessments. The DSD stated RN C should have measured and described Resident 163's right buttock wound on 10/9/19. Review of Resident 163's clinical record, indicated on 10/9/19 the skilled nurse described the above wound as buttock redness. Review of the facility's undated policy, Pressure Injury and Wound Care, indicated skin inspections will be completed each shift and as condition changes . Appropriate interventions are implemented . documentation of assessments and interventions are completed in the electronic medical record . Procedure on admission: a systematic skin inspection and description of wounds . Nursing Staff: provide appropriate skin and/or wound care. Inspect skin to identify moisture associated skin damage. Based on observation, interview, and record review the facility failed to maintain standards of practice for two of three sampled residents (161 and 163). 1. For Resident 161, PR (per rectum) medications were not administered appropriately 2. For Resident 163, the licensed nurse did not instruct the resident to rinse her mouth after a breo inhalation (fluticasone-vilanterol, inhaler with steroids). 3. For Resident 163, the licenced nurse did not accurately and consistently assess, treat, and document a buttock wound. The physician's order for wound care was incomplete when it did not specify the location of the wound. This failure could result in ineffective medication administration and wound care and could lead to the residents' discomfort and complications. Findings: 1. During a random medication pass observation on 10/8/19 at 9:55 a.m., registered nurse C (RN C) administered 2 medications PR while Resident 161 was lying on his right side. RN C did not apply a lubricant during the administration of a valium (muscle relaxant) and morphine (narcotic pain medication) suppository. During a review of Resident 161's clinical record, it indicated he was admitted on [DATE] for hospice care (comfort care). A physician order dated 10/8/19 indicated to administer morphine 30 mg rectally every 12 hours and diazepam 5mg rectally every 4 hours. During an interview with RN C on 10/8/19 at 3:51 p.m., she confirmed the above observation. RN C stated she could have used a lubricant for the resident's comfort. During an interview with MDS (minimum date set) nurse on 10/8/19 at 1:38 p.m., she stated that during PR administration, the use of a lubricant was advisable for the resident's comfort. During an interview with the director of nursing (DON) on 10/10/19 at 12:38 p.m., she stated residents should be on left side lying position when administering PR medications. 2. During a random medication pass observation on 10/8/19 at 10:32 a.m., RN C administered the breo inhaler to Resident 163. RN C did not instruct the resident to rinse her mouth after the administration. During an interview with RN C on 10/8/19 at 3:51 p.m., she confirmed the above observation. RN C stated she was not aware she should have advised the resident to rinse her mouth after the breo inhalation administration. Lexi.com (online drug literature website) indicated patient using breo should rinse mouth with water after inhalation and expectorate rinse solution. Review of the facility's 2018 Nursing Drug Handbook, indicated to teach patient to rinse mouth without swallowing after breo inhalation to reduce the risk of candidal infections (oral thrush/infection). Review of the facility's policy, Administration of Medication, dated 1/2019, indicated licensed nurses should ensure safe administration of medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assist one of one sampled resident (166) to eat a pureed diet (all food is ground to a soft, smooth consistency, like a pudding for residents who have trouble chewing or swallowing) when staff allowed Resident 166 to keep bananas in her room. This failure had the potential to result in Resident 166 choking or aspirating food into her lungs. Findings: A review of the clinical record for Resident 166 indicated she was admitted to the facility on [DATE] with a diagnosis of pelvic fracture (broken bone) and she had a brief interview for mental status (BIMS, a tool to assess cognitive status) score of 15 (scores of 13-15 indicate intact cognition). During an interview and concurrent observation of Resident 166 in her room on 10/08/19 at 10:46 a.m., she stated she was unhappy with her pureed diet and she only liked the food brought in by her son. Resident 166 pointed to a bunch of bananas on her side table. Resident 166 stated staff would let her have the bananas. During an interview with the speech therapist on 10/8/19 at 1:05 p.m., he stated Resident 166 had a choking risk if she did not follow her pureed diet. During an observation and concurrent interview with Resident 166 in her room on 10/9/19 at 1:24 p.m., a bunch of bananas were observed on her side table. Resident 166 stated she asked one of the girls after breakfast yesterday to peel a banana for her and she ate one half of the banana. During an interview with registered nurse D (RN D) on 10/9/19 at 1:29 p.m., she stated she needed to look at her list to see if Resident 166 could have bananas. After checking the list, RN D stated Resident 166 had an order for a pureed diet and was not supposed to have bananas at her bedside. RN D confirmed Resident 166 had bananas at her bedside. During an interview with the registered dietician and nutritionist (RDN) on 10/9/19 at 1:33 p.m., he stated Resident 166 should not have bananas at her bedside because she was on a pureed diet. The RDN reviewed the clinical record and stated there was no evidence the family had a training on pureed diet. The RDN stated, the dieticians would not routinely instruct the family on therapeutic diets, but they would do so when they were notified the family would bring in food from home. During an observation in Resident 166's room on 10/10/19 at 12:36 p.m., Resident 166 sat up in her bed with a tray of pureed food on the over-the-bed table in front of her. Review of the facility's undated policy, Meals and Menus, indicated resident's families are permitted to bring in non-perishable food. For therapeutic, modified diets, the Registered Dietician can review food from home to assure that it is allowed within the limitations of the physician's diet order.

Based on interview and record review, the facility failed to ensure a medication was not administered without adequate monitoring or without adequate indications for its use for one of 22 residents (Resident 65), when Wellbutrin (an antidepressant medication) was administered without adequate indications for its use with monitoring. This failure had the potential for an adverse reaction and the inability of staff to assess the effectiveness of the medication due to not having a specific indication or behavior to monitor to assess if the medication is correct and adequate. Findings: During a review of Resident 65's physician's orders and concurrent interview with the MDS Coordinator on 10/9/19 at 2:33 p.m., an order for Wellbutrin indicated the behavior to be monitored was agitation. The MDS Coordinator stated, there was no evidence what specific agitation Resident 65 would show. The facility's policy and procedure, Westland House Policy and Procedure: Informed Consent to Psychotropic Medications, dated 2019, indicated .The nature of the behavior that is the reason the medication is being given or recommended.

Based on observation, interview, and record review the facility failed to ensure nursing staff implemented accepted standards of infection control practice for two of three sampled residents (3 and 169) when an aseptic technique was not maintained during peripherally (away from the central part of the body) inserted central catheter (PICC, a long catheter inserted through a peripheral vein, often in the arm, into a larger vein in the body, used for intravenous (IV, into vein) medication administration) line dressing changes. This failure had the potential to result in catheter related blood stream infections (CRBSI). Findings: 1. During an observation on 10/9/19 at 2:25 p.m. of Resident 3's PICC line dressing change, registered nurse C (RN C) removed Resident 3's PICC line dressing and measured his PICC line length. RN C next donned sterile gloves and with a disinfectant soaked swab, scrubbed the skin of Resident 3's right arm, beginning with the area furthest away from and surrounding the PICC line insertion site. RN C next scrubbed Resident 3's skin close to the PICC line insertion site, and with the same swab, then wiped the PICC line insertion site and tubing. During an interview with the minimum data set (MDS, an assessment tool) coordinator on 10/9/19 at 3:10 p.m., she stated when scrubbing the skin during a PICC line dressing change, the nurse should have cleaned the PICC line insertion site first and then gradually should have cleaned the surrounding skin, working out away from the insertion site. The MDS Coordinator stated the nurse should have never cleaned the PICC line site after cleaning the arm, if using the same cleaning stick. During an interview with the director of staff development (DSD) on 10/9/19 at 3:12 p.m., she stated the nurse should have cleaned the PICC line insertion site and first few inches of PICC line tubing with a new cleaning stick first, prior to cleaning the surrounding area. Review of Peripherally Inserted Central Cather - Dressing Change at https://medlineplus.gov/ency/patientinstructions/000462.htm indicated to first clean the catheter, slowly working away from the insertion site, then clean the skin around the site. 2. During an observation on 10/10/19 at 10:48 a.m. of Resident 169's PICC line dressing change, RN D donned sterile gloves and removed the dressing from the PICC line site. RN D then held a measuring tape along the length of the PICC line, stabilized the tape next to the PICC line insertion site by placing her first two gloved fingers onto Resident 166's skin, causing the gloves to no longer be sterile. RN D then placed the same first finger, which had just touched Resident 169's skin onto the PICC line insertion site while holding the measuring tape to finish the measurement. During an interview with RN D on 10/10/19 at 11:15 a.m., she acknowledged she should not have placed her finger on the PICC line insertion site while measuring the PICC line. During an interview with the DSD on 10/9/19 at 3:12 p.m., she stated the nurse should have not touched the PICC line insertion site with a contaminated item. Review of the facility's undated policy, Peripherally Inserted Central Catheter (PICC) Dressing Change, indicated to place a transparent dressing over the PICC line insertion site, remove gloves, and then measure the PICC line catheter. Review of CDC guidelines at https://www.cdc.gov/hai/pdfs/bsi-guidelines-2011.pdf (p. 33) indicated to maintain aseptic technique (using practices and procedures to prevent contamination with germs) during care of a PICC line, to inspect the PICC line insertion site visually during a dressing change and to palpate (touch) the PICC line insertion site through an intact dressing.