**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure residents received care consistent with professional standards of practice to prevent the development and worsening of pressure injuries for one (#14) resident reviewed for pressure injuries out of 25 sample residents. Specifically, the facility failed to ensure interventions for Resident #14's pressure injury were consistently implemented. Findings include: I. Professional reference According to the National Pressure Injury Advisory Panel, Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline, third edition, [NAME] Haesler (Ed.), EPUAP/NPIAP/PPPIA: 2019, retrieved from https://www.internationalguideline.com/guideline on 12/1/23. Pressure ulcer classification is as follows: Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as the body's natural (biological) cover; and should not be removed. Suspected Deep Tissue Injury: Depth Unknown 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. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. Risk Factors and Risk Assessment -Consider individuals with limited mobility, limited activity and a high potential for friction and shear to be at risk of pressure injuries; -Consider individuals with a Category/Stage 1 pressure injury to be at risk of developing a Category/Stage 2 or greater pressure injury; -Conduct a pressure injury risk screening as soon as possible after admission to the care service and periodically thereafter to identify individuals at risk of developing pressure injuries; and, -When conducting a pressure injury risks assessment: Use a structured approach; Include a comprehensive skin assessment; Supplement use of a risk assessment tool with assessment of additional risk factors; Interpret the assessment outcomes using clinical judgment. Skin and Tissue assessment -Assess the pressure injury initially and as soon as possible after admission/transfer to the healthcare service; -Re-assess at least weekly to monitor progress toward healing; -Assess the physical characteristics of the wound bed and the surrounding skin and soft tissue at each pressure injury assessment; and, -Monitor the pressure injury healing progress. Support Surfaces For individuals with a pressure injury, consider changing to a specialty support surface when the individual: Cannot be positioned off the existing pressure injury. Support surfaces are specialized devices for pressure redistribution and management of tissue load and microclimate. The importance of using a high specification pressure redistribution support surface in all individuals at risk of pressure ulcers or with existing pressure ulcers is highlighted. II. Facility policy and procedures The Skin Management policy, dated June 2022, was provided by the director of nursing (DON) on 12/4/24 at 1:05 p.m. The policy read in pertinent part: Residents receive care to aid in the prevention or worsening of wounds and/or pressure ulcers. Individuals at risk for skin compromise are identified, assessed, and provided treatment to promote healing, prevent infection, and prevent new pressure injuries from developing. Ongoing monitoring and evaluation are provided for optimal resident outcomes. III. Resident #14 A. Resident status Resident #14, under the age of 65, was admitted on [DATE]. According to the computerized physician orders (CPO), the diagnoses included sepsis (infection) of right knee with unspecified organism, effusion (fluid accumulation) right knee, unilateral osteoarthritis right knee, unspecified severe protein calorie malnutrition and pressure induced deep tissue damage of left heel, right heel and right buttock. The 11/7/23 minimum data set (MDS) assessment revealed the resident had intact cognition with a brief interview for mental status (BIMS) score of thirteen out of 15. The resident required partial/moderate assistance with activities of daily living (ADL) from staff members for bed mobility, positioning, and transfers (toileting not assessed due to medical condition). The resident was at risk for the development of pressure injuries and had two unstageable pressure injuries. B. Resident interview Resident #14 was interviewed on 11/29/23 at 4:38 p.m. The resident said he developed the wounds to his heels and buttock due to lying in bed too long. The resident said he was hospitalized prior to admission to the facility due to an infection in his right knee. The resident said the right knee was extremely painful and he could not roll left to right and could not extend or straighten his leg due to the pain. The resident said he could not walk, had trouble putting pressure on the right leg and tried to extend the knee but could not. The resident said the hospital doctors drained a lot of red/yellowish fluid from the knee and he had to take antibiotics for six weeks. The resident said staff come in to check on him but don't know how often, staff tried to reposition him but it was too painful. The heel protectors did not stay in place because he used his feet to raise himself in bed to eat and drink. C. Resident observations On 11/29/23 at 2:03 p.m. the resident was covered with a sheet with his lower extremities exposed. The resident has bilateral heel protectors on but both heel protectors were covering his calves, not his heels. On 11/30/23 at 8:04 a.m. the resident had the left heel protector on his left foot, the right heel protector was not positioned correctly on his foot and instead was covering his right calf. There was no pressure reducing or air mattress on the resident's bed. -At 9:40 a.m. registered nurse (RN) #1 entered the resident's room to perform wound care. RN #1 removed the resident s non-skid sock from the right foot and the right heel protector was on the resident's right calf. -At 11:00 a.m. both heel protectors were on the bed and not on his heels. -At 12:51 p.m. there was an air mattress inflating outside the resident's room to replace the resident's mattress. D. Record review The comprehensive care plan last revised on 11/3/23, revealed the resident had potential for skin breakdown and documented the resident admitted with right knee surgical site, open area to right buttocks and deep tissue injury to left heel, deep tissue injury to right heel (11/5/23). The primary goal was the skin will remain intact. Wounds will show signs/symptoms of healing through the next review. Target date 11/26/23. Interventions included applying skin moisturizer/barrier as needed. Check frequently for incontinent episodes and assist with wash, rinse and dry soiled areas and change clothes prn (as needed). CNA (certified nurse aide) to monitor skin daily and licensed nurse to check skin thoroughly on a weekly basis. Encourage adequate fluid and nutritional intake. Encourage/assist with turning and positioning frequently. Heel boot while in bed. Pressure reducing mattress on bed. Report any changes or abnormalities in skin to the charge nurse/MD (medical doctor) immediately. Treatment as ordered. Wound doctor to follow. The 11/1/23 Braden scale assessment (scale for predicting pressure injury risk) documented the resident was at mild risk (lower probability of developing a pressure injury, but needs to be managed with routine procedures as a preventative measure) for developing a pressure injury. The assessment revealed the resident had no sensory perception impairment, was rarely moist, his mobility was slightly limited and his nutrition was adequate. The resident required moderate to maximum assistance with repositioning, therefore, required a lift to avoid sliding against the bed sheets. Scoring: 17.0 or at lower risk for the development of pressure ulcers. Nursing note dated 11/4/23 During wound care intact deep tissue injury noted to the right heel. Skin prep applied, heel floated, and heel boot applied. Resident did not report pain during examination to right heel. Director of Nursing aware. Writer placed a call to the resident's power of attorney, unable to leave a message, voice messaging not set-up. The Head to Toe Skin Check dated 11/5/23 documented that the resident did not refuse a skin check. The resident had existing bruises, existing pressure ulcers to his upper buttocks, a left heel deep tissue injury, a right knee status post surgical incision that was well approximated a left knee abrasion, scabbed areas all over body in various stages of healing due to recent recovery from scabies and lice. Interdisciplinary team (IDT) note dated 11/7/23 documented the IDT met and reviewed new skin issues related to the right heel. Place heel boot to float right heel. On 11/7/23 at 3:32 p.m. a skin/wound note documented the resident refused to be seen by the wound care doctor. The wound care evaluation note dated 11/21/23 written by the wound care physician assistant documented the resident was seen as a new patient for an evaluation of pressure injuries and moisture associated skin damage of the sacrum. Patient had scabies several weeks ago and the hospital cleared him. Patient now states he's been having itching on the left buttock and hip recently. Recommended PCP (primary care physician) evaluation to assess possible Scabie recurrence. The patient is at high risk for new or worsening wounds, recommended continuing off loading measures and floating heels. Wound Assessment #1 documented : The right heel was a deep tissue injury, persistent non-blanchable deep red, maroon, or purple discoloration pressure ulcer and had received a status of non-healed. Initial wound encounter measurements are 5.0 centimeters in length, 2.5 centimeters in width with no measurable depth and an area of 25 square centimeters. There was no drainage noted. The periwound skin did not exhibit erythema, periwound skin did not exhibit signs or symptoms of infection. Wound Orders: Wound cleansing and dressing: Apply betadine and leave open. Float heels and reposition frequently. Wound Assessment #2: The left heel was a deep tissue injury, persistent non-blanchable deep red, maroon, or purple discoloration pressure ulcer and has received a status of non-healed. Initial wound encounter measurements are 2.5 centimeters in length x 2.0 centimeters in width, no measurable depth with an area of 5 square centimeters. There was no drainage noted. The periwound skin did not exhibit erythema, periwound skin did not exhibit signs or symptoms of infection. Wound Orders: Wound cleansing and dressing: Apply betadine and leave open. Float heels and reposition frequently. Wound Assessment #3: The right buttock wound is partial thickness moisture associated with skin damage and has received a status of non-healed. Initial wound encounter measurements are with no measurable depth. There is no drainage noted. The periwound skin exhibited maceration (the softening and breaking down skin resulting from prolonged exposure to moisture). The periwound skin did not exhibit erythema, periwound skin does not exhibit signs or symptoms of infection. Diffuse partial thickness breakdown and blanching erythema roughly 5% dermis. Wound Orders: Apply barrier cream every shift. Skin Injury Evaluation per Wound Care 11/28/23 at 12:38 p.m. Right heel unstageable wound, not classified as unavoidable, measures 4 (length) x 4 (width) centimeters, no tunneling, no exudate, no odor, 100% eschar, defined wound edges, surrounding skin normal, no pain, treatment betadine. Interventions: pressure reducing mattress, heel protectors. -However, observations (see above) the resident's heel protectors were not consistently positioned correctly or on the resident and the air mattress was not placed on the resident's bed until 11/30/23. The 11/20/23 CPO revealed to apply heel boots to both heels related to deep tissue injuries, ensure boots are on at all times, except during cares. IV. Staff Interviews Licensed practical nurse (LPN) #1 was interviewed on 11/28/23 at 4:06 p.m. LPN #1 said she was found the wound on the right heel as she was completing a head-to-toe skin assessment on 11/4/23. LPN #1 said the resident had two other wounds, one on his sacrum and the other on the left heel. LPN #1 said both the sacrum and left heel wounds occurred at the hospital and were pre-existing. The right heel wound developed at the facility because the resident could not straighten his right leg and pushed himself up in bed using his feet. LPN #1 said she immediately put heel protectors on the resident's feet. LPN#1 said she notified the director of nursing (DON) and reported the presence of the resident's wounds. Certified nurse aide (CNA) #1 was interviewed on 11/30/23 at 12:49 p.m. CNA #1 said the resident kept his right knee flexed and could not straighten it without extreme pain. The DON was interviewed on 11/28/23 at 3:35 p.m. The DON said the resident had two wounds. One on the right heel and one on the left heel. The DON said she was unaware of the right buttock wound. The DON said the right heel wound was found on 11/7/23 and heel protectors were recommended at that time. The DON said the left heel wound was pre-existing and occurred prior to his admission to the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure two (#14 and #10) out of 19 sample residents were kept free from abuse. Specifically, the facility: -Failed to prevent a resident-to-resident altercation between Resident #15 and #10; -Failed to prevent a resident-to-resident altercation between Resident #15 and #14; -Failed to care plan and address the altercations involving Resident #15; and, -Failed to educate and train staff on triggers and the potential for Resident #15's aggression. Findings include: I. Facility policy and procedure The Preventing Resident Abuse policy, dated 11/1/17, was provided by the nursing home administrator (NHA) on 8/15/22 at 8:30 a.m., included in part, Our facility will not condone any form of resident abuse and will continually monitor our facility's policies, training programs, systems, etc., to assist in preventing resident abuse. The facility's goal is to achieve and maintain an abuse-free environment. Assessing, care planning, and monitoring residents with needs and behaviors that may lead to conflict or neglect. II. Altercation on 6/16/22 A. Investigation Resident #10 was observed giving Resident #15 a hard time in the dining room. Resident #10 stated, 'you're late, there is no food left for you.' Unsure if he was joking, Resident #15 became upset yelling at him 'to shut the (expletive) up.' Resident #10 stated, 'I want a new roommate, I don't want to live in the same room as this (expletive).' Resident #10 stated his roommate, Resident #15, came to dinner and asked Resident #10 what was for dinner. Resident #10 stated pulled pork. Resident #15 became upset asking again what was for dinner. Resident #10 stated pulled pork. Per Resident #10's report, Resident #15 became upset, yelling, and kicked Resident #10's left posterior leg with his right foot. Resident #10 stated he was not in pain. Resident #10 stated he was not afraid. Resident #10 was his own person (decision maker). Resident #10 was separated from Resident #15. All notifications (were) made. The resident was taken to (different room) for the evening per NHA. Resident #10's skin was intact, no discoloration noted at this time. Oncoming nurse aware, residents separated at this time. The conclusion of the internal investigation, Security video footage provided evidence that Resident #15 did kick Resident #10's left lower leg with his right foot while seated in the dining room. This was an isolated incident between these two roommates in the dining room. There is no pattern to physical abuse in this community. III. Altercation on 6/26/22 A. Investigation Dietary cook (DC) #1, heard Resident #15 in the dining room say, 'don't hit me' to Resident #14, who was seated next to Resident #15. DC #1 stated she then witnessed Resident #15 hit Resident #14's left forearm with his right hand. DC #1 immediately alerted the nurse and with the nurses assistance separated the two residents. The nurse then notified this administrator and nurse management. The nurse performed a nurse assessment on each resident and found no injury and both residents reported not being fearful from the incident. The conclusion of the internal investigation, The video evidence from the security cameras in the dining room supported the witness (DC #1) statement, the victim's statement, and the nurses assessment notes. The incident was isolated in our community and not indicative of widespread physical abuse occurring with our residents. -The facility indicated the altercation was isolated, however Resident #15 was the aggressor in the altercation that occurred on 6/16/22 (see above). IV. Resident #10 A. Resident status Resident #10, over the age of 90, was admitted on [DATE]. According to the August 2022 computerized physician orders (CPO), diagnoses included cerebral infarction (stroke), hypoxia (low oxygen levels), and muscle weakness. The 5/23/22 minimum data set (MDS) assessment revealed the resident's cognitive status was intact with a brief interview for mental status (BIMS) score of 15 out of 15. He had no behaviors or rejections of care. V. Resident #14 A. Resident status Resident #14, age [AGE], was admitted on [DATE]. According to the August 2022 computerized physician orders (CPO), diagnoses included senile degeneration (loss of intellectual ability), depression, and dependence on wheelchair. The 6/2/22 minimum data set (MDS) assessment revealed the resident's cognitive status was severely impaired with a brief interview for mental status (BIMS) score of six out of 15. She had no behaviors or rejections of care. VI. Resident #15 A. Resident status Resident #15, age [AGE], was admitted on [DATE]. According to the August 2022 computerized physician orders (CPO), diagnoses included cellulitis, muscle weakness, and abnormalities of gait. The 6/8/22 minimum data set (MDS) assessment revealed the resident's cognitive status was intact with a brief interview for mental status (BIMS) score of 15 out of 15. He had no behaviors or rejections of care. B. Record review -The resident did not have a care plan to address behaviors to include aggression toward other residents. -The facility failed to provide education and training to staff on Resident #15's altercations and potential triggers for aggression. VII. Interviews Certified nurse aide (CNA) #1 was interviewed on 8/16/22 at 2:23 p.m. She said Resident #15 had only had one incident with another resident that she was aware of. She said Resident #15 had not been aggressive toward another resident recently.She said Resident #15 was not aggressive. She said she had not received training on Resident #15's potential triggers and interventions for him. CNA #2 was interviewed on 8/16/22 at 2:31 p.m. She said she had not been in the facility long. She said she had not received training for Resident #15. She said she was not aware of any altercations involving Resident #15. Licensed practical nurse (LPN) #1 was interviewed on 8/16/22 at 2:33 p.m. She said she knew Resident #15 had been in an altercation with one resident. She said a resident (Resident #14) had tapped him on the arm, and Resident #15 hit her, the Resident #14 hit him again, and then Resident #15 hit her again before getting separated. -However, what LPN #1 said regarding the altercation that occurred on 6/26/22 did not match the facility ' s investigation of what happened (see investigation above). LPN #1 said she had not received training on Resident #15 to include interventions and triggers. The social services director (SSD) was interviewed on 8/16/22 at 2:39 p.m. He said Resident #15 had a history of becoming agitated quickly, and could de-escalate quickly as well. He said if staff were to see Resident #15 escalated, the staff were to move him to a different location. He said staff should have been educated on triggers and interventions to prevent possible further incidents. He said there should have been a person-centered individualized care plan in place to address the altercations Resident #15 had been involved in. He said he would write a care plan and educate staff to promote the highest practicable well being for Resident #15 and all the residents in the facility. The director of nursing (DON) was interviewed on 8/16/22 at 2:50 p.m. She said she was not aware of Resident #15 having any behaviors. She said she was not sure of the altercations. She said she was not sure if staff education had been provided. She said going forward to prevent future altercations she did not want Resident #15 to sit next to the two individuals Resident #15 had previously had altercations with. The nursing home administrator (NHA) was interviewed on 8/16/22 at 2:45 p.m. He said the incident on 6/16/22 had included review of video footage that revealed Resident #15 had indeed kicked Resident #10. He said review of the 6/26/22 video footage also revealed the altercation between Resident #14 and #15. He said the facility was aware Resident #15 had a quick temper. He said Resident #15 was easy to redirect. He said the team had strategized trying different seating locations in the dining room. He said the facility did not want any altercations between residents and was working diligently to prevent future altercations for all residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to provide assistance with activities of daily living (ADLs) for two (#42 and #41) of five residents reviewed for ADL decline out of 42 sample residents. Specifically, the facility failed to; -provide positioning device for dependent Resident #42 to prevent leaning while in wheelchair receiving care and; -provide positioning device for dependent Resident #41 with lymphedema to right arm while sitting in a wheelchair. Findings include: I. Facility policy and procedure The Request for Therapy Services policy and procedure, dated April 2007, was provided by the director of nurses (DON) on 10/10/19 at 4:36 p.m. It read in part, a therapist shall interview the resident and consult with the attending physician as to the type of treatment to be administered. Therapy is scheduled in coordination with nursing services and is documented in the resident's medical record. II. Residents status A. Resident #42 Resident #42, age [AGE], was admitted on [DATE]. According to the October 2019 computerized physician orders (CPO), diagnoses included profound intellectual disability and joint derangements unspecified. The 9/18/19 minimum data set (MDS) assessment revealed the resident had short and long term memory problems, and severely impaired cognitive skills for daily decision making. He required extensive, two persons assistance with transfers, and extensive, one person assistance with dressing, eating, and personal hygiene. He required total assistance with toilet use and had no functional limitations in range of motion to upper and lower extremities. 1. Observations On 10/8/19, 10/9/19 and 10/10/19 at approximately 11:30 a.m., Resident #42 was observed in the dining room. He was leaning to the left side while sitting in his wheelchair. No positioning support or device was observed. On 10/9/19 at 8:06 a.m., Resident #42 was observed in the dining room, assisted by a nurse aide with breakfast meal. He was leaning to the left side while sitting in his wheelchair. No positioning support or device was utilized. During the observations, the resident was not reposition or encouraged to reposition self. 2. Record review The comprehensive care plan, revised 9/30/19, identified activities of daily living (ADL) self-care performance deficits. Interventions included: adjust the level of care according to his individual needs. The plan of care identified risk for falls related to impaired balance. Interventions included occupational therapy (OT) for evaluation and treatment for wheelchair management and safety. The CPOs, dated October 2019, read in part, OT treatment to include therapeutic activities and adjustments to new environment. Resident to participate in the restorative program. The OT evaluation and plan of treatment, dated 9/5/19, was provided by the therapy director (TD) on 10/10/19 at 9:31 a.m. It read in pertinent part, Resident referred to OT services related to reports from staff, patient demonstrated decreased safety with performance transferring self from his wheelchair and leaning forward and or backwards while in wheelchair. OT identified functional limitations as a result of posture included sitting upright, functional mobility, repositioning self, skin integrity, and propelling wheelchair. OT recommended the use of anti-tilt bars on the back of wheelchair to prevent patient from tipping over and falling out of a wheelchair. 3. Staff interviews The TD was interviewed on 10/10/19 at 9:20 a.m. She said Resident #42 was able to position himself while sitting in a wheelchair. She said a rehab evaluation would be performed if a resident is referred by the nursing department. She said the resident was evaluated last month with recommendations for an anti-tipping device for the wheelchair. The DON was interviewed on 10/10/19 at 1:39 p.m. She said no device was used for positioning. She said Resident #42 is on the restorative program. B. Resident #41 Resident #41, age [AGE], was admitted on [DATE]. According to the October 2019 CPOs, diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, lymphedema, generalized edema, arteriovenous fistula, dependence on renal dialysis, and stage four chronic kidney disease. The 9/29/19 MDS assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. He required extensive assistance for bed mobility, transfers, dressing, personal hygiene, and toilet use. He had functional limitations in range of motion with impairment on one side of the upper and lower extremities. 1. Observations On 10/8/19 at 10:33 a.m. Resident #41 was observed sitting in his room in his wheelchair with severe lymphedema to his right arm. The right upper extremity was resting on his lap with no arm support observed. On 10/10/19 at 8:35 a.m. the resident was observed during transfer to his wheelchair. He was assisted by two nurse aides. The resident was transported to a dialysis center. He did not have any upper extremity support and his right arm was resting on the arm of the wheelchair. 2. Record review The comprehensive care plan, dated 9/25/19, identified ADL self-care performance deficit related to cerebrovascular accident (CVA) with right side effect. Intervention included arm board to the right side of his wheelchair. 3. Staff interviews The TD was interviewed on 10/10/19 at 3:14 p.m. She said due to Resident #41 having a right arm fistula, no intervention was put into place to reduce the edema. She said the lap tray attached to the wheelchair should be utilized for arm support. The certified occupational therapy assistant (COTA) was interviewed on 10/11/19 at 10:51 a.m. She said she received recommendations for Resident #41 to apply a bandage called, Tubigrip. She said she placed the bandage to his right extremity for a trial and error. She said the arm board should be in place at all times while Resident #41 was up in the wheelchair. The DON was interviewed on 10/10/19 at 1:39 p.m. She said Resident #41 received therapy for his right upper extremity. She said she was not familiar with the treatment and more information can be obtained from the rehab department.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to ensure the necessary respiratory care consistent with professional standards of practice, the resident's care plan, goals and preferences was provided for three (#29, #3 and #15) of three residents reviewed for Continuous Positive Airway Pressure/Bi-level Positive Airway Pressure (CPAP/BiPAP) non-invasive ventilation therapy, of four residents received CPAP/BiPAP therapy, out of 24 sampled residents. Specifically, the facility failed to: - Assure the resident care policy and procedures for respiratory care and services included safe handling, cleaning, storage and staff training for CPAP/BiPAP treatments, - Identify CPAP/BiPAP therapy in minimum data set (MDS) assessment, - Develop comprehensive person-centered care plan, including the residents goals and preferences for CPAP/BiPAP therapy, and - Address the respiratory services and monitoring in residents' records. Cross reference to F880 (Infection Prevention and Control); the facility failed to properly maintain, clean and store CPAP/BiPAP equipment in a sanitary manner, per the manufacturer's recommendations. Findings include: I. Facility policy The October 2010 CPAP/BiPAP Support facility policy, provided by the director of nursing (DON) on 10/10/19 at 1:17 p.m., did not include maintenance, cleaning and storage of CPAP/BiPAP masks. II.Professional reference According to [NAME] (2019) Keeping it Clean: CPAP Hygiene, retrieved from https://www.usa.[NAME].com/c-e/hs/better-sleep-breathing-blog/better-sleep/keeping-it-clean-cpap.html , identified: -It was vitally important to keep everything as clean as possible, masks can be a prime breeding ground for bacteria and mold. -Daily clean the mask (including areas that come in contact with skin) using a damp towel with mild detergent and warm water then let the mask air-dry on a towel. -Wash the mask weekly, to keep it free of bacteria and germs, with warm water and a few drops of ammonia-free, mild dish detergent. Swirl it around for about five minutes, rinse it well then let it air dry during the day on a towel. III. Residents status A. Resident #29 Resident #29, under the age of 60, was admitted on [DATE]. According to October 2019 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD) and heart failure. The 8/23/19 minimum data set (MDS) assessment revealed the resident had no cognitive deficits with a brief interview for mental status (BIMS) score of 15 out of 15. She received oxygen therapy. The assessment did not include CPAP/BiPAP therapy. The October 2019 physician order documented a BiPAP treatment every night for sleep apnea. 1. Resident interview Resident #29 was interviewed on 10/09/19 at 9:24 a.m. She said she used her BiPAP every night. She said she did not observe or noticed the staff cleaned her BiPAP mask and respiratory equipment. She said once a month she was provided new respiratory mask and tubing. 2. Observations The following observations of Resident #29's BiPAP equipment were made on: - 10/9/19 at 9:24 a.m. - 10/9/19 at 5:15 p.m. - 10/10/19 at 10:49 a.m. - 10/11/19 at 9:45 a.m. All observations revealed Resident #29's respiratory mask was on the bedside table, unclean with dark discolored residue inside the mask. 3. Record review The comprehensive care plan, dated 5/22/19, identified Resident #29 was at risk for impaired gas exchange related to COPD. Interventions included a BiPAP respiratory mask at night. The interventions did not include cleaning, maintenance or resident's choices for the respiratory equipment and treatment. Further record review revealed the facility failed to address the BiPAP respiratory therapy and monitoring in the resident's records. B. Resident #3 Resident #3, under age [AGE], was admitted [DATE]. According to October 2019 CPO, diagnoses included COPD and obstructive sleep apnea. The 6/24/19 and 9/24/19 MDS assessments revealed the resident had no cognitive deficits with a BIMS score of 15 out of 15. She received oxygen therapy. The assessments did not include CPAP/BiPAP treatment. The October 2019 physician order documented a CPAP treatment every night for sleep apnea. 1. Resident interview Resident #3 was interviewed on 10/09/19 at 9:24 a.m. She said she used her CPAP every night. 2. Record review According to the manufacturer's instructions for Resident #3 CPAP, provided by the clinical nurse consultant (CNC) on 10/10/18 at 3:00 p.m., identified: -To wash the water tub and air tubing, weekly, in warm water with a mild detergent, rinse them thoroughly and allow them to air dry. -To refer to the mask user guide for detailed instructions on cleaning the mask; the mask user guide was not provided by the facility with the manufacturer's instructions. The comprehensive care plan, initiated 3/21/18, identified Resident #3 was at risk for impaired gas exchange related to COPD. Interventions included CPAP at night. The interventions did not include cleaning, maintenance or resident's choices for the respiratory equipment and treatment. Further record review revealed the facility failed to address the CPAP respiratory therapy and monitoring in resident's records. 3. Observations The following observations of Resident #3 CPAP equipment were made on: - 10/9/19 at 9:24 a.m. - 10/9/19 at 5:15 p.m. - 10/10/19 at 10:49 a.m. - 10/11/19 at 9:45 a.m. All observations revealed Resident #3 respiratory mask was on the bedside table, unclean with dark discolored residue inside the mask. C. Resident #15 Resident #15, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to October 2019 CPO, diagnoses included COPD, heart failure and sleep apnea. The 7/19/19 MDS assessment revealed the resident had no cognitive deficits with a BIMS score of 15 out of 15. He received oxygen therapy. The assessments did not include CPAP/BiPAP treatment. The October 2019 CPO documented CPAP during the day, when sleeping, and to receive 3L of oxygen via CPAP at bedtime. 1. Observations The following observations of Resident #3 CPAP equipment were made on: - 10/9/19 at 5:25 p.m. - 10/10/19 at 10:59 a.m. - 10/11/19 at 9:55 a.m. All observations revealed Resident #15's respiratory mask was on the bedside table, unclean with dark discolored residue inside the mask. 2. Record review The comprehensive care plan, initiated 10/12/18, documented the resident had impaired gas exchange related to COPD, sleep apnea, and heart failure. Interventions included a CPAP at night. The interventions did not include cleaning, maintenance or resident's choices for the respiratory equipment and treatment. Further record review revealed the facility failed to address the CPAP respiratory therapy and monitoring in the resident's records. 3. Interviews The BiPAP manufacturer representative was interviewed on 10/17/19 at 11:31 a.m. She said all respiratory masks should be washed daily with warm water and a gentle detergent (like baby soap), and let to air dry; to prevent respiratory infections. Certified nurse aide (CNA) #4 was interviewed on 10/10/19 at 2:28 p.m. She said CNAs did not clean Resident #29's, Resident #3, and Resident #15's respiratory masks, nor their respiratory equipment and it was not a part of the residents' care. Registered nurse (RN) #1 and licensed practical nurse (LPN) #1 were interviewed on 10/10/19 at 3:29 p.m. They said BiPAP and CPAP respiratory masks should be cleaned once a week to prevent respiratory infections. They said the respiratory masks were to be removed from the tubing, for cleaning, then were to be placed on a barrier (like a paper towel) to dry and were not to be placed directly on a table without a barrier. The DON was interviewed on 10/10/19 at 11:31 a.m. She said Resident #3 and Resident #15 used CPAP, and Resident #29 used a BiPAP. Once a month they received new respiratory masks and respiratory tubing from outside companies. She was not aware the respiratory equipment for the above residents was not maintained properly. She said she will research the manufacturers' instructions. She said she will educate the nursing staff to have CPAP and BiPAP respiratory masks cleaned. She said the residents' records did not address appropriate maintenance of their BiPAP and CPAP equipment and masks. The clinical nurse consultant (CNC) was interviewed on 10/10/19 at 3:00 p.m. She said the facility used the manufacturer's instructions as a references for the CPAP/BiPAP used by Resident #3, Resident #15, and Resident #29. Facility follow up On 10/11/19 at approximately 9:00 a.m. the DON provided the following: - Resident #29's, October 2019 CPO, dated 10/10/19, physician's order read, clean BiPAP respiratory mask on a weekly basis, with warm soapy water and allow to air dry. Empty the reservoir and let it air dry for daily maintenance of the BiPAP equipment. The comprehensive care plan, dated 10/10/19, included the following interventions: clean BiPAP on a weekly basis with warm soapy water and allow to air dry. The reservoir should be emptied and left to air dry. - Resident #3, October 2019 CPO, dated 10/10/19, physician's order read, clean respiratory tubing and mask once a week with dish detergent in the morning and let it air dry. Empty the reservoir and let it air dry; for daily maintenance of the CPAP equipment. The comprehensive care plan, dated 10/10/19, included the following interventions: CPAP machine should be cleaned weekly with warm soapy water and allowed to air dry. The reservoir should be emptied and left to air dry; for CPAP daily maintenance. - Resident #15's, October 2019 CPO, dated 10/11/19, physician's order read, clean respiratory mask on a weekly basis with warm soapy water and allow to air dry. Empty the reservoir and let it air dry; for daily maintenance of his CPAP equipment. The comprehensive care plan, dated 10/10/19, included the following interventions: clean respiratory mask on a weekly basis with warm soapy water and allow to air dry. The reservoir should be emptied and left to air dry for daily maintenance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** E. Resident #9 Resident #9, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the October 2019 computerized physician orders (CPO), diagnoses included metabolic encephalopathy, chronic obstructive pulmonary disease (COPD), and respiratory conditions due to smoke inhalation. The 7/5/19 minimum data set (MDS) assessment revealed the resident's cognition was intact with a brief interview for mental status (BIMS) score of 13 out of 15. She was independent with all activities of daily living. The respiratory treatments included oxygen therapy. 1. Record review The October 2019 CPOs, revealed continuous oxygen treatment at three liters per minute by nasal cannula to maintain oxygen saturation at or above 88 percent for COPD. The comprehensive care plan, initiated 3/29/18 and revised on 4/22/19, identified risk for impaired gas exchange related to COPD. Interventions included oxygen at three liters by nasal cannula. 2. Observation On 10/8/19 at 9:36 a.m., the oxygen concentrator in the resident's room, was infusing oxygen through a nasal cannula at 2.5 liters per minute (2.5LPM) and not connected to the resident. The nasal cannula tubing was hanging over the bed side rail, not bagged, and the nasal prongs touching a shirt that was on the bed. F. Resident #30 Resident #30, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the October 2019 CPOs, diagnoses included fracture of first lumbar vertebra and chronic obstructive pulmonary disease. The 8/23/19 MDS assessment revealed the resident's cognition was intact with a BIMS score of 15 out of 15. The respiratory treatments included oxygen therapy. 1. Record review The October 2019 CPO, revealed continuous oxygen at four liters per minute by nasal cannula to maintain oxygen saturation at or above 88 percent for COPD. The comprehensive care plan, initiated 8/14/19 did not address oxygen therapy. 2. Observation On 10/9/19 at 9:49 a.m., the resident's portable oxygen tank was observed on the back of the wheelchair, not in use, with nasal cannula tubing attached and draped over the back of wheelchair, with the nasal prongs not bagged and touching the seat. G. Resident #31 Resident #31, age [AGE] was admitted on [DATE]. According to the October 2019 CPOs, diagnoses included abnormal gait and mobility, lack of coordination, chronic respiratory failure, and COPD. The 8/28/19 MDS assessment revealed the resident's cognition was impaired with a BIMS score of five out of 15. The respiratory treatments included oxygen therapy. 1. Record review The October 2019 CPO revealed, oxygen as needed during the day and night, at two liters per minute flow, to maintain oxygen saturations at or above 88 percent for chronic respiratory failure. The comprehensive care plan, initiated 8/19/16 did not address oxygen therapy. 2. Observation On 10/9/19 at 3:36 p.m., Resident #31's oxygen concentrator was observed near the head of the bed, not in use, nasal cannula connected to the concentrator with the tubing draped over the bedside table, not bagged and the nasal prongs touching the bed side rail. H. Resident # 194 Resident #194, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the October 2019 CPOs, diagnoses included acute respiratory failure with hypoxia and COPD. The 9/26/19 MDS assessment revealed the resident's cognition was intact with a brief interview for mental status (BIMS) score of 13 out of 15. The respiratory treatments included oxygen therapy. 1. Record review The comprehensive care plan, initiated on 9/17/19, revealed a risk for impaired gas exchange related to COPD. Interventions included oxygen as ordered, change oxygen tubing, nasal cannula, and humidifier as needed and according to the facility protocol. 2. Observation On 10/8/19 at 9:28 a.m. Resident #194's oxygen concentrator was observed with nasal cannula attached and not bagged, lying at the head of the bed with the nasal prongs touching the linens on the bed. 3. Staff interviews Registered nurse (RN) #2, was interviewed on 10/9/19 at 10:01 a.m. She said the oxygen tubing is to be stored in a bag when not in use. She said the night shift changes the tubing and oxygen bags weekly. She said a bacteria could get on the nasal cannula and can cause a resident to inhale dirt and dust when not properly stored. Certified nurse aide (CNA) #3 was interviewed on 10/9/19 at 1:53 p.m. She said the oxygen tubing is changed by the oxygen company weekly. She said when not in use the oxygen tubing should be stored inside a bag that is provided by the oxygen company. The director of nursing (DON) was interviewed on 10/10/19 at 1:33 p.m. She said the oxygen tubing should be stored off the floor. She said sometimes there is a bag for the tubing and sometimes there is no bag. She said a respiratory infection may result when tubing is not properly stored. She said the facility used the Center for Disease Control (CDC) website for reference on oxygen storage. Based on observations, interviews and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically the facility failed to: - develop and implement a cleaning schedule for the respiratory equipment (CPAP/BIPAP) to prevent infections for residents #29, #3 and #15, - provide catheter care according to infection control standards for Resident #27, - maintain hand hygiene during wound care for Resident #27, - provide wound care treatment according to the infection control standards for Resident #27, and - ensure the oxygen equipment, including tubing and nasal cannulas, was stored in a sanitary manner for Residents #9, #30, #31 and #194 I. Facility policy According to the 11/1/17 Wound Care policy, provided by the director of nursing (DON) on 10/10/19 at 1:17 p.m., hand hygiene was to be performed between glove changes. The October 2010 CPAP/BiPAP Support facility policy, provided by the director of nursing (DON) on 10/10/19 at 1:17 p.m., did not include maintenance, cleaning and storage of CPAP/BiPAP masks. According to the October 2010 Catheter Care, Urinary policy, provided by the DON on 10/10/19 at 1:17 p.m., read, use a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately four inches outward. According to the undated Hand Hygiene Program facility policy, provided by the DON on 10/10/19 at 1:17 p.m., hand hygiene was to be performed between glove changes. II. Professional references According to [NAME] (2019) Keeping it Clean: Continuous Positive Airway Pressure (CPAP) Hygiene, retrieved from https://www.usa.[NAME].com/c-e/hs/better-sleep-breathing-blog/better-sleep/keeping-it-clean-cpap.html , identified: -It was vitally important to keep everything as clean as possible, masks can be a prime breeding ground for bacteria and mold. -Daily clean the mask (including areas that come in contact with skin) using a damp towel with mild detergent and warm water then let the mask air-dry on a towel. -Wash the mask weekly, to keep it free of bacteria and germs, with warm water and a few drops of ammonia-free, mild dish detergent. Swirl it around for about five minutes, rinse it well then let it air dry during the day on a towel. According to the Centers for Disease Control and Prevention (CDC) (4/29/19) Hand Hygiene in Healthcare Settings, retrieved from https://www.cdc.gov/handhygiene/providers/index.html identified: -Cleaned hands protected patients from deadly germs. -Hand sanitizer was to be used after glove removal. -Gloves were not a substitute for hand hygiene. -Visibly soiled hands were to be washed with soap and water. III. Residents' status A. Resident #29 Resident #29, under the age of 60, was admitted on [DATE]. According to October 2019 computerized physician orders (CPO) diagnoses included chronic obstructive pulmonary disease (COPD) and heart failure. The 8/23/19 minimum data set (MDS) assessment revealed the resident had no cognitive deficits with a brief interview for mental status (BIMS) score of 15 out of 15. She received oxygen therapy. 1. Resident interview Resident #29 was interviewed on 10/09/19 at 9:24 a.m. She said she used her BiPAP every night. She said she did not observe or noticed the staff cleaned her BiPAP mask and respiratory equipment. She said once a month she was provided new respiratory mask and tubing. 2. Observations The following observations of Resident #29's BiPAP equipment were made on: - 10/9/19 at 9:24 a.m. - 10/9/19 at 5:15 p.m. - 10/10/19 at 10:49 a.m. - 10/11/19 at 9:45 a.m. All observations revealed Resident #29's respiratory mask was on the bedside table, unclean with dark discolored residue inside the mask. 3. Record review The comprehensive care plan, dated 5/22/19, identified Resident #29 was at risk for impaired gas exchange related to COPD. Interventions included a BiPAP respiratory mask at night. The interventions did not include cleaning and maintenance of the resident's respiratory equipment. B. Resident #3 Resident #3, under the age of 65, was admitted [DATE]. According to October 2019 CPO, diagnoses included COPD and obstructive sleep apnea. The 6/24/19 and 9/24/19 MDS assessments revealed the resident had no cognitive deficits with a BIMS score of 15 out of 15. She received oxygen therapy. 1. Resident interview Resident #3 was interviewed on 10/09/19 at 9:24 a.m. She said she used her CPAP every night. 2. Record review According to the manufacturer's instructions for Resident #3 CPAP, provided by the clinical nurse consultant (CNC) on 10/10/18 at 3:00 p.m., identified: -To wash the water tub and air tubing, weekly, in warm water with a mild detergent, rinse them thoroughly and allow them to air dry. -To refer to the mask user guide for detailed instructions on cleaning the mask; the mask user guide was not provided by the facility with the manufacturer's instructions. The comprehensive care plan, initiated 3/21/18, identified Resident #3 was at risk for impaired gas exchange related to COPD. Interventions included CPAP at night. The interventions did not include cleaning and maintenance of the resident's respiratory equipment. 3. Observations The following observations of Resident #3 CPAP equipment were made on: - 10/9/19 at 9:24 a.m. - 10/9/19 at 5:15 p.m. - 10/10/19 at 10:49 a.m. - 10/11/19 at 9:45 a.m. All observations revealed Resident #3 respiratory mask was on the bedside table, unclean with dark discolored residue inside the mask. C. Resident #15 Resident #15, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to October 2019 CPO, diagnoses included COPD, heart failure and sleep apnea. The 7/19/19 MDS assessment revealed the resident had no cognitive deficits with a BIMS score of 15 out of 15. He received oxygen therapy. 1. Observations The following observations of Resident #3 CPAP equipment were made on: - 10/9/19 at 5:25 p.m. - 10/10/19 at 10:59 a.m. - 10/11/19 at 9:55 a.m. All observations revealed Resident #15 respiratory mask was on the bedside table, unclean with dark discolored residue inside the mask. 2. Record review The comprehensive care plan, initiated 10/12/18, documented the resident had impaired gas exchange related to COPD, sleep apnea, and heart failure. Interventions included a CPAP at night. The interventions did not include cleaning, maintenance or resident's choices for the respiratory equipment and treatment. 3. Interviews The BiPAP manufacturer representative was interviewed on 10/17/19 at 11:31 a.m. She said all respiratory masks should be washed daily with warm water and a gentle detergent (like baby soap), and let to air dry; to prevent respiratory infections. Certified nurse aide (CNA) #4 was interviewed on 10/10/19 at 2:28 p.m. She said CNAs did not clean Resident #29's, Resident #3, and Resident #15's respiratory masks, nor their respiratory equipment and it was not a part of the residents' care. Registered nurse (RN) #1 and licensed practical nurse (LPN) #1 were interviewed on 10/10/19 at 3:29 p.m. They said BiPAP and CPAP respiratory masks should be cleaned once a week to prevent respiratory infections. They said the respiratory masks were to be removed from the tubing, for cleaning, then were to be placed on a barrier (like a paper towel) to dry and were not to be placed directly on a table without a barrier. The DON was interviewed on 10/10/19 at 11:31 a.m. She said Resident #3 and Resident #15 used CPAP, and Resident #29 used a BiPAP. Once a month they received new respiratory masks and respiratory tubing from outside companies. She was not aware the respiratory equipment for the above residents was not maintained properly. She said she will research the manufacturers' instructions. She said she will educate the nursing staff to have CPAP and BiPAP respiratory masks cleaned. She said the residents' records did not address appropriate maintenance of their BiPAP and CPAP equipment and masks. The clinical nurse consultant (CNC) was interviewed on 10/10/19 at 3:00 p.m. She said the facility used the manufacturer's instructions as a references for the CPAP/BiPAP used by Resident #3, Resident #15, and Resident #29. D. Resident #27 Resident #27, under the age of 65, was admitted on [DATE]. According to October 2019 CPO, diagnoses included diabetes mellitus and COPD. The 8/21/19 MDS assessment revealed the resident had no cognitive deficit with a BIMS score 14 out of 15. She required extensive, two persons assistance with bed mobility and dressing, she was totally dependent on two staff with transfers and toilet use. She had indwelling urinary catheter. She had two, stage IV (four) pressure ulcers.She received oxygen therapy and was under hospice care. 1. Observations A catheter care was observed on 10/10/19 at 8:08 a.m. Certified nurse aide (CNA) #1 wiped back and forth (from the insertion site at the urethra and away from the urethra/insertion site) along Resident #27's Foley catheter using the same wipe and on the same side of the wipe. A stage IV pressure ulcer wound care was observed on 10/10/19 at 8:23 a.m. Registered nurse (RN) #1 used the same 4x4 gauze (sprayed with wound cleanser) and wiped the outside area of Resident #27's coccyx pressure wound then wiped inside the coccyx pressure wound; she did this twice with the same 4x4 gauze. After RN #1 cleaned the pressure wound she removed her gloves and donned another pair of gloves without performing hand hygiene. After these observations RN #1 identified she should have performed hand hygiene prior to donning the other set of gloves. 2. Record review The comprehensive care plan, initiated on 2/26/19 and revised on 6/20/18, identified Resident #27 had a potential for urinary tract infection (UTI) due to an indwelling catheter. Interventions included to assist with perineal care after each incontinent episode. There was no intervention addressing daily catheter care. According to the October 2019 treatment administration record (TAR), Resident #27 received Foley catheter care every shift; two times a day. 3. Interviews CNA #1 was not available for an interview. CNA #5 was interviewed on 10/10/19 at 1:00 p.m. She said when staff provided catheter care they were to wipe catheters in one direction only, away from where the catheter was inserted; to prevent infections. Staff were to perform hand hygiene between glove changes. CNA #4 was interviewed on 10/10/19 at 2:00 p.m. She said when staff provided catheter care they were to wipe catheters in one direction only, away from where the catheter was inserted not back and forth; to prevent infections. Staff were to perform hand hygiene between glove changes. The licensed practical nurse (LPN) #1 was interviewed on 10/10/19 at 1:45 p.m. She said when staff provided catheter care they were to wipe catheters in one direction only, away from where the catheter was inserted not back and forth; to prevent infections. The DON was interviewed on 10/10/19 at 8:23 a.m. She said staff were to wipe in one direction when providing catheter care, from the insertion site of a catheter then away from the insertion site. Staff were to use only one wipe at a time when wiping a catheter. Staff were not to wipe back and forth along a catheter. She said staff were to perform hand hygiene in between glove changes to prevent infections. She said nurses were to clean inside a pressure wound with a different set of 4x4s then those used to clean around the pressure wound. The clinical nurse consultant (CNC) was interviewed on 10/10/19 at 3:00 p.m. She said the facility used the CDC as a reference for catheter care, hand hygiene, and glove changes. She said the facility used the manufacturer's instructions as a references for the CPAP/BiPAP used by Resident #3, Resident #15, and Resident #29. She said the facility used the Utilization of the Wound Ostomy Continent Nurses Society (WOCNS) website as a reference for pressure wound care. The WOCNS website required a membership and could not be accessed for additional references. The Centers for Disease Control and Prevention (CDC) health care specialist was interviewed on 10/22/19 at 1:39 p.m. She said when performing urinary catheter care, one was to wipe away from the peri-urethral area along the catheter (in one direction, utilizing one wipe at a time) when providing catheter care and cleansing of the catheter insertion side.