Based on observations, interviews, and record review, the facility failed to ensure medications and biologicals were securely stored for one resident (Resident #43) of one resident sampled for medication storage. Findings included: On 1/28/2025 at 8:05 AM, in Resident #43's room, one tube of topical menthol analgesic was observed on the bedside table and one container of Dimethicone-Zinc Oxide-Vitamin A-Vitamin D ointment was observed on the bedside nightstand. An interview was conducted with Resident #43 following the observation. Resident #43 stated he used the topical menthol analgesic for back pain and he used the Dimethicone-Zinc Oxide-Vitamin A-Vitamin D ointment on his feet. Review of Resident #43's care plan, revision on 1/29/2025, read Observe resident taking his/her medications as needed to ensure proper storage and self administration of medication. Provide a lock box for resident to store medications PRN [as needed]. Obtain order from physician stating that resident is able to self administer medications. Provide education of proper storage of medications and monitor to ensure that resident is properly storing medications. On 1/29/2025 at 9:48 AM, in Resident #43's room, one tube of topical menthol analgesic was observed on the bedside table and one container of Dimethicone-Zinc Oxide-Vitamin A-Vitamin D ointment was observed on the bedside nightstand. During an interview on 1/29/2025 beginning at 9:48 AM, Staff A, Licensed Practical Nurse/Unit Manager confirmed there was one tube of topical menthol analgesic on Resident #43's bedside table and one container of Dimethicone-Zinc Oxide-Vitamin A-Vitamin D ointment on the bedside nightstand. She confirmed the medications should be securely stored in the resident's nightstand that was equipped with a key accessible lock. During an interview on 1/29/2025 at 10:10 AM, the Director of Nursing stated she would expect the resident would follow the rules and have the medications securely stored. Review of the facility policy titled Storage of Medications, last reviewed 1/31/2024, read Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Review of Resident #49's clinical record documented admission to the facility on 5/26/2021 with a diagnosis of neuromuscular dysfunction of the bladder. Review of Resident #49's January 2025 physician orders revealed the following: - An order dated 8/2/2023, Suprapubic insertion site: cleanse with NS [normal saline] pat dry and cover with split sponge every day shift. - An order dated 4/2/2024, Enhanced Barrier Precautions every shift. - An order dated 12/2/2024, Cleanse Wound to left distal ankle with NS [normal saline], apply calcium alginate, Santyl, cover with dry dressing. One time a day for wound care. During an observation on 1/29/2025 at 8:30 AM, there was signage posted outside of Resident #49's room above his room number and of PPE, including gloves, masks, and gowns, hanging in a caddy on the residents door. The signage read STOP enhanced barrier precautions everyone must: .wear gloves and a gown for the following high-contact resident care activities.wound care: any skin opening requiring a dressing . On 1/29/2025 at 8:30 AM, Staff B, Registered Nurse (RN) and Staff E, RN Clinical Educator were observed, during care for Resident #49, dressing an open wound to the left distal ankle and cleansing and dressing the resident's supra-public urinary catheter site without donning PPE in accordance with the posted signage. During an interview on 1/29/2025 at 8:50 AM, Staff, B RN stated, Yes, I should have put on PPE prior to conducting wound care. I normally do, you make me nervous. During an interview on 1/29/2025 at 8:53 AM, Staff E, RN Clinical Educator stated, Just came to help her I didn't realize he was on EBP. I thought that was for the other resident, but I know any time we complete wound care we should be dressing out with PPE. I didn't think and I teach this process. Review of Resident #84's clinical record documented admission to the facility 1/20/2022 with a diagnosis of encounter for attention to gastrostomy. Review of Resident #84's January 2025 physician orders revealed the following: - An order dated 1/27/2024, Enteral Feed order .Jevity 1.5 at 75 cc [cubic centimeters]/hour via feeding tube for 10 hours with auto flush at 200cc/hour every 4 hours. On at 5pm till 750 ml [milliliters] total volume infused. - An order dated 12/21/2024, Enhanced Barrier Precautions-PEG [percutaneous endoscopic gastrostomy] tube. During an observation on 1/29/2025 at 9:27 AM, there was signage posted on the outside of Resident #84's room above his room number with PPE, including gloves, masks, and gowns in a storage container under the signage by the resident's door. The signage read STOP enhanced barrier precautions everyone must: .wear gloves and a gown for the following high-contact resident care activities.Device care or use : .feeding tube . During an observation on 1/29/2025 at 9:27 AM, Staff D, Licensed Practical Nurse (LPN) initiated enteral feeding for Resident #84. After aspirating gastric contents from the gastrostomy tube, Staff D, LPN initiated Jevity 1.5 at 75 ml/hour via gastric pump. No PPE was donned during the observation. During an interview on 1/29/2025 at 9:30 AM, Staff A, LPN Nurse Manager stated, Any residents on Enhanced Barrier Precautions, staff have to wear PPE which includes a mask, gown, and gloves, when providing direct patient care. That includes wound care and gastrostomy feeding for infection control. During an interview on 1/29/2025 09:45 AM, Staff D, LPN stated, I should have used PPE any resident on Enhance Barrier Precautions we have to dress out when providing direct care. During an interview on 1/29/2025 at 9:48 AM, the DON stated it is her expectation a gown, gloves, and mask is utilized when providing gastrostomy feedings and wound care to resident's on EBP. Review of the policy number 21.08.003 titled Enhanced Barrier Precautions, last reviewed 3/31/2024, showed: Standard: Prevention, containment, and eradication measures, including the use of Enhanced Barrier Precautions (EBP) are indicated, as informed by the Centers for Disease Control and Prevention (CDC), to prevent and control the spread of novel, targeted, and emerging multi-drug-resistant microorganisms, defined as CDC-targeted MDROs. The prevention and control of CDC-targeted MDROs by this center is considered a resident safety measure. Enhanced Barrier Precautions (EBP). Enhanced Barrier Precautions are a transmission based approach that falls between Standard and Contact Precautions. Examples of high-contact resident care activities requiring a gown and glove use include: Transferring, changing linen, performing hygiene, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube .wound care: any skin opening requiring a dressing. 2.) Review of Resident #269's clinical record documented admission to the facility on 1/16/2025 with a diagnosis of chronic pulmonary edema. Review of Resident #269's January 2025 physician orders revealed, Ipratropium-Albuterol Solution 0.5-2.5 (3) MG[milligrams]/3ML, 3 ml inhale orally every 6 hours for shortness of breath During an observation on 1/27/2025 at 10:10 AM, Resident #269's nebulizer mask was uncovered and lying on the bedside table. An interview was conducted with Resident #269 following the interview. Resident #269 stated, I normally take my nebulizer twice a day. They gave me the treatment around 3:30 AM. Review of Resident #269's Medication Administration Record showed Ipratropium-Albuterol Solution was administered on 1/27/2025 at 5:00 AM and 11:00 AM. During an observation on 1/27/2025 at 2:20 PM, Resident #269's nebulizer mask was uncovered and lying on a table. During an interview on 1/27/2025 at 2:31PM, Staff C, LPN stated, the nebulizer should have been placed in a bag for storage. During an interview on 1/27/2025 at 2:55 PM, Staff A, LPN stated, nebulizers are to be placed in a bag for infection control after the procedure has been completed. During an interview on 1/28/2025 at 10:50 AM, the DON stated, nebulizer needs to be placed in a bag for storage to prevent contamination, until next use. Photographic Evidence Obtained Based on observations, interviews, and record review, the facility failed to ensure an effective infection control and prevention program to prevent the spread of infection was implemented by 1.) failing to use appropriate personal protective equipment (PPE) while performing care for three residents (#113, #49, and #84) on Enhanced Barrier Precautions on three (Upper 300 Hall, Lower 400 Hall, and Upper 400 Hall) of four facility Halls and 2.) failing to follow professional standards of practice for storage of respiratory equipment for one resident (#269) of four residents observed on respiratory therapy. Findings included: 1.) During an observation on 1/27/2025 at 11:23 AM, Resident #113 had an Enhanced Barrier Precaution (EBP) sign on the wall beside the room door and a storage container containing PPE, including masks, gloves, and gowns, beside Resident #113's door. Staff F, Certified Nursing Assistant (CNA) and Staff G, CNA were observed in the resident's room standing on either side of the resident and assisting with transferring Resident #113 using a sit to stand lift (a specialized medical device designed to assist individuals with limited mobility in transitioning from a sitting to standing position) into his wheelchair. Both staff members were observed wearing gloves and were not wearing gowns. Staff G, CNA combed Resident #113's hair while Staff F, CNA moved the resident's urinary catheter bag from the sit to stand device and secured it to the resident's wheelchair. Staff G, CNA repositioned Resident #113 in his wheelchair, placed his bedside table within reach, gathered a bag of dirty linen and trash bag from the trash can, exited the room, and proceeded down the hallway to the dirty utility room. Review of the signage on Resident #113's door showed, STOP: Enhanced Barrier Precautions. Everyone must: clean their hands, including before entering and when leaving the room. Providers and staff must also: Wear gloves and a gown for the following High-Contact Resident Care Activities .Transferring, Changing Linens, Device care use: Central line, urinary catheter, feeding tube, wound care: any skin opening requiring a dressing. Review of the medical record showed Resident #113 was admitted on [DATE] with diagnoses including wedge compression fracture of the second thoracic vertebra, malignant neoplasm of the bladder, and benign prostatic hyperplasia with lower urinary tract symptoms. Review of Resident #113's January 2025 physician's orders revealed an order dated 12/12/2024, for Isolation: Enhanced Barrier Precautions (EBP) Foley Cath [catheter] use every shift EBP [Enhanced Barrier Precautions]. During an interview on 1/29/2025 at 11:09 AM, Staff F, CNA stated, I wasn't wearing a gown when I was taking care of him [Resident #113] or transferring him. I should have been. During an interview on 1/29/2025 at 11:10 AM, Staff G, CNA stated, I wasn't wearing a gown either when taking care of [Resident #113]. I need to wear a gown when they are on EBP and have a catheter, I should have. I'm sorry. During an interview on 1/29/2025 at 9:34 AM, the Director of Nursing (DON) stated, I expect staff to be following the EBP signs on the doors and wearing appropriate PPE when performing care. I expect the staff to be wearing gowns when performing direct care for a resident with a [urinary] catheter. They should have been wearing full gear.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to administer medications in accordance with resident preference for one (#1) of three residents sampled for medication administration. Findings included: A review of Resident #1's medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, pleural effusion, and asthma. Resident #1 was discharged from the facility on 9/30/2024. A review of Resident #1's medical record revealed the following orders: - An order, dated 9/11/2024 for Trelegy Ellipta 100-62.5-25 micrograms (mcg) aerosol powder, breath activated, give one inhalation by mouth in the morning for COPD/shortness of breath. The order was discontinued on 9/29/2024. - An order, dated 7/6/2024 for Trelegy Ellipta 100-62.5-25 mcg aerosol powder, breath activated, give one inhalation by mouth once daily. The order was discontinued on 7/6/2024. A review of Resident #1's progress notes dated 7/6/2024 at 9:08 AM revealed Resident #1 informed facility staff during medication administration she did not want Trelegy Ellipta administered due to a history of adverse reactions and had not taken the medication in years. Resident #1's progress notes dated 7/6/2024 at 10:42 AM revealed Resident #1 had a history of adverse reactions to Trelegy Ellipta and she had been using a different medication (Breztri) in place of the Trelegy Ellipta. A review of Resident #1's 5-day Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 9/13/2024 revealed under Section C - Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 14, indicating Resident #1 was cognitively intact. A review of Resident #1's medication administration record (MAR) for September 2024 revealed Resident #1 was administered Trelegy Ellipta 100-62.5-25 mcg on 9/12/24, 9/16/24 to 9/20/24, 9/23/24 to 9/25/24, 9/27/24, and 9/29/24. A telephone interview was conducted on 10/23/2024 at 2:30 PM with Resident #1's representative (RR). The RR stated facility staff offered Resident #1 Trelegy Ellipta several times during her admission to the facility and Resident #1 had to inform the facility she was not able to take the medication due to a history of adverse reactions. The RR also stated Resident #1 was usually able to recognize when facility staff attempted to administer Trelegy Ellipta to her, but she was very lethargic near the end of her admission and may not have recognized the medication when the facility attempted to administer it. The RR stated Resident #1 would normally take the medication Breztri instead of the Trelegy Ellipta, but the facility pharmacy was not able to provide the medication, so the resident used her own supply of Breztri from home. An interview was conducted on 10/23/2024 at 3:09 PM with Staff B, Licensed Practical Nurse (LPN). Staff B, LPN stated she cared for Resident #1 on several occasions and the resident was ordered Trelegy Ellipta because when an order for Breztri was put into the resident's order set the facility pharmacy would change the order to Trelegy Ellipta. Staff B, LPN also stated if a resident had a history of adverse reactions to a medication, the nurse should contact the resident's physician to have the medication discontinued. An interview was conducted on 10/24/2024 at 11:50 AM with the facility's Director of Nursing (DON). The DON stated she spoke with Resident #1's provider Staff D, Advanced Practice Registered Nurse (APRN)) over the phone to discuss why Trelegy Ellipta was ordered for the resident during her admission to the facility. The DON stated Resident #1 had an intolerance to several inhalant medications and the resident's provider worked to find a inhalant medication she would be tolerant of to manage her COPD symptoms. The DON stated if Resident #1 or the RR did not want Trelegy Ellipta to be administered, the resident's provider should have been notified and the medication should have been discontinued. A telephone interview was conducted on 10/24/2024 at 1:05 PM with Staff D, APRN. Staff D, APRN stated Resident #1 had been prescribed multiple inhalant medications over the years to manage her COPD and had an intolerance to Trelegy Ellipta. Resident #1 was taking Breztri while at home, which she was tolerant of. Staff D APRN informed facility staff to not administer the Trelegy Ellipta to Resident #1 and to only administer Breztri to the resident. Staff D, APRN stated Resident #1 was prescribed Trelegy Ellipta several times during her admission to the facility due to a formulary interchange, which resulted in the pharmacy replacing Breztri with Trelegy Ellipta any time it was ordered for the resident. Staff D, APRN also stated if Resident #1 or the RR did not want Trelegy Ellipta administered, the nursing staff should have called her to make the appropriate adjustments to the resident's orders. A review of the facility policy titled Resident Rights, last revised in February 2021, revealed under the section titled Policy Interpretation and Implementation, federal and state law guarantee certain basic rights to all residents of the facility. These rights include the resident's right to be informed of, and participate in, his or her care planning and treatment and the resident's right to choose an attending physician and participate in decision-making regarding his or her care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to assess, maintain in a sanitary manner, and provide dressing changes for one (#5) of three residents with central intravenous (IV) catheters. Findings included: On 10/23/24 at 9:33 a.m., Resident #5 was observed lying in bed and appeared to be alert and oriented to person and situation. An intravenous pole with pump was observed in the corner of the room, visible from the doorway. The resident confirmed having an intravenous site, holding up his right arm where a single lumen peripherally inserted central catheter (PICC) was observed. The woven outside portion of the dressing appeared to be worn and old, the transparent middle portion revealed an approximate quarter-size area of a dried red/black substance surrounding the catheter insertion site. One side of the woven portion of the dressing was no longer attached to the resident. The dressing did not reveal a date of when it was applied, the needless connector was not attached to the end of the catheter, and the line was not closed shut. Resident #5 reported having the (IV) site for at least a week. The resident allowed photographic evidence to be obtained. On 10/23/24 at 9:53 a.m., Staff A, Licensed Practical Nurse (LPN) reported Resident #5 had a urinary tract infection and a PICC dressing was changed every 7 days. The staff member observed Resident #5's PICC line, confirming the dressing was not dated, the dressing was coming off, and there was no cap on the end of the catheter. On 10/23/24 at 10:25 a.m., the Director of Nursing stated there were 2 residents with IV sites and provided a handwritten list of the 2 residents. Resident #5 was not on the list. Review of Resident #5's admission Record revealed the resident was admitted on [DATE] and 8/16/24. The record showed the resident was the responsible party and included diagnoses not limited to site not specified urinary tract infection (onset 10/3/24) and Extended Spectrum Beta Lactamase (ESBL) resistance (onset 9/9/24). Review of Resident #5's Minimum Data Set (MDS) dated [DATE] revealed the resident's Brief Interview of Mental Status score of 13, indicating an intact cognition. The resident had an indwelling urinary catheter and in the 7 days prior to the assessment, the resident had received antibiotics. Review of the IV vendors information showed a Right 3CG non-valved PICC was inserted into Resident #5's right basilic vein with an internal length of 45 centimeters (cm) and 0 cm external length. The information showed time in for the vendor was 3:40 p.m. (1540) and out time was 4:35 p.m. (1635) on 10/2/24. Review of Resident #5's October Medication Administration Record (MAR) revealed the following physician orders: - Insert PICC line, may use lidocaine 1% for placement - one time only for klebsiella urinary tract infection (UTI) for 1 day. Ordered 10/2/24 at 9:00 a.m. and completed on 10/2/24 at 4:32 p.m. - Ertapenem Sodium solution reconstituted 1 gram (GM) - Use 1 gram intravenously every 24 hours for Klebsiella UTI related to Urinary Tract Infection site not specified for 10 days. Order 10/2/24 and started 10/2 and ended on 10/11/24. The MAR showed the 10/2 dose was not administered. The review did not show staff were assessing the PICC line, did not include orders for flushing the line before or after administration of the antibiotic or for after the treatment had ended. Review of Resident #5's October Treatment Administration Record (TAR) did not include orders to change the dressing on the resident's PICC line, change the end cap of IV catheter, or to monitor the site for any issues. During an interview on 10/23/24 at 4:00 p.m., the DON stated the expectation was for the dressings of PICC/Central lines to be changed every 7 days, (and) if soiled or any impediment as needed. She stated there should be orders for monitoring the site every shift, flushes, and dressing changes. The DON reviewed Resident #5's orders and confirmed the resident did not have orders to monitor (the site) or for dressing changes. Review of the undated, blank Midline and CVAD (Central Venous Access Device) Dressing Change Competency provided by the Director of Nursing (DON) on 10/24/24 revealed the dressing change was an sterile procedure after removing the old dressing, staff should clean site, apply new securement device, apply protective disk (optional), apply transparent dressing over the site, affix label with date and nurse's initials, removed and replace the needleless connection device(s), measure external length of catheter, measure resident's arm circumference, dispose of trash, wash hands, and document the procedure in medical record and MAR. Review of the policy - Peripheral and Midline IV Catheter Flushing and Locking, revised March 2022, showed The purpose of this procedure are to maintain catheter patency and function; to prevent mixing of incompatible medications and solutions my colon and to ensure entire dose of solution or medication is administered into the venous system. The guidelines instructed 6. Use preservative- free 0.9% sodium chloride for lacking a peripheral or midline catheter. Do not flush or lock a peripheral or midline catheter with heparin. The frequency of flushing was shown as: 1. For short and long PIVC's and midline catheters used for intermittent infusions, flush the catheter and aspirate for blood return prior to each infusion and at least every 24 hours to access catheter function. Lock following each use. 2. For catheters not being used for intermittent infusion, flush and lock at least once every 24 hours. (See Peripheral and Midline IV Catheter Removal.) The procedure for flushing to maintain patency of catheter was described as: 1. Assemble supplies. 2. Perform hand antisepsis. [NAME] non-sterile gloves. 3. Disinfect needless access device (end cap, access port) with alcohol wipe. 4. Attach prefilled saline syringe to needleless access device. 5. Unclamp catheter. 6. Flush with preservative- free 0.9% sodium chloride using the push- pause technique. Leave 0.5 to 1.0 milliliter (mL) of flush and syringe to avoid pushing air into catheter. 7. Remove syringe. 8. Attach prefilled saline syringe to needleless access device. 9. Lock with preservative- free 0.9% sodium chloride. Leaves 0.5 to 1.0 mL a flush in syringe to avoid pushing air into catheter. 10. Remove syringe and clamp catheter. 11. Remove gloves. 12. Discard used supplies in appropriate waste container. The policy instructed staff to: 1. Document procedure in Treatment Administration Record. 2. Note location of catheter, condition of insertion site, and dressing in nurse's notes. 3. Record any complications and/or communications with the physician in nurse's notes. The policy - Legal Aspects of Infusion Therapy for Nurses, revised 2/2019 revealed the purpose was To identify licensed personnel who are designated by the facility to perform infusion therapy. The policy showed Nurses administering infusion therapies will practice within the scope of practice for their licensure as established in the state nurse practice act, and within their clinical level of competency as established by the facility training and competency evaluation programs. The scope of practice for Specific Infusion Therapy for Nursing Functions showed the Following procedure/ functions associated with infusion therapy must be verified with the state nurse practice act regarding Registered Nurse (RN) and Licensed Practical Nurse (LPN) scope of practice, as the regulations differ from state to state. The procedure/functions included but not limited to: - 5. Caring for and maintaining infusion equipment and catheters (peripheral and central venous access catheters) this includes flushing, dressing changes, site assessment, site rotation (for short peripheral catheters only), changing IV tubing, and needleless connection devices. - 9. Observing and reporting on catheter patency, insertion site, complications, (and) resident reaction to treatment. - 11. Documenting treatment, observations, complications, interventions, (and) resident response to treatment. The Facility/Administration Responsibilities for IV therapy revealed the following: - 1. Developing and improving policies and procedures for infusion therapy. - 2. Providing education or verifying qualifications on the staff that will be providing infusion therapy period this may include IV fundamental classes, precepting and/for clinical competency evaluations. - 3. Assuring that federal and state regulations are followed, along with the Facility policy and procedure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure two (#5 and #7) of three residents sampled for Intravenous (IV) sites had Enhanced Barrier Precautions posted and Personal Protective Equipment (PPE) available nearby. Findings included: On 10/23/24 at 9:33 a.m., Resident #5 was observed lying in bed. The observation revealed the resident had a single lumen peripherally inserted central catheter (PICC) inserted into the right upper extremity. The resident stated the PICC was due to having an antibiotic for a urinary tract infection (UTI) and had the IV site for at least a week. The observation revealed the door or entryway to Resident #5's room was not posted with Enhanced Barrier Precautions and the nearest available PPE was in front of room [ROOM NUMBER], 2 rooms away from the resident. On 10/23/24 at 9:44 a.m. an observation was made of Resident #7's doorway. The door or entryway to the room was posted for Enhanced Barrier Precautions and did not have available PPE. The resident showed writer a right-side chest wall IV site which the resident reported getting chemotherapy and antibiotic for a wound infection. The dressing on the site was dated 10/21/24. The nearest PPE was available in front of room [ROOM NUMBER], around the corner and the third room from the resident room. An interview was conducted with Staff A, Licensed Practical Nurse (LPN) on 10/23/24 at 9:53 a.m., the staff member reported want to say Resident #5 had a UTI and Resident #7 had a wound to right foot with a wound vac. An interview was conducted with Staff C, LPN on 10/23/24 at 10:45 a.m., the staff member stated Enhanced Barrier Precautions (EBP) was used for people with IV's, foleys, and colostomies. The staff member stated that's the policy of the facility. An interview was conducted with the Director of Nursing (DON) on 10/23/24 at 4:00 p.m., the DON stated the policy for EBP was if they met protocol, met protocol at admission, if they warrant (the resident) was put on EBP. The acceptable placement of PPE is within 2-3 rooms of the doorway and there should be PPE in the caddy's at all times. The policy - Enhanced Barrier Precautions, dated August 2022, revealed Enhanced Barrier Precautions (EBP) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. 1. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi- drug resistant organisms (MDROs) to residents. 2. EBPs Employee targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gowns are applied prior to performing the high contact resident care activity (as opposed to before entering the room). b. Personal protective equipment (PPE) is changed before carrying for another resident. c. Face protection may be used if there is also a risk of splash or spray. 3. Examples of high- contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing; b. bathing/showering; c. transferring; d. providing hygiene; e. changing linens; f. changing briefs or assisting with toileting; g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ ventilator, etc.); and h. wound care (any skin opening requiring a dressing). 5. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of multi-drug resistant organism (MDRO) colonization. 6. EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk. 10. Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required. 11. PPE is available and placed in an area near or outside of the resident's rooms. (Photographic evidence was obtained)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure medication was stored appropriately in three out of three medication carts audited and on two out of two units related to unlocked treatment cart, medication on the floor, and medication unlocked on medication carts. Findings included: An observation was conducted on 7/17/24 at 9:50 a.m. of a treatment cart at the end of the 300-hall sitting outside of a resident room. The nurse was inside the room, behind the privacy curtain. The medication cart had 2 intravenous medications and 1 topical medication sitting in the attached plastic side compartment that has no lock. No other staff were in the hall. The nurse, Staff E, Licensed Practical Nurse (LPN) exited the resident room and was interviewed at that time. The nurse said she brought the medications to her cart, and she was going to go hang them up. An observation was conducted on 7/17/24 at 12:27 p.m. of a treatment cart unlocked near the 300-unit nurses' station. No staff were at the nurses' station at the time. The treatment cart remained unlocked at 1:00 p.m. after multiple staff members walked past the cart. An observation was conducted on 7/17/24 at 2:44 p.m. of a medication cart near the 300-unit nurses' station with 6 blister packs of medication sitting on top. There was no nurses at the medication cart. Staff were observed to be approximately 10 feet from the cart talking, but no one was watching the medication cart. An observation was conducted on 7/18/24 at 10:28 a.m. of a yellow pill on the floor in the hall outside of resident room [ROOM NUMBER]. There were no staff members in the hall. Staff H, LPN, was brought to the location. Staff H was not working that hall, but she removed the pill from the floor and believed it was pantoprazole, used for reflux or heartburn. She said the pill should not have been left on the floor, and she would dispose of it properly. An audit was conducted on 7/18/24 at 11:50 a.m. of a medication cart on the 400 unit with Staff F, LPN. The medication cart had 5 loose pills in the drawers of the cart. Staff F confirmed there should be no loose pills in the medication cart. She said night shift was supposed to clean the medication carts. Staff F said she had been educated on picking up loose pills if they dropped. An audit was conducted on 7/18/24 at 12:02 p.m. of a medication cart on the 300 unit with Staff D, Registered Nurse (RN.) The medication was observed to have 13 loose pills throughout the drawers of the cart along with dirt and debris. One drawer contained liquid medication that was spilled in the cart along with a plastic bag with a bottle of liquid Valproic Acid that did not have a lid on it. The lid was in the bottom of the plastic bag. Staff D was not sure why the lid was not on the Valproic Acid. She said she had been educated on loose pills not being allowed in the medication carts. She said if a nurse dropped a pill they should dispose of it properly. Staff D said night shift was responsible for cleaning the carts. An audit was completed on 7/18/24 at 12:20 p.m. on another 300 hall medication cart assigned to Staff E, LPN accompanied by Staff G RN/Unit Manager (UM). The cart contained one individual package of an Atorvastatin 10 mg tablet that was not labeled with a resident name or in a bag with a resident name/prescription. The single pill pack was sitting in a drawer with bottled medications. Staff G said the medication should not be in the cart without a resident name/prescription, and she would remove the medication. An interview was conducted on 7/18/24 at 12:10 p.m. with Staff G, RN/UM. She said management does weekly checks on the medication carts to take out medication for residents that have been discharged and ensure no loose pills were in the cart. She said all nurses should check their own carts and keep them clean. Staff G said when pharmacy delivered new blister packs of medication, the nurses should lock them in the carts immediately. They should not be left on top of the medication cart. She confirmed no medication should be left on the floor or unsecured. Photographic evidence was obtained. An interview was conducted on 7/18/24 at 1:20 p.m. with the Regional Director of Nursing (RDON). She said medications should always be locked in the medication cart or medication room and there should be no loose pills on the floor. She reviewed pictures of medications left on the top and the side medication carts and confirmed that was a problem. Review of a facility policy titled Standards and Guidelines (SG) Medication Storage, revised 10/24/22, showed: Standard: It will be the standard of this facility to store medications, drugs, and biologicals in a safe, secure and orderly manner. Guidelines: 1. Medications, drugs, and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received, unless otherwise necessary. 2. The nursing staff shall be responsible for maintaining medication storage an preparation areas in a clean, safe and sanitary manner. 3. Drug containers that have missing, incomplete, improper or incorrect labels should be returned to the pharmacy for proper labeling before storing. 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications, drugs, and biologicals shall be locked when not in use and trays or carts used to transport such items shall not be left unlocked if out of a nurses' view.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to ensure an accurate advance directive for code status based on the resident's expressed wishes for one resident (#323) out of forty-four sampled residents. Findings included: A review of the admission Record showed Resident #323 was admitted on [DATE]. The admission Record for the resident included diagnoses not limited to Chronic Obstructive Pulmonary Disease with (acute) exacerbation, acute respiratory failure with hypoxia, acute on chronic systolic (congestive) heart failure, acute pulmonary edema, and subsequent non-ST elevation (NSTEMI) myocardial infarction. An electronic record review, on [DATE] at 3:38 p.m., identified Resident #323 wished to be a Full Code, identifying that in an emergency situation the resident had chosen for staff to initiate cardio-pulmonary resuscitation (CPR). A Social Service progress note, dated [DATE] at 12:38 p.m., indicated the Resident had signed a DNR (do not resuscitate) with hopes the MD (medical doctor) would be here to sign it. The DNR was sent by Fax to the MD as well as placed in the MD's box at the nurses' station. It has yet to be signed. The code status has been updated to Full Code until the MD signs the DNR. Resident has been made aware. The electronic review of Resident #323's admission summary, dated [DATE], indicated the resident had elected a DNR code status. The care plan for Resident #323 identified a description of Resident's Advance Directive wishes. The care plan, created on [DATE], indicated the Resident HAS Advance Directives on record, Do Not Resuscitate (DNR). The Advance Directive care plan was resolved and revised on [DATE] by the Social Service Director (SSD) identifying the resident had an Advance Directive on record, Do Not Resuscitate. During an interview on [DATE] at 4:35 p.m., Staff A, Registered Nurse (RN), stated Resident #323 was a very recent (admit) and had come to the facility as a full code. Staff A stated staff got the code status of the residents in report and the status was written on the report sheet. Staff A reviewed the report sheet lying on the medication cart and stated Resident #323 was a DNR, identified by a D on the report. Staff A reviewed Resident #323's physician orders and identified an active order that indicated the resident was a full code. The staff member stated if the resident had an issue that she would code (perform CPR) her (Resident #323). On [DATE] at 4:42 p.m., a review of the 300-unit's Advance Directive binder, located at the nursing station, identified Resident #323 did not have a Do Not Resuscitation goldenrod form, indicating that CPR would be initiated in an emergency situation. An interview, at 4:48 p.m. on [DATE], was conducted with the Social Service Director (SSD). The SSD stated she spoke with the Attending Physician's office and the physician was to be in today to sign the DNR. The SSD stated on [DATE] Resident #323 told her that she was a DNR and after reviewing the hospital records and the 3008 (Medical Certification For Medicaid Long-Term Care Services and Patient Transfer Form ), both identified the resident's code status as DNR. She stated she had an order in the electronic clinical record on [DATE] and the facility had been waiting for the physician to sign the DNR for seventeen (17) days. The SSD reviewed the clinical record and identified the Attending (physician) visited the resident numerous times since Resident #323's admission. She identified the DNR had been faxed to the physician's office on the [DATE] to be signed by the physician and the MD office's fax machine was having an issue faxing it (DNR) back. The SSD reported at the physician's office there was a signed DNR but the facility did not have a signed one. She reported the resident was a DNR up until [DATE] and that on [DATE] the Attending signed the order for the DNR status. She stated nursing changed the order on [DATE] to reflect the resident was a Full Code. The SSD explained on Fridays, the resident DNRs are reviewed but she was off on Friday ([DATE]) and the assistant was not able to complete the review. Resident #323 stated, on [DATE] at 5:16 p.m., she was a DNR at the hospital and at the facility. The resident reported being unaware that her code status had been changed and not wanting any help (CPR). The 5-day Minimum Data Set (MDS), dated [DATE], identified Resident #323's Brief Interview for Mental Status (BIMS) score was a 12 out of 15, indicative of moderate cognition impairment. On [DATE] at 5:27 p.m., the Director of Nursing stated Resident #323 was fairly new and she (DON) was aware of the discrepancy in the resident's code status. She stated the facility had located the signed DNR and the facility completed an audit on DNRs yesterday and the SSD found the facility did not have a signed goldenrod DNR for Resident #323. The DON stated a goldenrod colored DNR was for transport and she wrote an order for a Full Code due to a conversation with the SSD. She acknowledged that she had not spoken with the resident. The DON reported the policy of the facility was that without a signed goldenrod DNR, a physician order had to be done daily. She stated there had been miscommunication between the SSD, herself, and the resident. She stated when she spoke with the physician (regarding the DNR) the physician informed her there was a signed DNR and the DON could write a telephone order for the resident's Full Code status. On [DATE] at 6:01 p.m., Staff B, Registered Nurse (RN) pointed out a free-standing rack at the 300-unit nursing station. She stated the left side of the rack was for things the physicians had to sign and the doctors were to put things on the right side once (they were) signed and, once in a while, the doctors would put things on the bottom right side, which was the area with paperwork for Medical Records to scan. She stated Medical Records picked up items every day except weekends to scan and nothing sat on the right side of the rack for more than 24 hours unless it was the weekend. The DON stated, on [DATE] at 6:10 p.m., while standing in the Social Service office, she spoke with the physician who had informed her the resident was wishy washy on the code status. The SSD provided a goldenrod colored DNR signed by both the resident and the physician on [DATE]. She stated she received it from Medical Records. The SSD stated when she spoke with the resident on [DATE] the resident was not wishy washy but had asked to speak with (family member) before making the decision. The SSD stated and reviewed the signed DNR from the hospital and stated she knew the facility needed a signed DNR by the resident if they were able to and that Resident #323 had the mental capacity to make healthcare decisions. The facility was asked to provide Active, Discontinued, and Completed physician orders for Resident #323, the facility did not provide either discontinued or completed orders. The active orders identified an order dated [DATE], Advance Directive: DNR. The Advance Directive initiated Care Plan identified the Regional Director of Clinical Services (RDCS) revised the resident's care plan on [DATE] to indicate the resident HAS Advanced Directives on record Do Not Resuscitate. The facility policy titled, Advance Directives (18.07.001), issued [DATE] and revised [DATE], acknowledged that It will be the standard of this facility that the resident has the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive and participate in advance care planning. Advance Directives/Advance Care Planning designations will be respected in accordance with state law and facility policy. The guidelines of the policy identified the following: - 2. Staff will assist residents or resident representatives if they wish to formulate an advance directive. - 5. Facility staff will provide assistance, if needed, if the resident/responsible party wishes to execute one of more directives. Facility staff will document in the medical record these discussions and any advance directives that the resident executes. - 15. Facility staff will document and communicate the resident's choices to the interdisciplinary team and to staff responsible for the resident's care. - 19. The Director of Nursing Services, Social Services, or members of the nursing staff or designee will notify the Attending Physician of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the resident's Minimum Data Set Assessments, medical record, and facility policy on Hospice/Palliative/End of Life Care, and interview with facility staff, it was determined the facility failed to complete a significant change assessment when one resident (#16 ) of a total sample of 44 residents, chose the Hospice benefit. Findings included: Review of the admission Record revealed Resident #16 was initially admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus with neuropathy and an above the knee amputation, rheumatoid arthritis, and chronic pain. A review of the resident's medical record revealed an order for Hospice care dated 08/29/2022. A Quarterly Minimum Data Set (MDS) Assessment was completed on 09/14/2022 which indicated the resident was on Hospice. A review of a list of all MDS assessments completed for Resident #16 did not reveal a significant change assessment to reflect the resident and Power of Attorney's decision to elect the Hospice benefit had been conducted. An interview was conducted on 11/30/2022 beginning at 3:45 p.m. with the Staff J, Registered Nurse (RN)/MDS Nurse. She confirmed the Hospice benefit had not been captured in a significant change MDS for Resident #16. A Regional MDS Staff member was present during the interview and she confirmed the facility should have opened up a significant change MDS assessment when Hospice was ordered. The facility's policy for the Standards and Guidelines for Hospice/Palliative/End of Life Care, revised 3/27/21, revealed the Standard: It will be the standard of this facility to provide, participate in or collaborate with the provision of dignified palliative, Hospice, or end of life care. Under Guidelines, point #10 read: The facility staff will complete a Significant Change in Condition MDS assessment when a resident or representative elects or discontinues Hospice services per RAI (Resident Assessment Instrument) guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interview the facility failed to develop and implement a comprehensive care plan for two residents (#21, and #98) of five residents related to hearing aids and pain. Findings included: 1. Review of Resident #21's admission Record revealed she was admitted to the facility on [DATE] with diagnoses that included fracture of the sacrum, fracture of the pubis, Alzheimer's disease early onset, and cognitive communication deficit. Review of the Minimum Data Set assessment (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 10 (Moderately impaired cognition). Observations of Resident #21 on 11/28/22 at 11:59 a.m. revealed the resident lying on her bed. It was noted at this time the resident was not able to hear and had difficulty communicating. Observation of the room at this time revealed a hearing aid was noted on the resident's dresser out of reach of the resident. Observations and interview with Resident #21 on 11/29/22 at 8:55 a.m. revealed the resident sitting up in her wheelchair. The resident was able to verbalize today but had difficulty hearing what was said to her. She confirmed the hearing aids are hers and that she did not want this surveyor to take them. Resident #21 indicated she can't hear but it is better if this surveyor spoke into her left ear and take off the surgical mask. Interview on 12/01/22 at 2:45 p.m. with Staff C, Licensed Practical Nurse (LPN) revealed the resident has hearing aids but won't keep it on she has only seen one. Staff C reported that she communicates with the resident by writing. Interview on 12/01/22 at 2:49 p.m. with Staff V, Certified Nursing Assistant (CNA) revealed she tried offering to put the resident's hearing aid in this morning, but the resident refused to put in the hearing aid. At this time Staff V went into the resident's room and the resident was offered the hearing aid, but she grabbed it and said no because the earpiece and the back piece cost too much and she is not paying it. The resident asked that we don't touch it and to keep it in her box. Review of the care plan, dated 10/20/22 with a revision date of 11/28/22, revealed behavior problem r/t (related to) no compliance with care/treatment regimen. Resident swatting and hitting at staff while trying to provide care. Resident refuses wts (weights), care, showers, etc. Resident has episode of crying alone, increased agitation, picks at brief into pieces, anxiousness and is at risk for further decline. Review of the baseline care plan revealed that Resident has problems hearing 10/19/22. Intervention included speak loudly, clearly and slowly. Be conscious of resident position when in groups, activities, dining room to promote proper communication with others. Take care not to startle the resident when approaching or entering the room. There was no mention in the resident's care plan related to the presence of a hearing aid and what staff should be doing with it. Interview on 12/02/22 at 4:51 p.m. with the Minimum Data Set (MDS) Coordinator revealed the resident's care plan should include the use of a hearing device and the care required. She reported the baseline care plan currently in place to address the resident's hearing has not been updated and that usually after 21 days the baseline care plan is updated to a regular comprehensive care plan. 2. Review of Resident #98's admission Record revealed she was originally admitted to the facility on [DATE] and re-admitted on [DATE] and had diagnoses that included fracture of lower end of right femur, infection of lower right knee, and osteoarthritis of right hip, acute postprocedural pain. Review of the MDS assessment, dated 11/19/22, revealed the resident had a BIMS score of 15 (cognitively intact). Observations of Resident #98 on 11/28/22 at 12:33 p.m. revealed the resident sitting up in her bed. The resident reported there was an incident where she did not receive her pain medication for three days. The resident reported that she was told it was due to the pharmacy not having it or not delivering it. Review of the Change in Condition, dated 11/2/22, revealed, Missed medication-night, missed two doses of MS Contin 30 mg (milligram) scheduled pain medication-Meds not available related to pharmacy not receiving a script for refill.; mental status increased level of pain, pain level of 9 ; ordered medications arrived and were administered.; MD (medical doctor) failed to send in script to pharmacy timely causing a delay in ordered medication. Emergency meeting with the Medical Director has been arranged by facility administrator. Review of the progress notes revealed the following: -11/2/22 14:00 (2:00 p.m.) Health Status- Writer along with ARNP (advanced registered nurse practitioner) went to assess for resident's pain to R (right) hip,, resident is taking Norco 5/325 PRN (as needed) q (every) 12 hours, Morphine ER 30 q 12 hours, Tylenol 325 2 tabs q12hrs PRN, along with Baclofen 10 mg bid ARNP wishes to make no changes to the medications. -11/2/22 20:17 (8:17 p.m.) - Morphine Sulfate ER abuse deterrent 30 mg q12hrs related to pain. Not available. -11/3/22 01:46 (1:46 a.m.) -emar (electronic medical record) -mNorco tablet 5/325 mg q12hrs as needed for Post-op tendon repair/chronic pain. Review of physician orders revealed the following: -Monitor for pain 11/18/22, -Morphine Sulfate ER 30 mg q12hrs related to infection of obstetric surgical wound, deep incisional site--Non -acute pain. 11/18/22, -Morphine Sulfate ER 30 mg q12hrs for Non -acute pain/chronic pain. 11/4/22, discontinued 11/9/22, -Morphine Sulfate ER 30 mg q12hrs for pain. (Emergency Supply) 9/7/22, discontinued 11/4/22, -Hydrocodone-Acetaminophen 5-325 mg q 6 hrs (hours) PRN for severe pain, break thru pain non acute pain. 11/18/22, -Acetaminophen 325 mg 2 tabs q 6 hrs for moderate pain; Mild pain 11/7/22, -Hydrocodone-Acetaminophen 5-325 mg q12hrs for severe pain, 11/4/22, discontinued 11/9/22, -Hydrocodone-Acetaminophen 5-325 mg q12hrs for pain, as needed (emergency supply) 10/4/22 discontinued 11/4/22. Review of the admission MDS dated [DATE] revealed, Medical condition-Pain; received scheduled pain medication regimen; received PRN pain medications. Review of current care plans revealed: Care plan related to potential for pain r/t History of falls, History of Fracture: hip 9/20/22 with interventions that included Administer and monitor for effectiveness and for possible side effects from routine and/or PRN pain medication 9/20/22. Care plan related to resident with actual pain 11/3/22 with interventions that included Administer and monitor for effectiveness and for possible side effects from routine and/or PRN pain medication 11/3/22. Review of the Incident report, dated 11/2/22, revealed that, Resident did not receive two doses of her MS CONTIN 30 mg scheduled pain medication. On 11/1/22 [Staff C, LPN] notified [Staff I, Advanced Registered Nurse Practitioner (ARNP)] for the resident's physician that resident only had 3 left. The MD did not call the medication in until 11/2/22 during the night causing a delay. This medication is not available in a med bank. The resident missed her 11/2/22 2100 (9:00 p.m.) and 11/3/22 0800 (8:00 a.m.) doses. Resident Description -Reported that the nurse notified her that the pharmacy did not receive the script for her pain meds. -Resident was administered ordered Tylenol 650 mg at the time of both missed doses. [family member] was notified of missed medication as well as MD reports he failed to order timely. An official grievance was done along with education for the nursing staff. Facility administrator arranged an emergency meeting with the MD for a corrective plan. Review of the November 2022 Medication Administration Record (MAR) indicated the MS Contin medication was not available on 11/2/22 2100 and 11/3/22 0900. Interview on 12/02/22 at 9:44 a.m. with the Director of Nursing (DON) revealed that prior to the incident the resident was on a long term scheduled dose of 30 mg MS Contin. She reported that MAR to cart audits are done weekly by the unit managers, which checks the supply of medications, and nurses two times weekly will check the supplies of narcotics. The DON reported in this case the nurse reported to the ARNP the resident was in need of a new script, but this information was not documented, and usually does not expect the nurses to document each time they talk to or make a request from the doctor. She reported that she does not know what the blue section of the blister pack is for. A phone interview on 12/02/22 at 10:38 with Staff G, Pharmacy Representative revealed she is aware of how blister packs look. She reported the navy blue section is the last seven doses of the medication. She reported when residents' medication is at this section it means the resident is due for a refill. A phone interview on 12/02/22 at 11:11 a.m. with Staff H, Quality Assurance Pharmacist revealed he is familiar with blister packs, and the blue section indicates the medication should be re-ordered. He reported that he was not aware of any incident regarding a late refill for Resident #98's MS Contin. A phone interview on 12/02/22 at 11:41 a.m. with Staff I, ARNP revealed for this resident's MS Contin the refills were being referred to the physician. She reported that she has ordered the medication to be filled on a couple of occasions but was not aware of the full details. Staff I reported that she is scheduled in the building four days a week Monday, Tuesday Wednesday and Thursday if assistance is needed. Review of the facility's policy titled, Comprehensive Assessments and Care Plans, with an issue date of 11/1/2016 and a revised date of 4/5/2021, revealed the following: 8. The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at 483. 10(c)(2) and 483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to provide one resident (#59) out of two sampled residents adequate, and ongoing discharge planning to ensure an effective transition to post-discharge care. Findings included: During an observation and interview on 11/28/22 at 2:35 p.m., Resident #59 stated, Don't think it's right they are sending me home. The resident elaborated that the facility had given the spouse a list of transport companies to call as Resident #59 would have to be discharged by stretcher. The resident reported not being able to transfer or bathe self, was not able to weight bear on left lower extremity, and spouse would be unable to assist. On 12/1/22 at 1:04 p.m., Resident #59 stated getting activities of daily living care was the biggest issue, sometimes it takes two hours or more to be changed (incontinent). The admission Record revealed Resident #59 was admitted on [DATE] and re-admitted on [DATE]. The admission Record included diagnoses not limited to fracture of unspecified part of neck of left femur subsequent encounter for closed fracture with routine healing, unspecified Type 2 diabetes mellitus with diabetic neuropathy, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, need for assistance with personal care, and not elsewhere classified difficulty in walking. The admission Minimum Data Set (MDS), dated [DATE], identified Resident #59's Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating an intact cognition. The MDS indicated the resident required extensive assistance from 2-persons for bed mobility and transfers, extensive assistance from 1-person for dressing, toileting, and personal hygiene, and totally dependent upon 1-person for bathing. The care plan, dated 10/10/22, for Resident #59 identified the resident plans to return home with spouse. The interventions related to this focus instructed staff to: - Establish a pre-discharge plan with the resident/family/caregivers and evaluate progress and revise plan as needed, initiated 10/10/22. - Make arrangements with required community resources to support independence post-discharge Home Health Care (HHC) (and) Medical Doctor (MD), initiated 10/10/22. The Social Service department Advance Directive Care Planning Tracking Form - Admission, dated 9/21/22 and 10/4/22, identified the Social Service Director (SSD) had discussed advance care planning with Resident #59 and documentation was located in the care plan and interdisciplinary plan of care (IPOC). The Initial Evaluation from the Social Service department, dated 10/4/22, for Resident #59 indicated the resident lived at home with spouse in a mobile home that had three stairs outside and the resident's discharge goal was to return home with his spouse. The evaluation identified a named home health company would provide additional supportive services. A telephone interview was conducted, on 12/1/22 at 4:28 p.m., with Resident #59's spouse. The spouse stated the resident and spouse did not want the resident to be discharged until they were able to get him out of bed or in the shower by themselves. The spouse reported getting a (telephone) call the other day indicating the resident was going to be permanently in a wheelchair. The spouse reported they were going to have a wheelchair ramp and a walk in shower built prior to the resident's discharge. The spouse stated, There's no way I can take care of him by myself. The spouse stated the caller informed her a hospital bed would be ordered, delivered within 48 hours, and then the next day Resident #59 would be discharged . The spouse reported the facility had not talked about other (discharge) alternatives with her. She stated, If it comes down to it, the resident could discharge home and get some home health care. An interview was conducted on 12/1/22 at 4:48 p.m., with the SSD who stated, . I have talked to her. The SSD stated Resident #59's spouse was insistent about taking the resident home and they did not feel it was a good idea. The SSD stated Resident #59 was a managed care resident and the case manager notified her to discuss alternative discharge plans as a Notice of Medicare Non-Coverage (NOMNC) would probably be done next week due to non-progression. A review of emails between the SSD and case manager confirmed this information and the SSD informed the case manager the spouse was adamant about taking the resident home. The SSD reported she gave the spouse the name of a volunteer company that would assist with building a wheelchair ramp for them. She stated that she spoke about long-term care with the spouse. The Director of Social Services confirmed that she had not documented that she spoke with the spouse. She stated she would add a late entry into the clinical record regarding the conversation with spouse. A review on 12/2/22 at 8:43 a.m., indicated the SSD produced, on 12/1/22 at 5:08 p.m., a late entry note for 11/29/22. The note indicated the SSD spoke with Resident #59's spouse, related to (r/t) further discharge planning. The note indicated the spouse was not interested in long-term care services but had written down the telephone number for the volunteer company to potentially have a ramp installed. The note indicated the spouse was insistent about bringing the resident home and a discussion had been conducted regarding the use of private caregivers and ordering physical therapy, occupational therapy, and skilled nursing (PT/OT/SN) home health services. The review of Resident #59's clinical record, at 8:43 a.m. on 12/2/22, did not identify any other Social Service progress notes. The facility provided, as requested, all of the Social Service progress notes related to Resident #59. The notes provided indicated a late entry note, effective on 12/1/22 at 1:33 p.m., was produced by the SSD. The note indicated the SSD spoke with Resident #59's spouse r/t further discharge planning. The note documented the spouse would prefer to bring him home but felt she would need more assistance. The SSD asked the spouse if she had contacted named assistance programs the SSD had discussed with her prior. The note indicated the spouse had not and contact information was provided again. The SSD noted the spouse was informed that she would have to contact them to begin the process through the application. The SSD noted that she provided the spouse with contact information for Medicaid long-term care services in the event she is unable to bring him home. The facility policy titled, Discharge Planning Process, issued 12/2017 and revised 3/21/21, indicated, It will be the standard of this facility that the facility will develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners, and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. The policy defined Discharge Planning as a process that generally begins on admission and involves identifying each resident's discharge goals and needs, developing and implementing interventions to address them, and continuously evaluating them throughout the resident's stay to ensure a successful discharge. The guidelines indicated the following: - The facility discharge planning process, which begins at admission will include the following: - (i) Ensure that the discharge needs of each resident are identified and result in the development of a discharge plan for each resident. - (ii) Include regular re-evaluation of residents to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes. - (iii) Involve the interdisciplinary team, in the ongoing process of developing the discharge plan. - (vii)(A) If the resident indicates an interest in returning to the community, the facility will document any referrals to local contact agencies or other appropriate entities made for this purpose. - (vii)(C) If discharge to the community is determined to not be feasible, the facility will document who made the determination and why. The policy identified discharge planning was part of the comprehensive care plan and should include, but not limited to, iv. Be re-evaluated regularly and updated when the resident's needs or goals change. The guidelines of the policy indicated that if the resident wishes to be discharged to a setting that does not appear to meet his or her post-discharge needs, or appeared unsafe, the facility treats the situation similarly to refusal of care and should: - 3 (i): Discuss with the resident (and/or his or her representative, if applicable) and document the implications an/or risks of being discharged to a location that is not equipped to meet his/her needs and attempt to ascertain why the resident is choosing that location; - (ii) Document that other, more suitable, options of location that are equipped to meet the needs of the resident were presented and discussed; - (iii) Document that despite being offered other options that could meet the resident's needs, the resident refused those other more appropriate settings. - (ix) Document, complete on a timely basis based on the resident's needs, and include in the clinical record, the evaluation of the resident's discharge needs and discharge plan. The results of the evaluation will be discussed with the resident or resident's representative. All relevant resident information. Will be incorporated into the discharge plan to facilitate its implementation and to avoid unnecessary delays in the resident's discharge or transfer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure that Activities of Daily Living (ADL) care for four (Residents #52, #59, #92, and #323) of 44 sampled residents were provided within an acceptable time frame. Findings included: 1. Resident #52 was observed and interviewed on 11/29/22 at 9:07 a.m., while lying in bed with the head of bed in an upright position. The resident reported using the call light and had to wait, sometimes for two hours. Resident #52 was admitted on [DATE] and re-admitted on [DATE]. The admission Record included diagnoses not limited to unspecified malignant neoplasm of bladder, hydronephrosis with renal and urethral calculous obstruction, acquired absence of left leg below knee, and pressure ulcer (stage 4) of sacral region. The 5-day Minimum Data Set (MDS) identified a Brief Interview of Mental Status (BIMS) score of 11 out of 15, indicating Resident #52 had moderate cognitive impairment. The MDS indicated the resident required extensive assistance from 1-person for bed mobility, dressing, toilet use, and personal hygiene. The MDS identified the resident had an indwelling catheter. Section H - Bladder and Bowel, of the MDS, indicated that the resident was occasionally incontinent of bladder and bowel. Resident #52's care plan identified that the resident required ADL assistance from 2-persons for toileting needs and staff members were to assist/provide ADL care and support as needed. The care plan indicated the resident had urinary incontinence and staff were to check the resident every 2-3 hours and/or as required for incontinence and to encourage to ask for assistance in advance of need and not wait until need to urinate is urgent. 2. Resident #59 was observed lying in bed, on 11/28/22 at 2:26 p.m., and during the interview at the same time reported using the call light only call when I need to be changed. The resident reported on one occasion he called at 7:00 p.m. and it was the next morning, 6 or 7 a.m., before getting changed. The resident stated last night it took an hour and half to be changed. On 12/01/22 at 1:04 p.m., Resident #59 stated getting ADL care was the biggest issue I have sometimes takes me two hours or more to be changed, not every time just sometimes. The resident stated staff at times answered the call light, turned it off, informed the resident they would be back, and did not come back, to me it seems like they plain forgot. An interview was conducted, on 12/1/22 at 4:28 p.m., with Resident #59's spouse. The spouse reported the resident informed her he had to wait seven hours to be changed, the call light was on, and a person came in, shut off the call light then never came back. One other time, the staff came back knowing they could not get him back in bed by themselves. The spouse stated the biggest thing was the resident having to wait for a response to the call light and when that happened, the resident called her. Resident #59 was admitted on [DATE] and re-admitted on [DATE]. The admission Record included diagnoses not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, fracture of unspecified part of neck of left femur - subsequent encounter for closed fracture with routine healing, and need for assistance with personal care. The admission Minimum Data Set (MDS) identified a Brief Interview of Mental Status (BIMS) score of 14, indicating an intact cognition. The functional status assessment of the resident indicated he required extensive assistance from 2-persons for bed mobility and transferring, and required extensive assistance from 1- person for dressing, toilet use, and personal hygiene. The bladder and bowel section of MDS revealed Resident #59 was occasionally incontinent of both. 3. Resident #92 was observed and interviewed at 12:40 p.m. on 11/28/22 in the resident room. The resident reported on a day during the previous week a male staff member came into the resident's room at 5:30 p.m., shut off the call light, and stated he would be back in a minute to clean her. The resident reported turning the call light on again at 6:30 p.m. and it was on about 45 minutes, when a female staff member came in and shut the light off. After a hour, Resident #92 turned the light on again, turned light on again at 8:30 p.m. and at 10:00 p.m. the male staff member returned. Resident #92 reported on that night when the male staff member returned, everything was soaked including the linen. The resident reported it was not unusual to wait a hour for the call light to be answered. The resident reported it happens all the time, the evening shift is the worse, and taking meal trays takes precedence. Resident #92 was admitted on [DATE]. The admission Record included diagnoses not limited to type 2 myocardial infarction, need for assistance with personal care, type 2 diabetes mellitus with diabetic chronic kidney disease, atherosclerotic heart disease of native coronary artery without angina pectoris, and unspecified chronic obstructive pulmonary disease. The admission Minimum Data Set (MDS), dated [DATE], identified a Brief Interview of Mental Status (BIMS) score of 15 out of 15, indicating an intact cognition. The MDS revealed Resident #92 required extensive assistance from 2-persons for bed mobility, transferring, toilet use, and extensive assistance from 1-person for personal hygiene. Section H of the MDS identified that the resident was always incontinent of bladder and bowel. Resident #92's care plan indicated the resident was incontinent of urine and staff were to check every 2-3 hours and/or as required for incontinence. Provide incontinent care as needed. 4. An observation and interview on 11/28/22 at 11:42 a.m. was conducted with Resident #323. The resident reported staff come in, turn off (call) light, say they are coming back in a minute, and may wait for 45 minutes before they come back. Resident #323 stated feels they should handle the situation then (coming in prior to shutting off light). Resident #323 was admitted on [DATE]. The admission Record included diagnoses not limited to other obstructive and reflux uropathy, chronic obstructive pulmonary disease with (acute) exacerbation, acute respiratory failure with hypoxia, acute on chronic systolic (congestive) heart failure, and acute pulmonary edema. The 5-day Minimum Data Set (MDS), dated [DATE], identified a Brief Interview of Mental Status (BIMS) score of 12 out of 15, indicating moderate cognitive impairment. Resident #323's functional status assessment indicated bed mobility and transferring occurred only once or twice with 2-person assist and toilet use and personal hygiene occurred only once or twice with 1-person assist. Section H of the assessment identified the resident had an indwelling catheter and bowel status was not rated. The care plan for Resident #323 indicated the resident had a urinary catheter related to urinary retention and failed catheter discontinuation. The care plan instructed staff to give catheter care as ordered. The policy - ADL Care and Assistance, issued 12/2016 and 3/27/2021, indicated that It will [be] the standard of this facility to provide the resident with Activities of Daily Living (ADL) care and assistance while attempting to maintain the highest practicable level of function for the resident. The guidelines of the policy indicated that staff should be [mindful] to provide ADL care with dignity, privacy, and respect to the resident, unless otherwise indicated by the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations record review and interview the facility failed to provide activities to meet the needs for residents with vision sensory deficits for one resident (#224) of two residents sampled for activities. Findings included: Review of Resident #224's medical record revealed that this resident was admitted to the facility on [DATE], had a diagnosis that included legal blindness, and a Brief Interview for Mental Status (BIMS), dated 11/21/22, with a score of 05 (severe cognitive impact). Observations of Resident #224 on 11/28/22 at 10:27 a.m. revealed the resident was in her room lying on a low bed with a scoop mattresses, the television on with a low volume that could not be heard when standing next to the television. In an interview with the resident at this time she reported that she was fine with no problems. Observations of Resident #224 on 11/29/22 at 9:00 a.m. revealed the resident was lying in a low bed with a scoop mattress and covered with a blanket. The resident's television was not on and no other activity was noted to be present in the resident's room. In an interview with the resident at this time she reported that she does not want to go anywhere for activity, but would like to have activities in her room, that she would like something to listen to or someone to talk to. She reported that she does not get any activity. Observations of Resident #224 on 12/01/22 at 11:59 a.m. revealed the resident lying in her bed in a low position, with a scoop mattress. Continued observations of the resident's room revealed there was no music playing, no television playing, and no activity noted except for the resident lying in bed sleeping. Interview at this time with Staff C, Licensed Practical Nurse (LPN), revealed that no activity has been provided to Resident #224 and they are trying to find the appropriate activity for her. Interview on 12/01/22 at 12:07 p.m. with the Activities Director revealed activities are provided to all residents. She reported if the resident does not want or would not benefit from group activity then individualized activity is provided with room visits, dvd/cd player, nail care, lotion therapy. aroma lotions. She reported that all attendance to the activities are documented in attendance in POC (plan of care). She reported for residents who are sight impaired they would provide large print bingo cards and help hearing and visually impaired residents during games. The Activities Director reported she could not think of any activity the facility currently provides for individual activity. She reported that Resident #224 is a new admit and does not come out to attend programs. She reported that she does encourage out of room activities. The Activities Director reported the Activities Assistant provides room visits one to two days a week, but does not document the actual activity provided or participated in by the resident. Interview on 12/01/22 at 12:54 p.m. with Staff E, Activities Assistant revealed that she has not done any activities with Resident #224 and is not familiar with the resident. Review of the Activity report provided by the Activities Director for the month of November 2022 revealed activity was provided to Resident #224 on 11/19/22, however it could not be determined what the activity was. Review of the activities initial evaluation, dated 11/17/22, revealed Resident #224 has a religious preference, currently has interest in entertainment, music/singing, socializing, and television. Her preferred activity setting is her own room during the morning and afternoon. The evaluation indicates the facility provides a calendar to encourage participation but does not document any additional leisure supplies provided. The summary section of the evaluation indicated Resident #224 was admitted from the hospital with an admitting diagnosis of metabolic encephalopathy and she is legally blind. She is alert to person, but otherwise has some confusion. She will need to be up and out of room daily for mental stimulation and to be around others. She will require assistance to and from group activities. We will otherwise. Involve her in spectator events and mental stimulation programs. Review of the baseline care plan, dated 11/14/22, revealed: The resident has vision problems related to resident being blind. Review of the care plan, dated 11/18/22, with a revision on 11/21/22 revealed the resident has impaired cognitive function or impaired thought processes r/t (related to) metabolic encephalopathy. She requires staff to anticipate her needs as she isn't able to make her needs known. She is at risk for further decline. Interventions included, Assist to and from group activities such as spiritual events, musicals, and mental stimulation programs,11/18/2, and Encourage the resident to participate in simple, structured activities based on their known interests per their cognitive needs. 11/18/22. Review of the facility's policy titled, General Recreation, with an issue date of 8/1/2007 and a revised date of 10/07/2022, revealed the following: 1. The facility shall provide an ongoing person-centered activities program that incorporates the resident's interests, hobbies, and cultural preferences which is integral to maintaining and/or improving a resident's physical, mental and psychosocial well-being and independence. 2. The facility shall create opportunities for each resident to have a meaningful life by supporting his/her domains of wellness (security, autonomy, growth, Connectedness, Identity, [NAME] and meaning). 3. The facility shall provide meaningful activities that reflects a person's interests and lifestyle, are enjoyable to the person, help the person to feel useful, and provide a sense of belonging. 4. The program will be based on the resident's comprehensive assessment and person-centered care plan, and meet the resident's interests and preferences, and support his/her physical, mental, and psychosocial well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the resident's medical record, review of the facility's policy on Hospice/Palliative /End of Life Care and the agreement with the hospice provider and interview with facility staff and the hospice nurse, the facility failed to ensure coordination of care between the facility and hospice, for one resident (#16) of one resident reviewed for hospice care. Findings included: Review of the admission Record revealed Resident #16 was initially admitted to the facility on [DATE] with diagnoses that included Type 2 diabetes mellitus with neuropathy and an above the knee amputation, rheumatoid arthritis, chronic pain and a personal history of malignant neoplasm of the kidney. A review of the resident's medical record revealed a physician's order for Hospice care dated 08/29/2022. A Quarterly Minimum Data Set (MDS) Assessment was completed on 09/14/2022 which indicated the resident was on Hospice. An interview was conducted with the Staff J, Registered Nurse (RN)/MDS on 11/30/2022 beginning at 3:45 p.m. Staff J confirmed that Hospice was initiated on 08/18/2022 and the facility held a quarterly care plan meeting on 09/01/2022 for a quarterly MDS that was completed on 09/14/2022. She reported both the resident's family member and Hospice were invited but neither attended. She was not able to provide documentation that anyone had actually invited the Hospice provider. Staff J, after reviewing her notes, confirmed it didn't look like Hospice was being invited to the care plan meetings. When Staff J was asked about coordination of care between the facility staff and the Hospice provider, she reported that she knew only of the binders Hospice kept their paperwork in and they were kept at the nursing station. She confirmed Hospice did not have access to the electronic medical record and they were not able to read other providers' notes or document the care they had provided. Staff J reviewed the care plan that had been developed on 09/14/2022 and referred to a care plan developed by the facility for the Resident #16's Hospice care. She confirmed it wasn't the Hospice care plan, it was the facility's care plan. She reported the Hospice care plan was probably kept in the binder at the nurses' station. A review was conducted of the progress notes maintained in the facility's electronic medical record for Resident #16 from the time of the initiation of Hospice (8/18/22) until 11/30/2022. A note written by the Social Services Director, dated 08/22/2022, referred to the completion of a significant change evaluation based on the resident's enrollment in hospice due to his significant health decline in many areas - cognition, behavior and mood, apparent signs of confusion and forgetfulness, appetite, and less participation in group activities. A note written by the Registered Dietitian was dated 09/13/2022 and referred to the recent start with the Hospice service. She documented the expected decline related to the disease progression. She added the resident had weight loss, had varied intake at meals, and the nutrition support had been added. The only nurse's note during that time period related to Hospice and coordinating care was dated 10/24/2022. The nurse wrote the resident was vomiting and she called Hospice for an order for an antiemetic medication. An interview was conducted with the resident's nurse, Staff K, Licensed Practical Nurse (LPN), on 11/30/22 beginning at 3:05 p.m. Staff K provided Resident #16's Hospice binder and confirmed the Hospice providers (nurses and aides) do not have access to the facility's electronic medical record. Staff K confirmed Hospice maintains their notes in their binders. She reported she usually sees the Hospice nurse once or twice a week and will update the nurse verbally as to any changes in the resident's condition. She reported she has the Hospice Nurse's phone number and can call with any concerns. The facility's policy for the Standards and Guidelines for Hospice/Palliative/End of Life Care revealed the Standard: It will be the standard of this facility to provide, participate in or collaborate with the provision of dignified palliative, hospice, or end of life care. Under Guidelines, point # 13 read: In order to provide continuity of care, the hospice, nursing home and resident/representative must collaborate in the development of a coordinated care plan. The nursing home and the hospice must be aware of the location and content of the coordinated care plan (which includes the nursing home portion and the hospice portion) and the plan must be current and internally consistent in order to assure that the needs of the resident for both hospice care and nursing home care are met at all times. Point #17 indicated the facility would designate a member of the facility's interdisciplinary team to be responsible for working with the Hospice representative to coordinate the care to the resident provided by the facility and Hospice staff. The policy indicated that the DON (Director of Nursing) would be the designated staff responsible for coordinating the care. An interview was conducted with the DON on 12/01/2022 beginning at 9:33 a.m. The DON reported the Hospice providers have access to the electronic medical record and either their notes were in the Progress Section of the record or any paper documentation would be scanned into the electronic medical record. The DON was notified the Hospice providers did not have access to the electronic medical record, as reported by the Regional MDS (Minimum Data Set) Coordinator in the interview that was conducted on 11/30/2022 beginning at 3:45 p.m. She was notified that no Hospice notes were in the Miscellaneous section of the electronic medical record, having been scanned in. The DON seemed surprised at the information and added the plan was for Hospice to have access. A review was conducted of the Agreement between the Hospice provider and the facility. Point #7 in the agreement was headed: Communications concerning hospice patient and included, The parties will communicate pertinent information with each other either verbally or in the hospice patient's record at least weekly and/or at each hospice patient visit to ensure the needs of each Hospice patient are addressed and met 24 hours per day. Documentation of such communication shall be included in the Hospice Patient's medical record. An interview by phone was conducted with the resident's Hospice Nurse on 12/07/2022 beginning at 9:50 a.m. The nurse confirmed that she speaks with the resident's nurse usually at every visit. She confirmed each of her patient's has their own binder for notes as the Hospice providers do not have access to the electronic medical record. She reported if the facility wanted her at the plan of care meetings they would invite her, but she could not recall the last time she was invited or attended a care plan meeting. She confirmed she did not have a copy of the facility's care plan for this resident and the hospice service.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interview the facility failed adequately provide pain management to 2 (#98, #221) of 6 residents sampled for pain out of a total sample of 44 residents. Findings included: 1. Review of Resident #98's admission record revealed that she was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses to include fracture of lower end of right femur, infection of lower right knee, osteoarthritis of right hip, and other acute postprocedural pain. Review of the re-admission assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 (cognitively intact). Observations of Resident #98 on 11/28/22 at 12:33 PM revealed the resident sitting up in her bed. The resident reported that there was an incident where she did not receive her pain medication for 3 days. The resident reported that she was told that it was due to pharmacy not having it or not delivering it. Review of the facility report dated 11/2/22 revealed Resident did not receive two doses of her MS CONTIN 30 mg scheduled pain medication. On 11/1/22 Staff C, Licensed Practical Nurse (LPN) notified Staff I, Advanced Registered Nurse Practitioner (ARNP) for the resident's Medical Doctor (MD) that resident only had 3 tablets left. The MD did not call the medication in until 11/2/22 during the night causing a delay. This medication was not available in a med bank. The resident missed her 11/2/22 9:00 PM and 11/3/22 8:00 AM doses. The resident was notified by the nurse that the pharmacy did not receive the script for her pain meds. Resident was administered ordered Tylenol 650 mg at the time of both missed doses. Daughter was notified of missed medication as well as MD reports he failed to order timely. An official grievance was done along with education for the nursing staff. The facility administrator arranged an emergency meeting with the MD for a corrective plan. Review of the Medication Administration Record (MAR) for November 2022 confirmed the MS Contin medication was not available for administration on 11/2/22 at 9 PM and 11/3/22 9 AM. Review of the Change in Condition documentation dated 11/2/22 revealed: Missed medication-night, missed two doses of MS Contin 30 mg scheduled pain medication. Meds not available related to pharmacy not receiving a script for refill; mental status increased level of pain, pain level of 9; ordered medications arrived and were administered; MD failed to send in script to pharmacy timely causing a delay in ordered medication. Emergency meeting with the Medical Director has been arranged by facility administrator. Review of the progress notes revealed the following: 11/2/22 2:00 PM Health Status- Writer along with ARNP went to assess for resident's pain to right hip, resident is taking Norco 5/325 PRN (as needed) every 12 hours, Morphine ER 30 every 12 hours, Tylenol 325 2 tabs every 12 hours PRN, along with Baclofen 10 mg twice a day (BID). ARNP wishes to make no changes to the medications. 11/2/22 8:17 PM Morphine Sulfate ER abuse deterrent 30 mg every 12 hours related to pain. Not available. 11/3/22 1:46 AM Electronic MAR -Norco tablet 5/325 mg every 12 hours as needed for Post-op tendon repair/chronic pain. Review of physician orders revealed: Monitor for pain 11/18/22 Morphine Sulfate ER 30 mg every 12 hours related to infection of obstetric surgical wound, deep incisional site--Non-acute pain 11/18/22 Morphine Sulfate ER 30 mg every 12 hours for Non-acute pain/chronic pain 11/4/22, discontinued 11/9/22 Morphine Sulfate ER 30 mg every 12 hours for pain (Emergency Supply) 9/7/22, discontinued 11/4/22 Hydrocodone-Acetaminophen 5-325 mg every 6 hours PRN for severe pain, break thru pain non acute pain 11/18/22 Acetaminophen 325 mg 2 tabs every 6 hours for moderate pain; mild pain 11/7/22 Hydrocodone-Acetaminophen 5-325 mg every 12 hours for severe pain 11/4/22, discontinued 11/9/22 Hydrocodone-Acetaminophen 5-325 mg every 12 hours for pain, as needed (Emergency Supply) 10/4/22, discontinued 11/4/22. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Medical condition-Pain; received scheduled pain medication regimen; received PRN pain medications. Review of the care plan dated 9/20/22 revealed a focus area of POTENTIAL for pain r/t History of falls, History of Fracture: hip with interventions that included Administer and monitor for effectiveness and for possible side effects from routine and/or PRN pain medications. Continued review of the care plan revealed an additional focus area of ACTUAL pain initiated on 11/3/22 with interventions to include Administer and monitor for effectiveness and for possible side effects from routine and/or PRN pain medications. Interview on 12/02/22 at 9:44 AM with the Director of Nursing (DON) revealed that prior to the incident the resident was on a long term scheduled dose of 30 mg MS Contin. She reported that MAR to cart audits are done weekly by the unit managers, which checks the supply of medications, and twice weekly nurses will check the supplies of narcotics. The DON reported that in this case, the nurse reported to the ARNP that the resident was in need of a new script, but this information was not documented, and usually she does not expect the nurses to document each time they talk to or make a request from the doctor. She reported that she does not know what the blue section of the blister pack was for. Phone interview on 12/02/22 at 10:38 AM with Staff G, Pharmacy Representative revealed the navy blue section of the blister pack shows the last 7 doses of medication. She reported that when residents' medication supply reaches the blue portion that means the resident was due for a refill. Phone interview on 12/02/22 at 11:11 AM with Staff H, Quality Assurance Pharmacist revealed that he was familiar with the blister packs, and the blue section indicated that the medication should be re-ordered. He reported that he was not aware of any incident regarding a late refill for Resident #98's MS CONTIN. Phone interview on 12/02/22 at 11:41 AM with Staff I, ARNP revealed that Resident #98's MS CONTIN refills were being referred to the physician. She reported that she had ordered the medication to be filled on a couple of occasions, but was not aware of the full details. Staff I reported that she was scheduled in the building 4 days a week - Monday, Tuesday Wednesday, and Thursday if assistance was needed. Resident #98 missed doses of MS Contin on Wednesday, 11/2/2022 and Thursday, 11/3/2022. 2. Review of Resident #221's admission record revealed he was admitted to the facility on [DATE] with diagnoses to include recurrent dislocation of right hip, orthopedic aftercare, major depressive disorder recurrent, and anxiety disorder. Review of the admission summary revealed the document was completed on 4/15/22 at 23:40 (11:40 PM). The admission summary included a pain screening which indicated No pain. Review of the record revealed the resident was admitted with a paper prescription dated 04/15/22 from the hospital for Acetaminophen-Hydrocodone 325 mg-5 mg every 4 hours for 3 days as needed for pain, moderate/breakthrough pain. Review of the facility's physician orders revealed an order date and start date of 4/16/22 for: Diclofenac-Misoprostol tablet delayed release (DR)75-0.2 mg - give one tablet by mouth two times a day for moderate pain. Hydrocodone-Acetaminophen Tablet 5-325 mg give one tablet by mouth every 6 hours as needed for moderate pain for 3 days. Review of Medication Administration Record (MAR) for the month of April 2022 revealed that the resident received his first dose of Diclofenac-Misoprostol 75 mg-200 mcg on 4/16/22 at 2100 (9:00 PM). Review of MAR for monitoring pain revealed the first documentation of pain was on 4/16/22 at a level of 8 during the day shift. The resident received Hydrocodone-Acetaminophen Tablet 5-325 mg as needed for pain at 1327 (1:27 PM). Review of the baseline care plan initiated 4/16/22 revealed the resident has pain or the potential to have pain. The base line care plan included only one intervention: If the resident receives medication to manage the pain, watch for side effects of the pain medicine. Review of the Discharge summary dated [DATE] at 11:34 indicated resident left AMA [against medical advice] with belongings wife states he was not pleased with care provided. resident refused to stay and speak with management tomorrow. Interview on 12/02/22 at 1:49 PM with the DON revealed Resident #221 may have missed 1-2 doses of his routine pain medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to ensure medications were stored securely and inaccessible by unauthorized staff, residents, and visitors for two residents (#324 and #52) out of a sample of 44 residents. Findings included: 1. A review of the Admission/re-admission Nursing Note, dated 11/14/22, showed Resident #324 was admitted on [DATE] and indicated the resident as oriented to person, place, time, and situation. The admission note identified that on 11/14/22 medications and orders were verified with the provider and the resident did not choose to self-administer medications. On 11/28/22 at 11:56 a.m., an observation was made of a bottle of cold sore medication with cotton-tip applicators in a brown medication bottle from a prominent national pharmacy and a bottle of over-the counter urinary pain medication sitting on the over-bed table of Resident #324. An observation was made on 11/29/22 at 5:14 p.m., of the bottle of cold sore medication and urinary pain relief medication continued to be stored on the over-bed table of Resident #324. The resident stated, at this time, she had not taken the pain relief medication for at least two to three days. The resident described the urinary pain relief medication as similar to Pyridium. On 11/29/22 at 5:18 p.m., Staff A, Registered Nurse (RN) stated the resident (#324) could probably self-administer medications. Staff A confirmed the resident had not been assessed for self-administration and was unaware of medications left at the bedside. Staff A observed three medications on Resident #324's over-bed table, which included the urinary pain relief tablets, oral pain medication containing 20% lidocaine, and a bottle of saline nasal spray. The nurse educated the resident that the facility required physician orders for the medications and could not be left at bedside. The Director of Nursing (DON) reported, on 12/2/22 at 4:44 p.m., that she was unaware of medications left at Resident #324's bedside. She stated apparently someone had brought them from the outside and the facility would start education on securing medications. A review of the November 2022 Medication Administration Record (MAR) did not indicate that Resident #324 had an order for cold sore lidocaine medication, urinary pain medication, or the saline nasal spray. 2. Review of the admission Record revealed Resident #52 was admitted on [DATE] and re-admitted on [DATE]. The admission Record included diagnoses not limited to stage 4 pressure ulcer of sacral region. The Minimum Data Set (MDS), dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating moderate cognition impairment. The Order Summary Report, active as of 12/2/2, included the following physician order related to the care of Resident #52's wound: - Cleanse wound to coccyx with Dakins, pat dry. Apply Calcium Alginate AG/silver to wound bed and cover with dry dressing every day shift, dated 11/22/22. An observation was conducted on 12/1/22 at 8:08 a.m., with Staff X, Registered Nurse/Wound Care Nurse (RN/WCN) of wound care for Resident #52. Staff X removed wound care supplies from the treatment cart that included an opened bottle of Dakins, a sodium hypochlorite solution. During the setup of supplies prior to starting the wound care, an opened bottle of Dakins was observed on a shelf under the television. Staff X stated the resident had a personal bottle (of Dakins) and placed the bottle next to the other bottle that she had removed from the treatment cart on the over-bed table next to the resident's bed. The nurse stated that Dakins had bleach in it so it cleans (wounds) real well. After completing the wound care as the nurse began cleaning up the used supplies, she placed the bottle of quarter-strength (green label) Dakins back on the shelf under the resident's television. Staff X stated, on 12/1/22 at 8:47 a.m., I think he's able to keep it, regarding the storage of the open bottle of Dakins unsecured in Resident #52's room. Then Staff X stated, Yeah that may be a problem. The Director of Nursing stated, on 12/2/22 at 4:44 p.m., she was aware of the Dakins bottle that was stored at Resident #52's bedside. She confirmed the bottle should not be there. The policy titled, Medication Storage, issued 8/1/2006 and revised 10/24/22, indicated: It will be the standard of this facility to store medications, drugs, and biologicals in a safe, secure and orderly manner. The guidelines identified, Only persons authorized to prepare and administer medications shall have access to the medication room, including any keys, unless accompanied by a license nurse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, and policy review the facility did not ensure one resident (#43) out of forty-four residents sampled was provided dental provided or made aware of dental services available to residents. Finding included: An interview was conducted with Resident #43 on 11/28/22 at 12:20 p.m. The resident stated she had beautiful teeth when she came to this facility and now her tooth is cracked. She stated she has not been able to see a dentist. Resident #42 was observed to have a chipped upper center tooth. Review of the admission Record showed Resident #43 was admitted initially on 8/13/21 and readmitted on [DATE] with diagnoses including epilepsy, hemiplegia, and hemiparesis following cerebral infarction affecting right dominant side. A review of Resident #43's admission Evaluation of Body Systems, dated 8/13/21, showed Oral status was checked for no problem. It stated a Baseline Care Plan as Resident has oral health concerns. With interventions including refer for dental care as appropriate. A review of Resident #43's care plans did not reveal any current care plans related to dental care. On 12/1/22 at 2:50 p.m. an interview was conducted with the Social Services Director. She stated the facility uses a contract company for dental services. She stated that company receives a list of new long-term care residents. The company then contacts the resident or family to see if they would like to enroll in dental services. She stated Resident #43 is not enrolled in dental services and has not seen a dentist since arriving at the facility. The Social Services Director stated she would reach out to the company to see what contact they had with the resident or family. On 12/2/22 at 1:50 p.m. the Social Services Director stated she spoke with the dental company, and they had no documentation regarding the resident or any resident/family contact. On 12/2/22 at 3:33 p.m. an interview was conducted with Resident #43's responsible party. She stated her [Resident #43] did not have a cracked tooth when she came to the facility. She stated she has never been told any information about a dental program or enrolling in dental care. She stated she was never contacted by a company regarding dental services at the facility. She stated her [Resident #43] was in a dental program in a previous facility, but she didn't know one was available at this facility. On 12/2/22 at 3:45 p.m. a follow up interview was conducted with the Social Services Director. She stated the process for dental is that she runs a report from the admission record and sends face sheets of new long-term care residents to the dental company. The dental companies sales/marketing team call the families or visits the residents. She stated she only knows who has dental if pulling the dental information from billing. She stated the dental company also sends notes after they visit residents. The Social Services Director stated the company has never provided a list of who they contacted, who denied dental care or who enrolled. She confirmed the facility has not asked for that information and it is not something they have tracked. She stated she is going to call the company and see if that is something they can do going forward. She stated she is going to ensure the company contacts Resident #43's family. A facility policy titled, SG (Standards and Guidelines) Dental Services/Oral Care, dated 12/7/2015 stated the following: It will be standard of this facility that dental services and oral care are available to meet the resident's oral health services in accordance with the resident's assessment, plan of care or emergency care. Emergency dental services includes services needed to treat an episode of acute pain in teeth, gums, or palate; broken or otherwise damaged teeth, or any other problem of the oral cavity that required immediate attention by a dentist. Guidelines: 1. Oral health services are available to meet the resident's needs and per the resident's wishes. Resident dental/oral status should attempt to be established upon admission and periodically through residency as is needed. 5. The Director of Nursing, or his/her designee, is responsible for notifying Social Services of a resident's need for dental services after identification of needs through assessment/evaluation or notification by a resident of their need for dental services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a complete medical record containing documentation of communication with the family and caseworker related to discharge planning was completed for one (#222) of six residents reviewed for discharge out of a total sample of 44 residents. Findings included: Review of Resident #222's admission record revealed that he was admitted to the facility on [DATE]. Review of the physician order dated 5/18/22 revealed the resident may discharge to another skilled nursing facility on 5/19/22. Review of the care plan dated 4/19/22 with a revision date of 5/19/22 (the day of discharge) revealed a focus area of: Responsible Party is planning to move the resident to a facility closer to family. They are hoping for a Veterans Administration (VA) Skilled Nursing Facility (SNF). Interventions initiated for this focus area were initiated on 4/19/22 and included: Establish a pre-discharge plan with the resident/family/caregivers and evaluate progress and revise plan as needed; Make arrangements with required community resources to support independence post-discharge HHC (home health care) and MD (medical doctor). Review of the Discharge summary dated [DATE] revealed the resident was transferring to another skilled nursing facility in order to be closer to his son's home. Resident in agreeable with transfer and is looking forward to being closer to his son for further visits. There are no further recommendations at this time. Interview on 12/02/22 at 5:54 PM with the Social Service Director (SSD) revealed that to her knowledge the resident's family member reported that he was working with the VA for placement. She reported that she worked with the VA caseworker on discharge planning and and sent her all the needed documents timely. She reported that she did not document any correspondents with the VA caseworker related to discharge planning. Continued interview with the SSD at this time revealed that there was a care plan meeting on 4/21/22 where the resident's family member wanted the resident to remain in the facility for long term care. She reported that as a part of the initial evaluation which was dated on 4/12/22, referrals were sent to the VA caseworker. The SSD had no other documentation to provide that would indicate on-going communication was established between the facility, family, the VA caseworker and the new skilled nursing facility selected by the resident's family to ensure a timely and smooth transition. Review of the facility policy titled Discharge Planning Process dated 12/2017 with a revised date of 03/21/2021 revealed that (ix) Document, complete on a timely basis based on the resident's needs, and include in the clinical record, the evaluation of the resident's discharge needs and discharge plan. The results of the evaluation will be discussed with the resident or resident's representative. All relevant resident information. Will be incorporated into the discharge plan to facilitate its implementation and to avoid unnecessary delays in the resident's discharge or transfer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, and the Plan of Correction (POC) review, the facility failed to ensure it had a functioning Quality Assurance (QA) Committee. The facility was actively involved in the effective creation, implementation, and monitoring of the POC for deficient practice identified during a recertification survey conducted on [DATE]. The facility was cited during the recertification survey for F 578. On [DATE] a revisit survey was conducted and the facility was recited at F 578. The facility had developed a Plan of Correction with a completion date by [DATE]. The facility had not comprehensively implemented the Plan of Correction for the identified quality deficiencies. Findings included: The Electronic Health Record (EHR) for Resident #1 was reviewed on [DATE] at 11:00 a.m. It revealed the resident was initially admitted to the facility on [DATE] and re-admitted on [DATE]. Observation of the information banner under Resident #1's name revealed code status listed as DNR (Do Not Resuscitate). A review of the physician orders revealed an order for Advance Directive: DNR dated [DATE]. The care plan for Resident #1 revealed a focus area for advance directives which included resident/representative had chosen to be a full code status, initiated [DATE]. A review of progress notes revealed an admission summary note dated [DATE] which documented, the resident has elected to be full code. A review of the Brief Interview for Mental Status (BIMS) assessment, dated [DATE], revealed a score of 15, indicating Resident #1 was not cognitively impaired. A review of the admission record revealed Resident #1 was his own responsible party and decision maker. An interview was conducted with Resident #1 on [DATE] at 11:24 a.m. He stated nobody at the facility, including physicians, had spoken with him about advance directives or code status. He stated his wishes for code status were to be resuscitated (full code). An interview was conducted with the facility Social Services Director (SSD) and the facility Director of Nursing (DON) on [DATE] at 11:45 a.m. The DNR status found in the EHR for Resident #1 was reviewed in the interview by the DON and the SSD. The DON confirmed the record revealed code status of DNR and according to the record and physician orders at this time Resident #1's code status was DNR. The SSD confirmed she had a role in identifying advance directives and code status for facility residents and reported part of the process was that she completed a document called IPOC (initial plan of care) when a resident was admitted to the facility, which included discussing advance directives and code status. She revealed these documents completed by her for Resident #1 in the EHR, one was dated [DATE] and included, Resident admitted for therapy with plans to return to [assisted living facility]. His 3008 stated he was a DNR, upon interview with resident he states that if he is found without a pulse, he wishes for us to provide him with CPR (cardiopulmonary resuscitation). He now has a Full Code order on file . The SSD reported she had immediately informed the nursing staff and said, I told the nurses, because I can't change a code status order. There was a second IPOC document completed by SSD dated [DATE] which included, .Resident readmitted to the facility after hospitalization .He wishes to remain a Full Code while in this facility. There have been no changes to his code status nor his initiated plans for discharge at this time. The DON and SSD confirmed these discrepant findings were cause for concern. Interview was paused so they could take immediate action. On [DATE] at 12:37 p.m. the interview resumed with the SSD and DON. The DON stated, we both went and spoke with the resident (Resident #1) after our previous conversation, let him know we had identified discrepancy on advance directives and code status, he clarified with us he wants to remain a full code and we told him we would seek an order from his doctor, and he agreed. The DON revealed in the EHR that code status orders and status had been changed to Full Code for Resident #1. Regarding her documentation on [DATE] that an order for full code was on file for Resident #1, the SSD stated, honestly, I should have waited until the order was put in, I told the nurse about it. Regarding how this discrepancy was not caught despite regular audits ongoing in the facility related to advance directives and code status, the SSD stated, I do a DNR audit every week every Friday, the reason why the DNR audit did not find the problem is because he (Resident #1) had a yellow DNR (State of Florida DNR order) in the binders and he had the order for the DNR (physician order in medical record). The SSD stated, during my weekly audit it did not trigger me to think I had a conversation with him about being full code. The DON reported when she was getting Resident #1's code status orders changed to full code she had spoken with his primary care physician's Advanced Registered Nurse Practitioner (ARNP) because she had called her to get the order. The DON reported the ARNP told her she was under the impression Resident #1 was a DNR. On [DATE] at 1:56 p.m. the DON and facility corporation Regional Nurse Consultant (RNC) followed up with a timeline of physician orders for code status for Resident #1. The RNC provided an order summary document and stated, he was changed to a full code on [DATE], on [DATE] ARNP went in and discontinued full code order and put in an order for DNR. DON interjected that the ARNP had told her she had made that change because she had a discussion with Resident #1. The RNC confirmed that following this, Resident #1 went to the hospital and she stated that when he returned to the facility on [DATE] he was a DNR from the hospital and she did not know those details. She revealed on the order summary that an order was put in for DNR as of [DATE] and had remained that way until this matter was brought to their attention on [DATE]. A telephone interview was conducted with the ARNP on [DATE] at 2:59 p.m. Regarding her process for determining code status for facility residents she stated, I generally go based off of the code status that's listed in their chart (clarified that she was referring to the information banner/header under the resident's name in the EHR). She stated she would also see if they had DNR documentation in their other documents. The ANRP stated that any time she had a discussion with any resident about code status she would document that. Regarding Resident #1, the ARNP said, I don't recall ever having a conversation with him about code status and stated in his case she would have gone off of what was in his chart on the banner in the EHR. Regarding whether she was involved in any facility process or meetings related to ensuring accurate code status for residents she stated she was not but said, it will be part of my process now. A review of facility policy titled, Standards and Guidelines: SG Determination of Code Status_Florida revised [DATE] revealed the following: 1. Upon admission the nurse completing the admission assessment will ascertain resident's desired code status (Full Code or DNR). 2. Upon determination of resident/responsible party wishes, the nurse will document those wishes in the admission nursing assessment. 4. The nurse will contact the attending physician and obtain order for Full Code or DNR per resident or responsible party wishes. 7. The electronic medical record (including electronic chat, point of care kiosk or eMar) will serve as the primary source of validation of code status should a resident be found unresponsive. A review of facility policy titled, Standards and Guidelines: SG Resident Rights, Dignity, and Visitation Rights revised [DATE] revealed that all facility residents have the right to request, refuse, and/or discontinue treatment, and to formulate an advance directive An interview was conducted with the DON and RNC on [DATE] at 1:56 p.m. regarding the audit process and they confirmed the process needed improvement in order to catch they type of error that was identified related to Resident #1. An interview was conducted with the SSD on [DATE] at 4:05 p.m. regarding whether she would be making any changes to her process going forward. She stated she would be following up with the nursing staff after completing her IPOC assessment until certain any needed changes to code status had been made. She stated she would follow up same day and in stand-down meeting if change had still not been made and said, I'm just going to bulldog it until I'm sure the nurse has followed up. Review of facility policy titled, Standards and Guidelines: SG Quality Assurance and Performance (QAPI) program revised [DATE] included the following: It will be the standard of this facility that the facility, including a facility that is part of a multiunit chain, will develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life. The governing body and/or executive leadership (or organized group or individual who assumes full legal authority and responsibility for operation of the facility) is responsible and accountable for ensuring that: --An ongoing QAPI program is defined, implemented, and maintained and addresses identified priorities. --The QAPI program is adequately resourced, including ensuring staff time, equipment, and technical training as needed. --The QAPI program identifies and prioritizes problems and opportunities that reflect organizational process, functions, and services provided to residents based on performance indicator data, and resident and staff input, and other information. --Corrective actions address gaps in systems, and are evaluated for effectiveness. --Clear expectations are set around safety, quality, rights, choice, and respect.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, and record reviews, the facility failed to provide nursing and related services that enabled residents to attain and maintain their highest practicable physical, mental and psychosocial well-being for seven (Residents #52, #59, #92, #321, #323, #26, and #50) of forty-four sampled residents related to call light response when assistance was required. Findings included: During an interview, the Director of Nursing (DON) stated, at 2:07 p.m. on 12/1/22, that a call light should not be shut off until the need was taken care of. On 12/1/22 at 2:22 p.m., during an interview with the Regional Director of Clinical Services (RDCS), DON, and Nursing Home Administrator (NHA), the RDCS and NHA stated the call light monitoring system did not allow for reports, (call light times) and could only be seen in real time. The RDCS stated she believed the facility would have to purchase that (reports) capability. An observation was conducted on 11/29/22 at 9:22 a.m., of a call light response monitor, located at the 300-unit nursing station. The monitor indicated that the call light for room [ROOM NUMBER] had been on for 23 minutes. 1. Resident #52 was observed and interviewed on 11/29/22 at 9:07 a.m., while lying in bed with the head of bed in an upright position. The resident reported using the call light and had to wait, sometimes for 2 hours. Record review revealed Resident #52 was admitted on [DATE] and re-admitted on [DATE]. The admission Record included diagnoses not limited to unspecified malignant neoplasm of bladder, hydronephrosis with renal and urethral calculous obstruction, acquired absence of left leg below knee, and pressure ulcer (stage 4) of sacral region. The 5-day Minimum Data Set (MDS) identified a Brief Interview of Mental Status (BIMS) score of 11 out of 15, indicating Resident #52 had moderate cognition impairment. The MDS indicated the resident required extensive assistance from 1-person for bed mobility, dressing, toilet use, and personal hygiene. The MDS identified the resident had an indwelling catheter. Section H - Bladder and Bowel, of the MDS, indicated that the resident was occasionally incontinent of bladder and bowel. Resident #52's care plan identified the resident required ADL (activities of daily living) assistance from 2-persons for toileting needs and staff members were to assist/provide ADL care and support as needed. The care plan indicated the resident had urinary incontinence and staff were to check the resident every 2-3 hours and/or as required for incontinence and to encourage to ask for assistance in advance of need and not wait until need to urinate is urgent. 2. Resident #59 was observed lying in bed, on 11/28/22 at 2:26 p.m., and during the interview at the same time reported using the call light only call when I need to be changed. The resident reported that one occasion he called at 7:00 p.m. and it was the next morning, around 6 or 7 a.m., before getting changed. The resident stated last night it took hour and half to be changed. During an interview on 12/01/22 at 1:04 p.m., Resident #59 stated getting ADL care was the biggest issue I have; sometimes takes me 2 hours or more to be changed, not every time just sometimes. The resident stated that staff at times answered the call light, turned it off, informed the resident that they would bed back and did not come back, to me it seems like they plain forgot. An interview was conducted, on 12/1/22 at 4:28 p.m., with Resident #59's spouse. The spouse reported the resident had informed her that he had to wait 7 hours to be changed, stating the call light was on, and a person came in shut off the call light then never came back to quarter to seven at shift change. The spouse stated the biggest thing was the resident having to wait for call light help and when that happened, the resident called her. Record review revealed Resident #59 was admitted on [DATE] and re-admitted on [DATE]. The admission Record included diagnoses not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, fracture of unspecified part of neck of left femur - subsequent encounter for closed fracture with routine healing and need for assistance with personal care. The admission Minimum Data Set (MDS) identified a Brief Interview of Mental Status (BIMS) score of 14, indicating an intact cognition. The functional status assessment of the resident indicated that the resident required extensive assistance from 2-persons for bed mobility and transferring and required extensive assistance from 1- person for dressing, toilet use, and personal hygiene. The bladder and bowel section of MDS revealed that Resident #59 was occasionally incontinent of both. 3. Resident #92 was observed and interviewed at 12:40 p.m. on 11/28/22 in the resident's room. The resident reported that on a day during the previous week a male staff member came into the resident room at 5:30 p.m., shut off the call light, and stated he would be back in a minute to clean her. The resident reported turning the call light on again at 6:30 p.m. and it was on about 45 minutes, when a female staff member came in and shut the light off again. After an hour, Resident #92 turned the light on again at 8:30 p.m. and at 10:00 p.m. the male staff member returned. Resident #92 reported on that night when the male staff member returned everything was soaked including the linen. The resident reported it was not unusual to wait an hour for the call light to be answered. The resident reported it happens all the time/ saying the evening shift is the worse, and taking meal trays takes precedence. Record review revealed Resident #92 was admitted on [DATE]. The admission Record included diagnoses not limited to type 2 myocardial infarction, need for assistance with personal care, type 2 diabetes mellitus with diabetic chronic kidney disease, atherosclerotic heart disease of native coronary artery without angina pectoris, and unspecified chronic obstructive pulmonary disease. The admission Minimum Data Set (MDS), dated [DATE], identified a Brief Interview of Mental Status (BIMS) score of 15 out of 15, indicating an intact cognition. The MDS revealed that Resident #92 required extensive assistance from 2-persons for bed mobility, transferring, toilet use and extensive assistance from 1-person for personal hygiene. Section H of the MDS identified that the resident was always incontinent of bladder and bowel. Resident #92's care plan indicated that the resident was incontinent of urine and staff were to check every 2-3 hours and/or as required for incontinence. Provide incontinent care as needed. 4. Record review revealed Resident #321 was admitted on [DATE] and discharged on 10/17/22. The admission Record included diagnoses not limited to other seizures, other specified urinary incontinence, colostomy status, and unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A grievance dated 10/12/22 indicated that staff were concerned about lack of care for Resident #321. The description indicated that staff had reported to the DON and NHA that the resident was left wet and not changed timely by an off-going CNA. The findings indicated, After interviews with staff, it was determined the resident was rounded on and changed during the 7-3 shift, it was not best practice timely. The plan to resolve revealed the employee was placed on a performance improvement plan (PIP) - further training along with written counseling for failure to notify her supervisor that she was having a hard time keeping up with her assignments. On 12/1/22 at 2:07 p.m., an interview was conducted with the Regional Director of Clinical Services (RDCS) and the DON. The DON stated a Certified Nursing Assistant (CNA) that worked the 3-11 p.m. shift filed a grievance against the 7 a.m. - 3 p.m. shift CNA regarding the lack of care provided to Resident #321. The investigation of the grievance revealed the 7 to 3 CNA had been in the resident room [ROOM NUMBER] 1/2 hours earlier and had reported that the assignment was too heavy. The CNA was placed on a performance plan, moved to another assignment, then ultimately terminated due to the inability to keep with the assignments and poor time management. The DON reported that the Unit Manager assessed the resident and felt Resident #323's urine was new and did not feel the resident had been sitting in urine for a long time. A review of the Documentation Survey Report, identified that the 7 a.m. - 3 p.m. staff member had documented the following on 10/12/22, the date of the grievance filed by the 3-11 p.m. CNA: - bladder continence: Incontinent at 8:09 a.m. - Bowel documentation: identified that at 8:09 a.m. Resident #321 had a large bowel movement that was putty like and was incontinent. (Resident #321 had a colostomy). The Documentation Report identified that staff members are required to document one time every shift (qshift) the care provided, and assistance provided for the residents' ADL care. The report indicated that on 10/12/22 the 3-11 p.m. CNA had not documented bladder incontinence until 8:29 p.m. and a large, loose, ostomy bowel movement, 12 hour and 20 minutes after the 7-3 CNA had documented. The care plan for Resident #321 indicated that the resident had an ADL self-care performance deficit related to (r/t) confusion, CVA, dementia, limited mobility, (and) weakness. The interventions identified that the resident required extensive assistance with ADL's. The discharge Minimum Data Set (MDS) dated [DATE] identified a Brief Interview of Mental Status score of 3 out of 15 for Resident #321, indicating a severe cognition impairment. The functional status assessment indicated the resident required extensive assistance with bed mobility, transferring, locomotion on and off the unit, eating, toilet use, and personal hygiene. Section H of the MDS identified that the resident did have an ostomy and was always incontinent of urine. 5. An observation and interview on 11/28/22 at 11:42 a.m. was conducted with Resident #323. The resident reported staff come in, turn off (call) light, say they are coming back in a minute, and may wait for 45 minutes before they come back. Resident #323 stated feels they should handle the situation then (coming in prior to shutting off light). During an interview on 11/29/22 at 10:20 a.m., Resident #323 stated the facility absolutely did not have enough staff because there were too few staff to take care of too many patients; I waited 2 hours the other night to get Tylenol. The resident continued to me that's unacceptable. Resident #323 reported having to wait 1.5 hours to be changed (due to incontinence) more than one time. Record review revealed Resident #323 was admitted on [DATE]. The admission Record included diagnoses not limited to other obstructive and reflux uropathy, chronic obstructive pulmonary disease with (acute) exacerbation, acute respiratory failure with hypoxia, acute on chronic systolic (congestive) heart failure, and acute pulmonary edema. The 5-day Minimum Data Set (MDS), dated [DATE], identified a Brief Interview of Mental Status (BIMS) score of 12 out of 15, indicating a moderate cognition impairment. Resident #323's functional status assessment indicated that bed mobility and transferring occurred only once or twice with 2-person assist and toilet use, and personal hygiene occurred only once or twice with 1-person assist. Section H of the assessment identified that the resident had an indwelling catheter and bowel status was not rated. 6. An interview was conducted with Resident #26 on 11/29/2022 beginning at 12:34 p.m. When asked about care she received from the aides, she reported earlier that morning, her aide (CNA L) left her before she was totally done getting dressed. She reported that she sat and waited for her to return, figuring the aide would be right back. She said finally she gave up and buckled her own sandals, but it took a while as the straps and buckles were tough for her to reach and manipulate. The resident said CNA L was aware she had a urinary catheter bag and the aide had held it up, as if she was judging how full it was. The resident said it was full and needed to be emptied before she was ready to leave the room for the morning's activities. She waited for the aide to empty the bag and when it didn't seem she was going to, she asked the aide about emptying it. She said CNA L seemed surprised that she would be asked to do that. She said she told the aide it was part of her job. The resident continued by saying she did not think there were enough aides as her aides always seemed very rushed and they did not finish providing the care before they rushed off. She reported she was completely dressed this morning, but the aide never thought to empty the catheter bag. A review was conducted of Resident #26's Plan of Care. On 09/02/2022 a care plan was initiated for the use of an indwelling catheter. Care plans initiated on 08/30/2022 reflected the resident's Activities of Daily Living (ADL) self-care performance deficient related to weakness and decreased mobility. Interventions included in the care plan listed the required assistance with ADLs such as toilet use. An interview was conducted on 11/29/2022 beginning at 1:00 p.m. with Staff M, CNA, Agency and Staff N, CNA. Staff M reported aides get report from the previous shift aides, who pass along what else might be needed in the next shift. She confirmed this would include the presence of the urinary catheter and aides should know to empty it when it gets full. Staff N reported at 1:05 p.m. on 11/29/2022 that aides pass along to the next shift what the resident needed, including that the resident has a catheter and that it needs to be emptied into the cup in the bathroom, which has marks on it to measure the amount. She said the amount should be documented. 7. Resident #50 was re-assessed as part of an Annual Minimum Data Set Assessment on 10/19/2022. The assessment identified the resident's functional status when transferring as requiring extensive assistance with two staff. Toileting and dressing required extensive assistance with two staff. A review of nurse's notes dated 11/22/2022 revealed the resident was assessed by the RN (registered nurse) on staff and received orders to transfer the resident to the emergency department where she was diagnosed with a right humeral fracture. An interview with the aide (CNA O) who had transferred the resident by herself on 11/22/2022 was conducted on 12/07/2022 beginning at 9:30 a.m. CNA O reported the resident had asked to be toileted and the aide tried to find someone to help her with the lift for the transfer for Resident #50, but she could not find anyone. She reported they must all have been assisting other residents. The aide confirmed she had been trained to transfer residents with a second staff member, but she did not. The resident was transferred to the toilet using a sit to stand lift but complained of hearing a pop and feeling immediate pain. CNA O reported there had been five aides working during the 3:00 p.m. to 11:00 p.m. shift on 11/22/2022. During an interview with the DON on 12/01/2022 at 12:00 p.m. she said that during her investigation of the incident no staff reported that they had been asked by the aide to assist in transferring Resident #50. A review of the Facility's Assessment revealed all staffing was identified as sufficient with no action plans in place. A review of the resident's abilities related to their function, mobility and physical disabilities revealed 42.5 % of the facility's admissions were assessed as requiring two persons to assist to complete their ADLs. The grievance log was reviewed for the past five months for concerns voiced by the residents related to response to their call bell. Eight grievances were voiced from July through to October related to having to wait for two hours after a bowel movement to be cleaned up as the call bell was not answered; medications were not provided for hours after being requested, on all shifts. A performance improvement plan was put into place in October. On 11/01/2022 a grievance was submitted that reported the resident sat in feces and listened to the call bell ring for 75 minutes at which time staff responded to it and reported they would get help. The grievance indicated another 75 minutes went by before an aide with a poor attitude answered the bell.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure appropriate infection prevention and control standards were maintained related to 1.) two (Residents #49 and #68) diagnosed with scabies; 2.) cleaning and maintenance of shared resident care equipment for two (Resident #75 and one unidentified); 3.) hand hygiene during wound care procedures for one Resident #52); 4.) sanitary maintenance of respiratory care equipment for two (Residents #323 and #325); and 5.) sanitary maintenance of urine catheter drainage bags for three (Residents #326, #21, and #224) residents of forty-four sampled residents. Findings included: 1. On 11/30/22 at 8:20 a.m., an observation was made of a contact isolation sign posted on the room door of Residents #49 and #68. An interview was conducted at that time with Staff R, Licensed Practical Nurse (LPN.) Staff R stated Resident #68 had gone to a dermatologist on 11/29/22 and was determined to have scabies. A review of admission records indicated Resident #68 was admitted to the facility on [DATE] with diagnoses including pruritus, changes in skin texture, disorder of the skin and subcutaneous tissue, and candidiasis. An interview was conducted with the Infection Preventionist (IP) and the Director of Nursing (DON) on 11/30/22 at 10:37 a.m. The IP stated Resident #68 had been treated multiple times by a dermatologist for scabies. She stated they have put the resident on isolation, moved him to another room, cleaned his room thoroughly, and bagged all his belongings for long periods of time. The IP and DON stated the resident had one person that visits approximately once a month. The DON stated she had spoken with the visitor, and they denied having any skin issues. The DON said Resident #68 had scabies on and off since January, stating, it comes and goes like it is dormant for a while then comes back. The DON said as per the dermatologist, live mites were observed on the performed skin scrapings. The DON stated the scabies have not affected the roommate, Resident #49. A review of provider notes for Resident #68 revealed: -1/17/22 On-Site Dermatology diagnosed scabies on left inferior mid abdomen, right lateral mid umbilical region, and a hypersensitivity reaction consistent with arthropod assault reaction on the left superior lateral thigh. -2/21/22 On-Site Dermatology diagnosed scabies on hands, right upper extremity, trunk, right lower extremity, left lower extremity, and left upper extremity. -3/21/22 On-Site Dermatology diagnosed scabies on the trunk, right lower extremity, left lower extremity, left upper extremity, neck and right upper extremity. -4/18/22 [name of clinic] diagnosed and treated the resident for scabies. -5/16/22 On-Site Dermatology diagnosed scabies on the whole body. -6/20/22 On-Site Dermatology diagnosed scabies on the trunk, right lower extremity, left lower extremity, left upper extremity, right upper extremity, and hands. -8/8/22 On-Site Dermatology diagnosed scabies on trunk, right lower extremity, left lower extremity, left upper extremity, and right upper extremity. -9/12/22 [name of clinic] diagnosed and treated for scabies. Cleaning recommendations were provided. -10/21/22 Resident was prescribed Hydroxyzine 25 milligrams (mg) three times a day for scratching and picking at his skin by primary care provider -11/29/22 [name of clinic] diagnosed and treated for scabies A review of progress notes and orders indicated Resident #49 was diagnosed and treated for scabies in August 2022, with an order for Elimite cream 5% apply from neck to toes one time only for rash on 8/2/22 and 8/10/22, and an order for Contact isolation for three days related to scabies. A skin integrity review on 8/11/22 revealed the resident had a rash on his upper and lower extremities. On 11/29/22 at 9:40 a.m. Resident #49 was observed in his bed sleeping and was bed bound. Additional record review revealed a progress note dated 11/30/22. It showed Resident #49 was seen by a provider regarding scratch marks on upper and lower extremities; treatment for scabies was ordered. A review of admission records indicated Resident #49 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including chronic heart failure, dementia, major depressive disorder, sepsis, schizoaffective disorder, an acute respiratory failure. The facility's Infection Control Monthly Tracking Logs were reviewed from September through November 2022; Residents #49 or #68 were not listed for infection control tracking. On 12/2/22 at 10:48 a.m. an interview was conducted with the Housekeeping Director. He confirmed clothes and linens are placed in the barrels and washed separately using sanitizer, then dried. He stated terminal cleaning for the room of Residents #49 and #68 will be completed once nursing informs him the residents have been treated. He said no linens have come to laundry from the room at this time and he is still waiting on the next step, when nursing is ready. An interview was conducted with Staff V, Housekeeper on 12/2/22 at 11:00 a.m. She confirmed she would be doing regular cleaning on Residents #49 and #68's room as soon as she finished the current room. She said since they are on isolation, she will wear her gown and gloves. The housekeeper was not aware of the reason for isolation precautions and was not aware a terminal clean was required. She stated she was going back and forth down the hall between all rooms. while doing daily regular cleanings. An interview was conducted with Resident #68 on 12/2/22 at 11:43 a.m. The resident stated he was upset because he has not been able to shower yet on 12/2/22 and was not able to shower on 12/2/22 due to not having any clothes to put on. He said his clothes are bagged up and he isn't going to shower and put dirty clothes on. Resident #68 said staff have not come in and cleaned his room. He stated he asked the Certified Nursing Assistant (CNA) to change his bedding and she did. During the interview, Staff Y, CNA came in the room and stated she didn't know why the resident's clothes were bagged up and had not been taken to laundry. She said she was unaware why the resident was on isolation. An interview with Staff R, Licensed Practical Nurse (LPN) was conducted on 12/2/22 at 12:00 p.m. She stated Resident #49 is refusing a shower and they have been unable to get him out of the room, therefore a terminal room clean has not been completed. An interview was conducted with the DON on 12/2/22 at 12:35 p.m. She stated the facility's Infection Preventionist is now out of town, and she is acting as IP at this time. The DON confirmed Residents #49 and #68 had received their scabies treatment and were in the same room. She stated the resident's belongings had been bagged up and the room had been terminally cleaned for him and the roommate. She was notified the terminal cleaning had not yet been completed and she said she was unaware. The DON was unable to provide the Infection Surveillance Worksheet for Resident #68. Related to tracking the process of infection control related to the two residents with scabies, she stated, as of yesterday (12/1/22), I haven't done anything with it. The DON confirmed a scabies infection should be tracked on the monthly infection control tracking log. The DON was asked about the process for resident showering/bathing during a diagnoses and treatment for scabies; she said Resident #68 takes showers in his room and right now it should probably be daily. The DON confirmed Resident #68 is very social and is often out of his room walking around the facility. The DON was unable to provide any contact tracing for staff members or residents possibly exposed to scabies and confirmed no prophylactic treatments had been offered. The DON confirmed she received the Centers for Disease Control and Prevention (CDC) links to the treatment and control of crusted (Norwegian) scabies from the local Department of Health. She stated they don't have confirmation it is crusted scabies, but that is the assumption. She agreed the facility should be following the CDC recommendations for crusted scabies. The DON also confirmed Resident #49 is bed bound and agreed he would have most likely been infected by scabies transferring from a staff member. On 12/2/22 at 1:00 p.m. a follow-up interview was conducted with the Housekeeping Director. He confirmed a terminal clean had not yet been completed on Residents #49 and #68's room, and he had not been asked to do anything in the room yet. He stated nursing told him there were no empty rooms to move the residents to so they couldn't do it yet. He also stated the Unit Manager (UM) told him they should continue with regular room cleanings due to the residents receiving oral treatment and not topical. The Housekeeping Director confirmed the common areas in the facility have been cleaned as normal. He said, if a resident was in a common area, they would call me, and I would do a deep clean. He said nursing would notify him and no one has called me to say [Resident #68] was in a particular location to do a deep clean. On 12/2/22 at 1:09 p.m. an interview was conducted with Staff T, Unit Manager (UM). He stated they were working on the getting a terminal clean but did not have anywhere to put the residents. He stated he interviewed residents around the isolation room, and none have had any itching. He said no contact tracing had been completed with staff. On 12/2/22 at 1:14 p.m. an interview was conducted with the Clinical Education Specialist, who was the UM on this unit prior to this week. She stated Resident #68 had previously been diagnosed with scabies, but she was not aware of anyone else ever having it. During the survey, observations were made of rooms on the 300 unit that had been vacant the dates of the survey. An interview was conducted on 12/2/22 at 2:08 p.m. with the Nursing Home Administrator (NHA,) DON, and the Regional Nurse. The Regional Nurse stated they just pulled the team together today to work on a plan. When asked why the room had not been terminally cleaned when the resident tested positive for scabies on 11/29/22, the Regional Nurse stated the Unit Manager (Staff T) and Clinical Education Specialist terminally cleaned Resident #49 and #68's room and wiped everything down. They said both residents had been treated, Resident #68 had showered, but Resident #49 refused. They confirmed the residents were in the same room. She also said, we do not have scabies running through the building. They stated [Resident #68] has a Brief Interview for Mental Status (BIMS) score of 8 (indicating moderate cognitive impairment) and we need to consider that when we listen to what he says. On 12/2/22 at 2:20 p.m. an interview was conducted with Staff T, UM, and the Clinical Education Specialist. The Clinical Education Specialist stated she terminally cleaned Resident #68 and #49's room and Staff T assisted her. Staff T confirmed he had not been trained on terminally cleaning a room; the Clinical Educational Specialist said she had been educated on how to terminally clean a room in 1992. The Clinical Education Specialist stated they pulled all the linens, clothes, and pillows from both residents. She said they bagged everything up and put it in the closet. She stated Resident #68 had been showered prior to cleaning. She confirmed both residents were in the room while the cleaning was being completed, and bagged linens and clothes remained in the closet. The Clinical Education Specialist said she used insecticide to clean the room, stating she did not know what it was - I just grabbed a bottle off a housekeeping cart. She stated the bottle was clear and unlabeled. The Clinical Education Specialist said she did not change the curtains but told the Housekeeping Director they needed to be changed. She stated Resident #68 was sitting in his wheelchair eating lunch while they were cleaning his room. The Clinical Education Specialist confirmed she did not clean Resident #68's wheelchair, nor wiped the tray table. She stated Resident #49's bed was not cleaned because he was in it and refused to get up and get a shower. She also stated they did not clean the floors, stating housekeeping would come around and do that. On 12/2/22 at 2:40 p.m. an interview and observation was conducted with Staff Z, Housekeeping. She said the housekeeping carts remain locked when not being used and stated there are three bottles of cleaner on each cart - 1 purple to clean toilets, 1 green to disinfect, and 1 blue to clean glass/windows. There were all observed to be labeled. She stated they never have un-labeled bottles on the cart. Review of a facility policy titled Investigation of Rashes, dated 3/27/21, revealed: This facility is committed to preventing the spread of skin infections between residents and to staff. If the cause is potentially infectious, the Infection Preventionist and clinical staff will do an investigation regarding the source and search for potential associated cases. If scabies if suspected: 5. Once scabies is diagnosed, Infection Control and Clinical Staff will do an exposure investigation. Review of a facility policy titled Infection Control Subject Scabies, dated 7/2020 revealed: It will be the standard for this facility to treat residents infected with and sensitized to Sarcoptes scabiei and to prevent the spread of scabies to other residents and staff. Prophylactic treatment for other residents or caregivers will be determined by the following factors: -The type of scabies (crusted vs non-crusted) to which a person has been exposed, -The degree and duration of skin exposure that a person has with the infested resident, -Whether the exposure occurred before or after treatment for scabies, and -Whether the exposed person works in an environment where he/she would be likely to exposed other people during the asymptomatic incubation period. For example, a nurse or caregiver. Begin treatment per Physician Orders Resident clothing and linen. -Change clothes and linen daily for 7 days -Plastic bag all laundry before removing from room. Environmental cleaning -clean resident room before resident showering/bathing and treatment so the treated resident does not use unclean areas. -Vacuum furniture made of fabric in the resident room and then wrap the furniture in plastic for 3 days. -Clean lobbies, lounges, etc., before resident showering/bathing and treatment so that treated resident (s) do not use unclean areas. -Clean and disinfect shower/bathing room after resident has received their treatment. Cleaning guideline of resident room day 1 and any follow up treatments. -Remove privacy curtain and place in plastic bag. Take to laundry. -Remove all linen except pillow. Strip bed carefully and place linen in plastic bag. (Mark- do not open for 3 days.) Take to laundry. -Disinfect mattress -Remove pillow (if plastic, disinfect. If cloth, place in plastic bag (mark- do not open for 3 days.) -Wash and disinfect bed, bedside table, nightstand (inside and out), closet, windowsills, and bathroom. -Wash and disinfect any other furniture in the room. -Repeat procedure post shower. Cleaning guideline for resident room daily; days 2-7. -Change linens daily. Place linen in plastic bag and take to laundry -Mop and disinfect floors daily. -Follow all other standard room cleaning procedures. Review of a facility policy titled Environmental Services Cleaning Guidelines, dated 5/16/21 revealed: Terminal cleaning 1. When a resident is discharged , the unit will be striped, including the cubical curtain. 2. Bed frame, mattress, bedside stand (inside and out), over-the-bed table, chairs, lights, walls, and bathroom and closet will all be cleaned with disinfectant. 3. The unit will be made up for a new resident. Isolation Rooms or Cleaning Special Care Areas 1. Standard cleaning procedures should be used for isolation rooms. However, isolation rooms should be cleaned last, or equipment and water changed before going into another room and hand hygiene performed. Terminal Cleaning of a Room Terminal cleaning of the room should be done when a resident who has been under source isolation is discharged . 1. Environment services should wear appropriate personal protective equipment, 2. Discard all disposable items or equipment as appropriate. 3. Remove any items or equipment to the designated area for cleaning disinfection. 4. Gently place all linen into the appropriate laundry bags. Bags must be secured before leaving the area. 5. Dust the high ledges, window frames and curtain tracks. 6. Wet clean all ledges, fixtures, and fittings. Including taps and door handles. 7. We clean all furniture including bedside stand, closet, and bedside table. 8. Vacuum clean fixtures, fittings, and floor. Only use a suitable vacuum cleaner with a high filter mechanism. 9. The bed mattress should be wiped with warm water and EPA approved disinfectant and dried thoroughly. Mattresses will be discarded if bodily fluids have penetrated into the mattress fabric. 10. Wash the skin, floor, and spot clean walls with the appropriate disinfectant. 11. Open windows if required to facilitate a thorough drying of all services. 2. An interview was conducted with Resident #75 on 12/2/22 at 11:30 a.m. She stated she is concerned because the CNA uses a blood pressure cuff on her roommate that has a fungus and then uses it on her without cleaning it between. She stated she uses hand sanitizer on her arm when the CNA is done. An observation was made on 12/2/22 at 4:10 p.m. of a CNA using a blood pressure machine CNA cuff on an unidentified resident in a common area; she then took the same blood pressure cuff to a resident's room and proceeded to use it on a different resident; she did not clean the cuff in between residents. An interview was conducted with Staff U, CNA on 12/2/22 at 4:12 p.m. The CNA confirmed she did go between two residents without sanitizing the blood pressure cuff. She stated she knows she is supposed to clean it but did not know where the sanitizing wipes were. She stated it is common for CNAs to use the equipment on multiple residents without being able to clean them. The CNA said she was not trained on which wipes to use for which equipment. The CNA confirmed she will also use the shower chairs with multiple residents without cleaning them, as she does not have access to sanitizing wipes. An interview was conducted with Staff R, LPN on 12/2/22 at 4:35 p.m. She stated sanitizing wipes are sometimes under the counter at the nurses' station. She said if they run out, they do not have a key to the main storage area to get more. She said there is only one key and someone on the 300 unit has it. No sanitizing wipes were observed at the nurses' station. On 12/2/22 at 7:18 p.m. during an interview, the DON stated the expectation is all equipment is cleaned between residents including blood pressure cuffs, shower chairs, pulse oximeters, and thermometers. She stated there should be sanitizing wipes at the nurses' station and medication cart. 3. A review of Resident #52's Order Summary Report, active as of 12/2/22, included the following wound care orders: - Cleanse wound to coccyx with Dakin's Solution, pat dry. Apply Calcium Alginate AG/silver to wound bed and cover with dry dressing everyday shift. - Left lower arm, Cleanse with Normal Saline (NS), apply xeroform. Wrap with kerlix gauze, in the morning every Monday (Mon), Wednesday (Wed), Friday (Fri), (and) Sunday (Sun). An observation was made, on 12/1/22 at 8:08 a.m., with Staff Member X, Registered Nurse/Wound Care Nurse (RN/WCN) of the stage 4 pressure ulcer in the sacral area for Resident #52. The nurse gathered supplies from a treatment cart parked in the hallway outside of the resident's room and placed them on the over-bed table next to the resident's bed. The WCN washed hands, raised the bed to approximately waist level, and removed rolled gauze with scissors that were cleaned with alcohol wipes. The WCN donned gloves, wet gauze with NS, patted the wound dry, removed gloves, donned another pair of gloves (no hand hygiene between removing and donning gloves), placed a petrolatum dressing on the open area to lower forearm, wrapped the arm with rolled gauze and used fabric to attach. The nurse removed gloves, washed hands, donned a pair of gloves, and assisted Resident #52 with repositioning and exposed the sacral area which did not have a dressing. The WCN ungloved, gloved (without hand hygiene), wet gauze with sodium hypochlorite solution, cleaned inside the sacral wound, and moved the biohazard bag from the chair beside the bed to the end of the bed. The nurse proceeded to wet gauze with Dakin's Solution and clean inside the wound twice more before removing gloves. The nurse removed gloves, donned another pair of gloves (without hand hygiene) wet gauze with solution and cleaned inside of wound repeating this twice before removing gloves and donning another pair (without hand hygiene). At that time, she stated the sodium hypochlorite solution had bleach in it, so it cleaned real well. The nurse opened 2 packages of Calcium Alginate/silver and packed the sacral wound, ungloved then gloved (without hand hygiene), opened a bordered dressing, placed the dressing on wound. She ungloved and washed hands prior to leaving the residents room to retrieve a pen. She washed hands, donned gloves, and cleaned pen with alcohol. She dated the sacral dressing, placed garbage in red bag, ungloved and repositioned resident. The WCN removed red biohazard bag to the soiled utility room. During an interview on 12/1/22 at 8:47 a.m. Staff X said she was supposed to put gloves on after repositioning and in between wounds. She stated hand hygiene was to be done before and after you leave the (resident) room and in between wounds. Review of The Centers of Disease Control and Prevention guidance, Clean Hands Count for Healthcare Providers, dated January 8, 2021, and accessed on 12/1/22 from (https://www.cdc.gov/handhygiene/providers/index.html) indicated to Protect yourself and your patients from potentially deadly germs by cleaning your hands. Be sure you clean your hands the right way at the right times. The guidance included that an Alcohol-Based Hand Sanitizer should be used: - Immediately before touching a patient; - Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices; - Before moving from work on a soiled body site to a clean body site on the same patient; - After touching a patient or the patient ' s immediate environment; - After contact with blood, body fluids or contaminated surfaces; - Immediately after glove removal. Review of the website, [NAME] Wound Physicians, dated May 12, 2020, How to Change a Wound Dressing accessed on 12/1/22 at (https://cert.vohrawoundcare.com/how-to-change-a-wound-dressing/) showed: Steps to applying or changing a bandage included the folllowing: When applying a new wound care bandage or dressing, it is essential to follow a few simple steps. Because a wound is an opening to the outside it is not sterile, and we apply dressings using a clean dressing technique. The procedure indicated that in step 2, after gathering supplies, staff were to Wash your hands with soap and warm water for 20-30 seconds then don clean gloves to remove previous dressing. After removal, clean the wound with gauze and saline/wound to dispose of the previous dressing, gauze utilized to clean the wound, and gloves used during cleaning of wound. The directions indicated that staff were to Rewash your hands with soap and water for 20-30 seconds and dry them. Put on a new pair of clean gloves and apply the new treatment and dressing. 4. An observation was conducted, on 11/28/22 at 11:44 a.m., of Resident #323's bilevel positive airway pressure (BIPAP) mask lying on the bedside dresser uncovered. On 11/29/22 at 10:30 a.m., Resident #323's nebulizer mask was observed lying on the bedside dresser, there was no storage bag or appropriate storage container visible. Record review revealed Resident #323 was admitted on [DATE]. The admission Record included diagnoses not limited to chronic obstructive pulmonary disease with (acute) exacerbation, acute respiratory failure with hypoxia, and acute on chronic systolic (congestive) heart failure. Review of the Order Summary Report identified a physician order that instructed staff to Clean BIPAP machine every evening and night shift related to unspecified chronic obstructive pulmonary disease and Albuterol nebulization 2.5 milligram/3 milliliter (2.5 mg/ 3 mL) 3 mL's inhale via nebulizer two times a day for shortness of breath (SOB). An observation was conducted, on 11/28/22 at 12:20 p.m. of Resident #325's continuous positive airway pressure (CPAP) nasal flanges (plugs) lying on floor under the bed. On 11/29/22 at 10:40 a.m., Resident #325 was observed wearing nasal flanges. On 12/2/22 approximately 11:50 a.m., Resident #325's CPAP nasal plugs and tubing was lying on the bed in front of the resident. Review of the Order Summary Report, active as of 12/2/22, identified the following: - Continuous Positive Airway Pressure (CPAP) - ok to use CPAP machine from home to use while in facility every evening and night shift for CPAP; sleep apnea. - Check CPAP sterile water - Clean CPAP machine The order report did not include an order to change CPAP tubing. On 12/2/22 at 3:11 p.m., an observation and interview with Staff Member AA, Licensed Practical Nurse (LPN) was conducted in Resident #325's room. The resident stated the tubing had not been changed since she was admitted to the facility on [DATE]. The resident was observed wearing the nasal flanges and the tubing was undated. Staff AA confirmed there was no water in the CPAP machine and the resident stated staff did put water in it at night. An interview was conducted, on 12/2/22 at 3:16 p.m. with the Director of Nursing (DON). The DON stated CPAP tubing should be changed weekly and dated. She reviewed the orders and confirmed there were no frequencies for the order to clean the CPAP machine and cleaning the machine should be done along with the tubing changes. Review of a facility policy titled - Respiratory Care and Oxygen Administration, issued 6/1/2009 and revised 3/27/2021, indicated: It is the standard of this facility to provide guidelines for respiratory care and safe oxygen administration. The guidelines of the policy indicated the following: - BiPAP and CPAP respiratory equipment should be used per physician orders and maintain infection control techniques. - Oxygen, trach, and nebulizer tubing is changed weekly and dated as verification that the tubing was changed. 5. An observation on 11/30/22 at 10:05 a.m., was conducted in the 300-hallway. The observation identified Resident #326 was being propelled in the hallway toward the 300-hall nursing station. The observation revealed the resident's urinary catheter tubing and drainage bag dragging on the floor under the resident's wheelchair. Immediately following the observation identified Staff Member BB, Certified Nursing Assistant (CNA) push the over-the bed table in front of the resident's wheelchair in the resident's room. Staff BB left the room, then returned and confirmed the tubing and bag was on the floor. The staff member reported not knowing how else to attach the drainage bag and left the room with the tubing and drainage bag still on the floor. Review of the record for Resident #326 revealed a physician's order that instructed staff to Insert/maintain indwelling catheter (16 French) - 30 cubic centimeter (cc) balloon for urinary retention. Review of Resident #21's record revealed she was admitted to the facility on [DATE] with diagnosis that included fracture of the sacrum, fracture of the pubis, Alzheimer's disease early onset, and cognitive communication deficit. The resident had a Brief Interview for Mental Status (BIMS) dated 10/26/22 with a score of 10 (Moderately impaired cognition). Observations of Resident #21 on 11/28/22 at 11:59 a.m. revealed the resident was lying in her bed and had a urinary catheter hanging on the side of the bed. Closer observations revealed that the urinary catheter was resting on the floor. Observations of Resident #21 on 11/29/22 at 08:55 a.m. revealed the resident was sitting up in her wheelchair. Closer observations of the resident revealed her urinary catheter bag was hanging under the resident's wheelchair and was noted to be resting on the floor. (Photographic Evidence Obtained) An interview on 12/01/22 at 08:43 a.m. with Staff C, LPN revealed the urinary catheter should be hanging on the side of the bed below bladder and should never be on the floor. Observations of Resident #21 on 12/01/22 at 12:41 p.m. revealed she was seated in her wheelchair at the nurses' station with Staff B, Registered Nurse (RN) present. Closer observations revealed the resident's urinary catheter bag was resting on the floor. An interview with Staff B, RN was conducted at this time. She stated she did not realize the resident's urinary catheter bag was on the floor. Review of Resident #224's record revealed the resident was admitted to the facility on [DATE] and had a diagnosis that included legal blindness. Observations on 11/28/22 at 10:27 a.m. revealed Resident #224 was in her bed. Closer observations revealed the resident had a urinary catheter drainage bag hanging on the side of the bed and resting on the floor. (Photographic Evidence Obtained) Observations on 11/28/22 at 10:37 a.m. revealed Resident #224 was lying in her bed. At this time Staff W, CNA was noted in the resident's room. An interview with Staff W at this time revealed she was just checking on the resident and cleaning up. The urinary catheter drainage bag was noted to still be touching the floor and was confirmed by Staff W. Observations on 11/29/22 at 09:00 a.m. revealed Resident #224 was lying in bed covered with a blanket. Closer observations revealed the resident's urinary catheter drainage bag was hanging on the side of the bed and resting on the floor. (Photographic Evidence Obtained) Observations on 12/01/22 at 08:38 a.m. of Resident #224 revealed the resident lying in her bed. Closer observation revealed that the resident had a urinary catheter drainage bag hanging on the side of the bed and resting on the floor. (Photographic Evidence Obtained) The bed was set [TRUNCATED]