**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for one sampled resident (Resident #1) reviewed for wandering, the facility failed to ensure a wander assessment was completed accurately, and failed to ensure a resident with known wandering behaviors had a wander guard order in place for use, had the wander guard applied in accordance with the plan of care, and failed to ensure orders were initiated to check placement and function of a wander guard. The findings include: Based on review of the clinical record, facility documentation, facility policy, and interviews for one sampled resident (Resident #1) reviewed for wandering, the facility failed to ensure a wander assessment was completed accurately, and failed to ensure a resident with known wandering behaviors had a wander guard order in place for use, had the wander guard applied in accordance with the plan of care, and failed to ensure orders were initiated to check placement and function of a wander guard. The findings include: Resident #1's diagnoses included vascular dementia, and anxiety disorder. Wander risk assessment dated [DATE] identified Resident #1 had a score of eleven (11), which indicated he/she was a high risk (score 0 to 8 = low risk, 9 to 10 = at risk, 11 and above = high risk). Nursing note dated 7/5/2025 at 6:18 AM identified Resident #1 was agitated and combative during early morning hours, struck Nurse Aide (NA) during care, displayed aggressive behaviors toward staff, including attempting to hit staff with walker. Ambulating rapidly through the hallways, unsteady on feet and unable to redirect. All de-escalation and redirection attempts were unsuccessful, refused medications, food and fluids, threw Ensure supplement at nurse. Physician notified with new orders to transfer to hospital for evaluation. Transfer to hospital at 6:15 AM. Review of the Hospitalization Records dated 7/5 to 7/24/2025 identified Resident #1 was admitted to the Behavioral Health Unit on 7/5/2025 and was discharged back to the skilled nursing facility on 7/24/2025. A readmission wander risk assessment dated [DATE] identified Resident #1 had a score of eight (8) and was deemed to be low risk (score 0 to 8 = low risk, 9 to 10 = at risk, 11 and above = high risk to wander). Review of the wander assessment dated [DATE] identified it was incomplete. Sections G and H were left blank and not answered. Section G question indicated to complete 72 hours post admission, and required to answer, the resident: has not wandered (0 points), has wandered within the home without leaving grounds (1 point), has wandered aimlessly within the home or off the grounds (5 points). Section H question indicated to complete at 1 month, quarterly, annually, with significant change and screening. The section required to answer, the resident: has had no reported episodes of wandering in the past 6 months (0 points), has had no reported episodes of wandering the past 3 months (1 point), has wandered in the past month (5 points). Review identified per the assessment directions, section H should have been completed when the assessment was performed, and should have added 5 points to the assessment, for a score of 13, at high risk. Interview and record review with the DON (Director of Nursing) on 9/8/2025 at 2:05 PM identified Resident #1 was identified as at risk for wandering/elopement prior to transfer to the hospital on 7/5/2025. Review of Resident #1's wandering risk assessment dated [DATE] identified she was unaware section G and H were blank. The DON stated staff should complete the assessment in accordance with the assessment directions, and section H should be completed as a screening. The DON stated although the assessment dated [DATE] identified Resident #1 was a low risk, if the staff had completed sections in accordance with the directions (complete section H for the admission screening), Resident #1's new score would have been eleven (11), indicative of a high risk to wander. Interview failed to identify why the wander assessment was incomplete and inaccurate. a. Record review identified all physician orders for Resident #1 were discontinued on 7/17/2025 due to the transfer to hospital, and he/she was no longer in the facility. Review identified the orders that were discontinued included an order for wander guard use and to check wander guard placement every shift and function daily. Record review identified Resident #1 was readmitted to the facility on [DATE]; nursing note dated 7/24/2025 at 2:45 PM identified Resident #1 was alert and oriented to person only. The readmission Resident Care Plan dated 7/24/2025 identified an elopement risk/wanderer. Interventions directed Resident #1 to wear a wander guard, check for placement and function as ordered, document wandering behavior, distract from wandering by offering pleasant diversions, structured activities, food, conversation, television, or a book, and to provide structured activities such as toileting, walking inside and outside, reorientation strategies to include signs, pictures, and memory boxes. APRN note 7/25/2025 at 11 AM identified Resident #1 was seen after readmission, Resident #1 ambulated with a walker independently, and was alert and oriented to person only. Review of the nursing progress notes from 7/25 to 8/6/2025 identified Resident #1 was noted to have wandering behaviors on 7/25, 7/28, 8/3, 8/4, and 8/5/2025. Record review identified although prior orders were re-instated upon readmission on [DATE], the order for wander guard use was not re-instated/renewed. Interview and record review with the DON (Director of Nursing) on 9/8/2025 at 2:05 PM identified Resident #1 was at risk for wandering/elopement and used a wander guard bracelet prior to transfer to the hospital on 7/5/2025. Interview identified Resident #1 remained a wander risk after readmission on [DATE]. The DON stated a wander guard was reapplied upon readmission on [DATE], in accordance with the resident plan of care, but was unable to provide documentation of the application. Further, the DON was unable to provide documentation of physician orders that directed use of a wander guard and to check placement every shift and function daily. Although the DON indicated staff should have entered new physician orders for use of a wander guard and to check placement every shift and function daily, interview failed to identify why that was not done. Review of the facility undated Wandering Risk Policy, directed in part, all residents who are at risk for harm because of wandering behavior will be identified for wandering/elopement risk upon admission to the facility. The wandering/elopement risk assessment will be utilized in the EMR (electronic medical records). Residents identified as high risk will have a wander guard bracelet applied.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 2 residents (Resident #32) reviewed for pressure ulcer, the facility failed to notify the resident representative of a new open area on the coccyx which required treatment. The findings include: Resident #32 was admitted to the facility on [DATE] with diagnoses that included right femur fractur, diabetes, and dementia. The quarterly MDS dated [DATE] identified Resident #32 had severely impaired cognition, was always incontinent of bowel and bladder and required maximum assistance with toileting, dressing, and personal hygiene. Resident #32 was totally dependent on staff for transfers and required maximum assistance to roll left to right. Resident #32 was at risk for developing a pressure injury but did not have any pressure injuries. The Braden Scale dated 4/3/25 identified Resident #32 was at high risk for developing a pressure injury. The care plan dated 4/22/25 identified Resident #32 has the potential for impaired skin integrity. Interventions included encouraging good nutrition and hydration, inspecting skin for signs of redness or breakdown, turning and repositioning throughout shift, providing incontinent care as needed, and using a draw sheet to move the resident in bed. The nurses note dated 6/15/25 at 7:53 AM identified a small slit to coccyx area was identified. The APRN was notified and gave a new order for triad cream every shift. A physician's order dated 6/15/25 directed to z guard to coccyx every shift for preventative skin protection. The interview with RN #1 on 6/15/25 at 9:37 AM indicated that Resident #32 had a stage 2 pressure injury to the coccyx when he/she returned from the hospital in December 2024. The pressure injury healed in January 2025 however, Resident #32 was identified with moisture associated skin dermatitis (MASD). RN #1 indicated that she has not followed Resident #32's coccyx or MASD since it was seen by the wound APRN in January 2025. RN #1 indicated that although Resident #32's coccyx and buttocks had healed, she was not sure when because she did not follow it weekly. An interview with RN #1 on 6/16/25 at 12:07 PM indicated she received a message yesterday, that she read today that Resident #32 had a new open slit to the coccyx with a treatment order for triad or z guard. RN #1 indicated that the supervisor or charge nurse were responsible to notify the resident representative and document the notification. RN #1 indicated that she had not seen the resident's coccyx and would assess it today after Resident #32 goes back to bed. After clinical record review, RN #1 indicated that the resident representative had not been notified of the new wound or treatment. RN #1 indicated that when a resident has a new wound and new treatment, the resident representative should be notified that shift or at least on that day. Interview with the DNS on 6/16/25 at 3:21 PM indicated that the nurse must inform the RN supervisor of a new open area. The DNS indicated the RN supervisor does the assessment or will call the wound RN #1 to do the assessment and the charge nurse is responsible to call the resident representative for notification. The DNS indicated that the notification must be documented in the resident's clinical record including who was notified. After clinical record review, the DNS indicated Resident #32's representative was not notified of the new slit to the coccyx or the new treatment order from yesterday. Review of the Resident Change of Condition identified the purpose was to monitor residents on a consistent basis who are experiencing a change of condition. A change of condition is a deviation from the resident's baseline in physical, cognitive, behavioral, or functional domains. When a resident has a change of condition the charge nurse will notify the shift supervisor, the physician will be notified. and the resident representative will be notified. Documentation must reflect notification to the supervisor, physician, and resident representative.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy and interview for 3 of 4 residents (Resident #2, 20, and 90), who had been transferred to the hospital, the facility failed to notify the Office of the State Long-Term Care Ombudsman of the transfers. The findings include: 1a. Resident #2 was admitted to the facility in October 2022. Review of the census form identified Resident #2 was transferred to the hospital on 2/5/24. The nurse's note dated 2/9/24 at 2:11 PM identified Resident #2 was readmitted to the facility. Review of the new routine discharge notification file uploaded dated 2/19/24 at 10:31 AM failed to reflect documentation that the Office of the State Long-Term Care Ombudsman had been notified of Resident #2's hospitalization on 2/5/24. b. Review of the census form identified Resident #2 was transferred to the hospital on [DATE]. The nurse's note dated 11/5/24 at 7:03 PM identified Resident #2 was readmitted to the facility. Review of the admission/discharge to/from report dated 10/1/24 - 10/31/24 failed to reflect the Office of the State Long-Term Care Ombudsman had been notified of Resident #2's hospitalization on 10/26/24. c. Review of the census form identified Resident #2 was transferred to the hospital on 1/31/25. The nurse's note dated 2/10/25 at 4:28 PM identified Resident #2 was readmitted to the facility. Review of the admission/discharge to/from report dated 1/1/25 - 1/31/25 failed to reflect the Office of the State Long-Term Care Ombudsman had been notified of Resident #2's hospitalization on 1/31/25. d. Review of the census form identified Resident #2 was transferred to the hospital on 2/20/25. The nurse's note dated 2/22/25 at 9:30 PM identified Resident #2 was readmitted to the facility. Review of the admission/discharge to/from report dated 2/1/25 - 2/28/25 failed to reflect the Office of the State Long-Term Care Ombudsman had been notified of Resident #2's hospitalization on 2/20/25. e. Review of the census form identified Resident #2 was transferred to the hospital on 4/23/25. The nurse's note dated 4/27/25 at 6:50 PM identified Resident #2 was readmitted to the facility. Review of the admission/discharge to/from report dated 4/1/25 - 4/30/25 failed to reflect the Office of the State Long-Term Care Ombudsman had been notified of Resident #2's hospitalization on 2/20/25. 2a. Resident #20 was admitted to the facility in March 2023. Review of the census form identified Resident #20 was transferred to the hospital on 2/4/25. The nurse's note dated 2/7/25 at 5:01 PM identified Resident #20 was readmitted to the facility. Review of the admission/discharge to/from report dated 2/1/25 - 2/28/25 failed to reflect the Office of the State Long-Term Care Ombudsman had been notified of Resident #20's hospitalization on 2/5/25. b. Review of the census form identified Resident #20 was transferred to the hospital on 5/3/25. The nurse's note dated 5/6/25 at 11:43 PM identified Resident #20 was readmitted to the facility. Review of the admission/discharge to/from report dated 2/1/25 - 2/28/25 failed to reflect the Office of the State Long-Term Care Ombudsman had been notified of Resident #20's hospitalization on 5/3/25. 3a. Resident #90 was admitted to the facility in June 2022. Review of the census form identified Resident #90 was transferred to the hospital on [DATE]. The nurse's note dated 12/9/24 at 4:23 PM identified Resident #90 was readmitted to the facility. Review of the admission/discharge to/from report dated 12/1/24 - 12/31/24 failed to reflect the Office of the State Long-Term Care Ombudsman had been notified of Resident #90's hospitalization on 12/6/24. b. Review of the census form identified Resident #90 was transferred to the hospital on 5/28/25. The nurse's note dated 6/6/25 at 12:33 PM identified Resident #90 was readmitted to the facility. Review of the admission/discharge to/from report dated 12/1/24 - 12/31/24 failed to reflect the Office of the State Long-Term Care Ombudsman had been notified of Resident #90's hospitalization on 12/6/24. Subsequent to surveyor inquiry the Administrator sent an admission, discharge, and transfer report dated 1/1/24 - 5/31/25 to the Office of the State Long-Term Care Ombudsman with Resident #2, 20, and 90 included in the report. Interview with the Administrator on 6/15/25 at 12:17 PM identified she was not aware that the report the business office was sending to the Office of the State Long-Term Care Ombudsman did not include the transfers out to the hospital. The Administrator indicated the business office was running the admission and discharge report which does not include the transfers out to the hospital. The Administrator indicated she will educate the business office. Review of the facility notice to Ombudsman of discharge resident policy identified to notify the ombudsman of discharge residents. Ombudsman programs promote policies and consumer protections to improve long-term services and support at the facility, local, state, and national levels. A list of residents who have been discharged from the facility will be sent to the Ombudsman monthly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #93 was admitted to the facility on [DATE] with diagnoses that included a fracture of the right femur, orthopedic aftercare, heart failure, and chronic kidney disease. The admission MDS dated [DATE] identified Resident #93 had moderately impaired cognition, was frequently incontinent of bladder, and toilet transfers were not attempted due to a medical condition or safety concerns. The care plan dated 5/28/25 identified Resident #93 was at risk for an alteration in fluid balance related to diuretic use. Interventions included monitoring and documenting any signs or symptoms of dehydration including decreased or no urine output, concentrated urine, or strong odor. The care plan further identified Resident #93 had renal insufficiency related to chronic kidney disease. Interventions included monitoring and documenting for any signs or symptoms of acute renal failure including oliguria (urine output less than 400 ml per 24 hours). A physician's order dated 6/13/25 directed to obtain a urinalysis and microscopic with reflex to culture. The progress notes dated 6/8/25 through 6/15/25 failed to identify documentation supporting the rationale for the physician's order dated 6/13/25 directing to obtain a urinalysis and culture specimen. The progress notes failed to identify that a nursing assessment had been completed prior to the urinalysis and culture being ordered. Interview with the Infection Control Nurse (RN #1) on 6/16/25 at 7:51 AM identified that she did not know why a urinalysis and microscopic with reflex to culture was ordered for Resident #93 on 6/13/25. Interview with LPN #2 on 6/16/25 at 8:39 AM identified that she worked on Thursday (6/12/25) and that Resident #93's representative (Person #1) had told him/her that the day before, a nurse aide told Person #1 that he saw specks of blood in Resident #93's urine. LPN #2 indicated that prior to Person #1 bringing it to her attention, she was not aware that Resident #93 had blood in his/her urine, and that was not communicated to her during shift report. LPN #2 indicated that Resident #93 did not appear to be in pain, and she notified the Nursing Supervisor (RN #2). The APRN note dated 6/16/25 at 1:30 PM identified that she had been asked by nursing staff to see Resident #93, today, nursing staff stated the patient's family noted some blood in the patient's urine and requested a urinalysis to be done. Urinalysis and culture were sent on 6/13/25. Results showed greater than 100,000 colonies of Enterococcus Faecalis. On exam today patient states he/she has dysuria (pain or burning during urination). The nurse's note dated 6/16/25 at 1:43 PM identified abnormal lab results were reported to the APRN this morning, with new orders to start Macrobid (antibiotic) 100mg, every 12 hours, for 7 days. Person #1 was notified of the abnormal lab results and new orders, and he/she agreed with the care plan. Interview with RN #2 on 6/16/25 at 3:24 PM identified that she believed that she was notified by the day shift supervisor that Resident #93 had a question of blood in his/her urine, on Thursday, June 12, 2025 and she assumed, since it had been reported to her, that the resident had been assessed by a RN and the that the medical provider had been notified. RN #2 indicated that if a nurse aide or charge nurse had notified her that Resident #93 had questionable blood in his/her urine, she would have assessed the resident, notified the medical provider, and obtained an order for urinalysis and culture or initiated the 3-day urine monitoring protocol. The late entry nurse's note dated 6/16/25 at 5:37 PM (effective 6/12/25 at 10:55 PM) identified that the charge nurse reported that the resident representative had told her that Resident #93 had blood in his/her urine the day before. No hematuria noted at the time. Resident will be seen by the APRN/MD in the morning. Interview and clinical record review with the DNS on 6/17/25 at 7:47 AM failed to identify timely documentation of a nursing assessment, physician notification, or clinical rationale for Resident #93's order for a urinalysis and microscopic with reflex to culture. The DNS indicated that based on the documentation she was unable to identify when Person #1 brought the concern of blood in Resident #93's urine to the staff's attention, and she would expect to see a nurse's note written by the charge nurse and a nurse's note written by the nursing supervisor which would include an assessment and notification to the medical provider. Interview with Person #1 on 6/17/25 at 9:06 AM identified that he/she was unable to recall the exact day but during the week prior, NA #5 had brought Resident #93 to the bathroom and indicated that he/she had blood in his/her urine. Person #1 further identified that a urine sample was later obtained, and Resident #93 is now on antibiotics for an infection. Interview with NA #5 on 6/17/25 at 9:19 AM identified that last week (on Wednesday to the best of his recall) he assisted Resident #93 to the bathroom and noticed a tint of pink discoloration in his/her urine. NA #5 indicated that he notified LPN #4, and she said she would look into it. Interview with LPN # 6 on 6/17/25 at 10:20 AM identified that she had worked as the daytime shift supervisor on 6/12/25 (overseen by the ADNS) and on 6/13/25 (overseen by the Administrator who holds an active RN license); review of the Supervisor Report dated 6/13/25 read, 6/12 Person #1 reporting blood in urine on 6/11. None noted by staff. LPN #6 indicated that she had worked on 7:00 AM- 3:00 PM on 6/12/25 and was not aware of the situation and became aware of the situation after reading the 6/13/25 Supervisor Report. LPN #6 identified that she notified the physician and LPN #1 obtained a urine sample, which was sent out for a urinalysis and culture because the sample looked cloudy. LPN #6 indicated that she did not write a note in Resident #93's clinical record because she forgot to transcribe it from her own notes into the electronic health record, but she did notify the physician who ordered the urinalysis and culture and notified Person #1. Interview with LPN #4 on 6/17/25 at 11:45 AM identified that on Wednesday of last week NA #5 notified her that Resident #93's urine looked a little pink, but he wasn't sure if it was blood. LPN #4 indicated that NA #5 had flushed the urine, so she was not able to see the appearance of the urine; Resident #93 did not report any concerns with pain during urination, at the time. LPN #4 further indicated that she instructed NA #5 not to flush Resident #93's urine next time he/she voids so she could see it. LPN #4 identified that she was not notified that Resident #93 urinated again and the resident did not have complaints, so she did not report the incident to the supervisor or begin symptom monitoring as she was not sure what to think because NA #5 was not sure what he saw, and Resident #93 was not reporting any symptoms. The facility's Resident Change of Condition policy directs when a resident has a change of condition, or there is the possibility of a change of condition due to an accident the following will occur: the charge nurse will notify the shift supervisor and keep her updated, vital signs will be taken, the physician will be notified of the change in condition, physicians orders will then be followed, family will be notified, observation and assessment as indicated (depending on the resident's condition), and documentation must reflect all observations, assessments, vital signs, and notification to supervisors, physicians, and family. 2. Resident #32 was re-admitted to the facility on [DATE] with diagnoses that included right femur fractur, diabetes, and dementia. The Braden Scale dated 1/1/25 identified Resident #32 scored a 16 defined as at high risk for developing a pressure injury. The quarterly MDS dated [DATE] identified Resident #32 had severely impaired cognition, was always incontinent of bowel and bladder and required maximum assistance with toileting, dressing, and personal hygiene. Resident #32 was totally dependent on staff for transfers and maximum assistance to roll left to right. Resident #32 had one stage 2 pressure ulcer and a surgical wound. Additionally, Resident #32 was at risk for developing pressure injuries. The care plan dated 1/3/25 identified Resident #32 has the potential for impaired skin integrity. Interventions included encouraging good nutrition and hydration, inspecting skin for signs of redness or breakdown, turning and repositioning throughout shift, providing incontinent care as needed, and lifting using a draw sheet to move resident. a. The wound APRN consultation note dated 1/10/25 identified Resident #32 had buttocks wounds which were evaluated. Resident #32 has urinary and fecal incontinence. APRN #3 noted on physical exam there are several small, irregular partial thickness, wounds, located at the right side of the natal cleft that have scant serous drainage and no odor. The area encompasses a total of 1.1 cm by 0.6 cm in terms of measurement. Distal to this, at the anoderm, is a small fissure measuring 0.3 cm by 0.1 cm with the same characteristics. There is no evidence of acute pressure. It is unlikely to be a pressure injury. The presentation of these wounds favors incontinence associated with dermatitis. Discontinue current wound treatment and start to rinse areas with normal saline, apply silver alginate, cover with foam dressing every Monday, Wednesday, and Friday and as needed. A physician's order dated 1/10/25 directed to cleans coccyx with normal saline followed by silver alginate then a foam dressing every evening shift on Monday, Wednesday and Friday. Review of the nurses and physician's notes dated 1/11/25 to 6/14/25 failed to reflect ongoing assessments of the buttocks areas. The interview with RN #1 on 6/15/25 at 9:37 AM indicated she was responsible for all wounds in the facility and the facility has a wound APRN that sees residents with her as needed. RN #1 indicated Resident #32 had a stage 2 pressure injury to the coccyx when he/she returned from the hospital in December 2024. In January 2025, the stage 2 pressure injury healed, and Resident #32 had MASD (moisture associated skin dermatitis) per the wound APRN. RN #1 indicated that she has not followed the residents coccyx or MASD since it was seen by the wound APRN on 1/10/25. RN #1 indicated everything must have healed by now on the buttocks but she was not sure when because she did not follow it weekly since 1/10/25 when she last had seen it with the wound APRN. After surveyor inquiry, a physician's order dated 6/15/25 at 11:10 AM directed to discontinue the treatment order dated 1/10/25 for silver alginate to wounds and start z guard to coccyx every shift. Interview with RN #1 on 6/16/25 at 12:07 PM indicated she was not aware the nurses were still applying the silver alginate to Resident #32's buttock because it should have been healed by now. RN #1 indicated that on 1/10/25 when APRN #3 saw Resident #32 he/she had MASD. RN #1 indicated there was a new treatment order for the silver alginate. After clinical record review, RN #1 indicated she should have followed Resident #32's buttock weekly but she did not. RN #1 indicated that she does not know when the MASD healed but as of 6/15/25, Resident #32 has a new open slit on the coccyx which does not have measurements. Interview with the DNS on 6/16/25 at 3:21 PM indicated no residents should have the same treatment for 4 to 5 months to the buttock. The DNS indicated the wound RN #1 should be following all treatments to the buttocks weekly and documenting the assessments to determine if the wounds have gotten better or worse and if the treatment orders need to change. The DNS indicated the wound RN was responsible to complete weekly measurements on Resident #32's buttock until it was healed. After clinical record review, the DNS indicated Resident #32 started a treatment on 1/10/25 of silver alginate, which was put in as indefinite, and it did not get discontinued until 6/15/25. The DNS indicated the wound RN needs to reevaluate the treatments to make sure they are appropriate. Interview the wound APRN, APRN #3, on 6/17/25 at 7:26 AM indicated she had seen Resident #32, and she had ordered the silver alginate due to resident's incontinence of urine and fecal matter because the silver alginate will kill any organisms in the wounds from the incontinence. APRN #3 indicated the facility follows the policy for MASD or pressure ulcers. APRN #3 indicated that a slit in the coccyx would most likely be MASD and it should be reevaluated by an RN to determine if it is pressure or MASD at least every 2 weeks. APRN #3 indicated if the pressure ulcer or MASD fails to show some evidence of progress toward healing within a maximum of 14 to 30 days, the area and the resident's overall clinical condition should be reassessed by an RN or the APRN and that assessment should be documented in the resident's clinical record. APRN #3 indicated that a resident should never have the same treatment for months unless there were reassessments of the wounds documented with a rational why it was not changed. b. The nurse's note dated 6/15/25 at 7:53 AM identified a small slit to coccyx area this morning. APRN was notified and gave a new order for triad cream every shift. A physician's order dated 6/15/25 directed to apply z guard to coccyx every shift for preventative skin protection. An interview with RN #1 (wound nurse) on 6/16/25 at 12:07 PM indicated she had reviewed a message today that was sent yesterday that Resident #32 has a new open slit to the coccyx and has a new treatment order for triad or z guard. RN #1 indicated when a resident has a new wound the supervisor is responsible to do the initial assessment and call the APRN for a new treatment order. RN #1 indicated the RN assessment of a wound must include measurements, description of the wound bed, peri wound area, drainage, and if there is an odor. RN #1 indicated this must all be documented in the progress notes. After clinical record review, RN #1 indicated the record failed to reflect a wound assessment documented including measurements for the new coccyx slit or any other descriptions of the wound that would have been expected with the initial wound assessment dated [DATE] by the RN. RN #1 indicated she has not looked at Resident #32's coccyx since the new wound was noted and Resident #32 is already out of bed today and requires a mechanical lift. RN #1 indicated that she will assess the wound later today or tomorrow morning. Interview with the DNS on 6/16/25 at 3:21 PM indicated that the nurse must inform the RN supervisor of a new open wound. The DNS indicated that the RN supervisor does the initial wound assessment or will call RN #1 to do the assessment. The DNS indicated her expectation was the RN wound assessment would include the wound measurements, color of the wound bed, odor, drainage, and surrounding tissue appearance. The DNS indicated this must be documented in the assessment in the clinical record and a treatment order must be obtained. The DNS indicated that RN #1 as the facility wound nurse should see it within a few days and then follow it weekly. After clinical record review, the DNS indicated the record lacked an RN assessment of the wound from yesterday. Review of the facility Skin Care Policy indicated based on the comprehensive assessments of a resident; the facility must ensure that a resident who enters the facility without a pressure injury does not develop pressure injures unless the resident clinical condition demonstrates that they were unavoidable. Also, a resident having a pressure injury receives the necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. Appropriate preventative measures will be implemented on residents identified at risk with a score of 18 or less on the Braden scale and the interventions documented on the care plan. Pressure injuries will be staged and measured weekly, in accordance with the practice guidelines, by the designated wound care nurse or designee. Although requested, a facility policy for pressure ulcers and MASD were not provided. Based on review of the clinical record, facility documentation, facility policy and interviews for 2 of 3 residents (Resident #32 and 41) reviewed for pressure ulcers, for Resident #32, the facility failed to ensure a physician's order was transcribed for a newly identified wound and failed to respond to hospice recommendations for a newly identified pressure injury, and for Resident #32, the facility failed to complete ongoing monitoring of a new open area on the residents buttocks, reevaluate the treatment and complete a wound assessment for a new wound, and for 1 of 2 residents (Resident #93) reviewed for UTI, the facility failed to ensure a nursing assessment and ongoing symptom monitoring were completed following the onset of urinary tract infection symptoms. The findings include: 1. Resident #41 had diagnoses that included peripheral vascular disease and dementia, and was receiving hospice services. The quarterly MDS dated [DATE] identified Resident #41 had severe cognitive impairment, required one person assist with bed mobility, two person assist with transfers and had at least one pressure ulcer present on admission. The care plan dated 2/18/25 identified Resident #41 had deep tissue injuries to the right and left heels. Interventions included to evaluate for changes in measurements, tissue changes, odor and drainage, and document and notify the physician. Wound consultation dated 4/11/25 identified Resident #41 had a community acquired pressure injury to the left heel that was now resolved. Recommendations included to discontinue any previous wound care to the left heel and apply a protective dressing weekly and as needed. Physician orders dated 5/17/25 directed to apply skin prep to the left heel followed by foam dressing three days a week as a preventative measure. a. A nurse's note dated 6/1/25 at 3:25 PM identified when changing foam dressing to left heel, an open area with small amount of green drainage and a slight odor was noted. The area was cleansed with normal saline and a dressing was reapplied per care plan. The supervisor and hospice nurse were made aware, and a message was sent to RN #1, the infection control nurse, to update as well. A nursing on call hospice note dated 6/1/25 identified Resident #41's left heel opened. The area was assessed and identified as an unstageable pressure ulcer that measured 2 x 2 x 0.5 with a scant amount of serous drainage with no odor. The note identified that a one-time order had been obtained to apply a small piece of calcium alginate followed by a foam dressing. The dressing was completed. Recommendations included follow up by the facility wound nurse, RN #1, the following day. Review of the physician's orders failed to reflect the order for the calcium alginate had been transcribed as recommended. An interview with LPN #5 on 6/17/25 at 7:37 AM identified he was the assigned charge nurse on 6/1/25 during the 7:00 AM -3:00 PM shift when the new wound was first identified. LPN #5 indicated he notified the nursing supervisor and hospice nurse on the unit and RN #1 through the electronic record communication board of the newly identified wound. LPN #5 observed the hospice nurse go to see the resident but received no other information regarding any further interventions as the nursing supervisor was responsible for notifying the physician and obtaining new orders. An interview with APRN #2 on 6/17/25 at 9:30 AM identified she provided medical services at the facility on a routine basis. APRN #2 identified she spoke with the hospice nurse about Resident #41's wounds but could not recall specific details regarding the notification. APRN #2 was agreeable to any recommended treatment plan and would have provided a verbal order. An interview with RN #6 on 6/17/25 at 10:37 AM identified she provided hospice services on 6/1/25 during the 7:00 AM -3:00 PM shift when Resident #4's new wound was first identified. RN #6 assessed the wound and spoke to RN #5, (the nursing supervisor who obtained a one-time order for calcium alginate) until the wound could be re-evaluated by the facility wound nurse the following day. RN #6 later identified she noticed the order was not transcribed in the electronic medical record but had forgotten to mention it to RN #5. An interview with RN #5 on 6/17/25 at 11:06 AM identified she was the assigned nursing supervisor on 6/1/25 during the 7:00 AM -3:00 PM shift but was unable to recall being notified of Resident #41's newly identified wound or any details of the incident but would have notified the physician of the new wound and documented the change of condition and transcribe any new orders/interventions. An interview with the DNS on 6/17/25 at 12:55 PM identified she would expect the physician's order to be transcribed after obtaining a physician's order for the one-time wound treatment. A review of the facility policy for order transcription directed physician's orders are to be transcribed to the electronic medical record (EMR) when appropriate. b. A wound consultation dated 6/6/25, five days following the hospice recommendations, identified Resident #41 had a new pressure injury to the left heel measuring 0.4 x 0.6, clean, pink with a moderate amount of serous drainage and no odor. Recommendations included to rinse the left heel with normal saline, apply calcium alginate and a foam protective dressing three times weekly on Monday, Wednesday, Friday and as needed. A wound evaluation dated 6/6/25 identified Resident #41 had a previously healed pressure ulcer that re-opened despite interventions. Resident #41 now had a facility acquired stage II pressure ulcer with a light amount serous drainage and no odor. The treatment plan included normal saline and a calcium alginate followed by a foam dressing. Physician's orders dated 6/11/25, five days post wound specialty recommendations, directed to cleanse the left heel with normal saline followed by a calcium alginate dressing three times weekly on Monday, Wednesday and Friday. A review of the MAR dated 6/6/25 through 6/15/25 identified the new wound treatment was initiated on 6/13/25, seven days post wound specialty recommendations. An interview with RN #1 on 6/16/25 at 10:46 AM and 6/16/25 at 12:46 PM identified she was responsible for overseeing wound management as part of her role and responsibilities. RN #1 indicated she had first assessed the wound on 6/6/25 along with the specialty wound consultant. Wound consultant recommendations included the application of a calcium alginate dressing. However, there was a delay in obtaining orders once the recommendations were made. As a result, the new order did not get transcribed until 6/11/25. An interview with the DNS on 6/16/25 at 2:48 PM and 6/17/25 at 12:45 PM identified any concerns related to changes in skin integrity was referred to RN #1. RN #1 was expected to see the resident on the next business day if the issue was identified on the weekend or the same day if identified during the week. For Resident #41, the DNS would have expected an RN assessment and the initiation of a new wound treatment within two days of when the wound was first identified and would expect nursing staff ensure any hospice recommendations were reviewed and responded to timely. A subsequent interview with RN #1 on 6/17/25 at 10:10 AM identified on most occasions, she did not assess wounds and treatment plans right away. RN #1 identified she was aware of Resident #41's open wound prior to 6/6/25. However, due to other responsibilities, she did not assess the wound until 6/6/25. RN #1 indicated Resident #41 had a protective dressing order in place previously and decided to wait for APRN #1 for new treatment orders. Additionally, RN #1 indicated upon receiving the recommendations, she forgot to have the orders reviewed and initiated for an additional five days as an oversight which led to the delay. An interview with RN #5 on 6/17/25 at 11:06 AM identified she was the assigned nursing supervisor on 6/1/25 during the 7:00 AM - 3:00 PM shift but was unable to recall being notified of Resident #41's newly identified wound or any details of the incident but would have notified the physician of the new wound and documented the change of condition and transcribe any new orders/interventions. Although requested, a policy on responding to hospice recommendations was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 residents (Resident #41) reviewed for pressure ulcers, the facility failed to evaluate the treatment plan and implement timely interventions in response to specialty wound care recommendations in a timely manner. The findings include: Resident #41 had diagnoses that included peripheral vascular disease, dementia and receiving hospice services. The quarterly MDS dated [DATE] identified Resident #41 had severe cognitive impairment, required one person assist with bed mobility, two person assist with transfers and had at least one unhealed pressure ulcer present on admission. The care plan dated 2/18/25 identified Resident #41 had deep tissue injuries to the right and left heels. Interventions included to evaluate for changes in measurements, tissue changes, odor and drainage, document and to notify the physician. A wound consultation dated 4/11/25 identified Resident #41 had a community acquired pressure injury to the left heel that was now resolved. Recommendations included to discontinue any previous wound care to the left heel and apply a protective dressing weekly and as needed. Physician orders dated 5/17/25 directed skin prep to the left heel followed by a foam dressing every three days as a preventative measure. A nurse's note dated 6/1/25 at 3:25 PM identified when changing foam dressing to left heel, an open area with small amount of green drainage and a slight odor was noted. The area was cleansed with normal saline and dressing reapplied per care plan. The supervisor and hospice nurse were notified on the unit, and a message was sent to RN #1, the infection control nurse, to update as well. A nursing on call hospice note dated 6/1/25 identified Resident #41's left heel opened. The area was assessed and identified as an unstageable pressure ulcer that measured 2 x 2 x 0.5 inches with a scant amount of serous drainage with no odor. The note identified a one-time order to apply a small piece of calcium alginate followed by a foam dressing was obtained and applied. Recommendations included follow up by the facility wound nurse, RN #1, the following day. A wound consultation dated 6/6/25 identified Resident #41 had a new pressure injury to the left heel measuring 0.4 x 0.6, clean, pink with a moderate amount of serous drainage and no odor. Recommendations included to rinse the left heel with normal saline, apply calcium alginate and a foam protective dressing three times weekly on Monday, Wednesday, Friday and as needed. A wound evaluation dated 6/6/25 identified Resident #41 had a previously healed pressure ulcer that re-opened despite interventions. Resident #41 now had a facility acquired stage 2 pressure ulcer with a light amount serous drainage and no odor. The treatment plan included normal saline and calcium alginate followed by a foam dressing. Physician's order dated 6/11/25, ten days post identification of a newly identified pressure ulcer and five days post wound specialty recommendations, directed to cleanse the left heel with normal saline followed by a calcium alginate dressing three times weekly on Monday, Wednesday and Friday. A review of the MAR dated 6/6/25 through 6/15/25 identified the new wound treatment was initiated on 6/13/25, twelve days post identification of the newly identified pressure ulcer and seven days post wound specialty recommendations. An interview with RN #1 on 6/16/25 at 10:46 AM and 6/16/25 at 12:46 PM identified she was responsible for overseeing wound management as part of her role and responsibilities. RN #1 identified wounds would be assessed weekly by nursing and she would re-assess if needed. Resident #41 had a previously healed community acquired pressure ulcer that had reopened. RN #1 indicated she had first assessed the wound on 6/6/25 along with the specialty wound consultant. Wound consultant recommendations included the application of a calcium alginate dressing. However, there was a delay in obtaining orders once the recommendations were made. As a result, the new order did not get transcribed until 6/11/25. An interview with the DNS on 6/16/25 at 2:48 PM identified any concerns related to changes in skin integrity was referred to RN #1. If identified during weekend hours, nursing would notify her through the electronic messaging board. RN #1 was responsible for assessing the wound and reviewing the treatment to determine if a treatment was needed, determine if a wound consultation was required and work with the facility APRN to obtain an order. RN #1 was expected to see the resident on the next business day if the issue was identified on the weekend or the same day if identified during the week. For Resident #41, the DNS would have expected an RN assessment and the initiation of a new wound treatment within two days of when the wound was first identified. An interview with APRN #1 on 6/17/25 at 7:04 AM identified she was contacted by the facility to provide wound specialty services monthly. APRN #1 worked directly with RN #1 or facility APRN for any wound related issues. APRN #1 identified she would expect to be notified no later than 72 hours of any non-urgent wound after an assessment and that contact be made from RN #1 as the first line of communication. APRN #1 indicated Resident #41 was receiving hospice services with palliative wound care. Although Resident #41 previously had orders for a dressing in place, calcium alginate was recommended when the wound opened. The initiation of the treatment would depend on when recommendations were reviewed and accepted by the facility APRN. An interview with LPN #5 on 6/17/25 at 7:37 AM identified he was the assigned charge nurse on 6/1/25 during the 7:00 AM - 3:00 PM shift when the new wound was first identified. LPN #5 indicated he notified the nursing supervisor and hospice nurse on the unit and RN #1 through the electronic record communication board of the newly identified wound. LPN #5 observed the hospice nurse go to see the resident but received no other information regarding any further interventions as the nursing supervisor was responsible for notifying the physician and obtaining new orders. An interview with APRN #2 on 6/17/25 at 9:30 AM identified she provided medical services at the facility on a routine basis. APRN #2 identified any wound related concerns were communicated through RN #1 and via EMR communication board. APRN #2 could not recall specific details regarding notification of Resident #41's wound but agreed with any recommended treatment plan and would have provided a verbal order. APRN #2 identified 10 days was too long for a new treatment to be initiated following the onset of a new wound. APRN #2 expected to be notified promptly for orders following any new wound recommendations and that treatment be initiated without delay. A subsequent interview with RN #1 on 6/17/25 at 10:10 AM identified most time she did not assess wounds and treatment plans right away. RN #1 identified she was aware of Resident #41's open wound prior to 6/6/25. However, due to other responsibilities, she did not assess the wound until 6/6/25. RN #1 indicated Resident #41 had a protective dressing order in place previously and decided to wait for APRN #1 for new treatment orders. Additionally, RN #1 indicated upon receiving the recommendations, she forgot to have the orders reviewed which led to a 5 day delay. An interview with RN #5 on 6/17/25 at 11:06 AM identified she was the assigned nursing supervisor on 6/1/25 during the 7:00 AM -3:00 PM shift but was unable to recall being notified of Resident #41's newly identified wound or any details of the incident but would have notified the physician of the new wound, document the change of condition and transcribe any new orders/interventions. An interview with the Medical Director on 6/17/25 at 11:45 AM identified she would expect RN #1 to be notified of any new skin issue so she can assess. Resident #41 was receiving hospice services with palliative wound care and should have had the treatment plan evaluated no later than 2 - 3 days following the identification of a new wound. The medical director indicated ten days was too long to initiate a new treatment even if there was an order prior for a protective dressing in place. A review of the facility policy for skin care directed residents with skin impairments will have appropriate interventions implemented to promote healing and a physician's order obtained for treatment. A licensed nurse will monitor, evaluate and document changes in the wounds condition and notify the provider of any changes as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #10) reviewed for unnecessary medications, the facility failed to ensure the consultant pharmacist monthly recommendations were reviewed and responded to by the physician and the recommendation consultation form was signed and dated including a rationale if necessary. The findings include: Resident #10 was admitted to the facility in July 2009 with diagnoses that included diabetes, anemia, dementia, and mild intellectual disabilities. The care plan dated 4/22/25 identified Resident #10 was on psychotropic medication. Interventions included follow up with the psychiatric group and a gradual dose reduction as needed. The quarterly MDS dated [DATE] identified Resident #10 had moderately impaired cognition and required total assistance with transfers, toileting, and personal hygiene. a. A physician's order dated 6/14/24 directed to obtain bloodwork, (CBC and BMP) once every 14 days for 8 weeks for anemia; ends on 8/28/24. Review of the Pharmacy Consultation Report dated 7/10/24 identified Resident #10 has a physician's order for CBC and BMP labs every 2 weeks but not able to find results in the medical record. Additionally, the prior hemoglobin results were low on 4/18/24. The form was not signed or dated by the physician as reviewed and to accept or reject recommendations. b. The physician order dated 9/16/24 (original date 5/20/22) directed to administer Seroquel (antipsychotic) extended release 24-hour tablet give 150 mg at bedtime for dementia with behavioral disturbances. Review of the Pharmacy Consultation Report dated 9/20/24 identified please attempt a gradual dose reduction for the Seroquel extended release. The form was not signed or dated by the physician as reviewed and to accept or reject recommendations. The physician order dated 10/15/24 and 11/29/24 directed to administer Seroquel (antipsychotic) extended release 24-hour tablet give 150 mg at bedtime for dementia with behavioral disturbances. c. Review of the Pharmacy Consultation Report dated 12/30/24 identified Resident #10 has a physician order for Afrin nasal spray as needed and has not been used in the past 90 plus days. Please consider discontinuing due to lack of use. The form was not signed or dated by the physician as reviewed and to accept or reject recommendations. After surveyor injury, the Afrin nasal spray was discontinued on 6/16/25. Interview with the Administrator on 6/15/25 at 2:55 PM indicated she was only able to find 1 pharmacy recommendation out of the 3 in the DNS office. The Administrator indicated that they were not in the resident's medical record that the DNS had a pile of pharmacy recommendations in her office. The Administrator indicated that she would keep looking. An interview with the DNS on 6/16/25 at 11:45 AM indicated that she had given the 9/30/24 and 12/31/24 pharmacy recommendations to the day supervisor RN # 3 today to have the APRN to address and sign them. Interview with RN #3 (7:00 AM to 3:00 PM RN supervisor) on 6/16/25 at 11:50 AM indicated that APRN #2 just signed the pharmacy recommendations for Resident #10 dated 9/30/24 for the trail of a GDR for the Seroquel and the pharmacy recommendation dated 12/31/24 to discontinue the Afrin Nasal spray. RN #3 indicated that she has already discontinued the medication. RN #3 indicated that APRN 2 signed and back dated the GDR for the date 3/1/25 but did not inform her if she agreed or disagreed with the pharmacy recommendation or if she was going to decrease the Seroquel. Attempted interview with APRN #2 on 6/16/25 at 11:55 AM she indicated that she was driving and would call back. The nurses note written by RN #3 on 6/16/25 at 12:10 PM indicated that the pharmacy monthly reports were reviewed by APRN #2. Interview with the DNS on 6/16/25 at 12:30 PM indicated that she was responsible for receiving the monthly pharmacy recommendations and for giving them to the providers each month. The DNS indicated that when she receives the monthly pharmacy's recommendations, she puts them all in the folders at the nurses stations and she depends on the providers to give them back to her when they sign them. The DNS indicated that she did not realize she was not getting them all back until after surveyor inquiry. The DNS indicated that most quarters at medical staff pharmacy report indicate that they are getting responses on approximately 80 - 86 %. The DNS indicated that she thought that was good but now realizes she needs 100%. The DNS indicated that most are done and moving forward she will need to make a copy to make sure she receives them all back by matching them up. The DNS indicated that she needs to put a system in place. Interview with the Administrator 6/16/25 at 12:46 PM indicated she had just spoke with APRN #2 and APRN #2 was not going to return surveyors call. The Administrator identified she was aware the monthly pharmacy recommendations for Resident #10 were not signed by a provider for 7/10/24, but the labs were done per the physician order, and the 9/20/24 recommendation was not reviewed and signed by APRN #2 until today. The Administrator indicated that the provider was responsible to review and agree or disagree with each recommendation and sign and date the form within each pharmacy consultant's visits and that wasn't done. Interview with Pharmacist #1 on 6/16/25 at 3:01 PM indicated that the admission reviews are done remotely and the monthly reviews are done in the facility for all residents. Pharmacist #1 indicated she mails the monthly report via email to the DNS. Pharmacist #1 indicated that the DNS is expected to fax back the providers responses to her once they are completed by the physicians. Pharmacist #1 indicated that all recommendations should be signed and dated by the providers whether they agree or disagree with the recommendations within 60 days. Although attempted, an interview with APRN #2 was not obtained. Review of the Consultant Pharmacy Services Policy identified the facility will provide pharmacy consultants with access to residents complete medical record including EMR's including laboratory results, physician progress notes, nursing notes, which may assist the consultant pharmacist in making professional judgement as to whether irregularities exist in the medication regimen. The consultant pharmacist will provide each resident with a monthly medication review to the facility identified personnel who will ensure that the attending physician, medical director, DNS, and other necessary facility staff receive the recommendations. The attending physician should document in the residents' EMR that the identified irregularity has been reviewed and what, if any, action has been taken to address it. The attending physician should address the consultant pharmacist's recommendations no later than their next scheduled monthly visit to assess the resident per facility policy and applicable state and federal regulations. The facility should maintain readily available copies of the consultant pharmacists' reports as part of the residents' permanent health record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility documentation, facility assessment, and interviews the facility failed to ensure nurse aides had the required 12 hours of education at least annually. The findings include: Interview with the DNS on 6/17/25 at 12:22 PM indicated that RN #1 was responsible for staff development and would be responsible to make nurse aides receive at least the annual 12 hours of education per year. Interview with RN #1 (staff development) on 6/17/25 at 1:43 PM indicated she is responsible for the education department, and she is notified when employees have not completed their education on the computer system. RN #1 indicated that she does not track the nurse aides education to make sure they have received at least 12 hours per year. RN #1 indicates that she assumes if they have done the online education programs from the hospital that they would meet the minimum required 12 hours per year. RN #1 indicates that she does not have a tracking tool or spread sheet to show monitoring of each nurse aides education hours and how she would track the hours. Interview with the Administrator on 6/17/25 at 1:47 PM indicated RN #1 was responsible to make sure the content of the topics were appropriate for the employee's education based on job titles on the computer education system. The Administrator indicated that the hospital sets up education programs for the employees to independently complete in the employee break room for the annual mandatories. The Administrator indicated that the hospital knows each assignment takes a certain amount of time, but no one monitors or tracks the number of hours of education that the nurse aides are completing. The Administrator indicated that if an employee does not complete education, she can print out a list and hang it up in the break room and they can tell the employee to look at the list. The Administrator indicated that if the employee does all the training on the list they would have more than 12 hours per year, but they do not track it The annual education form, not dated, listed topics and which job title needs to complete which topics but does not indicate the amount of time each one takes for each individual employee or topic. Review of the Facility assessment dated [DATE] identified staff competencies include hand hygiene, infection prevention, mechanical lifts, IV therapy, and catheter care. Staff are educated through live in-services, email communication, power points and the HealthStream platform, including compliance training and mandatory infection control training. The education plan is provided to ensure staff competency in providing care for residents with communication, resident rights, abuse, neglect, and exploitation education, infection control training and testing for comprehension, quality assurance and performance improvement annual training, compliance and ethics training, behavioral health training, and non-pharmacological interventions education annually. Although requested, a facility policy for staff education requirements was not provided.

Based on review of facility documentation, facility assessment and interviews for 4 out of 5 nurse aides in the last 2 years, the facility failed to ensure annual evaluations were completed. The findings include: Interview with Human Resources Person (HR #1) on 6/17/25 at 10:38 AM indicated the DNS received the employee annual evaluations via a computer program and she is responsible to complete the evaluations, and the employee signs the evaluation in the computer. HR #1 indicated that the DNS and leadership team are instructed they must meet with the employee and go over the evaluation. HR #1 indicated the employee can go into the computer and sign the evaluation. HR #1 indicated that the computer program system will automatically send a message to the employee as a reminder that the evaluation needs to be reviewed and signed. HR #1 indicated the annual evaluations are done based on the fiscal year and currently was the 10/1/23 until 9/30/24 and the employee has from 10/1/24 until March 2025 to review and sign the annual evaluations. HR #1 indicated that if the employee does not go into the computer and sign by March 2025 the DNS or a supervisor can go in and just sign the evaluation and close it with or without reviewing it with the employee. Additionally, HR #1 indicated technically that the DNS or supervisor can sign and close any evaluation after the 10/1/24 date without reviewing it with the employee. After review of the employee files, HR #1 identified that NA #1, NA #2, NA #3, and NA #4 had not signed their performance evaluations for the last 2 fiscal years dated 10/1/22 to 9/30/23 and 10/1/23 to 9/30/24. 1. Review of employee personnel file for NA #1 identified the date of hire was 5/5/03, NA #1 is a full-time employee and NA #1 did not sign the annual performance evaluation reviewed for the fiscal year 10/1/22 to 9/30/23 with a review due date by 12/1/23, or fiscal year 10/1/23 to 9/30/24 with a review due date by 2/14/25. 2. Review of employee personnel file for NA #2 identified the date of hire was 4/29/02 and NA #2 is a part time employee. NA #2 did not sign the annual performance evaluation reviewed for the fiscal year 10/1/22 to 9/30/23 with a review due date by 12/1/23 or Fiscal Year 10/1/23 to 9/30/24 with a review due date by 2/23/25. 3. Review of employee personnel file for NA #3 identified the date of hire was 3/14/16 and NA #3 is a part time employee. NA #3 did not sign the annual performance evaluation for fiscal year 10/1/22 to 9/30/23 with a review due date by 12/1/23 or Fiscal Year 10/1/23 to 9/30/24 with a review due date by 2/14/25. 4. Review of employee personnel file for NA #4 identified the date of hire was 3/14/16 and NA #4 is a part time employee. NA #4 did not sign the annual performance evaluation for fiscal year 0/1/22 to 9/30/23 with a review due date by 12/1/23 or Fiscal Year 10/1/23 to 9/30/24 with a review due date by 2/14/25. The Fiscal Year Annual Performance Reviews Form identifies if the employee signs this form that the employee has reviewed the evaluation, and the signature indicates that the employee has been advised of his or her performance status. Interview with the DNS on 6/17/25 at 12:22 PM indicated that she, as the DNS was responsible to make sure all annual nursing staff evaluations were completed. The DNS indicated she did some of the annual performance evaluations last year and all of them this year. The DNS indicated that all nursing staff performance evaluations were due by 3/1/25 for the previous fiscal year. The DNS indicated that she fills out the employee's performance evaluations and then sends them to the Administrator to add any comments. The DNS indicated when she got the recent performance evaluations returned to her, she finalized them all no later than 1/26/25. The DNS indicated she sent the evaluations to the employees' phone to alert the employee the evaluation was complete and to come see her or they can sign the evaluation on the phone. The DNS indicated that she had posted dates and times for a 2-week period that the employee could come in and sit with her to review and sign their evaluations. The DNS indicated that no employee came to her to review their evaluations during the 2 weeks she gave them at the end of February 2025. The DNS indicated that all employees' annual reviews must be completed with the employee as discussions of the reviews done by 2/9/25. The DNS indicated that all evaluations should have been finalized by 2/9/25 with review and signatures. The DNS indicated she was not told to do anything else, except if the employee does not sign it that she was to go in and sign it and close it as finalized even if the employee had not seen it. The DNS indicated she nor the supervisors go and directly speak with the employees to review the evaluations and to obtain signatures. The DNS indicated that on 2/9/25 there were a lot of annual evaluations she had to finalize that were not signed by the employees and she closed them. The DNS indicated that she needs a better tracking system to make sure all the nursing employees review and sign their annual evaluations. Review of the facility Performance Appraisals Policy identified because of the importance; appraisal of performance is considered one of the key responsibilities of every supervisor and manager in the organization. Performance appraisal is the process by which work performance and workplace behaviors that support our culture are measured and feedback given to an employee by their manager. The common evaluation date will usually be the first payroll period of January of each year, unless otherwise indicated by business conditions. The Department Manger is responsible for preparing an accurate and through performance appraisal on each employee and presenting the appraisal to the employee prior to the common merit date. Employees who have not received a review will not be eligible. It is incumbent on Managers to ensure this takes place annually. The performance appraisal forms require the employee's signature, the evaluators' signature, and the next level supervisor's signature. The signature on the performance appraisal form acknowledges that the employee and the supervisor have reviewed the evaluation.

Based on review of facility documentation, facility policy and interviews, the facility failed to ensure food temperature logs were maintained every shift and failed to ensure food was covered and dated in accordance with infection control practices. The findings include: 1. A tour of the facility kitchen and food temperature logs dated 5/12/25 through 6/15/25 on 6/15/25 at 6:56 AM identified 22 of 102 occasions (20 during the evening meal) were missing recorded food temperatures over the 34-day period. An interview and facility documentation review with [NAME] #2 on 6/15/25 at 6:56 AM identified the cooks were responsible for ensuring food temperatures were recorded at every meal. [NAME] #2 indicated that the food temperature entries were incomplete. An interview with the regional Food Service Director on 6/16/25 at 6:45 AM identified he would expect food temperatures to be recorded for every meal and was initiating education for all dietary staff. A review of the procedure for daily temperature and sanitation log directed that all food temperatures be checked and recorded at each meal. 2. Observation of a walk-in refrigerator on 6/15/25 at 6:56 AM identified the following. a. One large tray of scrambled eggs without a cover or date. The top of the eggs making direct contact to the bottom of the tray stacked on the rack above. The temperature of the refrigerator was 38 degrees F. b. One large tray, half with French toast, half with hash browns without a cover or date. An interview and facility documentation review with [NAME] #2 on 6/15/25 at 6:56 AM identified the eggs, French toast and hashbrowns had been prepared the day prior and placed uncovered in the refrigerator for cooling. The food should have been checked by the evening shift staff and covered once cooled. An interview with the regional Food Service Director on 6/16/25 at 6:45 AM identified the food should have been checked and then covered once the temperature reached 41 degrees F. The shift cooks and supervisors were responsible for checking the temperature and then covering as soon as the temperature reached 41 degrees F. The regional Food Service Director further identified food should not come in contact with any other surfaces while cooling. The facility procedure for cooling food directed that cooling time begins at 135 degrees F. Cool from 135 degrees F to 70 degrees F in two hours, then from 70 degrees F to 41 degrees F in four hours. Once at 41 degrees F, it is ready to be covered, labeled and stored in the refrigerator.

Based on observations, review of facility policy, and interviews for one of two shower rooms, the facility failed to ensure the shower/bathroom was free of odors and failed to ensure that dirty linen carts were not stored in the shower/bathroom where clean linen is stored. The findings include: Observation on 10/23/2023 at 11:45 AM of the 3rd floor bath/shower room (Windsor Unit) identified the room had a strong smell of urine and soiled laundry. The room also contained four wheelchairs, four laundry bins filled with soiled laundry/linens, a mechanical lift, an office chair, and two shower chairs. There was also a closet that contained clean briefs, a separate toilet room that was unflushed and appeared to contain feces, the floor around the toilet also appeared to be soiled. Observation on 10/24/23 at 9:00 AM of the 3rd floor bath/shower room (Windsor) identified three laundry bins containing soiled linen, and a garbage can less than a quarter full. The toilet was clean but there was an odor of urine and soiled linen. Interview on 10/24/23 at 9:40 AM with NA#3 indicated that dirty carts are put in the shower room during meals so that they are out of the halls. NA#3 further noted that there was a dirty utility room on the third floor, but the bath/shower room is closer in proximity to her assigned work area, so she placed the carts there. In addition, NA#3 also identified that placing the soiled linen carts in the shower area was a long-time practice and noted she had not been told to not place the carts there by anyone. NA#3 further acknowledged that there was a strong odor of urine in the shower room. Interview on 10/25/23 at 10:45 AM with the Infection Control Nurse indicated there was a dirty utility room on the 3rd floor and dirty items should be stored in a room that does not have clean items present due to the possibility of cross contamination. The Infection Control Nurse further identified that storing the soiled linen carts in the shower room had been in practice for years and that the DNS and Administrator were aware of the issue. Interview on 10/25/23 at 11:00 AM with the Administrator identified the shower rooms had been cleaned and she was not aware of any reason the dirty laundry carts could not be stored in the shower room during meals. The Administrator also indicated that there were broken tiles in the shower room and noted she did not detect a foul odor in the shower room. Observation on 10/27/23 at 12:50 PM of the third-floor shower room identified it contained four wheelchairs, two shower chairs, a chair scale, and a wheelchair scale, a bedside tray, an office chair, a mechanical lift, a covered code cart. The soiled linen carts were not in the room and the room did not have a foul smell. Review of the Laundry/Linen Processing policy indicated that soiled linen is bagged, removed from use, and placed into the designated rolling laundry hampers. When the hampers are filled, they are emptied by placing soiled linen bags down laundry chute in the chute room. Based on observations, review of facility policy, and interviews for one of two shower rooms, the facility failed to ensure the shower/bathroom was free of odors and failed to ensure that dirty linen carts were not stored in the shower/bathroom where clean linen is stored. The findings include: Observation on 10/23/2023 at 11:45 AM of the 3rd floor bath/shower room (Windsor Unit) identified the room had a strong smell of urine and soiled laundry. The room also contained four wheelchairs, four laundry bins filled with soiled laundry/linens, a mechanical lift, an office chair, and two shower chairs. There was also a closet that contained clean briefs, a separate toilet room that was unflushed and appeared to contain feces, the floor around the toilet also appeared to be soiled. Observation on 10/24/23 at 9:00 AM of the 3rd floor bath/shower room (Windsor) identified three laundry bins containing soiled linen, and a garbage can less than a quarter full. The toilet was clean but there was an odor of urine and soiled linen. Interview on 10/24/23 at 9:40 AM with NA#3 indicated that dirty carts are put in the shower room during meals so that they are out of the halls. NA#3 further noted that there was a dirty utility room on the third floor, but the bath/shower room is closer in proximity to her assigned work area, so she placed the carts there. In addition, NA#3 also identified that placing the soiled linen carts in the shower area was a long-time practice and noted she had not been told to not place the carts there by anyone. NA#3 further acknowledged that there was a strong odor of urine in the shower room. Interview on 10/25/23 at 10:45 AM with the Infection Control Nurse indicated there was a dirty utility room on the 3rd floor and dirty items should be stored in a room that does not have clean items present due to the possibility of cross contamination. The Infection Control Nurse further identified that storing the soiled linen carts in the shower room had been in practice for years and that the DNS and Administrator were aware of the issue. Interview on 10/25/23 at 11:00 AM with the Administrator identified the shower rooms had been cleaned and she was not aware of any reason the dirty laundry carts could not be stored in the shower room during meals. The Administrator also indicated that there were broken tiles in the shower room and noted she did not detect a foul odor in the shower room. Observation on 10/27/23 at 12:50 PM of the third-floor shower room identified it contained four wheelchairs, two shower chairs, a chair scale, and a wheelchair scale, a bedside tray, an office chair, a mechanical lift, a covered code cart. The soiled linen carts were not in the room and the room did not have a foul smell. Review of the Laundry/Linen Processing policy indicated that soiled linen is bagged, removed from use, and placed into the designated rolling laundry hampers. When the hampers are filled, they are emptied by placing soiled linen bags down laundry chute in the chute room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, review of facility documentation, review of facility policy and interviews for four sampled residents (Resident #12, #21, #27 and #28) who had physician's orders for controlled medications, the facility failed to ensure resident specific controlled medications were not borrowed and administered to other residents. The findings include: Observation during the medication storage review on the third floor with LPN #6 on 10/26/23 at 2:00 PM of medication cart #2 identified the Controlled Substance and Disposition Records for Residents #12 and #21 contained entries indicating that their medications were borrowed for other residents. Interview at the time of the observation with LPN #6 identified that she was directed to borrow from another resident when Residents #11 and #107 did not have any medication available. Resident #12's diagnoses included chronic respiratory failure with hypercapnia, chronic obstructive pulmonary disease, type 2 diabetes, chronic kidney disease, anxiety, chronic pain, atherosclerosis of extremities bilateral legs. The significant change MDS assessment dated [DATE] identified Resident #12 was moderately cognitively impaired, required total assistance for bed mobility and toilet use and required extensive assistance for dressing, eating and personal hygiene. Resident #12's care plan dated 8/10/23 identified a focused area of self-care deficit with interventions of assistance with dressing, oral care, use of mechanical lift to get out of bed, showers and monitoring for skin breakdown. The care plan further identified the resident was being followed by hospice with interventions that included: encourage support system of friends and family, medications as ordered, monitor for signs and symptoms of pain, and psychosocial follow up regarding feelings towards end of life. The APRN's progress note dated 7/25/23 identified Resident #12 was admitted to hospice services. The note further identified that an order for Lorazepam (anxiolytic) 0.25 mg every 4 hours for anxiety as needed. Review of the Controlled Substance Disposition Record for Resident #12 identified an order for Lorazepam with instructions to administer Lorazepam 0.5 mg, one-half tab (0.25mg) every 4 hours as needed for anxiety. Further review of the documentation identified Lorazepam was borrowed and dispensed to Resident #107 on 9/12/23 at 9:14 and 1:54 (AM or PM was not specified for either dose). Further review of the record identified 4 tabs were dispensed for each dose (for a total of 1mg) The physician's order dated 8/9/23 directed Resident #107 be administered Lorazepam 0.5 mg give 2 tablets three times a day for anxiety. Resident #21's diagnoses included cerebral atherosclerosis, hypertension, myopathy, vascular dementia, major depressive disorder, anxiety disorder, and atherosclerosis of bilateral legs. The annual MDS assessment dated [DATE] identified Resident #21 was cognitively intact, required supervision for bed mobility, dressing, and toilet use, and was independent for personal hygiene, ambulation and eating, The Resident Care Plan (RCP) dated 2/9/23 identified Resident #21 was at risk for pain with interventions that included administer analgesics as ordered, monitor and document side effects of pain medication, anticipate the need for pain relief and respond immediately to any complaint of pain, report any changes in activity and monitor for decreased appetite. The RCP further addressed the resident's use of opioid therapy with interventions that included assess for alteration in mental status, assess for signs of constipation and increased somnolence, and evaluate the effectiveness of medication. Physician's orders dated 4/1/23 directed Resident #21 be administered Lorazepam (used to treat anxiety) 0.5 mg at bedtime, and Tramadol (opioid analgesic) 50 mg every 6 hours as needed for pain. Resident #21's Controlled Substance Disposition Record for the Tramadol identified two tablets (100mg total) were dispensed (borrowed) on 4/18/23 at 8:20 (AM or PM was not noted), and 4/20/23 at 8:00 AM and 5:00 PM for Resident #11, Review of the Medication Administration Record (MAR) for Resident #11 indicated that the resident had an order for Tramadol 50 mg, with directions to administer two tablets twice per day for pain. The MAR also identified the medication was administered on the dates indicated on Resident #21's Controlled Substance Disposition Record. Observation during the medication storage review on the second floor with LPN #7 on 10/26/23 at 2:20 PM of medication cart #1 identified the Controlled Substance and Disposition Records for Residents #27 and #28 contained entries indicating that their medications were borrowed for other residents. Interview at the time of the observation with LPN #7 identified she was not the nurse who had borrowed the medication and could not explain the why the medications were borrowed for other residents. Resident #27's diagnoses included spastic hemiplegia, unspecified pain, dementia, anxiety, depression. A quarterly MDS dated [DATE] identified Resident #27 was moderately cognitively impaired, required supervision for bed mobility, transfers, eating, ambulation, toileting, hygiene, and limited assistance with dressing. The RCP dated 9/22/23 identified Resident #27 was at risk for pain with interventions that included administering analgesics as ordered, monitor and document side effects of pain medication, and monitor and report any signs of pain. The RCP further addressed the resident's use of opioids with interventions that included assess for alteration in mental status, constipation, increased somnolence, effectiveness of medication and to offer non-pharmacological measures for pain relief. Physician's orders dated 10/6/23 directed Oxycodone (narcotic)20 mg, administer 1 tablet twice per day and every 12 hours as needed for pain, Methadone (narcotic)30 mg every 12 hours for pain. Resident #27's Controlled Substance Disposition Record for Oxycodone 20mg identified that on 10/9/23 at 3:00 AM and 10:30 AM two tabs (40mg) were borrowed for Resident #420. Review of Resident #420's MAR identified an order for Oxycodone 40mg every three hours as needed for pain. Resident #28 diagnoses included chronic obstructive pulmonary disease, chronic diastolic heart failure, osteoporosis, atherosclerosis of bilateral legs, and vascular dementia. The RCP dated 8/24/23 identified Resident #28 as at risk for pain with interventions that included administering analgesics as ordered, monitor and document side effects of pain medication, and monitor and report any signs of pain. The quarterly MDS assessment dated [DATE] identified that Resident #28 was moderately cognitively impaired, required extensive assistance for bed mobility, transfers, dressing, ambulation, toileting, hygiene and was independent with eating. Physician's orders dated 9/12/23 directed to administer Tramadol 50 mg ½ tab every 4 hours as needed for pain. Resident #28's Controlled Substance Disposition Record identified Tramadol 25mg was borrowed and administered to Resident #88 on 9/25/23 at 4:12 (AM or PM not specified). Review of Resident #88's MAR identified an order for Tramadol 50 mg give 25 mg two times per day for pain. Interview with LPN #3 on 10/27/23 at 10:00 AM identified she began working at the facility 3 months ago and identified that the process for obtaining a controlled medication if a resident has run out of their ordered medication is to contact the nursing supervisor who checks the Pyxis (secure medication storage for narcotic and other controlled medications) for the medication. She further identified that she was instructed by RN #2 (Nursing Supervisor) to borrow the controlled medication from another resident when it was not available in the Pyxis. LPN #3 further noted that she was unable to recall specific details because this occurred after she first started working at the facility. LPN #3 indicated that she did not feel that this was the right thing to do because she was not used to this practice and was not aware if the resident's medication was replaced. Interview with LPN #5 (floor nurse) on 10/27/23 at 10:10 AM identified she began working at the facility 1.5 years ago and noted the process for obtaining a controlled medication if a resident has run out of their ordered medication is to contact the supervisor who checks the Pyxis for the medication. In addition, LPN #5 identified that the process for ordering medications involves the floor nurses or the nursing supervisor calling the pharmacy to order the medication when they are running low. She also indicated that the APRN does rounds once per week and checks to see if any medications need refills. She further identified that she was told by her Supervisor (RN #2) to borrow a controlled substance from another resident when it was not available in Pyxis. LPN #5 identified she was aware that borrowing controlled medications was not right to do but did feel she had a choice. Interview with RN #2 on 10/27/23 at 10:20 AM identified the process for reordering controlled medications is for the nurses to call the orders into the pharmacy or for the nurses to request the supervisor to call the pharmacy. If the nurse runs out of medication on the floor, he/she goes to the supervisor to request the medication from Pyxis. RN #2 identified that although she does not give specific directions to the nurses to borrow medications from one resident to use for another resident, she is aware that they do this when the medication is not available in Pyxis. She further identified she was aware that it was not a good practice. Interview with the DNS on 10/27/23 at 10:55 AM identified she is responsible for keeping the Pyxis system filled and does a bi-monthly inventory. Supervisors are supposed to inform her if medications are running low so that she can order them. She further indicated that she has sent several emails to staff reminding them of timely re-ordering of controlled substances so that they do not run out of the residents' medications. The DNS further identified that if the medication is not available in Pyxis the expectation is for the nurse to call the medication order into the pharmacy as urgent (which usually involves the pharmacy delivering the medication within a few hours). The DNS also identified that she is aware the staff have been borrowing medications from one resident to use for another resident when they run out and identified that this is not an acceptable practice. The Pharmacy Services and Procedures Manual policy indicated that prior to the administration of medication, facility staff should take all measures required by facility policy and applicable law, including, but not limited to verifying each time a medication is administered, that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident. The policy further stated to document the administration of controlled substances in accordance with applicable law.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, facility policy review and interviews for eight sampled residents (Residents #1, #10, #11, #13, #46, #52, #58, and #86) reviewed for oxygen administration and respiratory treatments, the facility failed to label and date oxygen tubing and failed to store nebulizer mask, oxygen and nebulizer tubing appropriately to prevent contamination and failed to follow the physician's orders for the correct oxygen setting The findings include: 1. Resident #1 's diagnoses included chronic obstructive pulmonary disease, heart failure, and cerebral infarction. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 was cognitively intact, and required extensive assistance for bed mobility, toileting and was totally dependent for transfers. A physician's order dated 2/15/23 directed to change oxygen tubing weekly, every Saturday night, using a label with date and initials. Treatment administration record dated 10/21/23, identified the oxygen tubing and nebulizer tubing was changed by the third shift and labeled with a date and initials. Observations on 10/25/23 at 8:58 AM Identified Resident #1's oxygen tubing found with no label, initials, or date. Nebulizer equipment found labeled dated and covered with a plastic bag. Interview on 10/25/23 at 9:20 AM with LPN #2 after making her aware that Resident #1's oxygen tubing was found not labeled/initialed or dated this morning at 8:58 AM. Oxygen was in use during the observation. LPN #2 explained that it would be replaced, labeled, and dated per policy. LPN #2 could not explain why the tubing or equipment was not dated, labeled, or stored correctly. Interview on 10/25/23 at 11:12 AM with the DNS identified she was unsure if the facility had a policy for oxygen and nebulizer use and storage and would ask the Administrator. Review of the Respiratory Equipment policy identified that when oxygen tubing is not in use it will be stored in a plastic bag to prevent contamination. Tubing found on the floor or dropped will be replaced immediately when identified. The 11-7 shift will be responsible for changing the oxygen and nebulizer tubing weekly on Saturdays. The tubing will be labeled with the date and initials of the nurse changing the tubing. Review of the Oxygen Administration policy identified nebulizer tubing and delivery devices should be changed weekly and as needed if they become soiled or contaminated and to keep delivery devices covered in a plastic bag when not in use. 2. Resident #10 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), asthma, and cirrhosis of liver. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #10 was moderately cognitively impaired and required limited assistance with bed mobility, transfers, locomotion on unit, toileting, dressing, and personal hygiene. Current physician's order for the month of October 2023 directed to titrate oxygen 0-4 Liters Per Minute (LPM) to maintain oxygen saturation greater than 90% every shift, Albuterol Sulfate Inhalation Nebulization Solution 0.63 milligrams (mg) per 3 milliliters (ml) inhale 3ml inhale orally via nebulizer every 4 hours as needed for shortness of breath, and Albuterol Sulfate Inhalation Nebulization Solution 0.63mg/3ml inhale 3ml inhale orally via nebulizer three times a day for asthma exacerbation. Observation on 10/23/23 at 9:00 AM identified Resident #10 was sitting in the recliner chair with a nasal cannula tubing connected to the condenser at 0 Liters per minute (LPM) with a label on the tubing dated 10/22/23 located on the floor between the recliner chair and Resident #10's bed. Also, identified a nebulizer machine on the nightstand with a nebulizer mask and tubing dated 10/22/23 that was without any covering. Observation on 10/24/23 at 9:50 AM identified Resident #10 was sitting in the recliner chair with a nasal cannula tubing connected to the condenser at 0 Liters per minute (LPM) with a label on the tubing dated 10/22/23 located on the floor between the recliner chair and Resident #10's bed. Also, identified a nebulizer machine on the nightstand with a nebulizer mask and tubing dated 10/22/23 that was without any covering. Observation on 10/25/23 at 8:30 AM with the Charge Nurse LPN #2 identified Resident #10 was lying in bed, a nasal cannula tubing was connected to the condenser at 0 Liters per minute (LPM) with a label on the tubing dated 10/22/23 located on the floor between the recliner chair and Resident #10's bed. Also, identified a nebulizer machine on the nightstand with a nebulizer mask and tubing dated 10/22/23 that was without any covering. Interview with the Charge Nurse LPN #2 on 10/25/23 at 8:30 AM identified that the oxygen tubing should not have been on the floor but should have been in a bag when not use. LPN #2 identified that the nebulizer mask and tubing when not in use should have been covered. After which, LPN #2 removed and discarded the oxygen tubing, and replaced and placed the oxygen tubing in a bag and covered the nebulizer mask and tubing using a plastic bag. Interview on 10/25/23 at 11:12 AM with the DNS identified she was unsure if the facility had a policy for oxygen and nebulizer use and storage and would ask the Administrator. Review of the Respiratory Equipment policy identified that when oxygen tubing is not in use it will be stored in a plastic bag to prevent contamination. Tubing found on the floor or dropped will be replaced immediately when identified. The 11-7 shift will be responsible for changing the oxygen and nebulizer tubing weekly on Saturdays. The tubing will be labeled with the date and initials of the nurse changing the tubing. Review of the Oxygen Administration policy identified nebulizer tubing and delivery devices should be changed weekly and as needed if they become soiled or contaminated and to keep delivery devices covered in a plastic bag when not in use. 3. Resident #11's diagnoses included Alzheimer's disease, chronic obstructive pulmonary disease (COPD), atrial fibrillation (AFIB), insomnia, hypothyroidism, heart block, overactive bladder, metabolic encephalopathy, and anxiety. The annual MDS assessment dated [DATE] identified Resident #11 had severe cognitive impairment and required assistance with activities of daily living. The care plan dated 8/10/23 identified Resident #11 was at risk for impaired respiratory status with interventions that included monitor breathing patterns and abnormalities, continuous oxygen with tube changes weekly, positioning to maintain optimal breathing and to pace activities to allow for adequate rest periods. The care plan further identified a self-care deficit with interventions that included assistance with dressing, hygiene, transfers with lift, showers, and monitoring skin integrity. The physician's order dated 10/6/23 directed the administration of oxygen (O2) at 3 liters via nasal cannula, change oxygen tubing weekly on night shift, and label with date and initials. The Treatment Administration Record (TAR) for [DATE] included documentation of oxygen administration at 3 liters continuous for all three shifts. Observation on 10/24/23 at 10:15 AM identified Resident #11's oxygen setting was set at 4 liters. Interview with LPN #6 (charge nurse) on 10/24/23 at 10:20AM identified the orders for Resident #11 oxygen setting were for 3 liters continuous. LPN #6 further indicated that the nurse is supposed to check the O2 setting on their shift to verify accuracy. Interview and observation with Administrator who is an RN on 10/24/23 at 10:25 AM identified Resident #11's O2 was set at 4 liters and not the physician prescribed 3 liters. The Administrator identified that the nurse on the shift was responsible for ensuring that the O2 setting was correct. The Administrator's note dated 10/24/23 at 10:46 AM identified Resident #11's O2 was noted at 4 liters per minute (lpm), breathing non labored, denied shortness of breath, pulse oximetry (measure of the saturation of oxygen in a person's blood) level of 99%. The note further identified the oxygen was adjusted to 3 liters per order. The facility Oxygen Administration policy indicated that oxygen is administered under the orders of a physician except in an emergency. The care plan should identify interventions for O2 therapy based on assessment and ordered services, type of system, when to administer, setting, any pulse oximetry orders and monitoring for complications. 4. Resident #13 diagnosis included heart failure, anxiety, and high blood pressure. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #13 as moderately cognitively impaired and required extensive assistance for bed mobility, transfers, dressing and toilet use. A physician's order dated 4/3/23 directed to change the nebulizer tubing weekly every Saturday night and use a label with date and initials. Treatment administration record dated 10/21/23 identified the nebulizer tubing was changed, by the third shift and labeled with date and initials. Observation on 10/23/23 at 8:46 AM Resident #13 on 2L O2 via n/c. O2 tubing found with no label or date. Resident observed with no name band. Observation on 10/25/23 at 8:50 AM Resident #13 in bed 2L of O2 via n/c on. Noted no date or label observed on the oxygen tubing. Tubing also found to be lying on the floor. Nebulizer medication cup dated and tubing not labeled. The face mask was on the back of the nebulizer machine and uncovered. No storage bags were located or visualized in the resident's room. Interview and observation on 10/25/23 at 9:17 AM with LPN #2 noted Resident #13 had no date on the oxygen tubing and the tubing was lying on the floor. LPN #2 was unsure as to why the tubing was not in a bag on the concentrator or bed, to prevent it from lying on the floor. LPN #2 also noted the nebulizer tubing was not dated and the nebulizer mask was uncovered. LPN #2 further identified that the policy regarding the use and storage of oxygen and nebulizer equipment was tubing should be labeled/dated and in a bag to prevent it from being on the floor, to prevent contamination or infection. Tubing is changed by the third shift every week and should be labeled with initials and dated. The nebulizer equipment should also be labeled/dated and covered and was also changed weekly by the third shift. LPN #2 proceeded to pick up the O2 tubing, removed it and provided the resident with new tubing and labeled it with initials and dated it. LPN #2 also covered the nebulizer equipment and conveyed that the resident may have removed the cover, as he/she self-administers the nebulizer treatment after it is set up by the nurse. Interview on 10/25/23 at 11:12 AM with the DNS identified she was unsure if the facility had a policy for oxygen and nebulizer use and storage and would ask the Administrator. Review of the Respiratory Equipment policy identified that when oxygen tubing is not in use it will be stored in a plastic bag to prevent contamination. Tubing found on the floor or dropped will be replaced immediately when identified. The 11-7 shift will be responsible for changing the oxygen and nebulizer tubing weekly on Saturdays. The tubing will be labeled with the date and initials of the nurse changing the tubing. Review of the Oxygen Administration policy identified nebulizer tubing and delivery devices should be changed weekly and as needed if they become soiled or contaminated and to keep delivery devices covered in a plastic bag when not in use. 5. Resident #46's diagnoses included chronic kidney disease, diastolic congestive heart failure, atrial fibrillation, dependence on supplemental oxygen and vascular dementia. A quarterly MDS assessment dated [DATE] identified that Resident #46 was moderately cognitively impaired, required extensive assistance for bed mobility, dressing, toilet use, personal hygiene and was independent with eating, The care plan dated 8/29/23 identified Resident #46 had difficulty breathing due to congestive heart failure with interventions that included check breath sounds and monitor for labored breathing, elevate the head of the bed, oxygen set at 2 liters per minute, encourage and monitor for adequate nutrition. The care plan further addressed the resident's self-care deficit with interventions that included assistance with dressing, hygiene, transfers with lift, and monitoring skin integrity. The physician's order dated 10/23/23 directed the administration of oxygen continuous at 2 liters via nasal cannula and change O2 tubing weekly, and label with date and initials. Review of the Treatment Administration Record (TAR) for [DATE] included documentation of oxygen administration at 2 liters continuous for all 3 shifts. During the initial interview and observation with Resident #46 and his/her family member on 10/23/23 at 10:15 AM, the oxygen was set at 1 liter. Clinical record review on 10/24/23 at 10:10 AM indicated MD order for O2 setting was for 2 liters. Observation of O2 setting for Resident #46 on 10/24/23 at 10:15AM identified O2 setting of 1 liter. Interview with LPN #6 on 10/24/23 at 10:20 AM confirmed Resident #46's order for 2 liters of continuous oxygen. LPN #6 further indicated that the nurse is supposed to check the O2 setting on their shift to verify accuracy. Interview and observation with the Administrator who is an RN on 10/24/23 at 10:25 AM identified Resident #46's O2 setting was at 1 liter. The Administrator identified that the nurse on the shift was responsible for ensuring that the O2 setting was correct. A note written by the Administrator dated 10/24/23 at 10:46 AM identified Resident #46's O2 was set at 1 lpm, breathing easy and non-labored, denied shortness of breath, pulse oximetry level 99%, adjusted O2 to 2 liters per order. The facility Oxygen Administration Policy indicated that oxygen is administered under the orders of an MD except in an emergency. The RCP should identify interventions for O2 therapy based on assessment and ordered services, type of system, when to administer, setting any spo2 orders and monitoring for complications. 6. Resident #52's diagnosis included Dementia, chronic pain, and repeated falls. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #52 was severely cognitively impaired and required extensive assistance for bed mobility, dressing, toilet use and was totally dependent for transfers. A physician's order dated 10/28/23 directed to change the oxygen tubing every Saturday on the night shift. Use a label with date and initials. Interview and observation on 10/25/23 at 9:20 AM with LPN #2 identified Resident #52's oxygen tubing was hanging off the side rail of the bed onto the floor. Oxygen tubing was without initials and a date. LPN #2 removed the tubing immediately and explained it was going to be replaced, labeled, and dated with initials. The nebulizer equipment was not labeled with date or initials. LPN #2 explained it would be replaced too, then labeled with initials and dated. Interview on 10/25/23 at 11:12 AM with the DNS identified she was unsure if the facility had a policy for oxygen and nebulizer use and storage and would ask the Administrator. Review of the Respiratory Equipment policy identified that when oxygen tubing is not in use it will be stored in a plastic bag to prevent contamination. Tubing found on the floor or dropped will be replaced immediately when identified. The 11-7 shift will be responsible for changing the oxygen and nebulizer tubing weekly on Saturdays. The tubing will be labeled with the date and initials of the nurse changing the tubing. Review of the Oxygen Administration policy identified nebulizer tubing and delivery devices should be changed weekly and as needed if they become soiled or contaminated and to keep delivery devices covered in a plastic bag when not in use. 7. Resident #58 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease, wheezing, and acute bronchitis. The quarterly MDS assessment dated [DATE] identified Resident #58 was cognitively intact and required limited assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. Current physician's order for the month of October 2023 directed Ipratropium-Albuterol Solution 0.5-2.5 (3) mg/3ml inhale orally every 4 hours as need for shortness of breath or wheezing via nebulizer, Budesonide Inhalation suspension 0.25 mg /2ml inhale orally via nebulizer two times a day for wheezing, and Oxygen 1-4 Liters as needed to keep oxygen saturation greater than 90% for hypoxia (lack of oxygen). Observation on 10/23/23 at 8:25 AM identified Resident #58 nebulizer machine with the nebulizer mask and tubing found on a chair next to Resident #58's bed that was without any covering. Observation on 10/24/23 at 9:40 AM identified Resident #58 was sitting in a wheelchair while Resident #58's nasal cannula tubing was connected to the condenser at 0 Liters per minute (LPM) with a label on the tubing dated 10/22/23 on the chair. Also, identified a nebulizer machine with nebulizer mask and tubing located on a chair next to Resident #58's bed without any covering. Observation on 10/25/23 at 12:00PM with the Charge Nurse LPN #3 identified Resident's 58's nasal cannula tubing was connected to the condenser at 0 Liters per minute (LPM) with a label on the tubing dated 10/22/23 on the chair. Also, identified a nebulizer mask and tubing located on a chair next to Resident #58's bed that was without any covering. Interview with the Charge Nurse LPN #3 on 10/25/23 at 12:00 PM identified that oxygen and nebulizer tubing's and nebulizer mask should be covered. LPN #3 identified that this was the responsibility of the night shift (11PM to 7AM). LPN #3 failed to identify why the oxygen tubing and nebulizer mask was not covered when not in use. Interview on 10/25/23 at 11:12 AM with the DNS identified she was unsure if the facility had a policy for oxygen and nebulizer use and storage and would ask the Administrator. Review of the Respiratory Equipment policy identified that when oxygen tubing is not in use it will be stored in a plastic bag to prevent contamination. Tubing found on the floor or dropped will be replaced immediately when identified. The 11-7 shift will be responsible for changing the oxygen and nebulizer tubing weekly on Saturdays. The tubing will be labeled with the date and initials of the nurse changing the tubing. Review of the Oxygen Administration policy identified nebulizer tubing and delivery devices should be changed weekly and as needed if they become soiled or contaminated and to keep delivery devices covered in a plastic bag when not in use. 8. Resident #86 was admitted to the facility on [DATE] with diagnoses that included hypertension, muscle weakness, and diarrhea. The quarterly MDS assessment dated [DATE] identified Resident #86 was cognitively intact and required limited assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. Current physician's order for the month of October 2023 directed Xopenex inhalation nebulization solution 0.63 milligrams (mg) per 3 milliliters (ml) inhale 0.63mg inhale orally every 4 hours as needed for congestion. The medication administration record for the month of October 2023 identified Resident #86 was given Xopenex inhalation nebulization solution 0.63 milligrams (mg) per 3 milliliters (ml) inhale 0.63mg inhale orally every 4 hours as needed for congestion on 10/8/23 at 4:46 PM. Observation on 10/23/23 at 8:20 AM identified Resident #68's nebulizer machine with nebulizer mask and tubing with a date of 10/8/23 on the top of a chess was without any covering. Observation on 10/24/23 at 9:45 AM identified Resident #68's nebulizer machine with mask and tubing with a date of 10/8/23 on the top of a chess was without any covering. Observation on 10/25/23 at 12:00 PM with Charge Nurse LPN #3 identified Resident #68's nebulizer machine with mask and tubing with a date of 10/8/23 on the top of a chess was without any covering. Interview with the Charge Nurse LPN #3 on 10/25/23 at 12:00 PM identified that oxygen and nebulizer tubing's and nebulizer mask should be covered. LPN #3 identified that this was the responsibility of the night shift (11PM to 7AM). LPN #3 failed to identify why the oxygen tubing and nebulizer mask was not covered when not in use. Interview on 10/25/23 at 11:12 AM with the DNS identified she was unsure if the facility had a policy for oxygen and nebulizer use and storage and would ask the Administrator. Review of the Respiratory Equipment policy identified that when oxygen tubing is not in use it will be stored in a plastic bag to prevent contamination. Tubing found on the floor or dropped will be replaced immediately when identified. The 11-7 shift will be responsible for changing the oxygen and nebulizer tubing weekly on Saturdays. The tubing will be labeled with the date and initials of the nurse changing the tubing. Review of the Oxygen Administration policy identified nebulizer tubing and delivery devices should be changed weekly and as needed if they become soiled or contaminated and to keep delivery devices covered in a plastic bag when not in use.

Based on observations, facility documentation, facility policy and interviews for 1 of 2 sampled nourishment room refrigerators the facility failed to accurately check temperature and identify that the temperature that was tracked was too high per safe food storage parameters. The findings include: Observation on 10/25/23 at 10:25AM of the 2nd floor Nourishment Refrigerator identified no temperature was tracked for 10/25/23. The temperature of the refrigerator was set at 42 degrees and no thermometer was located. Interview on 10/25/23 at 10:30 AM with Dietary Assistant #1 identified that housekeeping is responsible for taking the temperature and that there should be a thermometer present, however none was located. Observation on 10/26/23 at 9:00AM of the temperature log identified no temperature was written in for 10/25/23 for the second floor Nourishment Refrigerator. The temperature was still set to 42 degrees. Interview with Housekeeper #1 on 10/26/23 at 9:45 AM identified that the temperature was recorded by opening the nourishment refrigerator on the 2nd floor hitting the button until it says 42 degrees and then hitting the freezer button until it says 0 degrees. He had not been shown how to take the temperature and he just looked at the set temperature. No thermometer could be located in the fridge. Observation of 2nd floor nourishment temperature log on 10/26/23 at 1:30 PM identified the temperature for 10/25/23 had been filled in since the 9:00 AM observation on 10/26/23. The temperature was recorded by RN #1. Interview with Dietary Manager on 10/27/23 at 9:30 AM identified that the temperature on top of the nourishment refrigerator on the 2nd floor was the set temp and that there should be a separate thermometer that the housekeeping should be reading it from. Dietary Manager also identified that if the temperature was indeed 42 degrees that the housekeeping supervisor should have been notified as their policy is that it should not be higher than 40 degrees. This temperature range is on the housekeeping log. He would be ensuring a thermometer is present in the refrigerator and freezer. Interview with RN#1 on 10/27/23 at 10:08 AM identified that the temperature had been checked by herself and the Administrator and that they do periodic audits of the refrigerator temperatures. RN #1 further identified that she read the temperature from the set temperature from the top of fridge. RN#1 identified there were two thermometers present in the refrigerator at this time, this was subsequent to surveyor inquiry. Interview with Director of Maintenance on 10/27/23 at 11:25 AM identified that temperatures should be recorded from a separate thermometer and not from viewing the set temperature at the top of the nourishment refrigerator. More training would be conducted with the housekeeper. If the temperature was indeed recorded at 42 degrees, he would expect to be notified if it was greater than 40 degrees. Review of the facility policy for Non-Medication Refrigerator/Freezer Temperatures directed the refrigerator and freezer temperature will be checked on 7-3 by the housekeeper assigned. The refrigerator temperature will be maintained between 33- and 40-degrees F. If the temperature is out of range, notify maintenance at extension 124 and recheck in 30 minutes and record on the temperature log.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for one sampled resident, (Resident #42) reviewed for positioning, the facility failed to develop and implement a comprehensive person-centered plan of care for positioning. The findings include: Resident #42 was admitted to the facility with diagnoses that included [NAME] Pick Disease, apraxia and cerebellar ataxia. An Occupational therapy note dated 8/25/20 identified the resident was referred for OT for custom wheelchair delivery, assessment of seating and positioning, adjustments, modifications and staff training. Skilled therapy services are medically necessary in order to address deficits, improve quality of life, and assist patient in returning to prior level of function. The new custom wheelchair included : headrest, Roho cushion, pelvic positioning belt with harness type front support, left side hemi tray, added right side hemi tray and non elevating bilateral leg rests. The care plan for ADL self-care performance deficit related to [NAME]-pick disease type C dated 3/1/21. Intervention included: to provide stand pivot transfer with assistance of two staff with gait belt, out of bed to facility custom tilt-in-space wheelchair, seat belt, Roho Cushion, head rest, bilateral leg rests, and bilateral side trays. The quarterly MDS assessment dated [DATE] identified Resident #42 had moderately impaired cognition, impaired speech, required extensive assistance of two staff for bed mobility, transfers, and toilet use; required extensive assistance of one staff for personal hygiene, and was incontinent of bowel and bladder. The MDS assessment also identified the resident requires a wheelchair for mobility. The physicians' orders reviewed from 8/9/19 through 8/19/21 did not reflect any custom wheelchair orders for 24-hour positioning. The nurse's notes reviewed from 6/15/21 through 8/23/21 identified no notes addressing the custom wheelchair 24-hour positioning plan. Observation on 9/19/21 at 11:00 A.M. identified the resident in a custom wheelchair in upright position. Observation on 9/19/21 at 12:30 P.M. identified the resident in a custom wheelchair in upright position. Interview with Person #1 (wheelchair vendor) on 8/23/21 at 9:40 A.M. indicated that if the chair needs modifications there would be a 24-hour repositioning plan in place along with physician progress notes within 90 days. Interview with the DNS on 8/23/21 at 11:47 A.M. identified he was unaware of the 24-hour repositioning plan in the past and indicated one will be implemented now. Interview with Administrator on 8/23/21 at 12:00 P.M. failed to identify anyone in charge of the 24-hour repositioning plan. The administrator did not know when it had stopped being monitored. The Administrator identified that he/she did not realized it was a requirement. Interview with Occupational Therapist OT #1 on 8/23/21 at 12:16 P.M. identified OT #1 did not report to anyone when OT #1 identified the resident's 24-hour positioning sheets were missing. OT #1 further indicated he/she thought it was because of the removal policy. Subsequent to inquiry, interventions added to the care plan on 8/19/21 included: The resident's positioning plan was modified to promote enhanced psychosocial functioning made possible by seating in a customized wheelchair for longer periods of time. Physical capacity for being adaptively seated may fluctuate. Positioning plan takes into consideration the resident's ability to be seated in a customized wheelchair for limited or extended periods of time depending on the resident's daily circumstances and needs. The Customized Wheelchair Policy dated August 2000 directed: The 24-hour positioning plan is devised by rehabilitation and nursing department, patient and attending medical doctor. Charge nurse is to document monthly notes and rehabilitation is to document quarterly notes. It shall address whether the nursing and direct care staff are properly implementing the required 24-hour positioning plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for one sampled resident, (Resident #42) reviewed for positioning, the facility failed to ensure a 24-hour positioning plan was in place in accordance to the comprehensive person-centered plan of care. The findings include: Resident #42 was admitted to the facility with diagnoses that included [NAME] Pick Disease, apraxia and cerebellar ataxia. The care plan for ADL self-care performance deficit related to [NAME]-pick disease type C dated 3/1/21. Intervention included: to provide stand pivot transfer with assistance of two staff with gait belt, out of bed to facility custom tilt-in-space wheelchair, seat belt, Roho Cushion, head rest, bilateral leg rests, and bilateral side trays. The quarterly MDS assessment dated [DATE] identified Resident #42 had moderately impaired cognition, impaired speech, required extensive assistance of two staff for bed mobility, transfers, and toilet use; required extensive assistance of one staff for personal hygiene, and was incontinent of bowel and bladder. The MDS assessment also identified the resident requires a wheelchair for mobility. The physicians' orders reviewed from 8/9/19 through 8/19/21 did not reflect any custom wheelchair orders for 24-hour positioning. The nurse's notes reviewed from 6/15/21 through 8/23/21 identified no notes addressing the custom wheelchair 24-hour positioning plan. Observation on 9/19/23 at 11:00 A.M. identified the resident in a custom wheelchair in upright position. Observation on 9/19/21 at 12:30 P.M. identified the resident in a custom wheelchair in upright position. Interview with Person #1 (wheelchair vendor) on 8/23/21 at 9:40 A.M. indicated that if the chair needs modifications there would be a 24-hour repositioning plan in place along with physician progress notes within 90 days. Interview with the DNS on 8/23/21 at 11:47 A.M. identified he was unaware of the 24-hour repositioning plan in the past and indicate one will be implemented now. Interview with Administrator on 8/23/21 at 12:00 P.M. failed to identify anyone in charge of the 24-hour repositioning plan. The administrator did not know when it had stopped being monitored. The Administrator identified that he/she did not realized it was a requirement. Interview with Occupational Therapist OT #1 on 8/23/21 at 12:16 P.M. identified OT #1 did not report to anyone when OT #1 identified the resident's 24-hour positioning sheets were missing. OT #1 further indicated he/she thought it was because of the removal policy. Subsequent to inquiry, interventions added to the care plan on 8/19/21 included: The resident's positioning plan was modified to promote enhanced psychosocial functioning made possible by seating in a customized wheelchair for longer periods of time. Physical capacity for being adaptively seated may fluctuate. Positioning plan takes into consideration the resident's ability to be seated in a customized wheelchair for limited or extended periods of time depending on the resident's daily circumstances and needs. The Customized Wheelchair Policy dated August 2000 directed: The 24-hour positioning plan is devised by rehabilitation and nursing department, patient and attending medical doctor. Charge nurse is to document monthly notes and rehabilitation is to document quarterly notes. It shall address whether the nursing and direct care staff are properly implementing the required 24-hour positioning plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility policy, and interviews for one of two residents (Resident #101) reviewed for respiratory care, the facility failed to ensure an order was obtained for oxygen and that the resident's oxygen tubing was dated. The findings include: Resident #101 was admitted on [DATE] with diagnoses that included chronic respiratory failure with hypoxia and chronic obstructive pulmonary disease. The hospital Discharge summary dated [DATE] identified chronic obstructive pulmonary disease on 2 liters of oxygen at baseline. The nursing admission note dated 7/28/21 indicted oxygen saturation of 91% on 2 liters via nasal cannula. Subsequent nursing notes indicated continued use of the oxygen. The care plans dated 7/29/21 identified a self-care deficit related to limited mobility and congestive heart failure. Intervention includes to provide the assistance of one staff with rolling walker while on O2 at 2 liters. The admission MDS assessment dated [DATE] identified Resident #101 had moderately impaired cognition, required extensive assistance of one to two staff for ADL, and utilized oxygen therapy. The Respiratory Therapist progress note dated 8/6/21 identified Resident #101 was on 2 liters of oxygen. The 8/11/21 Respiratory Therapist progress note identified oxygen rate was increased to 4 liters after an episode of shortness of breath. Observations on 8/16/21 at 10:15 A.M. and 8/17/21 at 11:20 A.M. identified the resident in bed or chair with Oxygen at 4 liters via nasal cannula. Observations also identified the oxygen tubing was not dated. Interview and review of the clinical record with RN #4 on 8/17/21 at 2:00 P.M. failed to identify an order for the use of the 2 liters oxygen on admission on [DATE] or for the increase in flow rate to 4 liters on 8/11/21. Review of the Treatment Administration Record also failed to indicate monitoring of the oxygen or change of the oxygen tubing. RN #4 indicated oxygen tubing is changed on Sundays and since the tubing was undated, RN #4 proceeded to change and date the tubing. Physician's order dated 8/17/21 directed for nasal oxygen 1-4 liters via oxymizer as needed for shortness of breath for dyspnea/pneumonia, keep oxygen saturation greater than 90%. Facility policy statement for oxygen administration directs staff to carry out oxygen administration per physician order. The physician's orders should include the type of equipment, desired concentration and time duration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility policy and interviews for one of two residents observed during a blood sugar collection via a glucometer for (Resident #15), the facility failed to implement infection control practices related to use of gloves. The findings include: Resident #15's diagnoses included type 2 diabetes mellitus with hyperglycemia, heart failure and dementia. The admission Minimum Data Set assessment dated [DATE] identified Resident #15 had severely impaired cognition and diabetes mellitus, required extensive assistance with mobility, dressing, toilet use, personal hygiene and total dependence for bathing. The care plan dated 6/8/21 identified Resident #15 has diabetes mellitus. Interventions directed staff to monitor the resident, to document and report any signs and symptoms of infection to any open areas such as redness, pain, heat, swelling and/or pus formation. The physician's order dated 8/5/21 directed staff to obtain finger stick blood sugar before meals and at bedtime. Observations on 8/16/21 at 11:45 A.M. identified LPN #2 obtained a blood glucose sample using the Evencare ProView glucometer for Resident #15 without the benefit of wearing gloves. It was further observed after the sample was obtained, LPN #2 took the glucometer with the resident's lancet with blood sample still attached and carried it to the medication cart at the end of the hallway. Further observation noted LPN # 2 removed the lancet and cleaned the glucometer with EPA approved wipes without the benefit of wearing gloves. LPN# 2 then performed hand hygiene with alcohol-based sanitizer. Interview with LPN #2 on 8/16/21 at 11:50 A.M. identified although most of the time she wears gloves when obtaining residents' blood glucose sample, she was not wearing gloves today during this procedure because the surveyor was watching her. Further interview with LPN #2 identified she does not tend to wear gloves when disinfecting the glucometer after obtaining resident's blood sample. LPN #2 further identified the facility practice is that gloves are worn for blood glucose sample procedures. However, LPN #2 was unable to explain why she was not in wearing gloves. Interview with the DNS on 8/16/21 at 1:00 P.M. identified the expectation is for staff to wear gloves while obtaining blood glucose samples and while disinfecting the glucometer to prevent the possible transmission of blood borne pathogens. The DNS identified that LPN #2 will receive additional in-service on importance of infection control practices while using the glucometers. The User's guide for Evencare ProView Blood Glucose Monitoring System indicated in the disinfection instructions to wash hands with soap and water, put on single use medical protective gloves, wipe the glucose meter thoroughly with an EPA disinfecting wipe, remove gloves and wash hand thoroughly with soap and water before proceeding to the next patient. It further indicated single use protective gloves should always be worn during disinfection procedures and by anyone performing blood glucose testing on another person.

Based on observations, interviews, and review of facility documentation, the facility failed to maintain the kitchen in a clean and sanitary manner. The findings include: A tour of the kitchen with the Food Service Director (FSD) on 8/16/21 at 10:27 A.M. and the following was identified: 1. The kitchen exhaust hood, located over the food preparation area was coated with thick and grimy dust material 2. The juice cooler shelves sides and bottom were noted with thick caked on dried brown substance. 3. The exhaust fan in the window was noted to be on and noted with coated thick layer of dust that adhered to the wiring vent and wires. Interview with FSD on 8/16/21 at 10:27 A.M. identified the kitchen exhaust hood was last cleaned on 3/17/21 and is scheduled to clean every six months but will be cleaned more frequently as needed going forward. The hood cleaning company was called and scheduled cleaning on 8/19/21. Further, interview with FSD identified the cook is responsible for cleaning the refrigerators during their shift and any spills should be cleaned immediately. The FSD identified the exhaust fan was not on the kitchen cleaning schedule and indicated a routine cleaning schedule will be implemented by maintenance. Review of facility Kitchen Routine Policy identified the following: the department cleaning of floors, walls, ceilings, general equipment, hoods, dish machine, refrigerators, cafeteria service line, food trucks and carts, tables, shelves, and storage cabinets is done by food & nutrition services. Professional cleaning of the kitchen hood vents is arranged by facility operations and is performed by an outside contractor such as: Exhaust hood vents, ceiling vents, fans, and light fixtures are maintained by facility operations. Daily and weekly cleaning assignments are determined and delegated by the supervisors. Daily cleaning tasks are specified by each assigned position. However, the cook's cleaning list observed on the check-off dietary aide check does not list the cleaning of the refrigerator on the cleaning check-off list .