Based on record review and interview, the facility failed to implement the discharge policy developed to ensure follow up with discharged residents for 1 resident (Resident #2) of 3 residents reviewed for discharge.Findings include: Review of Resident #2's admission record showed the resident was admitted with diagnoses that included sepsis, acute respiratory failure with hypoxia, type 2 diabetes mellitus with ketoacidosis and hyperglycemia without coma, acquired absence of right leg below knee, encounter for orthopedic aftercare, acquired absence of right great toe, morbid severe obesity due to excess calories and encounter for surgical aftercare, and discharged on 6/17/2025. During an interview on 6/30/2025 beginning at 10:44 AM, Staff A, Case Manager, stated, [Resident #2's name] elected to discharge home from the facility on 6/17/2025 after his insurance company discontinued payments for skilled services. I called [Resident #2's name] insurance company and they told me to set up home health care with their parent company. The insurance company would set up day of discharge home health care and gave me a reference number for the home health services. I found out on 6/20/2025 that home health services have not been to [Resident #2's name] home. I contacted [Resident #2's name] parent insurance company that told home health services have not been set up for [Resident #2's name] because of the limitations of his plan. I do not know why [Resident #2's name] parent insurance company has provided a reference number for home health services. I did not follow up with [Resident #2's name] to verify home health services are being provided to [Resident #2's name]. I did not do a follow up call. I just forgot to give him a follow-up call. I have not talked to him. During an interview on 6/30/2025 at 10:48 AM, the Director of Nursing stated, My expectation is that a follow-up call is made to discharged residents to check on them. During an interview on 6/30/2025 at 11:12 AM, the Administrator stated, [Resident #2's name] discharged from the facility on 6/17/2025 due to his insurance company declining to pay for additional skilled services. I was notified by adult protective services on 6/20/2025 that [Resident #2's name] was not receiving home health services. Review of the facility policy and procedures titled Discharge Planning last reviewed on 5/22/2025 read, Procedure. 6. Within twenty-four (24) to forty-eight (48) hours (or next day) after discharge to home, another nursing facility or to another type of residential facility such as a board-and-care home, a follow up phone call, or if necessary, home visit will be made to ascertain that community services/referrals are indeed being provided according to the discharge plan.

Based on observation, record review, and interviews, the facility failed to ensure care and services were provided for a PICC (Peripherally Inserted Central Catheter) access device in accordance with professional standards of practice for 1 (Resident #1) of 3 Residents reviewed with a PICC access device. Findings include: Review of Resident #1's clinical record documented re-admission to the facility on 2/5/2025 with diagnosis that included intraspinal abscess and granuloma (cluster of white blood cells), osteomyelitis (infection of the bone), and urinary tract infection. During an observation on 2/24/2025 at 09:45 AM Resident #1 was lying in bed with a PICC noted in the upper right arm. There was a transparent dressing cover the top of the PICC. The transparent dressing was dated 2/9/2025. (Photographic evidence obtained) During an interview on 2/24/2025 at 09:45 AM Resident #1 stated, I came into the facility with the catheter from the hospital and the dressing was changed once since then. It has not been changed since then. During an interview on 2/24/2025 at 10:08 AM Staff A, LPN (Licensed Practical Nurse) stated, The dressing should have been changed on the evening shift after seven days. I administered Vancomycin through the line and did not pay attention to the date of 2/9/2025 on the dressing, I should have changed it. During an interview on 2/24/2025 at 10:20 AM Staff B, LPN Unit Manager confirmed the transparent dressing to Resident #1's upper right arm was dated 2/9/2025 and stated, The PICC dressing is dated 2/9/2025. It was not changed and should have been changed every seven days. Review of Resident #1's physician orders dated 2/9/2025 read, Change Dressing on admission or 24 hours after insertion and weekly thereafter and PRN [as needed]. Review of Resident #1's Treatment Administration Record for February 2025 documented that PICC dressing change was not completed every seven days as ordered. During an interview on 2/24/2025 at 3:59 PM the Director of Nursing stated, My expectation is for the PICC line dressing to be changed within 24 hours after admission and then every seven days and as needed, if the dressing is soiled. The PICC line dressing should have been changed on the 17th, but it was not and has not been changed since 2/9/2025.

Based on observation, interview, and record review, the facility failed to maintain a clean and homelike environment in one hall out of three main front hallways. Findings include: During an interview on 8/12/2024 at 11:09 AM, Resident #58 stated, Did you see the black stuff in the hallway on the ceiling, over there where they do Bingo. It should be cleaned off. During an observation on 8/12/2024 at 2:20 PM, the hallway between main dining room and 400 Hall had a water leak in a ceiling tile and black substance on upper support header. (Photographic evidence obtained) During an interview on 8/12/2024 at 2:45 PM, the Maintenance Director confirmed there was a leak in the roof above the hallway and stated it had been an issue for a while. During an interview on 8/13/2024 at 3:30 PM, Resident #35, Resident Council President, stated that Resident Council has reported concerns to management with water leaking and mold on the ceiling in the hallway outside of the main dining room for a long time. Review of the facility policy and procedure titled Maintenance dated 11/30/2014 and reviewed on 1/23/2024 showed it read, Policy: The facility's physical plant and equipment will be maintained through a program of preventive maintenance and prompt action to identify areas/ items in need of repair. Procedure . The Director of Environmental Services will perform daily rounds of the building to ensure the plant is free of hazards and in proper condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #2's physician order dated 2/26/2024 showed it read, CCD NAS [Controlled Carbohydrate Diet No Added Salt] diet, Regular Texture, regular/thin liquids consistency, all meats chopped. Review of Resident #2's quarterly MDS dated [DATE] showed it read, K0520. Nutritional Approaches . C. Mechanically altered diet require change in texture of food or liquids (e.g. pureed food, thickened liquids) . 3. While a Resident: No. During an interview on 8/14/2024 at 10:25 AM, Staff A, MDS Coordinator, stated, [Resident #2's name] had orders for all meats chopped. The mechanically altered diet should have been coded yes. 3. Review of Resident #10's admission record showed the resident was most recently admitted on [DATE] with the diagnoses including other lack of coordination, unspecified dementia, muscle weakness, difficulty in walking, other seizures, restlessness and agitation, and cognitive communication deficit. During an observation on 8/13/2024 at 8:24 AM, Resident #10 was lying in bed with bed position at the lowest level and a sign on the closet door that read, call don't fall. Review of Resident #10's annual MDS dated [DATE] showed the resident did not have any falls since admission or prior to assessment under Section J1800. Review of Resident #10's progress note dated 4/25/2024 showed it read, Discussed fall that occurred on 4/24/2024 @ 515PM [at 5:15 PM]. Resident was found on the floor in her room. Resident stated that she was getting up to walk and fell. Bump noted to top of scalp. MD [Medical Doctor] and family notified. New intervention for lab review for AMS [Altered Mental Status]. Review of Resident #10's Change in Condition form dated 4/24/2024 showed it read, Situation: Fall without injury. Review of Resident #10's care plan initiated on 5/24/2022 showed it read, [Resident #10's name] is at risk for falls r/t [related to] lack of coordination, other symptoms and signs involving cognitive functions and awareness and need for assistance with personal care. Review of Resident #10's care plan initiated on 12/11/2023 showed it read, [Resident #10's name] has actual fall-poor balance, unsteady gait r/t unspecified dementia, unspecify severity without behavioral, psychotic or mood disturbance, and anxiety, altered mental status, other lack of coordination, other symptoms and signs involving cognitive functions and awareness and need for assistance with personal care. During an interview on 8/14/2024 at 10:20 AM, Staff A, MDS Coordinator, stated, [Resident #10's name] is coded incorrectly. She did have fall prior to the assessment. Review of the facility policy and procedure titled MDS with the last review date of 1/23/2024 showed it read, Policy: The center conducts initial and periodic standardized, comprehensive and reproductive assessment no less than every three months for each resident including, but not limited to, the collection of data regarding functional status, strengths, weakness, and preferences using the federal and/or state required RAI. Procedure . Each person completing a section or portion of a section of the MDS signs the attestation statement indicating its accuracy. Based on record review and interview, the facility failed to ensure assessments accurately reflected the resident's status for 1 of 4 residents reviewed for discharge status (Resident #102), 1 of 4 residents reviewed for nutrition (Resident #2), and 1 of 5 residents reviewed for falls (Resident #10). Findings include: 1. Review of Resident #102's admission record showed the resident was admitted to the facility on [DATE] and discharged on 6/25/2024 to an Assisted Living Facility. Review of Resident #102's MDS (Minimum Data Set) discharge return not anticipated assessment dated [DATE] showed Section A2105- Discharge Status documented the resident was discharged to a short-term general hospital. Review of Resident #102's progress note titled Discharge Summary and dated 6/25/2024 showed it read, Pt [Patient] discharged to ALF [Assisted Living Facility]. Pick up with ALF staff via wheelchair. discharged with personal belongings, discharge papers and remaining prednisolone eye drops and insulin pen. During an interview on 8/13/2024 at 12:27 PM, Staff A, MDS Coordinator, verified that Resident #102 was coded as discharging to short-term general hospital.

Based on observation, interview, and record review, the facility failed to ensure that residents received wound care treatment in accordance with professional standards of practice for 1 of 5 residents reviewed for skin conditions, Resident #85. Findings include: During an observation on 8/12/2024 at 8:55 AM, Resident #85 had a bandage placed over her forehead dated for 8/10/2024 with unreadable initials under the date. The bandage was not adhered to the head with all adhesive not touching the skin. The bandage was being held on with dried blood from the wound the bandage was covering. During an observation on 8/13/2024 at 10:15 AM, Resident #85 had a bandage placed over her forehead dated for 8/10/2024 with unreadable initials under the date. The bandage was not adhered to the head with all adhesive not touching the skin. The bandage was being held on with dried blood from the wound the bandage was covering. Review of Resident #85's physician order dated 1/2/2024 showed it read, Woundcare [Sic]-forehead open area cleanse with NS [Normal Saline], pat dry, cover with DPD [Dry Protectant Dressing] change daily and PRN [as needed]. Review of Resident #85's Treatment Administration Record (TAR) for August 2024 for wound care of the forehead showed no entry documented on 8/11/2024. During an interview on 8/14/2024 at 2:20 PM, the Director of Nursing (DON) stated, All physician orders need to be followed and if the nurse feels the order is not appropriate for the resident, she would be expected to contact the ordering physician to inform and obtain new orders for the wound care. During an interview on 8/14/2024 at 2:46 PM, Staff E, Wound Care Licensed Practical Nurse (LPN), stated, The dressing was not changed for the resident on 8/12/24. The wound care order would stay yellow on the charting system, and the nurse would know that the wound did not get the dressing changed and they would be obligated to complete the order. Review of the facility policy and procedure titled Dressing Change with the last review date of 1/23/2024 read, Policy: A clean dressing will applied [Sic] by a nurse to a wound as ordered to promote healing . Procedure . Apply treatment as order [Sic] and clean dressing.

Based on record review and interview, the facility failed to ensure medical records were accurate for 1 of 5 residents reviewed for skin conditions, Resident #10, and 1 of 6 residents reviewed for medication administration, Resident #20. Findings include: 1. Review of Resident #10's physician order dated 6/19/2024 read, Woundcare [Sic]- sacrum apply house barrier cream three times a day and prn [as needed] . Order Status: Active . Start Date: 06/19/2024. Review of Resident #10's Medication Administration Record (MAR) for June 2024 for administration of house barrier cream on sacral wound showed no entries documented on 6/20/20204, 6/23/2024 and 6/24/2024 at 5:00 AM. Review of Resident #10's MAR for July 2024 for administration of house barrier cream on sacral wound showed no entries documented on 7/3/2024 at 1:00 PM, and on 7/7/2024, 7/10/2024, 7/13/2024, 7/21/2024, 7/24/2024, and 7/27/2024 at 5:00 AM. Review of Resident #10's MAR for August 2024 for administration of house barrier cream on sacral wound showed no entries documented on 8/1/2024, 8/4/2024, 8/7/2024, and 8/10/2024 at 5:00 AM. During an interview on 8/14/2024 at 1:45 PM, the Director of Nursing stated, The application of the barrier cream is being done, but the staff is not documenting it in the MAR. If the order is on the MAR, staff is expected to accurately document in the system. 2. Review of Resident #20's physician order dated 8/7/2024 showed it read, Midodrine HCl Oral Tablet 5 mg [milligram] (Midodrine HCl), Give 1 tablet by mouth every 8 hours related to orthostatic hypotension hold for BP >110 (blood pressure greater than 110). Do not administer past 6 PM. Review of Resident #20's MAR for August 2024 showed Midodrine HCl 5 mg was administered at 10:00 PM on 8/8/2024, 8/9/2024, 8/10/2024, and 8/13/2024. During an interview on 8/13/2024 at 9:42 AM, the Director of Nursing stated, [Resident #20's name] order was a transcription error. It will be updated. Review of the facility policy and procedure titled Documentation of Progress with the last review date of 1/23/2024 showed it read, Policy: Documentation of a resident's condition will provide an accurate and timely record of their progress taking into consideration their acuity and length of stay. Review of the facility policy and procedure titled Physician Orders with the last review date of 1/23/2024 showed it read, Policy: The center will ensure that Physician orders are appropriately and timely documented in the medical record.

Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene while providing wound care, failed to implement enhanced barrier precautions, and failed to ensure staff used appropriate personal protective equipment while providing high contact care to the residents on enhanced barrier precautions to prevent possible spread of infection and communicable diseases. Findings include: 1. During an interview on 8/13/2024 at 8:45 AM, Staff E, Wound Care Licensed Practical Nurse (LPN), stated, [Resident #36's name] has a surgical wound on her abdomen and a pressure ulcer in her coccyx area, which she acquired during her last hospital stay. During an observation on 8/13/2024 at 9:03 AM, Staff E, Wound Care LPN, and Staff F, Certified Nursing Assistant (CNA), entered Resident #36's room. There was no enhanced barrier precautions sign or personal protective equipment outside of the resident room. Staff E and Staff F performed hand hygiene and donned gloves but did not don a gown. Staff F assisted Staff E with positioning Resident #36. The resident was turned on her side and a hydrocolloid dressing dated 8/10/2024 was observed. Staff E removed the dressing from coccyx and performed hand hygiene. Staff E prepared all wound care supplies and donned gloves and placed a barrier on the back of the resident's buttocks area. Staff E cleaned the open wound located in Resident #36's coccyx with gauze and normal saline. Without performing hand hygiene, Staff E patted dry the wound. Then, Staff E removed her gloves and performed hand hygiene. Staff E donned new pair of gloves and applied dressing to the coccyx area. Staff E and Staff F adjusted and placed briefs back on Resident #36. Without performing hand hygiene or removing the gloves used to dress the coccyx wound, Staff E continued to remove dressing located in the center of Resident #36's abdomen. Staff E removed gloves and washed her hands. Staff E donned new pair of gloves and applied iodine to Resident #36's surgical incision. Staff E preformed hand hygiene and donned new pair of gloves. Staff E applied new dressing to abdominal incision and readjusted Resident #36's briefs. Without performing hand hygiene or removing the gloves used to apply dressing to the abdominal incision, Staff E lifted Resident #36's left foot and applied skin prep to the left heel deep tissue injury wound. Review of Resident #36's physician orders dated 8/13/2024 showed it read, Isolation type-Enhanced Barrier Precautions d/t [due to] open wounds. 2. During an observation on 8/13/2024 at 10:14 AM, Staff E, Wound Care LPN, and Staff F, CNA, donned gloves and gown before entering Resident #3's room. Staff E preformed hand hygiene and removed old dressing and removed gloves. Without performing hand hygiene started to open the packets of gauze. Staff E donned new pair of gloves without hand hygiene and cleansed the wound in sacrum area with normal saline. Without performing hand hygiene, Staff E patted dry the cleaned area. Staff E removed gloves and performed hand hygiene and donned new pair of gloves. Staff E applied treatment and dressing to the sacral area. Staff E removed her gloves and performed hand hygiene and cleansed the wound on the right posterior thigh, which was not covered by a dressing. Staff E cleaned the wound and without hand hygiene, patted dry the area. Staff E removed her gloves and performed hand hygiene and applied dressing to the right posterior thigh. Review of Resident #3's physician orders dated 8/13/2024 showed it read, Isolation type-Enhanced Barrier d/t wounds. During an interview on 8/13/2024 at 10:42 AM, Staff E, Wound Care LPN, stated, I should have done hand hygiene after cleaning the wound and when I removed my gloves [for Residents #3 and #36]. [Resident #36 name] does not have orders for enhanced barrier precaution that is why I didn't gown. I should have performed hand hygiene after cleaning the wound and also when removed the abdominal dressing after touching the briefs with the gloves. During an interview on 8/14/2024 at 11:04 AM, the Director of Nursing (DON) stated, Staff are expected to don gloves and gown when providing direct care to the residents who are on enhanced barrier precautions. [Resident #36's name] has enhanced barrier precautions due to her open wounds. Staff are expected to perform hand hygiene after cleaning a wound and moving onto another step and once they remove their gloves, they should perform hand hygiene before donning new set of gloves. Review of the facility policy and procedure titled Enhanced Barrier Precautions with the last review date of 1/23/2024 showed it read, Policy: Enhanced barrier precautions (EBP) is used to reduce the spread of Multidrug-resistant organisms (MDROs) among residents by utilizing gloves and gowns for high contact resident care activities. Definitions . High contact care activity- provide opportunities for transfer of MDRO to staff hands and clothing. High contact care activities include: dressing, bathing/showering, transferring, providing hygiene, such as brushing teeth, combing hair and shaving, changing linens, incontinent care, toileting, device care or use, such as central line, urinary catheter, feeding tube, tracheostomy or ventilator, wound care. Enhanced Barrier Precautions (EBP): the infection control process that reduces the spread of MDROs by using gloves and gowns for high contact care activities . Procedure: 1. Identify residents who are appropriate for EBP including . b. Resident who have a wound and/or indwelling medical devices. Review of the facility policy and procedure titled Dressing Change with the last review date of 1/23/2024 showed it read, Policy: A clean dressing will applied [Sic] by a nurse to a wound as ordered to promote healing. Sterile dressing will be used only if specifically ordered. Procedure . Perform hand hygiene, Apply gloves, Remove and dispose of soiled dressing, Remove gloves, Perform hand hygiene, Apply gloves, Evaluate wound for type, color, amount of drainage, Cleanse wound as ordered, dispose of gauze, Remove gloves and perform hand hygiene. Review of the facility's Skills Competency Assessment: Clean Dressing Change with the last review date of 1/23/2024 showed it read, The employee demonstrates skills and competence in the following . 10. Place supplies on prepped work surface and position wastebasket/bag in accessible area for dressing disposal per universal precautions. 11. Perform hand hygiene (soap and water or hand sanitizer) and apply gloves. 12. Open dressing packaging, Write date, time and nurse initials on cover of dressing or pre-cut tape. wipe scissors before and after use with alcohol pad. 13. Remove gloves. perform hand hygiene (soap and water or hand sanitizer). 14. Apply glove. Provide privacy and position resident comfortably and appropriately. Monitor pain level prior to beginning and during dressing change. 15. Place a clean barrier under area to be dressed. 16. Remove soiled dressing and dispose of as per policy. 17. Remove gloves. Performed hand hygiene. 18. Apply gloves. Assess wound for type, color, amount of drainage. Obtain wound culture if indicated. 19. Cleanse wound as ordered . 21. Remove gloves. Perform hand hygiene. 22. [NAME] gloves and applies [Sic] treatment as ordered. Review of the facility policy and procedure titled Hand Hygiene with the last review date of 1/23/2024 showed it read, Overview: The CDC [Centers for Disease Control and Prevention] defines hand hygiene as cleaning your hands by using either handwashing (washing with soap and water), antiseptic hand wash, or antiseptic hand rubs (i.e. alcohol-based sanitizer including foam or gel) . Process: Hand hygiene should be performed . After contact with blood, body fluids, or excretions, mucous membranes, non-intact skin, or wounds dressings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure 2 of 3 residents reviewed for preadmission screening and resident review (PASRR), Resident #38 and Resident #22, were referred to the appropriate state designated authority for Level II PASRR evaluation and determination. Findings include: Review of Resident #38's admission record revealed the resident was admitted to the facility on [DATE] with diagnoses that included unspecified psychosis not due to a substance or known physiological condition (onset date 1/5/2022). Review of Resident #38's psychiatry progress note, date of service 6/24/2024, revealed the resident had diagnoses that included brief psychotic disorder. Review of Resident #38's Level I PASRR completed by the facility staff on 3/27/2024 failed to reveal documentation in Section 1: PASRR Screen Decision-Making A. MI [Mental Illness] or suspected MI (check all that apply) that Resident #38 had a diagnosis of psychotic disorder. Review of Section IV: PASRR Screen Completion. Individual may be admitted to a Nursing Facility (check one of the following) showed it read, No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required. Review of Resident #22's admission record revealed the resident was initially admitted on [DATE] and most recently admitted on [DATE] with diagnoses that included pseudobulbar affect (onset date 7/9/2021), delusional disorders (onset date 5/11/2021) and unspecified psychosis not due to a substance or known physiological condition (onset date 1/14/2021). Review of Resident #22's psychiatry care plan note, date of service 6/10/2024, revealed the resident had diagnoses that included brief psychotic disorder and pseudobulbar affect. Review of Resident #22's Level I PASRR completed by the facility staff on 3/27/2024 failed to reveal documentation in Section 1: PASRR Screen Decision-Making A. MI or suspected MI (check all that apply) that Resident #2 had diagnoses of pseudobulbar affect, delusional disorders and psychotic disorder. Review of Section IV: PASRR Screen Completion. Individual may be admitted to a Nursing Facility (check one of the following) showed it read, No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required. During an interview on 8/14/2204 at 12:35 PM, the Director of Nursing stated Resident #38's and Resident #22's PASRRs were not accurate, should include the residents' psychiatric diagnoses and needed to be corrected.

Based on observation, interview, and record review, the facility failed to follow safe smoking practices for 4 of 5 residents reviewed for accidents, Resident #3, #15, #35, and #61. Findings include: 1. During an observation on 8/12/2024 at 8:49 AM, there was a pink device with mouth piece on top of drawer in Resident #3 room. Review of Resident #3's Smoking Evaluation dated 8/12/2024 showed it read, Summary of Evaluation: Resident is determined to be 0. Safe Smoker. Review of Resident #3's care plan initiated on 5/3/2024 showed it read, Focus: The resident smokes a vape . Interventions . Notify charge nurse immediately if it is suspected resident has violated facility smoking policy. During an observation on 8/13/2024 at 2:55 PM, with Staff G, Licensed Practical Nurse (LPN) Unit Manager, the smoking box located in the nursing station did not contain any vaping devices. During an interview on 8/13/2024 at 2:55 PM, Staff G, LPN Unit Manager, stated, It is not smoking time. The vapes should be in the box stored away. I do not see any vapes in the box, not sure where they could be. The staff scheduled for supervising the smoking break is responsible for collecting the vapes when it is the end of the smoking break. 2. During an observation on 8/13/2024 at 3:13 PM, Resident #35 was sitting up in his bed with a black vaping device on top of the resident's bedside table in front of him. During an interview on 8/13/2024 at 3:13 PM, Resident #35 stated, We were told we could have our vapes with us. I do not go outside to use it. I vape in my room. You cannot smell it. The staff and doctors have seen me and have not said anything to me. Review of Resident #35's Smoking Evaluation dated 8/12/2024 showed it read, Summary of Evaluation: Resident is determined to be 0. Safe Smoker. Review of Resident #35's care plan initiated on 5/3/2024 showed it read, Focus: [Resident #35's name] smokes a vape . Interventions . Notify charge nurse immediately if it is suspected resident has violated facility smoking policy. 3. During an observation on 8/13/2024 at 3:21 PM, Resident #15 had a vaping device on top of his bed. Resident #15 handed the vape to the Director of Nursing (DON). During an interview on 8/13/2024 at 3:21 PM, Resident #15 stated, I always have my vape with me, but you can take it. Review of Resident #15's Smoking Evaluation dated 8/12/2024 showed it read, Summary of Evaluation: Resident is determined to be 0. Safe Smoker. Review of Resident #15's care plan initiated on 5/3/2024 showed it read, Focus: The resident smokes a vape . Interventions . Notify charge nurse immediately if it is suspected resident has violated facility smoking policy. 4. During an observation on 8/13/2024 at 3:23 PM, Resident #61 was sitting up in his bed. When the DON requested the vape device, the resident refused. After the DON explained the policy, Resident #61 top out vape device from inside a bed pan on top of his bedside table and gave it to the DON. During an interview on 8/13/2024 at 3:23 PM, Resident #61 stated, It is my right to have my vape. I am not a prisoner. I have never signed a policy stating I am not able to have the vape with me. Review of Resident #61's Smoking Evaluation dated 8/12/2024 showed it read, Summary of Evaluation: Resident is determined to be 0. Safe Smoker. Review of Resident #61's care plan initiated on 5/3/2024 showed it read, Focus: The resident smokes a vape . Interventions . Notify charge nurse immediately if it is suspected resident has violated facility smoking policy. During an interview on 8/13/2024 at 3:30 PM, with the DON stated, I have been here in the facility for two months and we know this is a problem and we are working towards addressing the compliance of turning in the vapes at the end of the smoking times. [Resident #3's name] did have it in her room and we removed the vaping device form her room. Review of the facility policy and procedure titled Smoking-Supervised with the last review date of 1/23/2024 showed it read, Policy: The center will provide a safe, designated smoking area for residents. For the safety of all residents the designated smoking area will be monitored by a staff member during authorized smoking times. Smoking is only allowed in designated areas and during designated times . Procedure . 8. Electronic cigarettes are permitted, but only in facility designated smoking areas. a. The same rules that apply to regular tobaccos cigarettes also apply to electronic smoking materials. b. Electronic cigarettes and materials, including the liquids, will be retained and stored by nursing staff.

Based on observation, interview, and record review, the facility failed to ensure a safe and sanitary homelike environment (photographic evidence obtained). Findings include: During an observation on 4/3/2023 at 11:33 AM, Resident #39's room had a tube feeding pole that had formula like substance dripped on the pole, the feeding pump, the wall, the floor, and the floor mat. The far wall was separated from baseboard from a previous repair. During an observation on 4/3/2023 at 3:32 PM, Resident #39's room had a tube feeding pole with formula like substance dripped on the pole, the feeding pump, the wall, the floor, and the floor mat. The far wall was separated from baseboard from a previous repair. During an observation on 4/4/2023 at 10:51 AM, Resident #39's room had a tube feeding pole with formula like substance dripped on the pole, the feeding pump, the wall, the floor, and the floor mat. The far wall was separated from baseboard from a previous repair. During an interview on 4/4/2023 at approximately 3:00 PM, the Administrator stated, This should not be. I think nursing is supposed to clean the pole. I expect the housekeepers to clean the rooms every day. During an interview on 4/4/2023 at approximately 4:00 PM, the Director of Nursing (DON) stated, I see the formula on the pole. Housekeeping will not touch any medical equipment. The pole is medical equipment. Nurses only have wipes. Review of the facility policy and procedure titled Cleaning and Disinfection of Resident-Care Items and Equipment revised in September 2022 reads, Policy Statement: Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC [Centers for Disease Control and Prevention] recommendations for disinfection and OSHA [Occupational Safety and Health Administration] Bloodborne Pathogens Standard. Policy Interpretation and Implementation . 1 . c. Non-critical items are those that come in contact with intact skin but not mucus membranes. (1) Non-critical resident care items include bedpans, blood pressure cuffs, crutches, and computers . (3) Non-critical items require cleaning followed by either low- or intermediate-level disinfection following manufactures' instructions. Review of the facility policy and procedure titled Daily Patient Room Cleaning revised in 6/2016, reads, Timing & Method . 5) Damp mop floor with germicide solution damp mop floor working from back corner to door, Use Wet Floor sign when finished . Additional Information . The goal of cleaning is Infection Control.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the resident assessment accurately reflected the resident's status for 1 of 3 residents sampled for discharge, Resident #101. Findings include: Review of Resident #101's records revealed that the resident was admitted to the facility on [DATE] with the diagnoses including mood disorder, mixed anxiety disorders, hypertension, major depressive disorder and encounter for screening for respiratory tuberculosis. The resident was discharged on 2/15/2023. Review of Resident #101's progress note dated 2/15/2023 reads, Note Text: 14:50 [2:50 PM] discharge reviewed with patient, any questions answered to pt [patient] satisfaction. Medically, [Resident #101's Name] says she is well and ready to be discharged . Medications provided to patient. Valuable accounted for, inventory sheet signed. [Resident #101's Name] states her husband will be picking her up, when he gets off work so until then, she is remaining in room [room number]. Review of Resident #101's physician order dated 2/14/2023 reads, D/C [discharged ] home with HHC [Home Health Care], SN [Skilled Nursing] & PT [Physical Therapy] to eval [Evaluate] and treat. Review of Resident #101's Minimum Data Set (MDS) Discharge return not anticipated assessment dated [DATE] revealed the resident status as being discharged to acute hospital. During an interview on 4/4/2023 at 12:30 PM, Staff D, MDS Registered Nurse, confirmed that Resident #101's MDS discharge assessment dated [DATE] indicated that the resident was discharged to an acute hospital, but the resident was discharged home. Review of facility policy and procedure titled MDS revised on 9/25/2017 and reviewed on 1/18/2023 reads, Procedure . Specified sections of the RAI [Resident Assessment Instrument] process are completed by the center designated interdisciplinary Team Members. Each person completing a section or portion of a section of the MDS signs the Attestation Statement indicating its accuracy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #12's medical records revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, asthma, angina, and heart failure. During an observation on 4/3/2023 at 10:18 AM, Resident #12 was receiving oxygen at 4.5 liters per minute via nasal cannula. During an observation on 4/3/2023 at 3:22 PM, Resident #12 was receiving oxygen at 4.5 liters per minute via nasal cannula. During an observation on 4/4/2023 at 8:34 AM, Resident #12 was receiving oxygen at 2 liters via nasal cannula. Review of Resident #12's physician order dated 2/9/2023 reads, O2 [oxygen] at 2 Liters as needed for O2 sat [saturation] below 92%. Resident #12's physician orders included no order for changing oxygen tubing or rate of oxygen flow. Review of Resident #12's care plan revealed no focus for oxygen delivery and monitoring. During an interview on 4/4/2023 at 3:52 PM, Staff E, LPN, Minimum Data Set (MDS) Coordinator, stated, I have visually seen her with oxygen and seen her take it off. Staff E stated, A care plan for respiratory and oxygen therapy needs to be written. 3. Review of Resident #70's medical records revealed the resident was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, pulmonary edema, anemia, and anxiety. During an observation on 4/3/2023 at 10:40 AM, Resident #70's oxygen tubing had no date. During an observation on 4/3/2023 at 3:33 PM, Resident #70 was receiving oxygen at 2 liters minute via nasal cannula. Nasal cannula tubing was not dated. During an observation on 4/4/2023 at 9:00 AM, Resident #70 was receiving oxygen at 2 liters per minute via nasal cannula. Nasal cannula tubing was not dated. Review of Resident #70's physician order dated 6/20/2022 reads, Oxygen as needed PRN [as needed] at 2 L [Liter] via nasal cannula as needed for shortness of breath. Review of Resident #70's care plan revealed no focus for oxygen delivery and monitoring. During an interview on 4/4/2023 at 3:52 PM, Staff E, LPN, MDS Coordinator, stated that no care plan was written for oxygen therapy. Staff E stated, A care plan for respiratory and oxygen therapy needs to be written. Based on record review and interview, the facility failed to develop and implement a resident-centered care plan to meet the residents' needs for oxygen administration for 4 of 13 sampled residents, Residents #11, #12, #70 and #97. Findings include: 1. Review of Resident #97's medical records revealed the resident was admitted to the facility on [DATE] with diagnoses including heart failure, atrial fibrillation, memory deficit following cerebral infarction, major depressive and anxiety disorder. During an observation on 4/3/2023 at 11:46 AM, Resident #97 was receiving oxygen via concentrator machine running at 2 liters per minute, with no date on the tubing. During an observation on 4/4/2023 at 8:14 AM, Resident #97 was receiving oxygen via concentrator machine running at 2 liters per minute, with no date on the tubing. Review of Resident #97's physician order dated 2/24/2023 reads, Change tubing, mask and/or nasal cannula weekly. May change sooner as needed. As needed for hygiene. Review of Resident #97's care plan dated 2/28/2023 revealed no focus on addressing administration of oxygen. During an interview on 4/5/2023 at 1:18 PM, the Director of Nursing confirmed that Resident #97's did not have a care plan for oxygen administration. 4. Review of Resident #11's medical records revealed the resident was admitted to the facility on [DATE] with diagnoses including heart failure, chronic obstructive pulmonary disease, and acute respiratory failure. During an observation on 4/3/2023 at 11:09 AM, Resident #11 was sitting in a wheelchair, wearing nasal cannula and receiving oxygen via condenser. The setting on the oxygen condenser was between 2.5-3.0 liters per minute. Oxygen tubing was not dated (photographic evidence obtained). During an observation on 4/3/2023 at 3:29 PM, Resident #11 was sitting on the side of the bed, wearing nasal cannula and receiving oxygen via condenser. The setting was between 2.5-3.0 liters per minute. Oxygen tubing was not dated. During an interview on 4/3/2023 at 3:30 PM, Resident #11 stated, I do not touch the settings. I just turn the condenser on/off. During an observation on 4/4/2023 at 8:30 AM, Resident #11 was wearing nasal cannula and receiving oxygen via condenser. The setting was between 2.5-3.0 liters per minute. Oxygen tubing was not dated. During an observation on 4/5/2023 at 1:31 PM, Resident #11 was eating lunch, wearing nasal cannula and receiving oxygen via condenser. The setting was at 3 liters per minute. Review of Resident #11's physician order dated 7/6/2022 reads, Respiratory: Oxygen - Continuous 2 L nc [nasal cannula] to maintain O2 stats above 92%. Review of Resident #11's care plan initiated on 8/31/2022 revealed no focus for oxygen administration. During an interview on 4/5/2023 at 12:20 PM, Staff E, LPN, MDS Coordinator, stated that oxygen should be on the care plan and it was not. Review of the facility policy and procedure titled Plans of Care dated 11/30/2014 and reviewed on 1/18/2023 reads, Policy: An individualized person-centered plan of care will be established by the interdisciplinary team (IDT) with the resident and/or resident representative(s) to the extent practicable and updated in accordance with state and federal regulatory requirements. Plan of care is to be maintained as part of the final medical record. Procedure: Develop a comprehensive plan of care for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment.

Based on observation, interview, and record review, the facility failed to ensure residents received care and services for midline catheter dressing change in accordance with professional standards of practice for 1 of 1 resident with midline catheters, Resident #6. Findings include: During an observation on 4/3/2023 at 11:07 AM, Resident #6 was lying in bed with midline catheter noted on left upper arm with the dressing dated 3/26/2023. Clear dressing was noted and secured. Under transparent dressing, there was dry dark blood noted around insertion site (photographic evidence obtained). During an observation on 4/5/2023 at 3:06 PM, Resident #6 was lying in bed with the midline catheter dressing dated 3/26/2023. Clear dressing was noted and secured. Under transparent dressing, there was dry dark blood noted around insertion site. Review of physician order dated 3/24/2023 for Resident #6 reads, Change Dressing on admission or 24 hours after insertion and weekly thereafter and PRN [as needed]. Every evening shift every Fri [Friday]. During an interview on 4/5/2023 at 3:30 PM, the Director of Nursing stated that the dressing was dated 3/26/2023 and should be changed as ordered weekly. Review of the facility policy and procedure titled Central Vascular Access Device (CVAD) Dressing Change last revised on 6/1/2021 reads, Guidance: 1. Perform sterile dressing changes using Standard-ANTT [Aseptic Non Touch Technique]: 1.1 Upon admission 1.1.1 If transparent dressing is dated, clean, dry, and intact, the admission dressing change may be omitted and scheduled for 7 days from the date on the dressing label . 1.2 At least weekly.

Based on observation and interview, the facility failed to ensure the resident environment remained free of accident hazards by failing to ensure oxygen tanks were stored securely (photographic evidence obtained). Findings include: During an observation on 4/3/2023 at 10:40 AM, there were two oxygen tanks in Resident #70's room, not secured in oxygen holders. During an observation on 4/3/2023 at 3:33 PM, there were two oxygen tanks in Resident #70's room, not secured in oxygen holders. During an interview on 4/3/2023 at 3:33 PM, Resident #70 stated, I use oxygen and use the oxygen tanks when I go outside, so I keep the tanks in here. One is empty and one is full.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the drugs and biologicals used in the facility were labeled and stored in accordance with currently accepted professional principles and included the expiration date when applicable in 1 of 4 medication carts and 2 of 3 medication rooms reviewed. Findings include: During an observation of North Medication Room on [DATE] at 9:45 AM with Staff A, Licensed Practical Nurse (LPN), Unit Manager, there was one Aplisol syringe with an expiration date of [DATE] in the refrigerator (Photographic evidence obtained). During an interview on [DATE] at 9:45 AM, when asked about the expired medication in the refrigerator, Staff A, LPN, Unit Manager, stated, The staff should go through the refrigerator once a week. During an observation of 500 Unit Medication Cart on [DATE] at 9:45 AM with Staff B, Registered Nurse (RN), there were one unopened Humalog Kwik PEN with a label indicating to keep refrigerated until opened, two unlabeled Glargine Insulin Pens, and one unlabeled Lyumjev Kwik Pen (Photographic evidence obtained). During an interview on [DATE] at 9:55 AM, Staff B, RN, stated, I did not go through my cart this morning. I was off this weekend and should have done so. During an observation of South Medication Room on [DATE] at 9:55 AM with Staff A, LPN, Unit Manager, there was one opened vial of Humulin 70/30 insulin with no label. The vial contained less than ½ a vial of insulin (Photographic evidence obtained). During an interview on [DATE] at 9:55 AM, when asked about unlabeled medication, Staff A, LPN, Unit Manager, stated, The staff should label the vial once opened. During an interview on [DATE] at approximately 3:45 PM, the Director of Nursing stated, I was aware, that should not be the nurses know better, they should have dated and pulled out of dates. Review of the facility policy and procedure titled Storage and Expiration Dating of Medications, Biologicals with an effective date of [DATE] and revision date of [DATE] reads, Procedure . 4. Facility should ensure that medications and biologicals that: (1) have an expiration date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier. 5. Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened or opened. 5.1 Facility staff may record the calculated expiration date based on date opened on the primary medication container.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received respiratory care consistent with professional standards of practice for 12 of 13 residents reviewed, Residents #6, #11, #12, #28, #44, #58, #59, #68, #70, #97, #98, and #204. Findings include: 1. Review of Resident #28's medical records revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, other pulmonary embolism without acute Cor Pulmonale (a condition that causes the right side of the heart to fail), essential (primary) hypertension, congenital pneumonia, sleep apnea, and longstanding persistent atrial fibrillation. During an observation on 4/3/2023 at 9:38 AM, Resident #28 was lying in bed, receiving oxygen via nasal cannula at 2 liters per minute. During an interview on 4/3/2023 at 9:38 AM, Resident #28 stated, I use 2 liters of oxygen. During an observation on 4/4/2023 at 9:52 AM, Resident #28 was lying in bed, receiving oxygen via nasal cannula at 2 liters per minute. Review of Resident #28's physician orders revealed no order for oxygen administration. During an interview on 4/4/2023 at 2:34 PM, Staff C, Licensed Practical Nurse (LPN), stated, [Resident #28's name] does not have a current order or a care plan for oxygen. They are currently being administered oxygen and have an oxygen concentrator in their room. 2. Review of Resident #6's medical records revealed the resident was initially admitted on [DATE] and readmitted on [DATE] with the diagnoses including essential (primary) hypertension, heart failure, unspecified atrial fibrillation, and wheezing. During an observation on 4/3/2023 at 10:05 AM, Resident #6 was in bed, wearing a nasal cannula with oxygen being administered at 2 liters per minute. During an interview on 4/3/2023 at 10:05 AM, Resident #6 stated, My oxygen should be set to 2 liters per minute. On 4/4/2023 at 10:28 AM, Resident #6 was in bed, wearing a nasal cannula with oxygen being administered at 2 liters per minute. Review of Resident #6's physician orders revealed no order for oxygen administration. During an interview on 4/4/2023 at 2:36 PM, Staff C, LPN, stated, [Resident #6's name] does not have a current order or a care plan for oxygen. During an interview on 4/4/2023 at 3:03 PM, the Director of Nursing (DON) stated, My expectation is that anyone in the building receiving oxygen should have an order before we administer oxygen. During an interview on 4/4/2023 at 3:23 PM, the Executive Director stated, It is my expectation that anyone receiving oxygen continuously or PRN should have a physician order. 3. Review of Resident #12's medical records revealed the resident was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, asthma, angina, and heart failure. During an observation on 4/3/2023 at 10:18 AM, Resident #12 was receiving oxygen at 4.5 liters per minute via nasal cannula. There was no date on the tubing. The nebulizer tubing was lying on the side table not covered and tubing was not dated. During an observation on 4/3/2023 at 3:22 PM, Resident #12 was receiving oxygen at 4.5 liters per minute via nasal cannula. Nebulizer tubing was lying on the side table not covered and the tubing was not dated. During an observation on 4/4/2023 at 8:34 AM, Resident #12 was receiving oxygen at 2 liters via nasal cannula. There was no date on the tubing for nasal cannula or nebulizer tubing. The nebulizer was lying on the table not covered. Review of Resident #12's physician order dated 2/9/2023 reads, O2 [oxygen] at 2 Liters as needed for O2 sat [saturation] below 92%. Resident #12's physician orders included no order for changing oxygen tubing or rate of oxygen flow. During an interview on 4/4/2023 at 3:52 PM, Staff E, LPN, Minimum Data Set (MDS) Coordinator, stated, I have visually seen her with oxygen and seen her take it off. Staff E stated, A care plan for respiratory and oxygen therapy needs to be written. 4. Review of Resident #44's medical records revealed the resident was admitted on [DATE] with diagnoses including asthma, shortness of breath, anemia, heart failure, and atherosclerotic heart disease. Review of Resident #44's physician orders revealed no orders for oxygen administration and no orders for oxygen tubing to be changed. During an observation on 4/3/2023 at 10:46 AM, Resident #44 was lying on his back with oxygen being administered at 2 liters per minute via nasal cannula, with no date on the tubing. During an interview on 4/3/2023 at 10:46 AM, Resident #44 stated, I am always on oxygen. During an observation on 4/3/2023 at 3:27 PM, Resident #44 was being administered oxygen at 2 liters per minute via nasal cannula, and the oxygen tubing was not dated. During an observation on 4/4/2023 at 8:36 AM, Staff A, LPN, North Wing Manager, confirmed that oxygen was being delivered at 2 liters per minute via nasal cannula and there was no date on the nasal cannula oxygen tubing. 5. Review of Resident #70's medical records revealed the resident was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, pulmonary edema, anemia and anxiety. Review of Resident #70's physician order dated 6/20/2022 reads, Oxygen as needed PRN [as needed] at 2 L [Liter] via nasal cannula as needed for shortness of breath. During an observation on 4/3/2023 at 10:40 AM, Resident #70's oxygen tubing had no date. During an observation on 4/3/2023 at 3:33 PM, Resident #70 was receiving oxygen at 2 liters per minute via nasal cannula. Nasal cannula tubing was not dated. During an observation on 4/4/2023 at 9:00 AM, Resident #70 was receiving oxygen at 2 liters per minute via nasal cannula. There was no date or time noted on the tubing. During an interview on 4/4/2023 at 9:00 AM, Staff A, LPN, North Wing Manager, stated, The oxygen tubing is not dated. I had the staff go through the department last night and label a plastic bag and hang the bag on all concentrators. 6. Review of Resident #58's medical records revealed the resident was admitted on [DATE] with diagnoses including diabetes mellitus, chronic obstructive pulmonary disease, and atrial fibrillation. Review of Resident #58's physician orders reads, Order Summary: Respiratory: Oxygen @ [at] 2 L [liters] via n/c [nasal cannula] continuous . Start Date: 06/28/2021 . Order Summary: Change tubing, mask and/or nasal cannula weekly. May change sooner as needed. As needed for hygiene . Start Date: 06/28/2023 . Order Summary: Resident tolerance of nebulizer treatment (Add corresponding code in supplementary documentation. Good= G, Fair= F, Poor= P every 6 hours as needed. Start Date: 07/08/2021. During an observation on 4/3/2023 at 10:23 AM, Resident #58 was sitting in a wheelchair in the hall with oxygen being administered via nasal cannula from portable oxygen tank set at 1 liter per minute. Nasal cannula tubing was not labeled. The nebulizer mask and tubing were lying on the table, not dated and not covered. During an observation on 4/3/2023 at 2:10 PM, Resident #58 was receiving oxygen at 1 liter per minute via nasal cannula on portable tank. There was no date on the oxygen tubing. Nebulizer mask and tubing were lying on the table, not dated and not covered. During an observation on 4/3/2023 at 3.22 PM, Resident #58 was receiving oxygen from concentrator via nasal cannula at 1 liter per minute. The tubing was not dated. The nebulizer mask and tubing were lying on the table, not dated and not covered. During an interview on 4/4/2023 at 8:34 AM, Staff A, LPN, North Wing Manager, confirmed that the oxygen rate was set at 1 liter, there was no date on the tubing for nasal cannula or nebulizer, and the nebulizer was not covered. During an interview on 4/4/2023 at 8:52 AM, Staff A, LPN, North Wing Manager, stated, The tubing was not changed and was not labeled as ordered. I had the night shift change all the tubing and place the clear bag with the date on it, last night. They were supposed to change all the nebulizer mask and place them in a bag. They missed this one. Oxygen tubing changes are done on night shift normally on Friday night. CNAs [Certified Nursing Assistants] or PCAs [Personal Care Attendants] change tubing and date the bag. 7. Review of Resident #68's medical records revealed the resident was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, acute respiratory failure, arrhythmias, atherosclerosis, heart failure, obstructive sleep apnea, cardiomegaly, anxiety, and anemia. Review of Resident #68's physician order dated 6/20/2022 reads, Change tubing, mask and/or nasal cannula weekly. May change sooner as needed . Oxygen @ 3 L via n/c Cont. [continuously] every shift. During an observation on 4/3/2023 at 9:56 AM, Resident #68 was lying in bed with oxygen being administered at 2 liters per minute via nasal cannula. There was no date noted on the oxygen tubing. During an interview on 4/3/2023 at 9:56 AM, Resident #68 stated, I think the setting is 3. I don't change it. I can't get out of bed myself. The oxygen tubing is only changed if needed. It's not changed weekly. During an observation on 4/3/2023 at 3:16 PM, Resident #68 was receiving oxygen at 2 liters per minute via nasal cannula. There was no date noted on the oxygen tubing. During an observation on 4/4/2023 at 7:48 AM, Resident #68 was receiving oxygen at 2 liters per minute via nasal cannula. There was no date noted on the oxygen tubing. During an interview on 4/4/2023 at 8:08 AM, Staff F, LPN, stated, Oxygen is checked by the nurse during medication administration for rate. Only the nurses adjust the oxygen. Aids can change the tubing. Oxygen tubing is changed normally Thursday or Saturday nights. During an interview on 4/4/2023 at 8:32 AM, Staff A, LPN, North Wing Manager, confirmed that the oxygen rate was at 2 liters per minute. 8. Review of Resident #59's medical records revealed the resident was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, and dependence on supplemental oxygen. Review of Resident #59's physician orders dated 4/3/2023 reads, Respiratory oxygen 2-3 L continuous NC [Nasal Cannula]. During an observation on 4/3/2023 at 10:28 AM, Resident #59 was lying in bed with nasal cannula prongs lying on the resident's left side of his cheek, not in nares. Oxygen was being delivered via nasal cannula at 1.5 liters per minute. The nebulizer was lying on table, not covered and not dated. During an interview on 4/3/2023 at 10:28 AM, Resident #59 stated, I use oxygen all the time. Tubing is changed when it starts to bother me, or it gets dirty. During an observation on 4/3/2023 at 3:27 PM, Resident #59 was being administered oxygen at 1.5 liters per minute via nasal cannula. The tubing was not dated, and the nebulizer was lying on table, not covered and not dated. During an interview on 4/4/2023 at 8:34 AM, Staff A, LPN, North Wing Manager, confirmed that Resident #59's oxygen rate was at 1.5 liters per minute and there was no date on tubing for nasal cannula or nebulizer tubing. During an interview on 4/4/2023 at 8:52 AM, Staff A, LPN, North Wing Manager, confirmed that the tubing was not changed and was not dated per facility policy for Resident #12, Resident #44, Resident #58, Resident #70, Resident #68 and Resident #59. Staff A confirmed that there were no orders for oxygen tubing to be changed for Resident #12 and Resident #59. During an interview on 4/5/2023 at 1:52 PM, Staff E, LPN, MDS Coordinator, stated that the residents that were using oxygen required a physician order. During an interview on 4/5/2023 at 4:24 PM, the DON stated, My expectation is that orders are followed at the rate of flow ordered and that tubing is changed on Friday nights and all tubing is dated at that time. All Residents receiving oxygen therapy need a physician order for oxygen and rate of delivery. Also, an order for oxygen tubing to be changed weekly and as needed is required for all residents receiving nebulizer treatments. 10. Review of Resident #97's medical records revealed the resident was admitted to the facility on [DATE] with diagnoses including heart failure, atrial fibrillation, memory deficit following cerebral infarction, major depressive and anxiety disorder. During an observation on 4/3/2023 at 11:46 AM, Resident #97 was receiving oxygen via concentrator machine running at 2 liters per minute, with no date on the tubing. During an observation on 4/4/2023 at 8:14 AM, Resident #97 was receiving oxygen via concentrator machine running at 2 liters per minute, with no date on the tubing. Review of Resident #97's physician order dated 2/24/2023 reads, Change tubing, mask and/or nasal cannula weekly. May change sooner as needed. As needed for hygiene. During an interview on 4/5/2023 at 1:18 PM, the DON confirmed that Resident #97's oxygen tubing and concentrator was not labeled or dated. 11. Review of Resident #98's medical records revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, atrial fibrillation, hypertension, major depressive disorder, and encounter for screening for respiratory tuberculosis. During an observation on 4/3/2023 at 11:01 AM, Resident #98 was sitting on the side of his bed with oxygen being administered at 3 liters per minute via nasal cannula with no label or date on the tubing. During an observation on 4/4/2023 at 8:48 AM, Resident #98 was lying in bed with oxygen being administered at 3 liters per minute via nasal cannula with no label or date on the tubing. Review of Resident #98's physician order dated 3/2/2023 reads, Change tubing, mask and/or nasal cannula weekly. May change sooner as needed. As needed for hygiene. During an interview on 4/5/2023 at 1:18 PM, the DON confirmed that Resident #98's oxygen tubing and concentrator were not labeled or dated. 12. Review of Resident #204's medical records revealed the resident was admitted to the facility on [DATE] with diagnoses including abnormalities of gait and mobility, dysphagia, type II diabetes mellitus, bipolar disorder, major depressive disorder, anxiety disorder, restless leg syndrome, and hypotension. During an observation on 4/3/2023 at 11:57 AM, Resident #204 was lying in bed with oxygen running at 3 liters per minute, with no date or label on the tubing. During an observation on 4/4/2023 at 8:35 AM, Resident #204 was lying in bed, being administered oxygen via nasal cannula at 3 liters per minute, with no label or date on the tubing. Review of Resident #204's physician order dated 3/29/2023 reads, Change tubing, mask and/or nasal cannula weekly. May change sooner as needed. As needed for hygiene. During an interview on 4/5/2023 at 1:18 PM, the DON confirmed that Resident #98's oxygen tubing and concentrator were not labeled or dated. Review of the facility policy and procedure titled Oxygen Therapy reads, Procedure: Physician's order for oxygen therapy shall include: Administration modality, FiO2 [the concentration of oxygen in the gas mixture] or liter flow, Continuous or PRN [as needed], PRN orders must include specific guidelines as to when the resident is to use oxygen. Documentation shall include . Start O2 [oxygen] flowrate at the prescribed liter flow or appropriate flow for administration device . Label tubing and humidifier with date and time. 9. Review of Resident #11's medical records revealed the resident was admitted to the facility on [DATE] with diagnoses including heart failure, chronic obstructive pulmonary disease, and acute respiratory failure. During an observation on 4/3/2023 at 11:09 AM, Resident #11 was sitting in a wheelchair, wearing nasal cannula and receiving oxygen via condenser. The setting on the oxygen condenser was between 2.5-3.0 liters per minute. Oxygen tubing was not dated (photographic evidence obtained). During an observation on 4/3/2023 at 3:29 PM, Resident #11 was sitting on the side of the bed, wearing nasal cannula and receiving oxygen via condenser. The setting was between 2.5-3.0 liters per minute. Oxygen tubing was not dated. During an interview on 4/3/2023 at 3:30 PM, Resident #11 stated, I do not touch the settings. I just turn the condenser on/off. During an observation on 4/4/2023 at 8:30 AM, Resident #11 was wearing nasal cannula and receiving oxygen via condenser. The setting was between 2.5-3.0 liters per minute. Oxygen tubing was not dated. During an observation on 4/5/2023 at 1:31 PM, Resident #11 was eating lunch, wearing nasal cannula and receiving oxygen via condenser. The setting was at 3 liters per minute. Review of Resident #11's physician order dated 7/6/2022 reads, Respiratory: Oxygen - Continuous 2 L nc to maintain O2 stats above 92%. Review of Resident #11's physician order dated 7/6/2022 reads, Change tubing, mask and/or nasal cannula weekly. May change sooner as needed. As needed for hygiene. During an interview on 4/6/2023 at approximately 3:30 PM, the DON confirmed stated that the oxygen setting was 3 liter per minute.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy and procedure review the facility failed to ensure residents received care and treatment for vascular access devices per physicians' orders and in accordance with professional standards of practice for 2 of 3 residents, Residents #1 and #10. Findings include: 1. Review of Resident #1's medical record documented the resident was admitted into the facility on [DATE] with diagnosis to include osteomyelitis of vertebral lumbar region (bone infection caused by bacteria). There was no documentation in the record of measurements of the arm circumference and the external catheter length having been conducted on the date of admission as required per the facility's policy and procedures. Review of Resident #1's physician order reads: 9/26/2022 PICC [peripherally inserted central catheter] or MID line [midline catheter]: Measure upper arm circumference and external catheter length on admission, with each dressing change and PRN [as needed] every day shift every Tuesday. Review of Resident #1's Treatment Administration Record (TAR) documented PICC or MID measure upper arm circumference and external catheter length on admission, with each dressing change and PRN every day shift every Tuesday. The TAR revealed the physician orders and the facility's policy and procedures were not followed on 09/23/2022, date of admission, 09/27/2022 and 10/04/2022. 2. Review of Resident #10's medical record documented the resident was admitted into the facility on [DATE] with diagnosis to include cellulitis of the right lower limb (potentially serious bacterial skin infection). Review of Resident #10's physician order reads: 9/27/2022 PICC or MID line measure upper arm circumference and external catheter length on admission, with each dressing change and PRN every day shift every Tuesday. Review of the TAR documented PICC or MID line measure upper arm circumference and external catheter length on admission, with each dressing change and PRN every day shift every Tuesday. The TAR revealed the physician orders were not followed on 10/04/2022, 10/18/2022, 10/25/2022, and 11/01/2022. During an interview on 11/8/2022 at 12:02 AM Staff C, License Practical Nurse (LPN) Manager North Wing stated, The arm circumference and length of catheters for PICC lines or MID lines are per physician orders. The measurements are on admission and with dressing changes, but the physician orders are specific for the patient. Measurements are documented on the Treatment Administration Record. Staff C reviewed the medical records for Residents #1 and #10 and confirmed physician orders were not followed for Resident #1 and Resident # 10 related to measurements and documentation for arm circumference and external catheter length. During an interview on 11/9/2022 at 09:36 Staff F, LPN stated, The measurement of the arm circumference and catheter for Mid-Line or PICC line was not completed for Resident #1 and Resident #10 and are supposed to be done each dressing change on Tuesday, but they are not always done as ordered. During an interview on 11/9/2022 at 09:48 AM Staff H, LPN stated, The measuring of the arm circumference and external catheter are measured on admission and as physician ordered. The measurements are documented on the Medication Administration Record or the Treatment Administration Record. Staff are trained on how to complete the measurements during orientation and yearly at the skills fair. During an interview on 11/9/2022 at 12:42 PM the Director of Nursing confirmed the orders were not followed related to measuring the arm circumference and external catheter length for Residents #1 and #10. I don't know why those orders are written. We do not always measure them but if it is an order then the orders have to be followed. Review of policy: Policy Titled: Central Vascular Access Device (CVAD) Dressing change Original Date1/15/2004 and Revision Date 6.1.2021 Produced by Omnicare reads Guidance 1. 1.1.1.1 Upper arm circumference with PICC, and external catheter length measurements must still be completed as part of the initial assessment.

Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice by failing to follow physician ordered parameters for administering medications for 1 of 5 residents, Resident #23, in a total sample of 37 residents. Findings: Review of Resident #23's record revealed the resident was admitted with diagnoses to include diabetes mellitus, chronic kidney disease with dialysis, chronic obstructive pulmonary disease, depression, generalized anxiety disorder and hypotension (low blood pressure). Review of Resident #23's physician order reads, Order Summary: Midodrine HCl Tablet 2.5 MG [milligrams], Give 1 tablet by mouth two times a day related to other hypotension (195.89) Hold for SBP [Systolic Blood Pressure] 115. Order Status: Active. Order Date: 07/21/2021. Start Date: 07/21/2021. Review of Resident #23's electronic medication administration record revealed Midodrine was held per parameters on 10/1/2021 at 5 PM when the blood pressure was documented as 100/62, on 10/8/2021 at 5 PM when the blood pressure was documented as 93/65, on 10/9/2021 at 5 PM when the blood pressure was documented as 110/52, on 10/14/2021 at 5 PM when the blood pressure was documented as 105/69, on 10/20/2021 at 5 PM when the blood pressure was documented as 100/62, on 10/24/2021 at 5 PM when the blood pressure was documented as 104/62, and on 10/26/2021 at 5 PM when the blood pressure was documented as 101/57. During an interview on 10/27/2021 at 4:15 PM, the Director of Nursing (DON) stated, This is not a very good order as it doesn't say to hold the medication for a systolic blood pressure (SBP) above 115, but we know what this medication is for and should not have held the medication when the blood pressure was under 115. We should have gotten an order to clarify the parameters for the medication to be held and we should have administered the Midodrine. We should follow physician orders when we administer medications. On 10/27/2021 at 4:20 PM, during review of the medication administration record with Staff D, Licensed Practical Nurse (LPN), who was the nurse that recorded the medication was held, she verified that the record indicated that the medication Midodrine was held for parameters. Staff D, LPN, stated, Well, the order says to hold it for blood pressure of 115. Oh no, it is Midodrine and that treats hypotension. Well, she sometimes refuses her medication, but I should have administered the medication if the blood pressure was below 115 or documented correctly if she refused the medication.

Based on observation, interview, and record review, the facility failed to ensure a resident was offered nutritional supplements as ordered by the physician for 1 of 5 residents reviewed for nutrition, Resident #18, in a total sample of 37 residents. Findings: Review of Resident #18's record revealed the resident had diagnoses to include cerebrovascular accident (stroke), Alzheimer's disease, major depression, anxiety disorder, and hypothyroidism. Review of Resident #18's weights revealed a weight of 112.8 pounds on 4/6/2021 and a weight of 101.4 pounds on 10/5/2021. This is a 10.11% weight loss in 6 months. Review of Resident #18's physician order reads, Order Summary: Magic Amt [amount] ordered PO [by mouth] in add direc [directly] with meals. Order Status: Active. Order Date: 07/09/2021. Start Date: 07/09/2021. Review of the dietary note dated 9/12/2021 by the Registered Dietician (RD) for Resident #18 reads, CBW [Current Body Weight]: 97 lbs, weight loss 6% x 30 days, diet: dysphagia pureed, meal intakes < 50% at times. Weight is stable x 1 week. Supplements in place: fortified foods, Medipass 120 ml TID [three times per day], and magic cup TID recommend increasing med pass 240 ml TID to promote weight maintenance. RD to monitor weight and follow up PRN [as needed]. On 10/25/2021 at 12:12 PM, an observation of Resident #18's meal tray, delivered by Staff G, Certified Nursing Assistant (CNA), showed no magic cup on the tray. Staff G removed the tray from the resident's bedside at 1:06 PM. The resident ate less than 25% of her meal. Staff G did not offer any alternatives and did not offer to assist resident with eating any more of her meal. On 10/26/2021 at 7:30 AM, an observation of Resident #18's meal tray delivered by Staff G, CNA, showed no magic cup on the meal tray. During an interview on 10/26/2021 at 7:50 AM, Staff G, CNA, stated, There is no magic cup on her tray. I don't know if she should have one. On 10/26/2021 at 1:00 PM, an observation of Resident #18 in the common dining area on the unit showed the resident was being supervised during the meal by staff. No magic cup was present on her tray. During an interview on 10/26/2021 at 1:04 PM, Staff H, CNA, verified that the resident did not receive her magic cup with her lunch meal and that it was marked on the resident's menu. Staff H stated, I'm not sure why the kitchen didn't send it. I was in the dining room with her and did not realize that it was not on her tray. I guess I should have checked it. During an interview on 10/26/2021 at 1:29 PM, Staff I, Licensed Practical Nurse (LPN), stated, We should be checking the trays to make sure that the ordered supplements are on them. Usually, the CNA will tell us if there is anything wrong with the meal. During an interview on 10/27/2021 at 9:30 AM, the Director of Nursing (DON) stated, I expect that staff will check the resident's meal tickets to make sure that the correct meals and supplements are being given to the correct resident. During an interview on 10/27/21 at 12:26 PM, the Registered Dietician stated, There are 890 calories per cup for the magic cups that will aid in maintaining her weights and make sure that she does not lose any further weight. She has had her supplements increased and this has helped her maintain her weight, but not receiving her magic cups will potentially affect her weight negatively.

Based on observation, interview, and record review, the facility failed to ensure garbage and refuse were disposed of properly. Findings: On 10/25/2021 at 9:17 AM, an observation during a tour of the garbage disposal area with the Certified Dietary Manager showed two full plastic garbage bags placed on the ground approximately 3 feet from the kitchen area back door. One of the full plastic garbage bags was opened on the side exposing the garbage. One of the two dumpsters was opened on the side. The dumpster was approximately half full of garbage. During an interview on 10/25/2021 beginning at 9:17 AM, the Certified Dietary Manager stated both bags of garbage should be securely closed and should have been disposed of in one of the dumpsters. He confirmed that one of the dumpsters was opened on the side and should have been closed. Review of the facility policy titled Dispose of Garbage and Refuse last reviewed on 6/30/2021 reads, policy Statement: All garbage and refuse will be collected and disposed of in a safe and efficient manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the drugs and biologicals used in the facility were labeled and stored in accordance with currently accepted professional principles and included the expiration date when applicable in 4 of 5 medication carts reviewed. Findings: On [DATE] at 8:55 AM, an observation of the medication cart on the 200 Hallway with Staff A, Registered Nurse (RN), showed one opened bottle of Humulin Insulin with no opened and expiration dates and no resident identifier, one opened Lantus insulin pen with no opened date or resident identifier, one opened bottle of Humulin R insulin with an expiration date of [DATE], and one opened bottle of Fluorometholone 0.1% eye drops with no opened or expiration dates. During an interview on [DATE] at 9:09 AM, Staff A, RN, stated, The insulin should be dated and in the pharmacy package, so we know who it is for. The bottle of Humulin R does have an expiration date of [DATE] and that resident isn't here any longer. I don't know why it is still on the cart. It shouldn't be. The eye drops should have the date they were opened or expire. On [DATE] at 9:13 AM, an observation of the medication cart on the 300 Hallway with Staff B, RN, showed one opened bottle of Timolol 0.5% eye drops with no opened or expiration dates, one opened bottle of Alphagan 0.15% eye drops with no opened or expiration dates, one opened bottle of Prednisolone 1% eye drops with no opened or expiration dates, one opened bottle of Timolol 0.5% eye drops with an expiration date of [DATE], and one opened bottle of Novolog Insulin with no opened date or resident identifier. During an interview on [DATE] at 9:18 AM, Staff B, RN, stated, All eye drops, and insulins should have when they were opened and when they expire. The timolol eye drops are expired and should not be on the cart and the insulin should be labeled with who it is for and when it was opened. On [DATE] at 9:19 AM, an observation of the medication cart on the 500 Hallway with Staff C, Licensed Practical Nurse (LPN), showed one opened Lantus flex pen with no opened or expiration dates. During an interview on [DATE] at 9:24 AM, Staff C, LPN, stated, The insulin should have the date it was opened and when it expires. On [DATE] at 9:35 PM, an observation of the medication cart on the 600 Hallway with Staff A, RN, showed two Tresiba Insulin Flex pens with no opened or expiration dates, one opened bottle of Travoprost 0.004% eye drops with no opened or expiration dates, one opened bottle of Gatifloxacin 0.5% eye drops with no opened or expiration dates, and two opened bottles of Prednisolone 1% with no opened or expiration dates. During an interview on [DATE] at 9:45 AM, Staff A, RN, stated, All eye drops should have the date they are opened and when they expire. The insulin pens should have the date they are opened. Review of the facility policy number 5.3 titled Storage and Expiration of Medications, Biologicals, Syringes and Needles with an effective date of [DATE] and an approval date of [DATE] reads, 4. Facility should ensure that medications and biologicals: 4.1 Have an expiration date on the label: 4.2 have not been retained longer than recommended by manufacturer or supplier guidelines. 5. Once any medication or biological package is opened, Facility should follow manufacturers/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. 5.1 Facility staff may record the calculated expiration date based on the date opened on the medication container.

Based on observation, interview, and record review, the facility failed to ensure foods were stored in accordance with professional standards for food service safety. Findings: On 10/25/2021 at 9:20 AM, an observation during a tour of the 300 Hallway nourishment room with the Certified Dietary Manager showed a frozen pink substance pooled in the freezer, an unlabeled/uncovered cup of frozen substance stored in the freezer, and an opened/undated plastic bag of vegetables stored in the refrigerator. During an interview on 10/25/2021 at 9:20 AM, the Certified Dietary Manager confirmed the freezer needed cleaning and the food items should be labeled, dated and covered. On 10/25/2021 at 9:25 AM, an observation during a tour of the 500 Hallway nourishment room with the Certified Dietary Manager showed an opened undated bag of bagels stored in the nourishment room, and a pink substance splattered in the refrigerator. During an interview on 10/25/2021 at 9:25 AM, the Certified Dietary Manager confirmed the refrigerator needed cleaning and food items should be labeled, dated and covered. Review of the facility policy titled Food Storage: Cold Foods last reviewed on 6/30/2021 reads, Procedures: . 5. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Review of the facility policy titled Food: Safe Handling for Foods from Visitors last reviewed on 6/30/2021, reads, Procedures: . 4. When food items are intended for later consumption, the responsible facility staff member will: - Ensure that the food is stored separate or easily distinguishable from the facility food. - Ensure that foods are in a sealed container to prevent cross contamination. - Label foods with the resident name and the current date. - Determine if food items are shelf stable and whether they can be stored in the resident room or stored under refrigeration. 5. Refrigerator/freezers for storage of foods brought in by visitors will be properly maintained and: - Equipped with thermometers. - Have temperature monitored daily for refrigeration ? [less than or equal to] 41 ? [degrees Fahrenheit] and freezer ? 0 ?. - Daily monitoring for refrigerated storage duration and discard any food items that have been stored for ? [greater than or equal to] 7 days. (Storage of frozen foods and shelf stable items may be retained for 30 days.)