Based on observations, interviews, and record review, the facility failed to ensure one (#40) out of twenty-one sampled residents were assessed for the self-administration of a topical pain patch dated for the day before the observation and left at bedside. Findings included: An observation was made on 1/16/24 at 10:31 a.m., of a topical patch dated 1/15/23, 3 p.m. - 11 p.m. shift by a Licensed Practical Nurse (LPN) laying on the dresser of Resident #40. During the observation the resident stated the nurse gave her the patch at night to put on her back. (Photographic evidence obtained) During an interview on 1/16/24 at 10:48 a.m., the Unit Manager (UM) stated no residents were allowed to self-administer medications. The UM stated on 1/16/24 there was one resident in the facility allowed to self-administer antacid tablets. During an interview on 1/17/24 at 1:15 p.m., the Director of Nursing (DON) stated only one resident was allowed to self-administer medications and Resident #40 was not the resident. During an interview on 1/17/24 at 2:28 p.m., Staff A, Registered Nurse (RN) stated Resident #40 was not able to self-administer medications. During an interview on 1/17/24 at 2:50 p.m., the Director of Nursing observed the photo taken of Resident #40's Lidoderm patch lying on the dresser and confirmed the patch had not been applied (due to the shape of the patch). Review of Resident #40's physician orders showed an order for Lidoderm Patch to Ribs 5% - Once daily apply to lower back. On (at) 8:00 p.m. and Off (at) 8:00 a.m. for lower back pain topical, ordered on 12/31/21. Review of Resident #40's Medication (Administration) Record dated January 2024 showed a Lidoderm patch had been applied to the resident's back as scheduled at 8:00 p.m. on 1/15/24 and had as scheduled at 8:00 a.m. been removed from the residents ribs on 1/16/24. Review of Resident #40's Minimum Data Set (MDS) showed a Brief Interview of Mental Status (BIMS) score of 12 out of 15, indicating moderate cognitive impairment. A request was made of the facility to provide Resident #40's Self-Administration (of medication) Assessment, which was not received. Review of the care plan for Resident #40 did not identify a focus related to self administration of the pain patch by Resident #40. The policy - Self-Administration of Medication Program, reviewed on 11/22/23, revealed it is the policy of the facility to allow the resident and or legal representative of the resident the right to self-administer medication when it has been deemed by the interdisciplinary team that it is clinically appropriate. A continued review of the policy showed: - 4. If a resident requests to self-administer drugs, it is the responsibility of the Interdisciplinary team (IDT) to determine that it is safe for the resident to self-administer drugs, before the resident may exercise that right. - 5n. The resident's ability to ensure that medication is stored safely and securely. - 6. Once the resident has been deemed safe by the IDT an order will be obtained from the resident's physician or physician or physician extender listing the medication(s) that may be self-administered, where the medications will be stored, who will be responsible for documentation and the location of administration. - 10. The decision that a resident has the ability to self-administer medication(s) is subject to periodic re-evaluation based on change in the resident's status. - 11. The resident will be re-evaluated on their ability to continue to self-administer medications in conjunction with the resident assessment instrument.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of the admission Record showed Resident #41 was admitted on [DATE] and readmitted on [DATE] with a diagnosis of Major Depressive Disorder, and other co-morbidities. Review of Resident #41's PASRR Level I Assessment, dated 07/25/2022 did not reveal a qualifying mental health diagnosis marked in section I A. Resident #41 was readmitted on [DATE] with a new diagnosis of Major Depressive Disorder. 5. Review of the admission Record showed Resident #207 was admitted on [DATE] with diagnoses of psychotic disorder, Alzheimer's Disease, Dementia with behavioral disturbance, mood disorder, and other co-morbidities. Review of Resident #207's PASRR Level I Assessment, dated 01/02/2024 did not reveal a qualifying mental health diagnosis marked in section I A. and had a primary diagnosis of dementia. Section II, (7) was marked yes for having validating documentation to support the dementia or related neurocognitive disorder (including Alzheimer's disease). During an interview on 01/17/24 at 01:59 PM, the Social Service Director (SSD) confirmed: Resident #3's PASRR does not reflect the diagnosis for MDD. The SSD confirmed the PASRR should have be corrected and submitted for a Level II screening. Resident #13's PASRR, completed on 11/22/18 did not show the resident had a MI, suspected MI, or the related Intellectual Disability (ID) related condition of Cerebral Palsy. The SSD confirmed the PASRR should have be corrected and submitted for a Level II screening. Resident #40's PASRR dated 12/07/21 did not show the resident had a MI, suspected MI, or ID and did not require a Level II PASRR evaluation. The SSD confirmed the diagnoses should be on the PASRR. This PASRR needs to be accurately completed and submitted for a Level II screening. Resident #41 was readmitted on [DATE]. A new PASRR was not completed. The SSD confirmed that a new PASRR would need to be completed to include the new diagnosis of Major Depressive Disorder and resubmitted for a Level II screening. The SSD confirmed Resident #207's PASRR is incorrect and needs to be redone and submitted for a Level II screening. Review of the facilities policy and procedures titled Coordination - Pre-admission Screening and Resident Review (PASRR) program, with a last review date of 11/22/2023 showed: Intent: it is the policy of the facility to assure that all residents admitted to the facility receive a PASRR, in accordance with the State and Federal regulations. Procedures: . 2. b. Referring all Level II residents and all residents with newly evident or possible serious mental disorders, intellectual disabilities, or related condition for Level II resident review upon a significant change in status assessment. 5. A nursing facility must notify the state mental health authority or state intellectual disability authority, as applicable, promptly after a significant change in mental or physical condition of a resident who has mental illness or intellectual disability for resident review. Based on record reviews, and interviews, the facility failed to confirm the accuracy of the Pre-admission Screening and Resident Review (PASRR) and to correct the document for five (#3, #13, #40, #41, and #207) out of twenty-one residents sampled. Findings included: 1. Review of Resident #3's admission Record revealed the resident was admitted on [DATE]. The record included the resident diagnosis of unspecified single episode of major depressive disorder with onset dates of 1/19/20, 5/18/20, 6/19/20, 10/16/20, and 10/10/22, and unspecified anxiety disorder with an onset date of 1/19/20. Review of Resident #3's PASRR, dated 5/18/20, did not reveal the resident had a Mental Illness (MI), a suspected MI, or an Intellectual Disability (ID). The PASRR showed the resident did not require a Level II PASRR screening. 2. Review of Resident #13's admission Record revealed the resident was admitted on [DATE]. The record revealed the resident's primary diagnosis on 12/5/18 was unspecified Cerebral Palsy and included the diagnoses of unspecified single episode major depressive disorder and unspecified anxiety disorder dated 11/27/18. The record revealed the diagnosis of Cerebral Palsy was recognized on 11/6/20 and 1/9/21 and the diagnoses of major depressive and anxiety disorders were documented on 11/27/18, 11/6/20, and 1/9/21. A review of Resident #13's PASRR, completed on 11/22/18 did not show the resident had a MI, suspected MI, or the related Intellectual Disability (ID) related condition of Cerebral Palsy. The resident's PASRR showed the resident did not require a Level II PASRR evaluation. 3. Review of Resident #40's admission Record revealed the resident was admitted on [DATE]. The record included diagnosis of moderate recurrent major depressive disorder with an onset date of 12/7/21. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] showed Resident #40 had a diagnosis of non-Alzheimer's dementia. A review of Resident #40's PASRR completed at an acute care facility on 12/7/21 showed the resident did not have a MI, suspected MI, or ID and did not require a Level II PASRR evaluation.

Based on observations, record reviews, and interviews, the facility failed to assess and obtain physician orders for the two wounds for one (#40) out of four resident sampled for skin conditions. Findings included: An observation was made on 1/16/24 at 10:35 a.m., of an undated large brown-colored adhesive bandage, applied to Resident #40's left wrist and a white 3x3 centimeter (cm) bordered dressing dated 1/15 on the outer aspect of the resident's right leg. During the observation on 1/16/24 at 10:35 a.m. Resident #40 stated (regarding left wrist) it happened a week ago, scraped it, and skin was hanging. The Resident stated the Band-Aid was changed over the weekend. An observation and interview was conducted on 1/17/24 at 2:24 p.m. with Resident #40. A white bordered dressing dated 1/15/24 continued to be observed on the resident's right lower leg. The resident reported rubbing the leg against the over bed table (pointing at it) last week. A large brown-colored undated adhesive dressing had been applied to the resident's left wrist. The resident reported tripping into the dresser and the nurse had applied the adhesive dressing this weekend. An interview and observation was conducted on 1/17/24 at 2:28 p.m. with Staff A, Registered Nurse (RN). The staff member stated Resident #40 did not have any skin conditions. The staff member stated if there was a dressing on the resident's lower leg it had not been applied by him. Staff A observed the white dressing on Resident #40's right lower extremity (RLE), confirming it was dated 1/15/24 and the adhesive dressing on right wrist. The resident reported to the staff member of scrapping it (leg) on the over bed table. Immediately following the observation, Staff A reviewed the electronic record of the resident and confirmed there was no report or treatment order for either injury. On 1/17/24 at 5:05 p.m., during an interview, the Infection Preventionist (IP) reported observing the skin tears of Resident #40 and both areas were old. The IP reported both areas should have had orders for treatments. A review of the facility report log dated 11/11/23 to 1/16/24 did not reveal Resident #40 had suffered any injury. Review of Resident #40's physician orders included an order for Weekly skin assessment to be completed in [electronic record] on Sunday 3-11 shift every week, to start on 6/8/23. A review on 1/17/24 at 1:45 p.m., revealed the last Interdisciplinary (ID) nursing note written on 9/5/23 was regarding the request by the Resident #40's Power of Attorney to discontinue the fentanyl patch. The ID notes did not include any information regarding the left wrist or right leg injury suffered by the resident. Review of Resident #40's January 2024 Treatment Administration Record (TAR) revealed no wound care orders until 1/17/24 and wound care had not been provided to the resident's right lower extremity or left wrist. A review of the Skin Evaluations revealed a skin assessment had last been completed on 12/24/23 on Resident #40. The facility did not provide any further weekly skin evaluations for 12/31/23, 1/7/24, and 1/14/24. On 1/17/24 at 2:50 p.m., during an interview, the Director of Nursing stated if it (an incident) happens during the day, wound care can see it, if not staff are to notify the physician and obtain any order for treatment. She stated if is a skin tear or pressure injury an incident report is required. The DON stated usually there was a nursing note generated in the incident report. She reviewed and confirmed there were no treatment orders for either skin injury. A policy titled - Charting and Documentation, undated, revealed All services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. The policy showed: - All observations, medications administered, services performed, etcera (etc), must be documented in the resident's clinical record. - All incidents, accidents, or changes in the resident's condition must be recorded. A policy titled - Wound Prevention, reviewed 11/23/21, revealed the purpose was to assist the facility in the care, services, and documentation related to the occurrence, treatment, and prevention of pressure as well as, non-pressure related wounds. The process showed Weekly skin checks will be conducted by the license nurse. This will be documented in the resident's Electronic Medical Record (EMR). The policy titled - Change in Condition Process, reviewed 11/23/21, The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notify, consistent with his or her authority, resident's representative when there is a change requiring notification.

Based on record reviews and interviews, the facility failed to ensure treatment was provided timely for one resident (Resident #39) out of the sampled two residents related to a Urinary Tract Infection (UTI) and Methicillin-Resistant Staphylococcus Aureus (MRSA). Findings included: A review of the Profile Face Sheet revealed Resident #39's diagnoses included but was not limited to benign prostatic hyperplasia without lower urinary tract. A review of the Physician's Orders for 02/10/22 revealed the following order: Urinalysis Culture and Sensitivity (UA C&S) with a start date of 02/02/22. A review of the lab results, dated 02/05/22, revealed a collection date and an order date of 2/02/22. The urine culture revealed Resident #39 had Methicillin-Resistant Staphylococcus Aureus (MRSA). The urinalysis showed the blood, protein, nitrite, and leukocytes were abnormal. The microscopic urinalysis showed the white blood cells, red blood cells, and bacteria were abnormal. The Interdisciplinary Notes dated 02/07/22 revealed the Physician Assistant saw the resident and a new order was received for Linezolid for UTI. A review of the Physician's Orders for 02/11/22 revealed the following order: Linezolid 600 mg (milligram) tablet by mouth every 12 hours for UTI (urinary tract infection) for 7 days with a start date of 02/08/22 and a stop date of 02/15/22. There was no physician order related to isolation. The Medication Record for 02/2022 reflected the Linezolid was administered as ordered starting on 02/08/22. The care plan related to infections revealed a category for UTI initiated on 02/07/22. The approaches included but were not limited to apply infection control precautions and procedures as needed. Several observations on 02/08/22 and 02/09/22 revealed a caddy with personal protective equipment (PPE) was not on or outside of Resident #39's room door. There was no signage that indicated staff had to wear PPE when providing care. On 02/10/22 at 12:59 p.m., Staff C, Licensed Practical Nurse (LPN), reported the caddy in the resident's room was put on the bathroom door today because he had MRSA in the urine and a UTI. Anyone that touches the resident and helps with activities of daily living (ADL) care must use personal protective equipment (PPE) reported Staff C, LPN. She reported staff knew they had to wear PPE because of the yellow caddy hanging on the bathroom door. On 02/11/22 at 10:50 a.m., the Infection Control Preventionist (ICP) reported she had not done any tracking for Resident #39 yet. They had a physician notebook the nurses use to write any symptoms or problems the residents are having. The ICP reported she looks through the book daily and looks at new orders every morning. She gets with the physician if the resident was symptomatic to order a UA and she was responsible for checking the results of the labs. She reported the turnaround time was not good for receiving UA results and it could take anywhere from 2-4 days. The UA for Resident #39 was ordered on 02/02. The results were received 02/05/22 per the labs, but she could not promise 02/05 was the date the facility received the results. After further review of Resident #39's electronic medical record, the Infection Preventionist stated they received the results on 02/07 at 11:21 in the a.m. She stated the doctor was called, and he said to put it in the book for tomorrow and the next morning he would write the orders. She confirmed they could call the labs for results. She confirmed the antibiotics for Resident #39 were started on the 8th. She stated a week was too long for waiting for lab results. The ICP reported she had not done a document or tracing on the infection. She tries to complete the infection report on Mondays. She agreed one week was a long time to wait before a resident gets treatment. She confirmed the nurses were allowed to initiate contact precautions. She confirmed there was no order for precautions. The ICP reported the nurses would put the order in and get the Certified Nursing Assistants (CNAs) to hang the caddy on the door. She reported nurses have the ability to initiate orders for isolation, but they have to notify her. The policy provided by the facility titled, Diagnostic Services, dated 10/22/20 revealed the following: Intent: It is the policy of this facility to ensure that laboratory, radiology, and other diagnostic services meet the needs of residents, that results are reported promptly to the ordering provider to address potential concerns and for disease prevention, provide for resident assessment, diagnosis, and treatment, and that the facility has established policies and procedures, and is responsible for the quality and timeliness of services whether services are provided by the facility or an outside resource. Procedure: 1. The facility will provide or obtain laboratory services to meet the needs of its residents and will be responsible for the quality and timeliness of the services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews the facility failed to ensure as needed (PRN) orders for psychotropic drugs were limited to 14 days for one (Resident #33) of seven residents investigated for unnecessary medications. Findings included: On 2/08/22 at 12:18 p.m. Resident #33 was observed lying in his bed fully dressed. A personal caregiver was present in the room. The resident appeared clean, dry and had no odors. The resident was unable to answer questions about his care and he appeared calm and cooperative. A review of the medical record revealed Resident #33 was admitted to the facility on [DATE] with diagnoses including: cognitive impairment, dementia, anxiety disorder, and mood disorder. A review of the Physician's Order set, dated 2/11/22, revealed an active order for Ativan 0.25 milligrams (mg) one by mouth every 6 hours as needed for anxiety started 11/2/21 with no stop date (last dose 12/8/21). A review of the comprehensive care plan for Resident #33 revealed the following focus area: Psychotropic drugs: [Resident #33] is on psychotropics due to depression, anxiety, and insomnia (start date 10/15/21). Goal: Will be free of depressive/anxious//insomnia behaviors and adverse effects of medication through the review date (goal date 5/9/22). Interventions included: Monitor and document all behaviors related to depression/anxiety/hypnotic such as episodes of tearfulness, withdrawal from friends/family. Monitor and document side effects of antidepressant, hypnotic, and antianxiety medications. Monitor for lowest possible dose. A review of the Medication Records from 12/2021 through 2/10/2022 revealed no documented behaviors for anxiety and only one dose of Ativan given on 12/8/2021. A review of the Medication Regimen Reviews (MRR) conducted by the Consulting Pharmacist (CP) indicated on 10/23/2021 a recommendation was sent to the physician to evaluate the resident for the appropriateness of Ativan 0.25 mg every 6 hours as needed. There was no response documented on the recommendation from the provider. On 2/11/22 at 11:10 a.m. an interview was conducted with the Director of Nursing (DON). The DON stated the policy is not to have PRN medications for more than 14 days for psychotropic medications. She stated they review all residents on these medications monthly in their psychiatric meetings. She stated the CP and nursing, all review residents for any gradual dose reductions to identify changes that need to be made. On 2/11/22 at 11:13 a.m. a telephone interview was conducted with the Consulting Pharmacist. She stated she had sent a recommendation on October 23rd, after her MRR for Resident #33 to address the PRN status of the Ativan. She stated she did not see that a change on the medication had been made. She stated she did prepare notes for the January meeting related to Resident #33. She stated another member of the pharmacy attended the meeting, so she was not aware of the outcome. She stated PRN psychotropics are something she would let the provider know about and the medications should not be continued without further explanations. She stated she would recommend if needed the medication be changed to a routine medication. A review of the policy titled, Pharmacy Services-Drug Regimen Free From Unnecessary Drugs, updated on 10/22/20, indicated the following: Intent: the intent of this policy is each resident's entire drug/medication regiment is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial wellbeing; the facility implements gradual dose reductions and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medications; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. 1 Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used: a. In excessive dose b. For excessive duration c. Without adequate monitoring d. Without adequate indications for its use e. In the presence of adverse consequences which indicate the dose should be reduced or discontinued f. Any combinations of the reasons stated 2 A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: a. Anti-psychotic b. Anti-depressant c. Anti-anxiety d. Hypnotic 3. Based on a comprehensive assessment of a resident, the facility will ensure that: c. Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. d. PRN orders for psychotropic drugs are limited to 14 days. Except, if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure isolation precautions were initiated in a timely manner for one resident (Resident #39) and failed to ensure appropriate hand hygiene was performed during wound care for one resident (Resident #4) out of the sampled three residents. Findings included: 1. A review of the Profile Face Sheet revealed Resident #39's diagnoses included but was not limited to benign prostatic hyperplasia without lower urinary tract. A review of the Physician's Orders for [DATE] revealed the following order: Urinalysis Culture and Sensitivity (UA C&S) with a start date of [DATE]. A review of the lab results, dated [DATE], revealed a collection date and an order date of [DATE]. The urine culture revealed Resident #39 had Methicillin-Resistant Staphylococcus Aureus (MRSA). The urinalysis showed the blood, protein, nitrite, and leukocytes were abnormal. The microscopic urinalysis showed the white blood cells, red blood cells, and bacteria were abnormal. A review of the Physician's Orders for [DATE] revealed the following order: Linezolid 600 mg (milligram) tablet by mouth every 12 hours for UTI (urinary tract infection) for 7 days with a start date of [DATE] and a stop date of [DATE]. There was no physician order related to isolation. The Medication Record for 02/2022 reflected the Linezolid was administered as ordered starting on [DATE]. The care plan related to infections revealed a category for UTI initiated on [DATE]. The approaches included but were not limited to apply infection control precautions and procedures as needed. Several observations on [DATE] and [DATE] revealed a caddy with personal protective equipment (PPE) was not on or outside of Resident #39's room door. There was no signage that indicated staff had to wear PPE when providing care. On [DATE] at 12:59 p.m., Staff C, Licensed Practical Nurse (LPN), reported the caddy in the resident's room was put on the bathroom door today because he had MRSA in the urine and a UTI. Anyone that touches the resident and helps with activities of daily living (ADL) care must use personal protective equipment (PPE) reported Staff C, LPN. She reported staff knew they had to wear PPE because of the yellow caddy hanging on the bathroom door. On [DATE] at 10:50 a.m., the Infection Control Preventionist (ICP) reported she had not done any tracking for Resident #39 yet. The UA for Resident #39 was ordered on 02/02. The results were received [DATE] per the labs, but she could not promise 02/05 was the date the facility received the results. After further review of Resident #39's electronic medical record, the ICP stated they received the results on 02/07 at 11:21 in the a.m. She confirmed the antibiotics were started on the 8th. The ICP reported she had not done a document or tracing on the infection. She tries to complete the infection report on Mondays. She confirmed the nurses were allowed to initiate contact precautions. She confirmed there was no order for precautions. The ICPreported she did not know when the caddy was put on the door. Normally the nurses would put the order in and get the Certified Nursing Assistants (CNAs) to hang the caddy on the door. She reported nurses have the ability to initiate orders for isolation, but they have to notify her. On [DATE] at 11:30 a.m., a policy related to isolation for MRSA was requested and not provided. A review of the Centers for Disease Control and Prevention document titled, Methicillin-Resistant Staphylococcus Aureus (MRSA) General Information Patient found at https://www.cdc.gov/mrsa/community/patients.html revealed: To prevent MRSA infections, healthcare personnel: Clean their hands with soap and water or an alcohol-based hand sanitizer before and after caring for every patient. Carefully clean hospital rooms and medical equipment. Use Contact Precautions when caring for patients with MRSA (colonized, or carrying, and infected). Contact Precautions mean: o Whenever possible, patients with MRSA will have a single room or will share a room only with someone else who also has MRSA. o Healthcare providers will put on gloves and wear a gown over their clothing while taking care of patients with MRSA. 2. A review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses of intracardiac thrombosis, diabetes mellitus, Parkinson's Disease, and peripheral vascular disease. The Physician's Order set dated [DATE] indicated an active order for wound care, with a start date of [DATE], as: cleanse wound on sacrum with normal saline, pat dry, apply Hydrofera Blue to wound bed, cover with Allevyn dressing daily. A review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed, under Section M--Skin Conditions, Resident #4 had a Stage 4 pressure ulcer, not present on admission. A review of the Comprehensive Care Plan for Resident #4 indicated the following focus area started on [DATE]: Pressure Ulcers: [Resident #4] has potential for impaired skin integrity, at risk due to weakness, dementia, Parkinson's. Goal: Will prevent resident from developing a pressure ulcer unless resident's clinical condition demonstrates that they were unavoidable. Skin will be kept as clean and dry as possible on a daily basis. Interventions included: obtain physician order for treatment and use of pressure relieving devices as indicated; treatment as ordered, cleansing, application of medications, packing and/or dressings change with wound status and progress. A review of the wound care notes revealed the following measurements: Stage 4 Coccyx date opened [DATE], [DATE]--2.7 x 0.5 x 0.4, [DATE]--3.0 x 0.6 x 0.4, [DATE]--4.0 x 0.9 x 0.2, [DATE]--7.5 x 4.0 x 0.2. On [DATE] at 10:49 a.m. Resident #4 was observed lying in his bed. The resident was friendly and appeared confused. Staff A, Registered Nurse (RN), Unit Manager and Staff B, Certified Nursing Assistant (CNA), were preparing to do wound care for the resident. The resident had been previously medicated and had been informed about the procedure. Resident #4 was confused and making jokes during the procedure. The nurse stated the resident has had the wound for a while and the wound care physician comes once a week to assess and measure the wound. The nurse stated the physician does all the measurements and provides any changes in orders as needed. Staff A, RN cleaned the overbed table with bleach wipes and let the table dry over two minutes. A drape was placed on the table. Both staff members cleaned their hands and put on gloves. Supplies for the procedure were placed on the table by the RN. The resident was prepared for the procedure by the CNA. The RN stated the dressing was already removed during care by a CNA due to soilage. The RN proceeded to examine the wound with her gloved hands and expose the area to be cleansed. The nurse removed her gloves, cleansed her hands, and put on a new pair of gloves. Staff A, RN then cleaned the wound with normal saline and four by four sponges from inside of the wound to the outside of the wound using five wiping motions. No hand hygiene or change of gloves was noted after the dirty wound was cleaned. The nurse then applied skin prep to the peri wound area. The nurse then applied the Hydrofera Blue to the inside of the wound. The nurse then applied the Allevyn dressing over the wound and secured it to the skin. The nurse then assisted to reposition the resident and replace the brief. No hand hygiene or change of gloves was noted prior to repositioning the resident after the procedure. The nurse removed her gloves, washed her hands, and placed a new pair of gloves on. The nurse then disposed of the garbage and cleaned the scissors and the table tray with bleach wipes. The nurse then removed her gloves, washed her hands, and left the room. An interview was conducted with Staff A, RN immediately after the wound care observation. The nurse confirmed she had not changed her gloves and washed her hands in between the cleaning of the wound and the application of the new dressing. The nurse stated she should have done so. A review of the policy titled, Clean Dressing Change, date last reviewed: [DATE] revealed the following: Intent: It is the policy of the facility to ensure change dressings in accordance with State and Federal Regulations, and national guidelines. Procedure: 11. Put on clean gloves 12. Remove dressings and place in the resident' trash can 13. Remove gloves and perform hand hygiene 14. Put on clean gloves 15. Cleanse wound with gauze and prescribed cleaning solution using single outward stokes. Use separate gauze for each cleansings wipe 16. Use dry gauze to pat the wound dry. 17. Remove gloves and perform hand hygiene 18. Put on clean gloves 19. Apply clean dressing as ordered and ensure the dressing is dated. 20. Remove gloves and perform hand hygiene 21. Reposition the resident and ensure the call light is in place. 22. Discard all disposable items into the appropriate receptacle 23. Clean the bedside stand/table with germicidal disposable cloth 24. Remove trash from resident' room 25. Wash and dry hands thoroughly 26. Document the completion of dressing change on the treatment record. On [DATE] at 10:38 a.m. an interview was conducted with the Director of Nursing (DON). She stated the nurse needed to wash her hands and change her gloves after cleaning the dirty wound and before placing the dressings. On [DATE] at 10:51 a.m. an interview was conducted with the Infection Control Preventionist. She stated she was informed about the error that occurred during wound care and confirmed hand hygiene and glove change should be performed after cleaning the dirty wound and before the nurse placed the clean dressings.

Based on interviews and record reviews, the facility failed to conduct ongoing COVID-19 outbreak testing in accordance with testing frequency parameters for one staff member (D) of three sampled staff members for COVID-19 testing. Findings included: An interview was conducted on 02/11/2022 at 11:24 a.m. with the facility's Infection Control Preventionist (ICP) and Nursing Home Administrator (NHA). The ICP confirmed the facility was in outbreak status that started on 12/11/21 and the last positive result for a resident was on 2/1/22 and for a staff member was 2/3/22. The ICP stated all staff in the facility were tested on ce weekly, and the NHA stated testing frequency was based off of the current guidelines. A request was made on 02/11/2022 at 12:02 p.m. for review of Staff D, Dietary's previous three COVID-19 testing results from the NHA. A review of Staff D, Dietary's COVID-19 testing results, dated 01/14/2022, revealed Staff D, Dietary tested negative for COVID-19. No other COVID-19 test results for Staff D, Dietary were provided by the NHA. An interview was conducted on 02/11/2022 at 12:21 p.m. with the NHA. The NHA stated Staff D, Dietary was recently hired on 01/07/2022 and addressed there was only one COVID-19 test result available. The NHA also stated he would check to see when the last time Staff D, Dietary worked and would follow up to see if any other results were available. A follow up interview was conducted on 02/11/2022 at 1:01 p.m. with the NHA. The NHA stated Staff D, Dietary last worked in the facility on 02/10/2022 and no other COVID-19 testing results were able to be found for Staff D, Dietary. A review of the facility policy titled, Testing Policy for COVID-19, last revised 05/21/2021, revealed under the section titled Staff Testing that staff members of the facility will be tested according to regulatory guidance. If a staff member is unable or unwilling to be tested, the individual will be removed from the schedule until test results can be provided.

Based on observations, record review, and interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen. Findings included: On 02/08/22 starting at 10:00 a.m., an initial tour of the kitchen was conducted with the Director of Dining and the chef. Rust was observed on the ceiling tiles in the dishwashing area. The Director of Dining stated they were in the process of remodeling, and it should take place within the next six months. There were two male staff members running dishes through the dish machine. One of the male staff members had an excessive amount of facial hair sticking out from around his surgical mask. He was not wearing a beard guard. Three gallons of expired milk dated 01/28, 02/02, and 02/05 was observed in walk in cooler number one. The following was observed in walked in cooler number two: *a case of raw thawed ground pork stored on the shelf above a case of fully cooked meatballs; *a case of raw thawed tenderloin stored on the shelf above a case of fully cooked meatballs; and *black buildup was observed on the ceiling and on the fan in the back of the walk-in cooler. A staff member was observed touching the trash can lid with her hand to throw trash away and then put the oven mitt on her hand with no hand hygiene until the Director of Dining interfered. On 02/10/22 starting at 10:37 a.m., a follow up tour of the kitchen was conducted. A personal phone was observed on the food prep table. The Director of Dining removed the phone after the surveyor asked who did the phone belong to. On 02/10/22 at 10:45 a.m., the Director of Dining confirmed the male staff member should have been wearing a beard guard. He stated the truck came on the day the expired milk was observed in the walk-in cooler and the person responsible for ensuring there were no expired foods in the walk-in cooler did not get to pull it out. He stated they receive deliveries almost daily. The Director of Dining stated the food code indicated that raw foods could be stored over ready to eat foods and they use the food code for their policy. He reported that maintenance replaced the rusty tiles and cleaned the fan in the walk-in cooler yesterday and maintenance would have to use a sand blaster to clean the ceiling. On 02/10/22 at 12:40 p.m., the Director of Dining stated they use the food code for all their policies. An online form had to be submitted for maintenance requests to submit work orders, but maintenance comes around 30-45 days to check for maintenance issues. Hand hygiene should be performed anytime you go from dirty to clean or changing tasks. They have hand washing signs posted throughout the facility. No personal items can be in the food preparation area.

Based on observations, interviews and record reviews the facility failed to ensure resident rights to privacy were maintained for 1 (#5) resident out of 2 residents observed for wound care related to failure to close the room door or privacy curtain while performing wound care to the resident's coccyx area. Findings included: Review of Resident #5's medical record showed that he was admitted most recently on 8/31/2020 with diagnoses that included Parkinson's Disease. A wound care observation was conducted on 12/03/2020 at approximately 2:00 p.m. The resident's roommate, Resident #900 was in the room sitting on the side of his bed facing Resident #5. Resident #900 said, Wound care again. I should not have to watch this. I am getting out of here. Resident #900 transferred himself to his wheelchair and left the room. Staff D, Registered Nurse (RN) assembled the wound care supplies on top of barrier on a clean bed side table. Staff D and Staff E, Licensed Practical Nurse (LPN), both washed their hands and donned new gloves. Staff E, LPN using the controls located on the foot of the bed raised the resident's bed then assisted the resident onto his right side. Neither Staff D nor Staff E closed the room door or pulled the privacy curtain before starting the dressing change. Staff E changed the dressing to the resident's coccyx area and then with his gloves on assisted the resident back on to his back and pulled the sheet over the resident. Staff I, Certified Nurse's Aide (CAN) entered Resident #5's room with Resident #900 rolling himself to his side of the room. Staff I said, Why did you guys not shut his door or at least pull the privacy curtain? Staff D, RN then picked up the used supplies/wrappers from the bedside table and put them in the trash can. Staff D and Staff E both removed their gloves and washed their hands. Staff D then pulled the trash bag out of the trash can and walked out of the resident's room. Upon completion of the would care Staff D confirmed she should have closed the resident's door and pulled the privacy curtain before starting his wound care. A request for the facility policy for dignity was made to the Assistant Director of Nursing (ADON). A copy of the [NAME] of Rights for residents of nursing homes from their admission pack was provided. A review of the [NAME] of Rights for residents of nursing homes revealed: You, as a long-term care resident, have the right to: Be treated courteously, fairly, and with the fullest measure of dignity right to privacy in receiving treatment and in caring for personal needs . An interview was conducted on 12/04/2020 at 4:11 p.m., the ADON said, It is my expectation that during resident care that the door and privacy curtain if needed are closed to provide privacy for the residents.

Based on observations, interviews and record reviews, the facility failed to perform pressure ulcer care in a manner to promote healing and prevent infection related to not performing dressing changes according to standards of practice and to provide pressure relieving devices for 2 (#5, #20) residents out of 2 sampled for wound care. Findings included: 1.An observation was conducted on 12/01/2020 at approximately 10:48 a.m., Resident #5 was in his room, eyes closed, in bed with a hospital gown on. The resident was positioned on his back. An observation was conducted on 12/03/2020 at approximately 10:18 a.m., Resident #5 was in his room in bed positioned on his back. Review of Resident #5's medical record showed that he was admitted most recently on 8/31/2020 with diagnoses that included Parkinson's Disease. Review of the Wound Care physician's visit report note dated 11/23/2020 showed the following: Focused Wound Exam Site 1: Stage 3 Pressure Wound with a duration of greater than 69 days. Wound size. 2.6 x 1.6 x 0.3 cm; Surface area 4.16 cm; Exudate: Moderate Serosanguineous; Slough 5%; Granulation tissue: This wound is in an inflammatory stage and is unable to progress to a healing phase because of the presence of a biofilm. Dressing Treatment Plan: Primary Dressing (s)Collagen sheet with silver apply once daily for 23 days; Alginate calcium apply once daily for 23 days. Secondary dressing (s) foam silicone border and faced apply once daily for 16 days . Plan of Care reviewed and addressed: Recommendations: Off-loaf wound; Reposition per facility protocol; Low air loss mattress; Multivitamin once daily PO (by mouth); Vitamin C 500 mg twice daily PO. An interview was conducted on 12/03/2020 at 8:45 a.m., the Physician Assistant (PA) stated, If the physician ordered an air mattress then the facility needs to put one on. I am not familiar with Resident #20. You will need to check with her physician. The resident's current physician orders for wound care with an order date of 11/18/2020 and a start date of 11/19/2020 to cleanse the coccyx wound with sterile normal saline (SNS), pat dry, apply collagen sheet with Ag (alginate), calcium alginate, cover with (brand name) dressing once daily. A review of the physician orders and the treatment administration record (TAR) for 11/2020- to 12/02/2020 revealed there was not an order for an air mattress. An order dated 9/01/2020 with out a stop date documented, Restorative nursing to perform bilateral upper extremity active range of motion 2 x 10 reps at all joints and bed mobility with care giver assistance daily 6 x a week. A review of the care plan for Resident #5 documented under Category 16: Resident #20 has the potential for impaired skin integrity, at risk due to thin fragile skin with a Start Date of 11/21/2020. Resident has a pressure ulcer present coccyx: With a goal that the pressure ulcer will reduce to a smaller size within 90 days. Interventions included: Treatment as ordered, pressure relieving device in wheelchair cushion and pressure reducing mattress air, and alternating air mattress and to monitor site for infection-redness, swelling, drainage, foul smell, decline in function, reduced mobility. Report signs and symptoms of infection to the physician, all with a start date of 11/21/2020. A wound care observation was conducted on 12/03/2020 at approximately 2:00 p.m. Staff D, Registered Nurse (RN) assembled the wound care supplies on top of barrier on a clean bed side table. Staff D and Staff E, Licensed Practical Nurse (LPN), both washed their hands and donned new gloves. Staff E, LPN using the controls located on the foot of the bed raised the resident bed then assisted the resident onto his right side. Staff D, RN picked up the residents catheter and un-hooked it from the side of the bed and put it up on the bed. Staff E said, No this is not an air mattress. Staff D, RN removed the soiled dressing, placed it in a clear bag, removed her gloves, washed her hands, applied new gloves, cleaned the wound four times with SNS solution and a gauze 4x4 cleaning from the outside of the wound, wiping through the wound and up near the gluteal fold and did not change gloves after they were contaminated during the cleaning of the wound. Staff D after completion of the cleaning of the wound, removed her gloves, washed her hands, donned clean gloves, applied the prescribed calcium alginate and covered the wound with a foam bordered dressing. Staff E with his gloves on assisted the resident back on his back and pulled the sheet over the resident. Staff D, RN then picked up the unused supplies/wrappers from the bedside table and put them in the trash. Staff D and Staff E both removed their gloves and washed their hands. Staff D walked out of the resident room and said, I will have to call the physician to get an order for an air mattress. At approximately 2:30 p.m., on 12/03/2020 Staff D, RN was informed of the breaks in infection control that were observed during wound care. Staff D, RN said I understand what you are saying. You clean the wound from the inside out. I should have changed my gloves more often. At approximately 2:40 p.m., on 12/03/2020 the Assistant Director of Nursing (ADON) was informed of the breaks in infection control observed during wound care. She said that the nurses had been trained to do wound care. An interview was conducted on 12/042020 at 9:20 a.m., Staff G, RN said, The beds we purchased have built in mattresses that can be turned into an air mattress, but a tube needs to be connected to it. No, the buttons on the foot of the bed only control the movement of the bed. Something needs to be attached to the bed to make it an air mattress. An interview was conducted on 12/04/2020 at 3:18 p.m., the ADON said, We put an air mattress on Resident #5's bed last night. I am not sure why there was not one on his bed. There was an order and he was care planned for one. At 17:07 p.m., on 12/04/2020 a copy of the physician orders for Resident #5 was provided by the Nursing Home Administrator (NHA) that revealed an order with a Start Date of 12/03/2020 for Air Mattress for pressure injury. 2. An observation was conducted on 12/03/2020 at 12:25 with Staff D, RN and Staff Resident #20 was in her room in bed lying on her back. The resident's caregiver was sitting at the bedside with a surgical mask on. The caregiver spoke up and said that the resident had just fallen asleep and asked that we come back later to change her dressing. The caregiver said, No she does not have an air mattress on her bed. An interview was conducted on 12/03/2020 at 12:28 p.m., Staff D, RN said, Resident #20's wound was like just a small opening. Then she returned form the hospital and now it is huge. It is on both sides of her coccyx. A review of the physician orders revealed an order dated 12/02/2020 for restorative nursing to perform bed mobility and transfers with CGA (care giver assistance) daily 6x/a week. A review of the care plan for Resident #20 documented under Category 16: Resident #20 has the potential for impaired skin integrity, at risk due to thin fragile skin with a Start Date of 12/01/2020. Resident has a pressure ulcer present coccyx: With a goal that the pressure ulcer will reduce to a smaller size within 90 days. Interventions included: Treatment as ordered, pressure relieving device in wheelchair cushion and pressure reducing mattress air, and alternating air mattress and to monitor site for infection-redness, swelling, drainage, foul smell, decline in function, reduced mobility. Report signs and symptoms of infection to the physician, All with a start date of 12/01/2020. A review of the current wound care orders for Resident #20 was conducted with Staff H, RN, who stated the order was for Santyl ointment 250 unit/gram topical ointment, Treatment Topical apply once daily to bilateral sacrum wound for open area. Cleanse area with Sterile normal saline (SNS), apply Santyl inside wound bed, apply gauze and cover with (brand name) for open area on sacrum. I do not see any wound measurements in the system yet. Maybe she has not been seen by wound care yet. A wound care observation was conducted on 12/04/2020 at 12:46 p.m., Staff H, RN cleaned the bedside table and assembled the wound care supplies and placed them on top of barrier on a clean bed side table. Observed on the foot of the resident's bed was an air mattress pump that was on and connected to the resident's mattress. A caregiver for the resident was sitting in a chair at the foot of the resident's bed. Staff H closed the door to the resident room and pulled the privacy curtain. Staff H, RN washed her hands and donned new gloves. Staff D rolled the resident onto her right side and removed the soiled dressing, placed it in a clear bag and removed her gloves. Staff H confirmed that the resident did not have an air mattress. The resident's coccyx area was red. Staff H removed her gloves and went into the resident bathroom to wash her hands. The caregiver said, I have wondered why she did not have an air mattress before since she has a wound. I guess they put it on her bed last night. Staff H then donned new gloves and cleaned the wound with sterile normal saline solution saturated 4x4 gauze. Staff H cleaned the wound 4 separate times, with clean gauze cleaning from the outside of the wound, wiping through the wound and up near the gluteal fold. Staff D, RN removed her gloves, washed her hands, donned clean gloves, applied the prescribed Santyl ointment and covered the wound with gauze and covered with (brand name). Staff H with her gloves still on positioned the resident back on her back and pulled the sheet up over the resident. Staff H removed her gloves, washed her hands. At approximately 1:10 p.m., on 12/04/2020 Staff H, RN was informed of the breaks in infection control that were observed during wound care. Staff H, RN said You're right, the wound should be cleaned from the inside out. Review of Resident #20's medical record showed that she was admitted most recently on 12/01/2020 with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD). An interview was conducted on 12/04/2020 at 3:18 p.m., the ADON said, We put an air mattress on Resident #20's bed last night. I am not sure why there was not one on her bed. There was an order and she is care planned for one. An interview was conducted on 12/04/2020 at 5:37 p.m., the Medical Director said, If the physician ordered the air mattress then the facility should have provided one. An air mattress, it would help off load the pressure of the wounds. On 12/03/2020 at 1:59 p.m., the ADON confirmed that neither Resident #5 nor Resident #20's controls located on the foot of the bed for the air mattresses were on. I checked with the IP who went in and checked each of the resident's beds and confirmed neither of them were on. (photographic evidence was obtained). Review of the facility's procedure for Clean Dressing Changes revised 10/30/2019 showed Steps in the Procedure: 2. Perform hand hygiene and assemble equipment and supplies needed for dressing change. 5. Put on gloves. Adjust bedside stand/table to waist level. Clean bedside stand/table with germicidal disposable cloth. Establish a clean field. 7. Remove gloves and perform hand hygiene. 8. Set up supplies on barrier. 9. Position the resident for comfort. 10. Perform hand hygiene. 11. Put on clean gloves. 12. Remove dressing and place in the resident's trash can. 13. Remove gloves and perform hand hygiene. 14. Put on clean gloves. 15. Cleanse wound with gauze and prescribed cleaning solution using single outward strokes. Use separate gauze for each cleaning wipe. 16. Use dry gauze to pat the wound dry. 17. Remove gloves and perform hand hygiene. 18. Put on clean gloves 19. Apply clean dressing as ordered and ensure the dressing is dated. 20. Remove gloves and perform hand hygiene. 21. Reposition the resident and ensure the call light is in place. 22. Discard all disposable items into the appropriate receptacle. 23. Clean the bedside stand/table with germicidal disposable cloth. 24. Remove trash can from resident's room. 25. Wash and dry hands thoroughly . A review of the facility policy and procedure titled Infection Control-Hand Hygiene with a reviewed date of 10/30/2020 revealed: #3. The Centers for Medicare and Medicaid service operations manual indicates that hand hygiene should be performed: a. When coming on duty; b. Before and after performing any invasive procedure (e.g., finger stick blood sampling); c. Before and after entering isolation precautions settings; . d. Before and after assisting a resident with meals; e. Before and after assisting a resident with personal care; f. Before and after handling peripheral vascular catheters and other invasive devices; . g. Before and after inserting indwelling catheter; h. Before and after changing a dressing i. Upon and after coming in contact with the resident's intact skin (e.g. when taking a pulse or blood pressure, and lifting a resident); j. Before and after assisting a resident with toileting; k. After blowing or wiping nose; l. After contact with resident's mucous membranes and body fluids or excretions; m. After handling soiled or used linens, dressing, bed pants, catheters , an urinals semi colons after handling soiled equipment or utensils; n. After removing gloves or aprons; o. After completing duty.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observations, record review and interview the facility failed to 1) ensure that oxygen was administered according to the physician orders for one (43) of 3 sampled residents and 2) failed to ensure respiratory equipment used for inhalation therapy was maintained in a clean and sanitary manner for 4 (12/01/2020, 12/02/2020, 12/03/2020, 12/04/2020) out of 4 days for 1 (#42) resident out of 3 residents with inhalation therapy observed. Findings included: 1. Observations on 12/1/20 at 11:01 AM of Resident #43's room revealed that the residents oxygen tubing was noted to be wrapped around the oxygen concentrator . Closer observations revealed that the oxygen tubing was unlabeled and un-bagged. Observations of the residents room on 12/1/20 at 1:28 PM revealed that the oxygen nasal [NAME] was attached to the oxygen concentrator with the excess oxygen tubing noted to be on the floor. It was noted that the oxygen tubing was unlabeled and un-bagged. Closer observation of the oxygen concentrator at this time revealed that the oxygen concentrator was set at 4 liters. Observation of resident #43 on 12/3/20 at 11:50 AM revealed that the resident was receiving oxygen from his oxygen concentrator which was observed to be set between 4.5 and 5. liters. Interview with the resident at this time revealed that he received continuous oxygen and that staff set up his concentrator. He reported that if he leaves his room then he uses the oxygen tank which staff also set up for him. At this time the excess oxygen tubing was noted to be lying on the floor. (Photographic evidence obtained) Review of the residence record revealed that the resident had a current physicians order for O2 at 3 LPM via NC Continuous every shift. Review of the residents care plan revealed that the interventions indicated the resident was to receive 2 liters of oxygen per minute. Observation of resident number #43 on 12/3/20 at 12:00 PM revealed that the resident was sitting in his room and he was receiving oxygen from his oxygen concentrator. Closer observations of the oxygen concentrator revealed that it was set between 4.5 and 5.0 liters per minute. Interview on 12/3/20 at 12:03 PM with the Assistant Director of Nursing (ADON) after reviewing the residents physician order revealed that the resident was to receive oxygen at 3 liters per minute. Interview on 12/3/20 at 12:05 PM with Staff A, RN revealed that the resident was to receive 3 liters of oxygen. Observations on 12/3/20 at 12:07 PM of the residents oxygen concentrator while in use by the resident with Staff A, RN and the ADON present in the room, the ADON inspected the oxygen concentrator and reported that the oxygen concentrator was running at almost 5 Liters She reported that it would be checked and changed to reflect the current physician orders. Interview on 12/3/20 at 12:10 PM with Staff A, RN revealed that the resident is on continues oxygen, and that she has worked with the resident for the past 2 days. She reported that the resident uses his oxygen tank when he is out of his room and that she checks the residents oxygen tank when he changes to it, but that she has not checked his concentrator. She stated that it is to be checked at least each shift. Interview on 12/3/20 at 12:11 PM with the ADON revealed that the expectation for the provision of oxygen is that the nurses are to follow physicians orders. Interview on 12/3/20 at 12:33 PM with the MDS Coordinator revealed that the care plan is based on physician orders and that the current care plan indicates 2 Liters. At this time the MDS Coordinator reviewed the resident's current physician orders and confirmed that the resident is currently on 3 Liters of oxygen and reported that she will update the residents care plan now to reflect his current order. 2. An observation was conducted on 12/01/2020 at 11:16 a.m., Resident #42 was in her room in bed. Observed the resident's nebulizer equipment for inhalation therapy stored in the top drawer of her night stand uncovered next to her brush and other personal items. (photographic evidence was obtained). The resident said, That is where the nurse's put it after they are done. An interview was conducted on 12/01/2020 at 2:48 p.m., The Infection Preventionist (IP) who said, Neb/pipes and respiratory equipment used for inhalation therapy, the nurses are supposed to clean them after use and put them in a plastic bag. The bags are supposed to be changed weekly. A review of the medical record for Resident #42 revealed a recent admission date of 11/21/2019 with a pertinent diagnosis of Chronic Obstructive Pulmonary Disease (COPD). The physician orders revealed a current order dated 10/19/2020 for Albuterol sulfate 0.63% mg/3 ml solution for nebulization vial inhalation as needed every 4 hours for shortness of breath. An observation was conducted on 12/02/2020 at approximately 11:30 a.m., Resident #42 was in her room up in her wheelchair. Observed the resident's nebulizer equipment for inhalation therapy stored in the top drawer of her night stand uncovered next to her brush and other personal items. (photographic evidence was obtained). An observation was conducted on 12/03/2020 at approximately 8:40 a.m., Resident #42 was in bed with her oxygen on. Observed the resident's nebulizer equipment for inhalation therapy stored in the top drawer of her night stand uncovered next to her brush and other personal items. (photographic evidence was obtained). An interview was conducted on 12/04/2020 at 8:33 a.m., with Staff H, Registered Nurse (RN) who said, After the resident completes a respiratory treatment the nurses are supposed to clean out the equipment, dry it off and put it back in the plastic bag that should be kept at the bedside. An observation was conducted on 12/04/2020 at approximately 12:50 p.m., Resident #42 was up in her wheelchair sitting next to her bed. Observed the resident's nebulizer equipment for inhalation therapy stored in the top drawer of her night stand uncovered next to her brush and other personal items. (photographic evidence was obtained). An interview was conducted on 12/04/2020 at 5:28 p.m., The ADON said, All nebulizer and oxygen equipment is to be stored in a bag. I am not sure when the last time it was used but it should not matter. We have a company that comes in and takes care of our respiratory equipment. A review of the facility policy titled Infection Control-Cleaning and Disinfection/Non-Critical care and shared equipment last reviewed on 10/30/2019 revealed, Intent: It is the policy of the facility to ensure that appropriate infection prevention and control measures are taken to provide a safe, sanitary, and comfortable environment to prevent the spread of infection in accordance with State and Federal Regulations and National guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility did not accommodate dietary preferences and intolerances for one (Resident #40) out of five sampled residents. Findings included: Resident #40 was admitted to the facility with a diagnoses that included pneumonia unspecified, Dysphagia, Gastro-esophageal reflux and chronic kidney disease. A review of Resident #40's quarterly minimum data set (MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of 9 signifying moderately impaired cognition. Section K on Swallowing and nutritional status showed diet orders of Regular diet, Lactose free. On 12/03/20 at 8:30 a.m., Resident #40 was observed in her room eating breakfast, her cereal bowl was full however she was not eating the cereal. Resident #40 stated, they gave me the wrong milk. I don't drink that. A regular milk carton was observed on her tray. On 12/03/20 at 12:18 p.m., another observation was made of Resident #40 being assisted with her meal by Staff C, Certified Nurse's Aide (CNA). Staff C, CNA told resident #40 that she did not receive milk with her tray. A review of Resident #40's meal ticket dated 12/03/20 revealed the following statement, sorry, out of lactose milk, waiting on delivery. The meal ticket also confirmed that Resident #40's diet included a lactose free diet. A review of physician's orders with a print date of 12/03/20 under Allergies confirmed that resident #40 was Lactose intolerant. Resident #40's Care Plan dated 07/23/19 under nutrition showed a goal to maintain nutritional status at optimal level possible with an approach to honor food preferences as applicable. The plan further confirmed a lactose free diet was ordered. A review of the dietary pre-interview screen dated, 11/25/19 under food allergies confirmed that Resident #40 was lactose intolerant. On 12/03/20 9:32 a.m., an interview was conducted with the Registered Dietician (RD). She confirmed that the resident was lactose intolerant and should not have been served regular milk. An interview with the Minimum Data Set (MDS) Coordinator conducted on 12/03/20 at 09:59 a.m. also confirmed that Resident # 40 should be served a lactose free diet. A follow-up interview was conducted on 12/03/20 at 12:12 p.m. with the Certified Dietary Manager (CDM). CDM reported that the truck delivery arrived this morning and the lactose milk was back ordered. When asked if there was a plan to meet the resident's needs in circumstances like those, CDM stated that they would go to the grocery store and get a gallon of milk. On 12/04/20 12:37 p.m. another interview was conducted with the RD who reported that Resident # 40 was not served lactose free milk this morning again because the truck still had not come. A review of the facility's policy titled, Food and Nutrition Services dated 10/22/20, states that the facility will provide each resident a nourishing diet that meets special dietary needs including preferences.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility did not provide assistive devices to ordered maintain independence during meals for one (Resident #40) out of five sampled residents. Findings included: Resident #40 was admitted to the facility on [DATE] with multiple diagnoses including dysphagia and muscle weakness. A review of Resident #40's quarterly minimum data set (MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of 9 indicating moderate cognitive impairment. A review of Resident # 40's Care Plan with a start date of 7/23/19 revealed a nutritional risk related to certification of terminal illness, therapeutic diet, and a history of weight loss. The goal is noted to maintain nutritional status at most optimal levels. Approach number 12 states to offer a lipped plate. During an initial tour of hallway 112-128 on 12/01/20 at 9:50 a.m., an observation was made of resident #40 in her room eating breakfast, served in a regular plate. Her meal plate was noted to be full. On a subsequent visit on 12/01/20 at 11:14 a.m., Resident #40 was observed sitting in bed, breakfast tray in front of her and the meal not touched. An interview with the resident revealed that Resident #40 did not know if she needed assistance with meals or what specialized equipment was prescribed in her care plan. On 12/02/20 08:49 a.m., Resident #40 was observed sitting in bed, eating breakfast without a lipped plate and with regular silverware, photographic evidence obtained. On 12/03/20 at 09:32 a.m., an interview was conducted with the Registered Dietician (RD) who confirmed that Resident #40 should have been served with a lipped plate and that a lipped plate was ordered for all meals. A follow-up interview was conducted with the Rehabilitation Director on 12/03/20 at 09:39 a.m. who stated that the lipped plate was ordered on every meal effective 10/16/20 for Resident #40. On 12/03/20 at 09:59 a.m., an interview with the Minimum Data Set (MDS) Coordinator was conducted. MDS stated that Resident #40 should have a lipped plate all the time. A review of Resident's 40's meal ticket order dated, 12/03/20 under equipment showed to provide a lipped plate. A review of the physician's order provided by the Rehabilitation Director confirmed that Resident #40 is to be provided a lipped plate with all meals. A review of the facility's policy titled, Food and Nutrition Services dated 10/22/20, states that the facility will provide special eating equipment and utensils for residents who need them.